Obsessive Compulsive Disorder is a disorder in the diagnostic and statistic manual of mental illness. It is characterized by intrusive obsessive thoughts which are distressing, and performance of repetitive compulsions aimed at alleviating the distress. OCD is among the top 10 leading causes of disability worldwide, and about 65% of individuals with the disorder experience depression alongside it. There are many misconceptions around OCD and the term is often used lightly, much to the chagrin of those living with OCD. They often think to themselves “if only you knew”. Individuals with OCD live with debilitating fear and anxiety. Their fears are specific, and the compulsions they perform can take over their lives.
What does OCD look like?
Most individuals with OCD realize that their fears are distorted and out of proportion, and that they likely will not come to pass in the way that they are feared to, and yet the anxiety, obsessive thoughts, and compulsions persist. This is because OCD is a cycle which a person can get stuck in. Individuals get caught in cycles of obsessive thoughts and worry which affect their mood and emotional state, which in turn leads to increased obsessive thoughts.
It is important to note that fearful obsessions in OCD are not generalized, they are very specific, and there is a variety of different ways OCD can present due to a wide variety of fearful obsessions people experience. Individuals may fear germs or contamination, contaminating others (common during COVID), harming themselves or others, fears surrounding sexual identity and/or orientation, and many others. When the specific worries and obsessions are persistent and unbearable, the individual may eventually start feeling compelled to perform certain behaviors to alleviate the distress.
These specific, often ritualized compulsions, are a result of the brain unconsciously producing involuntary compulsions to act in whatever way it “thinks” will reduce the anxiety. Initially intended as a coping mechanism, these compulsions can become powerful and relentless. The greater the state of anxiety, and the more the person gives in to the to compulsion or flees the trigger, the more strongly they will come to feel the compulsion.
Acting on the compulsion and experiencing relief quickly leads the compulsion to become a neurobiologically wired coping mechanism, meaning they will continue to experience it when they feel anxious, especially if the anxiety is originating from their obsessive fears. Because the compulsions are a maladaptive coping mechanism, meaning they result in short term relief but increasing long term dysfunction, the compulsions become a progressive problem. Individuals may reach a point where they are performing these specific behaviors for more than an hour, sometimes many hours, every day.
It is possible in OCD to have more than one fear, and individuals who experience OCD may experience it at different times in their lives, sometimes with a recurring theme, or with a different one altogether. OCD often develops during times of intense stress, when anxiety is unrelenting. A rational or irrational fear may present and the individual can get caught in the anxiety cycle of worry, avoidance, and compulsions.
Some individuals seem to be more susceptible to OCD than others, experiencing relapses and multiple episodes with different themes. Some individuals seem to be more prone to getting stuck in obsessive thoughts than others. Research has found hyperactivity in the CSTC (cortico-striatal-thalamo-cortical) loop of the brain in individuals with OCD, among other findings, and it is possible that genetic differences account for some of the risk of developing OCD.
Keep in mind that every person engages in compulsive behaviors, tics, and other behaviors which may alleviate anxiety. According to the DSM a person should not receive the diagnosis unless the compulsions cause clinically significant distress, or they engage in the compulsions for more than an hour a day.
Different types of compulsions
Whereas there are many different fears and themes to OCD, there are also different types of compulsions. Perhaps the most important distinction to make between compulsions is whether they are egosyntonic, or egodystonic. Is there moral distress related to the compulsion? The compulsion to endlessly check the stove (no moral distress) would be considered egosyntonic, but the compulsion to harm others (high moral distress) would be considered egodystonic.
This distinction is important because individuals will respond differently to these compulsions. Individuals with egosyntonic compulsions experience relief from the compulsion and may act on it regularly, but individuals with egodystonic compulsions experience distress from the compulsion and begin to avoid situations, people, events, etc. where these distressing compulsions may arise. Both responses lead to exacerbation of the condition.
OCD compulsions versus addictive cravings
For individuals with ego dystonic compulsions, it may be helpful to draw a distinction between the temptation experienced with addiction and cravings, and the compulsions experienced in OCD. They are not the same, in fact aspects of their treatment are in direct opposition to each other. With addictive cravings and temptation, avoidance of triggers is important and leads to improvement in the condition. With OCD compulsions, avoidance of triggers leads to worsening of the condition.
Perhaps the most important distinction between addictive cravings and OCD compulsions, is that there is no desire or craving associated with the compulsions of OCD, as is the case with addiction. Individuals with ego dystonic compulsions are horrified at the thought of acting on their compulsions, and they fear one day losing control of themselves. Individuals who experience addictive type cravings likely are not horrified at the thought of acting on their cravings, and often operate in a sense of denial, believing that they are in control of themselves. As addicted persons realize that they are not in control, and as individuals with OCD realize they are in control, their respective disorders will improve.
Individuals with both disorders concurrently may confuse the two, thinking that because they feel out of control with their addictive behaviors, they might lose control in other areas of life as well. However, one should not be concerned that an individual with egodystonic compulsions is going to act on a compulsion. One should be more concerned for the safety of the person who feels compulsions to harm others, than for the safety of those the individual is afraid they will harm.
Cognitive Distortions
Another important concept in OCD is that of cognitive distortions. Perhaps all cases of OCD (and most disorders where anxiety is a symptom) experience some degree of cognitive distortion. A cognitive distortion, in this context, is a distorted belief that arises in the presence of intense anxiety. To put it simply, it is something an individual may believe in a state of high anxiety which they would not normally believe if they were not extremely anxious. These distortions may come and go from one moment to the next based on a person’s mood or anxiety level at the time.
Individuals with OCD tend to experience cognitive distortions intensely and frequently, to the point that even clinicians in some cases confuse it with psychosis. They may at times truly believe and feel convinced that the house is on fire, that they have contracted a serious illness, or that they are becoming or going to become a murderer, child molester, or commit suicide. Individuals with OCD may even ask themselves, “am I crazy?”. These cognitive distortions are not psychosis and will improve or worsen along with the condition.
In OCD the brain essentially becomes hardwired toward certain fears, the adage of “neurons that fire together wire together” ringing true here. The fears become pathological and for this reason an outside observer may not understand it or consider the individual’s thinking and behavior odd, and even the individual themself generally knows that their fear is out of proportion to the danger it presents.
How do you treat OCD?
The most important treatment for OCD is Exposure and Response Prevention (ERP). Put simply, you must expose yourself to the fear without performing the compulsion. Additionally, avoidance of the fear will cause the fear and compulsion to become stronger. This process takes courage, willpower, and diligence. It can be difficult, especially at first, and you may need to go at your own pace. Remember that it gets easier. It may be helpful to focus on your reasons for recovering to help produce the motivation needed.
Keep in mind that if you are experiencing OCD, you have not “ruined” your brain. OCD is a treatable disorder. The prognosis is highly variable and dependent upon diligence in treatment. It may remit completely, but even severe cases can reach a point in recovery where the disorder no longer bothers them regularly. It is possibly to improve and remit partially if the individual does not complete ERP thoroughly and for a sufficient length of time.
As a general rule, the more diligently one pursues ERP, the more quickly and thoroughly they will recover. Keep in mind, however, that recovery from OCD will take time. Changes in the brain are progressive, and times of stress and mood instability can lead to recurrence of symptoms. Each person and every case is different, and the length of time to achieving remission can range widely. It is common that even in long term recovery and remission, traces of the disorder may remain, ranging from gentle compulsions on rare, stressful occasions, to fears occasionally being re-experienced during times of stress, albeit to a lesser degree. Medication can be helpful in recovering from OCD, but it should not be seen as a replacement for Exposure and Response Prevention.
Sometimes the most important thing an anxious person, or individual with OCD can do to stabilize their mood, is to break out of the worry cycle, filling themselves with a determined resolution to not worry about their specific fear the next time it cognitively or materially shows up, no matter how hard it is to push it away.
Remember that each trigger is an opportunity to expose yourself to the fear without responding. It is an opportunity to recover and re-educate your brain on what it should and shouldn’t fear. If you have tried and failed, then muster the courage to try again to overcome your OCD. The most important thing you can do is not give up!
