Obsessive-compulsive disorder (OCD) may bring to mind an overly tidy person or a TV character with quirky fixations. But for many people with the disorder, OCD is distressing and sometimes debilitating, says Craig Sawchuk, Ph.D., L.P., a Mayo Clinic psychologist and expert in OCD treatment.
OCD is often a self-reinforcing cycle of:
- Obsessions — These are repeated, unwanted thoughts or images that cause anxiety or distress. Examples include intense fears about germs or violent thoughts of harming someone.
- Compulsions — These behaviors are attempts to ease the distress caused by obsessions or to prevent something bad from happening. This could be repeatedly washing hands to get rid of germs, or mental rituals such as repeated prayers or mantras. However, these behaviors provide only temporary relief. “It can be unbelievably consuming,” Dr. Sawchuk says, with obsessions and compulsions taking up several hours each day.
Below, Dr. Sawchuk explains OCD and the treatments available for this condition.
Q: Can you give an example of an OCD obsession and compulsion cycle?
A: One common theme is an obsession involving doubt followed by some form of checking behavior. For example, a person could be leaving for work and think, “Did I lock my door?” This question isn’t coming from a place of idle curiosity. It’s coming from the idea that, “If I didn’t lock up, somebody could break into my house.” These thoughts tend to go to the worst-case scenario, and to someone with OCD, these scenarios feel likely to happen.
To prevent this from happening or to stop the anxiety, a person with OCD goes through rituals — the compulsions. They may unlock and lock their door multiple times. But halfway to work, the thoughts come back: “Are you sure you were really paying attention when you locked the door?” These thoughts can build a strong urge that leads them to go back home and go through all the rituals again.
When nobody breaks in, it reinforces the belief that all that checking was necessary to prevent a break-in. The cycle can strengthen over time. Eventually, the person may be checking the door 10 times or filming themself locking the door and then checking the video again and again. It’s a trap: The more you fight with these thoughts and seek reassurance, the more stuck in the OCD cycle you become.
Q: Everyone occasionally thinks “Did I lock the door?” What makes these types of thoughts so powerful in OCD?
A: There are a couple of beliefs that are more characteristic of OCD. One is a high sense of responsibility and guilt, as in: “If I don’t take care of this, this bad thing will happen.” Those with OCD also can have difficulty with uncertainty. They need to know, without doubt, that everything is OK.
People with OCD also can experience a blurring of action and thought. Intrusive thoughts are actually very common. For instance, if you’ve ever been in a really high place and looked down, you may have thought, “What if I lost control right now and pushed somebody over this ledge?” Most people experience an intrusive thought and think, “That’s kind of weird,” and then move on. In people with OCD, thoughts are very significant. They question, “Why am I thinking about that? What does that say about me?” They make moral judgments about themselves, such as, “I must be a horrible person.”
Q: When does behavior cross the line from “quirky” or “perfectionist” to OCD?
A: It becomes a disorder when the obsessions and compulsions consume more and more of your time, effort and energy during the day. The relative cutoff is spending more than an hour a day caught up in the intrusions and rituals. But there are other important factors to consider. Maybe OCD is interfering with work or relationships because you’re getting caught up in rituals. If your quality of life is affected, it’s a good idea to seek help.
Q: Will a healthcare professional really understand the disturbing thoughts that can come with OCD, such as unwanted sexual or violent thoughts?
A: It depends on who you’re talking to. Some healthcare providers are not familiar with OCD and may be alarmed by a description of these thoughts. But a provider experienced in OCD will recognize these for what they are, will not judge you, and will give you effective strategies to deal with these thoughts. The International OCD Foundation can help you find OCD therapists, clinics and support groups.
Q: How do you break the cycle of OCD?
A: In many ways, OCD behaviors can be overlearned habits. Exposure and response prevention (ERP) is a treatment designed to break those habits. You can receive ERP at therapy appointments, intensive outpatient programs or residential programs. The simplified explanation of ERP is that a therapist will ask you to do the opposite of what the OCD is telling you to do. So if the OCD is saying, “Avoid!” then you may need to get closer and approach the situation (the exposure). When the OCD says, “Do this ritual!” we teach you to resist the urge (response prevention). This isn’t simple, and we try to make it a fair fight by starting with smaller challenges before working up to difficult ones. We’ll help you learn to cope with the anxiety and avoid giving in to compulsions. Then we practice these exposures many times to retrain the brain.
We may do seemingly strange things in treatment. For example, someone with OCD may be taking showers for hours at a time, multiple times a day. Eventually, we try to get that person touching floors and then touching their face, then resisting that urge to wash and disinfect. This can be a powerful learning experience and test of one’s fears. It demonstrates that what seems extreme is often actually quite safe.
For intrusive thoughts, sometimes we ask people to write out scripts of their imagined worst-case scenarios and reread the scripts many times in a given day. Initially, their anxiety might build, but with more readings, those thoughts start to become boring and lose their significance. When that happens, the thoughts become less frequent.
Q: Are medications used to treat OCD?
A: Generally, ERP is enough for mild OCD. For moderate to severe OCD, your care team will typically add medication — usually an antidepressant — to behavior therapy. One of the distinguishing features of OCD is that higher doses of medication seem to work better than lower doses. So it’s a balancing act to try to advance the dose while managing any side effects.
Q: How well does treatment work?
A: Without treatment, OCD doesn’t tend to go away on its own. But OCD is very treatable, even if you’ve had it for years or decades. It’s not a light switch — you can’t “turn off” OCD. It’s more like a dimmer switch, and you can turn the OCD down to more manageable levels.
However, OCD can be a relapsing condition. One important thing about treatment with ERP is that you are learning how to be your own best therapist. That way you can maintain and build upon your progress outside of therapy appointments. Good therapy isn’t something that’s done to you, it’s done with you.
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