Introduction

Obsessive Compulsive Disorder (OCD) is commonly associated with a fear of germs and a fixation on cleanliness, leading to obsessive cleaning or tidying behaviour. However, the reality of this disorder, particularly its “pure O” form, often differs drastically from the stereotypes. This article will delve into the complexities of this illness.

Overview: OCD and pure O

OCD is an, often debilitating, neuropsychiatric condition,¹ which involves the following key symptoms:²

Obsessions

Repetitive intrusive thoughts (which can also take the form of mental images) that cause anxiety or distress. These intrusive thoughts are disturbing, irrational and unwanted. They are likely to follow certain themes, including, but not limited to:

• Violence, e.g., thoughts about harming one’s spouse
• Sexual, e.g., thoughts about sexually harming one’s child
• Contamination, e.g., thoughts about catching an infectious disease
• Accidental harm, e.g., thoughts about accidentally running someone over while driving
• “Magical thinking”,³ e.g., thoughts like “if I don’t turn the light switch on and off 10 times, my spouse will die”

OCD is ego-dystonic,⁴ meaning that, logically, sufferers are aware that these thoughts are illogical and they do not reflect their true beliefs or desires. Instead, they often represent their worst fears.

Compulsions

Repetitive behaviours and avoidance, performed in an attempt to alleviate the anxiety or distress caused by the intrusive thoughts, for example:

• Avoiding using knives
• Avoiding being alone with their child
• Excessive hand washing
• Repetitively turning a light switch on and off

In purely obsessional OCD, referred to as “pure O”, there are no physical compulsions. However, pure O is still OCD. Its name is somewhat misleading because it does, in fact, involve compulsions, the difference is that these compulsions are performed mentally,⁵ for example:

• Counting or repeating a phrase in their head
• Ruminating on a thought, trying to work out if it is true
• Mentally reviewing memories to check whether they harmed someone

Those with pure O also commonly seek reassurance, from others or by researching online, and may avoid certain situations.

Stigma: taboo intrusive thoughts

OCD is often surrounded by taboo, particularly when it involves intrusive thoughts of a sexual or violent nature. Despite the fact that these themes are common amongst OCD sufferers,⁶ many individuals suffering with these symptoms feel ashamed and fear social rejection.⁷ This can prevent them disclosing the content of their intrusive thoughts or they may avoid seeking help altogether.

The reality is, unwanted intrusive thoughts do not reflect a person’s beliefs or desires, they are simply the unpleasant symptoms of a mental health condition. Suitably qualified mental health professionals should be able to identify, diagnose and/or treat OCD, including cases that feature violent, sexual or other taboo intrusive thoughts.

Causes: do genetics play a part?

The cause of OCD is a debated topic and it is thought that both environmental variables, such as upbringing or childhood maltreatment,⁸ and genetics⁹ play a role. Although a single “OCD gene” has not been identified, researchers speculate that a combination of different variations, or alleles, of certain genes may elevate the likelihood of OCD developing.

However, possessing high-risk genes doesn't necessarily guarantee OCD development, but it might increase the susceptibility, especially in the presence of adverse life events or childhood experiences. In contrast, individuals lacking these high-risk genes might be less prone to developing OCD even if they experience similar environmental triggers.

Seeking support: therapy and medication

OCD is considered to be one of the top 10 most debilitating disorders,¹⁰ with shame often preventing people from seeking support, but it is treatable. Treatment options include:¹¹

Therapy

A form of Cognitive Behavioural Therapy (CBT) called Exposure Response Prevention (ERP) is the gold-standard therapy for this disorder. This involves facing anxiety-provoking situations and allowing intrusive thoughts to enter the mind without performing a compulsion. 

Medication

For therapy-resistant or severe cases of OCD, medication can be prescribed. These will commonly be selective serotonin reuptake inhibitors (SSRIs), which are a type of antidepressant that increase levels of a neurotransmitter, serotonin, found naturally in the brain.

If you are experiencing any of these symptoms and suspect you may have OCD, you can seek help from a mental health professional, such as:

• A psychiatrist, who can diagnose, treat and prescribe medication
• A clinical psychologist, who can diagnose and provide psychotherapy
• A BACP registered counsellor or psychotherapist, who can provide counselling or psychotherapy, but cannot diagnose

It is best to find a mental health professional who has experience and training in treating OCD specifically, as some forms of therapy may be detrimental for those with OCD.¹²

FAQs

Are people who get inappropriate sexual or violent intrusive thoughts more likely to commit sexually inappropriate or violent acts?

No, intrusive thoughts do not represent a person’s beliefs, desires or intentions. OCD is ego-dystonic, meaning the intrusive thoughts are unwanted and distressing, often representing their worst fears.

“I love cleaning and keeping a very tidy house, does this mean I have OCD?”

No, OCD is ego-dystonic, therefore, if you enjoy cleaning and tidying, that is likely not a sign of OCD. However, if you clean and tidy excessively due to fears of contamination or something bad happening, this could be a sign of OCD.

Can you have OCD but be messy?

Yes, not everyone with OCD has obsessions relating to contamination or order, therefore, people with OCD can be messy and untidy.

Is OCD permanent?

While OCD is considered a chronic condition, there are highly effective treatments available and it can be managed to the extent that OCD sufferers can live normal and fulfilled lives.

Summary

• OCD is a debilitating, but highly treatable, psychiatric disorder
• It involves obsessions, scary intrusive thoughts, and compulsions, repetitive mental or physical behaviours performed to reduce feelings of anxiety
• Pure O is still OCD, but does not involve physical compulsions
• Intrusive thoughts can often be sexual or violent in nature
• OCD is ego-dystonic, meaning the sufferer is aware that their obsessions and compulsions are irrational and untrue but the high level of anxiety, caused by the intrusive thoughts, leads them to continue performing compulsions
• Treatment options include therapy, especially ERP, and medication, usually SSRIs