Obsessive-Compulsive Disorder is frequently misunderstood and misrepresented. Popular media often portrays OCD as quirky or dramatic, missing the deeply distressing and disruptive nature of this condition. In reality, OCD is a mental health issue that can significantly interfere with daily life.
At Midpoint Counseling, we understand the complexities of OCD. Our goal is to provide education and treatment that help individuals gain freedom from the grip of obsessive thoughts and compulsive behaviors.
quick facts
- OCD affects approximately 2.3% of adults in the U.S.
- It is often undetected because it can look very different from person to person.
- OCD involves a cycle of unwanted thoughts and compulsions that temporarily relieve distress.
- The condition is highly treatable with specialized care.
CORE CONCEPTS
What is Obsessive-Compulsive Disorder?
OCD is characterized by cycles of obsessions and compulsions that interfere with relationships, work, and overall wellbeing.
Obsessions: Difficulty managing unwanted and intrusive thoughts, images, or impulses that cause intense distress.
Compulsions: Time-consuming behaviors that feel like they must be completed in order to alleviate the distress, even thought hey maintain the underlying problem.
This up-and-down pattern that can last for many years if not treated.
Nearly everyone experiences unwanted and intrusive thoughts, ideas, doubts, or images.1,2 In fact, the thoughts of people without OCD concern the same topics experienced by people with OCD! The difference is that rather than dismissing them, individuals with OCD often view them as threatening or significant, which leads to compulsive behaviors aimed at reducing discomfort.
Obsessive-compulsive disorder is common, affecting about 2.3% of adults in the U.S. at some point in their lives.3
Most of the time OCD is apparent by one’s early 20s, with about half of people experiencing symptoms in childhood.4
OCD is often undetected because it looks very different from person to person.5 Two people with OCD may display problems that sound completely different from one another. It also frequently co-occurs with other mental health issues, which can make it difficult for mental health professionals to diagnose unless they’re specifically trained on OCD and its various presentations.
COMMON THEMES IN OCD INTRUSIONS
Types of Obsessions
Obsessions are distressing, repetitive thoughts or images that feel intrusive and unacceptable. They arrive with a jolt and contain a strong urge to resist, control, ignore, suppress, or dismiss them. The mind, in other words, gets "stuck" on something it finds highly distressing and can't get off it.
Doubt is what keeps obsessions spinning.
The themes often revolve around questions that can't be answered definitively, which fuels ongoing cycles of anxiety.
Examples of obsessive themes:
Contamination or disease
Violence or harm
Sexuality
Morality or blasphemy
Making dangerous mistakes
Horrific or disgusting images
Symmetry or things not feeling "just right"
BEYOND ANXIETY
Dysphoria in OCD
What distinguishes OCD from anxiety disorders is the experience of “dysphoric” emotions that are separate from the anxiety.
OCD is not just anxiety.
Dysphoric emotions are most often profound feelings of guilt, shame, or embarrassment due to the disturbing nature of the obsessive thoughts. This unfortunately keeps many people from reaching out for help. It also means that the compulsive behaviors used to lower this discomfort can be quite private and not obvious to anyone else.
COMMON RITUALS FOR RELIEF
Types of Compulsions
Compulsions are physical or mental actions performed to reduce the discomfort caused by the obsessions. They may be obvious (overt) or hidden (covert).
Overt
- Repeated washing
- Checking
- Ordering or arranging
- Reassurance-seeking
- Confessing
- Undoing an action
Covert
- Counting
- Memory checking
- Self-reassurance
- Mental undoing / repeating
- Arguing internally
- Ritualized prayer
- Monitoring or planning
Compulsions are any observable behavior or internal mental ritual that feels driven, pressured, and necessary.
All forms of compulsive behavior are intended to create a feeling of safety, calm, or order. If they’re not able to be completed for some reason, the emotional discomfort will continue to increase.
THE SCIENCE BEHIND OBSESSIONS AND COMPULSIONS
Biological Factors that Contribute to OCD
No body scan can diagnose OCD, but research points to certain brain-based differences in people with OCD:
Variations in orbitofrontal-subcortical circuitry, which is responsible for shaping thoughts, directing attention, detecting errors, and influencing motivation.6
Variations in the medial prefrontal cortex, which leads to excessive self-focused attention and preoccupation with negative evaluations.7
Altered activity in the insula, which leads to increased preoccupation with what your body is feeling and appears to play a role in sensitivity to feelings of disgust.8
Genetics and environment both play a role in the development of OCD.
The International OCD Foundation reports: "There is no definitive evidence that OCD is a learned behavior or is solely caused by environmental factors." 9
Presently, genetic factors appear to explain 45-65% of the variance of OCD symptoms at different ages, with the remainder being influenced by differences in environment.10
Midpoint Counseling offers virtual and in-person care for OCD. Contact us to learn more.
EVIDENCE-BASED APPROACHES TO TREATMENT
3 Targets for Treating OCD
Effective OCD treatment focuses on interrupting the avoidance patterns that sustain the disorder.
People who work to let go of avoidance as a strategy and aim for these three core targets are much more likely to regain the sense of flexibility in their lives that has been lost.
1. Build your tolerance of uncertainty.
Rigidly seeking certainty fuels OCD. Treatment helps you learn to accept ambiguity and remain engaged in life despite unanswered questions.
When you don't have this flexibility, life becomes about unnecessarily controlling situations, fixating on negative possibilities, and over-preparing to prevent their occurrence. Intolerance of uncertainty and overestimations of risk are at the heart of most issues with anxiety and why they’re so important to bring within healthy limits.
2. Increase your tolerance of discomfort.
Learning to sit with uncomfortable urges without acting on them is key to breaking the compulsive cycle.
This increases your personal threshold for discomfort before interpreting thoughts and feelings as critically important and requiring action. The lower the threshold, the more fixated you’ll be on potential risk rather than building mastery over the situation that caused the trouble. This continues the cycle of compulsive behavior to achieve short-term relief.
3. Strengthen your confidence in your abilities.
Rather than trying to eliminate fear, the aim is to deliberately allow and invite feeling fearful without resorting to safety behaviors.
This target can seem somewhat counterintuitive, but it creates opportunities to build confidence in your abilities to respond well to whatever your mind presents. There are no rigid efforts to control and avoid anymore, but instead flexible actions that create resilience and flexibility.
GOLD-STANDARD TREATMENT
Exposure Therapy & OCD
While there are many approaches to OCD, some have more evidence supporting their efficacy than others.
Exposure and Response Prevent (ERP) is currently considered the gold standard of treatment for obsessive-compulsive disorder.11,12 This structured therapy involves:
Gradually facing feared situations (exposure)
Resisting the urge to perform compulsions (response prevention)
ERP creates opportunities to associate feared situations with:
- A lack of danger
- Greater tolerance of uncomfortable feelings
- Confidence in abilities to handle outcomes
This is done with the guidance of a mental health professional to engage in realistic tasks, with manageable steps, in a systematic way, and consistently over time. The new learning gathered from exposure practices inhibits old fearful thoughts, helping to break free from rigid compulsive coping strategies.
GETTING THE MOST OUT OF EXPOSURE WORK
How to Optimize Exposure Practice
The goal of ERP is not to eliminate anxiety, but to stay in the situation until fully violating your expectation of something intolerably bad happening.
Before each exposure, ask:
- What do you expect will happen?
- What do you expect this will feel like?
- How high do you think your distress will be?
- How well do you think you’re going to be able to manage that?
- Do you think you can tolerate that and choose to do this and still be standing at the end?
After each exposure, reflect:
- Did anything surprise you?
- What did you notice that you didn’t expect?
- What was your experience not acting on rituals?
- Did you notice a greater tolerance for uncertainty?
- What can you take from your experience in this situation that you can apply next time?
You cannot think your way out of OCD.
Exposure therapy creates opportunities to test your hypotheses about feared outcomes. This cannot be done by simply thinking your way through it. You need to go and face what’s been avoided with a curious attitude and a willingness to learn through experience.
INEFFECTIVE STRATEGIES AND TREATMENT
What Doesn’t Help OCD
Not all strategies are considered effective or even appropriate for treating OCD. Many well-meaning therapists can even find themselves using approaches that are contraindicated and unwittingly maintain the cycle of obsessive-compulsive behavior.
The following is a short list of strategies that may appear reasonable and supportive, but do not work for OCD:
Relaxation techniques alone
Thought suppression
Overanalyzing obsessive thoughts
Compassionate repeated reassurance
Long-term insight-oriented psychotherapies
These approaches can reinforce OCD and delay recovery.
While well-meaning, each can end up being used as avoidance from truly participating in the three targets of treatment listed above. In fact, they can turn into new compulsions that continue the cycle of distress and are best left out of the treatment plan.
FINDING SUPPORT
Break Free From OCD
Breaking free from OCD means aiming for new targets. A new approach and a new mindset can help bring fear and anxiety that’s gotten out of hand back under healthy control.
If you’ve been struggling with obsessive-compulsive behavior and are having a hard time doing the things you want to be doing, consider reaching out to us at Midpoint Counseling. We’re here to help you find greater balance and freedom from the overwhelming experiences of OCD.
References:
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Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour research and therapy, 16(4), 233–248. https://doi.org/10.1016/0005-7967(78)90022-0
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Salkovskis, P. M., & Harrison, J. (1984). Abnormal and normal obsessions--a replication. Behaviour research and therapy, 22(5), 549–552. https://doi.org/10.1016/0005-7967(84)90057-3
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Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94
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Kalra, S. K., & Swedo, S. E. (2009). Children with obsessive-compulsive disorder: are they just "little adults"?. The Journal of clinical investigation, 119(4), 737–746. https://doi.org/10.1172/JCI37563
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Bloch MH, Landeros-Weisenberger A, Rosario MC, Pittenger C, Leckman JF. Meta-analysis of the symptom structure of obsessive-compulsive disorder. Am J Psychiatry. 2008 Dec;165(12):1532-42. doi: 10.1176/appi.ajp.2008.08020320. Epub 2008 Oct 15. PMID: 18923068; PMCID: PMC3972003.
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Bartz, J. A., & Hollander, E. (2006). Is obsessive-compulsive disorder an anxiety disorder?. Progress in neuro-psychopharmacology & biological psychiatry, 30(3), 338–352. https://doi.org/10.1016/j.pnpbp.2005.11.003
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Fitzgerald, K. D., Stern, E. R., Angstadt, M., Nicholson-Muth, K. C., Maynor, M. R., Welsh, R. C., Hanna, G. L., & Taylor, S. F. (2010). Altered function and connectivity of the medial frontal cortex in pediatric obsessive-compulsive disorder. Biological psychiatry, 68(11), 1039–1047. https://doi.org/10.1016/j.biopsych.2010.08.018
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Berlin, H. A., Stern, E. R., Ng, J., Zhang, S., Rosenthal, D., Turetzky, R., Tang, C., & Goodman, W. (2017). Altered olfactory processing and increased insula activity in patients with obsessive-compulsive disorder: An fMRI study. Psychiatry research. Neuroimaging, 262, 15–24. https://doi.org/10.1016/j.pscychresns.2017.01.012
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What causes OCD?. International OCD Foundation. (2024, October 7). https://iocdf.org/about-ocd/what-causes-ocd/#note-67-1
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Krebs, G., Waszczuk, M. A., Zavos, H. M., Bolton, D., & Eley, T. C. (2015). Genetic and environmental influences on obsessive-compulsive behaviour across development: a longitudinal twin study. Psychological medicine, 45(7), 1539–1549. https://doi.org/10.1017/S0033291714002761
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Jason Peruchini, LMFT
Jason Peruchini is a licensed psychotherapist and anxiety treatment professional who helps people address issues in mental health to live better lives.
