Obsessive-compulsive disorder: more than tidiness and cleanliness

In the office someone lines up the pens on their desk and laughs: “Sorry, I’m a bit OCD.” Two floors down, a man sits in his car in the car park, having turned back home for the third time. He knows the hob is off. He checked it before he left, then once more from the door, and then with a photograph on his phone. Now he is looking at that photograph and cannot believe his own eyes. He will be twenty minutes late for the meeting and will say, again, that the traffic was bad.

The first person used the abbreviation to mean that they like order. The second may be living with a disorder that has almost nothing to do with how much you like order. The difference between them is not one of degree but of kind: the first enjoys the tidy pens, while checking brings the second no satisfaction at all, only a few minutes of peace before the next wave of doubt.

In this post I explain what obsessive-compulsive disorder (OCD) is, how the cycle that maintains it works, and who treats it. Two things at the outset. This post is not a test, and you cannot use it to work out whether you have OCD; that is for a psychiatrist or clinical psychologist to judge. And I do not treat OCD myself. What I can do is help you understand it well enough to know where to turn.

A word we use for the wrong thing

In everyday speech “OCD” has become a label for being meticulous: tidy wardrobes, colour-coded folders, a clean kitchen. That comes at a price. Someone who really has the disorder hears, in that usage, that it is an endearing quirk, and finds it all the harder to say that thoughts torment them for hours a day. Someone who does not have it gets the impression that cleanliness is the core, and fails to recognise the forms that have nothing to do with cleanliness.

How many people does the disorder actually affect? In the American national survey of mental health, 2.3% of adults met the criteria for OCD at some point in their lives, while more than a quarter of respondents said they had experienced obsessions or compulsions at some time (Ruscio et al., 2010). That gap matters. Intrusive thoughts and small rituals are very widespread; the disorder is much rarer. A single odd thought, or a habit of pressing the door handle twice, therefore means nothing in itself.

The line is drawn by the diagnostic manual: we speak of a disorder when obsessions or compulsions are time-consuming, the example given being more than one hour a day, or cause marked distress, or get in the way of work, relationships and everyday life (American Psychiatric Association, 2013). Whether that holds for a particular person is assessed by a professional in conversation, not by an online questionnaire.

Obsessions: thoughts that get stuck

An obsession in the clinical sense is not being very interested in something. It is a thought, image or urge that arrives uninvited, keeps returning, and causes anxiety or disgust. The most common themes are contamination and dirt, doubt about whether you did something properly, fear of harming someone, intrusive images with violent or sexual content, questions of faith and morality, and a need for things to be symmetrical or “just right”.

The essential feature of obsessions is that they run against what the person wants and believes about themselves. A loving mother gets an image of dropping her baby down the stairs. A religious person gets a swear word in the middle of a prayer. That is why they are so frightening: they do not speak of wishes, but strike precisely at what the person holds most dear.

As early as 1978, Stanley Rachman and Padmal de Silva showed that people without the disorder have such thoughts too, and that in content they hardly differ from clinical obsessions; they differ in frequency, persistence and the distress they set off (Rachman & de Silva, 1978). Why a thought is not an action and is not your character is covered in detail in Intrusive thoughts: why you have thoughts that frighten you — and why they are not your character, so I will not repeat it here. There is also a short description in the knowledge base under intrusive thoughts.

Compulsions: the visible and the invisible

A compulsion is an act the person feels they must carry out in order to reduce anxiety or prevent something terrible. The ones we all know are visible: washing hands, checking locks and the hob, arranging objects, repeating a movement until it is “right”.

What is less well known is that a large share of compulsions are hidden from view. The person counts in their head, repeats a word or a prayer, “cancels out” a bad thought with a good one, goes over the memory again and again to check whether they ran someone over on the way to work. From the outside they look lost in thought. On the inside they are performing a ritual every bit as exhausting as hand-washing.

A particular form is seeking reassurance: the question “Are you sure I locked up?”, the tenth online search of symptoms, asking a partner to say once more that nothing will happen. Avoidance belongs here too. Someone afraid of hurting another person puts the knives away in the cellar; someone afraid of contamination no longer touches door handles. Avoidance is not a compulsion in the narrow sense, but it works by the same logic.

The cycle that keeps the disorder going

Obsession and compulsion are linked in a cycle. Something triggers a thought. The thought brings anxiety and the feeling that something must be done at once. The act reduces the anxiety for a moment. And that relief is exactly the problem.

The compulsion works. In the short term. Anxiety drops, and the brain remembers two things: that the danger was real, and that it was this very act that averted it. It never gets the chance to learn that the anxiety would have eased by itself, and that the house would not have burnt down even if the hob had not been checked a fourth time. So with each turn the cycle tightens: one check stretches into three, and three into a ritual with rules.

Why you cannot “just stop” the thought

People close to you often say: “Just don’t think about it.” The advice is well meant and it does not work. In a well-known experiment, Daniel Wegner and colleagues told people not to think of a white bear and showed that a suppressed thought returns more often later (Wegner et al., 1987). The effort to make the thought go away keeps it alive.

The British psychologist Paul Salkovskis added a key part of the explanation. In his account the problem lies not in the thought itself but in the meaning the person gives it. Someone who meets an image of an accident with “that’s just a thought” moves on. Someone who concludes “if I thought it, I am responsible for preventing it” has to do something (Salkovskis, 1985). An inflated sense of responsibility, the belief that a thought is as dangerous as an action, and difficulty tolerating uncertainty are the fuel the cycle runs on.

Something follows from this that is, for a person with OCD, both a relief and a disappointment: complete certainty cannot be reached. No amount of checking answers the question “what if” in such a way that it does not come back in a new form. How the brain turns one “what if” into a hundred is described in “What if …”: why the brain would rather predict a hundred disasters than one calm day.

The following exchange is a composite, not a real person; it shows how the cycle sounds from the inside.

“I know it’s stupid. I know the door is locked.”
“And you go back anyway.”
“Because if I don’t, it’s all I think about all day. What if this time it really isn’t?”
“What happens when you check?”
“Five minutes of peace. Then I wonder whether I unlocked it by accident while I was checking.”
“So checking doesn’t give you an answer.”
“No. It only gives me a break.”

Habit, meticulousness or disorder

Because the word is so widely used, it is worth saying what separates habits and personality traits from the disorder. The comparison below is not a test, and you should not draw conclusions about yourself from it. Its purpose is to show what a professional is actually looking at.

Perfectionism deserves a particular mention. A person who has to do everything flawlessly can suffer a great deal, but as a rule experiences those standards as their own and as correct. With OCD the experience is different: the person mostly knows the fear is excessive and is ashamed of the ritual. I wrote about perfectionism and spinning thoughts in Perfectionism and overthinking: two sides of the same fear.

How OCD is treated, and by whom

The good news is that OCD is among the mental disorders for which we have well-researched treatments. A review article in The Lancet names two as the best supported: cognitive behavioural therapy with exposure and response prevention, and medication from the group of serotonin reuptake inhibitors (Abramowitz et al., 2009).

Exposure and response prevention means that the person, together with a therapist, gradually and in a planned way approaches what they fear, and does not carry out the ritual. In this way the brain gets, for the first time, the experience the compulsion has always prevented: anxiety rises, then eases, and nothing terrible happens. In a larger American trial this therapy, alone or combined with the medication clomipramine, was more effective than the medication alone, and all three were better than placebo (Foa et al., 2005). The general principle of exposure is explained in Exposure: why panic has to be approached, not avoided, and the tool for dividing a fear into steps is described in the knowledge base as the exposure ladder.

With OCD I do not recommend trying this on your own. Exposure without a plan can be too much, or can unintentionally turn into a new ritual. The diagnosis is made and the treatment led by a psychiatrist or clinical psychologist, and medication is prescribed by a doctor. In Slovenia the first step is your GP, who assesses the situation and refers you on. It is also worth knowing that people with OCD often take a long time to seek help, most often out of shame about the content of their thoughts. To a professional who works with OCD, that content is nothing new.

I do not provide exposure and response prevention, I do not diagnose, and I do not prescribe medication. As a marriage and family therapist in training under supervision, what I can offer, alongside treatment led by a suitably qualified professional, is a space for what the disorder does around itself: shame, exhaustion, tension in the couple relationship and in a family that has adapted to the rituals. That is a complement to treatment, not a replacement for it. Sessions take place in person in Ljubljana, and I also work with English-speaking clients.

Reassurance: why it helps only for a moment

The most delicate part is the role of the people close to you. When someone you love asks in distress “Did I really lock the door?”, answering “yes, you did” is the most natural thing in the world. And once or twice there is nothing wrong with it. The difficulty begins when the question becomes part of the cycle: the answer brings relief, the relief fades quickly, the question comes back. At that point reassurance works much like checking, except that somebody else carries it out.

It does not follow that you should stop answering tomorrow. A sudden refusal leaves a person alone in intense anxiety, they experience it as punishment, and the trust between you frays. Changes to reassurance belong in a treatment plan; you agree on them together, ideally with a professional, and they happen gradually. Until then it is enough to notice the pattern and to be able to talk about it in a calm moment, not in the middle of a wave.

The mechanism is explained in more detail in Checking and reassurance-seeking: why the relief is so short-lived, and what you can do as a partner, parent or friend in When someone you love has OCD: how to help without taking part in the rituals.

Exercise: a map of the cycle

This exercise is not treatment and does not try to stop anything. It is observation. It is useful twice over: you see more clearly what is happening, and when you go to your GP or a clinical psychologist you can show them something concrete instead of the sentence “I think too much”.

1. Choose one pattern that repeats. Only one, for example checking the door, or a question you keep putting to your partner.
2. For three days, each time it appears, write down four things. What triggered it, which thought came, how strong the anxiety was from 0 to 10, and what you did.
3. Add how long the relief lasted. A minute, ten minutes, an hour? No judging, only a number.
4. On the fourth day, read your notes as a whole. Look at what time of day the pattern is strongest, what feeds it (tiredness, an argument, coffee), and how much time it took altogether.
5. Take the notes with you. If the pattern takes up a lot of time or gets in your way, show them to your GP. If not, you have learnt something useful about yourself.

If you notice that the note-taking has itself become something you have to do “just right”, drop it. That, too, is information worth discussing with a professional.

Where this explanation does not apply

The cycle I have described is useful, but it does not explain everything that gets stuck in the mind.

Worry that circles around real problems, money, health, work, is closer to general anxiety than to OCD. Brooding over the past, “why did I say that”, is often rumination, which goes with low mood. Routines that give an autistic person predictability, and that they find comforting, are not compulsions. A good many other things can look similar, which is why telling them apart is a professional’s job and not a blog reader’s.

Nor is every explanation of OCD a psychological one. Heredity and the way the brain functions play a part in the disorder, which is why medication helps many people, and taking it is not a sign of weakness. How therapy and medication complement each other in anxiety problems more generally is the subject of Therapy or medication for anxiety: what the research shows.

And one limit of my own approach. Exploring childhood and relationships can say a great deal about where an inflated sense of responsibility or a fear of mistakes comes from. By itself, though, it does not as a rule break the cycle of obsession and compulsion. Someone who talked for years about why they check, without ever working on the checking itself, might unintentionally acquire one more way of seeking certainty. So with OCD, the treatment that has been researched for it comes first, and conversation about relationships goes alongside it.

If hopelessness appears along with the thoughts, or the thought of harming yourself, do not wait: in Slovenia the Samarijan confidential helpline 116 123 is available 24 hours a day, the mental distress helpline (Klic v duševni stiski) in Slovenia on 01 520 99 00 between 7 pm and 7 am, and in an emergency call 112.

What to remember

• OCD is not a love of order. It is a cycle of unwanted thoughts and acts that reduce anxiety only briefly.
• Most people have intrusive thoughts; the disorder is much rarer. We speak of it when thoughts and rituals take up a lot of time, cause severe distress or get in the way of life.
• Compulsions can be invisible too: counting in your head, reviewing memories, seeking reassurance from people close to you.
• A psychiatrist or clinical psychologist makes the diagnosis and leads the treatment. The best researched are exposure and response prevention and medication; the first step is your GP.
• Do not withdraw reassurance overnight. Changes should be agreed, gradual and part of a treatment plan.