~What is OCD? A Brief Primer~

When you hear “OCD,” what do you think of? Someone washing their hands over and over again? Someone checking to make sure the backdoor is locked? Maybe you think of someone in your life who is a “perfectionist” or a “neat freak.” All of these symptoms and characteristics certainly do describe some individuals with OCD. But they can also describe people without OCD and fail to capture the true essence of what OCD is. OCD stands for Obsessive-Compulsive Disorder, and to properly understand what OCD is, we need to understand its two primary components – obsessions and compulsions.

The aspect of OCD that the culture at large is most familiar with is compulsions. This is the handwashing and the lock-checking that most of us think of when we hear “OCD.” Compulsions are specific behaviors – either physical or mental – that an individual feels compelled to enact. Compulsions come with a strong sense of urgency. Most individuals with OCD feel like they must do their respective compulsions RIGHT NOW. A natural question comes from this. Why compulsions? Why do they exist and feel so urgent?

To answer this question, we have to look at the first part of the OCD equation – obsessions. An obsession is an unwanted, intrusive thought, feeling, image, or urge. Unwanted and intrusive are the two keywords here. The individual with OCD does not seek out the thought (or image, urge, etc), and they experience it as an intrusion – as an outsider entering unbidden into the house of the mind. The individual finds the content of the intrusion emotionally disturbing. Therefore, they try to do something to make it go away. The things they do are the aforementioned compulsions.

Let’s look at an example. The well-known hand washing compulsion is common in individuals suffering from the contamination subtype of OCD. What is the obsession behind this compulsion? It may be an intrusive thought, “What if that doorknob I just touched is dirty?” Or, it might simply be a pervasive feeling of “dirtiness” whenever the individual stands near unwashed dishes. It is not uncommon in OCD for the obsession to be simply a distressing emotional experience, rather than a fully fleshed out thought. Regardless, the individual experiencing either one of these obsessive experiences then enacts a compulsion to try and make the experience go away. This is where the handwashing would come in. The individual furiously washes their hands, trying to scrub away the thought or emotional experience that distresses them.

Unfortunately, the compulsion does not make the obsession go away in a lasting sense. No matter how much the individual with contamination OCD scrubs, there will always be another source of contamination out in the world, another intrusive thought around the corner. But the compulsion gave them a little relief, even if just for a moment. So, the next time they experience an intrusive contamination thought, it is only natural to rush back to the sink. The distress is briefly scrubbed away… until they spot the next dirty dish or trash can. Thus, the cycle continues. Compulsion driving further compulsion.

Looking briefly at a second example will help us to understand the wide variety of OCD experiences. Individuals suffering from the scrupulosity subtype of OCD commonly experience intrusive thoughts related to morality or religion. The thought may be something like, “What if I committed a sin without realizing it? What if God is upset with me?” One of the most common corresponding compulsions in this subtype is excessive confession or prayer. When this happens, the behavior is driven by anxiety, rather than by devotion to a faith or belief system. The individual might feel compelled to pray or confess over and over again, until they feel like they “meant” it or they are satisfied that God isn’t “upset” with them. In this example, the individual prays so they can find relief from their intrusive “what if” thoughts about God and sin. Unfortunately, just like in the previous example, this relief is only temporary.

The key to OCD treatment lies in breaking this cycle. Exposure and Response Prevention, the most popular treatment for OCD, contends that the best way to stop the cycle is to stop these compulsions. Human beings cannot reliably control our thoughts and feelings, or the number of “dirty” dishes we run into in the world. What we can control is our behavior. Therefore, honing in on the “C” in OCD is our best path forward. By allowing intrusive thoughts (the “O”) to simply be there, without doing anything to try to make them go away, the individual with OCD learns overtime that they do not need to participate in compulsions. They learn that, in fact, intrusive thoughts usually go away on their own. They learn that their feared outcomes do not actually happen. Breaking the compulsion driven OCD cycle is what allows this new learning to take place. The individual with contamination OCD learns that nothing bad actually happens if they don’t wash their hands after touching a dirty dish. As the compulsions take a back seat, the individual with OCD is able to respond to thoughts more effectively, and get back to living a functional, meaningful life.