Obsessive-compulsive disorder (OCD) is often thought of as a disorder of extreme cleanliness and organization. While contamination and perfection are common obsessions, OCD encompasses a wide variety of themes.
In this article, we’ll go through some of the lesser-known subtypes of OCD and how they can affect people.
What is an OCD theme?
Put simply, OCD is a mental health disorder that includes obsessions (unwanted thoughts, images, and experiences that cause distress) and compulsions (actions, rituals, and avoidances to reduce that distress).
The content of obsessions can vary widely from person to person and can change over time. Sometimes they are based on negative experiences, but for others they feel completely random. The over-arching content of these obsessions are called themes or sub-types.
Some commonly described themes include:
- Contamination OCD (obsessions related to cleanliness, germs, etc.)
- Harm OCD (fearing that you will harm someone)
- “Just right” OCD (feeling intense distress when things are out of place or do not meet defined rules someone has set for themself- sometimes referred to as perfectionist OCD)
Before we go through these in detail, it’s important to note that just because these subtypes are less commonly spoken about, it does not mean they are less common or less impactful to the people who experience them. Many people with OCD experience obsessions related to a multiple themes.
The themes we’ll discuss include:
- Pedophilia OCD (P-OCD)
- Somatic OCD
- Existential OCD
- Suicidal OCD
- Sexual Orientation OCD
- False Memory OCD
- Insanity or “going crazy”
- Relationship OCD
- Health OCD
Pedophilia OCD (P-OCD)
POCD is one of the most stigmatized OCD themes, and to some extent, it’s understandable why. To be abundantly clear, people with P-OCD are not pedophiles, and they do not pose any more danger to children than someone without P-OCD. In OCD, obsessions are unwanted and cause significant distress.
When someone reports that they are having thoughts of being sexually attracted to children, it’s not unusual for that to be met with immediate disgust, fear, and judgment. But a trained OCD clinician knows to ask more questions to understand the nature of these thoughts.
If they are having these thoughts, aren’t disgusted by them, and truly feel they desire sexual contact, of course that is concerning and should be handled as a safety issue.
But people with P-OCD are deeply disgusted by their obsessions and go to great lengths to avoid these thoughts or stop them from happening. In many cases, people with POCD are actually highly preoccupied with the safety of children and will avoid being in any potentially harmful situation with them for fear of experiencing more obsessions.
This theme focuses mostly on automatic body functions, things like blinking and breathing. For most people, these sensations don’t really enter their awareness, and the brain continues to do them at appropriate intervals to maintain proper body function.
For people with Somatic OCD, these body functions become the focus of obsessions, and this can cause great distress. There are often questions about whether they are breathing “correctly” or if they are chewing enough times before the swallow so that they don’t choke. It also often shows up in the concept of focus.
Because these body processes are automatic for most people, maintaining them requires no effort or focus. For people who obsess about these body functions, there is often fear that they will never be able to not focus on them, therefore removing their ability to manage other responsibilities, joys, or goals in their lives.
Most people have experienced the occasional question about their existence, the universe, or the meaning of life. There are questions that we simply don’t have answers to, and for some people, these cause minor discomfort and then are quickly forgotten in favor of a new thought.
For people with existential OCD, these become intense and unforgettable. Because there is no answer, the search for peace and anxiety reduction around these questions can feel never-ending.
Scrupulosity (moral/religious obsessions)
Holding oneself to a moral code is typically not a concern, but for people with scrupulosity themes in their OCD, it becomes a singularly focused mission that can cause major disruptions in their daily life and relationships.
Even people without a strong religious belief can find themselves managing obsessions related to religious morality. While it may not seem too challenging to experiences obsessions about being a good person, imagine for a moment that you had to assess every single move you make in a day, sometimes down to the tiniest purchase, interaction with a stranger, and past experiences.
Suicidal OCD can be especially difficult to diagnose and treat, because it can feel risky not to immediately jump into action on a safety plan.
There should be a thorough risk assessment any time someone expresses thoughts of suicide, but if it is determined that someone is experiencing suicidal OCD, it’s important to remember that they are not at any increased risk of suicide than people without this subtype.
This theme can include unwanted images and thoughts of killing oneself, often coupled with intense fear and questions like “does that mean I want to kill myself?”. Compulsions are often seen in the form of avoidance (avoiding certain places, people, things that might trigger the thoughts and getting rid of things they could harm themselves with) as well as seeking reassurance and continually running through the thoughts to determine their validity.
Sexual Orientation OCD
People of any sexual orientation can experience this type of OCD, and it focuses on the concept of not knowing one’s sexuality for certain, not necessarily that there is something wrong or immoral (though some people experience obsessions around this specifically).
There’s no test to know one’s sexuality without any uncertainty, and this ambiguity can wreak havoc on people with sexual orientation OCD. They often experience obsessions on questions like “am I gay because I think my friend is pretty?” and “If I am, does that mean I need to break up with my partner?”.
False Memory OCD
Have you ever wondered if something you remember actually happened, or if you’ve forgotten something? Maybe you’ve experienced a gap in memory and felt uncomfortable when you hear an account of something you were present for but have no memories of.
People with false memory OCD experience this regularly, and aren’t able to move past the uncertainty of whether something happened or not. Compulsions typically look like constant mental reviewing or asking for reassurance from others.
Real Event OCD
In contrast to false memory OCD, real event OCD occurs when someone experiences obsessions related to events that actually happened, often ones they feel shame or guilt for.
It’s not uncommon for people, especially those prone to anxiety, to mentally review past events and to some extent re-experience the emotions they felt at that time. In real event OCD, these thoughts are constant and intrusive, and people will often engage in some form of compulsion to relieve distress from these obsessions.
Compulsions in real event OCD range from mentally reviewing the event and thinking about the consequences (real or imagined), attempting to do the opposite to “right the wrong”, and compulsive apologizing without feeling absolved of the issue.
Insanity or “going crazy”
It’s not uncommon to wonder if you might “lose it” one day, or even to feel like you are starting to if you haven’t slept well or are under severe stress.
If insanity or “going crazy” is the focus of someone’s obsessions, they will spend considerable time wondering about “clues” that they might be going insane. They’ll check and recheck to make sure they are not seeing things, and that they have a grip on reality.
It can become increasingly difficult to manage obsessions and compulsions once the foundation of reality becomes uncertain based on someone’s obsessions.
Most people have questioned if a relationship is right for them at some point. For people with relationship OCD, these questions and uncertainties become the focus of obsessions. Questions like “What if we’re not right for each other?” and “what if I (or they!) wake up one day and want something different?” are common.
Compulsions often revolve around continually “checking” that they have made the right choice, assessing their feelings for their partner vs. other people, and seeking reassurance from their partner about the longevity of the relationship.
Pure-O (obsessions without typical compulsions)
A major tenant of OCD is the combination of both obsessions and compulsions. When clinicians started noticing a specific form of OCD in which there are obsessions present (well beyond the type of worries seen in something like Generalized Anxiety Disorder), but no compulsions in the typical sense, Pure-O was identified.
With more investigation, practitioners soon understood that it is not fully accurate to say these folks do not experience compulsions. Rather, their compulsions are purely mental or cognitive in nature. They may not be engaging in outward rituals, but they are doing things repetitively with the purpose of reducing distress.
For example, a person may have obsessions related to causing harm to others, but instead of putting away all their knives, they may repeat a phrase that brings them peace and distracts them from the thoughts.
For many people with Pure-O, the compulsions are under-the-radar, so much so that they may not even understand that they are engaging in themselves. This can make diagnosis a challenge, but it’s imperative to understand these patterns as OCD rather than general worries.
There are many people who worry about their health, and a wide spectrum of sensitivity to health symptoms exists. Being a “hypochondriac” is sometimes just an excessive worry about health, but for people with health OCD, the obsessions are frequent and unable to be managed.
Health OCD compulsions are often reassurance-based. Seeking medical care or repeatedly taking one’s own vitals provides a small amount of reassurance, but the uncertainty of how quickly health can change is deeply unsettling to people with Health OCD.
Though technically not an OCD theme on its own, emetophobia often shows up within an OCD pattern. Many people strongly dislike or even fear throwing up, but people with emetophobia will experience frequent obsessions about it and go to drastic measures to avoid the possibility of throwing up.
Sometimes that looks like avoiding certain foods or smells, avoiding anyone who is ill or could vomit, but sometimes it becomes severe enough that someone avoids all public interactions or eating anything but a few “safe” foods. There is a strong pattern of obsession (thoughts, images, and sensations of nausea) and compulsions (avoidance of all triggering stimuli).
Why are these themes lesser known?
The reasons why these might be lesser-known themes vary, but typically boil down to two main issues:
As you read through the list, you might have been struck with discomfort reading a few of the themes. Pedophilia OCD and Sexual Orientation OCD are two that are often lesser known solely because they come with significant shame and fear or judgement if someone were to disclose that they were dealing with these issues.
If someone isn’t aware that these forms of OCD exist, it can be difficult to build the courage to talk about what they are experienc
- Difficulty with accurate diagnosing
Additionally, many of these lesser-known themes are difficult to diagnose if a provider doesn’t have extensive training in assessing for diagnosing OCD. Health OCD, for example, can often be written off as being a “hypochondriac” and Pure-O just looks like high anxiety on the surface.
It’s difficult to accurately describe or even understand the nuances of these symptoms, and it can take many years for someone to seek and receive an accurate diagnosis and treatment.
What can you do if you experience obsessions related to these themes?
While the presentations of different themes can look very different from each other, all of the themes we’ve listed here still follow a typical OCD pattern of obsessions and compulsions. Therefore, they will still respond to the types of treatments that work for other subtypes of OCD.
Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. In this treatment, a skilled clinician will help guide you in understanding your obsession and compulsion patterns, and gradually challenge you to sit with the distress and uncertainty that comes with these obsessions without performing the compulsions that would typically (though only temporarily) reduce your anxiety and distress.
Even in themes that may feel uncomfortable to sit with, this treatment has proven to be effective. Remember, the theme OCD has chosen to fixate and obsess on is much less important than the underlying fear of uncertainty.