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José feels certain that if he doesn’t organize his closet in a particular order, he’ll wear mismatched clothes and be mocked by his colleagues. If a stray sock or tie disrupts his ordering system, he panics and can’t leave home until the system has been restored.

Jennifer has been married for 10 years. Although her husband says he’s happy with their marriage and has no history of infidelity, Jennifer can’t stop worrying that he will cheat. If he comes home later than expected or doesn’t respond to her texts right away, Jennifer panics and asks whether he still loves her.

Lisa adores her infant son. Yet she constantly imagines herself killing the baby. Not only does Lisa fear she may someday snap, but her fixation with the idea convinces Lisa that she must be evil. Lisa spends hours mentally reviewing past interactions with children to determine whether she might be capable of such a horrific act.

Jennifer, José, and Lisa all share characteristics of obsessive-compulsive disorder (OCD).

It’s a relatively common condition: As many as 2.3 percent of individuals will meet the criteria at some point in their lives. Most of us worry at least occasionally about what might go wrong if we don’t plan ahead or follow safety precautions, and to an extent this vigilance is essential to our survival (imagine what would happen if we didn’t make sure the oven was turned off after baking). For those diagnosed with OCD, however, the worries and and precautionary behaviors are so time-consuming and difficult to control that they interfere with daily life.

How OCD Works

OCD is grounded in a fixation on what might happen. Defined as obsessions, these what ifs often involve fears of harm befalling oneself or someone else, such as getting sick or getting into a car accident. But they can also include fears about one’s own capacity for inflicting harm: What if my dark thoughts mean deep down I am an evil person? What if I lose it and strangle my child?

The what ifs become a pervasive, distressing drumbeat. And while the probability that they may come true often ranges from somewhat possible to highly unlikely, it’s virtually impossible to know for certain, let alone feel certain, that they won’t.

It’s that feeling of uncertainty — the anxiety — that sets off the second part of the OCD equation: compulsions.

These behaviors temporarily alleviate the anxiety associated with a particular what if. Compulsive behaviors can range widely, from those directly related to the individual’s fear, such as repeatedly checking that the doors are locked, to those that may seem (to an outside observer, at least) illogical or even superstitious, such as whispering a prayer anytime a “bad” thought crosses one’s mind or arranging everything in sets of three.

Such neutralizing behaviors can also exist entirely in the mind. Mental compulsions can include memorizing facts or lists, conjuring a specific word or image, or analyzing one’s thoughts, actions, or memory. For example, an individual who obsessively worries they might stab their partner might compulsively replay past relationships hoping they’ll find evidence that they aren’t capable of such things.

No matter what form the behaviors take, to qualify as compulsions they must be unrealistic or excessive and difficult to stop, even if maintaining them gets in the way of living one’s life.

So why do they start in the first place?

Research suggests that OCD is both inherited and learned: A biological predisposition sets the stage; experience sets it into motion. Some people can identify a clear origin for their particular what if, such as enduring a life-threatening trauma. Others who suffer from OCD may not be able to trace the root cause of their obsession.

Arguably more important than why they form, how OCD patterns solidify tells us much about why they can become so debilitating.

Though they don’t actually prevent the what if from coming true, compulsive behaviors alleviate — at least temporarily — the fear that it might. Just as behaviors that bring about positive feelings can be addictive, so can those that take away distressing feelings. Known as negative reinforcement, this cycle is powerfully self-fulfilling: The more someone trains their brain to believe they can ease a particular fear only through a compulsive behavior, the harder it is to stop that behavior, irrational as it may seem to others.

Treatment Options

OCD can be exhausting, embarrassing, and, in its most severe manifestations, incredibly debilitating, leading some people toward prolonged isolation. But even those who appear to be high-functioning experience significant internal distress. Fortunately, the disorder can be effectively treated.

In addition to the enormous amount of mental, emotional, and physical energy that obsessions and compulsions expend, OCD leads some to question their own inherent goodness as a human, especially if their obsessions involve the capacity to harm others or otherwise contradict their values. Such thoughts are often extremely shameful. As a result, some sufferers avoid getting help for fear they may be misunderstood at best, arrested at worst.

Yet honesty is crucial when treating OCD: Only by openly acknowledging the what ifs can one defuse their power. A good therapist will offer a safe, nonjudgmental environment in which clients can share their darkest fears (and as long they don’t perceive anyone to be in imminent harm, mental-health professionals are ethically bound to maintain confidentiality).

Additionally, by mitigating the physiological response to triggering situations, certain medications can make it easier for individuals to tolerate feelings of anxiety and resist the urge to ritualize. Yet medication tends to work best as a complement rather than a substitute for therapy.

A specific technique called Exposure and Response Prevention (ERP) therapy, supported by a raft of clinical studies, is considered the first-line approach to treatment for OCD. It involves purposely engaging with a triggering situation, then resisting the urge to carry out the anxiety-relieving compulsion. Instead, individuals must tolerate the anxiety until it naturally begins to dissipate, which may take several minutes or several hours.

They repeat this procedure at regular intervals until the triggering situation no longer elicits an anxiety response, a process known as habituation. Depending on their particular triggers, they may then replicate the procedure with more distressing situations.

Those who struggle primarily with mental compulsions follow a similar process using imaginal exposure, which entails purposely visualizing the feared situation playing out in full. Sometimes individuals record themselves describing these events, then listen to the script over and over again until it loses its power.

People can learn to manage OCD without achieving habituation. Some triggers may always elicit anxiety, but with practice individuals learn that they can feel anxious without resorting to their compulsive behavior. In other words, they learn to tolerate the what if.

Overcoming OCD also entails learning to accept that no matter what one does or doesn’t do, it’s impossible to know for certain that a feared outcome won’t come true. That means Jennifer learns to accept that no matter how many times she asks for reassurance, she can never guarantee that her husband won’t cheat. No matter how perfectly ordered his closet, José may one day accidentally sport mismatched socks — or feel embarrassed in front of his colleagues. No matter how much Lisa analyzes her past behavior, she can never know for sure what she is or isn’t capable of.

Learning to live with what ifs is not easy. But uncertainty is a part of life, and accepting it allows for the freedom to simply live.

Types of OCD

Representations of OCD in popular culture tend to involve excessive cleaning, checking, or organizing. In fact, the disorder encompasses a broad array of themes. Here are just a few.

  • Contamination: No matter how much they clean, sanitize, or avoid “unhygienic” situations, those with contamination OCD fear they might contract and/or spread harmful germs.
  • Harm/Violence: People fear that they might harm others through action (losing control and lashing out) or inaction (such as forgetting to turn off the oven).
  • “Just Right”: This fixation on perfectionism involves the feeling that one can never get things “just right,” be it the order of a closet or the wording of an email.
  • Order and Symmetry: Think perfectly spaced hangers or a pantry in which every can faces exactly forward — this type involves striving to achieve specific, highly rigid order in one’s environment.
  • Pure O: Those with Pure O (purely obsession), which is characterized by distressing intrusive thoughts, do not engage in behavioral compulsions. However, they may rely on mental compulsions, such as replaying the past, to neutralize their fears.
  • Relationship: Marked by pervasive insecurity about relationships, this can manifest as jealousy (for example, questioning a partner’s love) or the opposite, such as fearing one doesn’t really love their partner.
  • Religious Obsessions, or Scrupulosity: This type is characterized by perceived blasphemous or immoral thoughts, fear of past or future sinful behavior, and/or a fixation on adhering to religious rituals.
  • Sexual: Disturbing sexual thoughts or urges cause the individual to question their morality, especially if they inadvertently become aroused by such thoughts.

Finding the Right Therapist

OCD is often missed or misdiagnosed. This is in part because individuals may avoid seeking help, but also because the disorder can take so many forms. Even trained mental-health professionals may miss the signs — especially if the compulsions are primarily mental — or focus on only the most obvious obsessive-compulsive patterns when in fact an individual may engage in many forms of OCD.

When seeking a therapist, look for one who has experience treating OCD. The International OCD Foundation also encourages individuals to interview a therapist before committing to treatment. For example, ask which assessments they use to diagnose the disorder and to identify the different forms it may be taking; ask which techniques they use in treatment, and be wary of anyone who doesn’t use ERP therapy. Membership in the International OCD Foundation or similar organizations is a good sign, as is specialized training in OCD.

OCD and COVID 19

Not surprisingly, the COVID 19 pandemic has presented significant challenges for those dealing with OCD-related contamination, as well as individuals who struggle with OCD involving perfectionism or fears of harming others.

Increased risk of contracting or spreading a dangerous disease may seem to justify excessive cleaning, checking or performing other protective rituals, and to be sure, greater vigilance has been necessary to slow the spread of COVID. But caution can quickly give way to debilitating compulsion among OCD sufferers.

The International OCD Foundation offers a list of suggestions aimed at helping suffers remain safe without exacerbating their symptoms. The organization encourages individuals to follow but not add to precautions recommended by the CDC, and to limit time spent gathering information about COVID safety. Their website also includes resources for self-care and a directory of therapists who specialize in treating OCD.

Alexandra
Alexandra Smith, MA, LPCC

Alexandra Smith, MA, LPCC is a licensed professional clinical counselor in Minneapolis.

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