What is the most common compulsion?

Obsessive compulsive disorder (OCD) is a chronic anxiety disorder characterized by recurrent intrusive thoughts (obsessions) that may result in repetitive behaviors (compulsions).

Obsessive compulsive disorder is common. It affects over 2% of the population, more than one in 50 people. More people suffer from OCD than from bipolar depression.

Obsessions themselves are the unwanted, intrusive thoughts or impulses that seem to "pop up" repeatedly in the mind. These intruding thoughts can be fears, unreasonable worries, or a need to do things. When a person is tense or under stress, the obsessions can worsen.

Compulsions are the behaviors that may result from the obsessive thoughts. The most common compulsions include repetitive washing (hands or objects) and "checking" behaviors. Compulsions may be rituals, repeating certain actions, counting, or other recurrent behaviors. Some people with obsessive compulsive disorder are obsessed with germs or dirt.

People with obsessive compulsive disorder can have mild or severe symptoms. Those with mild obsessive compulsive disorder may be able to control their compulsive behaviors for certain periods of time (for example, at work) and may successfully hide their condition. However, in severe cases, obsessive compulsive disorder can interfere with social and occupational functioning and cause disability.

The symptoms of obsessive compulsive disorder often appear early in life. They most commonly begin in childhood, the teen years, or early adulthood. Males and females of all races are equally affected, and obsessive compulsive disorder generally persists throughout life, with fluctuations in severity.

While the exact cause of obsessive compulsive disorder is not known, scientific evidence points to a possible biological abnormality. Levels of brain chemicals called neurotransmitters have been shown to be imbalanced in people with OCD.

Obsessive compulsive disorder can also be accompanied by other anxiety disorders, depression, eating disorders, or other psychological conditions. Some people with obsessive compulsive disorder are able to understand that their thoughts and actions are unrealistic and inappropriate, while others lack this insight.

Antidepressants that affect the neurotransmitter serotonin can provide relief for up to 75% of people with obsessive compulsive disorder. The most commonly prescribed drugs are the selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac). Behavioral therapy can also be an effective treatment option. Psychotherapy for obsessive compulsive disorder may involve insight into the disruptive thoughts and impulses and confrontation with them in an attempt to control the associated compulsions.

Obsessive-compulsive disorder (OCD) is a psychiatric condition that causes people to have distressing and repetitive thoughts (obsessions) that often lead to an action they feel the need to perform (compulsions). They may need to do these compulsions once or repeatedly until they feel more at ease. Obsessions and compulsions can vary from person to person, but doctors usually characterize these into specific groups. People often experience symptoms from several different categories, which can evolve over time. Here are some of the most common.

1. Organization

Possibly the most recognizable form of OCD, this type involves obsessions about things being in precisely the right place or symmetrical. For example, someone may feel the need to have all wall hangings level, make all labels on cans in the pantry face outward, or keep everything on their desk completely neat. If the person doesn’t perform the compulsions to make everything just right, they might experience distress or even thoughts that the lack of organization will cause some unrelated harm to them or their loved ones. 

2. Contamination

Contamination OCD revolves around two general ideas. The first is the thought that people can spread non-viral illnesses through touch or proximity. The second is that everyday things, thoughts, and words can “contaminate” a person, making them feel unclean. People with this type often feel the need to wash their hands repeatedly and clean items frequently to avoid spreading the perceived contamination. They may fear making themselves or someone else ill from being careless, or they might feel disgusted and uncomfortable around “unclean” items, which can lead to avoidance of certain objects, people, or places.

3. Intrusive Thoughts 

People who experience intrusive thoughts have distressing and often abhorrent ideas pop into their heads seemingly at random. These obsessions can involve hurting a loved one, causing harm to a stranger, or even the idea that simply thinking about something can make it more likely to occur. To quiet these obsessions, a person might have to perform an action, such as saying something aloud or repeating something mentally. While people who experience intrusive obsessions may have violent or harmful thoughts, they neither agree with them nor do they act upon them. In fact, these ideas are so contradictory to how they feel that people often become distressed that their mind even created the thought in the first place. 

4. Ruminations  

This type has similarities with intrusive thought-based OCD, but there are some key differences. The ideas that get stuck in the head of someone with rumination-based OCD aren’t repulsive or distressing. Instead, they might be philosophical, religious, or metaphysical conundrums (essentially questions that have no proven answers). People who experience ruminations will be stuck on this topic for a while and might ignore responsibilities while they try to figure out an answer. Since these questions often have no definitive solution, people might feel unsatisfied or empty after thinking about this topic for so long. 

5. Checking 

Checking is an obsession in which a person is concerned about causing damage or harm by being careless. Their compulsions might include checking doors to make sure they’re locked, stoves to make sure the burners are off, or their wallet to make sure their credit cards, IDs, and cash are all still there. They might have to check something multiple times or even stare at it for a period before they can feel more at ease. 

If any of these obsessions or compulsions sound familiar to you, or even the general concept sounds right (without the thoughts and actions lining up directly), schedule an appointment with your Baylor St. Luke’s Medical Group primary care physician. If you think your child may be exhibiting OCD symptoms, speak with their pediatrician. They can refer you to a psychiatrist and help you on the way to diagnosis and treatment.

Sources: 
OCD UK | Types of OCD
International OCD Foundation | OCD and Contamination

When someone is affected by Obsessive-Compulsive Disorder their natural response is to fight their unwanted and anxiety provoking intrusive  thoughts with purposeful behaviours and deliberate actions (this includes both mental and physical actions, seeking reassurance and avoidance of people, places and objects), these behaviours are called compulsions.

Occasionally some people affected by OCD will report no obvious obsessive fear, just compulsions. In these rare cases, either the individual does not have OCD (OCD needs to include both obsessions and compulsions for a diagnosis) or most likely they did have an obsessive fear/worry originally, but it has been forgotten over time. Now, their obsession is that feeling of discomfort we discussed on the obsessions page.

Compulsions or compulsive acts can be defined as repetitious, purposeful physical or mental actions that the individual feels compelled to engage in according to their own strict rules or in a stereotyped manner.

Typically, the individual experiences a sense of resistance to the act but this is overridden by the strong, subjective drive to perform the action. Most often the principal aim behind the compulsive behaviour is to generate relief (usually only temporary) from the anxiety elicited by the preceding obsession.

These behaviours involve repeatedly performing purposeful and meaningful actions in a very rigid and structured routine, specifically in relation to the obsessional thoughts usually carried out with a view to prevent perceived danger or harm coming to oneself or to a loved one.

In some cases, the person recognises their compulsive actions are irrational, but none-the-less feels bound to carry them out. As mentioned on the previous page, people living with obsessions and compulsions related to Obsessive-Compulsive Disorder are the least likely people to actually act on their thoughts, with the nature of the thoughts being fear, rather than a prelude to intent.

Often a person living with OCD will feel a heightened sense of responsibility to perform the neutralising behaviour simply because they feel doing so will prevent harm coming to themselves or loved ones. Equally, sometimes the person with OCD will have an overwhelming urge to obtain that ‘just right’ feeling with no other reason than to feel comfortable.

For example, a common and well-known stereotypical perspective of an OCD compulsion is someone who washes his or her hands (because of an obsessive fear of contamination). People without the illness will wash their hands when they are dirty and ‘see’ that they are dirty. In contrast someone with OCD whose obsessions are focused on contamination fears will often ‘feel’ their hands are dirty, and therefore keep washing until they ‘feel’ clean, their OCD will convince them that doing such a ritual keeps their loved ones safe by not contaminating them. It is this heightened sense of responsibility, and need to protect loved ones that often drives the person with OCD to repeat the endless cycle of ritualistic behaviours (compulsions).

In 2005 The National Institute for Health and Clinical Excellence (NICE) published their guidelines for the treatment of OCD and BDD, within their findings they published this table to illustrate the types of compulsions that people with OCD have reported.

Other examples of common compulsions include:

• Mental reassurance of trying to remember a particular incident or event, sometimes from the same day or from decades before. The obsessive thought could be that the sufferer thinks they may have acted inappropriately in the past.
• Checking of switches, cars, doors, taps, locks, body reactions. The obsessive thought might be to prevent danger from fire/break-in or signs of arousal.
• Mental rituals (like counting or checking) to attempt to ‘neutralise’ an obsessional thought. The obsessive thought might be that something bad may happen if not carried out.
• Excessive washing of one’s hands or body. The obsessive thought might be a fear of being contaminated or contaminating a loved one, which might cause harm/illness.
• Checking that items are arranged ‘just right’ and constantly adjusting inconsequential items, such as pens on a table, until they are aligned to feel ‘just right’ as opposed to looking aligned. The obsessive thought might be that something bad may happen to a loved one if not aligned correctly.
• Avoiding particular places, people or situations to avoid an OCD thought. The obsessive thought might be about harming someone or fears that people or places are contaminated.
• Saying out loud (or quietly) specific words in response to other words. The obsessive thought might be to neutralise specific fears.
• Avoidance of kitchen knives and other such instruments (for example locking them in a drawer). The obsessive thought might be the person fears they will stab a loved one inadvertently.
• Hoarding. The obsessive thought about discarding something important or harm happening if dangerous items are discarded.*

* Hoarding is included in this list above, and may still be an OCD compulsion where a person hoards, if they do so for clear obvious obsessive reasons. However some aspects of hoarding are no longer considered to be OCD and may be a separate condition altogether. We will look at hoarding in another chapter.

It’s important not to discount compulsions (rituals) if they don’t appear on these lists, remember OCD can latch itself on to absolutely anything, and these are only the most common examples of compulsions.

A compulsion can either be overt (i.e. observable by others), such as checking that a door is locked or covert (an unobservant mental act), such as repeating a specific phrase in the mind.

Overt compulsions typically include checking, washing, hoarding or symmetry of certain motor actions.

Covert compulsions, or ‘cognitive compulsions’, as they are sometimes referred to, are the carrying out of mental actions, as opposed to physical ones. Examples include mental counting, compulsive visualisation and substitution of distressing mental images or ideas with neutralising alternatives. Practical examples would be a sufferer who feels compelled to silently repeat a string of words over and over again upon experiencing a negative or violent thought. Or it could be the need of a sufferer to transpose negative words or images which may intrude into their consciousness with positive ones e.g. feeling compelled to mentally substitute the word ‘hell’ that pops into their head, either as a thought or as a visual image, with the word ‘well’.

Some sufferers will think they only have intrusive thoughts and don’t have compulsions, commonly referred to as ‘Pure O’ by the OCD community. ‘Pure O’ is a form of OCD where people mistakenly believe that it differs from traditional OCD and that it features no outward compulsive manifestations; instead, they mistakenly are led to believe that anxiety-inducing obsessions take place only in the mind.

However, in reality a person with ‘Pure O’ will have compulsions which manifest as unseen mental rituals, as well as physical compulsions such as checking (various types of checking from checking on Google to checking for own body reactions/sensations), seeking reassurance from loved ones or avoidance of particular objects, places or people that trigger their obsessional thoughts. They’re all compulsions (mental or physical) nonetheless, which is why the term ‘Pure O’ is both unhelpful and imprecise. To be clear, ‘Pure O’ is like any other form of OCD, it will involve both obsessions and compulsions.

Another key compulsive behaviour, particularly where the sufferer lives with another person is the need to seek constant reassurance. Initially, like any compulsion, when reassurance is received the sufferer will feel an initial sense of relief, but the doubts and uncertainty caused by OCD will return, and the need to seek further reassurance follows.

Common examples of reassurance seeking will be to ask a loved one “did I lock the door?”, “did I upset or offend you?”, “did I turn the taps off?”, “did I hit something when driving?”, “did I touch that child inappropriately?”, “did I wash my hands enough?”, “do you still love me?”. Of course, for the family member it is natural when you love someone to try and relieve their anxiety and anguish by answering such questions, but like any OCD compulsion, if you engage in it once, once is never enough and it reinforces the need to further engage in reassurance seeking behaviour.

Any relief that any of the compulsive behaviours provide is only temporary and short lived, they simply reinforce the original obsession and need to carry out the compulsion, creating a gradual worsening cycle of OCD symptoms. The image below illustrates this point, and offers a very simplistic model of how OCD works and the basic characteristics of OCD. However, the process of how our thoughts (obsessions) and our behaviours (compulsions) are entwined is far more complex, so we look at that in much more detail later in this chapter.

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