The OCD Iceberg
Learn more in honor of OCD Awareness Week!
It’s often the case that when I tell someone that my clinical practice is specialized in treating Obsessive-Compulsive Disorder, the person responds with something like, “Can you help my husband? He is soooo OCD,” followed by examples of said husband loading the dishwasher precisely or similar behavior. While order, symmetry and tidiness can be a subtype of OCD, these traits are only the tip of the OCD iceberg. Below the surface lurks a variety of obsessive themes that are rarely represented in popular discourse.
In honor of this year’s OCD Awareness Week, I’d like to bring more attention to the actual meaning of a debilitating condition. I’ve treated plenty of clients who formerly didn’t know there was a name for their problem. Sadly, they just thought they were bad people due to the scary or taboo nature of their thoughts. Many suffer in silence. Psychotherapists themselves may have received minimal education on OCD in graduate school, and then may also have a stereotypic view of the disorder, making it hard to recognize in clients.
So, what is OCD?
OCD is characterized by the presence of obsessions and compulsions, which lead to significant distress and impairment in functioning.
Obsessions are intrusive and unwanted thoughts, images, or urges that are anxiety provoking or otherwise distressing (may also provoke depression, disgust, or “not right” feelings). We all have weird or unwanted thoughts, but people with OCD engage in a reasoning process that convinces them they need to take the thought seriously and take action, which then reinforces the frequency and intensity of the thought.
Compulsions are frantic behavioral or mental attempts to reduce the distress or “neutralize” the obsession. The individual feels strongly driven to perform these acts, often despite having insight they are behaving irrationally. It feels like too big a risk NOT to do the compulsion. Compulsions are often so time consuming and energy draining that the person is unable to function optimally. Both obsessions and compulsions cause pronounced psychological pain.
Many are familiar with the “top of the iceberg” OCD presentations - the obsessive themes that show up in most media portrayals of OCD. These obsessions can be debilitating in their own right. I’ve seen clients with contamination OCD wash their hands with bleach or get stuck at the sink or in the shower for hours. I’ve seen teens refuse to leave the safe perimeter of their rooms. I’ve seen clients staying up all night with checking or organizing compulsions. I’ve seen preoccupation with responsibility or perfection rendering the person unable to complete work or school tasks.
You may be less familiar with the “bottom of the iceberg” presentations. These are harder to see because the compulsions may be internal and not observable. Sufferers often do not come forward. They may not know they have OCD or they are afraid that if they say their thoughts out loud, the listener will believe they are dangerous.
Some examples of clients I’ve treated that represent common OCD presentations but are less often portrayed:
Post-partum OCD: A new mom was experiencing upsetting thoughts or images around causing harm to her baby through negligence, abuse, or losing control. This led to avoidance of picking up baby (relying on others for help) as well as agonizing rumination around the meaning of these thoughts and if she was dangerous to her child.
Harm OCD: A man was experiencing intrusive thoughts while using kitchen knives, “what if I stab my wife out of the blue?” This led to hypervigilance around knives and any sharp objects, only going into the kitchen if spouse wasn’t home. Harm OCD leads to extreme shame and fear of oneself.
Pedophilia OCD (POCD): An adult woman had a long history of avoiding children after she began to be plagued by unwanted thoughts. “What if I am a pedophile? What if I lose control and harm a child?” In addition to avoidance, client logged all contacts with children in order to reassure herself she didn’t do anything wrong. She longed to be mother, but held off for years because she was so fearful. She delayed seeking help because she was worried the therapist would believe her to actually be a pedophile.
Sensorimotor/Hyperawareness OCD often involves preoccupation with the idea that one must attend to normal functions of the body, like breathing, blinking, swallowing, heart beating, etc. For example, a woman was so concerned about forgetting how to swallow that it made eating very unpleasant. The more she tried to swallow, the more difficult and unnatural it became, which reinforced the thought that she would forget how to do it. This led to weight loss and nutritional deficiencies.
Scrupulosity involves extreme fear of violating religious or moral rules or experiencing sacrilegious thoughts or images. For example, a woman engaged in compulsive prayer and confessing after ordinary interactions in public. “Did I have a bad thought about that person? Did I act on it? Did I betray my morals and think something inappropriate?”
Hit and Run OCD: A man experienced so much fear that he would hit someone in his car and not know it that he circled the block to check repeatedly. Eventually he quit driving because it became so fraught.
Existential OCD: A teen became obsessed with the idea that nothing around him was real. “What if we are living in a simulation?” This idea was so frightening to him that he had trouble leaving his house, and he spent hours in his head, trying to figure out how to “prove” that his life was real.
Thought-action fusion: “If I have the thought, then I will make it happen.” For example, a woman saw a commercial for a prescription medication and the word “cancer” stuck in her mind. She needed to neutralize the word by doing a compulsion in order to prevent herself from having cancer. “If I think the word, it’s a bad omen it will happen.”
These examples are just snippets of cases. They don’t capture the daily, relentless grind of having these types of thoughts on auto-repeat. When your mental energy is spent on obsessing and constant anxiety activation, it leaves little space for other areas of life or capacity for joy.
It’s important to note that for all OCD obsessions, the content is ego dystonic. This means that the thought or image is unwanted and experienced as intolerable or horrific; it’s the opposite of the person’s authentic self. So, the person with POCD or Harm OCD is not dangerous to others. The obsession represents the worst possible scenario or “what if,” thus the reason it elicits such fear and the drive to compulse.
The good news is that OCD is highly treatable once we understand the condition! OCD is best understood as a process of thinking and behaving versus particular content. It can be about anything, though I have already written about some common subtypes. If you have OCD and are reading this article, I may not have mentioned your subtype. That’s okay! OCD will follow a similar pattern of obsessions and compulsions, regardless of the theme, and it can all be addressed with evidence-based treatment.
So, what about treatment?
The research consensus is clear that CBT is the front-line treatment for OCD; in particular, a type of CBT called Exposure with Response Prevention (ERP). In ERP the individual is taught about the learning and conditioning process that keeps OCD alive. We then go about learning a new process through deliberate behavior change.
Exposure involves willingly engaging with feared thoughts, objects, settings, and situations. Response prevention involves eliminating safety behaviors - compulsions, rituals, worry, rumination, or avoidance - that occur as a result of obsessions.
Over time, clients learn that their obsession wasn’t dangerous after all, that thoughts are just thoughts, the super-computer of the mind spitting out faulty data. They were actually strengthening the fear by attending to obsessions with compulsions.
A growing body of research suggests that another type of CBT called Inference-Based CBT (I-CBT) is also efficacious. I-CBT helps clients take a zoomed out, bird’s eye view of the reasoning process that convinces them to engage with what-if questions and doubts. We assist the client in leaving the world of imagination (where obsessions live) and back into here-and-now reality and self-trust.
Acceptance and Commitment Therapy (ACT) is another evidence-based approach supported by research, though ACT is used adjunctively with ERP, as both models utilize exposure and reduction in experiential avoidance. Other therapies that might be used to support the first-line treatment include metacognitive approaches, as well as mindfulness-based therapies.
In a nutshell, there is hope and help if you have OCD and have never been treated or have not received the types of treatment I’ve mentioned. Before starting with a new therapist, ask them about their experience with OCD and the treatment modality they use. Find someone who discusses one of the treatments I’ve listed.
Thank you for hanging in there with a long article! It’s important. The International OCD Foundation reports that approximately 1 in 100 adults has OCD and 1 in 200 children. This number expands when we consider those who haven’t come forward or those that have some symptoms of OCD but don’t meet full criteria for diagnosis.
There is a good chance someone you know is experiencing OCD. You can help by sharing the information you’ve learned from this article when you hear OCD being discussed or stereotyped. Learn more by checking out the resources available from the International OCD Foundation.
That’s all for now. Please share if you see fit!