Common symptoms of OCD include fear of contamination leading to washing and cleaning compulsions, fear of being harmed or causing harm and compulsive checking, sexual/violent obsessions and need to undo the thoughts, need for symmetry leading to ordering and arranging, or having a “not right” feeling and repeating behaviors until a “right feeling” is achieved.
Episodes may be brief or long, and the severity can range from mild to incapacitating. Thankfully, OCD symptoms can be managed with therapy, specifically exposure and response prevention (ERP) for OCD, and sometimes anxiety medication.
What Is Obsessive Compulsive Disorder?
OCD is a neurobiological and heritable disorder1 (some consider it an evolutionary biological disorder)2 that affects about 2.5% of the world’s population3 and is likely underestimated and misdiagnosed. Obsessive compulsive disorder is often referred to as the doubting disease. The hallmark of OCD is uncertainty which provokes anxiety. People with OCD experience intrusive unwanted, often disturbing thoughts, images, or impulses that provoke the need to be certain that their thoughts have not caused negative events to occur in reality.
Compulsions (rituals) are performed as attempts to make the thoughts and anxiety go away, to achieve certainty that they have not caused something bad from happening and are done out of a sense of moral duty that if there is something they can do to prevent harm then they should. These attempts never work since they only reinforce the power of the obsessions and fear. Fortunately, there are treatments that are effective no matter how long a person has had it or the level of severity.
Common Symptoms of OCD
Evolutionary biologists propose that typical OCD symptoms derive from survival instincts.2 There are many different types of OCD symptoms that have been considered to fit into four categories.4
The four most common categories of OCD obsessions are:
1. Contamination obsessions & Washing or Cleaning Compulsions
This is characterized by a fear of spreading germs, getting sick or getting others sick. There may also be an emotional contamination fear of having contact with a person or place, or anything associated with a bad experience (like avoiding wearing a piece of jewelry given by an ex-partner).
2. Obsessions About Causing Harm or Making Mistakes & Checking Compulsions
This includes a fear of being negligent or careless resulting in a catastrophic event, like a house catching fire or accidentally using poisonous chemical products.
3. Obsessions About Order & Symmetry & Ordering/Arranging Compulsions
“Just right” OCD is characterized by the need for everything to be in order (superstitious fears that something out of place may be bad luck; experiencing a not-right-feeling without an obsessive fear).
4. Obsessional Thoughts Concerning Sex, Religion, & Violence for Which Mental Undoing or Thinking “Good” Thought Rituals Are Performed
These obsessions could include:
- Intrusive pedophilia or rape obsessions leading to an avoidance going to public places out of fear there may be children present
- Images of stabbing someone that lead to an avoidance of using sharp objects
- Blasphemous images of religious icons or committing an unpardonable sin that compels praying rituals or avoidance of attending religious services
Other OCD themes include:
- Superstitious fears related to numbers, dates, words, or colors
- Moral perfectionism
- Indecision or fear of making mistakes
- Relationship and gender/sexual identity obsessions (do I really love my partner? Am I gay? Do I have signs of being the wrong sex?) that provoke checking and reassurance-seeking behaviors from others
- Existential issues (Who am I? What is real? Does anything matter?) accompanied by mental ruminations and excessive soul searching
- Body focused/health obsessions not related to problems of body image (hyperawareness and catastrophic thoughts set off by normal body sensations and excessive/ineffective medical appointments for reassurance that nothing is wrong, but the person is still not convinced)
Common OCD Compulsions
Compulsions are deliberate physical or mental behaviors that are performed to reduce anxiety, “fix” or “undo” intrusive thoughts, prevent harm or bad luck, prove the thoughts are not intended, and to restore one’s moral or spiritual standing, or to “right” discomfort.
Common compulsive symptoms of obsessive compulsive disorder include:
- Cleaning
- Checking
- Counting
- Arranging
- Repeating
- Asking for reassurance
- Praying
- Mental reviewing of an event, conversation, etc.
- Compulsions that include certain words or phrases to undo the obsession
- Idiosyncratic compulsions the person invents
Signs of OCD
General signs of OCD could include:
- Problems making even simple decisions
- Frequent asking of reassurance-seeking questions, the answers to which are never accepted because the problem is doubt, not logic or facts
- Excessive internet searching on a topic as a means of acquiring certainty about an obsessive theme
- Overt or covert counting and repeating behaviors. Sometimes the person has a certain number they use and its multiples (e.g. repeats steps 4 times and if not satisfied repeats 8, 12, 16, etc. until he or she feels “right”)
- Being stuck in place until a “right” feeling is achieved
- Being late; keeping family or friends waiting
- Not showing up or attending social events to avoid being triggered
- Looking distracted
People should consider any kind of avoidance behavior (mental or physical) to be a ritual. Some people get confused about what their rituals are because their level of functioning has been limited. Think about a typical day and what you don’t do because of the control the OCD has over your decisions and behaviors.
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) measures severity and has a checklist of common symptoms for adults and children.
Signs of OCD in Children
Children with OCD may have trouble moving from one task to the next without performing some kind of transitional OCD routine, become perfectionistic and rigid about schoolwork or enrichment activities, may be “fussy” about how things are arranged or about cleanliness, have limited foods they eat or ordered rules about eating, or have the need for things to be done in the exact same order every day.
Signs of Pediatric OCD include:
- Rule following
- Perfectionism
- Arranging
- Being late for school
- Demanding parents/family repeat something a certain way until it is said right
- Holes in paper from erasing due to a need for perfect penmanship and word choice
- Problems taking tests because of a need for certainty that answers are perfect, being stuck before being able to move on, or poor time management
Children are comforted by having established routines. These can be bedtime rituals (having a story read to them, sleeping with a special item, etc.), aligning stuffed animals on their bed before leaving the house in the morning for school, or eating only certain foods. These non-OCD rituals are typically outgrown around 8 years old. However, children with OCD will maintain these or create new rituals that become very rigid and rule-based.5
During the school age years social and friend relationships become important as well as peer pressure to fit in. Children with OCD are often set apart because they may display “odd” behaviors. They may become isolative and lonely.
Signs of Obsessive-Compulsive Disorder in Young Adults
Late onset, according to some researchers, is said to begin from the age of thirteen to twenty-three.6 Young adults are coming into their own. Issues around separation, identity, and sexuality are prominent themes. The stress of going to college, becoming independent and moving away from family, and other events that occur during late teens/early twenties can cause the first episode of those predisposed to OCD, due to the activation of the neurobiological system involved in OCD.
Signs of OCD in young adults may include:
- Sudden need for dependency
- Avoidance of social events, including dating
- Seeming withdrawn and anxious
- Asking repetitive questions for reassurance
- Requests made to accommodate the OCD such as imposing OCD rules in the household
- Incomplete school assignments
Signs of Obsessive-Compulsive Disorder Adults
Adults may experience symptom interference with their family and work obligations. They may have had their obsessions change over time or during a new episode.
Potential signs of OCD in adults include:
- Being late for work
- Work is slow; may not meet deadlines
- Perfectionism
- Trying to have control beyond one’s duties
- Frequent bathroom breaks at work for hand washing
- Over responsibility in the home or workplace
- Missing out on family time
- Needing control and setting OCD rules in the household
Signs of Obsessive-Compulsive Disorder in Seniors
When an elderly person develops OCD symptoms later in life, it could be related to the onset of Alzheimer’s disease or dementia since they also occur in the brain’s frontal lobe. A study reported that elderly men have a decrease in symptoms while females experience an increase of symptoms.7 Very little research has been conducted on elders with OCD, with the exception of hoarding. Symptom presentation appears to be the same across the lifespan.
OCD Types by Gender
With regard to gender, the onset of OCD was found to be earlier in men whose symptom dimensions were harming, sexual, and religious obsessions. Symptom dimensions in women were predominantly harming, contamination/cleaning, and somatic concerns.7
Pregnancy in women with OCD can cause a worsening in severity. Some women develop OCD during pregnancy which may or may not remit after giving birth. New fathers have also experienced similar occurrences of intrusive thoughts of harming the baby as women.
Cultural & Religious Factors
Cultural factors are important to keep in mind since some of what are culturally based norms for some may seem like OCD symptoms to others. Certain beliefs and practices should be understood and therapists must be sensitive not to try to change what are diverse practices of culture and religion. A subtype of OCD, scrupulosity, has religious aspects to the obsessive fears and normal religious practices may be transformed into OCD rituals.
When & How to Get Help With OCD
Whenever the signs of OCD start appearing, even in early childhood, seeking treatment will provide the best outcome for symptom control and quality of life. Psychiatry has come a long way in providing treatments across the lifespan. Remember, how long someone has had OCD and how severe the symptoms are do not affect the effectiveness of treatment.
How OCD Is Treated?
Standard treatments for OCD are behavior therapy and medication. Some may benefit from one or the other while others do best with a combination of both.
Therapy
Behavior therapy, specifically exposure and response prevention (ERP), is the gold-standard psychological treatment for OCD. Studies show that ERP alone is more effective than medication alone. Exposure involves the person facing his or her triggering situation while response prevention consists of the person resisting all ritualistic urges. Consistent practice will result in habituation, which is getting used to the situation.
Other modalities of therapy such as Acceptance and Commitment Therapy and Cognitive Behavioral Therapy are good adjuncts for augmenting ERP or helping reluctant people get ready for ERP treatment. People seeking OCD treatment may learn mindfulness as a coping strategy for managing stress but will not work in getting obsessions under control.
Medication
First line medications commonly prescribed for OCD are selective serotonin reuptake inhibitors (SSRIs).8 Second medications may be prescribed to augment the SSRIs if the symptoms are less responsive, and typically contain dopamine or glutamate.9 Various other agents are also available if the other medications are not sufficient, such as antipsychotics.10
Treatment Timeline
Fortunately, it doesn’t matter how long or how severe an episode of OCD is for treatment to be successful. In many cases, there is an early onset of OCD (age three or earlier)11 and up to age eighteen.12 Early onset may make the course of psychosocial development different from the child’s peers which is why early intervention is so important. An adult with early onset OCD may not have a reference for living without OCD fears and behaviors, although they know that others do not live by the same OCD “rules,” and they can learn to live freely.
How to Find a Therapist
The best resource for finding an OCD therapist is through the International Obsessive Compulsive Disorder Foundation. Another resource is an online directory, where one can filter for a therapist who specializes in OCD and exposure and response prevention (ERP). It is important to understand that cognitive therapy or supportive psychotherapy alone are typically insufficient.
Because OCD has medical parity, treatment is typically covered by health insurance. The Americans with Disability Act protects those with OCD from being discriminated against and can have reasonable accommodations made at work.
Final Thoughts
Although there is no cure for now, OCD is a very treatable problem and fully engaging in treatment will give you a level of control over your symptoms and you can achieve a meaningful and long lasting recovery. Obsessions can change over time which is why the content of obsessions is unimportant. Change can be difficult, but every ritual you resist is an investment in your recovery. Your symptoms and the disorder don’t define you.
For Further Reading
- Helpful OCD Books
- International Obsessive Compulsive Disorder Foundation
- The IOCDF also has a list of support groups for individuals or families
- Parents may also find their kid-friendly videos helpful
- OCD Resource Center
- Not Alone Notes: Support for and by people who feel isolated and lonely living with OCD
- Beyond OCD
- Mental Health America
- National Alliance on Mental Health
- MentalHealth.gov
