Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) affects approximately 1% of the population, yet it is often undiagnosed or untreated. Research estimates that on average, it takes 14-17 years for a person to be properly diagnosed and treated. OCD symptoms are often misunderstood by other treatment providers and the general public. It is common for a person to reach out to an OCD specialist after having researched their symptoms either for the first time, or after an unsuccessful treatment attempt.

Obsessions are intrusive and unwanted thoughts, images or sensations that are typically “ego-dystonic,” or out of line with a person’s identity and value system. Compulsions are performed in an effort to reduce discomfort and uncertainty, and can be overt or covert. “Pure O,” or Pure Obsessional OCD, is a term used to describe a presentation of OCD in which obsessions are identifiable, but compulsions are mainly or solely mental. Mental compulsions may involve reviewing, checking, evaluating, or predicting different thoughts, images, sensations or situations. This makes it challenging to identify which thought processes are compulsive.

Once thought to be a treatment-resistant disorder, OCD can be isolating and frustrating to live with if a person does not have the skills to manage symptoms. Fortunately, research studies have repeatedly demonstrated that Cognitive Behavioral Therapy (CBT) and Selective Serotonin Reuptake Inhibitors (SSRIs) are efficacious treatments that can lead to significant symptom reduction. For more information on medication for OCD, please visit the International OCD Foundation’s website and consult with a psychiatrist.

There can be several barriers to seeking treatment, including guilt, shame, fear, and doubt. It is important to know that you are not alone, and it is possible to find a trustworthy clinician to guide you through the treatment process. I have worked with hundreds of clients who have presented with a variety of “themes,” including the following:

Relationship OCD

Relationship OCD is not only limited to romantic relationships, but may also include family members, close friends, or other loved ones. Depending on the nature of the relationship, obsessions may revolve around topics such as compatibility, attraction, and strength.

Common obsessions:

  • What if I don’t love my partner enough?
  • What if my lack of frequent excitement is a sign that we’re incompatible?
  • Why did I notice or feel attracted to that other person?
  • Why did I imagine myself being with someone else?
  • Why am I noticing my partner’s flaws?
  • What if I’m stringing my partner along, and I end up causing serious emotional harm?

Common compulsions:

  • Checking to see if you “feel” in love
  • Mentally reviewing past interactions to assess whether you feel “excited” enough when you are with your partner
  • Neutralizing thoughts about people other than your partner
  • Mentally checking whether you are truly bothered by your partner’s flaws
  • Asking others for reassurance about the “rightness” of your relationship
  • Confessing obsessions to your partner or others
  • Breaking up with your partner to “get it over with” or rid of anxiety

Sexual Orientation OCD

Sexual Orientation OCD involves obsessions about any aspect of a person’s sexual identity.

Common obsessions:

  • What if I’m wrong about my sexual orientation?
  • What if I’m not actually gay/bisexual/heterosexual?

  • What if there were signs of my “true” sexual identity earlier in life?
  • What if I was aroused when I just saw that person?

  • What if I lose attraction or love for my partner ?

Common compulsions:

  • Checking for evidence of arousal (sometimes tested during sexual activity or when watching pornography)
  • Mentally reviewing dating/sexual history to evaluate potential “evidence”

  • Excessive research regarding sexuality in order to gain reassurance
  • Asking others for reassurance about one’s sexual identity

  • Avoiding media or people for fear of becoming aroused or experiencing intrusive thoughts, images, or sensations

Harm OCD

Harm OCD can manifest in several forms, including fears of engaging in self-harm, harming others, and emotional harm. These obsessions can be difficult to disclose to others for fear of being misunderstood or facing legal consequences.

Common obsessions:

  • Why did I just have a flashing image of hurting that person?

  • Why did I feel the “urge” to hurt myself/that person?

  • What if I’m experiencing depression and become suicidal?

  • Does my lack of excitement or contentment mean that I don’t want to live anymore?

Common compulsions:

  • Avoiding objects that could be used as weapons against oneself or another person

  • Avoiding TV, movies, music, etc. that depict or mention anything related to physical harm or violence for fear of intrusive thoughts

  • Checking in to see if there is an “urge” to cause physical harm

  • Mentally reviewing conversations to see if emotional harm was caused

  • Researching whether you exhibit traits of someone who is likely to commit crimes

Pedophilia OCD

Pedophilia OCD symptoms are often difficult to share with others, as there is a fear of being prematurely judged or misunderstood. Simply put, a person fears that they are exhibiting signs of being a pedophile. Though most people would agree that pedophilia involves attraction towards those who are under 18, people with this theme may have different perceptions of what it means to be a pedophile.

Common obsessions:

  • Why did I notice that child is cute?

  • Why do I feel anxious around children/teenagers?

  • What if that person I found attractive is actually under 18 even though they look like an adult?

  • Why was I attracted to someone who was younger than me when I was in high school?

  • Why do I enjoy “immature” things (e.g. Disney movies)?

Common compulsions:

  • Checking for physical arousal

  • Assessing whether anxiety is a sign of something more nefarious

  • Mentally reviewing or researching for clues that could reveal the person’s real age

  • Mentally reviewing memories of grade school to see if there was any “evidence” of pedophilia earlier in life

  • Assessing whether one’s emotional “immaturity” could be another sign

Sensorimotor OCD

Sensorimotor OCD typically involves a preoccupation with different bodily functions and sensations, such as breathing, swallowing, or blinking.

Common obsessions:

  • What if my breathing/blinking/swallowing never returns to normal?

  • What if I can never fully focus on anything else because of my breathing/blinking/swallowing?

Common compulsions:

  • Attempting to “normalize” or regulate one’s breathing/blinking/swallowing

  • Avoiding any triggers that could throw off one’s breathing/blinking/swallowing

  • Mentally checking to see if the breathing/blinking/swallowing is “normal” or still bothersome

Real Event OCD

Real Event OCD symptoms typically involve repeatedly revisiting a particular event from their past for a variety of fear-based reasons. These can include fear of having caused harm without realizing it, being accused of a crime, or being responsible for something that violates one’s value system.

Common obsessions:

  • Why did I remember or think of that new detail?

  • Why did I have an image of myself doing that?

  • Maybe someone will accuse me of having done something terrible

Common compulsions:

  • Mentally reviewing the past event to make sense of it

  • Neutralizing the image or checking to see if the image seems realistic

  • Asking others for reassurance regarding the past incident

  • Confessing to others, including authority figures

Moral Scrupulosity OCD

Moral Scrupulosity OCD symptoms involve frequently questioning one’s moral character. Symptoms vary depending on a person’s value system and beliefs. Though it is reasonable to try to make ethical and moral decisions whenever possible, a person exhibiting symptoms of moral scrupulosity will feel incredibly distressed when they believe they have missed the mark or forgone an opportunity altogether.

Common obsessions:

  • What if I’m a terrible person for having this thought/image/sensation?

  • What if my loved ones would disown me if they knew this about me?

  • What if I was just dishonest?

Common compulsions:

  • Mentally reviewing and checking to see if one has acted immorally

  • Punishing oneself (e.g. isolating from others)
  • Asking others for reassurance, excessively apologizing or confessing what you consider to be immoral about yourself

Contamination OCD

Contamination OCD symptoms have been more widely discussed and represented in the media, but that does not detract from how distressing they can be. Once a person believes they are contaminated, they are likely to engage in overt compulsions to rid of feelings of disgust.

Common obsessions:

  • What if my hands are contaminated after touching that?

  • What if I start contaminating the rest of my environment?

Common compulsions:

  • Excessive handwashing

  • Avoidance of anything that is considered contaminated 
  • Mentally reviewing what you may have touched


Cognitive Behavioral Therapy (CBT) is the gold standard for treating OCD symptoms. CBT is a collaborative effort between the therapist and client that aims to build insight and equip the client with tools to manage their symptoms. This treatment protocol is effective for all OCD “themes.” Clients are taught about the OCD cycle in the psychoeducational phase of treatment so that they can spot OCD symptoms in the future should their content shift. This won’t necessarily happen for every client, but the goal is to make the client feel empowered and able to maintain their recovery. OCD “themes” typically develop after a person has repeatedly engaged in compulsive behavior, so it is crucial for a client to have a strong understanding of the OCD cycle.

The first step of CBT involves cognitive restructuring, which is a widely practiced tool. The process involves learning about and identifying cognitive distortions (e.g. catastrophizing, all-or-nothing thinking, magnifying, etc.). Once a client is able to identify their cognitive distortions, they can practice generating alternative thoughts that reflect experience, reason, and objectivity. It is important to note that cognitive restructuring can be done compulsively. Clients may use their alternative thoughts as reassurance, or practice it right after a spike of anxiety or discomfort. Instead, cognitive restructuring should allow a person to consider other realistic possibilities while tolerating uncertainty. I work on cognitive restructuring examples in session to demonstrate how to incorporate and tolerate uncertainty before we get to Exposure with Response Prevention (ERP).

Mindfulness training involves becoming more non-judgmentally aware of the present moment. For example, a client may find that they prefer to practice mindful walking instead of sitting down to a guided practice, and vice versa. Whatever the preferred method, clients learn to use their senses to connect to their internal and external experiences. Mindfulness is an ongoing practice that gives clients the ability to pause and simply notice what’s going on. It is not meant to be used to compulsively get rid of anxiety. Each experience will be different from the last. For specific recommendations, please look at the Resources page.

Exposure with Response Prevention (ERP) is the behavioral component of CBT. During the psychoeducational phase of treatment, clients are asked to keep a log of their symptoms for a week or longer. This provides useful data that can be used to build an exposure hierarchy after learning about ERP. Effective ERP is gradual and requires flexibility, as targeted OCD symptoms may vary on a daily or weekly basis. It is important to avoid “flooding” or starting with an exposure that is too hard. Clients will notice that as they work through their hierarchy, exposures that were initially deemed very difficult will become more manageable.”

At the end of treatment, clients should feel confident in their ability to implement and practice exposures and other skills as necessary. Clients may reach out to their therapist for “booster” sessions when they need to briefly consult on their approach to managing symptoms.

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