What is OCD?
Obsessive-compulsive disorder (OCD) is a long-term mental health condition characterized by recurring, unwanted thoughts, urges, feelings, sensations, or images that cause significant distress. In response, individuals with OCD engage in compulsive behaviors or mental actions in an effort to counteract these obsessions or reduce discomfort. These symptoms disrupt daily life and cause intense anxiety, fear, and other challenging emotions. However, treatment—such as Exposure and Response Prevention (ERP) therapy along with medication—has been proven highly effective in helping individuals manage their symptoms and enhance their quality of life.
Even though OCD affects an estimated 1 in 40 people globally, it remains a largely misunderstood condition. A therapist explains that “society—whether through movies, online information, or casual conversations—often contributes to confusion and misconceptions about OCD.”
In This Article
The primary symptoms of OCD consist of obsessions and compulsions.
What are obsessions?
Obsessions in OCD are commonly referred to as intrusive thoughts, but they can also manifest as intrusive images, sensations, feelings, or urges that lead to anxiety or distress. These obsessions often revolve around specific themes, such as an intense fear of contamination from germs or a fear of causing harm to oneself or others.
Typical obsessions associated with OCD encompass:
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An overwhelming desire for perfection, symmetry, or for things to be "just right"
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Concerns and uncertainties regarding one's "true" sexuality
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A strong fear of contamination or illness
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Ongoing anxiety about breaching religious, moral, or ethical values
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Preoccupations with bodily sensations or involuntary physical functions
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Intrusive thoughts about violence or causing harm to oneself or others
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Doubts and anxieties related to relationships, particularly intimate ones
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Persistent doubts about past events (False Memory OCD)
According to Patrick McGrath, PhD, Chief Clinical Officer at NOCD, it’s important to remember that “these obsessions do not reflect a person’s true values or desires. In fact, they are often the exact opposite: a caring mother may be flooded with distressing images of harming her newborn, while a dedicated elementary school teacher might be plagued by fears of being sexually attracted to his students.”
Additionally, it’s important to recognize that everyone experiences intrusive thoughts occasionally. However, most individuals can dismiss these thoughts, understanding that they do not indicate a threat or reflect their values or identity. In contrast, for those with OCD, these thoughts carry significant weight and can feel perilous, leading to intense negative emotions such as fear, distress, anxiety, or discomfort.
What are compulsions?
Compulsions are repetitive actions or mental processes that individuals with OCD feel compelled to perform in reaction to their obsessions. These behaviors aim to alleviate anxiety or distress or to avert a perceived negative outcome. However, since engaging in compulsions only offers temporary relief, the obsessions inevitably resurface, which contributes to what is known as the OCD cycle.
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“For example, if you fear harming others,” Ibrahim explains, “someone experiencing this thought might engage in compulsions like avoiding sharp objects or steering clear of people they believe could be harmed.”
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Compulsions can significantly restrict one's life. As Sommer G., a member of the NOCD community with harm-related OCD, shares, “I stopped watching the news because I was afraid the violence depicted would trigger violent thoughts. I considered knives and forks to be unsafe and only ate with spoons.”
Common compulsions associated with OCD include:
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Checking: Repeatedly verifying that the stove is turned off or that the door is locked.
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Tapping/touching: Performing actions like tapping your knee a specific number of times to feel “okay” or “just right.”
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Reassurance-seeking: Asking loved ones questions like, “Did you see me push anyone when we were walking down that busy street?” or “Do you really love me?”
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Avoidance: Steering clear of places, situations, or stimuli that could trigger intrusive thoughts.
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Excessive washing/cleaning: Engaging in hand washing, showering, or disinfecting surfaces multiple times throughout the day.
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Rumination: Persistently dwelling on thoughts, sometimes for hours on end.
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Mental reassurance: Providing yourself with affirmations such as, “I would never do anything terrible like that because I’m not a bad person.”
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Thought-replacing: Substituting a “bad” thought with a “good” one in your mind.
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Obsessions and compulsions can consume significant amounts of time and energy, greatly diminishing the quality of life for those with OCD, impacting everything from daily tasks to career and relationship aspirations.
OCD is classified as a distinct condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, some clinicians and their patients find it beneficial to discuss OCD subtypes, which represent various categories of fears and obsessions commonly encountered. Identifying these subtypes can foster a sense of community among individuals facing similar challenges and assist therapists in creating targeted treatment strategies.
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If your subtype is not included in this list, it doesn’t imply that you don’t have OCD—everyone’s experience is unique, and many individuals’ symptoms may not align perfectly with any particular theme. Furthermore, people with OCD may experience multiple subtypes simultaneously, and these subtypes can evolve over time.
Common OCD subtypes:
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Existential OCD
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Contamination OCD
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False Memory and Real Event OCD
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Harm OCD
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Health and Contamination OCD
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Perfectionistic OCD
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Pure OCD
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Relationship OCD
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Religious (Scrupulosity) OCD
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Responsibility OCD
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Sensorimotor OCD
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Sexuality and Gender OCD
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Postpartum OCD
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Pedophile OCD
OCD can develop in childhood or early adulthood, with the majority of cases beginning in individuals aged 18 to 29. While the exact causes of OCD are not fully understood, several potential risk factors have been identified.
Genetics
Although scientists have not identified a specific gene or set of genes that directly causes OCD, it is believed that genetic factors contribute to its development. Studies indicate that individuals with a first-degree relative, such as a parent or sibling, who has OCD are at an increased risk of developing the disorder themselves.
Biology
Research indicates that individuals with OCD share certain biological characteristics. For example, there is evidence suggesting that OCD is associated with heightened activity in specific areas of the brain. Compulsions such as excessive cleaning and checking may be related to the wiring of the thalamus, which is responsible for relaying motor and sensory signals. Additionally, an imbalance in certain neurotransmitters, the brain's chemical messengers, might also contribute to the disorder.
Stressful life events
While no research has specifically examined how stressors impact individuals with OCD, self-report studies indicate that 25 to 67% of people with the disorder associate significant life events with the onset of their symptoms. Many individuals with OCD note that their symptoms emerged during particularly stressful periods or following specific traumatic experiences.
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However, experts advise against making definitive conclusions about cause and effect. “Some individuals with OCD have also gone through traumatic events, but that doesn’t imply that such an event will necessarily lead to OCD,” Ibrahim stated.
Many individuals seeking treatment for OCD often turn to therapy; however, a lack of relief may indicate that the wrong type of therapy was used, rather than therapy itself being ineffective. For example, while talk therapy and general Cognitive Behavioral Therapy (CBT) can benefit various mental health issues, they may actually worsen OCD symptoms in some cases.
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The gold-standard treatment for OCD is Exposure and Response Prevention (ERP), a specialized behavioral therapy developed specifically for this condition and supported by extensive clinical research.
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ERP involves gradually exposing individuals to situations that trigger their obsessions and assisting them in resisting the compulsion to engage in their usual responses. This is accomplished through techniques known as response prevention. Over time, ERP helps individuals learn to tolerate the discomfort and anxiety associated with their obsessions instead of succumbing to compulsions that only perpetuate the OCD cycle and exacerbate symptoms.
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ERP is customized to meet each person's unique needs. For instance, someone with Relationship OCD who constantly fears their partner might leave may engage in reassurance-seeking behaviors, such as repeatedly asking their partner for confirmation of their devotion. In ERP therapy, the therapist might suggest journaling the phrase “I don’t know if we’ll be together forever” and encouraging the individual to sit with the discomfort this thought evokes. Although it may seem counterintuitive, allowing discomfort to exist can ultimately diminish the power of obsessive thoughts.
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Regarding medication, it can play a crucial role in treating OCD, especially for individuals experiencing severe symptoms or co-occurring mental health conditions. Combining medication with ERP may enhance the effectiveness of therapy. Commonly prescribed medications include SSRI antidepressants like fluoxetine (Prozac) and sertraline (Zoloft), though some tricyclic antidepressants (TCAs) and atypical antipsychotics may also be beneficial.
While Exposure and Response Prevention (ERP) and medication are generally considered the primary treatments for OCD, there are situations where supplementary or alternative treatments may be needed to effectively manage symptoms. Below are some additional treatment options that a healthcare provider might suggest for OCD:
Acceptance and Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) may be suggested when Exposure and Response Prevention (ERP) proves less effective or as a means to enhance ERP skills. Instead of directly confronting distressing thoughts, ACT focuses on altering the relationship with those obsessions. As noted by Ibrahim, "With ACT, you learn to coexist with intrusive thoughts, images, urges, sensations, and feelings without judgment."
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For instance, an individual with Contamination OCD might perceive anything unclean as hazardous. ACT promotes the acceptance of these thoughts and feelings without taking action, emphasizing mindfulness. The primary objective is not to resist or diminish obsessions and compulsions but to accept these thoughts as transient occurrences.
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While there is limited research supporting ACT's effectiveness as a standalone treatment for OCD, it can still be beneficial. Ibrahim states, "ACT can be helpful, but it doesn’t typically serve as a standalone treatment for OCD." However, ACT can complement ERP therapy by enhancing motivation to persist in treatment. "We often combine two treatment modalities for OCD," she adds.
Transcranial magnetic stimulation (TMS)
When traditional therapies such as ERP and ACT fall short in effectively treating OCD, a non-invasive medical option like Transcranial Magnetic Stimulation (TMS) may be considered. Ibrahim explains, “TMS is a secondary treatment choice when your combination of medication and therapy hasn’t yielded sufficient results.”
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TMS utilizes short magnetic pulses to stimulate the neurons in the brain. Initially approved by the U.S. Food and Drug Administration (FDA) for depression, subsequent research demonstrated its efficacy in alleviating OCD symptoms, leading to the FDA's approval for this use in 2018. “TMS targets a specific area of the brain, regulating the neural activity of the brain structures linked to OCD,” Ibrahim states. She also notes that deep TMS, a variation of TMS, can be particularly effective for those with treatment-resistant OCD, potentially resulting in a reduction of symptoms by 30% or more.
Individuals with OCD typically endure the disorder for an average of 14 to 17 years before obtaining a diagnosis and accessing appropriate treatment. Therefore, it’s crucial to connect with the right professionals promptly to avoid wasting valuable time struggling with OCD. “The best approach for assessment and treatment is to seek out a specialist in ERP therapy,” advises Ibrahim.