Demystifying OCD

Written by Dylan Crum, MSW, LSW

(he/him/his)

In this short blog post, I will be clarifying some common misconceptions about obsessive-compulsive disorder (OCD), describing how it presents, and how it can be treated. OCD is a condition in which individuals experience intense, unwanted, and often distressing obsessions which are then either avoided or neutralized with compulsory behaviors. Obsessions are often experienced as intrusive thoughts, whereas compulsions can take the form of physical actions or thoughts. 

The OCD Cycle

For all individuals with OCD, and even those who display some OCD tendencies but do not meet full criteria for an OCD diagnosis, their symptoms present in a predictable, but not always visible, cycle. This is referred to as the “OCD Cycle”, and consists of 4 phases. 

1. Fear-Inducing Stimulus

The first step in the OCD cycle is experiencing an intrusive, obsessive thought or fear, often when triggered by something in our environment. The focus of obsessive fears tend to revolve around aspects of our identity that they prioritize or highly value (e.g., our cleanliness, safety, morality, piety, etc.). As a result, these fears symbolize more than just an unwanted environmental condition or feeling - they often feel like an existential threat to our identity. 

It is highly important to consider that a fear-inducing stimulus can vary greatly from person to person. OCD-based fears are more than just needing our surroundings to be clean and orderly, as is commonly depicted in media or used in our everyday lexicon. 

1. Anxiety and Distress

Following the activation of OCD-based fears by an intrusive thought or environmental factor, individuals with OCD will experience intense distress. In the brain, this is caused by quick and involuntary activation of our amygdala, which serves as the “threat detector" of the nervous system. Individuals with OCD have an overactive amygdala, leading to greater and more common distress when the focus of obsessions are touched upon. An additional layer causing distress is the aforementioned existential threat to one’s identity, as someone’s obsessive fears becoming true would likely have dire consequences for their self-perception. In OCD, this distress is so intense that it needs to be “neutralized” through physical or mental actions.

1. Compulsory Behavior

Compulsory behaviors within OCD fulfill the function of “neutralizing” obsessive fears mentioned above. These behaviors resolve the internal conflict triggered by an intrusive fear or, in other cases, provide a level of certainty that is undermined by the fear response. While in many situations these behaviors are directly and obviously linked to the source of the fear (e.g., excessive hand washing for those with contamination OCD), they do not have to be. In many cases, there is an element of “magical thinking” involved in compulsory behaviors, in which the compulsion is only loosely tied to the obsessive fear. In some situations, rituals are performed or actions are repeated a certain number of times until it just feels “right”. These types of compulsions can be harder to properly identify as symptoms of OCD due to their loose connections to the source of fears, but can be accurately labeled by viewing them in the context of the OCD cycle.

1. Temporary Relief

The last step in the OCD cycle is the temporary relief that is elicited by compulsory behaviors. This relief is often immediate and may vary in length depending on the source of the fear and the intensity of OCD symptoms. In my opinion, this stage in the OCD cycle is the most crucial to understanding why it is just that - a cycle. When someone with OCD experiences this relief, it has two primary effects: first, it validates the source and extent of the intrusive fear and second, it reinforces the effectiveness and perceived necessity of the compulsory behavior. This has the total effect of reinforcing the overall OCD cycle, while also just feeling good in comparison to the distress felt at earlier points in the cycle. Invariably, however, for those with OCD, this relief will fade. Typically, this relief will slowly fade over time until a new stimulus retriggers one’s obsessive fears, restarting the whole cycle.

How Do We Treat It?

Now that you have a better understanding of the OCD cycle, you may be wondering: what can be done about it? The gold standard treatment for OCD is known as Exposure and Response Prevention (ERP), and is an offshoot of Cognitive Behavioral Therapy (CBT) mixed with elements of exposure therapy. ERP achieves change through what are known as in-vivo exposures. These are planned exercises in which one will intentionally expose themselves to the source of their obsessive fears while abstaining from their typical compulsive behaviors. If done systematically and consistently, these exposures will break down the OCD cycle by weakening the automatic connection between fears and compulsions. Over time, this will gradually improve one’s ability to tolerate uncertainty, which is typically the true fear underlying obsessive fears. ERP teaches people that they can tolerate distress and fear caused by this uncertainty without needing to engage in their compulsions to achieve a state of psychological safety. While ERP may not fully cure OCD for most, it can certainly make this condition more manageable and less impactful on day-to-day life.

Putting It All Together

Through explaining the OCD cycle and describing its primary treatment, I hope to draw a distinction between OCD and other mental health disorders, primarily anxiety. OCD is commonly confused for anxiety because this is often the primary symptom, and in many cases one’s compulsions can seem like justified, natural steps taken to resolve this anxiety. It is only through observing one’s symptoms in comparison to the OCD cycle that a true distinction can be made. OCD is not just anxiety; it represents a complex cycle of behavior that interferes with our quality of life and causes regular, distressing threats to our perceived safety and identity. If you feel that you or someone you know suffers from OCD, contact a mental health professional with experience treating this condition.