OCD — intrusive thoughts and compulsive rituals

Obsessive compulsive disorder (OCD) is an anxiety-related condition characterised by:

  1. Obsessions — intrusive, unwanted thoughts, images, or urges
  2. Compulsions — repetitive behaviours or mental acts performed to neutralise anxiety

Affects roughly 1–2% of people — often begins before age 25. It is highly treatable with specialist CBT — yet average delay to treatment is years due to shame.

Obsessions — common themes

Contamination:

  • fear of germs, illness, bodily fluids
  • mental contamination — “bad” feelings from people/places

Harm:

  • intrusive thoughts of stabbing, pushing someone — Pure O variant without visible compulsions
  • checking locks, stoves, driving route

Symmetry/exactness:

  • need for order — “not right” feelings

Religious/moral (scrupulosity):

  • blasphemous thoughts, excessive guilt

Relationship OCD:

  • doubts about partner love — constant reassurance seeking

Key: thoughts are ego-dystonic — opposite of desires — person horrified, not pleased.

Compulsions

Overt:

  • hand washing until raw
  • checking appliances, doors — hours daily
  • ordering, counting, touching

Covert (mental rituals):

  • praying, repeating phrases
  • memory reviewing
  • confession to partner repeatedly

Relief is temporary — anxiety returns — cycle intensifies.

OCD vs everyday habits

OCDPreference
DistressSevere if preventedMild annoyance
TimeHoursMinutes
InsightKnows excessive, cannot stopChooses behaviour
FunctionImpaired work/relationshipsOrganised life

Not “being tidy” — disability-level ritual in severe cases.

  • Body dysmorphic disorder (BDD) — obsession with perceived appearance flaw
  • Hoarding disorder — difficulty discarding
  • Tic disorders — overlap Tourette + OCD

Diagnosis

GP → IAPT (high-intensity) or specialist CAMHS/adult mental health

Y-BOCS score — severity measure

Exclude:

  • autism — preference for sameness without typical OCD anxiety cycle
  • psychosis — beliefs held as true, not resisted
  • OCPD — personality style without intrusive obsessions

Treatment

ERP — exposure and response prevention

Gold standard CBT:

  • expose to feared trigger (touch door handle)
  • prevent compulsion (no washing)
  • anxiety rises then falls — habituation
  • homework between sessions

Requires therapist trained in ERP — generic counselling less effective.

Medication

SSRIs — higher doses than depression:

  • fluoxetine, sertraline, fluvoxamine
  • 12-week trial before switch

Clomipramine — tricyclic — effective — side effect burden

Combine with ERP for moderate-severe.

What does not work

  • reassurance from family — feeds OCD
  • avoidance — maintains fear
  • ** alcohol** — worsens anxiety long term

Supporting someone with OCD

  • do not participate in rituals (within therapeutic plan)
  • encourage ERP, not reassurance
  • patience — recovery non-linear

OCD Action — UK charity.

Prognosis

Many achieve significant improvement with ERP — complete cure uncommon but functional recovery common.

Relapse with stress — booster ERP helps.

Common questions about obsessive compulsive disorder

What are obsessions and compulsions in OCD?
Obsessions — persistent unwanted thoughts, images, or urges (e.g. contamination, harm to others, blasphemy, symmetry doubts). Compulsions — repetitive actions (hand washing, checking locks, counting, confessing) or mental rituals (praying, neutralising thoughts) performed to reduce anxiety from obsessions.
Is OCD the same as being neat or perfectionist?
No — personality preference for order is not OCD. OCD involves intrusive thoughts causing significant anxiety and time-consuming rituals the person often recognises as excessive but cannot stop without distress. Functional impairment distinguishes disorder.
Can OCD cause violent thoughts?
Intrusive thoughts about harming others are common in OCD — ego-dystonic — the person is horrified by thoughts and avoids harm, performing rituals to prevent imagined danger. Different from psychosis or risk — assessment distinguishes Pure O/harm OCD from genuine risk (rare).
How is OCD treated on the NHS?
High-intensity CBT with exposure and response prevention (ERP) — gradually facing feared situations without compulsion. SSRIs (fluoxetine, sertraline, fluvoxamine) at higher doses than depression — 12-week trial. Clomipramine second-line. Combined therapy and medication often best for moderate-severe OCD.
Does OCD go away on its own?
Sometimes mild cases fluctuate — chronic OCD rarely resolves without treatment and often worsens under stress. Early ERP improves long-term prognosis. Relapse prevention continues ERP principles after formal therapy.

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