Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Why Not All Compulsions Are Visible

By Teda Kokoneshi, LMHC, CCTP

May 20, 20215 minute read

Reviewed byApril Kilduff, MA, LCPC

Why not all compulsions are visible

Many people who struggle with recurrent thoughts, images, or urges that are intrusive and unwanted (i.e., obsessions) notice that they respond to these obsessions by engaging in repetitive mental or physical behaviors to decrease their levels of distress (i.e., compulsions). The frequent pairing of obsessions and compulsions together is how many individuals come to understand they are experiencing symptoms of obsessive-compulsive disorder (OCD). Understanding the diagnosis often serves as an important gateway to seeking much-needed treatment.

Other individuals, however, might dismiss the possibility of OCD because they don’t feel like they experience any particular repetitive behavior that results from their obsessions. Their suffering is amplified by having to grapple with a struggle that they can’t put a name to. But not all compulsions are visible, and learning about these invisible compulsions could offer great relief to people living with these OCD symptoms.

During my clinical training to become an NOCD therapist, I found out that many people actually perform purely mental compulsions to relieve the distress caused by their obsessive thoughts. While these mental compulsions aren’t as visible as a physical compulsion, like repetitive hand-washing, they are still very distressing and are responsible for significant life interference for most individuals who experience them. Importantly, mental compulsions certainly don’t mean that a person wouldn’t meet the diagnostic criteria for OCD. 

It’s relatively straightforward for a person with contamination OCD to understand their excessive hand-washing behavior as a compulsion used to soothe their fears about getting germs on their body and spreading them. A person with scrupulosity OCD, however, might not recognize the compulsion in their habit of mentally reviewing every detail of a particular interaction to make sure that they didn’t behave in a “sinful” or “amoral” way. They might not realize that when done frequently and with the purpose of relieving anxiety, mental reviewing is a compulsion.

Even if they recognize that these compulsive mental acts are distressing, they might rationalize them by labeling them as a normal response to a stressful social situation. But the key between a normative reaction to stress and a mental compulsion is a sense of urgency related to performing a compulsion, as well as the repetitive nature of the entire experience. The desire to find certainty at all costs, or to prevent something horrible from happening through performing the mental act, is the tell-tale sign that it has become a mental compulsion. 

Below you will find various mental compulsions to look for if you are considering OCD as an explanation for any distress you, or someone you know, might be experiencing:

Mental Reviewing

When checking or reassurance-seeking becomes impossible due to no longer being in the same location of the event you are obsessing about, or not having anyone to seek reassurance from, a person might go in their own head and repeatedly “rewind and replay” a particular scenario. In reviewing the situation, they may try to understand every detail and its implications, such as if the words they spoke might have offended someone, or what their own subtle emotional responses were to a particular interaction, in order to determine if they made some type of mistake or “sinned.”

Scenario Twisting

This is similar to mental reviewing, but in your mind you are changing one or a few small details to the actual past event to see how you would have reacted if the person(s) you interacted with said or did something slightly differently. A person who has pedophilia OCD or harm OCD, or who otherwise obsesses about their “goodness” as an individual, might be particularly prone to scenario twisting. It is an effort to find ultimate certainty about whether they are, or are not, the dangerous/bad person they worry about being, based on how they would have reacted to a fictitious scenario.

Reverse-ruminating

When a person with OCD anticipates a future event will cause them unbearable anxiety, they rehearse the imagined event in their mind in an effort to prepare beforehand for any potential pitfalls or dangers lying ahead. They can rehearse any detail of the future event, including their behavior, the anticipated behavior and words of people they’re interacting with, and their reactions to these things.

Thought Neutralization

When an unwanted thought or image pops up in their mind (e.g., “I might violently attack my loved ones”), the person will neutralize it by replacing it with a good thought or image that counters their worst fear (e.g., “I love my family and would never want to harm them”). While this might be a “natural,” instinctive reaction, it can further the cycle of OCD if they engage in it compulsively, feeling like it is necessary to do it to avoid horrible things from happening.

Self Reassurance

Rather than seeking reassurance from external sources, some people with OCD try to provide reassurance to themselves mentally. A person with any type of OCD might tell themselves over and over again that “these are just thoughts” and that they don’t hold any bearing on reality.

Any of the mental compulsions mentioned above can combine or overlap with one another. They can hold great power over someone’s daily life, and if left untreated, they can cause great suffering and interfere with functioning in social, occupational, family, and academic life as well as other realms.

If you see your own thought patterns reflected in any of the above mental compulsions, it may be time to seek treatment for your OCD. Exposure and response prevention (ERP) therapy is the most effective treatment available for OCD. In ERP, an individual works with a therapist to face the fears underlying their obsessions while preventing themselves from engaging in any compulsions. ERP works for mental compulsions just as well as for physical ones, so make sure to share these mental compulsions with your therapist as part of your treatment.

If you are struggling with mental compulsions and you feel like you need help please know that NOCD offers ERP training in all 50 states as well as the UK and Canada. A free 15-minute call with our care team and we can set you up with a qualified therapist who can help you to start feeling better and gain control of your OCD.

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