A Psychologist Answers FAQ about OCD
By Meng-lin (Benny) Hsieh, Counseling Psychologist in Taiwan
Summary: Obsessive-Compulsive Disorder (OCD) involves frequent intrusive thoughts (obsessions) and ritualistic behaviors (compulsions) that a person performs to reduce the distress those thoughts cause. OCD is different from general anxiety, is maintained through a cycle of avoidance and negative reinforcement, and is treatable — the first-line treatments are medication and Exposure and Ritual Prevention (ERP). This FAQ answers the most common questions people ask about OCD: what it is, how to recognize it, how it affects daily life, and what treatment looks like.
What Is Obsessive Compulsive Disorder (OCD)?
OCD is a diagnosis for people who experience frequent "obsessions" or "intrusive thoughts," and develop ritualistic "compulsions" to mitigate the distress caused by the obsessions. Obsessions and compulsions are frequent, adding up to several hours per day, almost every day of the week. The combination of obsessions and subsequent compulsions can be highly disruptive of a person's day-to-day, oftentimes adding stress to the individual either through shame or guilt, sometimes even straining the relationships that they have with others.
What Are Some Common "Types" of OCD?
Although technically an obsession could be about any situation, many people's obsessions revolve around certain "themes":
- Cleanliness / contamination (e.g. fear of dirtiness or of falling ill due to germs)
- Order / completeness (checking)
- Safety / harm
- Scrupulosity (fear of offending a higher power)
- Morality
…just to name a few.
What Is the Difference Between OCD and Anxiety?
The obsessions that people with OCD experience stand out from other symptoms by being "knowingly illogical" — meaning that people with OCD often know at the cognitive level that their obsessions do not make logical sense. And yet, they are so bothered by the distress associated with the obsessions that they feel compelled to complete their compulsion or ritual, in an attempt to lower that distress.
Anxiety, on the other hand, is rooted in ruminative thinking. People who have anxiety disorders (such as Generalized Anxiety Disorder) often believe the anxious thoughts to be true, or similar to people with OCD, can't or won't take the "risk" of not worrying about something.
How Do I Know If I Have OCD?
If you suspect you have OCD, you are definitely not alone. A study reported that 65.05 people out of every 100 thousand people in Taiwan have been diagnosed with OCD (Huang et al., 2014). This means that almost 15,000 people in Taiwan have sought either inpatient or outpatient treatment for their OCD. This statistic is also likely an underestimate, due to the fact that not everyone with OCD would seek treatment.
The best way to find out if certain symptoms amount to OCD is through a structured clinical interview. We recommend speaking with a mental health provider, such as a psychiatrist or a psychologist, to discuss the possibility of an OCD diagnosis, as well as treatment options.
How Are OCD Symptoms Maintained?
There is not one exact cause of OCD. Generally, OCD is caused by both inherent (e.g. genetic predisposition) and environmental factors. However, the symptoms of OCD are primarily maintained through the mechanism of avoidance.
First, certain stimuli become associated with distress. Then, an individual learns that by performing the ritual (cleaning, washing, counting, checking, etc.), the distress drops, which in turn "negatively reinforces" the compulsion. The next time the individual encounters the stimulus, they perform the ritual again, strengthening the association between obsessions and compulsions. Gradually, these behaviors develop into ingrained patterns that are difficult to shake off without external assistance.
How Does OCD Impact a Person's Life?
Obsessions by definition are very distress-inducing. Imagine feeling as if you are compelled to monitor throughout the day whether your "safe space" has been contaminated by germs. Or when intrusive thoughts pop into your mind at inconvenient times.
For people who have more severe levels of OCD symptoms, they spend up to 8 hours or more a day either being vigilant about obsessions or trying to stave off — or even surrendering to — their obsessions by performing complicated and drawn-out rituals (e.g. washing bedsheets every day; quadruple-checking every email for spelling errors; distracting themselves from unwanted thoughts about friends and family). For some people, the distress associated with their obsessions becomes so unbearable that they begin to "externalize" their rules, turning normal social interactions into a landmine.
It's easy to see how OCD symptoms become highly debilitating, and can even have a negative impact on a person's ability to work and maintain relationships.
Does Having OCD Make Me a Bad Person?
No, it doesn't. When we judge a person's character, it is not fair to make judgements based solely on circumstance. Since nobody really chooses to have OCD, such judgements are not only unhelpful — they are fundamentally flawed and untrue.
Major goals of behavioral treatments for OCD include exploring and understanding the function of OCD behaviors in your daily life, learning strategies to cope better with the symptoms, and ultimately embracing some aspects of OCD as a part of what makes you unique as a person.
What Treatments Are Available for OCD?
Medication and Exposure and Ritual Prevention (ERP) are the first-line treatments for OCD. In Taiwan, a psychiatrist assesses and diagnoses an individual with OCD. Then they discuss different treatment options: medication, ERP, or sometimes a combination of both. If you suspect you have OCD, we recommend speaking with a mental health provider to figure out what treatment plan is best suited for your needs.
How Does ERP Work?
ERP is an evidence-based treatment specifically designed to decrease OCD symptoms by removing avoidance. Recall that OCD symptoms are primarily maintained through the mechanism of negative reinforcement. In ERP, the provider introduces a stimulus that is associated with distress, and then coaches the patient as they try to stop themselves from performing their rituals — merely observing how their distress fluctuates throughout the process.
You can think of ERP as a reversal of sorts: together with a trained provider, you develop a "fear hierarchy" by listing out various scenarios that cause significant distress, and gradually work your way up the ladder. By working systematically through your list of fears, you begin to learn that the distress that comes from NOT performing the rituals is often lower than expected, and that the distress goes away on its own. In research, this process is called "inhibitory learning."
Essentially, ERP replaces the original negative reinforcement pathway with a different one. Through repeated iterations of the new pathway, the feelings associated with the distress-inducing stimuli change. ERP has been found in clinical trials to be as effective as medication.
How Long Does ERP Take?
The length of ERP varies greatly depending on symptomology, treatment setting, and treatment adherence. In outpatient settings, a full course of focused ERP typically takes a few months up to one year.
How Can Friends and Family Support People with OCD?
Stress is associated with greater symptomology for people with OCD. The best way to support friends and family who might be struggling with OCD is to encourage them to seek and stay in treatment.
Often, people with OCD feel like they are a burden to their loved ones. Please don't assume that your friend or family member with OCD "just wants to make your life harder" or is "just being difficult for no reason." Practice patience, empathy, and give each other grace instead. Like many situations in life, compassion is key. As Mary Poppins would say: "A spoonful of sugar makes the medicine go down."
At Blooming / Blooming-Anhe Center for Counseling Services, our therapists are experienced in supporting clients living with OCD and related anxiety conditions, using evidence-based approaches such as ERP. If you recognize yourself or a loved one in this article, we welcome you to reach out and begin that conversation with us.
References
American Psychiatric Association. (2022). Obsessive-compulsive disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
Foa, E. B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 199-207. DOI: 10.31887/DCNS.2010.12.2/efoa
Foa, E. B., Yadin, E. & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive Compulsive Disorder - Therapist Guide (2nd ed.). Oxford University Press.
Foa, E. B., Simpson, H. B., Liebowitz, M. R., Powers, M. B., Rosenfield, D., Cahill, S. P., Campeas, R., Franklin, M., Hahn, C.-G., Hembree, E. A., Huppert, J. D., Schmidt, A. B., Vermes, D. & Williams, M. T. (2013). Six-month follow-up of a randomized controlled trial augmenting serotonin reuptake inhibitor treatment with exposure and ritual prevention for obsessive-compulsive disorder. Journal of Clinical Psychiatry, 74(5), 464-469. DOI:10.4088/JCP.12m08017
Huang, L. C., Tsai, K. J., Wang, H. K., Sung, P. S., Wu, M. H., Huang, K. W. & Lin, S. H. (2014). Prevalence, incidence, and comorbidity of clinically diagnosed obsessive-compulsive disorder in Taiwan: A national population-based study. Psychiatry Research, 220, 335-341. DOI: 10.1016/j.psychres.2014.08.011
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Huppert, J. D., Cahill, S., Maher, M. J., McLean, C. P., Bender Jr., J., Marcus, S. M., Williams, M. T., Weaver, J., Vermes, D., Van Meter, P. E., Rodriguez, C. I., Powers, M., Pinto, A., Imms, P., Hahn, C.-G. & Campeas, R. (2013). Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder. JAMA Psychiatry, 70(11), 1190-1199. DOI: 10.1001/jamapsychiatry.2013.1932