By Kathryn Spence
Accredited BACP Psychotherapeutic Counsellor, Accredited BABCP CBT Therapist, EMDR Therapist
InnerFocus Therapy
09 December 2022
What is OCD?
OCD is 'well known' about publicly but it is often misunderstood and there are so many different facets and maintenance cycles that it can be hard to fully understand and then recover from. In this article I am going to try and explain in one place these different facets as a 'one stop summary' to build understanding and help with recovery.
OCD is characterised by obsessive thinking or intrusive thoughts which lead to feeling intensely distressed (most commonly feelings of anxiety, but also shame, guilt, anger, sadness), these emotions and sensations feel intolerable and so we act in ways to neutralise the thoughts, or in ritualistic or compulsive ways, to reduce the associated distress.
The Three Variations of OCD
‘Pure O’ is when we are experiencing mainly obsessions and intrusions with fewer overt compulsions. For example, intrusions might include thoughts of harm to loved ones, which causes the person to feel scared of the thoughts and may use compulsions such as cognitive avoidance i.e. trying to push the thought away, or seeking reassurance from another person to reduce the distress.
‘Pure C’ is more common when a person has no obvious intrusive thought which triggers the compulsion. But it would be an error to think the person has no thoughts, when we dig deep enough it is caused by a fear about something, but it is driven by more of a felt discomfort. For example, a sensory feeling or anxious body sensations, which feel too uncomfortable to tolerate. This leads the person to do something to get rid of the feeling, they might use compulsions such as ordering or cleaning until the feeling passes.
OCD is a more obvious combination of both obsessions and compulsions. A situation triggers a thought, which leads a person to feel anxious, and thus leads the person to do something (a compulsion) to try and reduce the danger. For example, someone driving their car, has the thought “What if I hit someone on my journey?”, they feel anxious that this might have happened (because they thought it), they start to imagine the consequences and the impact if this is true, which leads to intolerable feelings of uncertainty and anxiety. To cope, the person may re-drive the route and check no one is injured, search the web and look for reports of an accident etc. until they're reassured enough no-one has been hurt.
Sub-Types of OCD
There are so many commonalities between people with all variations of OCD, but unlike other diagnoses, OCD presents differently for people too. There are many sub-types of OCD depending on the fear a person is experiencing, here are some of the most common:
Relationship OCD (R-OCD)
It is normal to question our relationships from time to time and we may have genuine feelings about our commitment to our relationship. However, in R-OCD, we experience constant doubts about whether you should / shouldn’t be in your relationship or whether your feelings are strong enough. This is considerably more frequent and intense that typical doubts and overshadows the relationship; we get caught up in the doubts and uncertainty, which leads to over-questioning or checking behaviours in order to try and resolve the doubts and reduce the distress we feel. This can lead people to end their relationship to get rid of the distress the doubts are causing. However, this continues into future relationships.
Contamination OCD
Obsessive thoughts about being contaminated by germs, contracting an illness, or feeling overly-responsible and guilty for causing illness in others we care about. This leads to increased avoidance of anything we deem as ‘dirty’ and washing compulsions i.e. hands, clothes, items we touch, items in the house.
Sexual / Paedophile OCD (P-OCD)
Obsessive intrusive thoughts that you are a paedophile or about i.e. violent sexual acts, which causes a great deal of shame, guilt, and fear. These thoughts are typically very upsetting (rather than enjoyable) and lead to avoidance as people often do not open up about these thoughts for fear of judgement or being disowned. However, these intrusive thoughts are very common, which many people experience and should not be confused with perpetrators (the feelings, behaviours and intentions of the thoughts are very different).
Harm OCD
Intrusive thoughts, images or urges of causing harm (or harm coming to) someone we care about, and can also include strangers. We then feel fearful of acting on these thoughts and internalise that we are ‘bad’ for having them. This is often managed by neutralising the thoughts, avoidance and sometimes rituals such as repeating a phrase, counting, doing something repeatedly to make sure the feared outcome doesn’t come true (even though the behaviour is unrelated to the situation e.g. switching light switches a certain number of times so mum doesn’t die), or compulsions such as hiding dangerous objects, reviewing actions to check you didn’t do it or seeking reassurance.
Checking OCD
An intense fear that you will cause something bad to happen (intentionally or not). This leads to repetitive behaviours to check for safety, such as checking the door is locked, the cooker is off, that you haven’t left the iron on. Often this is driven by an over-inflated sense of responsibility and feeling of guilt that you are to blame if something was to happen. Therefore in an attempt to cope with the doubt, you check, make a mental note of turning something off, take photos etc. to reduce the uncertainty and anxiety.
Existential OCD
Obsessing about questions that cannot possibly be answered, such as the purpose of life or whether you’re real, and being unable to move past these questions. As with other types of OCD, the doubt and uncertainty feels intolerable, so you may use compulsions to try and reduce your anxiety, i.e. spending hours thinking about the question, researching the thoughts in order to find answers, seeking reassurance.
Hyperawareness or Sensorimotor OCD
A heightened sensitivity to sounds or visual stimuli, such as flickers of light, certain colours, chewing noises, traffic noises or breathing sounds. Which leads to obsessing about the stimuli and a fear of feeling trapped in a cycle of hyper-awareness that we cannot escape from. To cope with this, you might use compulsions such as body scan, mental checking to see if it’s ‘normal’, use distraction, seek reassurance, research or avoid places where you might be triggered.
Sensorimotor OCD
A hypersensitivity to bodily sensations, which we become pre-occupied with leading to feelings of distress. Such as clicking joints, visual floaters, swallowing or skin sensitivities, which then need to “feel right”. We develop ‘selective attention’ to the sensation and therefore attend to them more, become obsessive and this increases distress and we find it difficult to focus in every day life.
OCD Behaviours
OCD behaviours fit into the ‘C’ in Obsessive Compulsive Disorder, but can fit into different sub-categories:
Neutralising
A cognitive behaviour to neutralise (try and reduce or null) the thought and feelings. This can include trying to substitute the thought with another more neutral thought, trying to push the thought away (thought suppression), avoidance, distraction or transformation of fearful images into verbal thoughts.
Compulsions
An urge to do something to prevent the feared outcome from coming true, such as checking, washing or cleaning, seeking reassurance, counting or praying.
Rituals
Rituals are compulsions but follow a more systematic pattern until it “feels right”. This may include counting a certain action which cannot be interrupted, repeating precise movements or phrases, or ordering.
Avoidance
Any behaviour which takes us away from the feared object, avoidance of places, people, reminders, items, as well as distraction or procrastination.
The Fundamentals of OCD
Misinterpretations
We all get intrusive thoughts! It’s totally normal and has been proved in many experiments. But we don’t all develop OCD; one of the reasons we do, is because we misinterpret that the thoughts mean something.
“Because I thought it, it must be true”
“I’m bad to have these thoughts”
“I’m responsible for preventing harm to others”
“Something bad will happen because I thought it”
“It’ll be the worst thing to happen”
“I won’t be able to cope if it happens”
Instead we need to know we have 70,000 thoughts a day (wow!), some are positive, some are neutral, some are negative, some are helpful, some are not, you are normal for having intrusive thoughts, let them pass, they don’t have to mean anything.
Some Examples of Normal Intrusive Thoughts |
In studies 80-99% of people surveyed had at least one unwanted unpleasant thought in the last month, some include:
|
Ego-Dystonic Thoughts
Pure-O is most commonly the experience of intrusive thoughts which are ‘Ego Dystonic’. This means the thoughts are the opposite of what we believe in and who we are. This is why they usually shock or appal us, but they are really just your brain trying to protect us by making sure we’re staying in line with our morals. A way to help distance ourselves from our thoughts and realise they are just thoughts is to say “I notice I have just had the thought that…” and let the thought pass.
Thought-Action Fusion (and Magical Thinking)
Thought-Action Fusion is the belief that because I thought about that unwanted event, it is more likely to happen. For example:
“Because I thought about getting a germ off a door handle and passing a disease onto my baby, the thought itself increases the chances of it happening, so I must act in a way to stop this happening”. This can then lead to compulsions such as avoidance or excessive cleaning etc.
“Because I thought I am going to scream out in church, then I will do it”.
The basis of this type of thinking is in how our brain works before the age of around 7 years old. At around 7 years old, we enter a developmental stage called ‘The Age of Reason’, where a child becomes more capable of rational thought. Before this stage, children still thinking very ‘magically’ and believe without questioning what they’re told, so the old phrase “Step on a crack, break your mother’s back” feels like truth. This happens with superstitions too; saying something positive and then having to touch wood in case it now won’t come true.
What we need to learn is that our thoughts and actions are separate. We have no control about intrusive thoughts entering our minds, but we can control our actions. Just because we think something doesn’t make it true… “If I think about winning the lottery, I don’t win the lottery!”
Emotional Reasoning Error
Emotional Reasoning is basing our judgements about a situation on how we feel rather than on objective information. For example, “I feel bad so it must be bad” or “I feel scared so it must be dangerous”. In OCD the underlying belief system is something like; “My thought made me feel scared, so it must be scary and therefore I need to act”. To update this belief, we can think “I notice I have had an intrusive thought, and my feeling is a reaction to that thought, is there any evidence? No, then don’t act and let the thought and feeling pass”.
Attention Bias
Once we become fearful of something, our brain is programmed to look for signs of danger associated with it; all in a bid to survive. This is a helpful process when there is real danger. For example, if you’re bitten by a poisonous snake and receive treatment and survive, you may start to unconsciously look for signs of this happening again. This is in order to help us spot the danger early to avoid it happening again; you spot a tie lying on the floor out of the corner of your eye and think it’s a snake. It happens as quick as a flash, without thinking (we don’t have time to think if we’re in danger, it’s safer to run and realise it wasn’t really dangerous later).
But this turns into a problem when there is no real danger. Our brain will still seek out survival at all costs, and if we perceive something as dangerous, our brain acts as if it is and signals the release of adrenaline and cortisol (anxiety hormones) through our body to prepare us for action (fight/flight/freeze). We then start to associate anything to do with the feared situation as a sign to protect ourselves. But then we spot danger when there is no danger and the attention becomes wider and wider.
In situations such as this, play spot the difference; “That was then, this is now. What’s different now? Is there any current threat happening?”
Intolerance of Uncertainty leading to Anxiety and Distress
A underpinning fear of most anxiety disorders, is being unable to tolerate doubt or uncertainty, and the associated anxiety and distress we feel when we’re worried about the future. Uncertainty is a fact of life, we can be certain of our past and what’s happening right now, but not what will happen next. We need to build up our tolerance and confidence at coping with uncertainty, as well as see when uncertainty has been positive e.g. a surprise present, an unexpected win, bumping into a long-lost friend and being pleased to see them, the examples are endless. Life would be no fun at all without uncertainty.
Neutralising or Cognitive Avoidance
When we think something we don’t like, it makes logical sense to try to push it away and not think about it, but there is a problem with this… Try this experiment:
The Pink Bunny Experiment (Thought Suppression) |
Imagine a pink bunny rabbit - its size, shape, texture, any sounds, any smells, how you feel about it. Now, for the next two minutes, think about anything that you want to think about, but whatever you do, DON’T think about a pink bunny. How did that go? I bet the thought of a pink bunny popped in your mind during that two minutes, even though you’ve never thought of one before? |
This is the “Ironic Process Theory”, which leads to two effects:
The Enhancement Effect – we think about the thing we’re trying to avoid more in the moment.
The Rebound Effect – the thought / image we’ve been trying to suppress will pop up intrusively at any given time with no obvious reason / trigger.
The more we try and control or avoid our thoughts the more they will come, the more we leave them alone, the less they will bother us. We get 70,000 thoughts a day! Your thoughts will come and go without you having to DO anything. Let them pass.
Compulsions & Rituals
All compulsions and rituals are additional behaviours we do in order to seek a feeling of safety, when they work temporarily or work on occasion it makes them habitual – we will keep doing them as they give us some relief.
However, they don’t allow us to find out we could cope without the behaviour, that the thoughts don’t come true, that the distress and anxiety passes by itself, it creates more doubts in the long term and the OCD snowballs. In time, the compulsions and rituals take up more and more time and energy and causes problems in every day life and in our relationships.
Avoidance
Avoidance is similar to compulsions and rituals above, we avoid to feel safer and avoid feeling anxious, and it works for as long as we can avoid the item, situation, person etc. But then more and more things become triggering and we have to avoid more and more of them to stay feeling safe. This works when the feared thing is actually dangerous, but when it isn’t, we don’t get to learn it’s safe and we can cope and the anxiety will pass by itself in the situation. Often anticipation is worse for this reason.
The Role of Early Experiences / Trauma
In my experience, all anxiety related disorders are rooted back to early experiences or traumas; it makes sense that our individual psychology is shaped during our development. It is therefore fundamental to understand these links in order to understand our OCD. Treatment varies depending on the needs of the individual, but a good understanding helps us understand how our OCD is trying to help us in the present, but it’s got itself all tangled up and is causing more problems than it’s trying to solve. Early experiences can include:
Emotional neglect and not knowing how to manage emotions so they feel overwhelming.
Feeling out of control as a child, so turning our attention to what we feel we can control - our behaviours.
High expectations put on us as a child to achieve.
Bullying.
Moral teachings.
Numerous childhood illnesses.
Abuse.
Watching pornography as a child.
Traffic accident.
Any form of trauma.
The list is endless.
It is the child’s interpretation of these events, coping strategies, emotional support etc. which can lead to the development of OCD as a child or later as an adult.
Treatment
There are various forms of therapy to help with OCD; I am going to discuss the therapies I am trained and experienced in, which have led to success in the clients I have worked with who present with OCD: CBT (ERP), EMDR and Psychotherapeutic Counselling.
Cognitive Behavioural Therapy – Exposure and Response Prevention
The main focus after understanding or formulating your OCD is the treatment of Exposure and Response Prevention (ERP). This has been shown to be an effective treatment of OCD and helps to ‘undo’ the maintenance cycles of OCD by changing our behavioural responses, rather than challenging the contents of our obsessions.
Our compulsions seek to reduce our distress and may work in the short term, but they also lead to numerous consequences. ERP involves exposure to the thought / obsession / triggers whilst preventing any of compulsive responses. Anxiety ‘habituates’ with continued exposure to safe triggers – this means the anxiety reduces in intensity and duration with repetition. It also increases our sense of coping and a reduction in anxiety in the long-term.
ERP allows us to:
Tolerate the uncertainty and associated anxiety / distress.
Find out our obsessions and associated misinterpretations aren’t facts.
Break the Thought Action Fusion belief system.
Think more rationally (rather than ‘magically’).
Learn our feelings are internal responses rather than something truly dangerous (emotional reasoning).
Learn to cope.
Re-claim our lives by reducing the time-consuming behaviours in the long-term.
I am going to explain the principles of ERP, however when we have OCD this is better planned and carried out with the help of a Therapist.
The key to ERP is that it is done in a structured, realistic and achievable way which isn’t going to ‘flood’ you with anxiety and end up causing the OCD to snowball even more.
Exposure must be Graded – make a list of all your triggers and compulsions, then rate your anxiety to each on a scale of 0-10 (0 being no anxiety, 10 being panic), order your list into a hierarchy. Start with the least anxiety provoking task first.
Response Prevention - stop ALL your compulsions whilst doing the exposure, overt behaviours such as checking, and covert behaviours such as neutralising or reassuring yourself.
Exposure must be Prolonged – you need to stay in the exposure until your anxiety has at least halved from your original score.
Exposure has to be Repeated – repeat this same exposure task until you no longer feel any anxiety (or have a score of at least 1/2 out of 10) before moving onto the next task on your hierarchy.
An example:
Touching a door handle (anxiety 4/10).
No handwashing, or avoiding touching anything or seeking reassurance.
Continue with the exposure until your anxiety has reached at last 2/10 then don’t wash your hands.
Do this numerous times per day/week until the trigger doesn’t produce anxiety.
Eye Movement Desensitisation and Reprocessing (EMDR)
EMDR is another effective treatment for OCD. EMDR works by allowing our nervous system and brain to ‘self heal’ by using Bilateral Stimulation (BLS) to ‘turn on’ our brain’s adaptive information processing system. Initially, with the help of a therapist you work through recent examples of your OCD until desensitised to triggers. Following this, you would identify and work through a ‘touchstone memory’ (the memories which led to the onset of OCD), as well as processing any future triggers.
Psychotherapeutic Counselling
In my experience, OCD is a coping strategy someone has adapted to cope with life, most often developing in childhood, which is why I think it is important to explore early experiences and find out the intentions of our obsessions and compulsions, e.g. to be safe, to avoid being held responsible for mistakes, to try and gain control. Understanding this helps us to update our Inner Child so we no longer feel the need to live our lives in these ways and releases us from our OCD. When used in combination with EMDR or CBT treatment can be enhanced for long-term effectiveness.
Next Steps for You or a Loved One
If you are suffering from OCD, or know someone who is, and feel one of these treatment approaches may be of help to you, please seek psychotherapy with someone who is experienced in treating OCD, so you can start to reclaim your life.
Show Sources:
PBS.org: "Piaget describes stages of cognitive development 1923-1952.
Keitaro, M., Nakao, T., Aikana, O., Sae, T., Hirofumi, T., Suguru, H., Taro, M., Kenta, K., & Shigenobu, K. (2020). Impacts of Stressful Life Events and Traumatic Experiences on Onset of Obsessive-Compulsive Disorder. Frontiers in Psychiatry, 11.
Rachman, S. (1997). A cognitive theory of obsessions. Behav Res Ther. 35, 793–802.
Rachman, S. A cognitive theory for compulsive checking. Behaviour Research and Therapy. 2002, 40, 625–639
Salkovskis, PM. (1999). Understanding and treating obsessive-compulsive disorder. Behav Res Ther. 37, 29-52.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles,
protocols, and procedures (2nd ed.). New York, NY: Guilford Press
Veale, D. & Willson, R. (2005). Overcoming Obsessive Compulsive Disorder: A Self-Help Guide Using Cognitive Behavioral Techniques. London: Robinson.
Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53(1), 5–13.
Various other sources of information learned over the years with no specific sources known.
Please follow me on Social Media for more information:
Facebook: @innerfocustherapynewcastle
Twitter: innerfocusther1
Instagram: innerfocustherapy
I am an accredited therapist and offer in-person therapy in Newcastle upon Tyne (UK) as well as online therapy within the UK. Please contact me to enquire about therapy: