OCD is often misunderstood in popular culture. It is commonly simplified and portrayed in media as obsession with cleanliness or order i.e. handwashing or arranging objects on a specific way, but there is a much more nuanced spectrum that OCD can manifest itself.

What is OCD?

Technically speaking, OCD is characterized by recurrent and persistent unwanted thoughts, images, or bodily sensations that provoke significant anxiety or high distress. As a response to this distress, the individual engages in repetitive acts, otherwise known as compulsions. These repetitive acts function to reduce the distress caused by the obsessions.

What are obsessions? Obsessions can range from intrusive repetitive thoughts, images, and bodily sensations to external stimuli, such as colors, words, or sounds. What makes an otherwise neutral stimulus become an obsession is its persistent nature and the level of distress that it generates in the OCD sufferer.

What are compulsions? Compulsions follow the obsessions. In other words, they are any acts that the OCD sufferer engages in to reduce, neutralize, or get rid of the anxiety triggered by the obsessions. Compulsions are categorized into physical and mental:

Physical compulsions are observable behaviors, such as washing hands, tapping, cleaning, checking if doors are locked, arranging items, and seeking reassurance from others.

Mental compulsions are internal and cannot be seen by others. Mental compulsions include replaying events and conversations, praying, repeating mantras over and over, counting, and rumination.

What makes an otherwise neutral mental activity become a compulsion is how excessively the sufferer engages with it and how hard it is for them to stop themselves from doing it. While compulsions can offer momentary relief from anxiety, they ultimately reinforce the OCD cycle and leave the sufferer feeling exhausted and stuck.

Putting it all together

OCD is a highly distressing condition that manifests in recurrent obsessions that lead to compulsive acts or rituals. Compulsions can be physical (checking stove) or mental (replaying events over and over in your head). Compulsions function to momentarily reduce the anxiety triggered by the obsessions (unwanted stimuli) but do not teach the sufferer how to effectively cope with anxiety and ultimately recover from OCD.

Recovery Journey

Fortunately, recovery from OCD is possible, and the journey starts by identifying the idiosyncratic way OCD shows up for you:

The answers to these questions can provide important data on how to work with your OCD.

If you believe you or someone you care about might be struggling with OCD, please know that you are not alone, and that recovery is possible with proper treatment.

Exposure and Response Prevention (ERP) Therapy is a top treatment for Obsessive-Compulsive Disorder (OCD). It helps people face their fears and feel anxiety, discomfort, and uncertainty without using compulsive behaviors. This process is key to helping individuals learn to handle distress and reduce OCD symptoms over time, giving them hope and control. 

Exposure and Response Prevention 

ERP has two main parts: exposure and response prevention. Exposure means facing the thoughts, images, objects, or situations that cause anxiety or discomfort. This can be done by directly facing the feared situation (real-life exposure), imagining the feared situation (imaginal exposure), or experiencing feared physical sensations (interoceptive exposure). Response prevention means not doing compulsive behaviors or mental rituals in response to the exposure. The goal is to stop the cycle of compulsion and reduce dependence on these behaviors for relief. Successful ERP involves not doing any compulsion while feeling anxiety and discomfort. 

Working with an ERP-trained therapist is very important. The therapist helps the client identify specific obsessions and fears, understand what triggers their anxiety, and recognize unique compulsions and rituals. This support reassures both the person with OCD and their families by identifying both obvious and hidden compulsions and providing a plan for recovery. Compulsions can include behaviors like checking, arranging, cleaning, tapping, or repeating, or mental compulsions like mental reassurance, thought suppression, rumination, mental checking, and mentally repeating words or phrases. Identifying compulsions is crucial as they are not always obvious, with mental compulsions being very hard to recognize and address. 

One challenge in doing ERP successfully is identifying and stopping compulsions and making sure that one compulsion is not replaced with another. For example, a client might stop a behavioral compulsion but start a mental compulsion instead. The main idea of ERP is learning to handle discomfort without trying to escape it through compulsions. This involves being aware of one’s responses to triggers and learning to live with anxiety and uncertainty without using compulsions. 

Exposures and OCD 

Exposures are crucial to recovering from OCD because the disorder makes people think they cannot handle the distress they feel when facing their fears. Also, OCD makes people believe that certain bad things will happen if they do not do specific compulsions. The purpose of exposure is to help individuals repeatedly see that their feared consequence does not happen even when they do not give in to their compulsion. This is the only way to break the OCD cycle because safety behaviors are the only part of the cycle that people can control. They cannot control their unpleasant thoughts, feelings, or sensations, but they can choose to react in a way that does not reinforce them. The more a person with OCD does exposure and response prevention, the more their brain learns that the initial trigger was not dangerous to begin with, reducing obsessions over time. 

Clients often ask what they should do during an exposure if not their compulsion. The answer is to stay present. For the exposure to work, the person must not do anything to reduce discomfort. Instead, they are encouraged to stay in the moment, feel uncomfortable, and notice their unpleasant thoughts, feelings, and sensations with curiosity and without judgment. This approach lets the individual see that anxiety decreases over time without the need to do anything about it. Trying to escape the discomfort only provides temporary relief and keeps the cycle going. 

Break free from the cycle of OCD

It is important to note that the goal of ERP is not to get rid of unpleasant thoughts, feelings, or sensations but to learn how to tolerate them without using compulsions. By facing their fears and not doing compulsions, individuals can see that their anxiety decreases over time and that they can handle the distress without using compulsive behaviors. This empowers them to break free from the cycle of OCD and regain control over their lives. ERP is a structured and systematic approach to treating OCD designed to build confidence in mental health professionals and help individuals regain control over their lives by reducing the power of obsessions and compulsions. Through the guidance of an ERP-trained therapist, clients can learn to face their fears, tolerate discomfort, and achieve lasting relief from OCD symptoms, showing how effective this approach is. Exposure and Response Prevention Therapy is a powerful tool in treating OCD, leading to lasting relief and a renewed sense of hope and empowerment. 

  

References 

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 

Abramowitz, J. S., McKay, D., & Storch, E. A. (Eds.). (2017). Obsessive-compulsive disorder: Contemporary issues in treatment. Wiley-Blackwell. 

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press. 

Franklin, M. E., & Foa, E. B. (2011). Treatment of obsessive-compulsive disorder. Annual Review of Clinical Psychology, 7(1), 229-243. https://doi.org/10.1146/annurev-clinpsy-032210-104533 

March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. Guilford Press. 

Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(Suppl 1), S29-S52. https://doi.org/10.1016/S0005-7967(99)00049-2 

Take a Minute to Consider These Questions

 If you answered yes to any of these questions, you may suffer from OCD – or obsessive-compulsive disorder. This illness is not rare; it affects at least four million adults in the United States and is the fourth most common psychiatric illness in this country.

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How Can OCD Impact Your Life?

OCD is a disorder that is often progressive and can become crippling. Some OCD sufferers never leave their homes because of the various rituals they need to perform. Others can’t function at work because they spend so much time secretly engaged in various rituals. 

Many obsessive thoughts and rituals are completely mental, not physical, so the illness can be almost invisible to everyone close to the person affected.   

As the name suggests, OCD has two parts: obsessions and compulsions.  Many people suffer from obsessions only, but a good number eventually develop compulsions.

GoodTherapy | Obsessive compulsive disorder

Obsessions

Obsessions are the thoughts, ideas, or impulses that repeatedly well up in the mind of the person with OCD. They may feel a need to do things almost too perfectly, an unreasonable concern about becoming contaminated by germs, or a persistent fear that harm may come to themselves or loved ones.

Compulsions

Compulsions are the behaviors that are done in reaction to this thinking, usually to try to gain some control over the uncontrollable. Following a behavioral routine gives the sufferer temporary relief through a false belief that the ritual can ensure that something unwanted will not happen. 

Usually, the person with OCD is fully aware that their thinking is irrational, but this does little to stop the behavior.  The obsessions and compulsions often lead to an unbreakable cycle including severe anxiety.

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When is OCD a Problem?

Most people experience obsessive thoughts or compulsive behaviors at one time or another, but the actual disorder of OCD is not present until the thoughts and rituals have become dominant features in their lives and some aspect of the person’s work, family, or social life is affected.  

Once the full criterion is met, OCD will often not go away, and therapy is needed before there are irreversible effects on a person’s social, academic, or work life. 

The good news about OCD is that it has a very positive prognosis – OCD is very easily overcome through therapy.  Most therapists use what is called cognitive behavioral therapy to bring about relief from OCD symptoms. Clients learn to monitor their thoughts and recognize the connection between their thinking, feeling, and behavior.

The therapist acts as a “behavioral coach” and often gives a lot of homework between sessions. Progress can be slow, but gradually clients learn to separate their thoughts from their behaviors. Once behavior changes even a little bit, there is a strong likelihood that things will get much better sooner than later. You’ll come away with a toolbox you can use to manage your symptoms in real time!

The bad news is that the isolation, embarrassment, and self-loathing caused by OCD can prevent some people from seeking help. They may be afraid that their thoughts or compulsions are so “crazy” that they’ll get laughed at or labeled as strange.  

GoodTherapy | OCD Therapy

 Find a Therapist

If you suspect you are suffering from OCD, consider finding a therapist. Be confident that they know that this problem is unpreventable and biological, just like an allergy or sight impairment.  You don’t have to be a prisoner of OCD.

The combination of therapy, sometimes along with medication, usually provides effective treatment. You can make a life-changing decision by recognizing the problem and having the courage to seek help. 

 You are not alone if you suffer from OCD, even though you may suffer in silence. Therapy can truly help and give you the resources to stave off relapses should they begin to come on in the future.

In fact, cognitive behavioral therapy often provides tips and techniques you can use to manage many kinds of anxiety, so it can often have lasting effects beyond OCD.

Dr. Alan Jacobson is a Licensed Psychologist who has been in practice for over 20 years. He has helped many adolescents and adults who suffer from OCD and other challenges with anxiety.  

The GoodTherapy Registry might be helpful to you. We have thousands of therapists listed with us who would love to walk with you on your journey. Find the support you need today.  

OCD vs OCPD

By Gary Trosclair, DMA, Licensed Clinical Social Worker

Do you really have OCD? Or is it OCPD?

OCD has become a household term we casually use to refer to anyone who needs to have things a certain way. As a casual term, it works well. It gives us a general sense of what’s being described. But if it’s used as an actual diagnosis to determine therapeutic treatment, it can cause problems. People who we might casually say have OCD may actually have a different condition, and the differences between these conditions call for a different approach to treatment.  

OCD, Obsessive-Compulsive Disorder, may look similar at first to a different condition, OCPD, Obsessive-Compulsive Personality Disorder, which is often overlooked and even misdiagnosed by clinicians. But OCD is an anxiety disorder, while OCPD is a personality disorder.

Diagnostic Difficulties

Far fewer people have OCD than have OCPD: 1.2% of the population has OCD,[1] while as much as 7.9% has OCPD.[2]   

About 20% of the people who have OCD also have OCPD,[3] making it difficult to distinguish between the two. And both diagnoses can be either severe or less-debilitating. Many people have some traits of Obsessive-Compulsive Personality Disorder but do not meet the full diagnostic criteria. These individuals can be very productive and fairly well-adapted socially.

Proper diagnosis should be completed by a licensed mental health professional. But following are some fundamental differences that may help you to better understand yourself in either case.

Symptoms: Specific vs. Generalized

People with OCD have specific obsessions (thoughts that are intrusive, involuntary, repetitive, irrational, and anxiety-provoking) and specific ritualistic compulsions (repetitive behaviors they can’t stop, such as checking and washing). On the other hand, the entire personality of someone with OCPD is affected by an overwhelming need to prioritize control, perfectionism, and order.

While people with OCD may try to control very particular things in order to quiet their obsessions, people with OCPD tend to be controlling universally. It’s as if the space they need to control is much larger. It’s not just the cupboards, it’s their entire world, and they can become very rigid about it.

Emotional Differences

People with OCD are more likely to feel anxious when specific things aren’t the way they want them to be. People with OCPD are more likely to feel angry if things aren’t the way they believe they should be.  

For instance, Angie, who suffers from OCD, is concerned about how the dishes get washed because she feels anxious if they aren’t absolutely clean.

But Arthur, who suffers from OCPD, insists that the correct thing is to have the entire house in order all the time. People with OCPD may justify their efforts to control by trying to prove that their way is the right way. They feel that they are trying to do the right thing to make life better for everyone, and their efforts can be helpful. But in many cases, they may become rigid in their actions, and, contrary to their motivations, they can make things more difficult for others.

People with OCD don’t necessarily restrict their emotions. However, they do try to control their thoughts (which can range from mildly uncomfortable to very disturbing) by doing compulsive things, such as repetitive and ritualistic cleaning and checking. 

But people with OCPD often try to control their emotions as well as their environment. They’re known for delaying gratification. They often give priority to their work, neglecting relationships and their own wellbeing. The emotions they are most aware of are anger, frustration, and resentment. They are more reluctant to be vulnerable than those with OCD, and may not even be aware of any underlying anxiety.

Angie gets anxious if the top is off the toothpaste tube because she fears germs. Arthur gets angry because it’s wrong to leave it off.

Shame or Pride about Their Condition

People with OCD don’t like their obsessions and compulsions and willingly seek help.

People with full-blown OCPD, because they try so hard to live their lives according to moral principles, are very proud of the way they live and don’t understand that they have a disorder. They tend to seek help only when forced to do so by a partner or when they become so depressed from trying to live with such demanding standards that they can’t go on that way any longer.

Motivations

People who have OCD are motivated to stay safe and to prevent catastrophes. People with OCPD are more motivated by rules and perfectionism. While they may justify their control by pointing to possible catastrophes, their underlying motivation often has more to do with wanting to avoid chastisement, blame, or failing to fulfill their responsibilities.

People with OCD are more clearly motivated to relieve their anxiety. While people with OCPD may also have underlying anxiety or a fear of being abandoned, their conscious concern is that they want to be respected rather than criticized.  

Behavioral Differences

While people with OCD may often behave in an insecure way because of their obsessions and compulsions, people with OCPD may become domineering, trying to hide their insecurities from themselves and others.  

People who have OCD spend much of their time in compulsive rituals such as cleaning and organizing. People with OCPD spend more time planning and working.

OCD efforts are usually maladaptive, except insofar as it helps them to maintain good hygiene. In contrast, some OCPD traits can be adaptive in a practical way, allowing them to succeed in the outer world, even if it makes them very unhappy. Because they are very conscientious, meticulous, energetic, and committed, they can make significant contributions in many fields, from art to public service to accounting. Most successful performers and athletes are compulsive to some degree.

Differences Among Compulsive Personalities

There are wide variations in the degree of unhealthiness among people with compulsive personalities, based on how controlling, perfectionistic, and rigid they are. Some, who don’t technically have OCPD but only have some compulsive traits, have very few maladaptive symptoms and can be very helpful in planning, organizing, and getting things done.

And there are wide variations in the style of compulsive personality: some are domineering, some are workaholics, some are compulsive people-pleasers, and others are so obsessive about getting things just right that they can’t get anything done.

Treatment

There is significant research to demonstrate that targeting the specific symptoms of OCD, as short-term Cognitive Behavioral Therapy (CBT) does,[4] can be effective for treating OCD.

There is far less research regarding the treatment of OCPD. In fact, according to psychologist and researcher Anthony Pinto, “there is no empirically validated gold standard treatment for OCPD.”[5]

However, there is reason to believe that approaching OCPD treatment by targeting specific symptoms may not be as effective as it is for OCD because of the pervasive nature of personality disorders. OCPD may benefit from a longer course of treatment in psychodynamic or expressive therapy.[6] This approach can help the individual to understand the possible benefits of their inherent personality style and to understand how those same traits can turn destructive when taken to extremes. Psychodynamic therapy can help them develop a better relationship with their emotions and use their need for control and perfectionism in a healthier way.

Getting to the Root Causes of OCPD

The causes of OCPD include genetic, environmental, and dynamic factors. These dynamic factors include the strategy the individual unconsciously adopted to cope with their particular combination of inherited traits and family situation. We can refer to these dynamic factors as old tapes, triggers, complexes, schemas, or patterns that they play out unwittingly, as if they were still living in the past with their families.

Attempting to treat the systemic, unconscious, and underlying character organization of OCPD by targeting just its external manifestations may not shift the underlying causes.

For example, some compulsives cope with their anxiety by externalizing, by getting those around them to do what they think should be done so that they feel safer. Other compulsives cope by internalizing, by taking too much responsibility on themselves and becoming people-pleasers to avoid a feared abandonment.

In most cases, people with OCPD feel a great need to prove themselves, and they attempt to do so with perfection, order, and control.  

Whatever the underlying dynamic, a therapeutic experience that gives the individual a chance to identify their specific coping strategy by seeing their old tapes play out in session with a therapist can be very effective. Does the client try to control the therapist? Does the client try to control his own emotions in session? Do they try to prove to the therapist that they are ethically good? This process often requires patiently developing awareness of emotions and the capacity to tolerate them in session, rather than reacting to them by trying to control themselves or the therapist.

The Potential Benefits of Compulsive Personality

If your basic character style is compulsive by nature, you won’t be able to change that. But you can begin to use your natural meticulousness, conscientiousness, and tendency to plan in a healthier, more conscious way that works well for you and the people around you. This can’t happen if efforts to change includes only trying to eradicate symptoms.  

I have referred to anxiety and a need for respect as motivations for the individual with OCPD. But on an even deeper level, they are motivated by a desire to help, plan, and repair in ways that can benefit everyone. Finding that original motivation can equip the OCPD sufferer with insight and direction, which can help them to heal and to be more helpful to those around them.

Footnotes

[1] National Institute of Mental Health website. Obsessive-Compulsive Disorder. https://www.nimh.nih.gov/health/statistics/obsessive-compulsive-disorder-ocd.shtml. Retrieved 12.23.20.

[2] Burkauskas, J. F., Naomi. (2020). History and Epidemiology of OCPD. In J. E. Grant, Anthony Pinto, Samuel Chamberlain (Ed.), Obsessive-Compulsive Personality Disorder (pp. 1-16). Washington, D.C.: American Psychiatric Association Publishing.

[3] Mancebo, M. C., Jane L Eisen, Jon E. Grant, Steven A. Rasmussen (2005). Obsessive Compulsive Personality Disorder and Obsessive Compulsive Disorder: Clinical Characteristics, Diagnostic Difficulties, and Treatment. Annals of Clinical Psychiatry, 17(4), 197-204. doi:10.3109/10401230500295305

[4] Foa, Edna B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience. Jun; 12(2): 199–207.

[5] Pinto, A. (2020). Psychotherapy for OCPD. In A. P. Grant JE, Samuel R. Chamberlain (Ed.), Obsessive-Compulsive Personality Disorder (pp. 143-178). Washington, D.C.: American Psychiatric Publishing.

[6] Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. doi:10.1037/a0018378

To find a therapist in your area who can help you work through the concerns in your life, click here.

Couple looking at plant roots while putting plants into potsEditor’s note: Gary Trosclair, DMA, LCSW is a private practice psychotherapist and Jungian analyst in New York City and Westchester County, New York. His continuing education presentation for GoodTherapy, titled “The Healthy Compulsive: Treating Obsessive-Compulsive Personality Disorder,” will take place on March 27, 2020 and is eligible for two CE credits. This event is available at no additional cost to Premium and Pro GoodTherapy Members (Basic Members and mental health professionals without membership can view this event live for $29.95). Learn more and register here.

If your partner is controlling, rigid, perfectionistic, and preoccupied with work and orderliness, they may have OCPD, or obsessive compulsive personality disorder. While even many therapists are unfamiliar with this diagnosis, it’s the most common personality disorder found in the United States, at a rate of about 7.9% of the population (Sansone & Sansone, 2011).

But it’s also the most unrecognized (Koutoufa & Furnham, 2014).

OCPD vs. OCD

Many people, even clinicians, confuse OCPD with OCD, obsessive compulsive disorder. While there is some overlap in symptoms, OCD is significantly different and is characterized by more specific problems such as repetitive hand-washing, locking and unlocking doors, the need to have everything clean and orderly, and intrusive thoughts.

People with OCPD, on the other hand, have issues that affect the entire personality. And this can have a more devastating impact on relationships.

One of the defining distinctions between OCD and OCPD is that people with OCPD tend to be good at delaying gratification—often too good.

One of the defining distinctions between OCD and OCPD is that people with OCPD tend to be good at delaying gratification—often too good. To understate the case, they’re not typically known for being fun-loving.

The Continuum of Compulsive Personality

Many people have just traits of OCPD, not full-blown OCPD. That is, they may struggle in some of the ways that people with OCPD do but don’t meet all of the criteria for the diagnosis. In fact, compulsive traits are found on a continuum—from healthy and adaptive to unhealthy and maladaptive, from conscientious and productive to rigid and destructive.

Partners with a compulsive personality style can be loyal, hard-working, reliable, productive, meticulous, conscientious, and dependable.

Still, even people who have just some traits of OCPD can be difficult to live with. They may insist on having things their way because they’re convinced their way is the right way. They can be very critical and domineering. They may emphasize work over relationships. And they can get so caught up in rules and schedules that they lose the point of whatever they’re doing.

For instance, they may often forget the point of a vacation. They tend to keep working the whole time and are prone to getting upset when things don’t go exactly as planned.

OCPD and Relationships

The same can be said for how people with OCPD handle their relationships. Doing things right can become more important than being happy together. As someone who frequently writes about OCPD, much of the correspondence I receive comes from partners of people with OCPD asking desperately for advice about how to live with them.

You can’t always work out relationships with people who have full-blown OCPD. If they refuse to go to individual therapy or couples therapy if they are unwilling to acknowledge that their life is out of balance, and if they don’t take responsibility for how they treat you, there may be little you can do but protect yourself.

Improving a Relationship with an OCPD Partner

Some relationships with OCPD partners can improve. Their compulsiveness can be enlisted in the service of the relationship.

But in this article, I want to focus on what partners of individuals with OCPD can do to improve the relationship.

In order to jump-start that process, you may need to consider that they don’t cause all the problems on their own. Conflict in relationships is most often an issue of fit and chemistry. And there are two sides to every story. As people with high levels of compulsiveness can become very adamant about being right, it can be hard not to get caught up in the same approach. This can lead to defending yourself rather than seeing what you might do differently to help the relationship get back on track.

Getting out of “right and wrong” thinking will probably take initiative on your part. And if you see that you have some role in the conflicts, you have more power to start the process of change.

Even if you don’t have a role in the problems, you may be the one who needs to instigate change. It’s not fair. But it just may be the reality of your situation.

Keys to Change in OCPD Relationships

Here are some things you can do if you want to stay in the relationship and try to make it work.

I will address these in three separate categories: how you see and treat your partner, how you communicate with your partner, and how you take care of yourself. Any one of these keys will probably not be enough in itself to initiate change. However, the three together can make a significant impact on the quality of your relationship.

Perspective

While it may have become skewed, the original intention of their rules was likely to make things safe for people.

Communication

Self-Care

While some relationships with partners who have OCPD may not be viable, others can improve with psychotherapy and a different approach from you, their partner. This will take heroic initiative on your part, but it may be worth it.

References:

  1. Koutoufa, I., & Furnham, A. (2014, January 30). Mental health literacy and obsessive–Compulsive personality disorder. Psychiatry Research, 215(1), 223-228. doi: 10.1016/j.psychres.2013.10.027
  2. Sansone, R. A., & Sansone, L. A. (2011). Personality disorders: A nation-based perspective on prevalence. Innovations in Clinical Neuroscience, 8(4), 13–18. Retrieved from www.ncbi.nlm.nih.gov/pubmed/21637629

Dome made of stained glass muralsReligious obsessive compulsive disorder (OCD) is a type of OCD that causes a person obsess over spiritual fears. It often involves religious compulsions such as excessive prayer. For example, a person might worry they are going to Hell and repeat a mantra to cope with this fear. Religious OCD is also called “scrupulosity.”

Religious forms of OCD are fairly common. In the United States, a 2002 study suggested 33% of people with OCD have religious obsessions or compulsions. More religious countries such as Egypt seem to have even higher rates of scrupulosity, with up to 60% of OCD cases involving religious themes.

Religious OCD can turn religious faith, which is often a source of comfort and community, into a trigger for anxiety. The emotional pain can feel overwhelming, but scrupulosity is highly treatable. Therapy is a key component of effective treatment.

What is Religious OCD?

In religious OCD, a person has persistent negative or anxious thoughts about their spiritual life. These obsessions often interfere with daily functioning. Individuals may be unable to suppress or ignore these thoughts.

Some examples of religious obsessions include:

Compulsions are behaviors people with OCD adopt to cope with their obsessions. They are often repetitive, time-consuming activities that the person does not enjoy. When a person cannot engage in their compulsions, their anxiety may rapidly escalate. Compulsions in religious OCD may or may not have religious themes.

Examples of religious compulsions include:

Unlike typical religious activity, spiritual compulsions are often motivated more by fear than faith. In many cases, people recognize that indulging in a compulsion won’t prevent their fears from becoming reality. Yet they may believe these compulsions are the only way to alleviate their anxiety.

What is the Difference Between Scrupulosity and Typical Religious Behavior?

Like the rest of the population, many people with OCD hold religious attitudes. It is common even for people without OCD to want to please God or religious authorities. So it can be difficult to distinguish typical religious attitudes from religious OCD.

Scrupulosity can affect members of any religious faith. The problem is anxiety, not religion. In general, religious behavior is considered compulsive if it doesn’t fit the cultural context. For example, a person may do cleansing rituals every day when their religion only mandates these rituals every week. Different communities of the same faith can have distinct expectations about religious behavior. The same actions may be typical in one place but considered excessive in another.

Another hallmark of religious OCD is that it undermines a person’s quality of life. It often causes extreme anxiety, guilt, and shame. A person may engage in rituals to the extent that they neglect work, school, or family obligations.

Scrupulosity can also interfere with one’s religious practices. An individual may focus so much on rules about cleanliness that they neglect other rituals. They may avoid attending religious ceremonies for fear of accidentally committing blasphemy. They may also believe other members of the faith do not take scripture seriously enough and feel isolated from their community as a result.

What Causes Religious OCD?

Religious OCD is not a distinct diagnosis. It is a specific manifestation of OCD. Thus, people with religious OCD may also have non-religious forms of OCD. Some people with religious OCD find their compulsions and obsessions change over time.

Like other types of OCD, the causes of religious OCD are not fully understood. Research suggests brains affected by OCD may have an imbalance of the neurotransmitter serotonin. This could be due to genetic factors, environmental factors, or a combination of the two. For example, a person with a family history of OCD might be more genetically vulnerable to the diagnosis. When something in the environment triggers their anxiety, OCD may appear.

A person’s obsessions may be more likely to have spiritual themes if:

It’s important to note that religion alone will not cause OCD to appear. Scrupulosity can affect members of any religious faith. The problem is anxiety, not religion. Even if a person becomes an atheist or abandons their religion, they will still have OCD (The theme of their obsessions and compulsions may change though.).

Therapy for Religious OCD

Therapy is often indispensable to the treatment of OCD. In therapy, a person can learn to manage their anxiety in ways that don’t undermine their quality of life. A therapist will not require a person to give up their faith – they only treat a person’s anxiety about said faith. Several types of therapy can be helpful in the treatment of religious OCD:

Exposure and response prevention therapy (ERP). In ERP, a person is exposed to their fear and then prevented from doing their compulsion. For example, a person may be asked to imagine that God is angry with them. Then, the therapist will help the person calm down as they experience anxiety.

ERP can help individuals learn to tolerate religious anxiety. Over time, a person can learn to accept uncertainty and feel less pressure to do their compulsions.

Cognitive behavioral therapy (CBT). This type of therapy can help with many forms of anxiety, including anxiety related to OCD. Cognitive behavioral therapy helps people detect, understand, and push back against automatic negative thoughts. For example, a Jewish person who fears they have accidentally eaten pork could be asked to assess the likelihood that meat was in their vegetarian salad.

CBT may be more helpful when one worries about concrete actions, such as saying a prayer wrong. CBT is generally less effective in addressing intangible fears, such as being destined for Hell. Due to the subjective nature of faith, debating the “logic” of religious beliefs may alienate the person in therapy.

Pastoral Counseling. Some people may find it easier to trust a therapist who shares their faith (especially when said faith is marginalized). Pastoral counseling incorporates spiritual elements such as scripture study or prayer. It can be especially helpful for people who worry that treatment means they must give up their religion.

Family Therapy: When religious OCD undermines family life, family counseling can help. If the affected individual is a young child, a therapist may use techniques suitable for their age. When religious OCD threatens a marriage, couples counseling can also help.

If you need help with religious OCD, you don’t have to cope with anxious thoughts and compulsions alone. Therapy can offer rapid, lasting improvements. You can find a therapist here.

References:

  1. Abramowitz, J. S., & Jacoby, R. J. (2014). Scrupulosity: A cognitive–behavioral analysis and implications for treatment. Journal of Obsessive-Compulsive and Related Disorders, 3(1), 140-149. Retrieved from http://jonabram.web.unc.edu/files/2014/05/Scrupulosity-model-2014.pdf
  2. Clinical definition of OCD. (n.d.). Retrieved from http://beyondocd.org/information-for-individuals/clinical-definition-of-ocd
  3. Ehmke, R. (n.d.). Understanding religious OCD. Retrieved from https://childmind.org/article/understanding-religious-ocd
  4. Exposure and response prevention (ERP). (n.d.). Retrieved from https://iocdf.org/about-ocd/treatment/erp
  5. Rady, A., Salama, H., Wagdy, M., & Ketat, A. (2012). Religious attitudes in adolescents with obsessive compulsive symptoms OCS and disorder OCD. Global Journal of Health Science, 4(6), 216-221. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4777005
  6. Scrupulosity [PDF]. (2010). Retrieved from https://iocdf.org/wp-content/uploads/2014/10/IOCDF-Scrupulosity-Fact-Sheet.pdf
  7. What causes OCD? (n.d.). Retrieved from https://iocdf.org/about-ocd/what-causes-ocd

Dear GoodTherapy.org,

Like most little boys, my 6-year-old son is messy. He tracks mud in the house, gets finger paint on the couch, and is basically a whirlwind of chaos. Until recently, it’s been a struggle to get him to wash his hands or take a bath. I come from a family of neat freaks, so sometimes I’m stricter with him than the situation deserves.

One day, my son came home after swimming in the creek down the road. When he grabbed a slice of pizza with his still-wet hands, my germaphobe alarm went off. I sat my son down and explained to him what germs were and how they could be on anything, even things that didn’t look dirty. I said he should always wash his hands so germs wouldn’t make him sick.

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My boy always ignored my lectures before, but this time he took me seriously. Too seriously. Now he washes his hands after touching anything: his stuffed frog, the TV remote, even doorknobs! If he plays outside, he’ll wash his hands twice over. The skin on his knuckles is literally raw from all the washing. When the hand soap in his room ran out, he had an honest-to-goodness meltdown.

I have tried to explain that he doesn’t need to wash his hands ALL the time, just after using the bathroom or playing outside. My words didn’t help. He’s deathly afraid of getting sick. You’d think there was a plague going on from how anxious he gets.

I feel as if I’ve broken my boy, and I don’t know how to fix him. I had no idea my words would give him such a severe phobia. I’d take it all back if I could. Please tell me, how do I help my son? —Crisis of Cleanliness

Submit Your Own Question to a Therapist

Dear Crisis,

I imagine that feeling as if you have “broken” your boy and not knowing how to “fix” him creates a tremendous amount of pain for you—regret and guilt were palpable as I read your question.

It’s hard for parents to know how something is going impact their children. You say your son usually ignores your lectures, so you had no idea he would react like this. You make the best decisions you can with the information you have at the time. Unfortunately, things go a bit awry sometimes. Try to be gentle with yourself and remember you were only trying to get him to be better about washing his hands, which is a reasonable and responsible parenting goal.

A therapist could be instrumental in helping your son identify his feelings and develop coping strategies.

I wonder if your son would be comforted by the fact exposure to some germs is good for developing the immune system. Perhaps you two could spend a little time reviewing reputable websites that cover this concept. Maybe you could even schedule an appointment with his pediatrician to talk about it. You seem to have his attention on this issue, so perhaps he would be interested in learning more.

It’s also possible that, in time, the issue will take care of itself. Children go through phases. Sometimes a behavior or fear that arises with great intensity just fades out.

If educating him on germs—not just the danger they pose, but the value they hold—and/or time don’t resolve the issue, it might be helpful to partner with a therapist to further explore his feelings. If he has a heightened sense of anxiety in general, it’s possible this issue has simply become the focus. A therapist could be instrumental in helping your son identify his feelings and develop coping strategies.

However you proceed, I hope you will remember that your intention was simply to get him to wash his hands more—a good thing. You couldn’t have anticipated such a dramatic response, especially given his propensity for ignoring your lectures. Issues sometimes arise despite parents’ best efforts. The fact you are reaching out for help and trying to work with your son to move past this shows what a loving and dedicated parent you are.

Best wishes,

Sarah Noel, MS, LMHC

Dear GoodTherapy.org,

I have bad OCD. Fear of germs, obsessive and anxious thoughts, needing things to always be perfect and orderly—you name the symptom, I’m pretty sure I have it.

Before you suggest it, I’m going to contact a therapist. But my question is whether, even with therapy, OCD gets worse before it gets better. Most things I see people dealing with, especially mental health issues, don’t tend to improve as they get older. If anything, their problematic thoughts tend to harden into fully formed habits and they become more difficult to shake. Is that the case with OCD? How quickly can I expect therapy to help? (For that matter, will it help at all? Will it cure me or just give me ways to cope?)

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From what I’ve read, obsessive-compulsive disorder isn’t the kind of thing you just “get over.” I want to know what kind of journey I need to buckle in for here, and whether the ride is likely to get bumpier before it smoothens out. Please be brutally honest, if need be. Thank you for your time. —Obsessing Over OCD

Submit Your Own Question to a Therapist

Dear Obsessing,

It sounds like you’re doing the most important thing you can do if you think you have obsessive-compulsive disorder (OCD). You’re investigating what you need to know and looking into seeking help to manage and, ideally, overcome your symptoms. Your instinct to contact a therapist is a good one. If you haven’t already done so, I strongly encourage you to not delay and schedule an appointment.

While I generally caution against self-diagnosing, you may be on to something. If I were to work with you, some things I’d want to know about your symptoms include when you recognized that they are a problem; what, exactly, you mean by “bad OCD”; and what you are already doing to help yourself feel better. I’d also want to know how much your symptoms are interfering in your relationships, job/school, or other daily activities.

I hear your concern about whether symptoms will get better before they get worse; rest assured this fear is unwarranted. It is more likely that symptoms could get worse by not doing anything about them. As you noted, these symptoms are unlikely to resolve on their own without you doing something different.

When you are having symptoms (whether it be for an OCD diagnosis or for something else), the most important thing is that when you recognize you are suffering, you reach out for help. The sooner you seek help, the sooner you will have answers to your questions as they relate to you, and the sooner you’ll learn how to treat your symptoms. Seeking help now also enables you to change your thinking patterns while you are younger, which will have positive implications for your future (countering your anecdotal observation that mental health issues get worse with age, especially when left untreated).

I hear your concern about whether symptoms will get better before they get worse; rest assured this fear is unwarranted. It is more likely that symptoms could get worse by not doing anything about them. As you noted, these symptoms are unlikely to resolve on their own without you doing something different.

Generally, obsessive thoughts and related symptoms are likely to improve when you commit to a course of therapy and not terminate prematurely. This might include cognitive behavioral therapy (CBT), another psychotherapeutic approach, medication, or a combination of the above. One important aspect of treatment effectiveness is learning to recognize what may be triggering your symptoms and how to avoid or prepare for these triggers in the future.

There are no guaranteed “cures” (meaning a promise of no relapses) for anything when it comes to OCD. Treatment will likely take time, and symptoms likely will not subside after just one session. If you start with an approach and it doesn’t seem like a comfortable fit, try to not get discouraged. There are multiple treatment options, and another approach may resonate better with you. Be patient with yourself and your progress.

With many mental health conditions, including OCD and anxiety, some of the most important things we can do are to learn how to build coping skills, increase self-awareness, promote self-compassion, and prevent relapses. In other words, it’s critical to be an active part of your treatment and self-monitor your symptoms.

Sincerely,

Marni Amsellem, PhD

Close-up photo of young adult leaning over journal while sitting outdoors and writing Are you in an addictive relationship with someone? Would you like to break free from your bondage and feel inner peace? Do you want to stop the obsessions, break the cycle of seeming insanity, and take back your life?

Then read on.

Addictions come in many forms. An addiction to a person involves obsessive thoughts about the relationship, feelings of hope, anticipation, waiting, confusion, and desperation. Addictive relationships are toxic and very powerful.

Healthy relationships do not involve constant drama and continual feelings of longing. Healthy relationships just are. When in a nonaddictive relationship, you simply know your loved one is available to you. You do not have to wonder, wait, or live in turmoil over your last or next encounter.

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The first step in recovery is to face the truth. Identify your toxic person as the “drug” of sorts you are addicted to. Before you can break any addiction, you need to own the reality you have one. Acknowledgment is the beginning of your journey toward recovery.

To help you face the truth, get out your writing pad and begin the process. Start by writing the following:

Once you have faced the truth, commit to yourself to live in the truth—to live in reality, no matter the cost. Recovery requires living in truth over living in fantasy. Addictive relationships are fantasies. You are in love with what you wish the person was, not what they are.

You are addicted to the brain chemistry attached to the anticipation and traumatic bonding surrounding the relationship. Because the relationship is so utterly unfulfilling, you are left with a constant state of emptiness, which is temporarily assuaged with each encounter with your object of obsession (the person).

It is a vicious cycle.

Once you have identified your thoughts, feelings, and patterns in your relationship, it is time begin abstention (if you haven’t already done so). You must abstain from your addiction. You can abstain in one of two ways:

  1. Abstain from the relationship completely (no contact); this includes texts and social media.
  2. Abstain from and emotional entanglements; this requires detachment.

This will be a very difficult part of your journey. The brain chemicals released when trying to detach are vastly different from the neurotransmitters and hormones released when you are with your loved one. The main chemical released during times of stress (including emotional stress) is cortisol. Any trigger (such as the loss of a loved one) releases chemicals from the noradrenergic system (which includes the release of cortisol and norepinephrine).

As you face another emotionally dysregulating departure from your loved one, your stress system goes into high gear, releasing stress chemicals in your body, which motivates you to “do something about this!” As you anticipate the relief from the stress, your brain releases chemicals such as dopamine, which offer that positive feeling of anticipation. You have entered the craving part of your addiction.

In order to break an addiction, you need to realize you are fighting these chemical responses. This means you will not feel good for a while. But rest assured, if you can abstain from responding to your brain chemistry, you can get through these tough times and your neurotransmitter system will eventually come to rest at a state of equilibrium.

Some suggestions for what to do while you are in this “craving cycle”:

Understand you cannot change anyone but yourself. Stop focusing on how the other person needs to change. You have no power over other people, and wishing others would change only serves to keep you hooked into a destructive pattern of waiting.

Understand you cannot change anyone but yourself. Stop focusing on how the other person needs to change. You have no power over other people, and wishing others would change only serves to keep you hooked into a destructive pattern of waiting.

The best thing you can do to help yourself on your journey of healing is to be proactive and set up a plan of emotional health “bottom-line behaviors” for yourself.

Here are some personal principles you can internalize to help you do just that:

Recovery from any addiction, including a relationship addiction, is hard but worthwhile work. You can do this through perseverance, hope, self-discovery, and grace. The best way to accomplish any long-term goal is to do it one step and one day at a time. Don’t scare yourself by thinking beyond today. Live each day as it comes and take the next indicated step on your journey to healthy living.

For compassionate guidance, seek the support of a licensed therapist in your area.

Shoulder and torso view of a person scratching their arm. The person is wearing a magenta top and has shoulder-length hair.Do you feel compelled to remove flakes of dead skin from your nose? Do you have a hard time keeping your hands off pimples and blackheads? What about those random bumps on your arm that arise unexpectedly? For people diagnosed with excoriation disorder, skin picking is a common response to these and other generally harmless skin irritants.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, excoriation—which falls under the umbrella of obsessive compulsion—is characterized by recurrent skin picking resulting in some sort of skin lesion; repeated attempts to stop the picking; potential impairment or distress over the picking; and an inability to attribute the skin picking to a medical condition, substance abuse, or another mental health diagnosis. Like hair pulling and nail biting, research suggests that excoriation may be a body-focused repetitive behavior (BFRB).

Most people who pick can typically find multiple sites on their body to pick, squeeze, or scratch. It is often a search-and-find mission using fingernails or some other designated instrument. The result of the picking can be inflamed, red, and sometimes bloody skin. When scabs develop, they may represent another reason to pick.

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People who pick their skin often are ashamed and feel the need to conceal excoriation through the use of makeup, extra clothing, or hats. The shame may add to the distress they feel regarding their appearance or their behavior toward their body. Often, there is an undercurrent of perfectionism with BFRBs, especially skin picking, and a deeply held belief that any imperfections must be eliminated.

Often, therapy will address underlying feelings and emotions that fuel the behavior, exploration of triggers that affect when and where the person picks, and soothing strategies to deescalate compulsive behaviors.

Would you be surprised to know that more than 75% of people diagnosed with excoriation are female? It is estimated that excoriation affects 1.4% of the general population, although many experts think the number may be higher. Most often, the condition begins at the onset of puberty and becomes chronic over time.

Skin picking may be triggered by tension, stress, or boredom and often has a compulsive element to it, meaning the person cannot stop themselves from picking and feels compelled to either relieve uncomfortable feelings or respond to minor skin irritations. Most often it occurs without full awareness of the behavior and when the person is alone. While reading, studying, on the phone, or watching television are all common scenarios for excoriation to occur. Many people spend up to one hour per day picking or resisting the urge to pick. Often, another person has noticed and mentioned the behavior.

Treatment for skin picking is often found in cognitive behavioral therapy, dialectical behavior therapy, rational emotive behavioral therapy, or acceptance and commitment therapy facilitated by a licensed mental health provider. Often, therapy will address underlying feelings and emotions that fuel the behavior, exploration of triggers that affect when and where the person picks, and soothing strategies to deescalate compulsive behaviors.

Those with BFRBs may also find relief with tactile and meditative strategies. Tactile replacements may be helpful in providing substitute relief and can include bubble-wrap popping, fidget toys, cooking, working with clay, painting, or even using a piece of ribbon as a soothing instrument to wrap, rip, and stroke. Meditative behaviors such as yoga, cleaning, walking, or listening to music can also be effective in soothing the urge to pick.

Although excoriation is a complicated and often distressing behavior, it is manageable with professional treatment and replacement behaviors.

References:

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
  2. OCD & Related Disorders Program. (n.d.). Excoriation. Retrieved from https://mghocd.org/clinical-services/excoriation/
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