OCD Cycle
Harm OCD
“What if I push this stranger onto the train tracks?”
Urge to pick up the kitchen knife on the counter and stab a family member
Image of sexually assaulting my friend
Common Obsession Themes
Pedophilia/Bestiality OCD
Image of touching a child inappropriately
Groinal response (a normal physical sensation of arousal, unrelated to sexual attraction/desire) at the sight of a child
“What if I’m attracted to my pet?”
Contamination (Physical/Emotional) OCD
“What if this toilet seat gives me an STI?”
“What if my apartment has a carbon monoxide gas leak and I can’t tell?”
“What if I pick up bad habits from watching TV shows about crime?”
Health Anxiety OCD
“How do I know I don’t have schizophrenia?”
“What if this cough is a sign of lung cancer?”
“What if I stop breathing while I’m asleep?”
Suicidal Ideation OCD
Urge to jump off a cliff during a hike
“Swerve the car off this bridge!”
Image of loved ones at my funeral
Real/False Memory OCD
“I had nonconsensual sex with my partner”
“How do I know that speed bump was not actually a person?”
“How do I know I turned the stove off before leaving?”
Scrupulosity/Religious OCD
“I am a bad person”
“How do I know if I committed an unforgivable sin?”
“How do I know if I offended that person?”
Existential OCD
“How do I know life isn’t a simulation?”
“What happens to all my thoughts/memories after death?”
“Scream out a slur in this crowd!”
Sexual Orientation OCD
“I am bisexual and have been lying to myself”
“How do I know I’m attracted to my partner?”
Image of person of non-interested gender during orgasm
Meta OCD
“How do I know I won't act on these thoughts?”
“How I do know I truly have OCD?”
“What if these thoughts feel too real to be OCD?”
Exception OCD
“What if treatment can’t help my form of OCD?”
“Other people who have OCD are telling the truth and I’m just pretending”
“What if my OCD theme makes me more dangerous than people with other themes?”
Diagnosis Deception OCD
“What if I tricked my doctor/therapist into giving me the wrong diagnosis?”
Backdoor Spike OCD
“If I start feeling less anxious, does that mean that I like these thoughts?”
(incomprehensive list by nature)
ERP Treatment OCD
“I MUST do the challenging thing that my obsession doesn't want me to"
(predominant intent being anxiety relief, not values/beliefs/desires...further clarification given in Compulsions section under Overcompensation)
OCD is Ego-dystonic
OCD can latch onto and hijack anything. OCD is an ego-dystonic disorder: obsessions (recurrent unwanted distressing intrusive thoughts, images, urges, commands, or sensations) do not align with the person’s values/beliefs/desires, and are often the exact opposite.
A person who values treating others well may struggle with harm obsessions.
A person who values protecting children may struggle with pedophilia obsessions.
A person who values moral integrity may struggle with scrupulosity obsessions.
A person who values honesty may struggle with diagnosis deception obsessions.
"Generic Doubt Disorder"
OCD is an anxiety spectrum disorder, specifically regarding “generic doubt” and intolerance of uncertainty. Irrespective of OCD, 100% certainty regarding anything is impossible to achieve. Obsessions can manifest differently person to person, but the content of OCD is completely irrelevant to the disorder. It is generic doubt. Period. OCD thrives where uncertainty is least tolerable, which happens to primarily be where a person’s most closely held values/beliefs/desires live. Consequently, there is often a significant amount of moral injury and hijacking of self-concept/joy that results from OCD. OCD themes are deeply personal and "non-contagious”. Learning about other themes unrelated to one’s values/beliefs/desires will not automatically induce these themes for them. The grass is always greener when comparing themes to another person with OCD, because each person’s constellation of themes is specific to their own values/beliefs/desires. It can be easier to tolerate uncertainty in areas outside of one's values/beliefs/desires because the stakes feel lower. OCD can have a habit of showing someone where their values/beliefs/desires reside in the most excruciatingly horrific way imaginable, by demanding relentlessly that the person is unworthy of their values/beliefs/desires. There is no timeframe regarding how often or for how long an obsession can recur (seconds, minutes, hours, days, months, years). It is not uncommon to have multiple OCD themes simultaneously that demand attention in a “whack-a-mole” type presentation.
Cognitive Distortions
OCD is irrational, and therefore, no amount of rational thinking can outmaneuver or problem solve for permanent certainty/elimination of doubt regarding the content in question. Rational problem solving can include content-related rumination/reasoning, reassurance seeking, googling, or checking. In fact, repeated checking results in worsening distrust of memory. Even though anxiety can FEEL extremely dangerous, it is not inherently physically dangerous. In the context of OCD/anxiety disorders, pathologic anxiety is a faulty cognitive process and does not imply true danger. OCD can involve emotional reasoning, where the anxious response to an obsession (recurrent unwanted distressing intrusive thoughts, images, urges, commands, or sensations) can convince the person to assign meaning to the obsession. Thoughts are just thoughts. There is no inherent meaning to any given thought. OCD can try to convince the person that the increased presence/frequency/severity of any given obsession must be related to the validity/truthfulness of the obsession. OCD can try to convince the person that engaging in compulsions is protective or provides utility. OCD can involve “thought-action fusion”, where it can mistakenly convince the person that an obsession did in fact occur as a true event.
Additional OCD cognitive distortions:
Increased risk aversion
Likelihood of threat overestimation and ability to cope underestimation
Negativity bias/catastrophizing
All or nothing thinking
Personal control/responsibility overestimation
Faulty irrational thought patterns
Barriers to Care
The illiteracy regarding OCD is rampant. The general population’s understanding is so inaccurate that it can make it difficult to notice one’s own OCD symptoms. Enjoying cleaning/organizing/color-coordinating is not OCD. If it is “enjoyable”, it is not OCD. There is still such a significant stigma regarding all mental health conditions. Whereas other medical diagnoses (eg. broken leg) are viewed as issues external to a person’s identity/character, mental health diagnoses are largely stigmatized to imply something about the internal “faultiness” of a person’s identity/character.
“Thought prosecution” is the fear that an individual will be prosecuted for divulging the content of their obsessions to a healthcare provider. This can be worsened by the ”thought-fusion” cognitive distortion, which can convince the person that divulging the content of their obsessions represents a confession for that crime having truly been committed. Healthcare providers need to be properly educated on OCD in order to help diminish this barrier to care and receive these individuals’ concerns compassionately.
On average, it takes someone with OCD between 14-17 years before receiving a diagnosis.
DSM Diagnostic Criteria
Obsessions: recurrent unwanted distressing intrusive thoughts, images, urges, commands, or sensations
and/or
Compulsions: ritualistic behavior to neutralize anxiety
Symptoms cause significant distress/impairment (social/occupational/functional) or occur >1 hr/day
Human brains have >6000 thoughts/day, some of which can be considered “brain junk”. The experience of intrusive thoughts is not specific to people with OCD. Almost everyone in the general population will occasionally experience intrusive thoughts. The response to the intrusive thoughts is the problem in OCD.
Treatment
Exposure & Response Prevention ERP therapy
and/or
Medication (drug classes that increase serotonin levels to decrease anxiety)
Traditional cognitive behavioral therapy CBT is used for many mood/anxiety disorders. However, given that CBT focuses on attempting to rationally analyze the content of the distress, it may offer little/no value in OCD and may end up worsening the symptoms.
OCD is a chronic illness that is highly responsive to treatment, however not curable.
Harm OCD
Urge to pick up the kitchen knife on the counter and stab a family member
Refusing to enter the kitchen (avoidance)
Trying to ”think kind thoughts” when these urges arise (thought stopping/replacing)
Compulsions
Pedophilia/Bestiality OCD
Groinal response (a normal physical sensation of arousal, unrelated to sexual attraction/desire) at the sight of a child
Anticipating a moment of physical arousal (sensation/symptom monitoring)
Not visiting family with young cousins/nieces/nephews (avoidance)
Contamination (Physical/Emotional) OCD
“What if my apartment has a carbon monoxide gas leak and I can’t tell?”
Setting daily alarms to ensure the batteries in the detector don’t die (checking)
Taking breaths in groups of 3 or a certain rhythm (counting)
Health Anxiety OCD
“What if this cough is a sign of lung cancer?”
Self-diagnosing using the internet (searching/googling)
Ensuring equal chest expansion when taking a deep breath (symmetry)
Suicidal Ideation OCD
Urge to jump off a cliff during a hike
Determining these urges mean that I don’t want to die (reflexive value sourcing)
Pausing to breathe after every 4 steps (counting)
Real/False Memory OCD
“How do I know that speed bump was not actually a person?”
Watching the news to see if there was a crime reported (searching/googling)
Replaying the event/memory in my mind (rumination/reasoning)
Scrupulosity/Religious OCD
“How do I know if I offended that person?”
Asking that person if I offended them (reassurance seeking)
Ensuring that each interaction “feels right” (“just right”)
Existential OCD
“How do I know life isn’t a simulation?”
Not watching fictional movies about dystopian technology (avoidance)
Trying to ”think happy thoughts” when these thoughts arise (thought stopping/replacing)
Sexual Orientation OCD
“How do I know I’m attracted to my partner?”
Confessing these thoughts to my partner (reassurance seeking)
Reviewing earlier texts for loving sentiment (checking)
Meta OCD
“How I do know I truly have OCD?”
Determining these thoughts “are not me” and ”are just my OCD” (OCD thought labeling)
Offsetting these thoughts with an equal number of “my own” thoughts (symmetry)
Exception OCD
“What if my OCD theme makes me more dangerous than people with other themes?”
Trying to change my themes to the ”correct” themes (“just right”)
Determining these thoughts “are not me” and ”are just my OCD” (OCD thought labeling)
Diagnosis Deception OCD
“What if I tricked my doctor/therapist into giving me the wrong diagnosis?”
Replaying the conversation/memory in my mind (rumination/reasoning)
Determining these thoughts mean that I value honesty (reflexive value sourcing)
Backdoor Spike OCD
“If I start feeling less anxious, does that mean that I like these thoughts?”
Anticipating physical manifestations of anxiety (sensation/symptom monitoring)
Trying to remain untreated/unwell (avoidance)
(incomprehensive list by nature)
Physical ritualization types:
Checking
Sensation/symptom monitoring
Searching/googling
Counting
Symmetry
“Just right”
Avoidance
Overcompensation (predominant intent being anxiety relief, not values/beliefs/desires)
Mental ritualization types:
Rumination/reasoning
Reassurance seeking
Thought stopping/replacing
Reflexive value sourcing
OCD thought labeling
Avoidance
Further clarification: An action based predominantly on opposition to the obsession, and specifically not based predominantly on one’s values/beliefs/desires, is still an action IN RELATION TO the obsession. The goal of treatment is to not have ANY relation to the obsession. It is the difference between living a life towards one’s values/beliefs/desires DESPITE having OCD vs simply overcompensating in the opposite direction of the obsession in order TO SPITE the OCD. The challenge of recovery is to just be, not to just be doing challenges to overcompensate one’s obsessions.
ERP Treatment OCD
“I MUST do the challenging thing that my obsession doesn't want me to"
Acting based predominantly on opposition to the obsession, and specifically not based predominantly on one’s values/beliefs/desires (overcompensation)
Exposure & Response Prevention ERP
Exposure: presence of an obsession
Response Prevention: compulsion resistance
At first glance, the logical place to break the cycle may appear to at be the beginning: the obsessions. However, intrusive thoughts, images, urges, commands, and sensations are just that: intrusive. This part of the cycle is automatic. Humans cannot control what thoughts enter our brains, however we can control how we respond to these thoughts. Treatment is aimed at breaking the cycle by minimizing compulsions and subsequently decreasing the presence/frequency/severity of the obsessions/anxiety and the cycle as a whole over time. Of note, compulsion resistance is NOT thought stopping.
(adapted from psychologytools.com)
If someone has made a habit of escaping anxiety via compulsions prior to the anxiety peak, truly experiencing the anxiety peak without escape can result in a heightened perceived sense of irresponsibility/risk/danger. It is important to challenge oneself within the therapeutic window: the "sweet spot" target zone where exposures produce anxiety that is not catastrophically overwhelming but is manageably provocative enough to provide the opportunity to achieve meaningful response prevention. The therapeutic window changes throughout recovery with respect to one's familiarity/relationship with anxiety.
Approaches to managing the therapeutic window include:
1) compulsion resistance progression: partial compulsion completion/delay of compulsion completion → replacement with less severe compulsion → outright compulsion elimination
2) exposure severity progression: engaging with lower severity stimuli to induce lower severity obsessions → engaging with higher severity stimuli to induce higher severity obsessions
Attempting to visualize the OCD cycle and its discrete components as they are happening in real time can be difficult, especially early in treatment. Intrusive thought obsessions in OCD can present at such an unrelentingly high frequency that the cycle can feel blurry and indistinguishable, akin to a wheel spinning too quickly to clearly identify the spokes. Both ERP and medication can help slow down the paradigm, inviting more clarity to the OCD cycle and its discrete components. Of note, there can be a “symptom/habit inertia” period in the beginning stages, where progress is being made that does not appear to be changing the speed/severity of the paradigm quite yet. Both breaking old habits and forming new habits take concerted efforts that may not exhibit results instantly. Once able to be visualized, the “power of the pause” is an important moment found immediately following an intrusive thought obsession, acting as the crossroads between practicing ERP vs engaging in the effortful choice of compulsions.
Non-Engagement Responses NERs
Affirmation of uncertainty:
“I genuinely don’t know”
“I can never be 100% certain”
Affirmation of anxiety:
“It's okay to remain anxious”
“Anxiety isn’t dangerous even though it can feel that way”
Affirmation of possibility:
“Maybe, maybe not”
“I guess that could happen”
Affirmation of difficulty:
“That would be terrible if it were true”
“That would suck”
Disarming sarcasm:
“Thanks for letting me know”
“Sweet, I appreciate it”
(Any combination of NERs)
Reassurance outside of the intrusive thought content is not a compulsion. Reassurance within the intrusive thought content is a compulsion. Radical acceptance of obsession presence is not content agreement.
It is important to truly believe in an NER/combination of NERs that feel like one's own voice in order to remain confident and committed to employing the response as often as the obsessions will demand. Some NERs may feel unnatural and can easily become repeatable empty phrases in the form of a compulsion if not careful.
Trigger Warnings
Triggers are stimuli that have the potential to induce an obsession. Triggers themselves are not exposures. Exposures are the presence of obsessions. The goal of ERP recovery is based in repeated exposure related obsession desensitization/habituation. “No longer getting triggered” is not the goal of recovery. Intentionally engaging with stimuli that have the potential to induce an obsession provides the opportunity to practice/reinforce ERP. Trigger warnings can artificially heighten levels of sensitization/provocation prior to engaging with stimuli that induce an obsession. Additionally, interacting with trigger warnings as intended can encourage compulsive avoidance. Trigger warnings can be counterproductive to allowing oneself to naturally experience a changing response to any given stimuli during the process of ERP recovery.
Recovery & Strength
Recovery is not defined by the absence of intrusive thoughts, images, urges, commands, or sensations, but rather the practiced non-participation of compulsive escape from anxiety. Recovery is about the reclamation of one’s values/joy by living alongside anxiety in the direction of one’s values. The World Health Organization WHO ranks OCD in the top 10 leading causes of disability worldwide. The experience of OCD can be traumatic. Trauma does not make someone strong, enduring it does.
It is not a sign of weakness to reach out for help. If ending one's life begins to feel like an option, please call 988 to reach the Suicide and Crisis Lifeline.
Resources
Creator/resource diversity ranges from the following:
Therapists
Licensed professional counselors
Social workers
Firsthand patient accounts
Advocacy organizations
Artists
& more
Much of effective therapy hinges on the importance of repetition. It may take seeing/hearing/engaging with a piece of information 1000 different times using 1000 slightly different approaches for the sentiment to be fully received. This can also be affected by where someone is in their recovery process, to be able to fully reconcile and implement the information constructively.
A healthy consistent “information diet” can help support this idea. Integration with one's own social media (whether via a main account or the creation of a separate OCD account) can be a simple yet powerful approach to achieving daily visibility of information to help with recovery.
This collection of educational materials is primarily a mix of content from the following creators/resources augmented with my personal OCD recovery experience. Clicking/scanning the QR code below will take you to an instagram page solely dedicated to a “Following” list with these curated creators/resources. Then navigate to the “Following” list to quickly and easily follow any/all of the +50 resources who post new content daily.
Content type diversity ranges from the following:
Written informational summaries
Graphical representations
Video discussions
Firsthand patient experiences
Community support groups
Comments/questions/replies
& more
