The real ocd : it's more than hand washing

OCD is a term often used in our culture in a light-hearted way for someone who is neat, organized, or quirky. People often refer to themselves or others in this way, just because they like their desk area in the office neat, or like to keep items in the pantry in an organized way. The term "OCD" has become commonplace in our everyday language, but these little personal preferences or sometimes idiosyncrasies have little or nothing to do with a sometimes debilitating diagnosis called Obsessive Compulsive Disorder (OCD). It is the purpose of this article to discuss what the "Real OCD" is really about, and the different types of symptoms that people may have.

Many think about OCD from characters from television or the movies. Classics are Bob from What About Bob, the character Monk from the television show of the same name, or Melvin Udall from the film As Good as It Gets. While these characters are entertaining and give us a glimpse at OCD from a humorous side, they are still very much a stereotypic in the way the people view OCD symptoms.

The REAL OCD may involve much more than hand washing or checking, and those afflicted with OCD know this to be a great misrepresentation of what the REAL OCD is all about.

Let’s Look at Some Facts

The REAL OCD affects up to six million adults in the United Sates at some point in their lives, and one third of those began to experience OCD symptoms in childhood. OCD impairs an individual’s quality of life, invades peace of mind, and consumes a great deal of time. It creates an immense amount of anxiety, fears, doubts, uncertainty, body symptoms, intrusive thoughts, ruminations, rituals, repetitions, reassurance-seeking, and avoidances. Unfortunately it is often times misunderstood, and often leads individuals to feel a great deal of anguish. Yet with the proper diagnosis and the correct form of treatment, there is hope – OCD is treatable with cognitive therapy.

Two Components

OCD has two components: obsessions and compulsions. Obsessions are unwanted and reoccurring thoughts, impulses and images, which cause significant distress and trigger heightened emotions including anxiety, disgust, guilt, and doubt. Compulsions are behaviors (rituals) or thoughts (mental rituals) that a person will use in attempt to neutralize, un-do, or prevent danger associated with the obsession. The compulsions are essentially ineffective, in that they keep the cycle going, actually contributing to the problem. OCD is time consuming, exhausting, and interferes with an individual’s quality of life.

Forms of the REAL OCD

OCD may take very specific forms, but can also vary from person to person. Common themes include feelings of over-responsibility, intolerance of uncertainty, over importance of thoughts, and a need to control or get rid of thoughts. Common obsessions include: contamination, germs, losing control, going crazy, harm to others or self, unwanted sexual or immoral thoughts, superstitious thoughts, and religious obsessions. Compulsions may involve checking, arranging, confessing, asking for reassurance, washing, repeating, tapping, blinking, counting, changing thoughts, replacing words, saving things, and repeating something until it "feels" right. The person may also avoid situations or triggers, or try to get family or friends to cooperate in the activity or ritual for them.

From the on-line community arose different titles from specific types of OCD. Some of these are MVA-OCD (relating to motor vehicle accidents), POCD (worrisome intrusions about being a pedophile); HOCD (worrisome intrusions about sexual orientation); HARM-OCD (relating to fears of people being hurt); ROCD (relating to relationship); and on and on.

As with all OCD forms, the rituals or responses can vary from tapping to counting to body tensing or some very personalized and specific ritual like thinking about a neutral item or having a neutral thought. Therefore, we will not go into the specific ways that people neutralize or ritualize. Instead, we will now take a look at some of these forms of OCD.

Contamination OCD

This form of OCD is one that may be familiar to people in general. It may involve avoidance of triggers, or a need to ritualize after coming into contact with various triggers. Some triggers may include garbage, household chemicals, phones, objects used by others, pets or even some people, things that are deemed dirty, things that are sticky, surfaces that people have touched, and fear of coming into contact with bodily secretions or blood. The fear may be coming into contact with germs or something that will get someone sick. It may be having a disgust feeling, or a variety of consequences such as getting someone else sick.

Harm OCD

Harm OCD has at its core themes of harm to self or others. The person may have a violent image or scary thought that pops into his or her head. There may be a fear of acting on this "pop up" to harm oneself or someone else. Sometimes it is a thought that something terrible will happen to a loved one because or the "pop up" image or thought. It may be that the person is triggered by an object such as seeing a knife and may worry and obsessive that they might lose their mind and become a murderer. At times people worry about someone they love becoming ill or having harm befall them, and so they ritualize to try to prevent it or to get rid of thoughts.

Embarrassing Thoughts OCD

This OCD type involves a fear of doing something in public that will be embarrassing. Sometimes it overlaps with other conditions such as social phobia. Here there is a fear of blurting out obscenities or insults, a fear of hurting someone’s feelings, or it can be a preoccupation with vomiting, burping or flatulence. Again rituals, neutralizing and/or avoidance are performed.

Losing Control or Going Crazy OCD

This is generally a category in which people feel that there is something seriously wrong with them and that their symptoms can be accounted for by other distressing conditions. Again, the content of the thoughts have nothing to do with the reality, but there is a pervasive doubt that something more serious is going on. Often this doubt persists, in spite of evidence and diagnosis of OCD by a professional. Themes include worries that the person might have schizophrenia, multiple personalities, becoming a serial killer, or losing their will and doing things that violate social norms or their value system.

MVA: Motor Vehicle Accident OCD

Also known as "hit and run OCE," this type is one in which people obsess about involved in a possible hit and run without realizing it. The fear is that they may have caused this event, and they worry that didn’t realize or they don’t recall it happening. The fear also includes being caught, arrested and thrown into prison, and that they will find themselves as a headline in the newspapers and, as a result, suffer public humiliation. Rituals can be many, but might include avoidance, checking the car, or checking for bodies at a particular scene, or checking for news stories in the local papers.

Feel Right OCD

This is a type in which people are under the assumption that, unless they do a specific ritual or routine, or unless they avoid a specific trigger, they will continue to have an uncomfortable feeling. They assume that the feeling will continue to bother them, and they will not "feel right" until they neutralize or avoid it. Predictions of the feeling not going away or increasing in distress, as well as thoughts about not being able to focus on tasks occur.

Prenatal or Postpartum OCD

This form of OCD occurs prior to giving birth or in the weeks that follow. The person may have thoughts or images that they will not be able to handle being a parent or they have scary obsessions about harm befalling the newborn infant. They worry about dropping the baby or doing something else that will harm the baby. Differential diagnosis excludes post-partum depression. The disorders are very different. In the case of prenatal or post-partum OCD, people often have thoughts and rituals that are quite similar to Harm-OCD.

Magical Thinking

This can occur across OCD types. It is the worry that, because a person has a thought, something bad is likely to occur. This is called thought-action fusion. An example might be that a person has a thought about doing something harmful, then the person thinks it might occur if they don’t ritualize. Object-action fusion occurs when the presence of an object triggers a worry about something occurring. For example, a person sees an object like a cleanser and worries that thye will put the cleanser in the meal. Emotion-action fusion is a variant on these and occurs when the person has an emotion such as anger or sadness, and they obsess about an action or event that may ensue because of the feeling.

Religious OCD or Scrupulosity

This OCD type involves confusion over religious matters, sin or consequences of sin such as eternal damnation. People may have bad thought in a religious building or while praying. They may have intrusive images about God or religious figures. They may worry that prayers are being done incorrectly. In some cases, religious objects need to be touched or kissed repeatedly. Catholics may repeatedly go to Confession. There are worries about being forgiven, doing things that may offend God, and having thoughts that are not proper. Sometimes there are distorted views about actual teachings of major religions or distortions of the image of God, such as a God who is out to get them.

Moral OCD

This tends to be similar to scrupulosity, but does not have anything necessarily to do with a particular religion. People may have worries about violations of ethical standards, law or higher principles. For example, a person may worry that they said or offending someone, and that they may be viewed as being prejudiced or in fact secretly be prejudiced. They ritualize or avoid triggers as a result.

ROCD

This is a term that developed from the on-line community referring to OCD that has its content in relationships. It involves uncertainty or doubt about one’s partner or the relationship. The person over-analyzes details, emotions, and actions, thereby questioning the relationship. Sometimes the over-analyzing leads to focus on some defect or finding fault with the other, or worries about faithfulness, or being loved, or if they in fact love the person. There may be a need for reassurance and checking, or obtaining approval. Sometimes there are questions about being attracted to others, among those whom the person finds to be inappropriate. Sometimes there are doubts about the partner’s being faithful, or if the person has an absence of feelings for the person whom they love. This type of OCD is also referred to as relationship-substantiation OCD.

HOCD

Homosexual OCD is another term that developed from the on-line community. It refers to unwanted thoughts about being gay or of a sexual orientation that that person does not desire to be. The person with HOCD can be either straight or gay, but has intrusive thoughts that are of a different orientation. For the straight HOCD patient, there are fears of being or becoming homosexual, there is great distress and rituals that involve checking, mental rituals, rumination, and avoidances.

POCD

This arose out of the online community as an abbreviation for pedophile OCD. Again, this is a form of OCD in which the person has intrusive thoughts and fears that he or she might secretly be a pedophile. Fears of being attracted to children emerge, and the person is disgusted by such thoughts. The person then reasons that is unnatural to have such thoughts pop into one’s head. They begin to obsess, thoughts increase, and they perform compulsions, mental rituals, and engage in avoidance.

Somatosensory OCD

This form of OCD is also called body-focused obsessions, sensorimotor obsessions or somatosensory obsessions. Those affected become aware and focused on autonomic processes, such as blinking, breathing, hand movements, eye gaze, swallowing, etc. They find themselves acutely and frustratingly aware of their own bodily sensations and feel that they cannot stop thinking about these sensations and the way they are doing them. They worry that this will consume them, take them off focus or it will make them vulnerable. They ritualize, compare, or try to stop thinking about it, increasing the focus on the symptoms.

Lucky/ Unlucky Number & Good or Bad Colors OCD

These OCD types are very much linked to magical thinking. The person worries that certain numbers or colors will bring about harm, so they try to avoid the number or colors or have to neutralize when they come up.

Symmetry OCD

This occurs when the patient has a need to do things or place objects in a balanced fashion. For example if there is a tap to the right elbow, the person must also tap the left. Arranging and ordering things in a symmetrical fashion is the intention. There is often considerable overlap with harm OCD, magical thinking and feel right.

Perfectionism OCD

This is a type of OCD and can sometimes be linked to a person’s personality. The intention is to do something completely or perfectly. The person can do things again and again in a certain way, and may pay particular attention to minute details while losing the scope of the entire task.

OCDRD or OCD Related Disorders

This is a new category of OCD disorders that includes hoarding, body dysmorphic disorder, psychogenic excoriation or dermatillomania (skin picking), trichotillomania (hair pulling), tics, and other similar things. While illness anxiety is in a different category, it does have some clinical overlap with OCDRD.

Final Thoughts

OCD takes many forms, and obsessions and compulsions vary from person to person. Certainly OCD is more than just a quirky habits, preferences or hand washing rituals. While terms such as ROCD, HOCD and POCD have arisen from patients, especially in the online community, the actual diagnosis is in fact OCD. There are certain pros and cons for using categories of this sort. However, awareness of the types can help to inform and to destigmatize people.

Increased knowledge about OCD may help people to get diagnosed and properly treated. Research has shown that the average person has wasted nine years from onset of symptoms of OCD to getting an accurate diagnosis. We know OCD can be effectively treated. Exposure and response prevention (ERP) and medication lead the way to getting people to feel well again.

Dr. Constance Salhany is the author of this article on Obsessive Compulsive Disorder. Find more information, about Cognitive Therapy here