Candace has repeated, intrusive thoughts about losing control and stabbing her children with a sharp knife. She becomes intensely anxious and is concerned that these unwanted thoughts signal her impending loss of control, or at the very least indicate that she is fundamentally a bad person. In an effort to be certain that she will not act on these horrific impulses, Candace insisted that her partner remove all sharp knives from their house.
This week is International OCD Awareness Week, and Candace is likely among the roughly three million people in the United States who have obsessive-compulsive disorder (OCD). OCD is not a disorder of quirkiness or being finicky. People with OCD experience recurrent, unwanted thoughts, images, or urges that cause distress, usually anxiety. These are called obsessions. They also engage in behaviors or thoughts that function to reduce distress, often by preventing feared outcomes or neutralizing obsessive thoughts. These are called compulsions.
When you think of OCD, perhaps you picture someone with contamination fears and excessive washing. You might be right. Perhaps you picture someone with the need to order and arrange everything symmetrically. You might be right. Perhaps you picture someone checking and rechecking the door lock, stove knob, or iron plug so as not to be responsible for a burglary, gas poisoning, or fire. You might be right.
But there is nothing special about contamination, order, or accidental harm, when it comes to OCD. OCD fears can focus on anything including violent harm, religion, taboo sexual fears, or one’s sexual orientation. Some individuals obsess about even less concrete things, such as acquiring unwanted characteristics of a bully by using a pencil he touched or losing part of one’s essence when discarding personal items. OCD is opportunistic, latching on to what matters to an individual. OCD has been called the “Imp of the Mind” because it tries to make you think most about the very things you find most unacceptable or matter most deeply to you. New parents with OCD often obsess about harming or neglecting their children, for instance.
Most people with OCD have insight about their fears (e.g., “I know you can’t get HIV from a door handle, but…”), and that is because symptoms are typically fueled by “what if” fears about what is possible, not necessarily beliefs about what is probable. Put differently, people with OCD struggle with tolerating uncertainty in the domains of their obsessions; however, efforts to achieve absolute certainty are doomed from the outset. How can one be literally certain that they are not a pedophile or that they truly did lock the door this morning, and are not conflating memories?
Among several cognitive styles, people with OCD also characteristically view thoughts as having moral or superstitious import, and they believe that one should control “bad” thoughts. As a result, someone like Candace might believe that her obsessions indicate either that she is a bad person or that she may in fact lose control and act on the thoughts. Whereas the experience of having bizarre intrusive thoughts is nearly ubiquitous among both those with and without OCD, the response to those thoughts differs. Those who treat their intrusive thoughts like meaningless neural noise do not experience anxiety about them. But people like Candace try very hard to avoid having certain thoughts or to suppress and cancel them, almost always to no avail. Try very hard not to think about something and you will find yourself thinking about it more.
Although they are sometimes effective in reducing anxiety in the short run, compulsions serve to maintain the symptoms in the long run. Imagine you have a negative experience with a dog and develop a fear of dogs. The more you avoid safe dogs, the more likely your fear will grow. Similarly, when you encounter a dog and you choose to leave the situation, you will experience a reduction in anxiety (which will reinforce the avoidance), and also fail to learn that the dog is safe and that you are capable of tolerating the anxiety, which will reduce on its own. Compulsions function like avoidance, temporarily reducing anxiety, but reinforcing the need to avoid and the perception that the obsessional trigger could otherwise be dangerous.
If Swarthmore is representative of the nation, nearly 40 current students will have OCD at some point. OCD tends to be chronic if untreated and is often associated with shame (imagine how some people might react if Candace disclosed her intrusive thoughts). It has been identified by the World Health Organization as among the top 10 causes of years lived with illness-related disability. The wonderful news is that first-line treatments for OCD, such as exposure and response prevention, are quite effective for most of those who complete an adequate trial of them. The sad news is that OCD is often undiagnosed or misdiagnosed for years; on average, it takes approximately 15 years from the onset of the disorder for individuals to commence effective treatment.
During International OCD Awareness Week, I encourage you to educate yourself about OCD. If you or someone you care about may have OCD, there are highly effective treatments available that can be life-changing. If you do not have a personal connection with OCD, learn more about what it is and what it is not. Play a role in reducing stigma and shame. Think about why comments like, “I wish I could be a little OCD,” or “I am soooooo OCD,” are as misleading, unhelpful, and sometimes hurtful as comments like “I wish I could have a little anorexia.” Whatever your connection with OCD, the International OCD Foundation is a fabulous resource, offering information, training, and treatment resources and referrals. Check out their website: https://iocdf.org/.
Jedidiah Siev, Ph.D.
Department of Psychology