The 4 Types of OCD
The four dimensions (or types), of OCD include; contamination, perfection, doubt/harm, and forbidden thoughts. Scroll toward the middle of the article to get more information on each type of OCD.
Obsessive-compulsive disorder (OCD), is a term that is tossed around quite casually these days. Recognize any of these?
Like your cabinets arranged just so? “I’m OCD!”
Double-check – or even triple-check – your locks? “You’re so OCD!”
“OCD” has made it into our popular language as a kind of catch-all phrase to describe anyone who seems just a little-too-focused on having things “just right.” Are they living with OCD?
OCD is more than just neatly arranged closets, checking or rechecking locks or even washing hands a lot. There’s a lot more to it.
What Is OCD?
OCD is a specific, neuropsychiatric, anxiety disorder that causes a person to experience uncontrollable, reoccurring thoughts (obsessions) and/or behaviors (compulsions) that he or she feels the urge to repeat over and over.
The behavior’s role is to decrease the distress or anxiety related to whatever the trigger experience is.
Over time, this stimulus-response becomes caught in a pattern or behavior loop that is repeated over and over again.
Repetitive handwashing is an iconic example of an OCD-type loop. Handwashing is only one component and the visible result of a perceived trigger or obsession, in this case, often “contamination” of some kind (real or imagined).
OCD is not uncommon.
In fact, according to the National Institutes of Health, OCD affects about 1.2% of the U.S. population and about 2% of the general population worldwide. OCD has been documented in both children and adults. Occurrence is slightly higher for women (1.8%) than men (0.5%). (1)
Contrary to popular belief, OCD is not a single symptom but rather a set of obsessions and compulsions that occur along a continuum.
There are some common themes in these thoughts and behaviors.
People living with OCD can experience obsessions, compulsions or both. But first, let’s talk about the different components of OCD.
What Are Obsessions and Compulsions?
Obsessions are intrusive, repetitive thoughts, urges, or mental images that create anxiety and distress. Some of the most common obsessions include:
- Fear of contamination or germs
- Symmetry and balance
- Forbidden or taboo thoughts involving things like sex or religious practices
- Thoughts of aggression/impulsivity towards self or others.
Compulsions are repetitive behaviors that a person with OCD feels compelled to do in response to their obsessive thinking. Some more common compulsions include:
- Excessive handwashing or bathing
- Arranging, counting or stacking things in precise ways
- Excessive checking and re-checking things like door locks
- Counting rituals
Now, these behaviors in and of themselves don’t alone suggest OCD. In fact, most people have some, what we might consider compulsive behaviors, but that does not an OCD diagnosis make.
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When Is It OCD?
People who have disorders like OCD experience a significant set of distressing consequences of their symptoms.
In order to be given a diagnosis of OCD, a person must meet a specific set of criteria as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).
Some of the hallmark signs of something more than just quirky behavior include:
- Attempts to control or neutralize distressing thoughts, urges or behaviors are not successful
- Excessive time is spent engaging in obsessive and compulsive behaviors
- There is no pleasure from time spent in these activities but there is brief relief from the anxiety they cause
- The obsessions and compulsions cause significant impairment in social, occupational or interpersonal functioning
What’s more, it is not uncommon to see people with OCD struggle with other issues such as depression or substance abuse in an effort to cope.
As you can see, true OCD is complicated and has a lot of pieces. Simply calling it OCD doesn’t tell the whole story.
The Four Dimensions (Types) of OCD
When we talk about OCD, we talk not only about the presence of obsessions, compulsions or both, we also talk about the focus of those symptoms.
Symptoms tend to fall into four general categories, called symptom dimensions that include both obsessions and compulsions. (2)
These dimensions are akin to looking at the different sides of an OCD box. They are not mutually exclusive. You can have elements from one or more of the dimensions. Each blend of symptoms is unique.
Contamination OCD is what most people think of when they hear the phrase “OCD.” Driven by an underlying fear of contamination or germs, people will go to great lengths to avoid situations seen as “risky” for exposure to contaminants. Some of the more common protective rituals include:
- Disinfecting and sterilizing, excessive cleaning
- Excessive handwashing
- Throwing away objects believed to be contaminated or sources of contamination
- Frequent clothing changes
- Creating “safe” or “clean” zones
These rituals provide temporary relief from the perceived risk of exposure to contaminants and germs.
People whose symptoms fall in this dimension have an overwhelming preoccupation with order and getting something “just right.”
They will spend inordinate amounts of time moving, counting, and arranging things to alleviate or prevent distress. They may also have specific superstitions about numbers, patterns, and symmetry.
These rituals are sometimes attached to magical thinking (i.e., the belief that something bad will happen if something is not “just right.”)
Some of the commonly seen behaviors include:
- A need for items to be arranged in a specific way
- An extreme need for symmetry or organization
- A need for symmetry in actions (if you touch your right elbow, you must also touch your left elbow)
- Arranging items until they feel “just right”
- Counting rituals
- Magical thinking, or believing something bad will happen if things aren’t “just right”
- Organization rituals or superstitions about the arrangement of objects
- Excessive attachment to and hoarding of certain items
The endless quest for perfection can be physically and mentally exhausting. The person may avoid social contact at home to prevent the symmetry and order being disrupted. This can have devastating effects on relationships.
This is the dimension of checking and re-checking.
People with obsessions in this dimension tend to experience intrusive thoughts, images or urges related to the fear of unintentionally harming themselves or someone else due to carelessness or negligence.
A common example is that of leaving the gas stove on before leaving home possibly causing a house fire. Along with their fear of accidental harm is also often an overwhelming feeling of self-doubt or dread and being responsible for what may happen.
Some of the common behaviors you might see are:
- Checking and re-checking things like door locks, stoves, windows, light switches, etc.
- Checking may include a symmetrical component of checking a specific number of times
- Repeatedly reviewing daily activities or retracing steps (mentally or physically) to make sure no one was harmed
This symptom dimension is characterized by unwanted, intrusive thoughts.
These thoughts are often of a violent, religious or sexual nature that significantly violates the person’s morals or values.
This dimension is particularly difficult to recognize and was once considered to be purely obsessional (thought-based).
In fact, people with this type of OCD do engage in behavioral rituals to manage these unwanted thoughts. These rituals tend to be covert and consist of mental compulsions and seeking reassurance.
Some of the common themes and rituals associated with this dimension include:
- Persistent intrusive thoughts that are often sexual, religious or violent in nature
- Persistent worry about acting on intrusive thoughts or that having them makes one a bad person
- Obsessions about religious ideas that feel blasphemous or wrong
- Engaging in mental rituals to dispel or cancel out the bothersome thoughts. Some of these rituals might include:
- Neutralizing thoughts through mentally canceling out negative thoughts with positive ones or excessive praying
- Excessive reviewing behavior or the seeking of reassurance
- Avoidance of situations perceived as thought triggers
It should be noted that, despite the nature of their thoughts, people with this type of OCD usually have no history of violence, nor do they act on their thoughts or urges.
They do, however, often believe their thoughts are dangerous and will devote enormous time and mental effort to suppress them.
What Can Be Done for Those Living With OCD?
Fortunately, there are many evidenced-based treatment options for those living with OCD.
If you are living with OCD, you’ve probably tried to resist the urges and spent inordinate amounts of time trying to manage symptoms with varying degrees of success.
You’re not alone.
It’s estimated that of the total number of adults with OCD, about 50% have what would be considered a significant impairment. Another 30% report moderate difficulty. (1)
The great news is that OCD is a highly treatable disorder. Medications, specific types of psychotherapy, and even some new technology mean relief is possible for many of those who deal with bothersome symptoms.
While there is no one-pill-wonder to treat OCD, there are medications that have been proven to be helpful. It’s estimated that medication can provide relief for about 40-70% of people. (3)
Selective serotonin reuptake inhibitors (SSRIs) are often the first-line choice for pharmacological treatment of OCD. These anti-depressant medications have shown to effectively reduce OCD symptoms for many people with few significant side-effects.
Fluvoxamine (Luvox) was one of the first of the SSRIs shown to be effective but research has found that there is little difference in efficacy between the SSRIs. Which one to choose may be based more on the potential for side effects, potential drug interactions, patient preference, and other considerations. (3)
Research shows that certain types of psychotherapy, including Cognitive Behavior Therapy (CBT) and other related therapies (e.g., habit reversal training) may be as effective as medication for many people.
A specific type of CBT known as Exposure and Response Prevention (ERP) has proven to be particularly effective in treating OCD. (4)
Exposure refers to being exposed to (i.e., spending time in) the thoughts, images, objects and situations that make you anxious and trigger your obsessions.
Response Prevention refers to making a choice to not engage in the usual compulsive behavior once the anxiety or obsessions have been “triggered.”
Initially, this process is conducted during sessions with a trained psychotherapist. Over time, the person learns how to do this on their own. ERP has been found to reduce compulsive behaviors in OCD, even for people who did not respond well to medication. (4)
ERP is not traditional “talk therapy.”
ERP involves a very specific approach and progression guided by a trained psychotherapist.
While traditional psychotherapy can be helpful to address some of the social and personal issues that can accompany living with OCD, symptom reduction requires specific interventions such as ERP.
New treatment modalities being explored, brain stimulation techniques such as Transcranial Magnetic Stimulation (TMS), Deep Brain Stimulation (DBS) and Transcranial Direct Current Stimulation (tDCS) are the next generation of treatment for several mental health issues including OCD.
While not yet readily available, there are a number of clinical trials and studies in progress.
Early results show particular promise for people who have treatment-resistant symptoms.
Transcranial Magnetic Stimulation (TMS)
Initially developed to address treatment-resistant depression, TMS uses an electromagnet to send pulses of magnetism into specific areas of the brain.
Studies of TMS applications that stimulate a part of the brain called the pre-Supplementary Motor Area (pre-SMA) have shown to be potentially helpful in reducing the abnormal brain excitability seen in OCD. (5)
Deep Brain Stimulation (DBS) and Transcranial Direct Current Stimulation (tDCS)
Deep Brain Stimulation (DBS), Transcranial Direct Current Stimulation (tDCS) and related kinds of stimulation involve the use of electrical current passed into the brain.
Unlike TMS, which can make neurons in the brain fire off nerve impulses, deep brain stimulation techniques are thought to shift the brain’s functioning in certain ways depending on the area of the brain stimulated. Some studies are finding positive results with OCD symptom reduction and clinical trials continue. (5)
While early results with neuromodulation are promising, understanding the use of this technology is in its early stages and most researchers suggest more study specifically related to OCD.
Where to start?
Start by going deep with your education on the symptomatology, treatment options, and other co-occuring disorders often associated with OCD. When you become an educated patient, you are more likely to find effective treatments faster. (Not to mention that many educated patients share that they save money on treatment dollars because they have a solid understanding of their own symptoms.)
Next, start building your team. Find a licensed psychotherapist who is trained in the treatment of OCD. Find a psychiatrist who treats OCD. Together you can build a treatment plan that works for you.
The most important thing to remember about OCD is that help is available and things can improve. New treatments are being developed and there are proven treatments to help reduce bothersome symptoms. It is possible to live a happy and less anxious life.
(1) National Institute of Mental Health. (2017, November). Obsessive-Compulsive Disorder (OCD).
(2) Leckman, J. F., Bloch, M. H., & King, R. A. (2009). Symptom dimensions and subtypes of obsessive-compulsive disorder: a developmental perspective. Dialogues in clinical neuroscience, 11(1), 21–33.
(3) Pittenger, C., & Bloch, M. H. (2014). Pharmacological treatment of obsessive-compulsive disorder. The Psychiatric clinics of North America, 37(3), 375–391.
(4) Skapinakis, P., Caldwell, D., Hollingworth, W., Bryden, P., Fineberg, N., Salkovskis, P., Welton, N., Baxter, H., Kessler, D., Churchill, R., & Lewis, G. (2016). A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health technology assessment (Winchester, England), 20(43), 1–392.
(5) Rapinesi, C., Kotzalidis, G. D., Ferracuti, S., Sani, G., Girardi, P., & Del Casale, A. (2019). Brain Stimulation in Obsessive-Compulsive Disorder (OCD): A Systematic Review. Current Neuropharmacology, 17(8), 787-807.