Obsessive-Compulsive Disorder is a severely misunderstood mental illness. The public perception of OCD is unfortunately limited to germaphobia, perfectionism, and cleanliness. I have often seen OCD misconstrued as being quirky or even used as a marketing tool. However, OCD can be incapacitating and severe cases constitute a legal disability as per the Social Security Administration. Personally, I’ve never seen any other disability utilized as a company name (though I’m certain there are other examples). This dissonance of public perception and reality follows the all-to-common story of undereducation and the pervasive power of media misrepresentation. Let’s counteract this by detailing how obsessive-compulsive disorder functions and why it can be crippling to those afflicted with it.
Art provides one of the best venues for demonstrating the pain and functions of mental illness. Erin Nielsen, a dear friend of mine, generously granted permission for me to host a drawing she presented at an OCD art exhibition. Before proceeding with the article, please send several minutes digesting her work.
Notice how few of her thoughts focus on disease or organization. Rather, she’s assaulted by fears of somehow being a terrible person, cheating on homework or a spouse, going to hell, and fearing that people will kill her family. These thoughts are quite terrifying and a far cry from what most people expect when they hear the term OCD. The thoughts themselves, called intrusive thoughts, are involuntary and clearly distressing. The “obsessive” half of OCD cannot let intrusive thoughts go and exacerbates their contents. Compulsions consist of ineffectual ritualistic behaviors meant to dissuade the obsessions and their perceived threats.
As obsessions are centered around intrusive thoughts, I will use the two interchangeably throughout the blog. Compulsions are sometimes called neutralizing behaviors and these terms will also be used interchangeably.
Intrusive thoughts are unwanted and involuntary thoughts or images that are distressing and often contrary to your conscience’s desires. Such thoughts are not restricted to OCD and, in fact, everyone experiences intrusive thoughts or images throughout their lives. Let’s use the stereotypical example of germaphobia to demonstrate:
You walk into a public bathroom at a crowded, downtown grocery store. After using the restroom, you wash your hands and exit. As you grab the door handle to enter, a thought pops into your head: “Someone might have touched this without washing their hands.”
The final thought is an intrusive thought. You didn’t choose to think about if someone washed their hands right as you touched the handle. Arguably, a certain amount of involuntarily thoughts are a benefit as might alert your conscience to things you might otherwise miss; this would explain their universality. People without OCD will stop thinking about that door handle shortly after leaving the restroom and resuming their shopping. Conversely, people with OCD will be unable to let go of the intrusive thought:
You leave the bathroom and begin walking down the dairy isle. The bathroom door handle is all you can think about. Did the last person to touch it have a disease? Am I diseased? Did I just get Norovirus? I must have Norovirus. My hand is coated in Noro. That jug of milk I put back has a virus. That lady just picked it up. She’s might die now. She’s going to die. I killed her. Am I going to die? Why did I kill her?
These thoughts can all occur in just a few seconds and can last for hours or even days. Importantly, a threat does not have to be present for intrusive thoughts to occur. With OCD, unwanted thoughts can occur randomly throughout the day and generate the same spiral as found in the above example. Of course, the intensity, repetitiveness, spontaneity, and explicitness of these obsessions will vary dramatically based on the severity of a person’s OCD and their specific fears.
An intrusive thought can occur about anything, but people with OCD have them at a high rate and their obsessions focus only on the negative thoughts. Look back at “Hopeless” above. None of the thoughts are positive, not a single one. The negative thoughts occur rapidly and constantly. Intrusive thoughts often feed themselves: one thought provokes another fear which provokes another thought. I call such events OCD spirals, as do many of my friends. Many people will dissociate during OCD spirals. In severe cases, any period of quietness turns into a spiral and can end in panic attacks. Unsurprisingly, I’ve known people with OCD who hate silences and will do anything to avoid them. There are certainly positive intrusive thoughts, but obsessive-compulsive disorder definitely does not latch onto those ones.
Close your eyes and imagine a summer day on the beach. List the sensations your brain brings to mind. How does the ocean smell? What does the air taste like? You may notice that your imagined vacation is quite vivid. Humans don’t just think in words and emotions. We think in any stimulus we can perceive: smell, taste, etc. The exercise above elicited a mental image: perceiving an experience that is not actually occurring.
Intrusive images are a very common symptom of OCD. Not only do you fear killing someone, abusing a child, or cheating on a spouse, but you see those events taking place in your head—these visualizations are often quite graphic. Intrusive images are not hallucinations as they do not mimic external perceptions. Rather, they are experienced exactly like the pseudo-vacation above but the subject matter is obsession-driven.
People with OCD may also have serious issues with Thought-Action Fusion (TAF). In brief, TAF is the belief that your thoughts increase the likelihood that you will act on them. A person with particularly high thought-action fusion may even construe their intrusive thoughts as actions. The last three thoughts from the example above—I killed her. Am I going to die? Why did I kill her?—are examples of high TAF. The sufferer went from fearing that the door handle might be dirty to believing that they are responsible for someone’s death.
Intrusive thoughts hold a lot of power and are integral to the functionality of OCD. They can occur in response to a present object but can also attack a suffer with no external provocation. The thoughts lead to obsessions and can result in spirals where the thoughts build off of each other.
As aforementioned, compulsions are performed in an attempt to either remove intrusive thoughts or minimize the perceived threat that the sufferer is obsessing about. I really want to emphasize the definition of compulsion before continuing. Merriam-Webster defines compulsion as an “irresistible [emphasis added] persistent impulse to perform an act”. Neutralizing behaviors are exacting urges that cause substantial distress if they are not performed; if a compulsion is supposed to remove a threat, then if the compulsion is not performed the danger must still be present as per the mind of the sufferer.
Compulsions are a natural learning response to an unusual stimulus. I am currently writing an entire article dedicated to that sentence (which I will totally remember to link right here one day probably), but lets keep this article a tad more brief. Animals learn to avoid uncomfortable stimuli and, if necessary, take action to remove them. Let’s use the example of bright sunlight to explain:
You walk out into the sun. It’s a bright day, maybe your heading to the beach from earlier, and your eyes hurt and water. Placing your hand above your eyes reduces direct sunlight and your eyes stop hurting. You’ve learned a behavior that removes a harmful stimulus and are more likely to repeat it in the future. However, you later learn to use sunglasses before going outside. Now you’ve learned a behavior that avoids the harmful stimulus in the first place and are more likely to repeat that behavior in the future.
Intrusive thoughts cause substantial distress and anxiety with high frequency and thus drive compulsive coping behaviors. Anxiety naturally fades over time after encountering a threat of any form. After an unwanted thought causes disquietude, any behavior taken before the agita dissolves may become a compulsion. Continuing with the bathroom handle example, handwashing is a common compulsion in response to contamination obsessions. The sufferer washes vigorously after touching the handle. Eventually, their obsessive spiral diminishes and no one dies from Noro.
Now they believe no one was hurt because of the dynamic hand washing. This connection is a natural form of learning, but the threat here is not real. Not becoming sick after washing your hands when coming into contact with dirt or fecal matter is a healthy outcome of this learning process. However, the handle looked clean and OCD generated the threat. Next time they touch a door handle, the need to wash their hands becomes overwhelming.
A staggering variety of compulsions exist in response to numerous obsessions. As aforementioned, any behavior occurring after an intrusive thought or an action meant to avoid previous intrusive thoughts can may become a neutralizing behavior. Compulsions are often centered around avoiding intrusive thoughts or extreme forms of distraction from the thoughts. Stereotypical examples of compulsive behaviors include showering multiple times, not shaking peoples hands, and organizing. Yet these examples barely, barely scratch the surface of the iceberg. Neutralizing behaviors can range from self-isolation to self-inflicted wounds. To capture this diversity, let’s list a number of compulsions:
- Skin picking
- Checking all the locks in the house twice before bed
- Never eating the last bite of a meal
- Hair pulling
- Never watching the news
- Maintaining rigid eye contact during a conversation
- Only watching Disney movies
- Avoiding children
- Never talking to anyone of the gender(s) you are attracted to
- Praying and repenting to your chosen deity/deities dozens of times a day
I’ll detail a new compulsion I developed recently to demonstrate how easy it is for people with OCD to become afflicted with new neutralizing behaviors. I work at a museum and volunteer at an aquarium. Both functions require me to walk most of the day and to travel between floors. I often walk 4+ miles and climb 440+ feet in elevation per day at the aquarium. Relevantly, I’m 285 pounds as of this writing. Throughout the day, I get mildly sweaty and decided that didn’t look good to the patrons. I was afraid they’d have a negative experience at the museum/aquarium because of me. I started rinsing my face whenever I went to the bathroom and on breaks. Then I was using the restroom at home and felt the overwhelming need to wash my face. Now, I feel the overwhelming urge to clean my face whenever I even see a sink.
Compulsions are unignorably powerful urges to perform ineffective behaviors in response to intrusive thought. There are innumerous different compulsions, but none of them are healthy coping mechanisms.
Obsessive-compulsive disorder is rooted in the neurobiology of the brain. It is not merely the product of poor coping skills or getting “hung up” on something. The phrase “Neurobiology of OCD” produces 31,200 results in Google Scholar. We still don’t know the exact cause of OCD, but our understanding is growing rapidly. Researchers have linked dopamine and serotonin signaling dysfunction and a few genes with obsessive-compulsive disorder. People with OCD have a delayed circadian rhythm and melatonin secretion which leads to poor sleep and symptoms that worsen in the latter part of the day (as I type this at 0252). MRI studies also indicate issues with high glutamate in a neurological circuit called the cortico-striatal-thalamic-cortical circuit (CSTC). The CSTC circuit may also have less neuron organization in people with OCD. These results sediment obsessive-compulsive disorder as a neurological and possibly genetic disorder.
OCD can be terrifying and extremely debilitating. The constant struggle with thoughts often centered around harming others creates near constant distress and fear. The media presentation of OCD as a quirk is severely damaging to sufferers. It’s difficult to tell others about your thoughts or ask for help if the public believes you enjoy organizing and you don’t like shaking peoples’ hands. I’ve had friends try to be more open about their OCD with coworkers only to get stared at in terror and disbelief.
OCD is the pathological obsession with morality.Unknown
As you’ve read this article, you may have notice a common theme with intrusive thoughts. In some form or another, almost every obsession is based on being an immoral person. Whether it’s being contaminated, hitting people with your car, or cheating on homework, OCD is centered on morality. In their struggle to avoid their graphic thoughts, sufferers are some of the most genuine, honest, empathetic, and helpful people I’ve ever met.
Obsessive-compulsive disorder is a disabling and chronic disorder. The power of intrusive thoughts and overwhelming compulsions cause sufferers immense stress and occupies hours of every day. OCD can cause depression, social isolation, and even drive people to suicide. Sadly, very few people understand OCD and the media grossly misrepresents this mental illness. As with many diseases and disorders, education and awareness are key to furthering treatment and improving the livelihood of those afflicted with this disorder. Perhaps more importantly, by understanding those with OCD, we can create stronger empathetic relationships and help support each other. You are not alone.
Return to “Hopeless” and spend a few more minutes engaging with the art. Has your understanding of OCD changed since you first interpreted the piece?
This Article and You
If you’ve been diagnosed with OCD and don’t feel like this article describes you, don’t doubt your diagnosis. My OCD is categorized as severe to extreme and, as aforementioned, the severity, explicitness, and frequency of intrusive thoughts varies by the classification of OCD and person-to-person. Conversely, if you notice yourself in this article, consider seeing a therapist or psychiatrist for an evaluation. Their support and care can be immensely helpful. However, note that this is a personal blog; don’t diagnose yourself from an online article and always defer to qualified professionals.
Have a great day and always practice self-compassion!A Fantastic Friend of Mine