Text adapted from "The patient with obsessive compulsive disorder" in Psychiatry in primary care by Peggy A. Richter and Steven Selchen (CAMH, 2019).
The cardinal features of OCD are obsessions and compulsions. Obsessions are intrusive, repetitive thoughts, urges, images or impulses that trigger anxiety and that the person is unable to suppress. Compulsions are repetitive behaviours or mental acts intended to reduce the distress caused by obsessions. They are often performed in a ritualistic or very specific way. People with OCD can experience either obsessions or compulsions, or both.
The table below lists some of the common themes of obsessions and compulsions in OCD.
Table 1 Common Themes of Obsessions and Compulsions
|Contamination||Concerns about dirt, germs, body waste, illness|
|Symmetry||Needing things “just so,” even or lined up in a certain arbitrary way|
|Aggressive||Usually focused on inadvertent harm, e.g., being responsible for a fire or break-in; horrific thoughts or images of deliberately harming others|
|Sexual||Disturbing sexual thoughts not consistent with one’s orientation or cultural norms, e.g., a gay person having unpleasant heteroerotic thoughts, having unwanted sexual thoughts about children|
|Religious||Thoughts about selling one’s soul to the devil; inappropriate thoughts about major religious figures; anxiety about committing a mortal sin|
|Somatic||Exaggerated fears of contracting a serious illness in the absence of identifiable high risk|
|Washing||Excessive hand-washing, showering, cleaning|
|Checking||Repeatedly turning the stove on and off; driving around the block to make sure one hasn’t hit anyone; repeatedly asking for reassurance|
|Ordering||Folding clothes “just so”; arranging all cans in the cupboard so labels face outward|
|Counting||Performing actions a certain arbitrary number of times, e.g., tapping each foot four times when getting out of bed|
|Repeating||Actions typically done to “cancel” out a bad thought or until it feels “right”; e.g., repeatedly going up and down the stairs or flushing the toilet|
Screening and Assessment
Ask the patient these three screening questions:
- “Do you experience unwanted thoughts, images or impulses that repeatedly enter your mind, despite trying to get rid of them? For example, worries about dirt or germs, or thoughts of bad things happening.” (Screening for obsessions)
- “Do you ever feel driven to repeat certain acts over and over? For example, repeatedly washing your hands, cleaning, checking doors or work over and over, rearranging things to get it just right, or having to repeat thoughts in your mind to feel better.” (Screening for compulsions)
- “Does this waste significant time or cause problems in your life? For example, interfering with school, work or seeing friends.” (This question helps to determine whether the severity of obsessive and compulsive symptoms in questions 1 and 2 meets the threshold for DSM-5 criteria.)
Assessing Patient Insight into OCD
Insight in OCD can fluctuate from good to absent or even to frankly delusional. It is important to assess because the degree of insight helps to determine the best treatment approach. Keep in mind that many patients may initially present their concerns as being realistic. Here is a useful way to ask about insight:
“I understand that in the moment when you are triggered, your [obsessions or compulsions] feel absolutely real to you. Sitting here in my office right now, do you think your [thoughts or behaviours] are logical? What do you think would happen realistically if you didn’t do [your ritual]?”
Obsessions can range from the mundane (“Did I lock the door?”) to the bizarre (“I may go into an alternate reality if I think the wrong thought”). However, it is not the content but the quality of the thoughts as intrusive, unwanted and difficult to suppress that makes them obsessions rather than delusions. OCD is sometimes called the “doubting disease” because pathological doubt fuels the symptoms for most people with the disorder.