What Does OCD Look Like?

By Jeremy Shuman, Psy.D.

The second week in October is OCD Awareness week.  This two-part blog series from Dr. Jeremy Shuman is intended to help folks recognize OCD in all its forms and understand what it takes to disrupt the obsessive-compulsive process.

Person 1 has a fear that they left their stove on and goes back in their house multiple times to check after leaving and locking up.  Person 2 is so disgusted by the water spots on silverware that they refuse to eat at restaurants or friends’ houses.  Person 3 feels that they can’t rest until they have repeated their evening prayer enough times that it feels right emotionally.  Person 4 is incredibly frustrated that they feel unable to concentrate on important things in their life because the sensation of dry eyes is so distracting it takes up all their attention.  What do these four individuals with wildly different behaviors, emotions, and beliefs have in common?  They are all living with OCD.

OCD is a chronic condition affecting 2%-3% of individuals at some point in their lives.  It is relatively common in this way, but it often presents along with more easily identified tic disorders, ADHD, autism, and/or anxiety disorders, which can lead to a missed diagnosis.  It also has an extremely varied presentation, in which stereotypes of checking and washing are only a small subset of possible manifestations.  A recent study suggested that 77% of licensed psychologists missed diagnosing OCD in a clinical vignette due to inadequate knowledge about a less common presentation.

OCD can manifest around any kind of thought.  Commonly we see fears about contamination, fear of thoughts involving harming others, fear of thoughts that are taboo in nature, and fear of negative consequences arising from a need for symmetry or order.  Common presentations of OCD that folks might not expect include a fear of vomiting, wondering if you hit someone with your car without noticing at the time, discomfort over a feeling of uncertainty about sexual orientation, wondering if the universe is real or not, fearing that a past mistake will be discovered in the present and lead to being “cancelled,” and fear that you could attempt suicide even though you want to live.  The possible themes OCD can take on are endless. 

The way that OCD is diagnosed is not based on the content of the worried thought or the specific behaviors that folks do in response to those thoughts.  Instead, the diagnosis is based on recognizing the process in which intrusive obsessional thoughts lead to undue distress and repetitive compulsive behaviors get reinforced when they work to remove that distress.  At its core, OCD is about escaping from uncomfortable internal experiences.  An intrusive thought about a flaming oven, filthy dishwater, nagging feeling of incompleteness, or irritated eyes can be experienced as more sticky, looping, loud, vivid, and/or startling by folks with OCD.  The nature of these private experiences seems to call for a behavioral response to deal with the discomfort; however, bringing attention to these thoughts through engaging with them to silence them serves the opposite of the intended purpose and instead reinforces the thoughts. When a behavior removes some of the distress from the experience of an intrusive thought, that behavior is at risk of being repeated until it gets stuck in a way where it takes a lot of work to perform and the distress that it addresses is unrelated to any real world threat.  With that behavior repeated over and over, the intrusive thought is going to get stuck too, as we learn to expect that the bad feelings reduce when we give that thought attention.  This process is OCD, not any specific fear or observable behavior.  We always have to ask how we respond to intrusive thoughts and why we do repetitive behaviors to look for the OCD pattern.

The general public can benefit from information to expand their understanding of the manifestations of OCD if it leads folks to ask for specialty help sooner.  For information about OCD, check the IOCDF website, Made of Millions, or the Anxiety and Depression Association of America.

The Center for Mindfulness & CBT has many providers who specialize in treating OCD. If you or a loved one is interested in gaining therapeutic support, fill in this form to be connected with a provider.