A primer on OCD

The first thing I want to say about OCD is that it is really hard. It attacks quality of life and can lead very quickly to despair. However, once you understand the process of OCD and get some practice responding differently to it, OCD need not get in the way of an excellent life. OCD is treatable, and does not have to define you.

OCD is the presence of obsessions (intrusive thoughts, doubt, urges, images, or sensations that are unwanted and unexpected) alongside compulsions, which are attempts to control or get rid of obsessions. Compulsions are mental behaviors or acts that one feels driven to do and serve the purpose of neutralizing obsessions, reducing distress and/or preventing unwanted events from happening.

OCD is notoriously hard to identify if you aren’t looking for it, and when you suspect it, you may obsessively doubt whether your symptoms are OCD. People with OCD may struggle to see their compulsions as actions they control. Here are a few facts to help you take action in treating your OCD.

  • OCD has one of the longest delays in identification: some estimate an average of 13 years

  • OCD is responsive to treatment but tends to self-reinforce rather than resolve on its own

  • OCD often involves mental compulsions that are invisible to others

  • People commonly find their intrusive thoughts so disturbing that they don’t share them with others

  • People may view obsessions as “bad” character rather than intrusive thoughts or obsessions

  • OCD has common onset periods: ages 7-12 and ages 17-20

  • OCD can also be stressor induced

  • Perinatal OCD can occur with few if any prior symptoms

  • People who develop OCD may have some predisposing characteristics, such as:

    • sensory processing differences, highly sensitive

    • superstitious

    • prone to black-and-white thinking

    • easily startled

    • hyperaware or hyper vigilant

    • experience difficulty making decisions

    • hyperfocus or inertia

    • easily dissociate

    • prefer predictability/order

Image of a little owl hiding behind a plant.

Common OCD Themes

Although OCD can center on any theme, these occur commonly. OCD tends to attach to a client’s values, vulnerabilities or sense of self.

  • Fear that you might do or have done something to harm someone else, when given possibility but no evidence. Compulsions may look like ruminating about interactions, checking if you ran someone over, rewriting emails and texts to ensure nothing offensive was stated. Harm OCD can center around relational harm, sexual harm, offending others, or being physically reckless.

  • Fear of becoming contaminated or contaminating others. Compulsions may look like excessive hand washing, elaborate cleaning rituals, refusing to be around certain family members.

  • Fear that you may be a pedophile despite having no desire to harm children. Compulsions may look like checking body responses, seeking reassurance, or avoiding playgrounds.

  • Fear that your sexual identity is fraudulent, or you will never truly be sure about your sexual identity. Compulsions include excessive googling and reading about sexual identity, avoiding certain people, sensation checking, ruminating.

  • Fear of being a bad person, of going to hell, or of doing something offensive. Fear of not being “good enough.” Preoccupation with degree to which you follow religious creed. Fear and preoccupation about morals, whether or not actions are moral, others’ morals.

  • This type of OCD arises during pregnancy or in the years following. Fear of harming a baby or fetus despite following best practices. Intrusive thoughts of violence despite lack of urge or intention to harm. Compulsions include checking heartbeat and breathing multiple times per night, rumination, avoiding holding the baby, extreme dietary restriction.

  • Fear of making a mistake and the consequences of being caught making a mistake. Fear that mistakes make you a bad person or will lead to horrible consequences. Difficulty stopping a project due to it not being just right, not feeling done. Fear of starting projects due to the possibility that it won’t be perfect.

  • Fear that negative sensations will go on forever. Trying out different positions, clothing, or arrangements until they feel “just right.” Preoccupation with autonomic functions such as breathing, blinking. Comes with intense pressure to right a wrong feeling, leading to often being late or not engaging in activities due to sensations.

  • Preoccupation with past events, what they mean about you as a person, whether or not they were real, what they symbolize or mean about the future. Continuous rumination about the event - the more you engage with material about the event, the more doubt you feel.

  • Preoccupation about whether or not you are in the “right” relationship, or whether or not you are a “good” partner (or have a “good” partner). This preoccupation leads to extensive rumination, testing of partner, reassurance seeking, and research. These acts temporarily resolve anxiety but do not answer the question about the relationship, and so the questions continue to resurface. Unfortunately, preoccupation with the status of the relationship can significantly negatively impact the relationship.

Image is a panorama of a dock overlooking a quiet river on a cloudy day

The obsessive-compulsive cycle

Here is an illustration of the OCD cycle according to ACT and ERP. The arrows show a process that moves from unwanted experience (such as intrusive thought) to fear, via doubt, vulnerability, and negative prediction, to compulsion, to temporary relief, and eventually back to a new obsession or repetition of the old one, because the person remains vulnerable and because compulsions don’t solve underlying problems.

I-CBT Map

This graph is a depiction of the OCD cycle from the inference-based CBT perspective. In this model the emphasis is on the doubt and the doubting process. It views obsessions less as intrusive, and more as a product of a specific thinking process. The components in the ICBT map are trigger —> doubt —> consequence —> anxiety —> copulsion

“feared self” as a “why” of OCD

Why do some people resort to compulsions as a way of responding to fear, while others don’t? Inference based CBT is an evidence-based treatment method developed 30 years ago that centers on concepts of inferential confusion and doubt. This method explains that a strong connection to a feared self makes some people vulnerable to making faulty inferences, which then leads to fear and compulsive attempts to avoid fear. Doubt that they would normally dismiss gets their attention because they are on the look out for risk of becoming a feared version of themself. This leads people to taking doubts seriously despite lack of sensory data. Awareness of the feared self and connection with felt and sensory experience are pathways to resolving OCD.

Here are some examples of feared selves:

  • Being trapped in an unending feeling

  • Being careless or negligent or out of control

  • Being a person who harms others

  • Being defective or “bad”

  • Being destined for suffering or doom

  • Being unlovable

  • Being embarrassed

  • Being duplicitous or having a secret agenda

  • Being prone to ill health or disease

Treating OCD

There are 4 methods that I use to treat OCD. Which methods we use depends on how your OCD is showing up, what other conditions you have, and your preference. While we don’t need to restrict treatment to one method, it can be helpful to try them one at a time.

  1. Exposure and Response Prevention (ERP) - This method is a form of cognitive behavior therapy (CBT) that involves identifying obsessions and compulsions and interrupting the obsession-compulsion cycle. We do this by moving gradually towards fears and practicing skills in place of compulsions. In this method, we create a list of challenges or steps that the client is willing to take (a hierarchy), and pick from the hierarchy to engage in practice. The practice involves doing something to trigger an obsessive thought, and practicing allowing feelings to come and go, rather than reacting to the thoughts and feelings. We move through the hierarchy until a person begins to feel confident that they can experience fear and other emotions without the need for a compulsive response. This method is most effective when the client practices exposure between sessions. ERP is a highly researched evidence based practice. Learn more: IOCDF on ERP

  2. Acceptance and Commitment Therapy (ACT) - ACT is a method of building cognitive flexibility through repeated contact with your felt experience while fully present and resourced. ACT helps you understand your values and move in the direction of priorities by untangling from reactions to your feared or unwanted experiences. ACT is a highly researched evidence based practice. Learn more: ACBS on ACT

  3. Inference-Based CBT (ICBT) - (also see my description above for vulnerable selves). I-CBT is a relatively brief treatment that intervenes at the earliest possible moment in the obsessive-compulsive cycle, the stage of doubt. ICBT helps people connect with their sensory experience in a moment of doubt, and break the spell of compulsive rumination. ICBT is relatively structured and follows 12 modules. ICBT has been researched and practiced since the mid-1990s, with over 100 peer reviewed studies. Although less known and available in the US, I-CBT is a standard of care in France and Canada. Learn more: https://icbt.online/

  4. Skill building, emotionally regulating, and integrating: I use a variety of modalities to support your nervous system. That may look like DBT skills introduction and practice. That may look like building a somatic self-care toolkit. That may include parts work to better understand and integrate your protective and vulnerable parts before requesting change.

Adapting OCD treatment

It is more common than not for a person coming in for OCD treatment to have other needs or complications. For example, untreated OCD can often lead to depression. A portion of people who have OCD also have PTSD or complex trauma, or are presenting with hyper-vigilance due to past events. Many people have both OCD and ADHD or OCD and autism, or all 3. OCD can travel together with low self-worth, self-criticism, and perfectionism, which each merit their own attention. OCD may also co-occur with physical health issues or a disability. When a person realizes they have relationship OCD, they may also have unsolved problems in their relationship that need attention. I think it is crucial that OCD treatment take into account your whole life and your priorities, as well as how you communicate, learn, and socialize. Sometimes people experience their OCD diagnosis as a suggestion that all problems are imaginary, and if you just stop overreacting, everything will be fine. I do not believe that and will not suggest such a thing.

Ways that I adapt OCD for you:

  1. Let you guide our priorities

  2. Make suggestions when a co-occuring issue may be making the treatment harder and get your buy in for different options to address this dilemma

  3. Work with a modality that matches your needs and preferences

  4. Allow for detours from the agenda to help you problem solve or get something off your chest

  5. Get to know your sensory needs and identify accommodations that can help with evocative parts of the therapy

  6. If you have ADHD and are doing a lot of checking, I can support you in discerning between helpful checks and compulsions

OCD-Adjacent conditions

These are conditions I can recognize and support with. Although their co-occurrence with OCD is not extremely frequent, there are elements of each of these conditions that have common factors with OCD. People with OCD may notice they have family members with these conditions. These conditions co-occur frequently with autism and ADHD.

Body Dysmorphic Disorder

Body Dysmorphic disorder is a preoccupation with a specific body part or element of appearance or self that one believes to be defective. The preoccupation with that body part is out of proportion to how others may view it. A person may find themselves centering their thoughts and actions on analyzing, checking, or attempting to correct what they view as a horrible flaw, and this process can end up crowding out other important life activities. It is common for a person with BDD to believe their perspective is inarguable truth, despite others’ voicing different opinions.

Hoarding disorder

Hoarding disorder is when a combination of acquisition of items and difficulty letting go of items that creates distress or impacts a person and/or their family’s ability to conduct day to day activities, including socializing. Acquisition and fear of discarding tends to be fueled by stories, hypotheticals and fears, and may be disconnected from present day needs or sensory information. It is common for people to not register the condition of a cluttered environment for a number of reasons.

Body-focused Repetitive Behaviors

BFRBs are repetitive movements, such a hair pulling, scratching, or skin picking that are done habitually and often without awareness that they are happening. BFRBs are difficult to control or stop, even when a person puts in great effort. BFRBs are powerful habits that function to self-soothe as well as distract from distress or pain. BFRBs can cause damage to the skin, hair, and nails.

Obsessive-Compulsive Personality Disorder

OCPD is a way of interacting with the world and others via preoccupation with order, perfectionism, morality, and control. People with OCPD have difficulty tolerating deviation from their plans and may experience difficulty in their relationships.