OCD Symptoms, Signs, & What to Watch For

What Is Obsessive Compulsive Disorder (OCD)?

OCD is a neurobiological and heritable disorder (some consider it an evolutionary biological disorder) that affects about 2.5% of the world’s population and is likely underestimated and misdiagnosed.^1,2,3 It is often referred to as the doubting disease. The hallmark of OCD is uncertainty which provokes anxiety. People with OCD experience unwanted intrusive thoughts, images, or impulses that provoke the need to be certain that their thoughts have not caused negative events to occur in reality (call obsessions).

OCD 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.

OCD Symptoms

The cornerstones of OCD symptoms are obsessions and compulsions. In some situations, these could be very evident to the person and others around, while other times, the symptoms could be harder to identify.

In OCD, the obsessions and compulsions take a large amount of time in someone’s day. Obsessions can distract people for long periods, and compulsions could take hours to perform.

Common OCD Obsessions

Evolutionary biologists propose that typical OCD obsessions derive from survival instincts.² There are many different types of OCD obsessions 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

Contamination OCD 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

Harm OCD 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). This is also seen in Symmetry OCD.

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 (scrupulosity OCD)
• Indecision or fear of making mistakes
• Relationship OCD 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.

Rituals

Compulsive rituals are behaviors or a series of behaviors a person does to counteract the obsession. The rituals may be until they “feel right” or achieve some other goals.

Examples of OCD rituals are endless and include:

• Turning lights off and on
• Organizing or lining up objects
• Touching items in a certain way or order
• Completing a certain routine before leaving the house
• Eating specific foods in a specific way
• Avoiding cracks in the sidewalks

Checking

These compulsions involve checking and rechecking certain items to, usually to ensure a sense of safety. Checking compulsions can consume expansive amounts of time.

Examples of OCD checking include:

• Making sure the stove is off
• Making sure the doors and windows are locked at home or on cars
• Checking on loved ones
• Making sure the water isn’t running
• Making sure food is still fresh in the refrigerator
• Checking on pets to make sure they have food and water

Correcting Thoughts

Correcting thoughts can be a form of mental compulsion. Rather than engaging in an outward behavior, these compulsions are invisible.

Examples of correcting thoughts include:

• Counting
• Reciting words or phrases
• Repeating instructions or directions
• Repeating thoughts in situations, like crossing the road or getting in the car

Seeking Reassurance

Often, compulsions only involve the person with OCD, but seeking reassurance works to bring another person or several people into the routine. Seeking reassurance could be linked to other compulsions or a stand alone compulsion. For example, asking someone if they think the house is safe after already checking the doors many times.

Other examples of seeking reassurance in OCD include:

• Asking for compliments
• Asking for confirmation a situation is safe
• Seeking reassurance that they are a nice, smart, or kind person
• Wanting confirmation that hands, house, or foods are safe and clean

Outward 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

Avoidance as a Sign of OCD

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.

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 OCD in Teens & 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 teens 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 OCD in 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 OCD 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.

Keeping Cultural & Religious Factors in Mind

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.

What Causes OCD to Get Worse?

A number of personal and environmental factors can cause OCD to get worse. If someone experiences new stress, trauma, or anxiety, these issues can exacerbate pre-existing OCD. Other times, OCD can make OCD worse. The condition tends to reinforce itself, so the more someone performs compulsions the more they feel the need to do so in the future. Without intervention, OCD may become much worse over time.

Do I Have OCD?

Determining if you have OCD can be tricky, because all people have some level of obsessions and compulsions.

To determine if you could have OCD, ask yourself:

• What are my obsessions?
• What are my compulsions?
• How long have they been present?
• Are they getting better or worse?
• How much time do they take out of my day?
• Are they making daily routines hard to accomplish?
• Could there be another explanation for these issues?

Getting an OCD Diagnosis

Looking into your symptoms is always helpful, but only a mental health or medical health professional has the education and experience to make an official diagnosis. You can begin by talking to your doctor or therapist about your symptoms and concerns. From there, they could ask a series of questions or offer you a rating scale to measure the degree of your OCD symptoms. Even if you don’t have OCD, you could have anxiety or a related condition that causes distress. The professional can help.

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

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.

It’s crucial that someone seeking therapy for OCD finds a specialist who is trained in ERP and has experience treating clients with OCD.

Medication

First line medications 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) and up to age eighteen.^{11, 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 therapist 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.