Obsessions and Compulsions

One of the best ways to educate yourself  about Obsessive-Compulsive Disorder (OCD) is to try and gain a better understanding of how the obsessions and compulsions are linked together in OCD behaviour. 

Obsessions In general, the obsessions that a person with OCD will experience generally fall into the category of persistent and uncontrollable thoughts, images, impulses, worries, fears and doubts (or a combination of these). Additionally they are intrusive, unwanted, disturbing and significantly interfere with normal life, making them incredibly difficult to ignore.

The obsessional thoughts that plague somebody affected with OCD are repetitive and intrusive by nature, and most importantly they are not voluntarily produced.   The affected person recognises that these often horrific and repugnant thoughts are their own and not controlled by some outer force or other person.

This in itself causes the sufferer to become even more upset at the very idea that they are capable of  having such thoughts in the first place.  However, what we do know is that people with Obsessive-Compulsive Disorder are the least likely people to actually act on their thoughts, partly because they are so repugnant to them to the extent that they go to great lengths to avoid them.  The compulsions performed as a result of having the thoughts are done so to try and prevent the thoughts actually happening.

The list below details just some examples of commonly occurring obsessions that affect people with OCD:

• Worrying that you or something/someone/somewhere is contaminated.
• Worrying about catching HIV/AIDS or other media publicised illnesses such as Bird Flu or Swine Flu.
• Worrying that everything needs to be arranged symmetrically or at perpendicular angles so everything is  ‘just right’.
• Worrying about causing physical or sexual harm to yourself or others.
• Unwanted or unpleasant sexual thoughts and feelings, including those about sexuality or fear of acting inappropriately towards children.
• Intrusive violent thoughts.
• Worrying that something terrible will happen unless you check repeatedly.
• Worrying that you have caused an accident whilst driving.
• Having the unpleasant feeling that you are about to shout out obscenities in public.

Most sufferers are actually aware that their fears are irrational but feel unable to control the thoughts, and the more they fight them, the more prominent they become in the person’s mind.

The problem is that the person with OCD will become besieged by the obsessive thoughts. In fact the word ‘obsession’ comes from the Latin ‘obsidere’ which means ‘to besiege’.  Naturally the sufferer neither wants nor welcomes the obsessional thoughts and will go to extreme lengths to block and resist them.  Invariably they return within a short period of time, often lasting hours if not days, which can leave the person  both mentally and physically exhausted and drained.  This causes deep anguish and despair.

People with OCD realise that their obsessional thoughts are irrational, but they believe the only way to relieve the anxiety caused by them is to perform compulsive behaviours, often to prevent perceived harm happening to themselves or more often than not, to a loved one.

The occurrence of an obsessional thought usually produces a feeling of discomfort. For many people this feeling is best described as anxiety, but some patients report that what they feel is not anxiety, but general unease, tension and discomfort.

Compulsions When someone is affected by Obsessive-Compulsive Disorder the natural response is to fight these horrible obsessional thoughts with purposeful mental or physical rituals and behaviours - the compulsions.
Compulsions are the repetitive physical behaviours and actions, or mental thought rituals, that are performed over and over again, in an attempt to relieve the anxiety caused by the obsessional thoughts.  But unfortunately, any relief that the compulsive behaviours provide is only temporary and short lived, and often reinforces the original obsession, creating a gradual worsening cycle of the OCD.

These behaviours involve repeatedly performing purposeful and meaningful actions in a very rigid and structured routine, specifically in relation to the obsessional thoughts, usually in an attempt to prevent perceived danger or harm coming to themselves, or to a loved one.

In most cases the person recognises their compulsive actions are senseless and irrational, but none-the-less feels bound to carry them out.  This is not for pleasure, but to feel they have ‘neutralised’ the perceived threat from the obsessional thought.  Often a person with OCD will feel a heightened sense of responsibility to perform the neutralising behaviour, simply because they feel doing so will prevent harm coming to themselves or loved ones.  What’s more they sometimes have an overwhelming urge to obtain that ‘just right’ feeling with no other reason than to feel comfortable.

For example; people without the illness will wash their hands when they are dirty and ‘see’ that they are dirty.  In contrast someone with OCD will ‘feel’ their hands are dirty, and therefore keep washing until they ‘feel’ clean, and by doing so will be keeping their loved ones safe by not contaminating them.  It is this heightened sense of responsibility, and need to protect loved ones, that often drives the person with OCD to repeat the endless cycle of compulsions.

The list below details just some examples of commonly-occurring physical or mental compulsions that affect people with OCD (in brackets are types of obsessional thoughts that may trigger such compulsive behaviours):

• Excessive washing of one’s hands or body (thought of being contaminated, by chemical or body fluids from oneself or another person).
• Excessive cleaning of clothes or rooms in the house,  (thought of having come into contact with germs from the outside or perceived contaminants from bodily fluids   For example contact with dog mess, needles or used condoms).
• Checking that items are arranged ‘just right’ and constantly adjusting inconsequential items, such as pens on a table, until they are aligned to feel ‘just right’ as opposed to looking aligned (thought that something bad may happen to a loved one if not aligned correctly).
• Mental rituals or thought patterns such as saying a particular phrase, or counting to a certain number, to ‘neutralise’ an obsessional thought (thought that something bad may happen to a loved one if not carried out).
• Avoiding particular places, people or situations to avoid an OCD thought (be it about harming someone, or contamination fears).
• Repeatedly opening and sealing letters / greetings cards that one has just written, maybe hundreds of times (fear of writing something offensive by mistake within the letter/card).
• Constant checking of light switches, handles, taps, locks etc to prevent perceived danger from flooding, break in, gas leak or fire. Checking can be a set number of times to a magical number, and often takes hours at a time to the point where sufferers often avoid going out so as not have to go through the rituals.
• Saying out loud (or quietly) specific words in response to other words (to prevent disaster happening).
• Avoidance of kitchen knives and other such instruments, (for example locking them in a drawer) to prevent coming into contact with them (thought of harming someone with a knife inadvertently).

A compulsion can either be overt (i.e. observable by others), such as checking that a door is locked or covert (an unobservable mental act), such as repeating a specific phrase in the mind.

Overt compulsions typically include checking, washing, hoarding or symmetry of certain motor actions.

Covert compulsions, or ‘cognitive compulsions’, as they are sometimes referred to, are the carrying out of mental actions, as opposed to physical ones.  Examples include mental counting, compulsive visualisation and substitution of distressing mental images or ideas with neutralising alternatives.  Practical examples would be a sufferer who feels compelled to silently repeat a string of words over and over again upon experiencing a negative or violent thought.  Or it could be the need of a sufferer to transpose negative words or images which may intrude into their consciousness with positive ones e.g. feeling compelled to mentally substitute the word ‘hell’ that pops into their head, either as a thought or as a  visual image, with the word ‘well’.

Some sufferers will have the obsessions but no outward compulsions, or so they think, –  a form of OCD often, but mistakenly, called ‘Pure-O’ (purely obsessional thoughts). ‘Pure O’ is a form of OCD where people mistakenly believe that it differs from traditional OCD in that it features no outward compulsive manifestations; instead, the anxiety-inducing obsessions, take place only in the mind. 

However, a person with ‘Pure O’ will still have compulsions which mainly manifest themselves as unseen mental rituals, and they will usually also engage in compulsive behaviours like seeking reassurance from loved ones, and avoidance of particular objects, places or people.  However they are compulsions nonetheless, which is why the term ‘Pure O’ is somewhat imprecise.
Pure O is like any other form of OCD -  it involves both obsessions and compulsions which can be successfully treated through Cognitive Behavioural Therapy (CBT).

Avoidance is a common compulsive behaviour, and this is where a sufferer, in a bid to try and prevent the distress and anguish and the hours of rituals caused by the OCD, will go to great lengths to avoid the objects, places or person/people that they feel triggers their obsessions.

 Another key compulsive behaviour, particularly where the sufferer lives with another person, is the need to seek constant ‘reassurance’. This in itself is another compulsion. Initially, like any compulsion, when reassurance is received the sufferer will feel an initial sense of relief, but the OCD doubts and uncertainty will return, and the need to seek further reassurance follows. Common examples of reassurance seeking will be to ask a loved one “did I lock the door?”, “did I upset or offend you?”, “did I turn the taps off?”, “did I hit something when driving?”, “did I touch that child inappropriately?”, “did I wash my hands enough?”.  Of course, it is natural when you love someone to try and relieve their anxiety and anguish by answering such questions, but like any OCD driven compulsion, if you engage in it once, once is never enough and it reinforces the need for the person with OCD to further engage in reassurance seeking behaviour.

With both obsessions and compulsions, receiving the highest quality of care, support and treatment for OCD, and sticking to the treatment plan, is the key to long term recovery from the illness.