What is OCD?
“Omg I’m sooooo OCD…”
“I can get so OCD about…”
“He loves to cook but sometimes he can just get too OCD about it…”
“I’m such a neat freak! I’m probably OCD…”
These are probably a few ways you’ve heard about OCD - describing some trait or tendency in yourself or someone else. Perhaps you’ve even said these yourself a few times. If I were to ask you what is the first thing that comes to mind when you think of “OCD”, what comes to mind? I wouldn’t be surprised if you thought of someone washing their hands, reordering their desk, checking their alarm clock or stoves over and over, or something similar to these descriptions. Yes, OCD does and sometimes can manifest itself in the form of these “phenotypes” (presentations), but OCD is a MUCH more complex and less understood experience.
What is OCD?
OCD stands for Obsessive-Compulsive disorder, and has 3 central components/aspects: Obsessions, Compulsions, and Impairment. Often, OCD is used as an adjective to describe some trait or tendency about someone, but in reality, it is a distinct mental health condition. Even as someone who is trained in OCD, I’m not a fan of what the terms “Obsessions” and “Compulsions” refer to in OCD because they are easily confused for other colloquial meanings. I like to think of “Obsessions” as intrusive mental phenomena that can take the form of specific thoughts, feelings, or urges which cause extreme distress and anxiety and which you don’t want. This may sound confusing: How could we experience thoughts, feelings, even urges about doing something that you don’t want to do? This is a profound mystery and the crux of the condition; the central reason why it makes us question and doubt the deepest notions and beliefs we hold about ourselves. Most of us feel that our thoughts and feelings define us. If we think or feel something, then of course that must reflect something about our core being and nature. A part of this is true, after all personality is really just our patterned way of thinking, feeling, and behaving. Yet a part of this is also not true. Thoughts are just that - thoughts, nothing more, nothing less. And it is this idea and deeply felt reality for OCD sufferers - that our intrusive thoughts (and the worrying and doubting that come afterwards) are significant or indicative in a deeper sense - that drives the cycle of OCD.
The nature and role of thought in everyday life can’t go understated. It’s estimated that we on average have around anywhere between 6,000 to 60,000 thoughts per day (Tseng & Poppenk, 2020). This is a beautiful and tragic reality. Our brains are basically supercomputers (prefrontal cortex) jerry-rigged on top of emotional, instinctive, survival mechanisms (mammalian brain). What this basically means is that now in addition to facing threats in the natural world, we also now have to face threats in the cognitive world. But not only that, threats in the cognitive world now feel as real and salient as threats in the natural world. This is why fears of the future, intrusive thoughts, or any other one of our anxieties (a.k.a fears in the cognitive world) feel like threats to our survival; like being face to face with a ravenous, hungry lion.
And thus it is no wonder that we try to do something about our intrusive thoughts to cope with the distress, confusion, and uncertainty they bring. To not do so feels like an act of suicide. In the case of OCD, this can look like doing something as overt as washing your hands over and over until it feels “just right” to saying a special phrase in your head a certain number of times, avoiding places, objects, or conversations, or engaging in any kind of minor distraction. These are all normal and natural responses - things that help us both quell the anxiety sparked by intrusive thoughts and seek reassurance and certainty about ourselves or the world. These things that we do in response to having intrusive thoughts - like seeking reassurance, avoidance, or making things “just right” - are what is meant by “compulsions”, which can take many different forms and vastly vary in severity. Compulsions are just the different ways that we try to prevent something bad from happening and seek control or certainty over our present environment. I like to use the word “safety behavior" instead. To seek safety is our deepest instinct and drive - that’s why we put on our seatbelt, have shelter, lock our doors at night, check the ovens and stove, or check in on close friends and loved ones. However, in the case of OCD, the ironic Catch-22 about compulsions is that while we do them to help protect us, they both continue the OCD cycle and thwart us from satisfying our other needs, like engaging in meaningful work, connecting with others, or taking care of our health. By engaging in compulsions, we fuel the idea that the intrusive thought, doubt, or worry is significant and the probability of our fear happening is likely. Yes, compulsions DO work - make us feel safer, more certain and less anxious, in the moment at least. Yet, doing them only validates the underlying fear that drives the compulsion in the first place.
Stepping Out of the Cycle
OCD has the longest “DUI” (duration of untreated illness) among all mental health conditions, ranging from 87.5-94.5 months (about 7-8 years) (Perris et al., 2023). This means that it takes someone who has OCD on average about 7-8 years to even start treatment. There are many possible reasons for this. There is obviously a cultural factor in terms of the public (mis)conception of OCD. But there is also the fact that the experience of OCD is so tightly linked to our sense of self and identity, creating a dizzying sense of shame and confusion.
How do we step out of the cycle then? Most branches of therapy up until the mid 1970’s thought that OCD was an untreatable condition, that is until the advent and popularization of ERP (Exposure and Response Prevention), a branch of CBT (Cognitive-Behavioral Therapy) (Abramowitz, Deacon, & Whiteside, 2019). ERP is a two fold process: Exposure and Response Prevention. Exposure is the process of identifying the exact triggers of your obsessions, and intentionally approaching those feared triggers. Of course, this process is done in a gradual, stepwise manner with a trained therapist. Response prevention, then, involves intentionally and voluntarily refraining from engaging in compulsions after exposure to those triggers. The profound implications of engaging in response prevention can’t go understated. By doing response prevention - that is refraining from doing a compulsion or safety behavior after exposure to a trigger - you voluntarily render yourself vulnerable to the very threat your fears have been trying to protect you from. This may sound daunting and downright counterintuitive: Why in the hell would I intentionally expose myself to the very thing I’m trying to protect myself from?!
Yes. I know. Here is the paradox though: In doing so, you allow yourself the opportunity to face the fear, inspect it for yourself, and learn something new about yourself and how scary it actually is. Do you think Dorothy would’ve learned that the omnipresent, all-powerful Oz was actually just a man, and that the idea of the grand Wizard of Oz was all just an elaborate hoax and illusion if she never journeyed into the Emerald City? Probably not. Our fears in OCD aren’t that different. By approaching them and inspecting them with our senses can we finally become released of them.
Coming Up
In the coming articles, I am going to further dive into the different subtypes and manifestations of OCD, as well as explore some common questions/confusions about ERP in OCD treatment, and probably wander down a few interesting rabbit holes along the way. I hope you’ve enjoyed this read, and I have attached a few more resources if you are curious, resonate with any of the above ideas, or are yourself or someone you know is suffering from OCD. See you next week.
Citations/References
Perris, F., Cipolla, S., Catapano, P., Sampogna, G., Luciano, M., Giallonardo, V., ... & Catapano, F. (2023). Duration of Untreated Illness in Patients with Obsessive–Compulsive Disorder and Its Impact on Long-Term Outcome: A Systematic Review. Journal of Personalized Medicine, 13(10), 1453.
Radomsky, A. S., Alcolado, G. M., Abramowitz, J. S., Alonso, P., Belloch, A., Bouvard, M., ... & Wong, W. (2014). Part 1—You can run but you can't hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 269-279.
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). Guilford Press.
Tseng, J., & Poppenk, J. (2020). Brain meta-state transitions demarcate thoughts across task contexts exposing the mental noise of trait neuroticism. Nature Communications, 11, Article 3480. https://doi.org/10.1038/s41467-020-17255-9
