Because only some of its symptoms are
visible, OCD is widely misunderstood. OCD
It’s not just compulsions
Experts have come up with a bunch of different models for the way OCD works, and it varies from person to person. But here are the basics:
This process can happen so quickly that it seems instantaneous. You might skip steps, or there may be extra steps in your case. Let’s go through each of the parts to find out more.
What’s a trigger?
Tons of things happen to us throughout the day. Certain things we barely even notice, while others make us feel happy, mad, sad, or however else. A trigger is one of those things in our environment (or sometimes in our own minds) that cause us to experience a certain thought or to feel a certain way. For instance, if you’re recovering from the grief of losing a loved one and you begin to feel sad when you hear their favorite song on the radio, that song is the trigger for your emotional state.
This trigger doesn’t exactly cause the feeling, because there are other things contributing to this process (like the way you already felt, or the thoughts that might come in between the trigger and the feeling), but it’s still the trigger in that moment. It’s important to note that the trigger is not always easy to identify. Sometimes you might have a lot of unpleasant thoughts and feelings for seemingly no reason at all.
What are intrusive thoughts?
An intrusive thought is a thought, image, or urge that seems to pop up in your mind out of nowhere. Sometimes these thoughts seem completely random, and other times they might be traced back to some type of trigger. Intrusive thoughts sometimes seem really harmless. But other times they’re frightening, confusing, or even debilitating.
Surveys of people without OCD reveal that they experience many of the same thoughts that completely derail people who have OCD. It’s hard to say whether or not people with OCD have these thoughts more often, but what we do know is that people with
OCD react to these thoughts very differently. We’ll talk more about this in the next section, but let’s start with a few examples of intrusive thoughts. Remember these are only examples. The brain can, and will, come up with everything.
What are obsessions?
Obsessions are unwanted and repetitive thoughts, urges, and images that quickly spiral from an initial disturbing thought and usually lead to a lot of distress. While closely linked to intrusive thoughts both in theme and nature, obsessions actually come a little later in the obsessive-compulsive process. When a person experiences an intrusive thought and makes a catastrophic assessment about it, the thought can latch on and spiral into a bunch of obsessions.
Let’s look at a common example: you’re driving along the highway, and you get the thought: I should drive off the road and smash into that barrier over there.
Someone without OCD thinks: Wow, that was weird. Of course I don’t want to do that. And then they drive along and forget it ever happened.
Someone with OCD thinks: Oh god, not this again, I’m going to drive off the road, this means I want my life to be over, I don’t really want my life to be over, I need to make sure I don’t drive off the road, but maybe I do want to drive off the road? And so on…
The intrusive thought is the same for both, but the assessment of that thought is different. This doesn’t mean the second person chooses or prefers this assessment. It’s simply what it means to have OCD. The person without OCD notices how strange the
thought was and keeps driving along. The person with OCD makes a catastrophic assessment of the thought and the obsessions begin.
Many people use intrusive thought and obsession interchangeably, but they’re not quite the same. And there’s an important middle step between them. As discussed above, everyone has intrusive thoughts: they pop into your head, and they’re strange or alarming. Most people might think for a few seconds about the unpleasant thought and then go on with their day. What’s different for people with OCD is their inability (or at least the inability they feel) to just let the thoughts pass by. Someone with OCD will have an intrusive thought, vastly overestimate its importance, and spiral into obsession.
The person with OCD assesses the thought as not only important and worthy of their attention but even catastrophic: wow, I need to do something about this right away. Instead of shrugging it off as a strange, passing thought, they feel an irresistably strong need to investigate the thought. This might mean figuring out where the thought came from, preventing the thought from coming true, or solving a problem that the thought
This catastrophic assessment, a key part of the obsessive-compulsive process, can happen almost instantaneously, and it’s usually just about indistinguishable from the obsessions themselves. But it’s also essential to any psychological understanding of why an intrusive thought that another person is able to dismiss as harmless can be so debilitating for someone with OCD.
We use the word “obsessed” in our culture to describe things we’re really interested in. He’s obsessed with her, she’s obsessed with checking her Instagram. But that’s not really how obsessions work for people with OCD. You’re not interested in your obsession any more than someone is interested in their stomach ache. You feel forced to think about it over and over, and it’s usually the most disturbing thing your mind could throw at you.
Since obsessions are closely tied to the initial intrusive thought that brings them on, they can really spin out in any direction from any thought like the ones listed on the previous page. Just as there are infinitely many intrusive thoughts, there’s no limit to the obsessions that people experience. However, people with OCD aren’t really bothered by every thought that pops into their head. Instead, their obsessions usually
emerge in response to just a few types of intrusive thoughts at any given time.
What kind of distress can occur?
Because intrusive thoughts and the obsessions that follow are so disturbing to people with OCD, a number of emotional and physical symptoms can arise. It’s really this distress, and not the thoughts themselves, that makes people think: Okay, I have to get rid of this feeling as soon as possible. And then come the compulsions.
Remember how you’ve felt right before taking an important exam in school, getting test results back from a doctor, or going to talk with your boss. The sensations that come with your body being “amped up” are similar to what a person with OCD feels when they’re dealing with obsessions. Their brain says “Time to be alert!” and their body responds by feeling on edge.
Physical symptoms often include restlessness, agitation, inner tension, dizziness, nausea, shortness of breath, exhaustion, gastrointestinal problems, body aches, dizziness, inability to sleep, and much more. Often the feeling of being immersed in
obsessive thought loops seems just a step away from a full-on panic attack.
Emotional symptoms also usually emerge in response to the obsessions: fear, guilt, shame, confusion, sadness, dread, irritability, anger, inability to focus, frustration, jumpiness, self-loathing, disgust, and so on. Often these emotional and physical symptoms work together in another kind of vicious circle: you start to worry, notice you’re feeling worse, and then worry about feeling worse.
We’re getting slightly ahead of ourselves on this part, but here’s one last thing while we’re talking about distress. Emotional and physical pain in people with OCD is by no means limited to the obsession stage. The pain might momentarily be soothed by compulsions, but it usually comes back even worse. And the compulsions can create new types of distress, too.
For example, let’s say Sam from our example above quits the babysitting job out of compulsive avoidance of anything that brings on that type of obsession. Sam returns home, and a few days is filled with regret that the job– and getting to spend time with the neighbor’s kids as usual– is a thing of the past. The avoidance has created new problems, and new negative emotions.
Someone with a hand-washing compulsions can end up destroying the skin on their hands, to the point where they have to wear gloves just to keep them intact. And someone who responds to obsessions about choking on food or eating contaminated food by compulsively restricting their eating can become extremely thin or even develop a comorbid eating disorder
An important thing to understand about OCD is that it’s a disease of cycles. A compulsion is used to get rid of the distress the obsessions have caused, but the compulsion ends up worsening that distress long-term, while leaving a bunch of other problematic symptoms in its wake.
Distress is present throughout the obsessive-compulsive cycle, but we’re talking about it here because the goal of compulsions is to get rid of the distress that obsessions cause.
What’s a compulsion?
When this distress gets overwhelming, people with OCD will often engage in compulsions: repetitive activities aimed at getting rid of distress and regaining a sense of control. Sometimes the compulsion is closely tied to the obsession (for example, handwashing in response to obsessions about contamination), but other times there isn’t a clear logical connection. Either way, compulsions seem to help because the person doing them feels that they removes some of the uncertainty that emerges when their obsessions appear. It’s called a compulsion because people feel like they are compelled, or forced, to do it. Here are just a few examples of compulsions:
Compulsions might provide a temporary sense of relief, but the anxiety quickly returns. You can never outrun your own mind, and anything designed to keep a certain thought out of your head is actually guaranteed to make that thought pop up more often. This is the part in your psychology lecture when the professor says, “Whatever you do, don’t think of a big pink elephant.” By trying not to think of something, you’re already thinking about it, and the obsession tends to get stronger.
So compulsions only work for a bit, and the thoughts start coming on more often as you try to get keep them away. This process begins to spiral, and the obsessive compulsive cycle can start to take up the better part of your day. The more you perform compulsions, the less you trust yourself and the more you believe that you should be afraid of your own thoughts. And you never find out what would happen if you didn’t do a compulsion, and let things happen. Here are a few examples of compulsions:
Of course, many people with OCD don’t think about their experience in these terms, and simply feel like they have to do the compulsion for some unknown reason. Others are aware of it but still feel like the compulsion will either prevent something bad from happening, or help them feel better for a while. Yet another form of compulsion is compulsive avoidance of situations that might bring about their obsessions again.
A common misconception about OCD is that people want to perform their compulsions. We see people washing their hands over and over, or refusing to leave their house, and assume that it’s part of their personality or a reflection of their interests. In reality, most people know that their compulsions don’t make any sense but are still unable to stop doing them. And even the people who don’t know this still aren’t doing the compulsions because they want to, but because they feel completely sure they have to.
For a small number of people, OCD symptoms become so severe that suicide is a risk. If you ever consider suicide, call your local suicide hotline or emergency number right away. In the United States, this number is 1-800-273-8255.
These resources were developed with:
Michael A. Jenike, MD
Founder, OCD Institute at McLean Hospital
Professor of Psychiatry, Harvard Medical School
Christopher Pittenger, MD, PhD
Director, Yale OCD Research Clinic
Associate Professor of Psychiatry and in the
Child Study Center, Yale School of Medicine