“I need to go organise my desk. I’m so OCD.”
“I’m obsessed with colour-coding my clothes and folding them by size and colour. That’s my inner OCD talking.”
It has become synonymous with a quirky preoccupation with order. Television characters such as Monk use their apparent OCD like a superpower that can help them solve crimes, or to see things other people can’t, and access a superior form of consciousness. Needless to say, these stereotypes are not an accurate depiction of OCD. Turning OCD into a joke or superpower can trivialise the lived experiences of people with the condition.
Just like other mental health disorder, stigma is one of the biggest problems faced by people with OCD, but oftentimes, people don’t realise that their words or actions are stigmatising or trivialising the suffering of those with OCD. The next time you hear someone say that someone or something is “so OCD”, engage them in a conversation about what OCD really means and why what they’re saying is dismissive and inaccurate. Ask them what do they know and how far is their understanding about the disease. Educate yourself about OCD, and work to raise awareness in your community however you might feel comfortable.
When one meets a person with OCD, they assume that the quirky person is obsessed with cleanliness and order and lives in constant fear. The abbreviation, OCD, has entered our everyday language; people often exclaim that a person is OCD, especially if that person is obsessed with cleaning (this is a form of ableist language).
"Turning OCD into a joke or superpower can trivialise the lived experiences of people with the condition."
There’s a common misconception that if you like to meticulously organise your things, keep your hands clean, or plan out your weekend to the last detail, you might be OCD. In fact, OCD (Obsessive Compulsive Disorder) is a serious psychiatric condition that is frequently misunderstood by society and mental health professionals alike.
Popular media has also minimised OCD to quirks and humour and has increased the amount of misinformation in society. For example, Sheldon Cooper from The Big Bang Theory, is widely believed by the public to have OCD just because he loves to keep things in an ordered manner, knocks on the door only/specifically three times, and does not let anyone sit on his spot. He likes these habits and wants to do them, but he is also very rigid and uncompromising about them. These quirks are often used as sources of humour in the show. However, people with OCD do not necessarily like being obsessively clean, orderly, or performing certain tasks; they feel a compulsion to do it and they cannot help it. Therefore, this assumption is slightly inaccurate. On a side note, not all people with OCD are concerned about hygiene and cleanliness. Some of them are messy and unorganised! We will discuss about this in more details below.
The representation of OCD in the media has also caused the public to confuse OCD with OCPD, i.e., Obsessive-Compulsive Personality Disorder. People with OCPD tend to be a little more rigid than people with OCD. But the discussion for OCPD will be for another day/article, now let's only focus on OCD.
"Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions)."
The facts about OCD have gotten muddled by popular culture and misinformation. People love to say that they’re “acting OCD” without any real knowledge of what the disorder is or what causes OCD.
People have a lot of harmful and scary ideas of OCD which can lead to avoiding treatment and staying in denial. This is exactly why the misused or loose usage of the term "OCD" in everyday language can be very dangerous.
Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions). To get rid of the thoughts, they feel driven to do something repetitively (compulsions). The repetitive behaviours, such as hand washing/cleaning, checking on things, and mental acts like (counting) or other activities, can significantly interfere with a person’s daily activities and social interactions.
In this section (in blue), a more medically accurate terms will be used, worry not, a much detailed and simpler terms will be used down below, feel free to skip this part if it confuses you.
ICD-10 criteria
The essential feature of obsessive compulsive disorder (OCD) is recurrent obsessional thoughts or compulsive acts.
Obsessional thoughts
Ideas, images or impulses that enter the individual's mind again and again in a stereotyped fashion
They are almost invariably distressing (because they are violent or obscene, or simply because they are perceived as senseless).
The sufferer often tries, unsuccessfully, to resist them
Recognised as the individual’s own thoughts, even though they’re involuntary and often repugnant
Compulsive acts or rituals
Stereotyped behaviours that are repeated again and again.
They are not inherently enjoyable.
They do not result in the completion of inherently useful tasks.
The individual often views them as preventing some objectively unlikely event, often involving harm to or caused by himself or herself.
Compulsive behaviour is recognised by the individual as pointless
Person often tries to ignore or resist the behaviour
- Resistance fades over time
- Resistance may not be present in severely or chronically ill people
For a definite diagnosis of OCD, the obsessional symptoms or compulsive acts or both must be present on most days for at least two successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics:
They must be recognised as the individual’s own thoughts or impulses.
There must be at least one thought/act which is resisted unsuccessfully.
The thought of carrying out the act must not be pleasurable
The thoughts, images, or impulses must be unpleasantly repetitive
Common obsessions
Fears of contamination (45% -> most common obsession)
Obsessional doubting (42%)
Bodily fears (36%)
Counting (36%)
Aggressive thoughts (28%)
Common compulsions
Checking compulsions (63% most common compulsion)
Washing (20%)
Insistence on symmetry (31%)
Epidemiology
Females = males.
Most common age at onset is early adult (mean age of onset is 20 years. Age of onset is younger in males than females)
Managements
Biological
SSRIs or clomipramine
Biological management should be accompanied by psychological intervention.
In extreme cases in which OCD symptoms are debilitating and unresponsive to all other biological or psychological treatments, psychosurgery may be considered as a treatment of last resort. Anterior cingulotomy and anterior capsulotomy are the two most common types of psychosurgery performed.
Two other forms of psychosurgery which are sometimes employed are the subcaudate tractotomy or limbic leucotomy
Psychological
Supportive: valuable
Psychoanalytical psychotherapy: no unequivocal evidence for effectiveness .
Cognitive behavioural therapy
Behavioural therapy
- Obsessions are more difficult to treat than compulsions
- Exposure and response prevention for compulsions.
- In someone with fears of contamination, encourage them to touch a door knob (i.e exposure stage) and discourage them from washing their hands (i.e response prevention stage) for an increasing amount of time with each exposure. Anxiety is neutralised by relaxation training.
- Thought stopping may be helpful for obsessions.
- Thought replacement: When an unwanted thought enters the mind, immediately replace the thought with a healthy, rational one.
Many people without OCD have distressing thoughts or repetitive behaviours. However, these do not typically disrupt daily life. For people with OCD, thoughts are persistent and intrusive, and behaviours are rigid. Not performing the behaviours commonly causes great distress, often attached to a specific fear of dire consequences (to self or loved ones) if the behaviours are not completed.
Many people with OCD know or suspect their obsessional thoughts are not realistic; others may think they could be true. Even if they know their intrusive thoughts are not realistic, people with OCD have difficulty disengaging from the obsessive thoughts or stopping the compulsive actions.
Obsessions
Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing emotions such as anxiety, fear or disgust.
Many people with OCD recognise that these are a product of their mind and that they are excessive or unreasonable. However, the distress caused by these intrusive thoughts cannot be resolved by logic or reasoning.
Most people with OCD try to ease the distress of the obsessional thinking, or to undo the perceived threats, by using compulsions. They may also try to ignore or suppress the obsessions or distract themselves with other activities.
Examples of common content of obsessional thoughts:
Fear of contamination by people or the environment
Disturbing sexual thoughts or images
Religious, often blasphemous, thoughts or fears
Fear of perpetrating aggression or being harmed (self or loved ones)
Extreme worry something is not complete
Extreme concern with order, symmetry, or precision
Fear of losing or discarding something important
Can also be seemingly meaningless thoughts, images, sounds, words or music
Compulsions
Compulsions are repetitive behaviours or mental acts that a person feels driven to perform in response to an obsession.
The behaviours typically prevent or reduce a person's distress related to an obsession temporarily, and they are then more likely to do the same in the future.
Compulsions may be excessive responses that are directly related to an obsession (such as excessive hand washing due to the fear of contamination) or actions that are completely unrelated to the obsession.
In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible.
Examples of compulsions:
Excessive or ritualised hand washing, showering, brushing teeth, or toileting
Repeated cleaning of household objects
Ordering or arranging things in a particular way
Repeatedly checking locks, switches, appliances, doors, etc.
Constantly seeking approval or reassurance
Rituals related to numbers, such as counting, repeating, excessively preferencing or avoiding certain numbers
People with OCD may also avoid certain people, places, or situations that cause them distress and trigger obsessions and/or compulsions. Avoiding these things may further impair their ability to function in life and may be detrimental to other areas of mental or physical health.
Not all rituals or habits are compulsions. Everyone double checks things sometimes. But a person with OCD generally:
Can't control his or her thoughts or behaviours, even when those thoughts or behaviours are recognised as excessive
Spends at least 1 hour a day on these thoughts or behaviours
Doesn’t get pleasure when performing the behaviours or rituals, but may feel brief relief from the anxiety the thoughts caused
Experiences significant problems in their daily life due to these thoughts or behaviours
Some individuals with OCD also have a tic disorder. Motor tics are sudden, brief, repetitive movements, such as eye blinking and other eye movements, facial grimacing, shoulder shrugging, and head or shoulder jerking. Common vocal tics include repetitive throat-clearing, sniffing, or grunting sounds.
Treatment
Patients with OCD who receive appropriate treatment commonly experience increased quality of life and improved functioning. Treatment may improve an individual's ability to function at school and work, develop and enjoy relationships, and pursue leisure activities.
Cognitive Behavioural Therapy
One effective treatment is a type of cognitive-behavioural therapy (CBT) known as exposure and response prevention (ERP). During treatment sessions, patients are exposed to feared situations or images that focus on their obsessions. Although it is standard to start with those that only lead to mild or moderate symptoms, initially the treatment often causes increased anxiety.
Patients are instructed to avoid performing their usual compulsive behaviours (known as response prevention). By staying in a feared situation without anything terrible happening, patients learn that their fearful thoughts are just thoughts. People learn that they can cope with their thoughts without relying on ritualistic behaviours, and their anxiety decreases over time.
Using evidence-based guidelines, therapists and patients typically collaborate to develop an exposure plan that gradually moves from lower anxiety situations to higher anxiety situations. Exposures are performed both in treatment sessions and at home. Some people with OCD may not agree to participate in CBT because of the initial anxiety it evokes, but it is the most powerful tool available for treating many types of OCD.
Medications
A class of medications known as selective serotonin reuptake inhibitors (SSRIs), typically used to treat depression, can also be effective in the treatment of OCD. The SSRI dosage used to treat OCD is often higher than that used to treat depression. Patients who do not respond to one SSRI medication sometimes respond to another. The maximum benefit usually takes six to twelve weeks or longer to be fully visible.
Patients with mild to moderate OCD symptoms are typically treated with either CBT or medication depending on patient preference, the patient’s cognitive abilities and level of insight, the presence or absence of associated psychiatric conditions, and treatment availability. The best treatment of OCD is a combination of CBT and SSRIs, especially if OCD symptoms are severe.
Neurosurgical treatment
Some newer studies show that gamma ventral capsulotomy, a surgical procedure, can be very effective for patients who do not respond to typical treatments and are very impaired, but it is underused due to historical prejudice and its invasiveness.
Deep brain stimulation, which involves an implanted device in the brain, has data to support efficacy and does not permanently destroy brain tissue as done in a capsulotomy. However, it is still highly invasive and complex to manage, and there are limited providers and hospital systems trained to offer this treatment and, able to provide the long-term support needed by patients.
So if OCD isn’t a quirk or crime-solving skill, what is it? Let’s look at some common myths that revolve around OCD.
"Obsessive compulsive disorder isn’t a quirk or personality trait."
Myth #1: you can be “a little OCD”.
OCD has been so frequently misrepresented in popular culture that it is common to say “I’m just a little OCD”, or “stop being so OCD”, in reference to being overly concerned with neatness or organisation. Misused or loosely used terms can cause a lot of distress to individuals who are living with the conditions. Obsessive compulsive disorder isn’t a quirk or personality trait; it is a legitimate mental disorder that causes significant distress and debilitation.
People with OCD aren’t just excessively focused on certain things; they suffer from consistent intrusive thoughts (obsessions), coupled with chronic feelings of danger or doubt, and these feelings often drive them to commit repetitive or specific behaviours (compulsions). So, your friend who likes to place sticky notes around the house to remind themselves to do tasks is not “being OCD”.
"Everyone has their own set of idiosyncrasies and quirks but that does not always mean they have OCD."
Myth #2: ‘We are all a little “OCD”.’
Firstly, as aforementioned, OCD is NOT a list of personality traits and quirks that even if you have one of them, you would qualify as having OCD.
Everyone has their own set of idiosyncrasies and quirks but that does not always mean they have OCD. OCD is part of the anxiety disorder umbrella, and for people with OCD, i.e., actually diagnosed with it, these compulsions stem from anxiety. OCD is not a joke and it can be hard to live with as one may miss out on a lot of things due to time-consuming obsessions and compulsions.
Secondly, OCD is not an adjective or figure of speech, so people must stop using it that way. It is grammatically incorrect and using phrases like ‘they are so OCD’ can invalidate a person’s experience with this condition, and lead to more misinformation. This would make OCD seem like a not-so-serious medical condition. Would a person say, ‘they are so cancer,’ or, ‘they act like they have dementia’? Think about it.
"OCD is not an adjective or figure of speech, so people must stop using it that way."
OCD is a mental health diagnosis. Describing OCD as a personal quirk or a joke ignores the very real needs of people with this condition. The problems with saying “I’m OCD” when you’re not and reasons not to use OCD as a joke:
Symptoms which may look funny or quirky from the outside may be a big source of stress for the person experiencing them. A “harmless” joke may unknowingly use a person’s suffering for amusement.
You never know someone else’s history. A person with OCD may hear the joke and wonder if you really feel that way about people like them.
OCD jokes create false perceptions about OCD. Stereotypes can make it harder for people with OCD to recognise their symptoms and get help.
Jokes about mental health can promote stigma. Stigma is linked to discrimination and can be a barrier to treatment.
"OCD is not a joke and it can be hard to live with."
Myth #3: All neat freaks have OCD.
While many cases of OCD are related to cleanliness or neatness, the disorder is more complex than someone who washes their hands a lot.
"The disorder is more complicated than simply being an organised person."
Again, being excessively focused on tidiness and organisation does not mean you have OCD. There are many people who like neatness and put an effort into making their lives orderly and planned out. These are personality traits and characteristics that are normal and healthy, and do not correlate to having obsessive compulsive disorder.
Some OCD obsessions can be related to being clean or tidy, but the disorder is more complicated than simply being an organised person. In the context of OCD, an ‘obsession’ doesn’t hold the same meaning as it may in day-to-day conversation.
OCD obsessions refer to severe intrusive thoughts, images, or impulses that feel outside of the individual’s control and interfere with important activities. Obsessions are often coupled with intense negative feelings such as endangerment, fear, doubt, or disgust, and people experiencing obsessions typically regard them as disturbing and unwanted.
Obsessions and the negative emotions that come with them lead people with OCD to engage in repetitive behaviours that temporarily counteract, neutralise, or eliminate their obsessions — these are known as compulsions. Not every routine or ritual is an OCD compulsion. Compulsions are actions that people with OCD feel driven to take from their negative thoughts and emotions, and often would rather not have to do these things. They also often can be time consuming or even torturous, as they get in the way with daily functioning and are simply a means to temporarily escape anxiety or fear.
The obsessions and compulsions that people with OCD experience can vary widely in their context or nature. Some common OCD obsessions include:
Contamination: dirt, bodily fluids, germs and disease, household chemicals, or environmental contaminants
Religious obsessions: excessive concern with morality or offending God
Harm: fear of harming others or being responsible for a terrible event
Unwanted sexual thoughts: perverse or forbidden sexual thoughts and images, thoughts about aggressive sexual behaviour toward others
Perfectionism: fear of losing or forgetting important information, concern with exactness or evenness, superstitious ideas about lucky or unlucky numbers
Losing control: fear of harming oneself or others on impulse, fear of blurting out insults or obscenities, fear of violent images in one’s mind
Similarly, common compulsions fall into respective categories:
Washing and cleaning: excessively washing hands, showering, brushing one’s teeth, or cleaning objects
Repeating: rewriting or rereading, repeating body movements, repeating activities in specific multiples
Checking: checking certain body parts, checking that nothing terrible has happened, checking that you didn’t make a mistake or harm yourself or others
Mental compulsions: praying to prevent harm, counting while performing tasks in order to end on a certain number, mentally reviewing events to prevent harm
Other compulsions: avoiding situations that trigger obsessions, asking for reassurance, arranging or putting things in order until it “feels right”
"Logic may not help people with OCD reduce their anxiety regarding something."
Myth #4: People with OCD do not know that they are acting irrationally. If they had known, they would have stopped.
People with obsessive-compulsive disorder are aware that some of their actions are irrational, but are unable to avoid these thoughts and actions. This is what makes living with OCD hard. OCD sufferers report feeling crazy for experiencing anxiety based on irrational thoughts and finding it difficult to control their responses.
These obsessions and compulsions often disrupt daily life as they are exhausting, time-consuming, and uncontrollable. Logic may not help people with OCD reduce their anxiety regarding something. Most people with OCD find compulsions a coping mechanism for the distress caused by obsessive thoughts.
"Just as with any other mental illness, it can’t easily be overcome just by “trying harder” or “thinking differently”."
Myth #5: People with OCD just need to relax.
People with OCD have a diagnosable condition and cannot simply “turn it off”. In order to deal with intrusive thoughts and learn how to live more productively, some individuals with OCD undergo years of therapy and treatment.
Just as with any other mental illness, it can’t easily be overcome just by “trying harder” or “thinking differently”. It can take a long time for someone to learn how to live with obsessive compulsive disorder.
Having OCD is not simply an overreaction to the stresses of life. While stressful situations can make things worse for people with OCD, they do not cause OCD. People with OCD face severe, often debilitating anxiety over any number of things, called “obsessions.” This level of extreme worry and fear can be so overwhelming that it gets in the way of their ability to function. To try to overcome this anxiety, people with OCD use “compulsions” or rituals, which are specific actions or behaviours.
These compulsions are not activities a person with OCD does because they want to, but rather because they feel they have to in order to ease their fears. OCD is not about logic — it is about anxiety and trying to get relief from that anxiety.
"OCD is very treatable."
Myth #6: People with OCD are just “weird”, “neurotic”, or “crazy” and there is no hope for them to ever lead happy functional lives.
With proper treatment, it is very possible for people with OCD to lead full and productive lives. Many people respond positively to behavioural therapy and/or medication. Specifically, Exposure and Response Prevention or ERP is considered the first-line treatment for OCD.
Additionally, medication (such as anti-depressants like SSRIs) may also be recommended for people with OCD. Family therapy can also be very beneficial since family members (including parents, siblings, and spouses) often play a major role in recovery.
Finally, many individuals report that support groups are very helpful. Support groups provide a safe, understanding place for people with OCD to feel less alone, as well as to teach and learn from their peers. People with OCD use one or several of these options to help them manage their OCD, as well as the support and understanding of their loved ones.
Myth #7: Someone with OCD will have the same obsessions their entire life.
The themes of OCD symptoms can change over time.
People with OCD engage in compulsions to reduce anxiety caused by obsessions. Both compulsions and obsessions can change with time. The underlying emotions— fear and anxiety— remain the same even as symptoms shift. In most cases, a person with OCD continues to experience fears across a common theme. Age, culture, and life experiences can affect these themes.
For example, a 12-year-old with OCD may be plagued by thoughts of their parents dying. At 25, that same person may fear the loss of their spouse. The specific worry has changed, but the underlying fear (losing a loved one) has not. The compulsive behaviours used to reduce anxiety can also shift.
Myth #8: OCD only shows up in privileged people who have too much time or too few problems.
OCD exists across cultures, classes, genders, and ethnicities. OCD appears in cultures across the world (although some symptoms are more common in different nations). People with higher social classes may be more likely to be diagnosed with OCD. People with less resources can experience more risk from potential stigma and thus avoid getting help.
Myth #9: OCD will never get better.
OCD is very treatable. It’s true that OCD probably won’t get better on its own. People with OCD can’t think or will their way out of their feelings and compulsive actions. Yet there are many treatments that can help with both obsessions and compulsions. These include:
Psychotherapy: Therapy can help a person with OCD understand why they have intrusive thoughts. It can also help people reduce their anxiety.
Cognitive behavioural therapy (CBT): teaches people to recognise automatic thoughts and counteract them. People may also learn how intrusive thoughts affect their behaviour.
Exposure therapy: exposes a person to something they fear in manageable doses until the fear becomes less potent.
Relaxation techniques: Relaxation can help people with OCD resist their compulsions. When obsessions cause less anxiety, the urge to do compulsions often fades.
Group therapy: Some people find talking to others with OCD helps them feel less alone. Group therapy can offer people social support and reduce stigma for intrusive thoughts.
Medication: Antidepressants, particularly selective serotonin re-uptake inhibitors (SSRIs), may help with symptoms of OCD. People with OCD may need a higher dose than people with depression.
Some people with OCD may wish to combine multiple treatments. A mental health professional can help someone create a comprehensive treatment plan for their unique needs.
Myth #10: OCD is funny.
OCD is often the butt of jokes in popular media, but it is no laughing matter. It is an incredibly debilitating and frustrating condition that can take a significant psychological toll.
Left untreated, OCD can severely limit a person’s ability to engage with others socially, maintain meaningful employment and participate in activities they enjoy.
Around 40 per cent of people with OCD experience depression at some time in their life, more than 60 per cent have suicidal thoughts at some point, and almost 25 per cent report having attempted suicide.
Fortunately, treatments such as cognitive-behavioural therapy (CBT) and medication can help people gain control and many people experience full-recovery.
OCD is very common, yet it is one of the most frequently misunderstood conditions. People confuse it with other mental health conditions like OCPD, and people restrict OCD to a specific set of symptoms, like hand-washing, due to what is often portrayed in popular media. If you are a person with OCD, do not let the myths about OCD stop you from getting the right treatment, and do not let people lower your self-esteem with these myths; you know who you are.