OCD Symptoms, Signs, & What to Watch For

What Is Obsessive Compulsive Disorder (OCD)?

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

OCD compulsions are rituals 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 key 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, like if someone has purely obsessional OCD and performs compulsions mentally. 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.

OCD Obsessive Thoughts

It is thought 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

Contamination OCD is characterized by a fear of spreading germs, getting sick, or getting others sick. There may also be a fear of 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). People with contamination obsessions may also have a fear of pooping.

2. Obsessions About Causing Harm or Making Mistakes

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

“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. Obsessive Thoughts Concerning Sex, Religion, & Violence

Sexual obsessions in OCD 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 Obsessions

Other OCD themes include:

• Superstitious fears related to numbers, dates, words, or colors
• Moral perfectionism (often called 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 (somatic OCD): 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

OCD Compulsions

OCD 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, restore the person’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

Checking 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 it could be 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 that 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

OCD Avoidance

Avoidance behavior (mental or physical) can also be a form of ritual. If someone cannot guarantee that something will go perfectly as planned, they may avoid the entire situation as the lack of control around it will likely trigger other obsessions and intrusive thoughts. Avoidance can be related to a variety of OCD themes, like someone avoiding doctors offices due to their obsessions related to germs or contamination.

The Severity of OCD Symptoms Can Vary

The way people experience OCD symptoms can vary based on severity of symptoms and environmental factors. The Y-BOCS is an assessment clinicians sometimes use to help understand how OCD is impacting a person’s life, which divides OCD into four levels of severity. Questions are centered around categories of obsessions like contamination, religious, or somatic, and types of compulsive responses like checking, ordering, or cleaning.

The severity levels of OCD are:

• Mild OCD: Mild OCD causes minimal issues in someone’s personal and professional life. People with mild OCD are able to function normally in most circumstances, and may only have mild obsessions that they are able to ignore or work around.
• Moderate OCD: In moderate cases of OCD, a person may function normally in some areas of life, such as work or school, while experiencing difficulties in other areas, like family relationships. They may be able to minimize or control compulsions in some areas of life, but in others they may need professional help to recognize and respond to obsessions in a healthier way.
• Severe OCD: In severe cases of OCD, a person may experience tension in their relationships with friends and family, issues at work, and feel controlled by their cycle of obsessions and compulsions. They may need the intervention of medication and therapy to be able to learn how to function normally before losing work and relationships because of their OCD.
• Extreme OCD: Extreme cases majorly impact a person’s relationships, emotions, and work, sometimes to the point of needing hospitalization. Someone with extreme OCD may lose their job, important relationships, and opportunities, and may lack the insight to see how their OCD is causing issues.

OCD Symptoms in Adults Vs. Kids

OCD symptoms in children and adults can feel similar, but they can look differently depending on the age of the child and personality of the adult.

• OCD can be misdiagnosed as ADHD in children⁵
• OCD in children can cause more severe symptoms
• The onset of symptoms in adults is often more sudden and easier to define
• There is a higher likelihood of comorbid mood disorders in adults

OCD Symptoms in Women Vs. Men

OCD symptoms in women and men can present differently, such as differences in the types of obsessions and compulsions commonly experienced, timeline of diagnosis, and types of environmental factors that worsen symptoms.^{6, 7} Women tend to be diagnosed on average later than men. They may also experience shifts in symptoms related to hormonal fluctuations.

Here are some common differences between OCD in women versus men:

• Women may have more contamination, symmetry, and harm obsessions
• Women may have more cleaning, checking, and reassurance seeking compulsions
• Women are generally diagnosed in adolescence or adulthood, while men tend to have diagnoses in childhood
• Symptoms sometimes begin in women during hormonal shifts, such as during puberty, pregnancy, menstrual cycles, or menopause

Outward Signs of OCD

While many symptoms of OCD are internal, if someone suspects that a loved one may have OCD, there are outward signs to look for, including increased avoidance of certain situations, counting or repeating behaviors, or reporting a feeling that things are “not quite right.”

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

OCD Signs 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.

Early signs of OCD in children could 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

Typical Behavior in Children Vs. Childhood OCD

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 rituals or create new ones that become very rigid and rule-based.⁸

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 isolated 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.⁹ As 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 very specific rules in the household
• Incomplete school assignments

OCD Signs in Adults

Adults may experience symptom interference with their family and work obligations. Additionally, as adult responsibilities increase, an individual with OCD may begin to take responsibility due to their OCD for things they cannot control. 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.¹⁰ Very little research has been conducted on older adults with OCD, with the exception of hoarding. Symptom presentation appears to be the same across the lifespan.

Can You Have OCD Obsessions Without Compulsions?

A key factor in the diagnosis of OCD is the presence of both distressing obsessions and compulsions to try to mitigate the anxiety and other negative feelings that come with the intrusive thoughts. However, for some, these compulsions may be internalized and not obvious to most people (or even the person with OCD!). This version of OCD is often referred to as Pure O. Internalized compulsions could include repeated mental checking, or reviewing a past memory over and over.

Keeping Cultural & Religious Factors in Mind

Cultural factors are important to keep in mind, since some cultural norms for one group of people 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 someone’s 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?

OCD is caused by a complex interaction between genetics and the environment. Many family and twin studies contain research which shows OCD is a highly heritable condition.¹

Risk factors for developing OCD include a combination of:

• Biology: According to research on human brain evolution, people with OCD may be using harm-avoidance strategies to extreme degrees.² In other words, the ability to imagine threats and “what-if” scenarios, puts people with OCD at a disadvantage from a biological perspective.²
• Genetics: Research supports findings that OCD runs in families and further, that certain genes may be involved in the presentation of OCD symptoms.¹ One twin study indicated the heritability of OCD symptoms at 65%, meaning that the remaining 35% were left to environmental or other factors.¹¹
• Stressful life events: Stressful life events do not cause OCD by themselves, but they can contribute to symptoms. Stressful life events can trigger symptoms of OCD to surface or worsen for people who are already genetically vulnerable.

What Can Make OCD 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.

Related Mental Health Disorders

OCD can co-occur with other mental health disorders. These disorders can impact those with OCD at a higher rate compared with those who do not struggle with OCD.

Common OCD comorbidities include:

• Depression: Low mood characterized by feelings of withdrawal, low motivation and lack of experiencing joy.
• Eating disorders: Disorders around food intake, weight, body image.
• Generalized anxiety disorder: Anxious thoughts that interfere with day to day living.
• Hoarding disorder: Obsessively keeping and storing items, many of which are a result of attempting to control the environment.
• Suicidal ideation: Thoughts and plans of taking one’s own life.

How to Tell If You Have OCD

Determining if you have OCD can be tricky, because many people have some level of obsessions and compulsions but would not meet the diagnostic criteria for OCD since the severity of their experiences isn’t interfering with their ability to function.

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?

Can OCD Be Prevented?

OCD cannot be prevented, but it can be managed. Many people with diagnosed OCD hope that treatment will help their obsessions disappear. It is important to accept that OCD is often a lifelong condition to manage, and that obsessions do not usually go away, even with treatment.

Rather, you can learn how to deal with the content of obsessions without using unhealthy compulsions to manage your distress. Through repeated efforts and lifestyle changes, you can learn new ways to handle obsessions instead of getting stuck in the obsessive-compulsive cycle.

How Is OCD Diagnosed?

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 OCD 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 to Seek Help for OCD

Whenever the signs of OCD start appearing, even in early childhood, seeking treatment as soon as possible will provide the best outcome for symptom control and quality of life. Psychiatry has come a long way in providing treatments across the lifespan.

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.^5,15 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 “rules,” and they can learn to live freely.

How OCD Is Treated?

Standard treatments for OCD are behavior therapy (usually in the form of exposure and response prevention therapy) and medication. Some may benefit from one or the other while many people do best with a combination of both.

Exposure and Response Prevention (ERP)

ERP for OCD is the gold-standard psychological treatment option. 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 simply means getting used to the situation.

Other modalities of therapy such as acceptance and commitment therapy for OCD and cognitive behavioral therapy for OCD are both good supplementary therapeutic modalities for boosting 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 ultimately learning how to habituate and face fears is the best treatment approach.

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).¹² Other medications may be prescribed to augment the SSRIs if the symptoms are less responsive, and typically contain dopamine or glutamate.¹³ Various other agents are also available if the other medications are not sufficient, such as antipsychotics.¹⁴

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, so finding an OCD specialist through a specific online OCD program like NOCD may also be a great fit for someone looking for an online therapy option.

Because OCD is a diagnosable disorder, 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.