In this series, I discuss some of the psychological diagnoses or terms that have filtered out to the public consciousness, and gotten twisted up along the way. The important thing to keep in mind is that this website, like any website, cannot tell you whether you actually do or do not have a mental illness or whether you do or do not need mental health treatment. My goal is to cut down on the miscommunications that can happen between client and therapist. As always, my disclaimer applies.
What is OCD?
Obsessive Compulsive Disorder is one of those uncreatively named mental health conditions, because it’s a disorder of obsessions and compulsions. An obsession is “recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety and distress” along with some attempts to control or neutralize them.” A compulsion is a “repetitive behavior that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.” The regular rules of mental health diagnoses also apply: this has to cause a significant level of intrapsychic distress or an impairment in functioning, and it can’t be better explained by another condition.
OCD is an interesting condition that I think gets misdiagnosed in both directions – over and under. I think part of the problem is that there are some OCD sufferers that are incredibly obvious. Charlie’s mom in Always Sunny in Philadelphia has to flip light switches three times and spin around or she thinks Charlie will die. Michael J. Fox’s character in Scrubs says “You know, I couldn’t have survived in medicine if I didn’t embrace my OCD. And since I was compulsive anyway, you know, I read the same text books over and over, I went through the procedures over and over, I imagined every worst-case scenario over and over and over and over and over and over and over…” this goes on for a little while. These are people with bizarre, obvious symptomology that’s hard to miss.
On the other end of the spectrum:
The backlash against this attitude of “I’m so OCD” is pretty much in full swing, to the extent that I worry that we might be overcompensating. There are plenty of people somewhere in between “I like to have a tidy home” and “I have to spend an hour checking the locks around my house or I think I’m going to die in my sleep,” but where does the line get drawn?
At the same time, there can be obsessions or compulsions that people don’t realize might qualify. The most famous compulsions are the cleaning and checking compulsions, like the ones in the media examples. However, hoarding, like the kind you’d see in that Hoarders show, is also a form of an OCD compulsion. This is part of what makes OCD so hard to pin down, when the presentation can range from the cleanest person you can imagine to this:
Why you don’t have OCD
Look at the person on your left. Now look at the person on your right. Now look at 98 other people. One of those people may have OCD.
At a yearly prevalence rate of 1.2%, OCD is about as common as other major mental illnesses, like Schizophrenia or Bipolar Disorder, and much less common than Anxiety Disorders, PTSD or Autism Spectrum Disorders, which might be what you really have. Anxiety Disorders and depression can both cause the obsessive worry that you see in OCD, but they don’t typically have the same compulsions, or the compulsions are more based in reality. Someone who is germophobic will wash their hands because they are afraid of being sick, but they can stop themselves once they have reached a level of acceptable cleanliness. People with OCD will continue washing well past the point that they are getting any benefit from the cleaning. People with PTSD will check their locks compulsively, but that’s because somebody actually broke into their house one time and they don’t want that to happen again.
People with Autism might have a seemingly compulsive repetitive behavior, like lining up objects or tapping on stuff, and they can have intense interests that would qualify as an obsession. Autism does also come with the social and communication deficits, but sufferers of severe OCD can also be so impaired by their compulsions that they have difficulty interacting with others. This is actually a really tricky distinction to make, but again the key identifying feature is the bizarre, non-sensical connection between the obsessions and the compulsions. Someone with Autism might be really into Pokemon, so they have a massive hoarder-like collection of Pokemon paraphernalia that they take immaculate care of. The connection here makes sense. They’re not collecting Pokemon because they think that their children will die if they don’t.
What if you do have OCD?
Don’t let Scrubs or The Aviator fool you, OCD is a treatable condition. The trickiest part might be getting that diagnosis. Again, even doctors struggle with it, which is why it takes on average 9 years and 3-4 doctors to correctly diagnose OCD. OCD can be a lifelong disorder or it can be something that comes and goes, and if you’re in the latter group you’re more likely to be successfully treated. Like many other disorders, having a good support network and stable situation can also really help your outcomes.
OCD is often treated with an SSRI, like Prozac or Celexa, so sometimes misdiagnosis isn’t the end of the world because these are also first-line treatments for depression. Like all medications, these have side effects, and they often won’t treat all of the symptoms alone. The best evidence supported treatment for OCD at this point is a form of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP). This mostly involves exposure to whatever might trigger the obsession, like dirt or some other contaminant, and preventing the compulsion that generally follows.
So the technique is pretty simple, but the difficulty comes in actually carrying it out. ERP is really effective and much better at preventing reoccurrances than medications… if you actually do it. The problem is that the drop out rate is pretty high. That’s not too surprising, considering what we basically ask people to do is face their deepest, darkest fears without their go-to coping strategy. The thing to remember is that the exposures ramp up gradually, and the real learning comes in when you are exposed to whatever, and you don’t get to do your compulsive behavior, and nothing bad happens. I mean, it might scare the hell out of you, but you survive. The crazy thing that you think you’re preventing with these compulsive behaviors – harm to your loved ones, loss of control, whatever – doesn’t happen just because you can’t wash your hands.
The funny thing about people with OCD is that they know this. They’re not psychotic or divorced from reality enough to really believe that the world will end if they have to clean up the stacks of newspapers in their kitchen. That’s what makes this a real compulsion, is that they feel like they have to do it anyway. Preventing the compulsion really confronts them with the absurdity of their actions in a way that they may have never done before. Not to get too poetic, but it’s the difference between knowing something is true in your head and feeling something is true with your heart, and that only comes with practice.