OCD, Obsessive Compulsive Disorder. Introduction
An obsessive-compulsive disorder is a mental condition characterized by recurring unwanted thoughts (obsessions) and compulsive behaviors. Most people are familiar with compulsive thoughts or actions, like checking if the door is locked, even when they know it is. The condition will be classified as a disorder when such behaviors repeat constantly, causing suffering or disrupting daily life.
OCD generally includes obsessive thoughts and compulsive actions. Obsessive thoughts are ideas or impulses that the person recognizes as irrational but can’t stop. They often trigger feelings of anxiety, discomfort, or disgust.
Compulsive actions are urged repetitive behaviors, even if people realize they are unnecessary or exaggerated. Patients are usually aware that their behavior is irrational, although this awareness varies between individuals and situations. A small percentage of patients, especially children, may have little or no insight into the exaggeration of their behavior.
After years of living with OCD, the compulsions can become so ingrained in life that the sense of their irrationality fades.
Symptoms of obsessive-compulsive disorders
Both obsessive thoughts and compulsive actions are leading symptoms of OCD. Obsessive thoughts are repetitive, unpleasant, and unwanted mental intrusions. They constantly invade consciousness and are often distressing and hard to suppress voluntarily.
Common obsessions include fear of germs, infections, or forgetting something important. Some people fear they might harm themselves or others or sexually harass someone. Having such thoughts doesn’t mean the person will act on them.
People with a fear of dirt or germs may repeatedly wash their hands or sanitize them. Those with order compulsions have strict ideas about how things must be arranged. Any deviation from this order makes them anxious and uncomfortable.
People with ordering compulsions believe that objects on desks, shelves, or around the house must be placed in specific spots and orientations. If this isn’t the case, they become restless, and the unease escalates into anxiety if the ritual—such as arranging items “correctly”—isn’t followed.
Hoarders can’t throw things away, even garbage, causing significant clutter. Counting compulsions involve repeatedly counting to find temporary relief.
Compulsive actions often evolve in complex rituals. Performing such rituals, individuals reduce the anxiety and restore a sense of safety. For example, people with washing or cleaning compulsions fear dirt and disease transmission, leading them to constantly wash their hands or clean the house.
Many people with obsessive thoughts and compulsions recognize them as excessive, irrational, and “not belonging to themselves.” However, they cannot stop these thoughts or actions by willpower. This leads to feelings of helplessness, which intensifies their anxiety.
Causes of Obsessive Compulsive Disorder
There are likely many reasons why people develop OCD. Genetic, psychological, and external factors probably work together. Stressful life events can occasionally cause OCD. Some individuals with OCD experienced childhood trauma, such as abuse or a sudden family death. Certain personality traits, like high responsibility and conscientiousness, may contribute. Individuals with OCD have often relatives with the same condition.
Biological factors
Genetics may predispose to developing Obsessive Compulsive Disorders. Relatives of those with OCD have several times higher risk. This genetic influence may be stronger for obsessions or early-onset of the condition.
OCD is linked to over activity in certain brain circuits, affecting impulse control. Neurotransmitter imbalances, particularly serotonin and noradrenaline, are involved in this process. This explains the effectiveness of antidepressants influencing both neurotransmitters.
Psychological factors
Personality traits, stressful life events and experiences, are also important in OCD development. Common childhood experiences include high expectations, strictness, and overprotective parenting that can lead to perfectionism, high standards, and responsibility and facilitate the onset of the condition.
The onset of OCD symptoms often coincides with stressful life transitions such as starting a career, retirement, or divorce.
The vicious cycle of OCD
There are several reasons why OCD persists. The explanation is that the factors triggering the OCD are still present because of the self-reinforcing vicious cycle.
Intrusive thoughts during compulsions maintain the cycle. Intrusive thoughts (e.g., “Is the stove off?”) are normal for many people. The problem arises when these thoughts are given dangerous, exaggerated meaning. This interpretation causes anxiety, leading to a strong urge to act, checking again and again if the stove is off.
Following the compulsion temporarily relieves anxiety but reinforces the thought’s strength. For example, checking if the stove is off gives relief but strengthens the fear of danger. This creates a vicious cycle that must be broken during treatment.
Aggressive or sexually intrusive thoughts often create similar vicious cycles. For example, “I could hurt my partner” may be interpreted as a real threat. The individual tries to avoid the thought or neutralize it with opposing thoughts.
Other compulsions, like mental rituals, for example, reciting a poem or counting, follow the same path, reducing anxiety. However, following the compulsions to anxiety, they amplify the thoughts, making them more frequent and intrusive.
Other factors maintaining the vicious cycles are the co-occurrence of psychiatric disorders, for example, anxiety, depression, exposure to stress, and lack of sleep.
This shows that OCD treatment must address deeper issues, not just the symptoms. A biographical analysis with a therapist and addressing the root causes helps to dissolve the symptoms.
Frequency of OCD in General Population
Obsessive-compulsive disorders are relatively common. About 2-3% of the population will experience OCD at some point, making it the fourth most common mental illness. Symptoms often appear in childhood or adolescence, with noticeable peaks at ages 12-14 and 20-22. For 85% of patients, the disorder begins before age 30, and men typically develop it 5 years earlier than women. In childhood, boys are slightly more affected than girls (3:2), but by adolescence, men and women are affected equally.
Diagnosis of OCD
Obsessive-Compulsive Disorder can sometimes be difficult to distinguish from other disorders with similar symptoms. For example, constant worries about the future might also indicate generalized anxiety disorder. OCD also frequently coexists with depression.
An OCD diagnosis requires symptoms for at least two weeks on most days. Compulsions must also significantly affect individual’s daily life. For a reliable diagnosis, it’s best to first consult a psychiatrists or psychologist. During the consultation, specific questions will be asked about the nature of obsessive thoughts and compulsive actions, such as:
- Do certain thoughts or images repeatedly appear and the person can’t dismiss them?
- How the affected individuals deal with the thoughts, images or action to control them?
- Does a person feel that the actions are irrational or excessive?
- Do individuals have a feeling to be forced to repeat certain actions against their will?
Course of OCD
Obsessive-Compulsive Disorder doesn’t develop overnight. It usually takes a long time to recognize this condition. At first, the obsessive-compulsive behaviors may not seem unusual to those affected. However, over time, they will realize how much time their reciprocal thoughts or rituals consume.
For some individuals, OCD begins in early adolescence and follows a chronic or fluctuating course. The progression of OCD varies individually. Symptoms may decrease temporarily, then worsen again.
Obsessive-Compulsive Disorder often leads to problems in work, family, or relationships. Without treatment, around 40% of adolescents improve after five years; however, in the remaining 60% of untreated individuals, OCD can become chronic.
Treatment of OCD
Obsessive-Compulsive Disorder can be cured if the condition is recognized and treated in early stage. In general, people with OCD need long-term treatment to suppress the symptoms. A successful treatment allows people to return to normal life with little or no symptoms.
An effective treatment method for OCD is the use of medication, especially antidepressants, such as SSRIs (selective serotonin reuptake inhibitors), or SNRIs (selective serotonin norepinephrine reuptake inhibitors.)
Relaxation techniques, like meditation or breathing exercises, support recovery.
The most frequently used psychotherapy in therapy of OCD is CBT (Cognitive behavioral therapy.)
However, combining medication and psychotherapy can result in the highest rate of symptom reduction or even a full recovery.
Living with OCD
Obsessions are distressing and can be very time-consuming. They may take over to the point where normal daily life becomes impossible. People with OCD often feel ashamed of their thoughts or behaviors. They try to hide their compulsions, as they might be confusing to others, which is exhausting.
Many hesitate to seek help or talk about their problem. Some fear being labeled “mentally ill” and worry about the impact on their job or family.
OCD also challenges families and leads to conflicts. Relatives may feel pressured to follow the compulsions themselves to avoid upsetting or scaring the sufferer, such as maintaining a specific order.
Parents often feel guilty, thinking they should have noticed their child’s problem sooner. But it’s normal for OCD to go unnoticed for a long time, especially since sufferers often try to hide their symptoms. Others with OCD might reject any form of help.
Family members are important support system. Living with the person affected, as they understand the disorder better than outsiders. When included in treatment, they play an important role in the process of recovery.
Forms of OCD
Many mental and physical illnesses share similar symptoms across patients. For example, panic disorders often cause heart palpitations, shortness of breath, and fear of losing control. In OCD, however, the variations between different forms can be vast. What unite people suffering from OCD are the uncontrollable thoughts and impulses. The number of symptoms also varies; some people have one compulsion, others face several.
Cleaning and Washing Compulsions
The most common forms of compulsions are cleaning and washing. Those affected feel intense fear or disgust toward dirt, bacteria, viruses, or bodily fluids. Public restrooms or garbage trigger severe contamination fears. These fears arise even without direct contact with the feared objects.
Thoughts like “My hands are still dirty” dominate.
This discomfort leads to excessive washing and cleaning rituals. Hands, the body, the house, or contaminated objects might be cleaned for hours. Ironically, excessive washing damages the skin, making infection even more likely.
The rituals are strict; if interrupted, they must start over. In some cases, washing might be used as a ritual to prevent misfortune or bad events.
To avoid compulsions, sufferers avoid situations they see as threatening. This leads to progressing social withdrawal and, over time, to full isolation.
Checking Compulsions
The second-largest group of OCD involves checking compulsions. People affected fear they’ll cause damage or catastrophe if through carelessness or neglect. They worry about fires from an unchecked stove or robbery through unlocked doors. Thus, they repeatedly check household appliances, doors, and windows. Even after repeated checks, they never feel fully reassured. They know that they checked the locked door several times but doubt their perception and repeat their actions again and again.
In extreme cases, individuals with OCD can spend hours checking without moving from the spot. The time-consuming procedures make the fulfilment of their social or professional obligations stressful and difficult, sometimes even impossible. At work, they also might repeatedly check routine tasks for mistakes out of fear.
Repetition and Counting Compulsions
The so-called repetition compulsions force people to repeat different actions a specific number of times. In counting compulsions, individuals feel the need to repeatedly count things, like books on a shelf, paving stones, or bathroom tiles. Until the required number is reached, they feel uncomfortable and tense. If they don’t follow their rules, they fear something bad might happen to themselves or someone they love. They don’t know why they must do this, but they feel rising anxiety if they stop the action.
Hoarding compulsions
Hoarders fear throwing away something valuable or important. They find it hard to distinguish between sentimental items and worthless trash. As a result, their homes fill with scrap paper, old newspapers, empty bottles, and broken furniture. In extreme cases, they even hoard garbage inside their homes or on the balcony. Many also collect discarded items like old car parts or broken appliances, hoping to fix them “someday.”
In recent times, media have increasingly reported on so-called “messies,” who suffer from “neglect syndrome.” Many of them also struggle with hoarding compulsions.
Subtypes of Obsessive-Compulsive Disorder
Many people associate OCD with washing and checking compulsions, imagining excessive handwashing or repeatedly checking the door to ensure it’s locked. These are indeed the most common forms of OCD. However, there are other forms that may not be immediately recognized as OCD.
Doubt-OCD
Doubt, which underlies all obsessions, is the primary feature here, focusing on everyday, seemingly obvious things: Are my socks really identical? Is this really my apartment behind the locked door?
Existential-OCD (also Philosophical-OCD)
Some OCD individuals develop obsessive, emotionally distressing thoughts focusing on existential topics. Unlike freely contemplating these issues, these questions are intrusive, uncontrollable, and cause anxiety. Questions like “Are we living in a matrix?” often arise. Thy constant overthinking about existence, reality, and the meaning of life, where no definitive answers exist. This form of OCD was described already over 100 years ago as “obsessional rumination.”
False Memory-OCD
The fear of having committed a terrible act without remembering it: theft, insult, injury, or murder. Compulsions involve mentally reconstructing events that never happened, fueled by doubts like, “What if something happened and I just can’t remember?”
Harm-OCD
Intrusive, aggressive thoughts with fears of harming others, often loved ones like children, parents, partners, or even oneself (Suicidal-OCD). These thoughts oppose the person’s true values and are experienced as unwanted. Such thoughts indicate OCD, not actual violent tendencies, and the individuals will never act upon them.
Hit-and-Run-OCD
The fear of hitting or running over someone without noticing it. Sufferers often can’t ease their obsessive doubts and feel compelled to drive the route again, checking for signs of an accident. Only then may they feel relief—or doubt resurfaces, and the route is driven a second or third time.
Hyperawareness-OCD
A distressing, constant overawareness of automatic bodily functions like swallowing, breathing, or blinking, or harmless phenomena like eye floaters. The fear often stems from thinking they might suffer from this awareness forever, greatly reducing their quality of life.
Just-Right-OCD
A strong urge for things to feel “just right,” especially in control, order, and symmetry obsessions. Instead of anxiety, sufferers feel unbearable tension, feeling something isn’t “right” yet. They strive to achieve a sense of correctness. Checking, arranging objects, combing hair, or adjusting clothing is repeated until it feels “right.” Pierre Janet, a French psychiatrist, first described this OCD-related phenomenon in 1903.
Meta-OCD
This term describes obsessive doubt that can even apply to the OCD itself. Particularly with aggressive or sexual obsessions, sufferers question whether it’s truly OCD or evidence of real aggressive or deviant intentions.
Sexual Orientation-OCD (SO-OCD) / Homosexual-OCD (H-OCD)
Intrusive, unwanted thoughts about having a different sexual orientation than lived, without real evidence. Heterosexual individuals fear being homosexual, while homosexual individuals may fear being heterosexual. Other forms, like bisexual, transgender, asexual, or having some kind of perversion concern, are possible.
Relationship-OCD
Obsessive doubt about an important relationship, often a partnership. Sufferers constantly question if the relationship is “truly” real or strong enough, despite no real reason for concern.
Schizophrenia-OCD
The fear of developing psychosis, similar to health-related hypochondriac fears. Instead of focusing on physical symptoms, sufferers search for signs of schizophrenia: “Did I hear a voice?” or “Did the wall slightly move?”
Suicidal-OCD
A subtype of aggressive obsessions involving intrusive thoughts of killing oneself, even without the intent to do so.
OCD, Obsessive-Compulsive Disorder. Summary
Obsessive-Compulsive Disorder manifests through obsessive thoughts and compulsive actions. Common obsessions include fears of forgetting something or becoming infected. Compulsive actions are rituals performed repeatedly. These rituals aim to reduce the distress from obsessive thoughts and restore calm. However, the relief is only temporary, and repetition of compulsive actions solidifies the illness, leading to its farther progress.
People with OCD recognize their thoughts and actions as irrational and exaggerated. However, they cannot stop them willingly, which intensifies their anxiety.
The root causes of OCD are related to multiple factors such as genetics, psychological factors, upbringing circumstances, and external events. Certain personality traits may also contribute to its onset.
The condition develops gradually over time. Many people with OCD slowly realize that their rituals consume more time and energy. The progression of OCD varies individually. Symptoms may decrease temporarily, then worsen again. Some experience symptom-free weeks or months. Also, the nature of compulsions may change over time.
Advanced OCD causes problems at work, in social life, and in partnerships. For some, the illness eventually dominates their entire life, leading to full invalidism. Therefore, crucial for effective OCD management is an early diagnosis and professional treatment by experienced psychiatrists and psychologists.