Obsessive Compulsive Disorder

When Your Brain Tells You Lies

Imagine locking your front door, stepping away, and then—Are you sure it’s locked? A tiny voice whispers in your mind. You check once, just to be safe. You start to walk away, but the voice insists. Again. And again. No matter how many times you check, the uncertainty lingers, gnawing at you. This is the exhausting loop of obsessive-compulsive disorder (OCD), where doubt isn’t just a passing thought—it’s a relentless force.

Yet, the term OCD is often tossed around casually, used to describe someone who’s “super neat” or “extra careful.” But OCD isn’t about tidiness—it’s about anxiety, fear, and the overwhelming need to silence the intrusive thoughts that scream something terrible might happen. It’s time to look beyond the stereotypes and uncover what OCD truly is.

Inside the OCD Mind: The Obsessions and Compulsions That Take Control

Obsessive-compulsive disorder (OCD) is often misunderstood as just being overly clean or particular about organization. In reality, it’s a relentless cycle of intrusive thoughts, distressing images, and compulsive behaviors designed to chase away anxiety—if only for a moment.

OCD is the 4^th most common mental disorder, and the World Health Organization ranks it as one of the 10 most debilitating conditions.  Despite that fact, many cases of OCD go undiagnosed or incorrectly diagnosed.   Part of the reason for diagnostic errors is that the condition is often co-morbid with another.  That means the OCD could appear along with depression or a variety of other diagnoses.  The distressing feelings that OCD cause often contribute to the development of a host of other conditions.  (Pampaloni et al., 2022)

At its core, OCD isn’t about preference; it’s about fear. Obsessions can take many forms, including:‍

Contamination: An overwhelming fear of germs, chemicals, or environmental pollutants.
Sexual Intrusions: Disturbing, unwanted thoughts or mental images of a sexual nature.
Violence & Harm: Excessive fear of hurting oneself or others, often accompanied by horrifying mental images.
Religious Scrupulosity: An obsessive fear of offending God or facing eternal damnation.
Identity Doubts: Persistent worries about sexual orientation or gender identity.
Responsibility Anxiety: The belief that failing to be careful enough could lead to disaster.
Perfectionism: A paralyzing fear of making mistakes or failing to meet impossible standards.
Relationship Fixation: Constant doubt over a partner’s flaws, feelings, or commitment.

To cope with these obsessive thoughts, individuals with OCD engage in compulsions—rituals meant to neutralize the anxiety. These might include:

Excessive washing and cleaning to remove perceived contamination.
Repeating words or actions until it “feels right.”
Over checking—doors, appliances, or even memories—to ensure no harm has occurred.
Rearranging objects in a precise way to reduce discomfort.
Counting rituals while performing everyday tasks.
Praying compulsively in an attempt to prevent disaster.

For those with OCD, these obsessions and compulsions aren’t quirks—they’re exhausting, time-consuming, and often debilitating. Understanding the reality of OCD is the first step in breaking the cycle of stigma and misinformation.

Here are some actual stories of individuals dealing with OCD.  Their names are changed to protect their privacy.    

John

During John’s late elementary school years, he started struggling to turn in homework, preferring to keep it at home to “check one more time” before turning it in.   As he became older, he worried that germs would be present in public places and he would wash his hands until they turned red, spending many minutes, sometimes entire class periods in the restroom at school.   When John learned to drive, he would wake worried that he had killed someone in a car accident and had forgotten it and would spend hours driving around his neighborhood looking for signs of a terrible accident.  

By the time he entered counseling in his late teen years, John estimated that he had probably more than half of his life upset and worried about “something”.  He described as playing “whack a mole”.  If he proved to himself that the anxious thought was false, another one, usually more terrifying in nature, would pop into his brain to take its place.    

Mary

Mary, a 38-year-old woman, battles intrusive thoughts centering on the fear of divine disapproval and the anxiety that failing to pray correctly could result in catastrophic consequences. In her daily life, these thoughts force her into prolonged, repetitive prayer rituals that interrupt her work and personal relationships. She has been fired repeatedly from jobs for praying instead of working although she explains to her managers that she is saving them from “God’s punishment”.  Her spouse has left her and taken custody of their two little girls due to her not feeding them regularly or getting them to school on time as her prayer rituals take precedence over everything else.  She often fears she completed her prayer rituals incorrectly and repeatedly starts the rituals over and over again. This cycle of obsession and compulsion not only consumes substantial portions of her day but also leaves her emotionally exhausted and isolated.

Diagnosing OCD

Clinicians will ask a series of questions.  There are assessment tools that measure OCD tendencies in adults and children. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is frequently used by clinicians when assessing individuals for obsessive-compulsive disorder. Its focus on symptom severity provides valuable insight into the impact OCD symptoms have on patients' lives.

Click here to see the Y-BOCS.   You will see that it is divided into questions assessing obsessive thoughts and another on obsessive behaviors that develop to alleviate the anxiety and distress the thoughts cause.  

OCD can develop later in life in response to a stressful or traumatic event, but it can appear in children as well.  

Another consideration is that in addition to OCD, which is considered a mood disorder, there is Obsessive Compulsive Personality Disorder (OCPD).   Individuals with OCPD are born with the condition.  Although the two have similarities, there are differences that distinguish them apart. Unlike a mental health disorder that may be short-term and treatable, a personality disorder is a lifelong disorder that disrupts thoughts, behavior, and mood. These issues can cause great distress to an individual.

In order to receive an OCPD diagnosis, you must exhibit four or more symptoms out of the following eight signs:

• Perfectionism that limits finishing tasks
• Neglecting relationships due to a devotion to work
• Hoarding money for worst-case scenarios
• Obsessing over ethics, values, and morality
• Not wanting to assign tasks without a guarantee that those assigned will perform them exactly as they asked.
• Not wanting to part with worthless items
• A disposition that is stubborn or rigid
• Obsession with maintaining order by using lists, schedules, and rules.

The diagnosis of OCPD will involve a screening questionnaire, much like an OCD diagnosis. In this questionnaire, you will be required to report on your own behavior throughout the year. Once the screening is complete, your healthcare professional will conduct an interview with you. They may also gather information from your family, friends, and peers.

Treating OCD and OCPD

Medication and talk therapy are the primary treatments.  Medication in a class called Selective Serotonin Reuptake Inhibitors (SSRIs) is a common first-line treatment for Obsessive-Compulsive Disorder (OCD). There are professionally researched types of talk therapy such as CBT that are very helpful.   Some individuals receive both SSRIs and talk therapy.  Others may want to try just one or the other to address their symptoms.    Below are treatment plans for John and Mary, illustrating how treatment works for individuals.

The Role of SSRIs  

SSRIs work by increasing the amount of serotonin available in the brain neurotransmitter that plays a key role in mood and anxiety regulation. Here’s how SSRIs help in the context of OCD:

1. Enhancing Serotonin Levels: SSRIs block the reuptake of serotonin into neurons, meaning that more serotonin remains in the synaptic gap (the space between neurons). This increased availability of serotonin helps stabilize mood and can reduce the anxiety that often fuels obsessive thoughts and compulsive behaviors.
2. Reducing Symptom Severity: By boosting serotonin levels, SSRIs help to moderate the overactivity in certain brain circuits that are believed to be involved in OCD. This can lead to a decrease in both the intensity of obsessions (the intrusive, distressing thoughts) and the urge to perform compulsions (the repetitive behaviors aimed at reducing anxiety).
3. Supporting Therapy: SSRIs are often used in combination with Cognitive Behavioral Therapy (CBT), particularly Exposure and Response Prevention (ERP). As SSRIs help lower overall anxiety and reduce symptom severity, they can make it easier for individuals to engage in and benefit from therapy, which further contributes to long-term management of OCD.

It’s important to note that while SSRIs can be very effective, they typically require several weeks of consistent use before noticeable improvements occur. Dosage adjustments may be needed to find the optimal balance between therapeutic effects and any potential side effects.

Treating Mary’s OCD with CBT and SSRIs

In pursuit of relief, Mary embarked on a tailored treatment plan incorporating Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP) techniques, alongside a course of SSRIs. Through therapy, she has gradually learned to confront the distressing thoughts without immediately resorting to her habitual prayers, discovering that the anxiety diminishes over time without the ritualistic response. Her treatment also includes mindfulness and stress management strategies to help reframe her intrusive thoughts and build resilience against overwhelming anxiety. Although Mary’s progress has been gradual, she has reported a significant reduction in both the frequency and intensity of her compulsive prayers, allowing her to slowly reclaim control over her life and re-engage with her community and work.

Treating John’s OCD with CBT

John’s treatment centered on a comprehensive, evidence-based approach combining Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP), psychoeducation.  John was resistant to medication and worked solely at first with a CBT therapist.  Initially, John received psychoeducation about OCD to understand how his intrusive thoughts and compulsive behaviors create a self-perpetuating cycle. Working collaboratively with his therapist, he identified and prioritized his most distressing symptoms—such as the compulsive homework checking, excessive hand-washing due to contamination fears, and the intrusive harm-related thoughts while driving—by creating a hierarchy of anxiety-provoking situations. The ERP component gradually exposed John to these feared scenarios (for instance, turning in homework without multiple checks or reducing hand-washing frequency) while preventing the immediate compulsive responses, thereby helping him learn that anxiety diminishes naturally over time.

Concurrently, John engaged in cognitive restructuring to challenge and reframe the irrational beliefs underlying his obsessions. This involved examining evidence for and against his catastrophic fears, such as the likelihood of causing harm or encountering dangerous contaminants, and replacing these thoughts with more balanced, realistic assessments. To further manage acute anxiety, the plan includes integrating stress-reduction techniques such as mindfulness meditation and deep breathing exercises.

Given the chronic and pervasive nature of his symptoms, a consultation with a psychiatrist was eventually recommended to assess the potential benefits of an SSRI regimen. With these combined strategies, John’s treatment plan was designed to reduce the frequency and intensity of his OCD symptoms, enhance his overall functioning, and empowered him to regain control over his life.

Action Steps

If you or someone you care about is dealing with OCD or you want to learn more, the International OCD Foundation has many resources. The IOCD Webpage Link has resources, handouts, brochures, self-assessments and much more.  

Be aware of your language.

People often say “I’m so OCD” to describe being orderly without being aware that they are stigmatizing and minimizing a serious condition that impacts millions of individuals in the Unite States.  

If you need additional help or resources, check out the   Find Help from the IOCD   page on the International OCD Foundation’s website.

References

_{Pampaloni, I., Marriott, S., Pessina, E., Fisher, C., Govender, A., Mohamed, H., Chandler, A., Tyagi, H., Morris, L., & Pallanti, S. (2022). The global assessment of OCD. Comprehensive Psychiatry, 118(152342), 152342. https://doi.org/10.1016/j.comppsych.2022.152342}