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The 4 types of OCD

It is critical to note that there will never be a definitive list of OCD types. In fact, according to clinical psychologist, OCD specialist, and survivor Dr. Jenny Yip, it typically takes 17 years for someone to get the proper diagnosis because they can have symptoms other than the four types described in this article.

The four dimensions (or types) of OCD discussed in this article include;

  • pollution
  • perfection
  • doubt/harm
  • forbidden thoughts

However, additional types include:

  1. OCD staring
  2. OCD relationship
  3. existential OCD

Also, different manifestations of OCD appear as the world changes. As the world adjusted to COVID-19 and underwent major social changes, such as the Black Lives Matter movement, existential OCD emerged.

When you question your beliefs, magnify the problem, avoid the problem through a repetitive compulsion, experience relief, and then interfere with your livelihood – you may be experiencing OCD symptoms. It’s complicated, but understanding this is the first step in realizing that you may be experiencing OCD symptoms and not something else, and there are treatments that work.

Obsessive-compulsive disorder (OCD) is a term that is thrown around quite casually these days. Do you recognize any of these?

Do you like your cabinets arranged like this? “I’m OCD!”

Double check, or even triple check, your locks? “You’re so OCD!”

“OCD” has become our popular parlance as a sort of catch-all phrase to describe anyone who seems too focused on doing things “right.” Are you living with OCD?

Probably not.

OCD is more than neatly organized wardrobes, checking or rechecking locks, or even frequent handwashing. There is much more.

What is OCD?

OCD is a specific neuropsychiatric anxiety disorder that causes a person to experience recurrent, uncontrollable thoughts (obsessions) and/or behaviors (compulsions) that they feel the need to repeat over and over again.

The role of the behavior is to decrease the distress or anxiety related to the triggering experience.

Over time, this stimulus-response becomes trapped in a pattern or loop of behavior that repeats itself over and over again.

Repetitive handwashing is an iconic example of an OCD-type loop. Handwashing is just one component and visible result of a perceived trigger or obsession, in this case often “contamination” of some sort (real or imagined).

OCD is not rare.

In fact, according to the National Institutes of Health, OCD affects approximately 1.2% of the US population and approximately 2% of the general population worldwide. OCD has been documented in both children and adults. The incidence is slightly higher for women (1.8%) than for men (0.5%). (1)

Contrary to popular belief, OCD is not a single symptom, but rather a collection of obsessions and compulsions that occur along a continuum.

There are some common themes in these thoughts and behaviors.

People living with OCD may experience obsessions, compulsions, or both. But first, let’s talk about the different components of OCD.

What are obsessions and compulsions?

Obsessions are repetitive, intrusive thoughts, impulses, or mental images that create anxiety and distress. Some of the more common obsessions include:

Fear of contamination or germs.
symmetry and balance
Forbidden or taboo thoughts involving things like sex or religious practices
Aggressive/impulsive thoughts towards oneself or towards others.
Compulsions are repetitive behaviors that a person with OCD feels compelled to do in response to their obsessive thoughts. Some more common compulsions include:

Excessive handwashing or bathing
Organize, count, or stack things accurately
Check and recheck things like excess door locks
counting rituals
Now, these behaviors alone do not suggest OCD. In fact, most people have some of what we might consider compulsive behaviors, but that doesn’t make a diagnosis of OCD.

When is OCD?

People who have disorders like OCD experience a significant set of distressing consequences from their symptoms.

To receive a diagnosis of OCD, a person must meet a specific set of criteria defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).

Some of the hallmarks of more than just peculiar behavior include:

Attempts to control or neutralize distressing thoughts, impulses, or behaviors are unsuccessful
Too much time is spent engaging in obsessive behaviors and compulsive.

There is no pleasure in the time spent on these activities, but there is brief relief from the anxiety they cause.
Obsessions and compulsions cause significant impairment in social, occupational, or interpersonal functioning.
Additionally, 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 many pieces. Simply calling it OCD doesn’t tell the whole story.

The four dimensions (types) of OCD.

when we talk about OCD, we’re not just talking about the presence of obsessions, compulsions, or both, we’re also talking about the focus of those symptoms.

Symptoms tend to fall into four general categories, called symptom dimensions, which include both obsessions and compulsions. (two)

These dimensions are similar to looking at the different sides of a TOC box. They are not mutually exclusive. It can have elements of one or more dimensions. Each combination of symptoms is unique.

Pollution 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 that are considered “risky” for contaminant exposure. Some of the more common protection rituals include:

  • Disinfection and sterilization, excessive cleaning
  • Excessive handwashing
  • Throwing away objects believed to be contaminated or sources of contamination
    Frequent clothing changes
  • Create “safe” or “clean” zones

These rituals provide temporary relief from the perceived risk of exposure to contaminants and germs.

People whose symptoms fall on this dimension have an overwhelming concern with order and making something “perfect.”

They will spend excessive amounts of time moving around, counting, and arranging things to relieve or prevent distress. They may also have specific superstitions about numbers, patterns, and symmetry.

These rituals are sometimes linked to magical thinking (ie the belief that something bad will happen if something isn’t “right”).

Some of the commonly seen behaviors include:

  • A need for items to be organized 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)
  • Arrange items until they feel “just right”
    counting rituals

Magical thinking, or believing that something bad will happen if things aren’t “right”
Organization rituals or superstitions about the arrangement of objects
Excessive attachment and hoarding of certain items.
The endless pursuit of perfection can be physically and mentally exhausting. The person may avoid social contact at home to prevent symmetry and order from being disrupted. This can have devastating effects on relationships.

This is the dimension of checking and checking again.

People with obsessions in this dimension tend to experience intrusive thoughts, images, or impulses related to the fear of inadvertently harming themselves or another person due to carelessness or negligence.

A common example is leaving the gas stove on before leaving home, possibly starting a house fire. Along with your fear of accidental harm, there is also often an overwhelming feeling of doubt or fear and of being responsible for what may happen.

Some of the common behaviors you may see are:

Check and recheck things like door locks, stoves, windows, light switches, etc.
The check may include a symmetric component of checking a specified number of times
Repeatedly reviewing daily activities or retracing steps (mentally or physically) to make sure no one has been harmed

This dimension of the symptom 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 purely obsessive (thought-based).

In fact, people with this type of OCD engage in behavioral rituals to deal with these unwanted thoughts. These rituals tend to be covert and consist of mental compulsions and quests for 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 that you act on intrusive thoughts or that having them makes you a bad person
Obsessions about religious ideas that feel blasphemous or inaccurate

Participate in mental rituals to dispel or cancel disturbing thoughts. Some of these rituals may include:
Neutralize thoughts by mentally canceling negative thoughts with positive ones or excessive praying
Excessive checking behavior or reassurance seeking.
Avoidance of situations perceived as triggers of thought.
It should be noted that, despite the nature of their thoughts, people with this type of OCD do not usually have a history of violence, nor do they act according to their thoughts or impulses.

However, they often believe that their thoughts are dangerous and spend a lot of time and mental effort suppressing them.

What can be done for those living with OCD?

Fortunately, there are many evidence-based treatment options for those living with OCD.

If you’re living with OCD, you’ve probably tried to resist urges and spent an inordinate amount of time trying to control symptoms with varying degrees of success.

You’re not alone.

It is estimated that of the total number of adults with OCD, around 50% have what It would be considered a significant deterioration. Another 30% report moderate difficulty. (1)

The good news is that OCD is a highly treatable disorder. Medications, specific types of psychotherapy, and even some new technologies mean relief is possible for many people dealing with bothersome symptoms.

While there is no single pill to treat OCD, there are medications that have been shown to help. It is estimated that the medication can provide relief to around 40-70% of people. (3)

Selective serotonin reuptake inhibitors (SSRIs) are usually the first-line option for the pharmacological treatment of OCD. These antidepressant medications have been shown to effectively reduce OCD symptoms in many people with few significant side effects.

Fluvoxamine (Luvox) was one of the first SSRIs to be shown to be effective, but research has found little difference in effectiveness between SSRIs. Which one to choose may be based more on the potential for side effects, potential drug interactions, patient preference, and other considerations. (3)

Psychotherapy.

Research shows that certain types of psychotherapy, including cognitive behavioral therapy (CBT) and related therapies (eg, habit reversal training), can be as effective as medication for many people.

A specific type of CBT known as Exposure and Response Prevention (ERP) has been shown to be particularly effective in treating OCD. (4)

Exposure refers to being exposed to (ie spending time in) the thoughts, images, objects, and situations that make you anxious and trigger your obsessions.

Response prevention refers to making the decision not to engage in habitual compulsive behavior once the anxiety or obsessions have been “triggered.”

Initially, this process takes place during sessions with a trained psychotherapist. Over time, the person learns to do this on her own. ERP has been found to reduce compulsive behaviors in OCD, even in 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 in addressing some of the social and personal issues that can accompany living with OCD, symptom reduction requires specific interventions such as ERP.

Neuromodulation

New treatment modalities are 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 treatments for various mental health problems, including OCD.

While not yet available, there are a number of ongoing clinical trials and studies.

The 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 to 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 useful in reducing the abnormal brain excitability seen in OCD. (5)

Deep brain stimulation (DBS) and transcranial direct current stimulation (tDCS)
Deep brain stimulation (DBS), brain stimulation

Transcranial direct stimulation (tDCS) and related types of stimulation involve the use of electrical current passed to the brain.

Unlike TMS, which can cause neurons in the brain to fire nerve impulses, deep brain stimulation techniques are thought to change brain function in certain ways, depending on the area of ​​the brain stimulated. Some studies are finding positive results in reducing OCD symptoms, and clinical trials continue. (5)

While early results with neuromodulation are promising, understanding of the use of this technology is in its early stages and most researchers suggest further studies specifically related to OCD.

Where to start?
Start by deepening your education about the symptomatology, treatment options, and other co-occurring disorders that are often associated with OCD. When you become an educated patient, you are more likely to find effective treatments faster. (Not to mention, 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 create a treatment plan that works for you.

The most important thing to remember about OCD is that help is available and things can get better. 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.

References:

(1) National Institute of Mental Health. (2017, November). Obsessive-compulsive disorder (OCD).

(2) Leckman, J.F., Bloch, M.H., and 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. and 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. and Lewis, G. (2016). A systematic review of the clinical efficacy and cost-effectiveness of pharmacological and psychological interventions for the treatment 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.

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