Traditionally it has been thought that there are four main categories of Obsessive-Compulsive Disorder (OCD), as well as numerous sub-types of the illness within each category. However, typically a person’s OCD will fall into one of the following four areas.
- Contamination / Mental Contamination
- Ruminations / Intrusive Thoughts
This list categories the most common forms of OCD and some of the fears associated with them. It is by no means an exhaustive list and there will always be forms of OCD that do not feature here, and obsessions or compulsions that are not listed either. However this does not mean it is definitely not OCD. Remember - if you are experiencing distressing and unwanted obsessions and compulsions, that impact significantly on your everyday functioning,this could represent a principal component in the clinical diagnosis of Obsessive-Compulsive Disorder.
Obsessive Compulsive Disorder is diagnosed when the Obsessions and Compulsions:
- Consume excessive amounts of time (approximately an hour or more).
- Cause significant distress and anguish.
- Interfere with daily functioning at home, school, or work; or interfere with social activities/ family life/relationships.
Types of OCD:
Checking - the need to check is the compulsion, the obsessive fear might be to prevent damage, fire, leaks or harm.
Common checking includes:
- Memory (checking ones memory to 'make sure' an intrusive thought is just a thought and didn't really happen).
- Gas or electric stove knobs (fear of causing explosion and therefore the house to burn down).
- Water taps (fear of flooding property and damaging irreplaceable treasured items).
- Door locks (fear of allowing a burglar to break in and steal or cause harm).
- House alarm (fear of allowing a burglar to break in and steal or cause harm).
- Windows (fear of allowing a burglar to break in and steal or cause harm).
- Appliances (fear of causing the house to burn down).
- House lights (fear of causing the house to burn down).
- Car doors (fear of car being stolen).
- Re-reading postal letters and greetings cards before sealing / mailing (fear of writing something inappropriate or offensive).
- Candles (fear of causing the house to burn down).
- Route after driving (fear of causing an accident).
- Wallet or purse (fear of losing important bank cards or documents).
- Illnesses and symptoms online (fear of developing an illness, constant checking of symptoms).
- People – Calling and Texting (fear of harm happening to a loved one).
- Reassurance (fear of saying or doing something to offend or upset a loved one).
- Re-reading words or lines in a book over and over again (fear of not quite taking in the information or missing something important from the text).
- Schizophrenia Symptoms – (fear that OCD is a precursor to Schizophrenia which will cause them to lose control).
The checking is often carried out multiple times, sometimes hundreds of times, and for hours on end, resulting in the person being late for work, dates and other appointments. This can have a serious impact on a person’s ability to hold down jobs and relationships. The checking can also cause damage to objects that are constantly being checked.
Contamination – the need to clean and wash is the compulsion, the obsessive fear is that something is contaminated and/or may cause illness, and ultimately death, to a loved one or oneself.
- Using public toilets (fear of contracting germs from other people).
- Coming into contact with chemicals (fear of contamination).
- Shaking hands (fear of contracting germs from other people).
- Touching door knobs/handles (fear of contracting germs from other people).
- Using public telephones (fear of contracting germs from other people).
- Waiting in a GP’s surgery (fear of contracting germs from other people).
- Visiting hospitals (fear of contracting germs from other people).
- Eating in a cafe/restaurant (fear of contracting germs from other people).
- Washing clothes in a launderette (fear of contracting germs from other people).
- Touching banisters on staircases (fear of contracting germs from other people).
- Touching poles (fear of contracting germs from other people).
- Being in a crowd (fear of contracting germs from other people).
- Avoiding red objects and stains (fear of contracting HIV/AIDS from blood like stains).
- Clothes (having to shake clothes to remove dead skin cells, fear of contamination).
- Excessive Tooth Brushing (fear of leaving minute remains of mouth disease).
- Cleaning of Kitchen and Bathroom (fear of germs being spread to family).
The cleaning or washing is often carried out multiple times often accompanied by rituals of repetitive hand or body washing until the person ‘feels’ it is clean, rather than someone without OCD who will wash or clean once until they ‘see’ they are clean. The time this takes can have a serious impact on a person’s ability to hold down jobs and relationships and there is also a secondary physical health impact of the constant scrubbing and cleaning on the skin, especially the hands. A person may also avoid entire places if they experienced contamination fears there previously. There is also a cost implication of the constant use and purchase of cleaning products, and also of items (especially electrical) that are damaged through excessive liquid damage.
Mental Contamination In addition to the more familiar type of contamination, that is commonly perceived to be the stereo-typical image of OCD, involving someone that washes their hands repeatedly after coming into contact with potentially dirty objects or environments, there is also a less obvious form called 'mental contamination.
The feelings of mental contamination share some qualities with contact contamination but have some distinctive features. Feelings of mental contamination can be evoked by times when a person perhaps felt badly treated, physically or mentally, through critical or verbally abusive remarks. It is almost as if they are made to feel like dirt, which creates a feeling of internal uncleanliness — even in the absence of any physical contact with a dangerous/dirty object. A distinctive feature of mental contamination is that the source is almost always human, unlike the contact contamination that is caused by physical contact with inanimate objects.
The person will engage in repetitive and compulsive attempts to wash the dirt away by showering and washing which is where the similarities with traditional contamination OCD return.
Hoarding - Another obsession long considered to be part of ‘OCD’ is the inability to discard useless or worn out possessions, commonly referred to as ‘hoarding’.
In the past it was suggested that hoarding, as a subtype of OCD, may be less responsive to treatment than other forms. However, as a result of more recent research, and due to a greater understanding of this problem, there is now significant evidence to suggest that treatment can be just as effective for this type of OCD, as with others.
Ruminations - Rumination is a term often used to describe all obsessional intrusive thoughts, but this is misleading. In the context of OCD a rumination is actually a train of prolonged thinking about a question or theme that is undirected and unproductive. Unlike obsessional thoughts, ruminations are not objectionable and are indulged rather than resisted. Many ruminations dwell on religious, philosophical, or metaphysical topics, such as the origins of the universe, life after death, the nature of morality, and so on.
One such example might be where a person dwells on the time-consuming question: Is everyone basically good?. They would ruminate on this for a long period of time, going over in their mind various considerations and arguments, and contemplating what superficially appeared to them to be compelling evidence.
Another example might be someone that ruminates about what would happen to them after death. They would weigh up the various theoretical possibilities, visualize scenes of heaven, hell, and other worlds and try to remember what philosophers and scientists have said about death.
With most ruminations it inevitably never leads to a solution or satisfactory conclusion and the person appears to be deeply pre-occupied, very thoughtful, and detached.
Intrusive Thoughts - Intrusive thoughts, in the spectrum of OCD, are where a person generally suffers with obsessional thoughts that are repetitive, disturbing and often horrific and repugnant in nature. For example, thoughts of causing violent or sexual harm to loved ones.
Because the intrusive thoughts are repetitive and not voluntarily produced, they cause the sufferer extreme distress - the very idea that they are capable of having such thoughts in the first place can be horrifying. However, what we do know is that people with Obsessive-Compulsive Disorder are the least likely people to actually act on the thoughts, partly because they find them so repugnant and go to great lengths to avoid them and prevent them happening.
Intrusive thoughts can cover absolutely any subject, but the more common areas of OCD related concerns covers the following sub- categories:
- Sexual Thoughts - Fear of:
- Magical Thinking - believing that:
- Religious - believing that:
- Violent Thoughts - fear of:
Relationship Intrusive Thoughts - Obsessive doubts over the suitability of a relationship, one’s partner or one's own sexuality are the main focus for the obsessional thoughts. Obsessional thoughts include:
- Constantly analyzing the depth of feelings for one's partner, placing the partner and the relationship under a microscope and finding fault.
- Constantly needing to seek reassurance and approval from one's partner.
- Doubts that one's partner is being faithful.
- Doubts that one may cheat on their partner.
- Questioning one’s own sexuality, and having feelings, thoughts and impulses about being attracted to members of the same sex.
The constant analyzing and questioning of the relationship and partner often places immense strain on the relationship and the result is a person with OCD will often end the relationship to rid themselves of the doubt and anxiety, which is usually often repeated with any subsequent relationship.
Sexual Intrusive Thoughts - Obsessive thoughts of unintentionally causing inappropriate sexual harm (i.e. to children) unintentionally, or the constant questioning of one’s own sexuality are the main focuses for these obsessional doubts. Obsessional thoughts can include:
- Fearing being a pedophile and being sexually attracted to children.
- Fearing being sexually attracted to members of one's own family.
- Fearing being attracted to members of the same sex (homosexual OCD) or for those who are gay fear of being attracted to members of the opposite sex.
- Thoughts about touching a child inappropriately.
- Intrusive sexual thoughts about God, saints or, religious figures.
The constant analyzing and questioning of one’s own sexual preferences, or the thought of being attracted to a child, are perhaps two of the most mentally disturbing aspects of OCD and, because of the nature of the thoughts, many sufferers are reluctant to seek help from health professionals, fearing they may be labelled.
A person that experiences these types of intrusive thoughts will avoid public places, like shopping centers, in an attempt to avoid coming into close contact with children. They may also avoid spending time with younger members of the family. For a parent with this form of the illness they avoid bathing and hugging their own children which can lead to emotional distress for both children and parent
Magical Thinking Intrusive Thoughts - is the fear is that even thinking about something bad will make it more likely to happen - sometimes also called ‘thought-action fusion’.
Sufferers are beset by intrusive bad thoughts. They try to dispel them by performing rituals - magic rituals, in effect - that are often bizarre and time-consuming and involve linking actions or events that could not possibly be related to each other. For example having the thought 'I may strangle someone' is regarded as being as reprehensible as actually strangling a person.
Another example is believing that simply imagining a horrific car crash will increase the likelihood of such a crash taking place, or a person may feel that if they don’t count to ten ‘just right’ harm will come to a family member. Other examples of magical thinking, or thought-action fusion intrusive thoughts include:
- A certain color or number has good or bad luck associated with it.
- Certain days have good or bad luck associated with them.
- A loved one’s death can be predicted.
- One’s thoughts can cause disasters to occur.
- Stepping on cracks in the pavement can make bad things happen.
- Whatever comes to mind can come true.
- Breaking chain letters will actually bring bad luck.
- Attending a funeral will bring death.
- One can inadvertently cause harm to others with thoughts or carelessness.
- Hearing the word ‘death’ will mean repeating the word ‘life’ to prevent death.
In each example listed above, the thoughts and events happening could not possibly ever be linked, but the person with OCD will believe that this possibility does exist, and as a result, this will cause them immense stress and anxiety. As a result, their silent internal compulsive behaviors will take hours, and often prevent them interacting with anyone else during this time.
Religious Intrusive Thoughts - OCD often fixates on areas of great importance and sensitivity and religion and matters of religious practice are prime candidates for OCD obsessions. Sometimes referred to as scrupulosity, religious intrusive thoughts include:
- Sins committed will never be forgiven by God and one will go to hell.
- One will have bad thoughts in a religious building.
- One will scream blasphemous words loudly in a religious location.
- Prayers have been omitted or recited incorrectly.
- Certain prayers must be said over and over again.
- Religious objects need to be touched or kissed repeatedly.
- One is always doing something sinful.
- Repetitive blasphemous thoughts.
- That the person has lost touch with God or their beliefs in some way.
- Intrusive sexual thoughts about God, saints or, religious figures.
- That the person has broken religious laws concerning speech, or dress or modesty.
- Intrusive bad thoughts that occur during prayer will contaminate and ruin or cancel out the value of these activities.
The constant analyzing and questioning of a person’s faith places immense strain on their beliefs and prevents the person deriving peace from their religion. As a result they will often avoid church and all religious practice out of fear of their thoughts.
Violent Intrusive Thoughts – obsessive fears of carrying out violent acts against loved ones or other people. Intrusive thoughts include:
- Violently harming children or loved ones.
- Killing innocent people.
- Using kitchen knives and other sharp objects (compulsion will include locking away knives and sharp objects).
- Jumping in front of a train or fast moving bus.
- Poisoning the food of loved ones (compulsion will include avoiding cooking for family).
- Acting on unwanted impulses, e.g. running someone over, stabbing someone.
- Thoughts about accidentally touching someone inappropriately, with the aim of hurting them.
Most sufferers with these types of fears often end up labeling themselves as a bad person, simply for having the thoughts. They falsely believe that having the thoughts mean they are capable of acting upon them. The constant analyzing and questioning of these disturbing aspects of OCD becomes incredibly upsetting and because of the nature of the thoughts many sufferers are reluctant to open up to health professionals to seek help, fearing they may be labelled.
A person with these types of intrusive thoughts will avoid public places like shopping centers and other places, where social interaction may be required, to avoid coming into close contact with people that may trigger the obsessive thoughts.
To sufferers and non-sufferers alike, the thoughts and fears related to OCD can often seem profoundly shocking . It must be stressed, however, that they are just thoughts, and they are not voluntarily produced. Neither are they fantasies or impulses which will be acted upon.
Symmetry and Orderliness - the need to have everything lined up symmetrically just ‘right’ is the compulsion, the obsessive fear might be to ensure everything feels ‘just right’ to prevent discomfort or sometimes to prevent harm occurring (see Magical Thinking). Examples include:
- Having everything neat and in its place at all times.
- Having pictures hanging aligned and straight.
- Having canned food items all facing the same way, usually forward.
- Having clothes on the rail all hanging perfectly and facing the same way.
- Having everything spotless, with no marks or smudges on windows and surfaces.
- Having books lined up perfectly in a row on a bookshelf.
Sufferers spend a lot of time trying to get the symmetry ‘just right’ and this time consuming checking can result in them being extremely late for work and appointments. They may also become mentally and physically drained if the compulsions take a considerable amount of time. The sufferer may also avoid social contact at home to prevent the symmetry and order being disrupted which can have a negative impact on social interaction and relationships.
This above list categorises the various common forms of Obsessive-Compulsive Disorder and some of the fears associated with them. However, it is not an exhaustive list and there will always be forms of OCD that are not listed. However, the following three components are generally present whatever the theme, avoidance, triggers and reassurance.
Avoidance is a common compulsive behaviour, and this is where a person with OCD will go to great lengths to avoid the objects, places or person/people that that they feel triggers their OCD. This will be their way of preventing the distress and anguish, and the hours of rituals they will be compelled to perform.
Examples include those with checking compulsions that may avoid tasks or situations that will increase their sense of responsibility and/or might be unsafe. A person who had the obsessional thought that they might stab their children went to great lengths to avoid contact with knives, scissors, and other sharp objects. A person, who feared that they might catch AIDS/HIV, totally avoided certain areas of London which was, in their mind, associated with AIDS/HIV. In some cases, certain 'unsafe' numbers, letters, or colors are avoided because the person feels that such avoidance is necessary in order to avert some disaster, usually to a loved one.
Trigger - Although not technically a type of OCD, a trigger is a place, person or object that sets off an obsession, a feeling of discomfort, or indeed a compulsive urge.
A trigger may be a physical object or an internal mental thought. For example, a person had the obsessional thought about stabbing someone every time they saw a knife or any other sharp object, so seeing the knife was the trigger that provoked the obsessions and compulsions. In order to to avoid hours of anguish this person would avoid knifes at all costs. An example of an internal mental trigger is where a person experienced distressing obsessions about death every time they thought about their deceased father. The memory of the father was the internal trigger for the obsessional thoughts.
What generally happens is a person with OCD will find their obsessions and compulsions so frightening, scary and mentally and physically draining, that they will go to great lengths to avoid triggers that instigate hours of obsessions and compulsions.
There are several terms and acronyms used within the OCD community and among health professionals which often lead to confusion. One such term is the word ‘ritual’ which some people, even health professionals, confuse and refer to as a ‘compulsion’. Whilst it is true that a ritual is a compulsive behavior (physical or mental), it is not just a specific compulsive behavior, it is more a set pattern of behaviors with a clear defined starting point and end point to complete it. For example ‘rub left side of face first, and then right side of face, then forehead’. In many cases if the sufferer is interrupted during the ritual then their OCD will dictate they must start the ritual again from the very beginning.
Acronyms - HOCD, POCD, ROCD: Some sufferers use acronyms to refer to their type of OCD. It is worth noting that these acronyms have no official medical meaning and have often been confused to mean different things to different people, for example, ROCD can be religious OCD or relationship OCD and POCD could be postpartum OCD or pedophile OCD, depending who you ask.
This confusion leads to delays in treatment where a person will seek specialists in POCD but are unable to find any, as POCD is not a medically recognized term. It is also possible that thinking of the illness to be something other than Obsessive-Compulsive Disorder (OCD) may also hinder progress in understanding and tackling the illness, especially if the OCD later changes guise chameleon-like.
For informational purposes the acronyms are commonly understood to refer to:
- HOCD – Homosexual OCD
- POCD – Pedophile OCD (but also widely used to describe prenatal and postpartum OCD)
- ROCD – Relationship OCD
The term ‘spike’, is also incorrectly and confusingly used by the OCD community, mainly across OCD message boards on the internet.
There seems to be two main uses of the term. The first is when it is used to describe the initial obsessional trigger, which then causes the anxiety and distress. So for example, someone afraid of harming a loved one will use the term ‘spike’ to refer to the knife they see which then triggers their obsessions and compulsions.
Another use for the term ‘spike’ in an OCD context is when it is used to describe the increase in anxiety caused by the obsessional thoughts. So in the example above, the person afraid of harming a loved one will see the knife, which causes their obsessive thoughts to increase (spike) their anxiety.
At present there is no official definitive explanation as to what the term ‘spike’ actually means, but the general consensus is that the term ‘spike’ is used to describe the combination of the OCD trigger, obsession, and distress caused by the anxiety.
For this reason, and to avoid any confusion, we generally believe the term ‘spike’ is perhaps a term to refrain from using. Rather it would be better to explain in detail your specific concern or problem, to ensure there is no loss of meaning or context. This is especially important in the patient-therapist relationship.