Understanding Obsessive Compulsive Disorder: Part 2

In this post, I am going to describe some of the “forms” or configurations of Obsessive Compulsive Disorder (OCD). A bit like looking at buildings from a distance. You can clearly see they are different but if you get up close you can see lots of unique detail. The first post was looking at buildings from an airplane (so to speak) so you only see major differences. In this post it will be closer but there is just no way to cover every detail. If you want a pretty thorough checklist of most details you can take a look at the checklists found here. (You will have to go to the bottom of the page and click on the link OCD evaluation forms.) I use these checklists in my office to make sure I am getting a comprehensive picture.

As I mentioned previously, where there are obsessions, there are always compulsions. An obsession is thoughts about something feared. A compulsion is the attempt to escape, minimize or fix that fear.

Obsession = possible danger/threat

Compulsion = attempt at possible safety

There are exceptions to any rule but the following are more common versions of OCD. I am always amazed at the clever variations there are with OCD. In the last year or so I have seen around 50 patients with OCD or something related. I still hear details that are unique. Not different from the pattern, just unique to the person. Nevertheless, following are frequent variations. I didn’t come up with these categories but I have long since forgotten where I got most of my ideas. At the bottom I will list a couple books that I know had much to do with my thinking on this and I am indebted to them.

(Please don’t use this to diagnose someone, even yourself. This is just a general guide to help you understand what might be going on with your child and if needed, to get some help for him or her.)

Types of Compulsions

Keep in mind there could be more than one obsession and even with one primary obsession, all kinds of compulsions. These can be external or internal. Sometimes people think if it is in your mind then it is an obsession and if it is a behavior it is a compulsion. Obsessions are mental fears but compulsions can be both mental and behavioral. Following are brief summaries of types of compulsions, sort of like a glossary. After discussing each obsession I will give some examples of compulsions that would be typical ways to respond to an obsession.

• Avoiding – This is the broad general category that all compulsions fit under. It is an attempt to escape, prevent or fix something deemed dangerous or threatening.
• Decontaminating – This involves actions that remove or minimize “dangerous” substances or ideas. I prefer decontaminate to cleaning because it may not always involve what most people would consider cleaning.
• Checking – This is the act of making multiple attempts to confirm if something did or did not happen. Would be better to call it double, triple, etc., checking. Often goal is protection or protecting. It usually involves repeating something until it is right.
• Undoing – This is an attempt to reverse, counteract or neutralize a thought or action.
• Organizing – This can be a focus on symmetry or arranging things in a way that removes distress. Evenness or exactness can be features.
• Perfection – Desire for truth, no visible flaws, or a level of moral purity that is extremely exacting (called scrupulosity).
• Counting – Focus on numbers, can be good number or bad numbers, or urge to count things or do things a certain number of times. Words can be used the same way.
• Moving – This involves moments like touching, walking a certain way, balancing one movement with another movement. Very similar to symmetry.
• Figuring Out – This is very sneaky compulsion. Involves researching (usually means searching the web), learning as much as possible, studying problem or own thoughts to prove or disprove something.

Obsessions about contamination

Fear of getting or giving a contaminant is the most frequently occurring obsession. Usually this is some sort of germ, virus or dirt. It can be something potentially dangerous like poisons (stuff under the kitchen sink is often the object of fear), radiation, medications, sharps, drugs, and more abstractly, things like asbestos, lead, mercury. It isn’t always a material or physical thing. For example, it can take the form of a moral contamination. For example hearing or seeing something “inappropriate” might be felt as a contamination. In that case the “thought” is contaminating. Often in kids you won’t be able to tell what exactly is feared particularly when it is more abstract like moral contamination but you will probably see the related compulsions. Often it is embarrassing to disclose the fear or just saying the words could “cause” contamination. The fear may be about personal contamination, a concern about contaminating someone else or both. The fear could lead to illness or death in the imagined scenarios.

Related Compulsions

Decontamination – Extreme cleaning like handwashing, long showers, rules about laundry are very common. Other examples might be using gloves, tissues, and disinfectants. Can be lots of questions about whether something is contaminated or not or insisting that family members “decontaminate” can be examples. A lot of compulsions can be done privately depending on the child’s age. What you will notice is really long amounts of time in the bathroom, rapid use of soap, excessive use of towels or paper products.

Avoiding: Avoiding touching things that could be contaminated. You might notice unusual mannerisms like keeping the hands away from the body or using sleeves or elbows to open doors. Avoiding walking in certain areas, avoiding chairs, rooms, or items like toys or electronics are frequent compulsions. Bathrooms and Kitchens are most often areas of fear.

Checking: If food is the issue checking expiration dates or making sure container is undamaged can take place. This is harder to see but a kid can be scanning for contaminants so you might notice periods of hypervigilance. The goal is to either avoid the contamination all together or if that is impossible to make every effort to remove or minimize the contaminant.

Sometimes parents get confused because their child’s room is a total mess or there are clearly dirty things around. It is all about what is a contaminant and it can be very specific. Dirt may not be a problem at all but a possible poison could be the focus. Or the things all over the floor might be contaminated and touching them is avoided.

Obsessions about harm

These are thoughts and fears about someone or something being harmed. Sometimes these thoughts can be very troubling and even violent. They can range from fear of a parent having cancer to fear that a pet will chew on a cord and be electrocuted. Sometimes these can be hard for kids to say out loud because of the reaction they might get or the fear that saying it might make it “happen”. Kids are not always able to explain the thoughts. Sometimes parents may worry that their child intends to harm him or herself or someone else. The key to look for is whether the thoughts are distressing, as in, “I don’t want to have the thoughts.” “The thoughts freak me out.” “I don’t want this to happen.”

Variations could be thoughts of harming people intentionally, harming accidentally, or going crazy and harming others. The thoughts can be repulsive, violent, or gruesome. Kids can be afraid of someone else’s thoughts impacting or controlling them. Keep in mind these thoughts are intrusive and unwanted. Less aggressive versions might be getting rejected, blurting out obscenities, insulting people or making obscene gestures. Also, property could be damaged or lost, causing anxiety. Important information could be forgotten causing offense. Often kids with this are afraid that just having the thoughts might “cause” bad to happen or that the thoughts mean they are a terrible and dangerous person.

Related Compulsions

Checking: Checking is just what it says. Probably a better description is massive, multiple and frequent checking. Everyone might double-check if they locked the door or turned off the water. If a driver is afraid he or she may have accidentally hit someone the driver could circle back many times checking for accidents or bodies. However, as with all OCD symptoms it is VERY excessive. Examples are:

• Security Related: doors, windows, etc. Making sure appliances, faucets, lights are off. Flames are out. Pets are safe.
• Harmful objects: Location of sharps, poisons, and stairs are blocked if baby in house.
• Avoiding mistakes: checking texts and emails over and over. What is read, may involve reading re-reading. Check writing for obscenities, faces for evidence of offending.
• Reassurance: Asking about health and safety and wanting to know if everything is okay.

Undoing: If fear is about thoughts then it might involve neutralizing with other thoughts, scanning memory for information, intense distraction, etc. Violent or harm thoughts are compulsively replaced with “good” thoughts and thoughts can be replayed over and over to make sure nothing bad was included. There can be formulas like five good thoughts counter one bad thought. Memories can be played backwards in attempts to undo them.

Organizing: making sure the environment is safe. Example would be to remove or secure things that could trip someone for example. The environment can be scanned to sharp objects like glass, needles, or nails.

Avoiding: Warning others about potential dangers as well as avoiding personally. Blocking access or covering up anything deemed dangerous.

Obsessions about Religious Matters

Of course, this is related to one’s personal beliefs or in the case of a child it might be the family’s beliefs. The fear often centers on worries about being offensive, rejected, or disliked by God or under control of an evil force. This can be over acts of commission or omission. (I usually see clients where this fear is connected to the Christian faith and my examples reflect that but it can be connected to any religious beliefs.) For example, kids who are Christians or whose family is Christian, the fear might be about committing the unpardonable sin or having to get “saved” over and over to make sure it was done right. Doubt is a very strong feature with this obsession. It may involve unacceptable thoughts about religious figures, fear of acting sinfully, fear of choosing to act sinfully, desire to be perfectly religious, being possessed or controlled by evil or going to hell. Children might ask for lots of reassurance or want to talk about the same spiritual issues over and over. Things that might be morally troubling are avoided or upon exposure there can be intense anxiety. Related to this is something called scrupulosity. Scrupulosity is a name for extreme moral standards. Kids can feel responsible for a parent’s mood or the moral behavior of classmates. It might be that every word has to be exactly true and unambiguous. This is so hard that sometimes it leads to abbreviated talking or extreme care/complications in speaking. For example, one kid would hear something “inappropriate” and took 3 sessions to tell me one of the most harmless words. She was afraid that just repeating it would lead to overwhelming guilt. I am not sure she used the word guilt; it was just an awful feeling.

Related Compulsions

Figuring Out: studying or finding out about troubling concerns like being saved, what is blasphemy, what is required for fully satisfying religious requirements like dietary laws.

Checking: repeating prayers, multiple responses to pray the prayer of salvation or multiple responses to altar calls. Extreme checking to make sure one food has not been in contact with another food (ex. milk and meat). Rethinking prayers to make sure the wrong thing was not said. Kids can try to remember things perfectly and replay events over and over in their minds.

Counting: numbers might be avoided or preferred. For example, the number 666 might be avoided including the number 6 alone or in multiples.

Undoing: frequently there is a lot of bargaining or attempts to prove one’s loyalty to God or “feel” safe with God. If during prayer there is a “bad” thought then there can be attempts to counter it with good thoughts, confession or acts of service.

Obsessions about Bad Luck

These are like superstitions on steroids. In my experience this is commonly fear of certain numbers. There are usually a lot of rules with this. There are probably favorite numbers as well. Failure to avoid the numbers could lead to something bad happening. There can be bad luck words as well. Additionally, the obsession can be fear of having bad luck, things causing bad luck, actions causing bad luck, colors and contact or association causing bad luck. Others, places and situations seen as unlucky could be avoided.

Related Compulsions

Avoiding: Making sure that things don’t happen in specific numbers. For example, if the bad luck number is 5 then stopping a book on page 5 would be avoided. If there are 5 stairs in the house a tread my be skipped or stepping on a tread twice might be added.

Counting: Things can be organized mentally based on numerical values. Actions, things, and thoughts are counted. A child may be doing math in their mind in order to reduce anxiety. Urge to count without specific reason.

Moving: The classic don’t step on a crack or a variation could be involved. Certain movements can be thought to prevent or cause a problem. Steps could be repeated or reversed by backing up.

Obsessions about Health and Body

Hypochondria is considered by many to be a type of OCD. It is hyper-vigilance about one’s health. It is often a fear of an undiagnosed illness like cancer. It is often hard to distinguish this from contamination fears. In kids, I frequently see this fear specifically related to some aspect of eating, digestion, vomiting or evacuation. It might be connected to choking, gagging and most commonly throwing up. Sometimes kids are afraid they will have to go to the bathroom and won’t make it in time. Another variation of this has to do with fears about physical appearance or shape. The fear might be that parts of the body are ugly, disfigured or the wrong size. It could be that a body part doesn’t work right. It could be obsessing that some part of the body is asymmetrical. Some kids are extremely bothered if clothing doesn’t fit just right.

Related Compulsions

Decontamination: Any potential sickness-causing situation, thing or person can be decontaminated if possible and avoided if not.

Checking: Checking with parents to see if parent thinks child is okay. Asking to have temperature taken or forehead felt for temperature are examples. Scanning body for physical symptoms is common. Checking for flaws in the mirror like blemishes. Repetitive movements to see if body part is okay. Checking for physical symmetry. Making sure food is certain quality or is not expired. Frequent requests for medical appointments to get expert to check.

Avoiding: Often results in school refusal. Lots of dietary limits, only certain foods acceptable. People that are ill may be avoided. Some kids will even seem to have an eating disorder because of restricted eating but they are trying to avoid anything that would make them sick.

Obsessions about Sexuality

I am directing this post toward parents with younger kids so because this is less common, certainly not impossible, I will only make a few comments. For obvious reasons, these thoughts are more common around and after puberty. All these fears attack a core value. In the case of sexual fears, the fear takes the form of being something that would make a child fear they are bad or perverted or would be perceived that way. It can be a fear of acting or being sexual in ways contrary to values. It might include forbidden or perverse thoughts such as sex with younger children, animals, or religious figures. It can take the form of a fear of gender identity confusion or acting out. In adults and older kids the fear may include a pseudo sexual arousal. While thinking of the terrifying thoughts, muscles in the genital area are tensed giving a sensation that is feared as “evidence” of arousal. This becomes part of the fear cycle.

Related Compulsions

Undoing: Attempts are made to suppress, counteract or replacing the thoughts with something else. This could involve a lot of confession or asking for forgiveness.

Figuring Out: Checking online to see if something is arousing or not. Researching to determine how someone can tell if they are gay or have some other sexual problem.

Checking: Scanning one’s body for signs or arousal.

Avoiding: Avoiding looking at genitalia or anything that could be arousing. Avoiding people or places that could cause feared action

Obsessions about Perfection

Other than contamination, I think this variation of OCD gets mentioned the most in the media. It seems to be the one most joked about. I remember as a young man the show, The Odd Couple, and this was a feature of one of the main characters. Common variations are keeping possessions or space perfect. The OCD version of this is not just a preference for order or cleanliness. As with all these examples the symptoms are very extreme. If something messes up or prevents this from happening the reaction will be intensely emotional. Putting things in order or making things symmetrical is another example. Wanting to have a “perfect” appearance or schoolwork done without wrinkles or marks might be how it presents. Getting less than perfect grades cause extreme distress. There might be resistance to using anything that is not perfect. Certain variations of this I have already listed as scrupulosity or body related concerns.

Related Compulsions

Perfectionism: Keeping possessions in unused or “perfect” condition. Only buy items that are deemed perfect. Laundry must be done certain way. Possession’s kept neat and clean. Making sure communication is perfect. Rereading to make sure there is perfect understanding. Schoolwork is repeated until it deemed perfect. Marks or wrinkles on papers could cause them to be redone or rejected.

Organizing: Notebooks and book bags can be exceptionally neat. Others are not allowed to touch for fear things will be messed up. Things are ordered and arranged in specific ways. Clothing has to be perfect. Could involve mental organizing. Things must be memorized or ordered in certain ways.

“Just Right” OCD and Disgust

I want to mention a couple areas that are slightly different from the way OCD usually presents. In the previous categories the obsessive thoughts are anxiety provoking. There is some feared consequence that could happen. For example, one young client was obsessed with the baby gate because he was afraid it would be left open and his younger brother would fall. “Just Right” OCD is different. When something is not right there is a great deal of distress but there is nothing bad that will happen if for some reason it can’t be made right. For example, sometimes kids will react extremely to how clothing feels. Nothing terrible will happen, it just feels bad. If something isn’t perfect it may not mean calamity, it just isn’t comfortable. Similarly, disgust may not always have a feared outcome. For example, a child might freak out when seeing a wart. However, the child isn’t imagining being covered in them, they just feel disgust. Essentially, these are treated in the same way but they are not characterized by a fear of a catastrophic outcome.

Resources:

Grayson, J. (2003). Freedom from obsessive-compulsive disorder: A personalized recovery program for living with uncertainty. New York: Jeremy P Tarcher/Putnam.

Abramowitz, J. (2006). Obsessive compulsive disorder. Cambridge, MA: Hogrefe & Huber.