OCD stands for Obsessive Compulsive Disorder. It is included under the umbrella category of neurodivergence, which includes autism, ADHD, dyslexia, Tourettes, and a host of other conditions. OCD shows up in obsessive thoughts and repetitive behaviors, both of which are an attempt to cull distress but actually create more distress in the long term. OCD often begins in childhood or during puberty. Onset can also occur during or after pregnancy, or during a major life stress or trauma. It’s one of the hardest mental health issues to fully treat. It is the tenth highest reason for disability in the world!
OCD gets missed for a number of reasons. The first is that there are very distinct stereotypes in the media and our society about what OCD is. People think they don’t have OCD, or a loved one doesn’t have OCD, if they aren’t counting things, tapping, or washing their hands excessively. OCD most commonly gets missed in mental health treatment when the person’s rituals are avoidance or mental rumination, as these are harder to notice by an observer. The second reason is that OCD and Generalized Anxiety Disorder (GAD) present in very similar ways, and most people with OCD also have GAD. OCD gets lost for these reasons and people suffer for years or lifetimes without treatment. Along with treating PTSD, OCD is the second diagnosis of focus in my private practice.
One of the same symptoms in people with anxiety and people with OCD is excessive worry. The big differences? OCD sufferers experience intrusive and unwanted images. These intrusive images may make them feel like a bad person, or may be very upsetting in nature. Intrusive images for people with OCD look like a cinematic masterpiece playing out in their mind; it is incredibly graphic. People with anxiety however, experience fear and worry, but it doesn’t play out in their minds like a movie. OCD also differs from GAD in that people with OCD have rituals and compulsions they use to resolve the worry. Stereotypical OCD rituals include knocking three times on a desk or needing to keep the thermostat at an even number. Less obvious rituals include mental rituals, the invisible symptom of OCD that is easy to miss because you don’t see a person doing it, and the person suffering from OCD may think they are just “thinking” a lot. People with GAD have safety behaviors, things they do to relieve the worry, like planning, list making, and "talking it through" with a loved one. If it's confusing to tell the difference between OCD and GAD it's because they are so similar, and co-occur so often. As OCD Specialist Dr. Jeremy Shuman, PsyD taught me: "when does dough become bread in the oven?" You can't have a definitive moment to say ah yes, this dough is bread now! However, there are very helpful clinical tools like the GAD-7 (for Anxiety) and the YBOCS-II (for OCD) that can determine if the Anxiety or OCD is sub-clinical, mild, moderate, or severe. I do measures both with all of my clients, to make sure we aren't missing anything.
Obsessions vs Compulsions
Obsessions are looping thoughts, impulses, or images that are unwanted and upsetting. Obsessions may include fears of contamination and getting sick; fears of harm (to self and others) with violent intrusive images; a need for symmetry or for things to be exact or perfect; and unacceptable thoughts often rooted in religion, relationships, or existential questions.
Compulsions are repetitive behaviors or mental acts that provide some temporary relief from the obsession, until a new trigger arises. Compulsions include rituals, such as vigilance and washing your hands over and over again; mental rituals such as feeling the need to go over things in your mind again and again (rumination), including praying, or checking lists; reassurance seeking from others or self; and avoidance, including proactive rituals to avoid something bad happening.
OCD is diagnosed when these obsessions and compulsions occupy hours of someone’s day, cause them distress, and when the person has little power or control over them.
OCD follows the same predictable sequence most of the time.There is a trigger that prompts the person to have what is called an obsessional doubt. This doubt has a consequence for their life, which would cause them anxiety. Finally, there is a compulsion that would cull the anxiety temporarily, until another trigger is experienced. It can look like this:
TRIGGER: Intrusive and unwanted violent, sexual, or racist thought or image.
OBSESSIONAL DOUBT: What if I am an evil/harmful/bad etc. person?
CONSEQUENCE OF THE DOUBT: I could hurt someone. People could find out the truth about me. If people thought I was a bad person, I would be alone.
ANXIETY: It would be terrible for to hurt someone! I couldn't live with myself. It would be terrible to be alone.
COMPULSION: Say a "good thought" in my head. Review past events to make sure I never harmed anyone. Ask a friend to reassure me I am good.
So in this example, you can see that the trigger was an intrusive thought. This person's OCD was activated by their own brain, not by an external event. You can see that the compulsions, other than seeking reassurance, also happen inside this person's brain. No one would ever know they have OCD because it doesn't manifest in physical rituals. The person themselves may not even know they have OCD, because they assume they are just "thinking" or really are an evil person. This is one of the most common expressions OCD I see in my work with clients who came to me originally for Anxiety, PTSD, and CPTSD. There is this underlying issue of OCD that no one every caught before.
Generational or Inherited OCD
OCD is one of the mental health issues that is passed genetically. OCD has a heritability rate of 40-50%, much higher than PTSD, anxiety, and depression. Every single time I diagnose a client with OCD, they mention that someone else in their family (or many family members) has it or has “OCD tendencies”.
Heritability is the percentage of gene expression determined by biological familial inheritance. It does not include environmental factors or chance. I can think of so many environmental factors my ancestors were exposed to that would increase the likelihood of developing a disorder like OCD. Religious and political persecution, loss of land and livelihood, threat to life. I understand my family’s OCD as a response to impossible circumstances, passed along (lovingly, I like to think) in attempt to keep us safe in an unpredictable and often dangerous world.
Traumatic Event-triggered OCD
Many people begin to experience their symptoms during a time of change or stress, like puberty or a traumatic event. A traumatic event can make someone’s symptoms skyrocket, but it is not the core reason OCD is there in the first place. The world we live in, with its uncertainty and unsafety for so many of us, doesn’t help those of us who deal with OCD. The pandemic is a great example of this, with so many of us needing to develop rituals around contamination and safety. I have heard from many clients and loved ones with OCD that since COVID their symptoms have worsened dramatically.
OCD is another great example of how the genetic, environmental stress, and trauma can all come together in mental illness. It is as complex as we are! OCD illustrates how the genetic component of mental health influences the ways in which our nervous system tries to keep us safe.
One in four people with PTSD also have OCD. Additionally, OCD and PTSD even have overlapping symptoms. With both mental health issues people experience unwanted thoughts and images, safety behaviors that minimize dysregulation, and avoidance of certain people, places, things that are triggering.
While there are many therapeutic treatments for PTSD, including EMDR and talk therapy, neither are successful for treating OCD. In fact, talk therapy exacerbates OCD, with the sessions ending up being 45-60 min of reassurance, feeding the reassurance-seeking compulsion. With the proper therapy however, OCD treatment is highly effective.
More questions about OCD? Here are some resources to learn more below. I also offer OCD therapy in Missouri and New York states, as well as OCD consultation for clinicians licensed anywhere.
Articles Referenced:
Valentine, Keara. “Here’s the Key Difference between OCD and Anxiety.” NOCD, 6 May 2021, www.treatmyocd.com/blog/is-ocd-a-form-of-anxiety.
Mataix-Cols D, Boman M, Monzani B, et al. Population-based, multigenerational family clustering study of obsessive-compulsive disorder. JAMA Psychiatry. 2013;70(7):709-717. doi:10.1001/jamapsychiatry.2013.3
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