What are Obsessions in OCD?

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Obsessive Compulsive Disorder (OCD) is a psychiatric disorder that affects approximately 1% - 2% of the population. Although one can develop OCD at any age, the average age of onset is 19.5 years, with 25% of individuals developing symptoms by 14 years of age.  Although males tend to exhibit symptoms more often in childhood, females tend to be affected at somewhat higher rates by adulthood.

Classified among the “Obsessive Compulsive and Related Disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnostic criteria include:

  • The presence of obsessions, compulsions, or both
    • Obsessions are defined as:
      • Obsessions are defined by recurrent, persistent, intrusive, unwanted thoughts, images, or urges that cause anxiety or distress
      • Attempts to ignore or suppress such obsessions or neutralize them by performing a compulsion
    • Compulsions are defined as:
      • Repetitive behaviors or mental acts an individual is driven to perform in response to an obsession or according to rigidly applied rules
      • The behaviors or mental acts are aimed at reducing anxiety or distress, or preventing a feared outcome; however, they are clearly excessive or not connected in a realistic way to that which they are intended to address
    • The obsessions or compulsion are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in one’s daily functioning
    • The symptoms are not better accounted for by the physiological effects of a substance, medical condition, or other mental disorder
      • It is noted that individuals may have good/fair or poor insight into the reasonableness of their symptoms. If poor insight, the individual’s symptoms may appear delusional in nature. It is also noted that symptoms may be tic-related in nature, if the patient has a history of tic disorder.

    Contrary a common misunderstanding in pop culture, obsessions are not pleasant; being “obsessed” with something or someone is not what is occurring when an individual thinks a lot about something with which they have a fondness and from which they derive pleasure. Obsessions, in the clinical sense, are aversive in nature.

    These internal experiences occur repeatedly, are unwanted, and feel as though they are outside of the individual’s control. They cause a great deal of discomfort, such as anxiety, disgust, fear, and overwhelm. The persistence of these ideas often interferes with the individual’s ability to attend to other things of importance to them.  Common obsessions include:

    • Contamination (e.g., dirt, germs, bodily fluids, disease, environmental contaminants, chemicals)
    • Harm (e.g., fear of harming oneself or others, fear of being responsible for something bad happening or the unintentional harm to something or someone)
    • Unwanted Sexual Thoughts (e.g., unwanted, forbidden, or perverse sexual thoughts, images, or impulses, including obsessions about homosexuality, sexual thoughts about children, incest, rape or sexual aggression)
    • Religiosity / Scrupulosity (e.g., thoughts about blasphemy or offending God, concern for moral judgment or behavior)
    • Losing Control (e.g., fear of acting impulsively and harming oneself or others, fear of acting impulsively and insulting others or saying something taboo or forbidden, fear of acting impulsively and stealing, unwanted mental images that are aggressive, violent, or otherwise horrific in nature)
    • Perfectionism (e.g., concerns with evenness, exactness, symmetry, a need to know or remember, being driven to adhere to rigid routine or expectation, need for something to feel just right)
    • Physical Illness (e.g., fear of acquiring an illness or disease which is unrelated to contamination obsessions)
    • Superstitious Beliefs (e.g., lucky or unlucky numbers, colors, words, or phrases)

    Obsessions often involve a feared outcome, such as being responsible for harm to oneself or to others, being defined as unethical or immoral, or imperfect. For example, obsessions regarding harm to others may involve the fear that one may unintentionally cause a fire by failing to use caution. This fear can become so overwhelming that it drives compulsions to minimize the perceived potential for harm and decrease the distress. In the aforementioned example, one might choose to check all outlets in the home before leaving the house to reduce the perceived risk that a fire will occur and drastically diminish the associated anxiety.  

    Compulsions are also commonly misunderstood and are diverse in presentation.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5thed. Washington, DC: American Psychiatric Association; 2013:251-4.

    Clark, David A.; & Radomsky, Adam S. (2014). Introduction: A global perspective on unwanted intrusive thoughts. Journal of Obsessive-Compulsive and Related Disorders. Available online 18 February 2014.

    Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.” Arch Gen Psychiatry 46:1006-1011,1989.

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