The “O” Of OCD: What Are Obsessions?

What are obsessions?

There are so many intrusive thoughts which could crop up, but for those without OCD, they are not particularly distressing. They might momentarily think ‘that was strange’ or briefly worry about it, but then the thought passess and they attach no significance to it. They get on with their life and likely never think about a particular intrusive thought again.

However, when it comes to someone with OCD, these intrusive thoughts become very distressing. We attach great significance to these thoughts, they play on our minds and don’t just go away. We may think that they make us a bad person, or fear that we’re at risk of acting on them, even though in reality we wouldn’t. This is when intrusive thoughts become obsessions. It’s not the thoughts which are the problem, they are completely normal: it’s the significance an individual attaches to these thoughts which makes the difference.

This 2020 article by Marla Deibler, PsyD defines obsessions as, “recurrent, persistent, intrusive, and unwanted thoughts, images, or urges that cause anxiety or distress.” Someone with OCD regularly has intrusive thoughts which feel uncontrollable: they can’t ignore these thoughts and they markedly affect their lives.

The charity OCD UK explains that, “the word ‘obsession’ comes from the Latin ‘obsidere’ which means ‘to besiege’.” This is fitting because these thoughts feel they are attacking you, surrounding you and bothering you, no matter how hard you try to resist: this fits with the definition of the word ‘besiege’.

Some people with OCD are self-aware and realise that their obsessive thoughts are irrational and not grounded in logic, yet they are unable to control them. Others may be unaware that these thoughts are not grounded in reality.

Obsessions vs compulsions

To be diagnosed with OCD you must experience both obsessions and compulsions. As we now know, obsessions are distressing intrusive thoughts. Compulsions are what someone with OCD does to ‘cope’ with their obsessions. They are repetitive behaviours or rituals which are performed either physically or mentally. For example, if someone has an obsession around harming themselves or someone else, their compulsion may be to hide anything in their home which they could use to harm others. If they fear a break in, they may repeatedly check their doors and windows are locked when they leave home.

The obsessions and compulsions don’t have to be logically linked. For example, if someone has an obsession that revolves around fear of their family being in an accident, they may need to ‘prevent’ this happening by carrying out checking behaviours, or by arranging something in their home in a specific order.

Although these compulsions may temporarily reduce anxiety, the anxiety returns quickly (and often stronger), leading the individual to have to carry out more compulsions. This is the cycle of OCD.

To summarize the difference between obsessions and compulsions:

• Obsessions: Intrusive thoughts which plague someone with OCD.
• Compulsions: The actions taken to ‘deal’ with obsessions.

What is pure-O OCD?

You may hear the term ‘pure-O’, which stands for ‘Purely Obsessional’. This is a sort of nickname used within the mental health community to refer to someone with OCD who only has mental compulsions, meaning their compulsions are carried out within their mind and aren’t visible to others. This might include replacing a negative thought with a positive one, or thinking back to turning the oven off to mentally check that they’ve done it for example.

Pure-O does not mean that the individual only struggles with obsessions. As we mentioned, all forms of OCD must include both obsessions and compulsions. It simply means their compulsions are covert, done within their own mind.

Thinking patterns which contribute to obsessions

There are some thinking patterns (or cognitive biases) which experts have identified as contributing to OCD. We’ll focus on four cognitive biases which particularly contribute to an individual attaching such significance to intrusive thoughts.

Inflated responsibility

Those with OCD feel an increased sense of responsibility, such as feeling they are responsibility for their loved one’s safety. You might believe you have the power to prevent harm to your loved ones, or likewise that you have the ability to cause them harm.

Over importance of thoughts

This specifically references intrusive thoughts, as those with OCD attach a great deal of significance to their intrusive thoughts. It’s also common to think that people without OCD don’t have intrusive thoughts.

Thought-action fusion

Thought-action fusion refers to the belief that by having a thought, you increase the likelihood of it coming true. For example, if you have an intrusive thought about your family member being in a road accident, you may fear that thinking this will make the event happen.

This pattern of thinking can also make you feel that having an intrusive thought is just as bad as if you carried out the action itself. For example, if you had an intrusive thought about harming your partner, you would feel guilty as though you actually carried out this imagined harm. You might also believe that having this thought means that you actually want to cause your partner harm. This is what makes you feel that you are a bad person in reaction to your obsessions.

Overestimation of danger

Someone with OCD is likely to be hyper alert to potential or perceived treats. They may see danger where there is none, or assume the worst from a situation which has a potentially bad outcome.

For example if you were called into a meeting at work, you might automatically jump to fears that you’ve done something so wrong that you are going to be fired on the spot. Someone without OCD may feel a bit nervous but consider a range of options as the reason for the meeting, such as receiving praise, receiving some constructive criticism, or perhaps getting a warning if they’ve done something wrong in the workplace.

How can obsessions affect your life?

Obsessions are very detrimental to an individual’s life and by nature are distressing. They can affect your life in multiple ways leading to:

• You feeling that you are a bad person
• You worrying about carrying out actions which don’t reflect who you are
• You fearing certain situations or events
• Finding it tough to focus on a task because there’s so much going on in your mind
• Lack of focus leading to job loss, relationship problems, trouble enjoying hobbies etc
• Your anxiety rising to levels which are tough to cope with
• You feeling isolated and alone
• Increased levels of stress
• Increased risk of comorbid mental health issues
• Difficulty sleeping

Types of obsessions

Contamination

Obsessions around contamination may include a fear of:

• Germs
• Dirt
• ‘Dirty areas’ (such as toilets or door knobs which lots of people touch)
• Bodily fluids
• Diseases and illnesses
• Environmental or chemical contaminants (such as cleaning chemicals around the house)

Someone who struggles with intrusive thoughts about contamination may be very frightened that they themselves or their loved ones may become contaminated, dirty or unwell. They may constantly feel as though they are not clean enough. They may feel mentally ‘dirty’. They might feel that specific areas of their home are never clean enough. This is not just a passing desire to stay healthy, but rather an all consuming fear of anything which they perceive could make them unwell.

Harm

Intrusive thoughts around harm can be focused on thoughts, fears or images of harming oneself, or of harming others. It may be that the harm obsessions focus on loved ones or strangers. They may focus on a specific individual.

While this can be focused around them doing the harm, it can also manifest as inflated responsibility. This means that you feel responsible for the safety of your loved ones or those you come into contact with. An individual with these thoughts may fear that their loved ones will have an accident or be hurt by someone else, and that this will be their fault because of their intrusive thoughts.

They may fear unintentionally harming someone or accidentally causing a situation which could lead to harm. This could be someone breaking into the home, which they feel they are responsible for keeping safe, or a fire occurring, which they feel responsible for preventing.

Order or symmetry

These obsessions center around needing to have things in a specific order, or lined up symmetrically. The individual may need to arrange things by order of size, colour, or facing in a specific direction. This can be items in the home, such as clothing, books, cutlery, or food on their plate at meal times: essentially any item they come into contact with.

People who struggle with this type of obsession may feel this urge to order things until they ‘feel right’. They may also fear that something bad will happen if they don’t do so.

Sexual

Intrusive sexual thoughts are perhaps some of the most shame filled, and certainly one of the most misunderstood. There are a wide range of intrusive sexual thoughts which an individual may struggle with. This 2020 article explains that some of the themes can include, “homosexuality/sexual identity, sexual abuse, sexual thoughts about friends, incest, infidelity, sexual perversions, sex with animals, violent sexual behavior, and blasphemous thoughts combining religion and sex.”

It’s vital to remember that these sexual thoughts or images are not fantasies. Just like the other obsessions we’ve discussed, they do not represent what the individual actually feels. In fact they are likely to feel very guilty and feel that they are a bad person because of these thoughts.

You might hear the term Pedophilia OCD (pOCD) in relation to intrusive sexual thoughts which are revolving around children. Like pure-O, this is a sort of nickname used within the mental healthy community to identify this type of obsession. The individual may spend a great deal of time feeling incredibly down on themselves and worrying about whether they are a pedophile.

You may also hear the term Sexual orientation obsessions in OCD (SO-OCD) or homosexual OCD (HOCD): these both refer to the same type of intrusive thoughts about sexual identity. The individual may fear that they are gay or straight for example, when they indentify as the opposite. They also may fear that others around them think they ‘appear’ gay or straight.

Unfortunately due to stigma (both self-inflicted and from others), many people with intrusive sexual thoughts don’t seek help because they are so ashamed and fear how they will be perceived if they reach out.

Relationships

You may hear this referred to as Relationship OCD (ROCD). These intrusive thoughts focus around worries about a relationship, such as fears that their partner isn’t ‘the one’, that they are not compatible, or that their partner isn’t attractive enough. Conversely the individual may also worry that their partner does not find them attractive enough or that they are ‘not enough’ for them. These obsessions can be present even in an otherwise completely healthy and happy relationship. Understandably, they can be hard to detect or distinguish between actual relationship doubts, even for the individual.

Religious

You may hear this referred to as Scrupulosity. Those with intrusive religious thoughts will be preoccupied with acting the ‘right’ way and sticking to strict morals. They will fear judgment or punishment from others or from a religious figure if they behave badly or say something blasphemous. They may have a deep set fear that nothing they do will be good enough for God. It’s also common to worry that you are not praying correctly, or enough. This can happen regardless of which religion you follow, and even for some people who don’t follow a set religion.

Urge to hoard

An individual may struggle with fear at the thought of discarding things, even if they are worn out or no longer useful. They may worry that something bad will happen if they throw away an item. They may also feel the urge to collect specific items, even if they are something with no particular use and they have no specific interest in the items as a hobby.

Losing control

It’s common to have a great deal of fear around the thought of losing control. Someone with these obsessions might fear that they will blurt out something in conversation that they don’t mean to say and offend someone or embarrass themselves. They might fear they will lose control and act on other obsessive thoughts, such as sexual or harm obsessions. They might worry that they will act on impulse and it will be out of character, which they would regret in retrospect. These fears can be all consuming.

Perfectionism

Many obsessions will focus around the need for things to be ‘perfect’ or ‘just right’. This may be striving for a feeling of things being ‘right’. It might also involve the need for things to be lined up correctly, to be even, or exact in the individual’s view. It can also involve the fear of losing or misplacing items, or fear of forgetting important information (which to an individual struggling with perfectionism, can feel like almost everything).

Understandably this can put a great deal of pressure on the individual and stress levels can skyrocket. This need for things to be ‘perfect’ can also lead to problems with decision making and taking a long time to do daily tasks, because they’re trying to make choices that will fit in with their rigid expectations.

This 2020 article on the topic describes perfectionism obsessions as, “concerned with evenness, exactness, symmetry, a need to know or remember, being driven to adhere to rigid routine or expectation, and an overall need for something to feel “just right.””

Physical illness

Someone with intrusive thoughts around physical illness may fear that they are going to become ill, or that they are unwell. This is a separate obsession from contamination, as it’s not related to germs or feeling dirty, but rather a fear that they will contract a serious illness or that ‘something is wrong’ with their body.

These fears can also cause somatic obsessions, which means that the individual is hyper aware of their bodily processes such as breathing, blinking, swallowing and so on. They will struggle to take their attention away from these usually unconscious processes, finding this very distracting and distressing.

Superstitious

This refers to an individual feeling that specific words, numbers, colours or phrases are ‘lucky’ or ‘unlucky’. They may fear that if they use ‘unlucky’ words for example, that something bad will happen to their family members. In this example they would be constantly on the lookout for threats in the form of ‘unlucky’ words.

This can also relate to specific actions or a series of actions which they feel are ‘unlucky’ or ‘lucky’, such as ‘knocking on wood’ if they say or think something negative, or avoiding walking under a ladder because it’s thought of as ‘unlucky’. This is more than just a ‘quirk’: like the other obsessions we’ve discussed it can cause extreme fear and significantly impact the individual’s life.

Risk vs reality

The charity OCD UK states aptly that, “there is no documented evidence suggesting anyone with OCD has actually carried out their actions, far from it, people with OCD go to extreme lengths not to carry out such actions.”

It’s really important that if you struggle with obsessive intrusive thoughts, even if you are very ashamed of them, that you reach out for help. There is a chance that you will face a doctor who does not understand the difference between risk and reality, however once you are able to see a qualified mental health professional who is well versed in OCD, they will be able to distinguish the difference. You may need to advocate for yourself to ensure you see an appropriate professional.

This article on risk in OCD explains that the National Institute for Health and Clinical Excellence (NICE) guidelines (used by professionals to diagnose and treat specific disorders) specifically state, “If healthcare professionals are uncertain about the risks associated with intrusive sexual, aggressive or death-related thoughts reported by people with OCD, they should consult mental health professionals with specific expertise in the assessment and management of OCD. These themes are common in people with OCD at any age, and are often misinterpreted as indicating risk.”

You have a right to get an accurate diagnosis and in turn accurate help. Don’t allow stigma to prevent you from getting the help you need. OCD does not need to take over your life forever: you can take your power back.

What to do if you’re struggling with obsessions

Seek treatment

The first thing you need to do is seek treatment. This can be scary, but it’s so important that you do so in order to overcome your OCD. If you don’t have a diagnosis, your first stop should be your doctor’s office. Explain your symptoms and your concerns, and ensure you are referred to see a mental health professional (as we’ve discussed, this is vital). You might need to advocate for yourself. You can do this in many ways, including:

• Being calm, clear and persistent
• Writing down what you want to talk about to ensure you cover everything you want to say (it’s easy to get flustered during a doctor’s appointment)
• Taking a loved with you for moral support
• Finding a professional advocate (through your local council, health service, or a mental health charity)
• Asking for a second opinion if you feel you aren’’t been heard
• Making a complaint if you feel you are being treated unfairly

Once you have a diagnosis, you will be able to get the treatment you need. For some treatments, such as medications, this will be through your doctor or mental health professional. For therapy, you might be referred to a therapist and put on a waiting list, depending on where you live. You could also choose to seek treatment privately, or in the comfort of your own home through online OCD treatment.

Monitor your symptoms

Both before and during treatment it’s a great idea to monitor your symptoms. You could keep a diary, a chart, or even just note them down in your phone or on a piece of paper. The more information you have, the more you understand your OCD and how it affects you. This equips both you, and your doctors, to better fight your OCD..

Find support

Living with obsessions is not easy. They plague your mind and make it incredibly difficult to function. It can feel like you are drowning in these relentless intrusive thoughts. It’s important you don’t go through this alone. Reach out for help and allow others to be there for you. If you feel they are supportive, speaking to loved ones about your struggles can be really useful. They can encourage you, listen to you, and even help you with practical things like coming to appointments with you.

If you don’t have support from your loved ones or you don’t feel this is a healthy option for you, you could find support from others with mental illness. There are some wonderful support networks online, through chat rooms, forums, and social media. You could also attend an in-person support group which can be very beneficial.

Practice self-care

Even though it’s difficult when you’re struggling mentally, you must practice self-care. Self-care refers to anything you do to take care of your physical and mental health. This includes eating well, exercising, keeping a regular sleep schedule, practicing personal hygiene, making time for hobbies and so on.

Keep up with treatments

As obvious as this may sound, it’s vital to keep up with any treatments you start in order to see results. If you are on medication, it’s important to take it every day, as instructed. It can be trial and error to find the right medication for you, and it takes time to start working so it’s important to be consistent.

Likewise when engaging in therapy it’s important to attend appointments or keep up with online sessions, and to do any ‘homework’ you’re given between sessions. It’s hard work to overcome OCD and it requires dedication, commitment and determination: it’s also well worth it to gain relief from your symptoms.

Don’t try to suppress your intrusive thoughts

This may sound counterintuitive, but it’s important not to try to suppress or push away your intrusive thoughts. This can actually lead to more anxiety and perpetuate the OCD cycle. This article states that, “Research has shown that the cycle of monitoring and thought suppression in people with OCD can lead to the development of more obsessive thoughts.”

Instead, you need to learn to recognise that the thought itself is not going to hurt you, and rather than trying to resist it, let it float by you. It’s all about attaching less significance to these thoughts over time. This, of course, is not easy and is something you will address more through therapy.

Challenge your obsessions

If you feel able, you can begin to challenge your obsessions. You can start by taking a pause and a deep breath when an intrusive thought creeps into your head, rather than reacting to it straight away: this is a step in the right direction.

By putting as much time as you feel able to between when you experience an intrusive thought and carrying out a compulsion, you are actively challenging your obsessions head on. Remember that it’s natural for this to feel uncomfortable, and if you struggle with it, it doesn’t mean you’re failing. You can always try again at a pace that suits you.

Remind yourself of the facts

When you’re struggling and your obsessive thoughts feel overwhelming, remind yourself of the facts. You could simply think through these facts like positive mantras, or you could voice them out loud. You could even write them down and put them up somewhere in your home.

Intrusive thoughts are normal

Remember that everybody, literally everyone at some point in their life (and sometimes quite often), has intrusive thoughts.

Your obsessions do not reflect who you are

The content of your obsessions is not a reflection on who you are as a person. They don’t represent your beliefs or values.

You are not a bad person

You are a good person. Your intrusive thoughts don’t make you a bad person. If you were a bad person, you wouldn’t be worried about the thoughts you’re having!

It’s not your fault

These obsessions and high anxiety come from your OCD, not from you. It’s not your fault. You didn’t do anything to cause this.

You are not alone

Even though OCD can feel isolating, you aren’t alone. There are so many others out there who are going through the same experiences. One in every 40 people in the US are estimated to have OCD, while in the UK three quarters of a million people are living with OCD.

There is hope

There are scientifically proven treatments available which can help you to control and overcome your OCD symptoms! Between 32% and 70% of people with OCD achieve remission from their symptoms! Remember that it is possible, and there is always hope.

Available treatments

Medication

The medication typically prescribed for OCD patients is antidepressants known as selective serotonin reuptake inhibitors (SSRIs). They can help to ease anxiety and are thought to correct chemical imbalance within your brain. You may be prescribed anti-anxiety medication such as sedatives.

Cognitive Behavioral Therapy (CBT)

CBT is the primary therapy for OCD. CBT works to replace negative thinking patterns and behaviours with more positive, helpful thought processes and coping strategies. Through CBT you can learn the tools you need to continue managing your OCD going forward.

Exposure and Response Prevention (ERP)

ERP is a form of CBT used to face fears and break the cycle of OCD. You will be guided through tackling your obsessions without reacting with compulsions, starting from the situation you fear least. This will be done in a very gradual, manageable way. As you tackle your fears, you will learn that you do not need to react to your intrusive thoughts.

Acceptance and Commitment Therapy (ACT)

ACT is another form of CBT which is incredibly useful when dealing with obsessions. The therapy focuses on learning that thoughts are just thoughts, that they cannot hurt you and do not need to lead to actions. Instead you learn to let these thoughts pass you by. You will also be guided through committing to positive, long term coping behaviours.

Mindfulness

Mindfulness is often used in conjunction with the other therapies we’ve mentioned to bring optimum results for OCD patients. Mindfulness practices focus on being present in the moment, releasing anxiety and stress, and replacing it with a sense of calm and relaxation.

Fundamentally, it’s important to remember that although obsessions can be incredibly difficult to live with, it doesn’t always have to feel overwhelming. There are ways you can overcome your obsessions, like the mental health warrior you are!

References

OCD UK, (2020), “What are obsessions?”

Marla Deibler, PsyD, (2020), “Obsessions in Obsessive-Compulsive Disorder (OCD)”. Very Well Mind.

Owen Kelly, PhD, (2020), “Connection Between Sexual Obsessions and OCD”. Very Well Mind.

OCD UK, (2020), “Risk Assessment in OCD”.

David Veale, Mark Freeston, Georgina Krebs, Isobel Heyman, Paul Salkovskis, (2009), “Risk assessment and management in obsessive–compulsive disorder”. Advances in Psychiatric Treatment, Volume 15, Issue 5, September 2009 , pp. 332-343

Owen Kelly, PhD, (2020), “How Can I Stop OCD Thoughts?” Very Well Mind.

Beyond OCD, (2019), “Facts about Obsessive Compulsive Disorder”.

OCD UK, (2020), “Occurrences of OCD”.

Elisabetta Burchi, Eric Hollander, Stefano Pallanti, (2018), “From Treatment Response to Recovery: A Realistic Goal in OCD”. International Journal of Neuropsychopharmacology, Volume 21, Issue 11, November 2018, Pages 1007–1013