Obsessive-Compulsive Disorder (OCD)

Often misunderstood

There is a common misconception that obsessive-compulsive disorder (OCD) is just a personality quirk, idiosyncrasy, or preference and that everyone is “a bit OCD.” In reality, OCD is a real mental health disorder. It is often debilitating and affects people of all ages and backgrounds, with women 1.6 times more likely to have it. It occurs when a person gets caught in obsessive thoughts and compulsive behaviors, that are distressing and feel outside of their control.

Obsessive-Compulsive Disorder Criteria (DSM-5-TR)

OCD is characterized by the presence of Obsessions or Compulsions (most of the times both) that are time-consuming; one hour or more/day or cause clinically significant distress or impairment in work, relationships, other important functioning such as self-care (DSM-5-TR).

Obsessions defined by:

1. Recurrent and persistent thoughts/urges/ impulses (sometimes images) that are experienced as intrusive and unwanted and, in most individuals, cause marked anxiety or distress.
2. The individual attempts to ignore, suppress, or neutralize them with some other thought or action (i.e., by performing a compulsion).

Obsessions can seem nonsensical, weird/superstitious, and/or inconsistent with your values and personality. They come in a variety of themes; see below for the most common ones.

Compulsions are defined by:

1. Repetitive behaviors or mental acts the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Important:

Most people experience both obsessions and compulsions, but not all.

• OCD expert Dr. Jonathan Grayson says, “Intolerance of uncertainty is the root of OCD.”
• Author, therapist, and OCD sufferer Shala Nicely writes, “Dr. Grayson is right! This was an aha, lightbulb moment: I thought. My OCD wants 100%, undeniable, absolute certainty about everything. And it makes me do rituals to try to get it, but it never can, because certainty is impossible. The only thing that’s certain is my OCD is afraid of uncertainty!”
• OCD has many themes, faces or “flavors” that often change over time, being replaced with new ones. OCD can wax and wane throughout a lifespan and typically appears before age 35. One of the key features is that the obsessions are unwanted.  
• Most people have obsessive thoughts and/or compulsive behaviors at some point in their lives, but that does not mean that we all have OCD. In order for a diagnosis of OCD to be made, the cycle of obsessions and compulsions must be to the point that it consumes a lot of time (more than an hour every day), causes anxiety and distress, or gets in the way of important activities that the person values.
• With OCD, there is often feelings of shame, self-doubt, embarrassment, feeling like a bad or crazy person for your thoughts that may be illogical/bizarre and for your compulsive behaviors/rituals/routines.
• Common OCD Types

People often have more than one theme (and there’s many more!)

• Contamination: excessive concern with germs, getting ill, disgust with bodily waste/fluids, fear of chemicals, household cleaners, and/or bothered by sticky substances.
• Health: Excessive worry over getting an illness in the future or worry over a heart attack without any symptoms (different from Illness Anxiety Disorder (AID) more characterized by misinterpreting current bodily symptoms as evidence of a current disease despite reassurance from doctors otherwise may go to the doctor more or avoid out of fear-formerly known as Hypochondriasis)
• Just right: concern with symmetry, exactness, perfectionism
• Order: need for order in environment. Excessive arranging, rearranging furniture, etc
• Responsibility: excessive concern with being responsible for making sure things are as they are “supposed” to be
• Harm: Fear about causing harm to yourself or others, even unintentionally.
• Moral/Scrupulosity: Excessive concern with blasphemy, sacrilege, sin, morality
• Perinatal/postpartum: Fears focusing on your newborn can be experienced by mothers and fathers. OCD onset can be triggered by pregnancy or giving birth. Obsessions can center around your baby’s health and safety, fears about them getting lost or kidnapped, sexual obsessions, or thoughts like what if my baby dies in their sleep? Maybe I’m not a fit parent, what if I touch my baby inappropriately? These obsessions can be followed by compulsive, even ritualistic, physical or mental behaviors, is exhausting and often debilitating. A certain amount of worry is a normal part of being a new parent. But when those fears cause a great deal of distress that disrupts your ability to function, please reach out instead of hiding in silence. Excellent resources include Post-partum Support International (PSI) and the International OCD Foundation with information and resources for loved ones.
• Sexual: excessive intrusive/unwanted sexual thoughts such as sexual orientation, sexual appropriateness, unwanted sexual images about molesting either your own children or other children
• Hyperawareness/Sensorimotor: excessive concern with awareness of breathing, blinking, swallowing
• Relationship: excessive concern with whether a relationship is “right” Such as doubting whether you truly love your partner or if you’re just going through the motions. Wondering whether you’re attracted to your partner or if you’re feeling attracted to someone else.
• Miscellaneous: obsessing over existential questions, feeling you need to know or remember certain things, fear saying certain things/blurting something out, fear not using the perfect word, etc.
• See below for Body Dysmorphic Disorder (BDD). Formerly a type of OCD, now its own category since 2013.

Common Compulsive Behaviors

• Cleaning: Strict cleaning routines, excessive handwashing/ use of sanitizers.
• Checking: Repeatedly checking doors are closed and locked, appliances are off, or other things to ensure they’re secure or where they belong.
• Repeating & Praying excessively: Counting, tapping, or saying certain words, prayers, phrases over and over.
• Arranging/Ordering/Need for Symmetry: Constantly organizing items in a specific order or pattern, excessive reorganization
• Food/Eating: ritualized eating behaviors. Arranging your food, knife, and fork in a particular order before being able to eat, eating according to a strict ritual.
• Mental Rumination: Rumination can be a part of anxiety, depression, and OCD. Like a “mental merry-go-round.” Clinically defined by “a repetitive thought pattern in which you think about things over and over from the past, in a continuous loop, as a way to analyze a particular thought and try to find assurance.” Rumination tends to consume a lot of mental space and emotional energy and feels draining to most people. Rumination in OCD can show up in many different themes. Examples include repeatedly replaying or reviewing a past event in your mind in order to analyze it or accurately recall it. Visualizing the checkout experience from your trip to the grocery store to look for signs that you might have shoplifted. Recalling your conversation with a coworker to be sure you didn’t say anything inappropriate.
• Miscellaneous: Rituals in your head to reduce anxiety, like saying prayers or thinking a “good” thought to undo a “bad” thought.  Asking other people to reassure you, confessing to wrong behaviors you never even did, telling other people certain words to feel better. Touching objects or people to prevent something bad happening.

Is it Normal or OCD?

We all experience a need for certainty and do things to try to achieve it. When it seems to take on a life of its own and impact daily life, it’s probably OCD. If you or a loved one has to do anything such as checking or a ritual repeatedly until the anxiety reduces enough to move on to the next activity, please reach out for help.

With the right support and a little hard work, healing is possible.

Body Dysmorphic Disorder (BDD)

BDD is a mental health condition where a person is preoccupied with a perceived or slight flaw in their appearance. People with BDD may experience significant emotional distress and engage in repetitive behaviors, such as mirror checking, grooming, or skin picking. BDD can affect people of any age, but it’s most common in teenagers and young adults

Individuals with BDD may express a variety of concerns regarding their appearance. Preoccupation may focus on one or more areas of the body – most often the face or head, but any body area can be involved. Common areas of concern include:

• Face (Eyes, nose, eyebrows, lips, jaw, chin, teeth)
• Skin (Complexion, color, composition)
• Hair (Texture, volume; can be concerning hair on head and/or body)
• Build (Height, muscularity)
• Breasts

Common negative beliefs about these areas of concern include:

• Defective appearance: “My body part is ‘deformed’ or ‘flawed,’” “My skin is terribly scarred,” or “I’m going bald.”
• Coloring: “My legs are too pale,” “My face is too red” (or too splotchy, uneven, etc.)
• Shape/size: “My biceps are too scrawny” (may involve body build, muscle tone, muscularity, and/or the size or shape of any body area)
• Asymmetry/disproportion: “My eyebrows are uneven”
• May develop elaborate. makeup/ beauty routines to hide the perceived defect

Online screening test: https://bddfoundation.org/information/do-i-have-bdd-test/

Hoarding Disorder

Hoarding disorder is a mental disorder that involves persistent difficulty in getting rid of possessions and the excessive acquisition of items that are not needed for which there is no space.

Experiencing worries about throwing away seemingly unimportant things you might need in the future (letters, bills, etc).

Urges to pick up and collect useless things.

The items may or may not have monetary value, pile up into clutter, and the person experiences significant distress when thinking about getting rid of and/or attempting to get rid of them.  The hoarding impairs daily life, such as stress to the person and family members, safety hazards (due to the potential for tripping and blocking exits), shame, and loneliness, leading to isolation, money, and housing problems.

Helpful article: https://www.mcleanhospital.org/essential/hoarding-disorder

Body-Focused Repetitive Behaviors (BFRB’s)

Trichotillomania- hair pulling

• A long-term urge to pull hair
• A brief positive feeling after pulling hair
• Inability to stop
• Uneven hair appearance
• Bare patches or total hair loss, maybe to the point of needing to wear a wig or having smooth eyelids/eyebrows.
• Trichotillomania can affect hair on the scalp, eyebrows, eyelashes, or other parts of the body, such as the pubic area, using fingers or tweezers.

Excoriation- skin-picking

An impulsive disorder related to obsessive-compulsive disorder. It is characterized by repeated picking at one’s own skin, which results in areas of swollen or broken skin and causes significant disruption in one’s life.

Skin picking is a body-focused repetitive behavior (BFRB) that typically begins during adolescence, often with, or after the onset of, puberty around ages 13-15, but may also occur among children or adults. The condition affects between 1.4 and 5.4% of American adults and is experienced by women more often than men.

Individuals may pick at healthy skin, minor skin irregularities (e.g., pimples or calluses), open wounds, blisters, scabs, or other types of lesions. This disorder is usually chronic, with periods of time where there is no picking alternating with periods of greater symptom intensity. If untreated, skin-picking behaviors may come and go for weeks, months, or years at a time. It is common for individuals with this disorder to spend significant amounts of time, sometimes even several hours a day, on their picking behavior. People may use their fingers or other tools, such as tweezers, pins, or pimple extractors, to do their picking.

Other Body-Focused Repetitive Behavior Disorders: Nail biting (onychophagia), Cheek biting (morsicatio buccarum), and Chronic tongue chewing.

Specific Phobias

(the most common anxiety disorder)

People with a specific phobia avoid places, situations, objects, and even types of people — clowns, for example — even if there is no threat or danger. Phobias do not necessarily stem from trauma involving the object in question. They usually develop suddenly and without an obvious explanation. Simply thinking about a phobia can cause anxiety. There are generally five categories of specific phobias:

• animal type (spiders, snakes, dogs)
• natural environment type (tornadoes, heights, water, fire)
• blood injection type (needles, medical procedures)
• situational type (flying on an airplane, enclosed spaces)
• other type (phobias that do not fit into the previous four categories)

Generalized Anxiety Disorder (GAD)

• Experiencing excessive worry and fear about real life concerns (health, work, finances, family) most days, for at least 6 months
• Continually feel on edge & overwhelmed
• Experiencing at least three anxiety symptoms: Disturbed sleep, difficulty focusing, muscular tension, restlessness, irritability, chronic fatigue
• Symptoms are not caused by an underlying medical condition and are significantly disrupting your life with work and/or relationships.

How do OCD & GAD differ?

Compulsions

People with OCD have a strong drive to engage in compulsions or rituals to reduce anxiety, while people with GAD do not. Compulsions can be physical, like washing hands or rearranging objects, or mental, like counting or repeating words.

Content of worrying & Anxiety Style

GAD worries about many things, often real-life concerns like health, finances, or family. OCD is more likely to obsess over a particular anxiety. OCD thoughts and worries are unwanted and often distressing/bothersome. They may cause a feeling of shame or fears that you are crazy. They are often inconsistent with your values and/or personality.

GAD tends to jump from one anxiety to another and can feel frantic. OCD fixates on one anxiety and feels like spiraling.

Social Anxiety Disorder

Common Fears & Symptoms:

• Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed, or humiliated (e.g,. fear of saying the wrong thing out of fear of judgment
• Avoidance of anxiety-producing social situations or enduring them with intense fear and anxiety (avoiding ear of using the public restroom for fear others will hear you (not due to fear of germs or dirt)
• Intense anxiety during social situation, excessive to the situation, interferes with daily living
• Dreading upcoming events (anticipatory anxiety)
• Performance fears
• Fear that others will notice your anxiety

Illness Anxiety Disorder (formerly Hypochondriasis)

Anxiety Attacks

Anxiety attacks are often triggered by worrying about a specific issue. Symptoms include muscle tension, racing heart, and knots in your stomach, which can last a moment, days, or months.

Panic Attacks

Panic attacks start suddenly and have no trigger, feeling like they come out of nowhere. Picture a tsunami or an angry, anxious Gorilla. These can cause more intense physical symptoms like heart palpitations, shortness of breath, chest pain, hot flashes, chills, stomach discomfort, a fear of dying, and a sense of being detached from reality.

Anxiety Attack Vs. Panic Attack

The main difference is that certain stressors often trigger anxiety attacks, and they may build up gradually. In contrast, panic attacks happen unexpectedly, are sudden and typically last 5 – 20 minutes.

Panic Disorder

People with panic disorder have frequent and unexpected panic attacks. These attacks are characterized by a sudden wave of fear or discomfort or a sense of losing control even when there is no clear danger or trigger. Not everyone who experiences a panic attack will develop panic disorder.

Symptoms:

• Sudden and repeated panic attacks of overwhelming anxiety and fear
• A feeling of being out of control, or a fear of death or impending doom during a panic attack
• An intense worry about when the next panic attack will happen
• A fear or avoidance of places where panic attacks have occurred in the past
• Physical symptoms during a panic attack, such as sweating, pounding heart, dizziness, chest pain, racing heart, difficulty breathing, and more.

Agoraphobia

Agoraphobia is a fear of situations or places that may cause feelings of panic, entrapment, helplessness, or embarrassment.

If you have agoraphobia, you may have difficulty leaving your house. Fears of crowds, traveling, elevators, movie theatres, malls, etc., might cause significant challenges.

People with agoraphobia may also have recurrent panic attacks, and the thought of leaving the house may cause considerable anxiety to the point of avoidance.

Agoraphobia often occurs with panic disorder. For example, if panic attacks happen in a specific place, the person might avoid that place and develop agoraphobia. In extreme cases, anywhere outside their home is a space of anxiety.