Obsessive Compulsive Disorder

Awareness of obsessive compulsive disorder (OCD) in the United States has grown significantly over the past 10 years. The American public has even developed a kind of fascination with the condition as evidenced by the it’s presence in reality TV shows, film, and literature. OCDism has also made it’s way into popular culture and slang: “you are ocding… that is so OCD… I am obsessed”. This popularization of OCD, however, has been a double edged sword: on the one hand it has helped remove some of the stigma typically attached to psychiatric disorders; on the other, it has also trivialized the condition. While it is true fleeting intrusions and minor compulsions are normal, OCD, the disorder, is far from a curious entertainment; rather it is a serious-and often chronic condition-that can lead to horrible suffering and even disability if not treated.
The American Psychiatric Association diagnostic manual (DSM-5) defines OCD as a condition characterized by the presence of either obsessions and/or compulsions” that occupy at least an hour per day of the person’s time. Obsessions are characterized by recurrent and persistent thoughts and/or images that are experienced as intrusive, unwanted and disturbing to the extent that the person is driven to Compulsions, the response to obsessions, intended to undo or “neutralize” this distress. These include a wide range of repetitive behaviors and/or mental acts such as checking, washing/sanitizing, counting, repeating, thought suppression. Compulsions or neutralizations can range from simple behaviors to very complex rituals that must rigidly conform to idiosyncratic multistep rules. Neutralizations can also be ”overt”, visible behaviors or "covert", such as mental reviewing, rumination, reassurance seeking or avoidance. As noted above, individuals with OCD neutralize to diminish the distress obsessions create; but this relief is short-lived, as the obsession soon recurs, and the cycle is repeated, which only further increases anxiety and depletion. The complexity of this recursive cycle will be further explored elsewhere on this page.
Most individuals with OCD recognize that their obsessions are not reasonable. However, there is a broad continuum of such insight in OCD sufferers. For those with poor insight, the line between real and imagined becomes blurred. This should not be confused with the momentary loss of rational thinking, while acutely anxious, that even sufferers with good insight experience when faced with an obsessional trigger. Those with poor insight are not able to see the line between imagination and reality, even when they are far removed from their OCD trigger situations. However, individuals with even moderate insight, are able to see the irrational nature of their obsessional fears between challenges. As a result, those with low insight are less likely to engage in treatment and, when they do, are more resistant to treatment interventions.
Subtypes and Dimensions of OCD
In the 1930s, psychologists began to divide OCD by subtypes based on compulsions-washing and checking,etc. In the 1970s, researchers started to develop questionnaires to identify subtypes of OCD based on symptoms. In the past 15 years, most psychologists, who study OCD, have argued that newer measurements suggest that beyond subtypes there are dimensions of OCD that can be grouped together based on themes and/or symptoms. While the addition of a dimensional perspective better captures the diverse and complex nature of OCD, researchers disagree about the dimensions themselves, whether they should be grouped theme or by symptom and whether subtypes should be used along side dimensions.
The scientific categorization of OCD has no doubt advanced over the past 80 years. Yet a unified system that captures the diagnostic complexity, etiology and best practices is still a work in progress. Another possibility is that as the science of genetics and neuroscience advances, the broad net of what we call obsessive compulsive disorder today will eventually be identified to be distinct syndromes with overlapping features. Moreover, while I believe it is important to have a general understanding of the evolution of diagnostic categorization, I feel that in clinical work a broad brush better lends itself to the practical tasks of identifying, understanding and treating OCD as we know it. To that end, I have organized the following abbreviated descriptions of the most common categories of dimensions (or subtypes) I see and treat in my practice.
  • Contamination and Washing
  • Fear of contamination by bacteria, viruses, chemicals, environmental pollutants or by thoughts or acts that one finds disgusting or morally reprehensible. Compulsive responses involve,repeated washing, cleaning and sanitizing. It is important to emphasize that in contamination OCD there is as much or more avoidance as there is sanitizing. There is also the concept of chains of contamination: “ He touched, the doorknob and is sitting on the couch. I will be contaminated if I sit on the couch”
  • Harm Doubting Obsessions and Checking
  • This is the almost iconic “checking compulsion”. Obsessions involve fear of an oversight concerning locking, turning off of doors, windows, stoves, lights, faucets, cars, or having hit someone while driving, but can include anything where there is potential of harm to oneself or others. There follows repetitive, incessant, and sometimes very prolonged, checking of these objects or actions, which only reinforces the illusion that something has been overlooked. The role of distrust of perception in this checking subtype will be subsequently explored as this page is developed.
  • Fear of Mistakes, Perfectionism Doubting and Checking
  • Obsessions of having made a mistake and not having met self-imposed, extremely high, “perfectionistic “ standards in some type of endeavor, task, action. This can be triggered by any situations where there are perceived performance-related consequences, but typically involves work, school or personal commitments. The compulsive responses to this obsession are endless: checking and reviewing of what has been done, scouring for any mistakes or errors that might have been made. The fear that something could have been missed or that the work done is simply not good enough only drives further checking and reviewing. As with harm-based doubting such repetitive checking brings no resolution. In fact, the frantic scan and hunt for the mistake leads to increased doubt, self distrust and confusion.
  • Tormenting Obsessions-Unacceptable Thoughts
  • This subtype is characterized by the experiencing of thoughts, intrusions and/or images that are unwanted and considered unacceptable, repugnant and/or immoral- that run contrary to the person’s values or ethics. Themes are unique to the persons, but commonly involve violent, sexual, racist, religious content and can include sexual identity, sometimes referred to as “homosexual OCD” (H-OCD). With regard to the latter, I have also seen the reverse: a lesbian fearing that she was straight. So, again, the uniqueness to the person factor is important.
  • In the past, this subtype has been referred to as “Pure O”, under the assumption that there was not a “compulsion”. This view has long been discarded, as indeed there is a (neutralization) response to the obsession, but it is also mental in nature. For example, a person might experience the obsessional doubt “what if I stabbed by spouse”, which is followed by the mental neutralization of visualizing throwing away the knife or mentally repeating reassuring statements, such as “ I would never do that “. Yes, both are purely mental in nature. However, while the first is the the intrusive obsession and second is the response ( compulsion/neutralization). But there is no pure obsession. In fact, the compulsions in this subtype are rarely just mental but involve many types of behaviors: distraction, complex avoidance, praying, confessing, reassurance seeking, etc.
  • In the coming months, I will be adding additional content about this subtype, it’s clinical features and treatment. As I have emphasized in the section titled “The Shadow World”, on the Maternal Anxiety page, the obsessional subtype, presents a unique challenge, as sufferers are naturally reluctant to come forward given the repugnant nature of the content. Yet, once in treatment, this group generally does well.
  • Symmetry, Ordering, Precision, Just right Counting
  • Onset of this subtype is typically seen in childhood and is characterized by the need for precision, exactness, completion, exactness or “just rightness”- that some researchers refer to as “sensorily-based perfectionism. Compulsions are directed toward achieving this state of just rightness. Examples of these typically include arbitrary rules of ordering, arranging objects by categories, positioning, straightening to achieve evenness, symmetry, left-right balance. Compulsions involve, but are not limited to, turning devices, lights, electronics on or off, opening-turning off faucets, tapping, touching, stepping-or not stepping-on certain things, cracks, sidewalks, etc. Almost universally, those with this subtype report a physical, urge-like “need” to complete the compulsion and the experience of intense, physical tension when compulsions are resisted. For some, this tension can become almost unbearable, resembling, at times, the build up of tension experienced in tic disorders. Not surprising, it appears that co-morbid (co-existing) tics disorders is more prevalent in this subtype.These obsessions often-but not always-can be accompanied by magical or superstitious beliefs that something “bad could happen”-usually to a loved one-if the compulsion is not acted on. In this grouping, for simplicity, I have included counting, which some might argue could be categorized separately. With counting compulsions, many of the completion, symmetry and/or rule-driven characteristics described above also occur. Counting often goes beyond numbers and repetitions, but often includes, angles, spaces, relationships between numbers, etc.
The estimated lifetime prevalence of OCD in the general population is between 1 and 2 %. Some researchers speculate that this percentage could be greater, as OCD can be under-reported. Women are affected at a slightly greater rate than are men 53% to 47%. This contrasts with other anxiety disorders where the ratio of female to male is 2 to 1.
Co-morbidity (co-existing conditions)
Psychiatric disorders, rarely occur in isolation; and OCD is no exception. In fact. OCD has a high rate of co-morbidity. Numerous studies have indicated that 75% of persons with OCD have at least one other psychiatric diagnosis. Co-morbid anxiety disorders tend to precede OCD whereas co-occurring depression more often follows the onset of OCD treatment.
Three models of treatment will be discussed in this section:
  • Exposure and Response Prevention (ERP) and Cognitive and Behavioral (CBT)
  • The Cognitive Model (CT)
  • The Inferential Based Approach ( IBT)


Behavioral therapy for OCD is the predominant treatment approach in the US. The primary intervention, Exposure and Ritual Prevention (EX-RP or ERP), first developed by Meyer in the 1960s, involves prolonged exposure to situations that cause distress or fear combined with prevention of “ritual completion”. An example would be repeatedly touching a doorknob and resisting urges to wash until contamination obsessions fade. ERP is the most researched approach and consequently, there is a significant body of evidence supporting it’s effectiveness. At the same time, a well documented problem with BT/ERP is that many cannot tolerate the distress the treatment causes. Consequently, roughly 40% of those treated with ERP either don’t complete exposure tasks or dropout.
To address this limitation, behavioral therapists began to use some cognitive therapy techniques-such as cognitive reframing (looking at the evidence for and against a particular fear)-prior to the ERP phase of treatment. Although research demonstrated some decrease in both drop-out and relapse, the ERP itself remained fundamentally unchanged and consequently oftentimes could not be tolerated.
I briefly treated OCD with ERP-based CBT, but found that there were aspects of ERP that seemed unnatural and unnecessary. While it made sense that someone with contamination obsessions tolerate the distress of touching a doorknob; it did not make sense- or seem appropriate- to have someone lick her fingers after touching a toilet seat or purposely make a mistake on a paper for school. That goes beyond the bounds of reasonable or rational. I also found that the cognitive techniques used by proponents of this hybrid approach, were mere window dressing for ERP.
  • There is a narrative in certain segments of the American OCD treatment community that ERP is the only effective evidenced- based method to treat OCD. This is simply not true.
ERP is particularly problematic, in my opinion, when used to treat tormenting obsessions. ERP for obsessions uses a technique called “imaginal exposure”, which involves first scripting out the obsession to it’s catastrophic and horrific end and then listening to this on a looped tape repeatedly . For example, someone with obsessional fears of harming his/her child, would write out the specific act of harm, in detail, from start to finish, including all the consequences that would follow, including incarceration, etc. The person would then listen to this script repeatedly until desensitizing. While some are able to tolerate imaginal exposure and desensitize, others can not. In fact, for those more vulnerable individuals, repeatedly listening to these scripts of horror, can be so unbearable that they stop therapy. Those who do drop out, however, can find themselves stuck in an ERP nightmare, clinging to the hope that they are “ just having obsessions”, yet terrified that the horrific content of these could be a sign of mental illness and consequently acted on. Left in this form of treatment limbo, they can sometimes resign themselves to “getting by” and “living” with their OCD; or, if more resourceful, they continue to look for other treatment options
There is a narrative in certain segments of the American OCD treatment community that ERP is the only effective evidenced-based method to treat OCD. This is simply not true. Yes, ERP, having been around since the 1960s, has accumulated the most efficacy research; but over the past 20 years, there has been a growing body of research demonstrating the efficacy of cognitive therapies that use other techniques and tools. I have seen many “ERP refugees”, who achieved success in overcoming their tormenting obsessions in ways they did not doing ERP. As this page is developed, I will further elaborate on my disagreements with this and other aspects of ERP. But for now, let if suffice to say that these early experiences cemented my belief that when treating OCD, understanding and addressing the complex cognitive processes at work is essential.

Cognitive Therapy (CT)

The cognitive model of OCD was first introduced in the 1970s, adapted Aaron Beck’s cognitive therapy to the treatment of OCD. In this model, “intrusive thoughts are [considered] normal phenomena experienced universally by people with and without OCD”. People without OCD simply dismiss these intrusive thoughts as meaningless and ignore them; whereas those with OCD go on to interpret intrusions through the lens of their “maladaptive beliefs”, such as exaggerated responsibility, intolerance of uncertainty. These appraisals cause distress and/or fear driving the person to “neutralize the obsession”. But relief is short-lived, and the simply cycle repeats itself.
Treatment in the cognitive model involves challenging these interpretations. Through socratic questioning of the evidence for and against such interpretations, the client is guided to develop an alternative “hypothesis”- another way of viewing the intrusion. Instead of exposure, per se, cognitive therapy uses behavioral experiments- to test the alternative “hypotheses” developed through cognitive reframing. Behavior experiments by definition also involve not acting on the compulsion (or ritual prevention, in the language of BT). In CT a situational triggers are gathered, and-when relevant-organized into hierarchy of difficulty. Progress, in behaviorally measurable terms, is also monitored. For a checker this could be leaving the house without checking the stove to prove that the stove really is off and reinforcing they adaptive beliefs: “ I really can trust what I do.. I can trust my memory… I am responsible, my fears are is farfetched”. With regard to tormenting intrusions, the cognitive model views these as a benign “firing off” of the mind that is not uncommon in the general population. When given meaning, according to this model, one goes on to develop obsessions. Treatment interventions, however, for tormenting obsessions do not involve looped tape exposure and desensitization to the tormenting intrusions. Rather, the focus is on challenging the erroneous interpretation of intrusions while facing situations avoided and dropping safety behaviors such as reassurance seeking. Be Over time, the person is able to recover normalcy, but with a understanding of how misinterpretations distort.
I shifted to the cognitive model of OCD and went on to train in cognitive therapy for OCD with Gail Steketee, a clinical researcher, who-together with Sabine Wilhelm, had just developed a new treatment manual based on cognitive methods. I immediately found the approach to be far more rational, relevant and effective than ERP alone. The contribution of the cognitive model of OCD can not be understated. By looking into how mental processes work in OCD, individuals gain insight that is paid forward when tolerating distress during the challenging tasks of behavioral change that must be tackled in treatment. Once I began using cognitive therapy methods, I repeatedly observed the dual benefit of increased success and decreased drop out
As much of a step forward that cognitive therapy represents, over time, I started to discover what I considered to be certain limits of the model. Cognitive therapy was developed in context of treating depression and non-obsessional anxiety. For example, a situation is interpreted in a biased way that negatively affects mood and behavior. The “automatic [distorted] thought” is corrected, new behaviors are initiated in line with the corrected view and there is change. OCD, however, is not so straight ahead. The model posits that “intrusions” are common to everyone and that the interpretation of these lead to obsessions. Challenge interpretations of the intrusions that “everyone has”, test new behaviors, and you achieve change. But is true that OCD starts with the interpretation of intrusions that “everyone has” ? Someone with contamination/washing OCD will fear they might be infected with HIV after touching a box in the supermarket. The person will then go on to worry about the “meaning” of having HIV but the obsession did not start with this interpretation; rather it appears to flow from a process of thinking that creates an illusion that HIV could somehow be on a box in a supermarket.

The Inferential Based Approach (IBA)

The Inferential Based Approach (IBA) was developed by Kieron O’Connor, a clinical researcher at the University of Montreal. In the IBA model, obsessions begin with an initial “inference of doubt” about what the senses perceive and common sense knows. An inference refers to “the process of using observation and background knowledge to determine a conclusion that makes sense: “Norman sees cookie crumbs on the floor and chocolate around his son's mouth. Norman can infer that his son got into the cookie jar”. Both the crumbs and the chocolate exist and are seen in a context that is known and relevant .
In a doubting inference, imagination and remote possibility override and replace reality, perception and trust in the senses or common sense; and a subjective story- not knowledge- is used to reach a conclusion that does not make sense and is not relevant to the specific situation in question.
Returning to the example of HIV in the supermarket, someone with OCD generates an imagined story that defies all known science as well as what their senses perceive and then confuses this imagined scenario with reality. The imagined narrative becomes lived in through the behavior of avoiding the box. Another example, in the IBA model, of how upside down reasoning characterizes obsessional doubt can be seen in the following sequence :
  • You close and lock a door and see that it is closed and locked.
  • But you distrust what your eyes see, and you think that perhaps the door is really open.
  • You think about a possible consequence of being robbed
  • Because you think about the consequence you experience fear and distress.
  • You then go on to check the door.
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Again, as can be seen in the doubting-checking sequence above, OCD starts with “crossing over” from reality to imagination (or the extremely implausible). In this cross over there is a confusion between what really is and what could be is. In the sequence above, the possibility that the door could be unlocked-in spite of evidence to the contrary-becomes lived in by checking the door (compulsive action). As anyone with OCD knows, compulsive action is not a way out, but a fast train back to the obsession. In fact, there can never be a resolution to obsessional doubt, as you can not resolve something that doesn’t exist to begin with. This is simply chasing shadows.

Inferential Based Treatment (IBT)

IBT starts with a typical thorough assessment and evaluation to identify the specific type and sub-type(s) of OCD in question. The IBT model is presented in tandem with the process of mapping out obsessional themes and behavioral sequences. The rationale for treatment goals is presented within the framework of the model.
The IBT section of this page will be further developed in the coming weeks and months. For now, highlights of what I consider to be key IBT concepts and steps are presented below:
  • Obsessional doubt is the starting point for OCD and it 100% imaginary and always originates from within the person
  • There is direct evidence for normal doubt and therefore it has a resolution. (Will it be a long winter). Obsessional doubt is born of imagination and internally projected possibility scenarios that are 100% irrelevant to the here and now. Consequently, there can be no (here-and-now ) resolution to obsessional doubt (You can imagine that a closed door might not be closed, but checking what you have imagined brings no resolution; it merely reinforces doubt and imagination.
  • In OCD doubting there is a selective and arbitrary relationship with possibility. A .01% chance of a feared event occurring is not enough reassurance. Rather the person wants 100% and/or a certificate from God. Yet, the possibility rules change for this event; and the certificate is no longer needed.
  • Because OCD is 100% imaginary, there is a distrust of the senses, common sense, relevant evidence.
  • In OCD there is a “cross over” from the real to an imagined OCD bubble. It is important to discover these cross over points ( remember the door example above)
  • Because sequences in the obsessional chain of thinking do not have a basis in the here and now, there is never linkage between these sequences in reality. They are instead justified by references to other contexts, events, actions or by arbitrarily invented rules. (People make mistakes, so maybe the door was locked and I didn’t see it)
  • Change in IBT begins with taking apart and unmasking the illusion behind the obsessional story. An alternative narrative is then built based on trust in the senses, common sense and perception This alternative narrative leads “to an entirely different conclusion than that of the obsessional doubt”. [My mind has tricked me into not believing that the door is not locked by pointing me toward thinking about doors elsewhere that are unlocked. However those doors are not my door. My eyes work fine and they see that my door is locked and will trust what my sense tell me] The strategies and specific use of the model in achieving this recovery of trust in reality varies depending on the subtype of OCD.
  • Behavior change in ERP is achieved through exposure; the cognitive model uses behavioral experiments. In IBT the testing of the renewed trust in reality is termed, well, “reality sensing”. This step into action highlights that obsessional doubt is always false “because it goes against reality. Reality sensing is “simply trusting and going with the senses rather than doubting and going away from them”. Reality sensing, thus, takes the lived-in obsessional prison and turns it on its head by traveling down path that is built on the real ground outside of the obsessional bubble. In Reality sensing the alternative story becomes lived in. [I know that the door is really locked because my senses see this. I will therefore trust what I see and resist the urge to check, no matter how powerful they are].
  • With this renewed trust, much repetition and much repetition the OCD sufferer is reinserted back into the the world. Once, there is a solid footing in this real space, oftentimes, certain, new life goals emerge, and these can be worked on
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