What Are the 4 Types of OCD?

What Is OCD?

Obsessive compulsive disorder is a mental health condition where an individual experiences intrusive thoughts, known as obsessions, and performs repetitive behaviors, known as compulsions, in response to these obsessions. People with OCD typically experience a high degree of anxiety when experiencing obsessions and implement compulsions to help reduce the intensity of their distress. Estimates indicate that roughly 2-3% of people in the United States are affected by OCD.¹

OCD can appear at any time throughout childhood to adulthood, however, there are two common time periods where OCD first appears: between 8-12 years old and late adolescence to early adulthood.² OCD can impact both men and women, however a  recent data review has indicated that women are 1.6 times more likely to have OCD than men.³ Family history of OCD and exposure to childhood trauma have been shown to be risk factors for this disorder.⁴

OCD is characterized by:

• Obsessions: Obsessions are recurring, intrusive thoughts that are unwanted and uncontrollable. They typically cause a high amount of distress and anxiety for the person experiencing them when they occur.
• Compulsions: Compulsions are repetitive behaviors that someone with OCD feels driven to do to reduce the distress that obsessions cause. These behaviors can take the form of observable actions others can see or mental compulsions that are unseen.

What Are the 4 Types of OCD?

OCD typically follows a recurring pattern of obsessions and compulsions, however, the theme of these obsessive thoughts and compulsive behaviors can vary. Studies have identified that there are 4 types of OCD that are more commonly seen.⁵ These include contamination, self-doubt, perfection, and forbidden thoughts.

The four types of OCD are:

1. Contamination OCD

Someone with contamination OCD typically has obsessions that focus on the fear of contracting an illness or disease, spreading disease, or being exposed to germs. They may have a fear of feeling unclean or being exposed to bodily fluids, sticky substances, or insects. Fears of contamination can often be divided into two groups: disgust-based or harm-based. Disgust-based fears focus on the discomfort of feeling unclean or dirty, whereas harm-based fears focus on fear of being contaminated by something.⁵

Compulsions in contamination OCD generally focuses on rituals to eliminate feared contaminants or take measures to avoid potential exposure to contamination. The contamination OCD subtype is often portrayed in the media as being most closely associated with OCD. However, research indicates that this subtype accounts for only one-quarter of OCD cases.⁵

Common intrusive thoughts for contamination OCD include:

• What If I touch something contaminated without realizing it?
• What if I spread illness to my loved ones?
• What if I unknowingly bring a contaminant into my home?
• What if I contract a disease from a public space?
• What if I have come into contact with germs and don’t know it?

Common compulsions for contamination OCD include:

• Repetitively washing hands
• Excessive or ritualized showering or bathing
• Avoiding public places or crowded places
• Excessive disinfecting or sterilizing areas of the home or objects
• Getting rid of “contaminated” belongings

2. Self-Doubt and Checking OCD

Individuals with this subtype of OCD typically experience fears related to the possibility of them harming themselves, harming others, or making a mistake due to their own carelessness. Because of the central theme of fear of harm, it has also been called harm OCD. Obsessions can take the form of repetitive thoughts about harm, questioning if you forgot something, or intrusive images that come up in your mind.

Compulsions that are completed in response to these obsessions are usually checking behaviors, such as checking the stove, locks, and windows. Because of this, it is sometimes called checking OCD as well. Research has indicated that individuals in this subtype often have less confidence in their own memories when asked whether they have completed a task.⁵ Another significant research finding has found a positive correlation between checking OCD and experiencing a traumatic event.⁵

Common intrusive thoughts for self-doubt OCD include:

• What If I accidentally hurt someone I love?
• What if I am responsible for something terrible happening?
• What if I accidentally ran someone over while I was driving?
• Intrusive aggressive or violent images
• What if I get fired because I made a mistake?

Common compulsions for self-doubt OCD include:

• Repetitively checking that all the doors are locked
• Checking repeatedly that the stove is off
• Checking that you didn’t unknowingly hit somebody while driving
• Excessively checking your belongings to ensure you didn’t forget an item
• Excessively checking that you did not cause harm to someone

3. Perfection OCD

Those with perfection OCD tend to have obsessions focused on symmetry, exactness, and order. Compulsions such as repetitive rearranging or organizing are typically seen in this subtype. Another type of OCD that falls into this category is known as just right OCD, where compulsions are performed until the “right” feeling is achieved. Obsessions with just right OCD vary and there is usually an overall feeling of incompleteness rather than a specific feared thought.

Research has found that this type of OCD is seen more frequently in men and often develops earlier in life.⁵ Anger has been shown to be more associated with perfection OCD, both expressing anger and suppressing it.⁵ Additionally, studies have found a link between traumatic experiences and this subtype of OCD.⁵

Common intrusive thoughts for perfection OCD include:

• What if something goes wrong because things aren’t perfectly done?
• I need to say just the right thing to this person or they won’t like me
• If I leave that item asymmetrical, my anxiety will never go away
• If I don’t straighten this picture, something terrible will happen
• If these plates aren’t lined up, my significant other may get into an accident

Common compulsions for perfection OCD include:

• Positioning items so that they are evenly spaced
• Repetitively organizing items on a desk
• Excessively rewriting something
• Performing actions evenly on both sides (for example, if someone touches your left shoulder, touching your right shoulder to make it even)
• Lining items up

4. Forbidden Thoughts OCD

Individuals who fall into this subtype have intrusive thoughts that are unwanted and are considered taboo or unacceptable, such as sexual intrusive thoughts. Unwanted sexual thoughts towards children, known as pedophilia OCD, may also occur with this subtype. It’s important to note that individuals with OCD do not want to engage in the behaviors that their thoughts contain. Instead, these thoughts produce a great deal of distress and feel out of control to the individual experiencing them. Many people with this subtype of OCD have a hard time sharing about the content of their obsessive thoughts due to the taboo nature of them and fear of judgment from others for having these thoughts.

Religious obsessions, known as scrupulosity OCD, also fall under this subtype. Compulsions are typically more mental compulsions with this subtype compared to other subtypes,⁶ such as praying or counting. Forbidden thoughts OCD has been shown to be more resistant to treatment compared to other subtypes and more difficult to monitor progress in treatment due to many compulsions being mental compulsions.⁵

Common intrusive thoughts for forbidden thoughts OCD include:

• What if I am sexually attracted to a child?
• I can’t be alone with a child in case I act on my obsession.
• What if I am unfaithful to my significant other?
• What if I committed blasphemy?
• I wasn’t completely honest about something, am I going to hell?

Common compulsions for forbidden thoughts OCD include:

• Avoiding playgrounds so as not to come across children
• Avoiding books, movies, shows that discuss or show sex
• Excessive praying (compared with what would be considered the norm for your religion)
• Thinking a “good” thought to balance out a “bad” thought
• Seeking reassurance from others

Are There More Than 4 Types?

These four subtypes have been consistently identified and replicated throughout studies.^5,6 However, some studies recognize only 3 subtypes—contamination, harm, and symmetry.⁷ Some people may identify with one particular theme within a subtype, such as only having scrupulosity OCD within the forbidden thoughts subtype or having “just right” OCD which falls into the overarching group of perfection OCD.

What Causes OCD?

Multiple factors have been studied as a potential cause for OCD. Genetics appear to play a role, particularly if you have a parent or sibling with OCD.⁴ Environmental factors, such as birth complications and exposure to traumatic events have been explored as risk factors for OCD.⁷ Neuroimaging has also observed differences in the brains of those with OCD.

Causes of OCD include:

• Genetics: Genes have been shown to play a role in OCD, especially if a parent or sibling has it. Protective factors may be able to mediate this, however, and genetics are not the sole cause of having OCD.
• Environmental factors: A variety of environmental factors have been correlated with OCD, such as birth complications, experiencing traumatic events, or experiencing many life stressors all at once.
• Brain differences: Imaging has shown that in individuals with OCD, there are problems in communication between the front part of the brain and deeper structures of the brain. Neurotransmitters such as serotonin, which are involved in sending messages between brain cells, are also impacted in the brains of people with OCD.⁸

Treatment for OCD

OCD treatment typically involves working with a therapist or taking medication. The gold standard treatment for OCD is an exposure therapy known as exposure and response prevention (ERP). This treatment approach has been widely studied as an effective treatment for OCD.⁹ ERP has been shown to be helpful for 7 of 10 individuals with OCD.¹⁰

At times, a provider may also recommend psychiatric medication in combination with therapy to manage symptoms. Obsessive thoughts can produce high distress, which some individuals may choose to manage with medication. Although ERP has been found to be the most effective treatment in research so far, other treatment approaches can also be implemented, such as acceptance and commitment therapy (ACT), mindfulness-based CBT, and EMDR.

Treatment options for OCD include:

• Exposure and response prevention (ERP): This approach involves completing exposures that provoke the feared obsession, without engaging in compulsive behaviors during the exposure. In collaboration with a therapist, an exposure hierarchy is created to guide this process, typically starting with a lower-distress exposure and slowly working up to higher-distress exposures.
• Medications: The type of medication that has been shown to be most effective in managing OCD symptoms are selective-serotonin reuptake inhibitors (SSRIs), also known as antidepressants. Some of the medications found to be helpful for OCD are: Luvox, Prozac, Zoloft, and Paxil.¹¹
• Cognitive behavioral therapy (CBT): CBT focuses on the link between thoughts, feelings, and behaviors. CBT for OCD attempts to break the link between obsessive thoughts and compulsive behaviors that are used to reduce distress caused by these thoughts. ERP also falls under the umbrella of CBT.
• Acceptance and Commitment Therapy (ACT): This approach focuses on psychological flexibility and encourages other ways to respond to distress caused by obsessive thoughts other than engaging in compulsive behaviors. ACT emphasizes letting an obsession pass and choosing a different response aside from a compulsion.
• Mindfulness-based CBT: Mindfulness encourages letting intrusive thoughts come and go, without judgment or the need to act on them. By taking an observational stance to these obsessions, the drive to act on compulsions in response to these thoughts can dissipate.
• EMDR: This approach can be particularly helpful if the onset of OCD symptoms can be traced back to a stressful or traumatic event. EMDR works to desensitize and reprocess prior events that are contributing to present-day distress, therefore decreasing symptoms of OCD.

When to Seek Professional Support

Seeking professional help is key in treating OCD, especially if symptoms have started to increase in severity. OCD symptoms can significantly impact an individual’s ability to perform daily tasks due to the amount of time consumed by engaging in compulsive behaviors or due to the high amount of distress caused by obsessive thoughts. Using an online therapist directory and filtering to find a therapist who specializes in OCD can be a helpful place to start

In My Experience

Obsessive compulsive disorder can be difficult to overcome alone, no matter the subtype. In my experience, I have found that seeking therapy to help with OCD can be highly beneficial to tackle these symptoms. Each subtype of OCD has its own challenges and traits and it’s important to work with a therapist who can thoroughly assess the specific symptoms you’re struggling with. Tackling OCD can be a hard road ahead but can provide much relief in the long run.