You’ve probably never seen the 2005 box-office blunder Deuce Bigalow: European Gigolo. I mean, why would you? Not only is the film over 15 years old, but it also earned a nice, big, fat L from critics worldwide.  Call it the anti-Oscar if you will, earning the unsightly honors of Worst Picture at the 26th Annual Golden Raspberry Awards. But even though the film probably hasn’t made a blip on your radar, chances are that Deuce’s portrayal of OCD falls in-line with how you view the disorder. “I have obsessive compulsive disorder. I have these little rituals that I can’t help doing. I can’t touch doorknobs, I snap my fingers when I see a bus, and when someone sneezes I slap myself three times. Before I can go on a date I have to collect five different colored tulips, eat two herring and drink a beer from a wooden shoe,” remarks Eva, Deuce’s girlfriend in the film. When we find ourselves being a little too extra, this cultural expression enters our mind.  I’m so OCD. See the fam doing a little too much hand-washing? Or perhaps your roommate has been a little over the top lately with organizing their room? You’re so OCD. Eva’s compulsive behavior and rituals eventually becomes one of the main outlets for comedy in the film, (unsuccessfully) attempting to make us ROFL. Deuce later asks Eva, “did you just kiss me nine times because you’re OCD?”  Because it is so poorly understood by the public, the wide-spread perception of OCD often divorces any suffering from the disorder, painting those with OCD as having a simplistic and one-dimensional quirk. So what is OCD, then?  Let’s get into it.

Harvard University defines OCD as, “[being] troubled by intrusive, distressing thoughts (obsessions) and [feeling] the pressure to carry out repetitive behaviors (compulsions).” This makes the reality of OCD far darker than the simplistic public portrayals. In terms of the specific content of the thoughts, OCD does not discriminate. It may influence how you view relationships, sex, work, health, death, the meaning of life, God, your image, your body… the list goes on. If left untreated, OCD can leave sufferers consumed by fear on a daily basis and spiraling into a black hole of depression. Say you struggle with relationship OCD, a subtype of OCD. These repetitive thoughts could look something like… Do I REALLY love her? This is a big commitment, what if I make the wrong decision? Can I find someone more attractive? We hooked up last night and I felt attracted, but how do I know she’s attractive ENOUGH for me? I mean, her boobs aren’t as big as I would like. Her nose is a little too rounded. But I really do love her… I know I’ve felt it before. So why don’t I in this moment? Is something off? What if I commit and then I don’t actually love her? What if I marry her and then I’m not attracted at that point? I need to make SURE that doesn’t happen. A common rebuke to the OCD conversation is the classic “...but isn’t that what everyone feels?” In this specific case, yes, some people do have these types of thoughts. But the key differentiator of OCD is the repetitiveness and stickiness of the thoughts. Try imagining the brain as a circular running track that surrounds a football field.  Maybe you were (or are) a track star in high school. Or at the very least, have run a mile at some point during grade school. The non-OCD brain might get tripped up at points as they run along the track, causing delays as they attempt to finish the race, but they eventually get there. But no matter how hard the OCD brain runs, it just can’t seem to keep going once it gets tripped up. With relationship OCD, this might mean that you end up having the same thought patterns about every single relationship you’ve ever been in.  You just can’t get past the... do I really love them? Or... are they good enough for me? Am I attracted to them? Maybe even the inverse.. Am I good enough for THEM? Will I lose them?! The way the OCD sufferer responds to these obsessive, intrusive thoughts is to engage in compulsions. To the brain, the purpose of compulsions is to try to gain certainty as to what you’re obsessing about.  These compulsions can either be physical or mental, as we put an absurd amount of energy engaging with tactics such as:

1. 1. Reassurance seeking
   2. Analyzing
   3. Avoiding
   4. Checking 
   5. Comparing
   6. Counting
   7. Dwelling
   8. “Figuring it out”

 With relationships, an OCD sufferer may compare how they feel right now to the last time they felt a euphoric feeling to their partner. They may count in their head how many days it’s been since the last time they felt euphoric or they felt “connected”. They may analyze their level of attractiveness towards their partner, compared to other people. They may check in on their feelings of attraction every few hours, to make sure it’s on track. They may even outwardly seek reassurance from their partner that they are connecting well or they may get freaked out by all of these thoughts that they avoid being near their partner. The more this goes untreated, the likelier the OCD sufferer may be to end the relationship. No matter if the person was actually a really good fit for them. In any case, the OCD sufferer must figure out an answer to these questions. One Reddit user says of their Relationship OCD, “Not trying to seek reassurance (I’m sorry if I am eek) but does anyone else get thoughts about dating other people? I’ve been with my boyfriend for a little over a year and things have been rocky recently, so I get the desire to break up and download a dating app. Part of me wonders if I’m truly in love with him and if he’s the one for me since it often feels like he loves me more than I love him.” In a separate thread, another user explains her dilemma between two men with a detailed analysis:  “The first is "conventionally" attractive, light, airy, and we have Disney romantic chemistry. I get around him and I relax entirely. He has a youthfulness about him that I value. But not only is he not my type . . . he shares none of my values, and has questionable relational skills. I cognitively know he doesn't have the emotional maturity for the long haul. And I think a life with him might feel like sparkling water . . . but it won't challenge me in all the ways I want to be refined as a woman, or really be as fulfilling as I'd like.” “The second triggers my ROCD like nothing else. He's not conventionally attractive--kind of rugged, mountain man (my preferred type). We share all the same values. Even the ones I'd tucked away in my heart thinking I'd never find a match because they were too antiquated. We have amazing sexual compatibility. Really . . . we fire on all cylinders. But our connection is more--rich, grounded, mature, adult, long-term and doesn't have Disney romantic fireworks chemistry. It's more practical and something that would continue to build over time.” If you go back to the eight compulsion tactics we mentioned above, nearly all of them can be found in these brief comments. Sometimes for the OCD sufferer, it could be minutes, hours, days or weeks until you figure out you’re engaging with compulsions. You may or may not resonate with the relationship theme, but the same obsessive and compulsive tendencies apply if you’re trying to make a career choice, investigate if your pee infection is actually cancer, figure out if God is real or if your friends facial expression subtly means that they don’t like you all that much.

In recent years, psychologists have been able to verify over 300+ subtypes of OCD. Yet this number can actually be limiting, because we can literally obsess over anything.

The compulsion is our attempt at gaining certainty and reducing our anxiety about the subject, but this anxiety-reduction is temporary. For example, if we go to the doctor to investigate if our pimple is actually skin cancer and they tell us we’re completely healthy, this gives us relief. But in some cases, it will only be a matter of time before we start obsessing about the pimple or another perceived health issue. OCD can be incredibly nuanced, and we can be easily convinced that every obsession that pops into our head is true due to its mere presence there.. This doesn’t mean we shouldn’t be wise about health or get things checked out, but compulsions aren’t helping us. In the end, OCD is primarily a disorder about uncertainty. We can’t deal with the ambiguity, so we do everything we can to feel 100% sure. But the reality is, nothing in life is 100% for certain. You may get hit by a car today. You may get fired, unexpectedly. You may have a brain aneurysm or you might actually be living in an existential video game. Going round and round with these cycles only serves to make our life smaller and smaller, more confined as each day goes on.

“Currently I can only leave my house for work and grocery shopping because everything else makes me too anxious,” says another Reddit user.  Another says, “I suffer from obsessive thoughts and it makes my life a living hell. I think of death every day now. I am scared of my own thoughts…it goes in a vicious circle in my head, again and again and again.” The tendency when we read things like this is to hold a one-dimensional mindset in terms of how we identify OCD within ourselves. We learned above how OCD works and we now look at it through the lens of others' experiences thinking… I've never struggled with those themes and I don't feel like they do, so I must not have OCD.  While yes, the majority of the population may not struggle with OCD, those that do suffer with OCD often have to wait a painful 10+ year period to get a proper diagnosis. We’re not here to diagnose you, but we want to help you avoid any possibility of going through needless suffering. You are a unique individual with unique struggles, so it’s important to be open-minded as to how your struggle might be manifesting.  At the very least, even if you don’t have OCD, taking this approach will help you develop the skills to identify obsessive tendencies in loved ones. OCD often looks different for everyone. The way one person’s anxiety manifests may be different than another person. One person may suffer, but be highly functional. Another person might not be able to leave their bed.  The particular subtype we’re struggling with at any given moment also holds weight to how anxious we get and how much perceived control we have over our obsession. All of these reasons contribute to why it’s helpful to explore the nuance in the OCD subtypes. As we mentioned above, there are 300+ known subtypes of OCD, which include:

Obsessing over finding the right partner, their characteristics, attractiveness, your compatibility, connection and feelings, if you (or they) are good enough. Example thoughts include: 

• • “Is she the one I want to be with?"
  • “Why aren’t I sexually attracted right now?”
  • “Am I attracted enough?”
  • “Why aren’t we connecting?” 
  • “Why don’t I feel the way I’m “supposed” to feel?”
  • “I love him so much, will I lose him?”
  • “I’m only going to get to have sex with her for the rest of my life”
  • “Am I actually enjoying sex right now?”
  • “Do I find this other person to be attractive? What does that mean?”

 Example compulsions may include:

• • Seeking reassurance from partner that they really love you
  • Analyzing your feelings regularly and rationalizing why you do or don’t feel a certain way
  • Avoiding being around them, withholding intimacy and/or breaking up
  • Periodically checking in on your partner’s body language or your feelings
  • Comparing your relationship to others and your feeling states to previous time periods
  • Counting the time intervals between moments of connection
  • Rigorous analyzing whether you missed the boat with an ex in the past
  • Strategizing how you’re going to get back with that ex in the future
  • Checking to see how your partner is interacting with opposite sex

Also known as scrupulosity, this subtype involves obsessing over your behavior, violating your own moral standards and spiritually speaking, how God feels about you. Example thoughts include: 

• • “Am I being a good Christian right now?”
  • “Why did I just curse them out in my head? Am I bad?”
  • “I’m not doing what Jesus would do right now”
  • “Have I been mean to my parents?”
  • “Did I come off kind enough to my roommate?”
  • “What does my one-night-stand mean about me?”
  • “I’m not reading my Bible enough”
  • “I’m not praying enough”

 Example compulsions may include:

• • Seeking reassurance from others that you are a good person
  • Counting how many times you’ve prayed or read your Bible recently
  • Rigorously analyzing your behavior to see if it lines up with Jesus
  • Avoiding being around people, for fear of being “bad” or coming off negatively
  • Checking someone else’s body language to confirm you’re coming off kind
  • Comparing your morality with other people’s, ranking your morality
  • Counting how long it’s been since you sinned
  • Being extremely rigid on following the rules

Subtype that involves dwelling on unanswerable questions, including the meaning of life, the nature of self, the universe, the existence of God and/or your purpose. Example thoughts include: 

• • “Does God actually exist?”
  • “What am I?”
  • “What is a hand? An eye?”
  • “What is the meaning of life?”
  • “Why am I here?”
  • “How do I know that’s me in the mirror?”
  • “Is everything pointless?”
  • “What’s my purpose?”
  • “Am I actually living in a video game?”
  • “Is reality a figment of my imagination?”
  • “What is a thought?”
  • “How is it that words just come out of my mouth?”
  • During sex, wondering “what am I doing right now?”

 Example compulsions may include:

• • Seeking reassurance from others that reality is in fact, real. 
  • Analyzing whether you feel a sense of purpose right now
  • Obsessively reading books and materials to investigate existence of God
  • Won’t stop trying to “figure it out”, holding thoughts in head to get to conclusion
  • Trying to block out the thoughts and running for shelter, mentally or physically
  • Analyzing the evidence for and against if you’re living in a video game

This subtype involves excessive rumination over whether God is speaking to you or it’s just your thought, whether you’re connecting with him, if you “feel” him near. Example thoughts include: 

• • “Was that my thought or God speaking in my mind?”
  • “Am I connecting with God enough right now?”
  • “Is he speaking through this scripture or am I just reading into it?”
  • “Do I feel him right now during worship? Or is it just psychological?”

 Example compulsions include:

• • Weighing the evidence for and against that it was God’s voice
  • Comparing how other people say they’ve heard God with what you’re experiencing
  • Counting the time intervals since the last time you felt connected to God
  • Avoiding reading the Bible, religious texts or praying to get away from thoughts
  • Seeking reassurance from others that it must or must not be God speaking to you

Officially labeled an OCD-related disorder, this involves a constant fixation on the state of your health, bodily feelings, pain and/or fluids. Also known as hypochondria. Example thoughts include: 

• • “Does this tingling in my foot mean that I have ALS?”
  • “Is this headache actually brain cancer?”
  • “Why if my urinal pain is actually a sign of something much worse?”
  • “Why do I have diarrhea right now?”
  • “Am I breathing properly right now? Do I have COVID?”
  • “What if I get sick?”
  • “I’m seeing floaters right now. Am I going blind?”

 Example compulsions include:

• • Excessive research online to try to diagnosis yourself
  • Urge to go to emergency room repeatedly
  • Repetitive visits back to doctor, even after they said you were fine
  • Closing eyes and reopening, excessively checking if vision is any better
  • Analyzing why the headache may or may not be cancer
  • Feeling your foot and touching it, to make tingling go away
  • Checking in periodically on your breathing
  • Examining your poop every time you go to the bathroom
  • Checking there isn’t blood in your urine every time you pee
  • Seeking reassurance from others that you’re fine or your condition is normal
  • Counting the days, minutes or hours since you last felt a symptom

Excessive rumination over the state of your mental health, how anxious or depressed you are, if you’re going crazy, if something is or isn’t an OCD thought. Example thoughts include: 

• • “I’ve been depressed for 7 days. Does that mean I’ll always be depressed?”
  • “I feel crazy right now. Am I losing my mind and control?”
  • “What if I just flip out?”
  • “Is this an OCD thought or not? How do I know?”
  • “Will my mental health struggles come back? Are they coming back right now?”
  • “Will OCD always dominate my life?”
  • “If I go back to that place, will the bad feelings come back?”
  • “I just felt panicky, will I start panicking again?”

 Example compulsions include:

• • Excessively researching your mental health condition online
  • Trying to “figure out” if you’re on the right path to recovery
  • Watching comedy movies to see if you laugh and feel happy feelings
  • Periodically checking in on your feelings and seeing if you feel anxious
  • Avoiding previous places you were anxious out of fear you’ll be anxious again there
  • Counting how long it’s been since you last felt good
  • Comparing present feeling-state with previous feeling states
  • Analyzing what it was about that feeling-state that you had better mental health
  • Weighing evidence for and against that something is an OCD thought
  • Periodically checking your mindset to see if you “feel crazy” or not in moment

Obsessing over your career path, your sense of purpose, whether you will succeed or not, whether you’re doing a good job or not, whether your boss likes you. Example thoughts include: 

• • “Is this business going to work out? Are we going to fail?”
  • “Would I have wasted all this time and we failed?”
  • “Am I living up to my potential?”
  • “Is my work purposeful? Is this all meaningless?”
  • “Do my boss and co-workers think I’m doing a good job?”
  • “Is this the right career path for me?”
  • “Is this the career path God wants me to follow?”
  • “Am I making the right choice by leaving this job?”

 Example compulsions include:

• • Staying late at work intentionally to influence whether your boss likes you
  • Overworking and not wanting to stop for fear of failure
  • Analyzing co-workers reactions and comments towards you
  • Counting the time interval since last time your boss gave you a complement
  • Seeking reassurance in crafty ways from investors, co-workers or boss
  • Checking performance reports religiously to ensure things are going well
  • Analyzing why this is a good career path and reassuring yourself you made good choice
  • Constantly weighing the pros and cons of staying in a particular job
  • Trying to make your work visible, so people see you’re being productive.
  • Holding onto work thoughts, even when you’ve stopped, for “progress” sake

Excessive rumination as to whether people like you, understand you, enjoy your company and what they think of you, your apartment, dog, family, spouse, etc. Example thoughts include: 

• • “Do they think badly of me?”
  • “Why did they just give me that look?”
  • “What did that comment mean?”
  • “They were looking at our apartment weirdly”
  • “Did they interpret my comment negatively?”

 Example compulsions include:

• • Rigorously analyzing people’s facial expressions to gauge how they feel about you
  • Repetitively reviewing a comment you made to figure out if they took it badly
  • Counting time intervals since the last time that person complimented you
  • Seeking reassurance from others that a specific person likes and approves of you
  • Replaying the events of a dinner or occasion to make sure you remember correctly
  • Subtly trying to seek reassurance from specific person that they like you

Now officially classified in DSM as an OCD-related disorder, this subtype involves excessive rumination over your looks, attractiveness, body parts and bodily shape. Example thoughts include: 

• • “Am I attractive enough?”
  • “My nose is too big”
  • “My boobs are too small’
  • “My arms aren’t muscular enough”
  • “My butt is too flat”
  • “I’m too fat”
  • “My arms jiggle too much”
  • “No one will love me because of how I look”
  • “Do I have too much belly fat?”

 Example compulsions include:

• • Excessively looking at yourself in the mirror
  • Grabbing parts of body and examining them
  • Flexing in the mirror to confirm if your muscle is or isn’t big enough
  • Excessively checking your hairline in the mirror
  • In some cases, going to get plastic surgery to fix features
  • Excessively working out to achieve a certain look
  • Seeking reassurance from others that you are attractive
  • Avoiding situations that would increase fear of being perceived unattractive

Frequently misdiagnosed in the medical field, this subtype includes frequent obsessions about whether or not you’re going to kill yourself. Example thoughts include: 

• • “I feel really depressed right now. Am I going to kill myself?”
  • “I just imagined jumping in front of that train. Does that mean I want to kill myself?”
  • “Just because I’m thinking about suicide, does that mean I want to do it?”
  • “How do I know I don’t want to commit suicide?”

 Example compulsions include:

• • Researching the suicides of other people, trying to see if they line up with your story
  • Analyzing the evidence for and against why you’d act on suicide
  • Checking in on your feeling-state to see if you feel depressed
  • Counting the time interval since you last had suicidal ideation
  • Comparing your feeling-state now to a happier period, dwelling on what this means
  • Avoiding anything that would remind you of suicide

Obsessing as to whether you’re going to hurt someone or not, physically or emotionally. This subtype involves lots of shame and secrecy out of fear of being judged. Example thoughts include: 

• • “I just imagined stabbing my wife. Do I actually want to do this?”
  • “What if I lose control and hurt someone?”
  • “It feels like I want to strangle my dog. I’m a danger to society.”
  • “What if I accidentally poisoned someone because I cleaned near their food?”

 Example compulsions include:

• • Hiding all the knives in the house
  • Avoiding being around your wife and/or dog
  • Researching online the background of killers and see if you fit profile
  • Examining people’s food to make sure it doesn’t have poison

Excessive rumination as to whether you are gay or not, if you’re attracted to the same sex and what that means about you. Example thoughts include: 

• • “Did that gay sex scene turn me on?”
  • “Do I think that he’s attractive? Do I want to have sex with him?”
  • “I just imagined his penis in my mouth. Does that mean I’m gay?”
  • “Was I just flirting with her? Will she think I’m a lesbian?”

 Example compulsions include:

• • Avoiding any movies that have gay relationships in them
  • Avoiding attractive people of the same sex
  • Analyzing the last time you were turned on by opposite sex to confirm you’re straight
  • Initiating sex with wife or husband to induce arousal and confirm you’re straight
  • Checking and looking at photos of same sex to see if you’re sexually attracted

Excessive rumination as to whether you are attracted to children or not, and what that means about you. These thoughts often cause shame if misunderstood. Example thoughts include: 

• • “Was I attracted to my nephew’s body parts when he was running around naked?”
  • “That little girl is pretty… does that mean I want to have sex with her?”
  • “I just imagined that little boy’s penis in my mouth. Does that mean I’m a pedophile?”
  • “Did I just come across as a little too playful with my son? Do I desire him sexually?”
  • “When we were on the playground, did I just touch her butt sexually?”

 Example compulsions include:

• • Avoiding being around any situations where kids are involved
  • Avoiding or turning off any movies where kids are on the screen
  • Researching the profile of pedophiles and if you fit the profile of one
  • Researching the legalities around pedophilia and what this would mean for you
  • Analyzing your thoughts to determine if you were actually attracted or not
  • Counting the time intervals from last time you thought you were attracted
  • Checking in periodically on your feeling-state when around a kid

Obsessive fixation on bodily functions such as blinking, your heartbeat, your swallowing, your breathing, your hearing or other sensations. Example thoughts / themes include: 

• • “I can’t stop noticing my blinking. Will this last forever?”
  • “I’m afraid I’m going to choke when I swallow”
  • “What if I never stop noticing my heartbeat? It feels like it’s popping out of my chest”
  • Constantly being aware of your bodily functions
  • Constantly fixating on other people’s bodily functions

 Example compulsions include:

• • Checking bodily functions: am I noticing my swallowing now?
  • Imagining and wishing for life without noticing bodily functions
  • Distracting yourself as much as possible so you don’t notice bodily functions

Constant fixation with germs or getting sick, both for yourself and for the loved ones around you. Ranks among the most stereotypical forms of OCD. Example thoughts include: 

• • “She was just exposed to dirt at the kid’s park. Will she get sick?”
  • “How many people touched the doorknob at the coffee shop?”
  • “Is the town filtering clean water into my house?”
  • “The floor is dusty. Is that going to get into our lungs?”
  • “If I shake his hand, how do I know where his hand has been today?”
  • “I forgot to wash the chicken before I cooked it, what if we get salmonella?”

 Example compulsions include:

• • Excessively washing hands and asking loved ones to wash hands
  • Avoiding touching any door knobs or only touching them with a cloth
  • Avoiding all public restrooms; refusal to go to bathroom out of house
  • Excessively cleaning the floors in the house
  • Analyzing in your head if you’ve cleaned enough
  • Trying to achieve a “just right” state of mind of cleanliness
  • Counting how long it’s been since you’ve cleaned something
  • Reviewing all the details of last time someone got sick and trying to figure out why

This subtype involves obsessing about one’s actions or non-actions related to the welfare of other people around you. Example thoughts include: 

• • “If I don’t check in before he starts driving, he might get in a crash”
  • “It will be my fault if my mom gets depressed if I don’t call three times a day”
  • “She went out for a walk late at night, but I didn’t warn her to be careful”
  • “I didn’t pray for her and now look at what happened. It’s my fault.”
  • “Did I just hit them with my car?”
  • “If I don’t get involved in every step of their recovery, they won’t get better”
  • “Did I leave the stove on? What if the house burns down and my dog dies?”

 Example compulsions include:

• • Making extreme decisions (i.e. having dad move in) with little consideration
  • Developing unhealthy dynamics with spouses, kids and/or family members
  • Checking and circling back to see if you hit someone with your car
  • Excessively calling your mother everyday to make sure she’s good
  • Calling parents every morning to make sure they are okay
  • Ritualistically praying for someone every night so they don’t die
  • Trying to prevent roommate going out for walk because it’s dangerous
  • Checking the phone every 30 minutes to see if they called back
  • Excessively looking for therapists for sister to make sure you get it “right”
  • Counting how long it’s been in your head since you last spoke to loved one
  • Rationalizing that other people are around so roommate won’t get hurt walking at night

Obsessing about always being up to date with information, whether that be emails, sports scores, texts, company reports or details about movies. Example thoughts / urges include: 

• • “What’s the score of the Yankee game?”
  • “Where do I know that actor from?”
  • “Did they email back?”
  • “Do I have a bunch of text messages right now?”
  • “Did we hit our goal for the quarter as a company?”

 Example compulsions include:

• • Checking company revenue every 15 minutes the last few days of month
  • Checking text messages and/or emails religiously
  • Immediately looking up the score of the Yankee game with no resistance
  • Watching a movie with phone or computer in hand to look up information
  • Refreshing Instagram feed compulsively to see if there’s new information
  • Excessively checking the news many times a day

Excessive rumination and reflection on an event that happened in the past and your ability to recall it correctly. Often is paired or part of other subtypes. Example thoughts include: 

• • “Did I accidentally say something inappropriate to my friend yesterday?”
  • “Did I hurt my brother or sister when we were younger and playing at the park?”
  • “When my son fractured his arm, did I just let it happen? Where was I?”
  • “Did I come across like I was flirting with my co-worker?”

 Example compulsions include:

• • Replaying the events of that incident in your mind over and over again
  • Seeking reassurance from loved ones that you got the order of events right

With this subtype, sufferers engage in superstitious thinking, believing that if they merely think something, it must come true.  Example thoughts include: 

• • “If I don’t text my parents before I take off from a flight, the plane might crash.”
  • “If I have a negative thought while I am speaking to a friend, something terrible will happen to him.”
  • “If I happen to look at the clock when it is 3:33 p.m., I will cause everyone I spoke to that day to have a terrible day.”
  • “If I have a negative thought, I need to balance it out with three positive thoughts in order for nothing bad to happen.”
  • “If I don’t make my bed in the morning, my mother will die.”

 Example compulsions include:

• • Texting your parents to ensure flight doesn’t crash
  • Avoiding the clock in the middle of the day
  • Thinking three positive thoughts in response to the negative thought
  • Making sure to make your bed every morning

Distinct from an actual hoarding disorder, this subtype involves excessive rumination on what will happen if they throw something out. Example thoughts include: 

• • “I’ve had my son’s baby clothes for 25 years, if I throw them out, will I lose my identity?”
  • “If I throw away this dirty tissue, what if someone gets sick from it?”
  • “My ex wrote me this beautiful card 10 years ago, if I throw it out, am I throwing him away forever?”
  • “I haven’t used this DVD in 5 years, but what if I’ll watch it some day?”

 Example compulsions include:

• • Storing away son’s baby clothes and other childhood belongings
  • Keeping the DVD and the love letter
  • Analyzing what will happen if you throw the item away
  • Rationalizing why it makes sense to keep the items

Excessive rumination that something just “doesn’t seem right” and the need to perfect things to make them “just right”.  make things right. Example thoughts / actions include: 

• • “This social media post has an uneven number of nine slides. I need a 10th item.”
  • “This diagram isn’t a perfect circle, I need to fix it.”
  • “My hair is lopsided on one side and neat on the other.”
  • “I need to email this person with just the right words so they understand me.”
  • “The picture frame is off-kilter, I need to re-balance it.”

 Example compulsions include:

• • Creating more content for social media post so it has an even number
  • Properly formatting and evaluating a word document before writing.
  • Always drawing diagrams in perfect circles or triangles.
  • Fixing hair so it’s perfectly symmetrical.
  • Reading and re-reading an email to someone before sending it so that it’s right

With all these subtypes in mind, we need to evaluate a few different variables to truly understand how OCD could be manifesting in you personally and/or in the life of a loved one. First, some forms of OCD are much more obvious to the eye. Take contamination OCD for instance, as the compulsions are physical. But for other themes, if all the obsessions and compulsions are happening in your head, the people around you might never notice. In fact, nothing may be obvious to you because obsessive thinking has been the norm your whole life. Films like Deuce may have shaped your stereotypical view of OCD, so the possibility of having OCD hasn’t even crossed your mind. To reverse this trend, it requires understanding the nuances of how OCD works and what might trigger these subtypes for you. One way we can do that is by not putting anxiety in a box in terms of what it looks like for the OCD sufferer. The anxiety that these themes produce can feel different in different seasons. So just because you’re not having a panic attack over your obsessions, doesn’t mean that it’s not affecting the decisions you make on a daily basis. OCD often attacks what’s most important to us, so while a health scare can seem paramount in one season, obsessing about work might be at the top of your list in the next. What once made you incredibly anxious may no longer do that if it’s not as important to you. Next, we also have to take into consideration our perceived level of control as it pertains to each theme. Now, keep in mind, we ultimately don’t really have control in any situation. But in the context of OCD, there are some themes that make it easier for you to engage with compulsions. For example, you cannot run away from the physical symptoms of an illness in your body. The tingling in your feet or the headache will come. And when it spontaneously happens, you’re more than likely to feel powerless. But we can avoid that with other themes, like Pedophilia OCD. There are some things we can do to try and keep ourselves “safe”. For example, we don’t necessarily have to be around children. And with something like Work OCD, we can control how much we work and we can work ourselves to death while still being under the delusion that this is making us not fail.  Trying to keep yourself “safe” is not beneficial, by the way. It actually makes you worse in the long-term. But we’re simply explaining this to give some context as to why certain themes might be causing more emotional distress than others at the present moment.  Depending on their theme, some people experience OCD with high levels of anxiety on a daily basis, while others have a consistent low-grade discomfort that causes dysfunction in their day. But one final thought to keep in mind here is that all OCD is the same in the sense that the only thing really changing is the content of our thoughts. As we’ll learn later, we take the same approach in therapy, regardless of the subtype.

Before we talk about how to treat OCD, it’s important to pause and acknowledge how to approach a diagnosis. Which goes to say, it’s never by diagnosing yourself.  Your mental health is too big of a deal to WebMD this. We mentioned above that our goal was simply to inform you, not diagnose you. And at this point, you may have a much better understanding of OCD and have a hunch that it might be something you have. That is encouraging news, if we could play a small step in you understanding yourself better, but still go to a OCD specialist to see if they diagnose you.  Because the reality is, you may have OCD or… you may not. As you begin trying to find a therapist, it’s important to understand that not all therapists are equal. Some list OCD as a specialty, but the reality is that it is just one of many things that they treat. This is one of the reasons why OCD is chronically misdiagnosed as basic anxiety or generalized anxiety disorder. Search for someone who is recognized for their OCD work, who has case studies and specifically leverages ERP (exposure-and-response therapy) and CBT (cognitive behavioral therapy) for treatment. We’ll talk about these treatments in a minute. Expect that you are going to have to pay out of pocket, because the mental healthcare system in the United States is not great. Quality therapists often aren’t covered by insurance, but this is well-worth the investment. Your mental health is too important. Some might read this and think we’re overly giddy about getting you a diagnosis. There’s a classic mindset in the West when it comes to mental illness that we need to avoid putting people in boxes and giving them labels, which only furthers the stigma. 

In our view, diagnoses are gifts that will add years to your life. Why wouldn’t you want to understand how your mind works and act accordingly? If you had high blood pressure and were about to have a heart attack, wouldn’t you want to know?

Of course, a misdiagnosis would not be good. Yet this is precisely why we’re advocating to see a quality therapist. Good therapists won’t diagnose you with OCD if you don’t have it.  But good therapists can also properly diagnose you if you do have OCD, which will change your life in the best way possible. No longer will you be in the dark, wondering why it seems like your brain works differently. This is one of the first steps to carving a personalized approach to tackling your mental health. The exciting thing to celebrate is that OCD is a very treatable condition, as we’ll get into with this next section. Where you are now doesn’t have to be where you’ll be tomorrow.

One of the primary ways that OCD specialists evaluate a potential diagnosis is through the YBOCS (Yale Brown Obsessive-Compulsive Scale). This is a 10-item, clinician administered scale to evaluate symptom severity. If they confirm a diagnosis after completing your initial sessions, pay attention to what happens next. Understanding OCD subtypes at a broad level is one thing, but it’s a discovery process to understand the nuances of how your OCD manifests. One of the first steps is identifying the potential themes that you struggle with. You can do this by keeping a thought catalog. Write down what you’re consumed with all day, what’s making you anxious and look over the list of OCD subtypes.  After doing this for a couple weeks, you’ll begin to understand what types of thoughts and themes continue to pop up for you, if you don’t know already. Next, the therapist should help you walk through a fear hierarchy, which ranks your obsessions top to bottom. The ones at the top cause the most anxiety and distress, while the ones at the bottom might be the easiest ones to tackle at first.  The more you build out your thought catalog and fear hierarchy, the more you’ll be able to identify the specific situations that trigger your OCD most and the compulsions you then start engaging with. Pay close attention to your mind. Are you rationalizing? Checking? Counting?  It will take time to identify the specific tactics your brain is using to compulse. This is critical information to gather, because otherwise it will be hard to make progress. Your understanding of how OCD works in your brain will stay at a superficial level. Treatment happens in the details.

The gold standard treatment for OCD is ERP (exposure and response prevention). As the name implies, the goal is to expose yourself to your obsessions without engaging in the compulsions. For example, you may struggle with some form of responsibility OCD or relationship OCD. Your partner went out to get groceries, but it’s been a couple hours. Rather than give into the urge to compulse in the form of checking your phone and watching the clock, you expose yourself. Resist the urge. Of course, this will throw your OCD through fits.  Wouldn’t anyone think something was strange if they weren’t home by now? What if they got kidnapped and I could have prevented it? What if my inaction is actually negligence? I need to check in with them right now. Anxiety will surge, but let the thoughts run by like a stream of water. Over time, you’ll find that your anxiety will start to decrease. You’ve now started the process of rewiring your brain to think differently. Or perhaps if you struggle with Work OCD, that means intentionally leaving on time everyday and fighting the urge to enhance the chances of impressing your boss. Again, your OCD will throw fits. They're looking for people who will go the extra mile. In fact, it has impressed him in the past. This seems wrong. I better stay. In response to that, the next urge will be to mentally compulse – to rationalize why your boss will be fine if you leave on time, to compare other times in the past when you left on time and they seemed fine. Resist the urge to engage these thoughts. Exposing yourself in the wake of mental compulsions means interrupting yourself mid-thought and saying, “they may or may not be fine if I leave on time. They may or may not think less of me. But these mental compulsions won’t help me gain any more certainty.” This likely will make you even more anxious by not entertaining these thoughts to find some semblance of certainty. But as with the responsibility OCD example, over time you’ll find that your anxiety will start to decrease as you reach a kind of equilibrium. Of course, there is nuance involved in our specific situations, which is another reason why therapy is so important. The goal is not to be negligent – to not check out a pressing medical issue, or to be lazy at work, or to not check in on your spouse after it’s been all day. One of the cognitive distortions that OCD sufferers usually struggle with is all-or-nothing thinking, which means we tend to look at things in extremes. By suggesting we leave work on time, our minds race to... so I'm supposed to be lazy? I'm supposed to do a crappy job? No, you’re learning to accept uncertainty and live life in the middle.  Circling back to what we talked about in the previous section, to properly go through the ERP process, this requires understanding your thoughts, obsessions and compulsions. ERP will not be as effective unless you’re able to identify the specific trends of your OCD. If this all sounds like a difficult process to go through that will only provoke your anxiety, that’s because it is! ERP is hard work. But what’s the alternative? To stay trapped in the vicious cycles of your OCD? Freedom is ultimately on the other side of ERP.  Remarkably, those with ERP success stories ultimately find themselves better equipped to cope with the uncertainties and tragedies of life than the average person.  

ERP is part of a larger umbrella of a universally-acclaimed talk therapy called CBT (cognitive behavioral therapy). Harvard defines CBT as, “A highly effective psychotherapy [that] focuses on how our thoughts, beliefs, and attitudes can affect our feelings and behavior.” It’s based on the idea that much of reality is shaped by our thoughts and feelings, not externally facing circumstances or variables, like people, situations or events. The benefits of CBT help us better cope with circumstances, even if the externally facing variables don’t change. Proponents of CBT are quick to point out that CBT is not merely about positive thinking, but rather realistic thinking. How do we interpret the events that happen within reality, both negative and positive? As one psychologist put it:  “The goal with cognitive therapy is to make sure someone has an accurate assessment of the situation. Some situations are genuinely awful, and a negative belief about them makes sense. Some situations are truly good, so a positive thought is accurate.” Of course, central to the idea of CBT would then be how you make sense of the world. How do we define what’s accurate, genuinely awful or truly good? How do we make sense of suffering, our experiences and the ways people have hurt us? Clearly, it can’t just be based on feel-good emotions.  Dr. John Gottman, one of the most influential psychologists in the world, details in his book The Science of Trust how women have told him some of the best sex they experienced was directly after physical abuse. We see this exact scenario play out with Nicole Kidman’s character in the critically acclaimed show Big Little Lies. But as we witness in the show, it’s doubtful any psychologist would encourage women to lean into their positive emotions in this scenario and view these experiences as “truly good”.   Objectively speaking, in any culture, there’s something deeply troubling about physical abuse. CBT works best when we align ourselves with objective truth and understand how the world actually works. Thousands of years before the modern roots of CBT, Jesus gave us a foundational paradigm for how to view our experiences.

1. 1. There is a Creator who designed a beautiful world, but humans only have a limited lens into the nature of reality.
   2. Since the beginning of time, something (clearly) has gone horribly wrong, springing about everything from wars and disease to death, mental health issues and racism.
   3. Humans are flawed and play an active role in hurting each other, infected by a condition Jesus labeled חטא (sin), which in its simplest form, means to miss the mark. Think in terms of archery, to which we are essentially missing the bull’s eye on the Creator's original design to love God and love each other.
   4. Jesus claimed to be the primary means himself in which all things are being restored to their original condition, inviting us to follow his way of life. 
   5. In the present day, we live in a time period of the “now” (present healing, reconciliation and beauty) and “the not yet” (future and final healing and reconciliation).

 Knowingly or unknowingly, aspects of this paradigm have undoubtedly influenced modern-day psychology and our approach to CBT. For a therapist to even guide a patient into an “accurate assessment” of the situation, requires them staking claims to what’s “genuinely awful” and “truly good”. It requires an acknowledgement that things aren’t as they should be and that humans do play an active role in hurting one another. It requires walking their patient through how to cope in the midst of suffering, to live between the healing available “now” and the hope of the “not yet”. And hereby is the importance of aligning ourselves with how the world (objectively) works when practicing CBT.  When it comes to treating a subtype like existential OCD, putting CBT into motion would involve getting the patient to see they only have a limited lens into the nature of reality. It is futile to try and “figure it out”. Furthermore, because humans are not designed to see the future, with every subtype it involves accepting a degree of uncertainty related to our obsessions. Harvard adds that, “CBT is designed to help a person with OCD recognize the unreasonableness of the fearful, obsessive thinking.” In the cases of subtypes like health OCD and contamination OCD, practicing CBT would require accepting that suffering will always be a future possibility. We are not guaranteed our health nor the ones we love, yet in the midst of this, Jesus gives us what many have said is the best take on suffering in all of history. Jesus and his followers knew that suffering (dealt rightly) can produce perseverance, which in-turn will make us complete as human beings. Why is it that we always enjoy the underdog story? Why is it that the most compelling narratives in film are often the tragedies that turn into triumphs? It’s because this simple truth is woven into the fabric of our existence. Time and time again we learn that to get the best results out of CBT, we have to get an accurate assessment of the situation. As we’ve observed, we do-so by aligning ourselves with how the world actually works and let everything else flow out of objective truth. To which Jesus says this to his followers: “Therefore everyone who hears these words of mine and puts them into practice is like a wise man who built his house on the rock. The rain came down, the streams rose, and the winds blew and beat against that house; yet it did not fall, because it had its foundation on the rock.”

While ERP and CBT are the gold standards of OCD therapy, they are not the only options.  SSRIs such as Luvox, Zoloft, Prozac, Paxil, Celexa and Lexapro are the most commonly used medications in conjunction with ERP and CBT. But most therapists would advise that medication is not a replacement for ERP and CBT, rather a supporting character for treatment. If you are thinking about taking medication, here are a few things to consider before moving forward:

1. 1. Avoid making this decision on your own. Consult with your OCD-trained therapist and come up with a comprehensive game-plan on how to treat your OCD first. 
   2. Educate yourself on medication. Scientists still aren’t exactly sure why SSRIs work for OCD, only that they do. SSRIs are generally considered safe, but given that they’ve only been in existence for a few decades, it’s difficult to know the long-term side effects. 
   3. Medication isn’t a cure-all. It’s shown to be 40-60% effective in reducing symptoms, which means some people won’t benefit from them at all. The process may also require trying different medications, as some work better than others based on the individual.
   4. SSRIs often come with unwanted side effects, such as elevated cholesterol, weight gain, lowered libido and insomnia, amongst other things. 

 A closing thought on the medication conversation:  There’s often a stigma associated with taking medication, but it’s time to question why that is. If someone was taking blood thinners to prevent blood clots, would that be frowned upon? How about insulin for type 2 diabetes? Or how about the eight oral medications typically used for multiple sclerosis? Ethnic stereotypes, religious dogma and misinformation have often been the culprits of the deep shame caused when we’re faced with the dilemma of whether to take medication or not. It’s time we rewrite the narrative, namely that it does not mean someone is weak, incapable or less “spiritual” because they are dedicated to go down this route. Rounding out the other alternative treatments for OCD are natural and herbal remedies, as well as deep-brain stimulation (DBS). While studies have been limited, research has identified 5-HTP, Milk Thistle, Inositol and N-Acetylcysteine as possible supplements that could be taken over-the-counter for OCD. Remarkably, a 2010 double-blind, placebo-controlled study comparing milk thistle and the SSRI Prozac showed little difference in the effectiveness of treating OCD symptoms. Lastly, when it comes to deep-brain stimulation, “a neurosurgeon implants ultra-thin electrodes deep in the brain in order to stimulate a specific region thought to be involved with OCD symptoms,” explains Harvard. But it isn’t easy to qualify for this, as it’s only offered to those who are severely ill and still have persistent symptoms even after going through ERP, CBT and trying different medications. DBS is considered a safe alternative, with very little side-effects post treatment. As we consider all of these treatments for OCD – ERP, CBT, SSRIs, herbal remedies and CBS – it’s critical to ask, what causes OCD in the first place?

In a previous blog, we covered the six underlying causes of mental illness, which are:

1. 1. Genetics
   2. Environmental
   3. Digital
   4. Circumstantial
   5. Ideological
   6. Existential

 When studying OCD, we find that some of these same factors are also at the root of the disorder. A 2017 study by Harvard and MIT revealed that four genes are commonly associated with OCD, including the NRXN1, HTR2A, CTTNBP2 and REEP3 genes. But just because we might have the “OCD gene”, doesn't necessarily mean that it will be activated, which is where causes 2-6 come in. The environment, particularly what we are putting in our body, likely plays a role in activating these genes and/or bringing the on-set of OCD. Harvard Medical School recently remarked: “For many years, the medical field did not fully acknowledge the connection between mood and food. The burgeoning field of nutritional psychiatry is [now] finding there are many consequences and correlations between not only what you eat, how you feel, and how you ultimately behave, but also the kinds of bacteria that live in your gut.” Emeran Meyer covered this heavily in his 2016 book The Mind-Gut Connection, adding: “We have made little progress in treating chronic pain conditions, brain-gut disorders such as irritable bowel syndrome (IBS) or mental illnesses… are we failing because our models for understanding the human body are outdated? The mind-body connection is far from a myth; it is a biological fact, and an essential link to understand when it comes to our whole body health.” The mere presence these common comorbidities across the broader population, as well the fact that 95% of the body’s serotonin receptors are located in the gut, presents powerful evidence of the environmental factors that impact OCD. By our estimation, this isn’t talked about nearly enough when it comes to finding a cure or creating treatments for OCD. The very medication used to treat OCD – SSRIs – is short for selective serotonin reuptake inhibitors.  The purpose of them is to increase serotonin levels to the brain.

This begs the question, why aren’t we putting much more research into how diet and nutrition relates to OCD, if the body’s serotonin receptors are located in the gut?

We must also not ignore how our circumstances have played a role in the on-set of OCD. Science has shown that if we had a childhood full of sexual abuse, bullying and/or some other overtly negative experience, this can impact our long-term mental health. In 2010, Harvard University reported: “Experiences are built into our bodies and significant adversity early in life can produce biological “memories” that lead to lifelong impairments in both physical and mental health.” Negative and traumatic life events, if not dealt with properly, can further fuel the presence of cognitive distortions. This causes an ideological disconnect between reality and how we interpret reality, which is partly why CBT has been shown to be so effective in treating OCD. Lastly, we must also consider how the digital age has influenced the presence of OCD in our lives. Smartphones and social media, by their mere existence, cause us to become more compulsive. The latest numbers suggest we pick up our phones anywhere from 50 to 300 times a day, meaning at minimum 3-4 times an hour.  An emerging thought-leader in the OCD space, therapist Shala Nicely writes: “Every time I pick up the phone mindlessly, I am giving my brain a little hit of positive or negative reinforcement. Just like every time I react to OCD as if it’s meaningful by doing a physical or mental compulsion, I get a little hit of anxiety relief. With either picking up the phone or doing a compulsion, sometimes I’ll get a big reward, sometimes a little one, and sometimes none at all, but my brain remembers the big payoffs (even though they don’t happen that often), and on the off chance that might happen again, it wants me to repeat the activity. Pick up the phone again! Do that compulsion again!” But given that smartphones and social media have only been around for about 15-20 years, it will be some time until we fully understand how this space is impacting our mental health.

So where does this leave us? The numbers suggest that about 2 to 3 million adults (up to 3% of the population) have been officially diagnosed with OCD in the United States. But by our estimation, it’s likely that far more people have OCD than the numbers reveal. The reason being, only a fraction of citizens in the United States actually go to therapy. And even if you do go to therapy, as we talked about earlier, OCD goes undetected.  Since many OCD sufferers don’t struggle with obvious physical compulsions, their obsessive and compulsive behavior goes unnoticed. Some people with OCD are high-functioning and if a therapist isn’t properly trained in identifying OCD, we’ve discussed how misdiagnosis can occur.

So how much of the population struggles with OCD? Could it be as high as 10%? 

It’s impossible to know. In a previous blog, we covered the eye-opening statistics surrounding mental health around the globe. Specifically in the United States, there are significant concerns around the lack of government funding towards mental health, accessible mental healthcare, affordable mental healthcare and quality mental healthcare. It’s been widely-documented that the healthcare system is essentially set-up to be a continuous loop of reactiveness and symptom-management, both for physical and mental illness.  We must ask the troubling questions – why does the government fund what they do? Why are controversial drugs being given a stamp of approval? Is there genuine concern about helping and healing people? Or is something else the motivating factor? In 2021, a group of Yale professors penned an op-ed in the Washington Post entitled, “The FDA is in desperate need of soul-searching” in which they outline how the FDA has fallen into bed with Big Pharma. It’s a common occurrence for FDA officials to swap roles with those on the boards of Big Pharma companies, such as Biogen. These are clear injustices and red flags that exist within the current operating system.  So if this is the case, where do we find our hope on the long-term outlook of OCD? Is it in medication? Is it in finding a great therapist? Or navigating the complicated and conflicting governmental factors to achieve success? These are all certainly parts of the equation, important and complementary aspects of our healing journey. But in our view the starting point of healing begins with taking a step back and considering how what you believe about the world affects your mental health.  We covered this in our blog on the root causes of mental illness, but we all live our lives by an ideology, which is a “a system of beliefs that we carry which shapes the way we interact with the world around us.” Whether we realize it or not, what we believe about the nature of reality, about God and about ourselves heavily influences the way we approach our OCD journey. In this regard, we’re big proponents of the way of Jesus as the most compelling way to make sense of the world. The way of Jesus proposes that healing is a holistic journey, made up of spirit, mind and body, with everything intertwined like a web. The way of Jesus helps settle the existential questions of the heart, like the meaning of life, our role in the world and the purpose of suffering, making healing a far less lonely journey as we get to walk side-by-side with the one who made us. Yes, there may be no cure for OCD, but settling our set of beliefs and then engaging with ERP has statistically shown to be a huge catalyst towards healing for many. The latest research indicates that 50-60% of those who undergo ERP see a reduction in symptoms.  This doesn’t mean the process won’t be painful. Healing often requires hard work.  But the tools are at our disposal for our tomorrow to be much better than our today. For more, click here to visit our Mental Health Hub.