OCD (Obsessive Compulsive Disorder)
Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by two core components: obsessions and compulsions. Obsessions are intrusive, unwanted thoughts, images, or urges that get stuck in our minds, often causing significant distress. Compulsions are repetitive, often ritualized behaviors—either physical or mental—that we engage in to reduce that distress or prevent a feared outcome.
OCD can manifest in a surprising variety of ways. Some individuals experience what is sometimes called "Pure O," where they are plagued by unwanted, often morally repulsive thoughts that make them doubt their ability to control their own actions. Others spend hours adjusting minute details in their environment, driven by an elusive sense of a "just right" feeling, struggling to explain what terrible thing they believe might happen if the mugs in the cupboard faced a different direction. It often feels as if people with OCD do many things "just in case" something bad happens, wanting to be absolutely sure they've done their due diligence. Unfortunately, the more we take these unnecessary protective actions, the more convinced we become that such actions are necessary, making it harder to persuade ourselves otherwise.
The Vicious Cycle of OCD
The experience of OCD can be understood as a self-perpetuating cycle. This cycle shows how a distressing thought (obsession) leads to anxiety, which prompts a compulsive behavior, providing only temporary relief. This relief, however, reinforces the belief that the compulsion was necessary, making the next obsession even more potent.
Obsessions: When Thoughts Become Tormentors
In everyday speech, "obsession" often refers to an intense preoccupation, like being "obsessed" with video games or unable to let go of a past relationship. While that implies deep rootedness, OCD obsessions are distinct: they produce profound fear and distress. Imagine being bombarded with terrifying images of your loved ones dying in a car crash, or the horrifying thought of you losing control and assaulting the very people you care about. Or perhaps you're plagued with questions that rip apart your sense of morality, such as, "What if I am a pedophile?" It’s crucial to understand that these questions and images represent the absolute worst fears of the person experiencing them, not their desires. Criminals don't lie awake at night worrying about the possibility of committing a crime; they plan it. A person with OCD, however, develops elaborate plans on how to stop these feared things from happening. They might avoid using knives at dinner, refuse to go out, or pray way in excess of what is usual, desperately hoping not to become the person they dread becoming.
The Universal Nature of Intrusive Thoughts
It's a common misconception that only those with OCD experience unsettling, unwanted thoughts. The truth is, most people without OCD and without criminal tendencies also experience intrusive thoughts, but they are typically able to shrug them away as annoying, fleeting vagaries of the mind. Research has consistently shown that more than 75% of individuals without OCD experience unwanted intrusive thoughts, as identified on the Obsessive Compulsive Inventory (Purdon and Clark, 1999; Belloch, Morillo, Lucero, Cabedo, and Carrió, 2004).The critical difference lies in how these thoughts are interpreted. Persons with OCD often believe that the very fact of having such a thought is indicative of something dreadful about themselves or their future.
Unpacking Unhelpful Beliefs that Keep OCD Going
There are three common assumptions about intrusions that amplify their painful impact:
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"My thoughts reflect my deepest desires or who I truly am." People who have unwanted intrusions related to losing control, committing acts of violence, or suicidal ideation often believe that such thoughts are a window into their true self. Yet, if that were true, shouldn't these thoughts be embraced rather than creating profound fear and self-disgust? The reality is that these thoughts are often ego-dystonic, meaning they clash violently with the person's core values and identity."
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If I imagine something, it's likely to happen." We often plan in our heads, and our plans might acquire vivid details. You might have imagined a vacation to Italy or Singapore, or a quiet retreat in your backyard. Chances are, your imagination helps shape your reality to some extent. However, no matter how vivid our imagination, we know that imagination by itself will not produce that trip to Singapore. On the other hand, we might spend time pacing the kitchen floor, imagining the worst car pile-up possible because our significant other is late, only for them to show up at the door, confused by our distress. Thoughts are mental events. Just because something happens in our minds doesn't mean it will happen in the physical world.
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The Paradox of Thought Suppression: "I must achieve purity of thought." Misguided by this idea, individuals scan the recesses of their minds for thoughts and ideas that "should" be banished. Yet, the more you search, the more you find. The more you try to erase a thought, the more your mind shines a spotlight on it because the very attempt at blocking a thought places it squarely in focus. Just try very hard not to think of a green apple… you probably just did.
Compulsions: The Quest for Certainty and Safety
Compulsions are the behaviors—mental or physical—that people engage in to reduce the distress caused by obsessions, to neutralize a perceived threat, or to achieve that "just right" feeling. One person might drive in circles to reassure herself that she hasn't killed a pedestrian without noticing it. Another might engage in mental undoing or neutralizing, like counting to 100 and apologizing each time an unwanted intrusion appears. Some people have a very strong urge to seek clarity and reassurance; I've seen many who would ask the same question several times in a row, or interrupt me mid-sentence to ask the very question I'm in the process of answering. Others cannot stop themselves from searching for a wallet they're already holding, convinced it's been left at the mall. Someone else might develop a belief that disturbing the sequence of tasks to clean the kitchen will bring disaster to their family, getting stuck in an ever-repeating loop.
Compulsions in OCD generally fall into three categories:
Unnecessary Safety Behaviors:
Actions taken to protect oneself and others from the perceived consequences of obsessions (e.g., excessive checking, avoiding certain objects).
Magical Thinking Rituals:
Behaviors associated with an irrational belief that performing them will prevent a specific negative outcome (e.g., "If I don't wash the faucet seven times, someone will get infected by my germs, and I will be responsible for their death").
"Just Right" Feeling Behaviors:
Repetitive actions that, when interrupted, create a profound sense of "wrongness" or incompleteness, leading to an urge for repetition until a specific feeling of "just right" is achieved, often without a clear, specific thought attached.
Breaking the Cycle: Exposure and Response Prevention (ERP)
Our work begins by building an inventory of the obsessions and compulsions being experienced. We work to understand and challenge the unhelpful beliefs associated with these obsessions and compulsions through cognitive interventions.
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The cornerstone of effective OCD treatment is Exposure and Response Prevention (ERP). This involves gently and systematically putting clients in situations that trigger their urges to engage in compulsions, but then having them refrain from engaging in those behaviors. The goal is to learn that, despite undeniable discomfort, nothing bad happens as a result of not engaging in their typical rituals. Over time, the anxiety naturally decreases, and the brain learns new, healthier associations. This process directly challenges the reinforcement loop of the OCD cycle.
This diagram illustrates the crucial difference: by resisting the compulsion, the individual learns that the anxiety, while uncomfortable, is temporary and will eventually subside on its own, without the need for the ritual (light green arrows). This breaks the cycle and weakens the hold of OCD. By giving in to compulsions, especially at peak anxiety, we fail to habituate, make our compulsions stronger and might even form a belief that compulsions are the only available source of relief (blue arrows). This makes OCD stronger.
Useful Resources
If you or someone you know is struggling with OCD, please know that effective help is available.
The International OCD Foundation (IOCDF) offers detailed descriptions of the many forms OCD can take and provides valuable resources.
Here are some highly recommended self-help books:
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The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioural Therapy by John Hershfield and Tom Corboy.
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Overcoming Harm OCD: Mindfulness and CBT Tools for Coping with Unwanted Violent Thoughts by John Hershfield and Jonathan Grayson.
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Break Free from OCD: Overcoming Obsessive Compulsive Disorder with CBT by Paul Salkovskis.
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Overcoming Obsessive Compulsive Disorder: A self-help guide using cognitive behavioural techniques by David Veale and Rob Willson.
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Overcoming Obsessive Thoughts: How to Gain Control of Your OCD by D. Clark and C. Purdon.
References:
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Belloch, A., Morillo, C., Lucero, M., Cabedo, E., & Carrió, C. (2004). Intrusive thoughts in nonclinical subjects: The role of frequency and unpleasantness on appraisal ratings and control strategies. Clinical Psychology and Psychotherapy, 11, 100-110.
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Purdon, C., & Clark, D.A. (1993). Obsessive intrusive thoughts in nonclinical subjects. Part I. Content and relation with depressive, anxious and obsessional symptoms. Behaviour Research and Therapy, 31, 713-72.