Obsessive-compulsive disorder (OCD) is a chronic (or long-term) mental health condition that causes a cycle of obsessions and compulsive mental or physical behaviors. These symptoms can significantly impact your day-to-day life, affecting your work, school, and relationships.
In this guide, we’ll discuss obsessions and compulsions in-depth and how evidence-based treatments like exposure and response prevention (ERP) therapy and medication can help you get your life back from OCD.
What are the symptoms of OCD?
OCD is characterized by two primary symptoms: obsessions and compulsions. Here’s a look at what each symptom entails.
Obsessions
The OCD cycle begins with unwanted intrusive thoughts, images, urges, feelings, and/or sensations known as obsessions. “Obsessions are the fears and doubts that make you feel anxious, scared, confused, and distressed,” says Tracie Ibrahim, LMFT, CST, Chief Compliance Officer at NOCD.
According to Patrick McGrath, PhD, NOCD’s Chief Clinical Officer, while everyone experiences intrusive thoughts from time to time, the difference is people with OCD need to find a meaning behind them.
“People with OCD think there must be a meaning to intrusive thoughts,” he explains. “‘Why did I think that I want that? What if that were to come true? Should I do something to try to make that never happen?’ People without OCD can go, ‘Well, that was weird,’ and move on.”
Intrusive thoughts are much different from impulsive thoughts or hyperfixations. OCD intrusive thoughts can feel disturbing and unwanted. In contrast, impulsive thoughts are sudden, intense urges or desires to do something spontaneously, often without thinking about the consequences. Hyperfixation is typically a deep focus on a specific topic, activity, or interest that brings enjoyment rather than distress.
People with OCD think there must be a meaning to intrusive thoughts. ‘Why did I think that I want that? What if that were to come true? Should I do something to try to make that never happen?’ People without OCD can go, ‘Well, that was weird,’ and move on.
Patrick McGrath, PhD
Common themes of OCD obsessions
OCD symptoms can be grouped together as themes or subtypes that fall under four main categories: harm, contamination, “just right,” and taboo topics.
Here are some common themes in OCD obsessions:
- Fear of being contaminated or contaminating others physically, mentally, or emotionally
- Fear of harming yourself or others
- Excessive worry about romantic and/or platonic relationships
- Excessive need for exactness and orderliness
- Fear of going against ethical, moral, or religious beliefs
- Fear of being responsible for something bad happening to yourself or others
- Excessive worry about identifying with the “wrong” sexual orientation
- Excessive concern about past events
- Excessive concern about bodily sensations or functions
- Unwanted sexual thoughts
Examples of OCD obsessions
- Did I get consent from the girl I had sex with at that party?
- What if my partner is not “the one?”
- What if I forgot to turn the stove off and burn down my house?
- If I sit in the waiting room, I might catch germs from the seat and get severely ill.
- I have to make myself blink to ‘check’ that it’s normal.
- I had a blasphemous thought during service. Will God forgive me?
- I just thought about stabbing my partner. Am I a bad person?
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Compulsions
Compulsions (also known as safety behaviors) are repetitive mental or physical behaviors performed to cope with the distress caused by obsessions and/or to prevent something bad from occurring. “Compulsions are what you do in response to the intrusive thoughts to try and neutralize, escape, fix, or avoid them,” says Ibrahim.
The issue with compulsions is that they’re only a temporary fix. “Unfortunately, the neutralization of distress usually works for a little while, and then we find ourselves back in the cycle of having to do everything all over again,” explains Dr. McGrath.
Compulsions are what you do in response to the intrusive thoughts to try and neutralize, escape, fix, or avoid them.
Tracie Ibrahim, LMFT, CST
Common OCD compulsions
OCD compulsions can be either physical or mental. Below are some examples of physical compulsive behaviors:
- Excessive handwashing and cleaning
- Checking stoves, doors, locks, etc.
- Body-checking, such as weighing yourself, pinching your skin, taking your measurements, or looking for a groinal response
- Counting objects, steps, or other things in a certain way
- Ordering or arranging items in a particular way until they feel “just right”
- Repeating acts or behaviors (e.g., repeatedly walking back and forth through a doorway)
- Seeking reassurance from others
- Performing rituals, such as repeating certain words or phrases
- Hoarding possessions
- Avoiding certain places, people, or situations
- Excessive prayer
- Excessive confession of potential wrongdoings
- Excessively researching to find answers to your doubts with 100% certainty
Mental compulsions can include:
- Mentally reviewing past events over and over again until you find clarity
- Counting in your head while performing tasks
- Mental reassurance (e.g., replaying an incident in your mind countless times to soothe yourself from the belief that you did something wrong)
- Rumination or overthinking
- Mental checking
- Memory hoarding
- Thought suppression
- Replacing “bad” thoughts with “good” ones
Obsessions and compulsions can be very time-consuming, as some people can spend a significant portion of their day trying to neutralize intrusive thoughts—which ultimately can interfere with the things they value.
Also, in many cases, OCD symptoms are ego-dystonic, meaning that they don’t typically align with your values. However, Ibrahim says there are instances where obsessions aren’t ego-dystonic, but the compulsions you do in response always are.
“My husband [who has contamination OCD] has intrusive thoughts about cleaning and values a clean house,” Ibrahim explains. “The thoughts about cleaning are not ego-dystonic. The part that’s ego-dystonic is that it’s not his value to compulsively clean a certain amount of hours a day because he’d rather be doing something else with his time.”
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Can OCD symptoms change?
It’s likely that your obsessions and compulsions will change or spike (flare up) throughout your life for various reasons. “Lack of sleep, not eating well, stress, moving, school, marriage, having a baby, hormones [can cause symptoms to change or flare up],” says Ibrahim. “I see pedophilia OCD or harm OCD coming up a lot when someone is pregnant or has a baby.”
However, Ibrahim says that some themes may just stick around. “Sometimes you have [an OCD theme] forever, which I call your ‘ride or die’ theme. They’ve been by your side for so long and never want to leave. New ones pop in and out over time, and we treat them all with exposure and response prevention (ERP) therapy the same way.”
Besides these life changes, Ibrahim emphasizes that it’s impossible to “catch” a new theme. “You’re not going to see a show about sexual predators and become one or develop a new theme about it. That’s not how themes pop up. Themes are not contagious.”
How are OCD symptoms diagnosed?
The first step of getting OCD treatment is getting diagnosed. When it comes to OCD, self-identifying your symptoms can be helpful for sharing your experiences with a clinician. From there, they can perform assessments to confirm an OCD diagnosis and help you start your treatment journey.
To diagnose OCD, therapists use the DSM-5-TR alongside the Structured Clinical Interview for DSM-5-TR (SCID-5), the Anxiety and Related Disorders Interview Schedule (ADIS-5), or the DIAMOND to assess whether you meet the DSM-5-TR criteria for OCD.
Standardized assessment tools, such as the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Dimensional Obsessive-Compulsive Scale (DOCS), and the Obsessive-Compulsive Inventory-Revised (OCI-R), may also be used to gain deeper insight into the severity and specific nature of your OCD symptoms.
When do OCD symptoms develop?
“Late childhood to early adolescence is a common window of time [for OCD symptoms to develop], but it can also happen earlier or later in life,” says Ibrahim. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), 25% of cases of OCD start before the age of 14, with the average age of onset for symptoms being 19 years old.
It’s less common for OCD symptoms to appear after the age of 35 (known as late-onset OCD), but it is possible. OCD symptoms may occur gradually over time, but there are rare instances of acute-onset OCD that can develop from conditions like Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) or PANS (Pediatric Acute Neuropsychiatric Syndrome). Children may be diagnosed with PANDAS/PANS if OCD, a tic disorder, or both suddenly appear after a streptococcal (strep) infection. The conditions may also occur when OCD or tic symptoms worsen following a strep infection.
To learn more about PANDAS/PANS or find a specialist, visit the PANDAS Physicians Network.
Are there gender differences in OCD symptoms?
While anyone can develop OCD, women are 1.6 times more likely to be diagnosed with the mental health condition than men. Limited research has also shown gender-based differences in themes of OCD symptoms. Boys and men have a higher prevalence of harm- and sex-related obsessions, with compulsions related to perfectionism and counting. In contrast, women are likelier to have obsessions tied to contamination and experience compulsions centered around cleanliness and orderliness.
As of now, there’s little research on the prevalence of certain OCD themes and symptoms in trans and non-binary people.
When to seek help
If obsessive thoughts and compulsive behaviors are interfering with your day-to-day life, relationship, work, school, or overall well-being, please seek professional mental help.
While everyone experiences intrusive thoughts now and then, OCD is much different, as these thoughts can cause significant distress and lead to compulsions that can take up a large portion of your day and be hard to control. If you leave your symptoms unmanaged, they can get worse over time, but if you work with a mental health professional—preferably someone who specializes in OCD, it’s possible to conquer your OCD symptoms.
How OCD symptoms are treated
The most effective treatment for OCD is exposure and response prevention (ERP) therapy. ERP is a form of cognitive behavioral therapy (CBT) specially designed to treat all themes of OCD. It is supported by decades of research and has been found to significantly reduce symptoms in 80% of people with OCD.
A therapist specializing in ERP will guide you through exposures, which are situations where you confront your fears head-on. Your therapist will then teach you response prevention techniques, which are exercises that help you refrain from engaging in compulsions like reassurance-seeking or checking.
Here are some examples of ERP exercises:
- Using a public restroom and delaying or skipping handwashing.
- Skipping a ritual prayer and tolerating the discomfort instead of repeating it.
- Watching movies with characters who have different sexual orientations than your own and resisting compulsions to check your sexual identity.
- Intentionally misaligning objects on a desk and leaving them that way.
- Avoiding reassurance-seeking behaviors, such as constantly asking your partner if they love you.
ERP is not an overnight process. It will take patience and consistency to see a significant change in symptoms over time.
If you have severe symptoms or co-occurring mental health conditions (such as depression and anxiety), OCD medication combined with ERP can also be an effective treatment plan. SSRI antidepressants like fluoxetine (Prozac) and sertraline (Zoloft) are the most common medications used in OCD treatment, but certain tricyclic antidepressants (TCAs) and atypical antipsychotics can also be effective.
Bottom line
Everyone experiences intrusive thoughts from time to time. However, if these thoughts are so distressing that you feel the need to perform compulsions for temporary relief, you may have OCD.
If you’re experiencing OCD symptoms, your best bet for getting them under control is through first-line, evidence-based treatments like exposure and response prevention (ERP) therapy. To get started, reach out to a therapist who specializes in OCD to create a customized treatment plan.
Key takeaways
- The main symptoms of obsessive-compulsive disorder (OCD) are obsessions and compulsions.
- Obsessesions can revolve around themes like contamination, relationship, harm, and perfectionism.
- Significant life changes, such as moving, getting a new job, or having a baby, can cause your symptoms to switch themes and/or become more intense.
- You can develop OCD at any point in your life, but it is more common during late childhood to early adolescence.
- Exposure and response prevention (ERP) therapy, a specialized form of cognitive behavioral therapy (CBT), is an evidence-based treatment for managing the symptoms of OCD.
