The Many Faces of OCD

In the last blog post, I gave a general overview of the experience of OCD and some first steps involved in stepping out of the OCD cycle. I want to turn attention now towards the different ways that OCD presents itself.

The Many Faces of OCD

The range of human fears is innumerable, and thus, there are many faces of OCD. However, there are patterned ways that OCD presents itself. These patterns or themes are referred to as “subtypes”, and are labels that are used to identify and differentiate the symptoms and experiences between different OCD sufferers. These “subtypes” of OCD aren’t different diagnostic labels; They are all OCD. But we use these labels as a short form way to organize and make sense of the types of obsessions, core fears, and compulsions someone experiences. Common subtypes include: 

• Harm OCD 

• Contamination OCD 

• Scrupulosity OCD 

• Order/Symmetry OCD 

• Perfection/”Just Right” OCD 

• Relationship OCD 

• Pure “O”

• Perinatal OCD

• Magical Thinking OCD

• Pedophilia OCD

This list may seem overwhelming, and it is. But what’s really interesting is that these subtypes also fall into distinct “groups” and themselves have their own themes. In fact, research on these different subtypes of OCD have identified 4 main OCD “clusters” or dimensions (Abramositz, 2009): 

• Concerns about being Responsible for Harm, Injury, or Bad Luck 

• Concerns about Contamination

• Unacceptable Thoughts 

• Concerns about Symmetry, Completeness, and the Need for Things to be “Just Right” 

These dimensions cover close to all of the ways that OCD can manifest and are used to conceptually understand and differentiate the ways that OCD presents itself, which has major treatment implications that I will explore in upcoming articles. Let’s dive into them.

Concerns about being Responsible for Harm, Injury, or Bad Luck 

This dimension refers to concerns about unknowingly or unintentionally causing or experiencing harm (injury, illness, bad luck, etc…) in some way. This dimension captures possible subtypes like Magical Thinking OCD, Existential OCD, or Scrupulosity OCD. Some examples include (Abramowitz, 2009): 

• Doubting whether you might have made a mistake that could result in something harmful or catastrophic.

• Worrying that a serious accident, disaster, injury, or other misfortune occurred because you weren’t careful enough to prevent it.

• Believing you can prevent harm or bad luck by performing actions in a specific way, counting certain numbers, or avoiding "bad" numbers or words.

• Fearing the loss of something important, like a wallet or documents, even if the likelihood of losing it is very low.

• Repeatedly seeking reassurance or checking to confirm that something bad didn’t (or won’t) happen.

• Mentally reviewing past events to ensure you didn’t make a mistake or do something wrong.

• Feeling compelled to follow a specific routine to prevent harm or disasters.

• Counting to certain numbers or avoiding "bad" numbers to reduce the fear of harm occurring

Concerns about Contamination

This dimension refers to concerns about contamination, which includes the common subtype of Contamination OCD, but also includes a lesser known subtype OCD called Emotional Contamination OCD, which involves concerns of being “contaminated” by certain people or certain places, and involves fears of taking on negative personality traits or being contaminated by certain environments that are thought to have “bad luck” (International OCD Foundation, 2009). For more in depth exploration of this subtype, check out this article: https://iocdf.org/expert-opinions/emotional-contamination/. Some other common examples of Contamination OCD are (Abramowitz, 2009):

• Thoughts or feelings that you have been contaminated due to contact with, or proximity to, a specific object or person.

• A sense of contamination from being in a particular place, such as a bathroom.

• Worries about germs, illness, or spreading contamination to others.

• Engaging in behaviors like handwashing, using hand sanitizers, showering, changing clothes, or cleaning items to address contamination concerns.

• Following specific routines (e.g., in the bathroom or while getting dressed) to mitigate feelings of contamination.

• Avoiding certain people, objects, or places to prevent perceived contamination.

Unacceptable Thoughts 

This dimension refers to having intrusive, taboo thoughts about sex, religion, or violence. This is often one of the most taboo and less understood subtypes of OCD, and causes significant distress and deep confusion, shaking suffers to the core of their being. This dimension includes subtypes like Scrupulosity OCD, Pedophilia OCD, Perinatal OCD, Harm OCD and others. Some examples could include: 

• Having intrusive thoughts and images of stabbing someone else or oneself with a knife

• Intrusive images of seeing someone's eyes being gorged out of their face while in conversation with them

• Intrusive thoughts of pushing a stranger, close friend or family member into on going traffic while on a walk

• Hearing the words “just kill them” while talking with a loved one

• Experiencing intrusive unwanted sexual or thoughts images or scenes between oneself and strangers, loved ones, or even religious figures

• Repeating certain actions or following specific routines in response to disturbing thoughts.

• Mentally engaging in rituals, such as saying prayers or performing mental actions, to counteract or eliminate unwanted thoughts.

This subtype brings up a very important concept and distinction in the field of psychology and in OCD treatment: the distinction between Ego Dystonic and Ego Syntonic thoughts. Ego Dystonic thoughts refer to thoughts that go against your core values and deeper intentions and aspirations (in other words, things you don’t want to do), whereas Ego Syntonic thoughts refer to thoughts that are in alignment with your core values and deeper aspirations (in other words, things you do want to do). It is this subtle yet major distinction that differentiates true homicidality or suicidality, from OCD; what makes intrusive thoughts intrusive and downright scary. Again, how could we experience thoughts, feelings, even urges about doing something that you don’t want to do? This is a profound mystery and bizarre action of the human brain. In fact, intrusive thoughts, across all of these dimensions, are a universal and common feature of the human experience (Clark & Rhyno, 2005). In other words, just because you have intrusive thoughts doesn’t mean that you have OCD. The difference between OCD suffers and non-OCD suffers isn’t in content, but in interpretation. I’ll cover this idea in more detail in subsequent articles.

Concerns about Symmetry, Completeness, and the Need for Things to be “Just Right” 

This category pertains to concerns about needing to be a certain way, and includes the subtypes of “Just Right”, Perfection, and Order/Symmetry OCD. Some examples include (Abramowitz, 2009): 

• Having strong concern for symmetry, balance, or precision

• Feeling a sense that something feels “off” or not quite “right.”

• Repeating actions or routines until they feel “just right” or perfectly balanced.

• Counting meaningless items, such as ceiling tiles or words in a sentence.

• Compulsively organizing or arranging items in a specific “order.”

• Repeating phrases or words multiple times until they feel “just right.”

The experience of this subtype may not involve intrusive thoughts; instead, it can sometimes involve intrusive, somatic feelings of discomfort or imbalance, which then drive compulsive organizing, (re)arranging, (re)reading, (re)editing or any other type of “undoing” behavior or related compulsion.

Coming Up

It’s important to note that we all have these types of concerns and worries in each of these dimensions. We all take precautions to make sure something bad won’t happen; are worried about getting sick and avoiding illness; like to have things match up evenly or in a way that feels good; or have random intrusive thoughts about taboo topics. Just because you may resonate with anyone of these experiences or examples doesn’t mean you have OCD. Only a thorough assessment with a trained therapist could ever warrant a formal diagnosis.

In the next article, I’m going to explore more in depth the biology underlying OCD and provide an overview of Exposure and Response Prevention, the gold standard treatment for OCD. For more information regarding the different subtypes of OCD, please check out this link at the International OCD Foundation (IOCDF): https://iocdf.org/expert-opinions/subtypes-of-ocd/. I hope you’ve enjoyed this read and I’ll see you next week!

References

Abramowitz, J. S. (2009). Dimensional Obsessive-Compulsive Scale (DOCS). Retrieved from Retrieved from http://www.jabramowitz.com/uploads/1/0/4/8/10489300/docs.pdf

Clark, D. A., & Rhyno, S. (2005). Unwanted intrusive thoughts in nonclinical individuals: Implications for clinical disorders. In D. A. Clark (Ed.), Intrusive thoughts in clinical disorders: Theory, research, and treatment (pp. 1–29). The Guilford Press.

International OCD Foundation. (2009). Expert opinions: Emotional contamination. Retrieved from  https://iocdf.org/expert-opinions/emotional-contamination/

Eilertsen, T., Hansen, B., Kvale, G., Abramowitz, J. S., Holm, S. E. H., & Solem, S. (2017). The Dimensional Obsessive-Compulsive Scale: Development and validation of a short form (DOCS-SF). Frontiers in Psychology, 8, 1503. https://doi.org/10.3389/fpsyg.2017.01503