Obsessive compulsive disorder - OCD treatment and therapy from NOCD

What Is Obsessive-Compulsive Disorder (OCD)? What Are the Symptoms of OCD? Here’s How It Works

Jun 25, 202117 minute read

  • Because only some OCD symptoms are visible, the condition is widely misunderstood.
  • Although there are many different types of OCD, the OCD cycle generally follows the same pattern: A trigger causes an intrusive thought. These intrusive thoughts cause such intense anxiety and distress that they drive a person to engage in a compulsion.
  • Obsessions and compulsions can lead to a number of emotional and physical symptoms that are a direct or indirect result of OCD.
  • To learn more about how OCD works and the different symptoms, visit the NOCD blog.

Types of OCD

There are many different types of OCD, and the condition can manifest in hundreds of different ways. For most people, OCD centers around one or multiple themes. The most common themes are perfectionism, contamination and fear of harming oneself or others.

Beyond these, OCD can fixate on subjects or fears, and it tends to fixate on what people care about the most. This can make the symptoms all the more distressing. For example, if someone values being a good and honest person above all else, they may experience obsessions and compulsions around the fear of having lied to someone in their life. This subtype is called moral or scrupulosity OCD.

OCD can also fixate on a person’s relationships (a subtype called relationship OCD) and cause them to experience doubting thoughts about one or more relationships that are important to them. In short, the content of the OCD obsessions and compulsions can change, but they almost always follow the same cycle.

How OCD works for most people

Experts have come up with a bunch of different models for the way OCD works, and it varies from person to person, but the OCD cycle is generally the same: an intrusive thought leads to anxiety or distress, leading to a compulsive behavior. The OCD cycle usually starts with a trigger.

What is a trigger?

A trigger is a circumstance in your present environment, or a thought you experience, that causes you to feel a certain way. For example, if every time you go to a restaurant you begin to fear you’ll get sick from food you didn’t prepare, the restaurant would be the trigger for your fears. If you’re grieving the loss of a loved one, a favorite song of theirs might send back a flood of memories. In this situation, the song is the trigger for your emotional state. 

A trigger isn’t always the sole cause of a feeling, but it may play a direct role in your emotional state. This can get complicated because there may be other circumstances in your environment that contribute to your emotional state. For example, if you’re already feeling grief following the loss of a loved one, a favorite song may be more likely to trigger feelings of nostalgia and sadness. 

For this reason, a person’s trigger may not be obvious. For example, you may feel grief and only later realize your emotional state coincided with hearing a particular song, having a conversation or reading an article that functioned as a trigger for your emotional state. 

What are intrusive thoughts?

An intrusive thought is a thought, image, bodily sensation or urge that seems to pop up in your mind out of nowhere. Sometimes these thoughts seem completely random, and other times they might be traced back to some type of trigger. Intrusive thoughts can be confusing, frightening or even debilitating.

Here’s the big secret about OCD: These thoughts that bother people so intensely? Everyone has them.

Surveys of people without OCD reveal that they experience many of the same thoughts that completely derail people who have OCD. It’s hard to say whether or not people with OCD have these thoughts more often, but what we do know is that people with OCD react to these thoughts very differently. We’ll talk more about this in the next section, but let’s start with just a few examples of intrusive thoughts.

Examples of intrusive thoughts from OCD

  • I’m about to jump in front of the train
  • I could grab that cop’s gun and shoot myself
  • I could just kill myself
  • I should walk over and push that person
  • I should insult this person I don’t know
  • I could cut myself with this kitchen knife
  • I should jump off this bridge right now
  • I could push my friend off this bridge
  • I could kill my child right now
  • I’m going to punch my brother right now
  • I want to see my sister naked
  • I want to kiss my uncle
  • I could steal from this store right now
  • I could grab the money from that tip jar
  • I probably got HIV when I got a blood test
  • I’ve messed up everything in life
  • The person I’m dating isn’t right for me
  • There’s someone better for me
  • I’ll just tear my clothes off right now.
  • I’m more attracted to that person than to my partner
  • Life has no meaning
  • My niece is attractive
  • That child is attractive
  • I could be gay
  • I could be straight
  • I’m living a sinful life
  • I’m not a good person
  • Breathing is strange, I should stop breathing
  • Blinking is weird — I don’t like that people blink
  • My family will be murdered
  • I could suddenly vomit in class
  • I should drive off the road right now.
  • I could run that person over right now.
  • Why not crash into that barrier?
  • I should just scream right now.
  • I’m going to tell my boss he’s an idiot right now
  • I might dump this coffee on my boss’ head

Examples of intrusive images or urges

  • Paying attention to the movement of your wrist and fingers every time you’re typing
  • Focusing on the movements your eyes make when you’re reading and being unable to pay attention to anything else
  • Noticing each time you move your head and being unable to stop keeping track of each movement
  • Experiencing an image of hurting another person 

Intrusive thoughts, images and urges can manifest in hundreds of different ways and often center around one or a few themes. The themes, like perfectionism, contamination or fear of harming oneself or another, are called OCD subtypes.

Why intrusive thoughts lead to anxiety

What’s different for people with obsessive-compulsive disorder is their inability to just let the thoughts pass by. Photo via Annie Spratt/Unsplash

Everyone has had some of these intrusive thoughts, or similar ones: They pop into your head, and they’re strange or alarming. Most people might think for a few seconds about the unpleasant thought and then go on with their day. What’s different for people with obsessive-compulsive disorder is their inability to just let the thoughts pass by. Someone with OCD will have an intrusive thought, vastly overestimate its importance and spiral into obsession.

Many people use “intrusive thought” and “obsession” interchangeably, but they’re not quite the same. As we saw above, everyone has intrusive thoughts. Like everyone else, people with OCD symptoms experience mental illness and get different types of intrusive thoughts; only some of these become obsessions. This helps us understand why someone with OCD can be unbothered by most intrusive thoughts but completely derailed by others. Just because someone has OCD does not mean they’re bothered by everything.

Let’s look at a common example: You’re driving along the highway and think, suddenly, “I should drive off the road and smash into that barrier over there.” Someone without OCD may think, “Wow, that was weird; of course I don’t want to do that,” and then drive along and forget it ever happened. But someone with OCD might think, “Oh, god, not this again; I’m going to drive off the road; this means I want my life to be over; I don’t really want my life to be over; I need to make sure I don’t drive off the road, but maybe I do want to drive off the road?”

The intrusive thought is the same for both, but the assessment of that thought is different. Unable to simply move on, the person with OCD makes a catastrophic appraisal of the thought — that it’s important or dangerous and requires their attention — and so the obsession begins.

What are OCD obsessions?

In the above example, the person with obsessive-compulsive disorder feels an almost unbearably strong need to prove to themselves that they don’t actually want to drive off the road. Obsessions emerge from a person’s strong feeling that they always need to be vigilant to different negative possibilities. In this case, it feels like the thought must mean that the person really does want to drive off the road, and so, if they let their guard down, their mind will take over and drive them off the road into the barrier.

Once an intrusive thought takes hold and starts becoming a source of distress, it has become an obsession. Obsessions are unwanted and repetitive thoughts, urges and images that quickly spiral from an initial disturbing thought and usually lead to a lot of distress. While closely linked to intrusive thoughts both in theme and nature, obsessions only arrive after the initial thought has been assessed in a certain way. In a way, a central problem of OCD is the belief that every thought is meaningful.

Let’s look at another example of this process…

How OCD obsessions get started

Situation: Sam is babysitting his neighbor’s kids on a Friday night. As usual, the kids need to take a bath before bed. They’re young enough that Sam needs to help them.

Trigger: The kids begin to get undressed for their bath.

Intrusive thought: Suddenly, Sam thinks, “I could be sexually interested in these kids.”

Obsessions: When an initial intrusive thought spirals, it can lead to an obsession. Here are some examples of obsessive thoughts:

  • Oh no, could I really be sexually interested in young kids?
  • Am I the type of person who would be like that?
  • Could I really be a pedophile?
  • Are these kids in danger when I’m around?
  • How can I be sure that I’m not like that?
  • I need to make sure that I’m not really that kind of person.

We use the word “obsessed” in our culture to describe things we’re really interested in. He’s “obsessed” with her; she’s “obsessed” with checking her Instagram. But that’s not really how an obsession works for someone with OCD. They’re not interested in their obsession in a typical way. Rather, they tend to feel forced to think about it over and over. An intrusive thought can become an obsession because it’s the most disturbing thing their minds could throw at them. And disturbing things can be hard to simply accept or ignore.

Since obsessions are closely tied to the initial intrusive thought that brings them on, they can really spin out in any direction from any thought like the ones listed on the previous page. Just as there are infinitely many intrusive thoughts, there’s no limit to the obsessions that people experience. However, people with OCD aren’t really bothered by every thought that pops into their head. Instead, their obsessions usually emerge in response to intrusive thoughts within just a few themes at any given time.

When does an intrusive thought become an OCD obsession? 

Intrusive thoughts are involuntary thoughts that are unwanted and very  disturbing, but they typically leave a person’s mind as quickly as they come. Intrusive thoughts are normal, and it’s common to experience them. For example, someone could be on a rooftop and suddenly have the thought, “What would happen if I jumped?”

Intrusive thoughts become part of the OCD cycle when they are impossible to let go of and lead the person experiencing them to believe the thoughts mean something about them as a person. After an intrusive thought pops into their head, a person may think,” I can’t believe I just thought about jumping from the roof. It must mean something is wrong.” Once a person begins to attach meaning to their intrusive thoughts and try to address them with compulsions, they become part of the OCD cycle. 

  • How to know if intrusive thoughts are from OCD? Learn more here

How to tell the difference between a disturbing thought and an OCD obsession

A mental health professional will be able to make an accurate diagnosis, but the main difference between a disturbing thought and an OCD obsession is how someone responds to these disturbing thoughts. Unwanted intrusive thoughts are common and impossible to control. 

Some intrusive thoughts pop into your head, but you dismiss them as unimportant or meaningless. You might be on a rooftop and think, “What would happen if I jump?” but immediately after, you tell yourself, “That was strange,” and move on. Even though it’s a disturbing thought, you know it’s not representative of who you are as a person.  

However, it’s when these thoughts cannot be dismissed — causing distress to the point where they can only be addressed through compulsions — that they become an OCD obsession. 

Emotional and physical symptoms of OCD: What kind of distress can occur?

Exhaustion, an inability to sleep, digestive problems, muscle tension, dizziness, shortness of breath and much more. Photo via Külli Kittus/Unsplash

Emotional and physical pain in people with obsessive-compulsive disorder is by no means limited to the obsession stage. The distress might momentarily be soothed by compulsions, but it usually comes back even worse. And compulsions can create new types of distress, too. Distress is present throughout the obsessive-compulsive cycle, but we’re talking about it here because the main goal of compulsions is to get rid of the distress that obsessions cause.

Because people with OCD spend most of their day feeling like they have to make sure something bad won’t happen, a number of emotional symptoms can arise. Among the most common are trouble focusing, irritability, anger, frustration, jumpiness, guilt, shame, feelings of dread and a sense of hopelessness.

People with OCD also experience a wide variety of unpleasant physical symptoms. Remember how you’ve felt right before taking an exam in school or getting test results back from a doctor? That feeling of being “amped up” is similar to what a person with OCD feels almost all the time. Their brain says, “Time to be alert!” and their body responds by feeling constantly on edge. This can lead to exhaustion, an inability to sleep, digestive problems, muscle tension, dizziness, shortness of breath and much more.

Sometimes the emotional and physical symptoms work together in another kind of vicious cycle — you begin to worry, notice you’re feeling worse and then worry about feeling worse. Many people with OCD also develop symptoms of other psychiatric disorders, like depression and substance abuse, and then they have to manage multiple conditions at once. These tend to occur at higher rates in people with OCD than in the general population, perhaps because of the amount of distress they experience.

Common comorbid conditions with OCD

People can also end up with any number of bodily symptoms from their compulsive behaviors. Someone with a hand-washing compulsion can destroy the skin on their hands over time. Another person, refusing to eat because of an obsession about choking or contamination, may become extremely thin and develop medical complications.

People are typically aware, to varying degrees, of the irrationality of their thoughts and behaviors. Many people with OCD know that their thoughts aren’t real and that their behavior might seem strange to others, but they can’t stop despite these insights. But others do believe that their obsessions might come true, and that their compulsions are preventing this. It’s important not to be too quick to say, “Your thoughts don’t matter! You just need to learn to sit with them,” because many people do feel like their thoughts are important. Plus, many people have had the same symptoms for years. It takes time to feel alright about letting your guard down for a bit.

What is a compulsion?

When their distress gets overwhelming, people with OCD will often engage in compulsions: repetitive activities, both behavioral and mental, aimed at getting rid of distress and regaining a sense of control. Compulsions develop over time, and sometimes they have nothing obvious in common with the content of the obsession. Anything that relieves distress is reinforcing, which means it’s going to seem more appealing the next time that distress shows up.

Eventually, a compulsion can become almost automatic because it’s been done so many times; once this happens, and it’s hard to do anything else, it has become a compulsion. This helps us understand why certain “bizarre” compulsions seem to help people feel better short-term even though they have no logical connection to anything else: because this behavior helped the person feel better at one point in the past and developed into a compulsion via reinforcement.

Examples of OCD compulsions

  • Excessive hand-washing
  • Constantly checking in with people to ensure their safety
  • Making sure things are neat and/or symmetrical
  • Checking locks, stoves and light switches repeatedly
  • Repeatedly counting or saying a word in your head
  • Checking trash repeatedly to make sure you aren’t throwing something valuable out
  • Looking for mistakes over and over when writing an essay or paying taxes
  • Looping back while driving to see if you’ve hit someone
  • Google searching
  • Mentally replaying situations to make sure you remember them completely
  • Getting reassurance about things from other people
  • Visiting different doctors to see if you have an illness
  • Repeatedly apologizing to someone or asking if they’re okay
  • Keeping yourself away from kitchen knives because you get thoughts about stabbing someone
  • Staying away from kids because you get sexual thoughts about them
  • Refusing to visit public places because you’re afraid you’ll catch an illness
  • Avoiding crowded areas
  • Replaying a past situation over and over in order to “solve” it
  • Neutralizing a “bad” thought with a “good” thought

Compulsions might provide a temporary sense of relief, but the anxiety quickly returns. You can never outrun your own mind, and anything designed to keep a certain thought out of your head is actually, perversely, guaranteed to make that thought pop up more often. This is the part in your psychology lecture when the professor says, “Whatever you do, don’t think of a big pink elephant.” By trying not to think of something, you’re already thinking about it, and the obsession tends to get stronger.

So compulsions only work for a bit, and the distressing thoughts start coming on more often as you try to keep them away. This process begins to spiral, and the obsessive-compulsive cycle can start to take up the better part of your day. The more you perform compulsions, the less you trust yourself and the more you believe that you should be afraid of your own thoughts. OCD tends to also make you increase the amount or type of compulsions you do over time to get that same sense of relief. And you never find out what would happen if you didn’t do a compulsion and just sat with the anxiety and distress.

Of course, many people with OCD don’t think about their experience in these terms, and simply feel like they have to do the compulsion for some unknown reason. Others are aware of what’s going on but still feel like the compulsion will either prevent something bad from happening or help them feel better for a while. Many engage in avoidance of situations that might bring about their obsessions again; this avoidance, too, can become a compulsion.

A common misconception about OCD is that people want to perform their compulsions. We see people washing their hands over and over, or refusing to leave their house, and assume that it’s part of their personality or a reflection of their interests. In reality, most people know that their compulsions don’t make any sense but are still unable to stop doing them. And even the people who don’t know this still aren’t doing the compulsions because they want to, but because they feel completely sure they have to.

OCD misdiagnosis: This is why OCD symptoms are commonly misdiagnosed

There are many reasons why OCD symptoms are commonly misdiagnosed. OCD symptoms are often confused with generalized anxiety disorder (GAD) because both conditions deal with anxiety and worry. The main difference is that people with OCD experience anxiety as a specific result of intrusive thoughts while people with GAD experience excess worry that is not related to intrusive thoughts. People with GAD experience excessive worry and often experience physical symptoms like insomnia and muscle tension. People with OCD, on the other hand, experience anxiety as a result of obsessive thoughts. People with OCD also develop compulsions, which is not the case with GAD.

Additionally, misinformation about OCD can lead to misdiagnosis. Many mental health professionals are not aware of the various subtypes of OCD, particularly how many obsessions and compulsions are mental. As a result, a mental health professional may think a person who has obsessive thoughts is simply anxious rather than experiencing symptoms of OCD.

Other diagnoses may be misdiagnosed as OCD because they have compulsive elements but are separate from OCD. For example, people who experience body-focused repetitive behaviors (BFRBs), such as nail-biting, skin-picking or hair-pulling, have an obsessive component to their behavior, but BFRBs are not considered OCD because they are not characterized by obsessive thoughts followed by compulsive behavior. Instead, a person with a BFRB is driven to engage in this behavior as a way to regulate their nervous system. 

Learn more about OCD and misdiagnosis:

In some cases, OCD symptoms can become so severe that people consider suicide. If you ever consider suicide, please call your local emergency number or go directly to a hospital. In the United States, you can also call the Suicide Hotline at 1-800-273-8255.

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