What Is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder (OCD) is a complex condition that leads people to experience intrusive thoughts (obsessions) and engage in repetitive behaviors (compulsions). 

The International OCD Foundation estimates that between 2 and 3 million adults in the United States have OCD.

A classic example is when someone’s fear of germs and contamination leads them to wash their hands so often that they damage their skin.

Obsessive-compulsive disorder often starts to show itself between the ages of 8 and 12 and in the late teens or young adulthood. If unchecked, it can cause distress and pain because people feel they can’t control their thoughts and actions. But it is treatable, if we start by understanding the fundamentals.

What is obsessive-compulsive disorder? And how can behavioral health professionals help clients regain a sense of control and agency over their lives?

Understanding Obsessions

The Mayo Clinic defines obsessions as “repeated, persistent and unwanted thoughts, urges or images that are intrusive and cause distress or anxiety.” When these thoughts intrude, people often try to push them aside, or they try to soothe themselves by making a ritual or compulsive behavior. Some of the more common themes for obsessions are: 

• Fear of germs or dirt

• A need to have things be orderly and/or symmetrical

• Thoughts or images of acting inappropriately

• Doubting that a door is locked or the stove is turned off

Compulsive Behaviors

In OCD, compulsive behaviors are the things we do to try to soothe the anxiety of an obsession. The person feels compelled, or driven, to repeat behaviors or mental acts that often have strict rules. These rituals are meant to reduce stress, but because they aren’t often connected realistically to the experience, they bring temporary relief, at best. Some compulsive behaviors include:

• Washing and cleaning

• Checking and rechecking

• Counting and putting things in order

• Following a strict routine

Related Disorders

Obsessive-compulsive disorder exists on a spectrum with other related conditions. According to David Tolin, PhD, ABPP, in the CWC training, Treating Obsessive-Compulsive Disorder and Related Disorders, the following disorders are related to OCD:

• Hoarding disorder is when someone has trouble letting go of possessions that other people might find useless. People with hoarding disorder often accumulate so many items that it interferes with relationships and quality of life.

• Body dysmorphic disorder is when someone is preoccupied with what they perceive as flaws in their appearance. They might check the mirror repeatedly, groom, pick their skin, or seek reassurance.

• Trichotillomania is a disorder where people pull out their own hair, lashes, eyebrows, or pubic hair—and they have trouble stopping themselves. A related disorder called trichophagia is when people consume the hair.

• Excoriation, also known as skin-picking disorder, is when people cannot stop picking at their skin and it causes lesions. 

Tolin lists pathological gambling and compulsive buying as conditions that are “not on the list, but perhaps could be.”

What Do These Disorders Have in Common?

Tolin’s training lists a number of transdiagnostic factors for OCD and related conditions. 

• Fear

• Perfectionism/incompleteness

• Avoidance

• Compulsivity

• Impulsivity

• Distorted beliefs

• Distorted information processing

Compulsivity and Avoidance

“Compulsivity and avoidance are cousins,” says Tolin. Avoidance is the passive version where someone goes to great lengths to prevent discomfort. Compulsivity is the more active cousin, when people take action to try to escape from discomfort. 

Diagnosing OCD

Diagnosing OCD can be difficult because of the overlap between the symptoms of obsessive-compulsive personality disorder, anxiety disorders, depression, and bipolar disorder. When we suspect someone may have OCD, they undergo a psychological evaluation to talk about thoughts, emotions, and patterns that affect the quality of life. 

A mental health professional will use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to see if the person meets the diagnostic criteria. And often people will have a physical exam to provide a baseline context and to see if there are other problems or complications that should be addressed.

Common Treatments for OCD

According to the International OCD Foundation, approximately 70% of people with OCD will benefit from the first-line treatment combination of cognitive behavioral therapy (CBT) and medication, usually serotonin reuptake inhibitors (SRIs). The most effective type of CBT for this condition is Exposure and Response Prevention (ERP). With exposure therapy, people learn to safely confront objects or activities that cause distress.

The Anxiety & Depression Association of America suggests that it is most effective for people to work with a therapist trained in ERP therapy on a regular basis, and then work on exercises in the real world to address compulsions and obsessions. For example, if someone has a fear of germs in public places, the therapist might ask them to touch a doorknob and then wait before washing their hands. As your brain learns that nothing bad happens, you train it to accept that the rituals are not essential for survival. 

The following are other approaches that have shown promise for addressing OCD and related disorders.

• Response prevention — reducing anxiety and encouraging healthy ways of coping
• Competing response practice — slowing the response down, improving awareness of behavior, and using competing behavior
• Stimulus control — identifying high-risk situations for a behavior and modifying the environment and circumstances to encourage alternative behavior
• Acceptance and commitment therapy — knowing that unwanted thoughts and feelings are unavoidable, identifying them, and reducing efforts to “fix” or escape from them
• Challenging distorted thoughts — also known as cognitive restructuring, where people learn to look at the evidence, consider alternative ways to think about something, and experiment with new behavior
• Motivational enhancement — features motivational interviewing, an approach that involves assessing someone’s willingness to change their behavior
• Competing response — retraining yourself to engage in an alternative behavior

Sometimes psychotherapy and medications are not enough to control OCD. For treatment-resistant OCD, some professionals refer patients to intensive outpatient and inpatient programs, deep brain stimulation (DBS), and transcranial magnetic stimulation (TMS).

Moving Forward

The Connecticut Women’s Consortium has several trainings that can help acquaint behavioral health professionals with OCD and related disorders.

“Face Your Fears: Conducting Good Exposure Therapy Across Diagnoses” is an on-demand course that explores the psychological mechanisms of exposure therapy. It’s taught by David Tolin, PhD, ABPP, director of the Anxiety Disorders Center at the Institute of Living/Hartford Hospital. Tolin demonstrates several types of exposure therapy and addresses several myths that lead to the underutilization of this effective treatment.

When we understand more about the ways obsessions and compulsions affect people’s quality of life, we can help them address these issues and create healthier ways of coping with life’s stresses, fears, and challenges.