What is one reason why some people with obsessive compulsive disorder engage in endless rituals?

Compulsions in OCD

Compulsions, also known as rituals, are behaviors people with Obsessive-Compulsive Disorder (OCD) perform in response to obsessions.  Obsessions are intrusive, unwanted thoughts that trigger anxiety, distress and uncertainty.  People perform compulsions to neutralize fears or attempt to make obsessions go away.  Compulsions are not pleasurable, but rather behaviors people feel forced against their will to perform in order to avoid a future catastrophe.  There is a sense of loss of control because of the inability to stop engaging in ritualistic behaviors, even if there is some insight that they are irrational and unproductive.

Every human does a small amount of compulsive behavior, but it doesn’t normally get in the way of a happy, healthy, and productive life.  It is a common occurrence to hear someone announce how they are “so OCD!”  Almost 100% of the time if I say I treat OCD for a living at a cocktail party, people respond by asking “Do you have a business card for this one?” gesturing to the person next to them.  It is not immediately clear if they have the fake or the real kind, but real OCD is no joke.  It is a severe and debilitating disorder that makes the sufferer feel imprisoned by simple tasks and experiences most people take for granted.  Diagnosable OCD refers to obsessions and compulsions that take at least 1 hour per day, but most often tend to steal even more time away.  Sufferers often find that compulsions are so time consuming that valued life activities often take a back seat to them.

Why are compulsions important?

Compulsions are the fuel to the fire of OCD.  By continuing to pour gasoline on OCD’s flame by performing compulsions, OCD strengthens and spreads quickly to other areas like a brush fire.  Eliminating compulsions is like placing a cover over the flame, depleting the oxygen OCD needs to continue to thrive.  In OCD treatment, there is a major focus on compulsions because they are normally the most concrete and accessible way to target the disorder.  We can’t always control our thoughts and feelings, but we can control our behavior.  Since thoughts, feelings and behaviors are interrelated, if we change our behavior then our thoughts and feelings follow.  In other words, finding a way to discontinue compulsions is the way to decondition anxiety and have less frequent and intense obsessions.  This must occur in conjunction with repeated exposure to fears using a form of behavioral therapy called Exposure and Response Prevention (ERP).

TYPES OF COMPULSIONS

Overt / Physical Compulsions – These types of compulsions are most observable by others.  The behavior is performed to gain certainty a bad outcome won’t occur, to reduce anxiety and ward off intrusive thoughts.  Relief that results from overt compulsions will often be short-lived and compulsions tend to spread to more and more areas of life without proper treatment.

Types of physical compulsions…

o   Checking

Checking is a common compulsion and can show up in response to almost every type of obsession.  A woman may check the stove, flat iron, faucet or door to ensure nothing dangerous will happen when she leaves home.  Checking can involve manually making contact with or visually checking for certainty when powering off appliances such as a coffee maker.  A person may check his temperature or blood pressure if he has health anxiety or check his eyes or tongue in the mirror if he fears he has contracted HIV.  A person may check the Internet for symptoms of depression or suicidality to be sure she won’t act out her OCD thoughts about killing herself.

A person who fears mistakes may excessively check emails to ensure he didn’t write something offensive or that it was sent to the correct person.  On many occasions, clients in my office find themselves checking their phones to ensure someone isn’t hearing their therapy sessions.  A sufferer of harm OCD may visually check behind him to ensure he hasn’t harmed the elderly woman he just passed, check his car for dents from unperceived car accidents, or check his body to make sure he is not sexually aroused by an inappropriate person such as a child or family member.  People with homosexual OCD (HOCD) may check the attributes of an attractive, same-sex person to gain certainty about sexual orientation.  In relationship OCD (ROCD), someone may check her significant other’s appearance to be sure they find him attractive enough.

o   Washing and Cleaning

People with contamination obsessions may fear not being perfectly clean , being permanently contaminated, contracting a disease from touching a contaminated object or are disgusted by the thought of being dirty.  Common contamination obsessions include bodily fluids (blood, urine, semen, feces), chemicals or cleaning supplies, garbage, and surfaces regularly touched by the general public (elevator buttons, doorknobs, gasoline pumps).  To neutralize obsessions, the contamination OCD sufferer will wash hands frequently, excessively or ritualistically.  Some do the same hand wash as a surgeon preparing for surgery.  People with OCD often lack a feeling of completeness and therefore continue to wash, waiting and failing to create the “all done” feeling non-sufferers have when they are finished washing.

Contamination OCD sufferers may take excessive time showering and grooming, waiting for the certainty of cleanliness to arrive.  Common compulsions include washing inanimate objects such as keyboards, cell phones and pens way more frequently than those without OCD.  Someone may only wear clothing once before she washes it again, even if it was only worn briefly.  Emotional contamination can occur when a person or object is perceived to be magically contaminated by a feared person, situation or emotional state.  For example, a young man who was bullied while away at college may perceive all belongings from his dorm room contaminated.  In this case, a person may clean, segregate or dispose of belongings from college.

o   Straightening, Arranging, and Placing

OCD sufferers with perfectionism obsessions feel the need for objects in their environment to look and feel right.  People often straighten and arrange objects to create a “just right” feeling.  OCD defines places where objects belong and it is up to the person to keep it that way.  They may arrange office supplies, papers, books and chotskis so they are lined up perfectly along the edge of the desk or night stand.  Items such as keys, wallet and cell phone must be placed in the same exact spot every evening.  Compulsive behavior may appear one way, but be motivated by an entirely different obsession.  For example, a man may notice his wife straightening the rug compulsively every time she sees a tiny wrinkle.  At first glance it looks as if she cares about perfection and feeling “just right,” but she reports thoughts and images of her family members tripping on the rug and becoming seriously injured or killed.

o   Repeating, re-picking, touching and tapping

OCD sufferers are often instructed by their OCD to repeat behaviors, touch or tap objects a safe or lucky number of times.  For example a girl may put on her shirt 3 times because she has 3 family members that she wants to remain safe.  Actions such as standing up from a chair, walking through a doorway or turning off a light switch may be repeated until the person feels “just right.”  When placing an object down, such as a glass on the table, it may not feel right if it touches the table too hard, soft, or just didn’t sound right. The person will repeat the action by picking the glass up and placing it down again trying to achieve the right sound, touch or feeling.

A compulsion may be repeated if it wasn’t performed to OCD specifications.  With contamination OCD, a person may repeat an entire hand washing ritual if the inside of the sink or the faucet was accidentally touched during the ritual.  Someone with a general fear of a bad thing happening during the day may repeatedly pick underwear out of his drawer while matching the selection to a good thought.  Picking merchandise off the shelf at a grocery store can be challenging and repeated if it doesn’t feel right, the item is ‘contaminated’ or a ‘bad’ thought came in during the selection process.

o   Avoidance

Avoidance is a common behavior those with OCD engage in to reduce the risk of a negative outcome based on a particular fear.  Almost every kind of obsession has some form of avoidance ritual.  Someone with a fear of burning the house down may avoid using the stove altogether.  A person with contamination obsessions often avoids touching door knobs, public restrooms or the phone or keyboard of another person.  After performing a washing ritual, people with contamination fears will protect their cleanliness by avoiding touching anything after the compulsion.  People may also believe ‘contamination’ can spread like wet paint.  They avoid touching objects and making contact between 2 objects.

Individuals with harm OCD may avoid giving a child a bath, using a knife, changing a diaper, or driving the car through a crowded area of town.  A man with ROCD may avoid looking at his wife in the morning before she puts her makeup on or avoid saying “I love you,” because what if it’s not really love.  A person with HOCD may avoid looking a same sex person in the eye, going into an area with a high population of gay people or watching television or movies with attractive same-sex actors.  Avoidance occurs to prevent having OCD thoughts and eliminate the possibility that the sufferer will engage in the feared behavior.  If she doesn’t go to her grandmother’s house, she will definitely not be able to go crazy and kill her.  Avoidance is also used to prevent future occurrences of unwanted thoughts.  A person with scrupulosity, imagined sin or immorality, may avoid driving by churches to avoid having blasphemous thoughts, something that will surely commit them to hell.

o   Reassurance-seeking

“Are you sure this thought doesn’t make me a bad person?”  This compulsion is performed to gain certainty that a feared outcome will not occur or to reduce anxiety by asking others for reassurance.  The OCD sufferer will often engage family, friends or professionals in lengthy conversations about his or her fear.  Reassurance does not stick and the person is often compelled to introduce new twists on the subject or challenge the person about their responses in attempt to get further information to ease anxiety.  It is very difficult for clients to resist asking for reassurance, and family members often believe they are doing something helpful by providing it.  It would not be wise to give a small child everything he asks for even if it prevents a tantrum, because misbehavior will be rewarded and increased.  While providing reassurance to someone currently suffering with an OCD spike may give them temporary relief, over time the person is learning compulsions are effective and reassurance-seeking increases.  And we all know what happens when compulsions increase.  Yep, obsessions and fears increase.  And the cycle continues…

Mental Compulsions  – These types of compulsions occur in the mind and are not observable by others.  They are performed silently by thinking, analyzing, reviewing, and replaying thoughts, situations, and memories mentally.  Until OCD sufferers learn about mental rituals, they may not believe they are performing any rituals at all.  Just as physical compulsions are used to ward off obsessions and feared outcomes, OCD sufferers may also engage in ritualistic thinking for the same reasons.

Mental rituals are less obvious than physical compulsions and a person may mistake them for obsessions.  Often times, an obsession is just a momentary suggestion from OCD to examine something scary, and the mental ritual is the thoughts that occur for a much longer period of time.  Obsessions and mental compulsions can be intertwined and difficult to discern from each other.  When clients say, “I’m obsessing all day long,” they probably mean that they are responding to obsessions with mental compulsions all day long.

OCD sufferers mistakenly feel that mental compulsions will be productive in reducing suffering.  They believe that once they’ve ironed out all the details of their obsession, then the unwanted thoughts will go away and they will feel comfortable and certain.  Nothing could be further from the truth.  The more time spent trying to figure out intrusive thoughts, the more convoluted, confusing and uncertain they become.

Since mental compulsions are thoughts, they are not always possible to stop.  Remember, we cannot always control our thoughts.  Sometimes they are so habitual that reassuring thoughts just pop into the mind spontaneously.  The best way to think about handling mental compulsions is to understand their purpose and label them as rituals when they occur.  The awareness of what is happening changes it from a compulsive behavior to simply watching that thing the mind does and therefore, regularly cuts them short.

Types of Mental Compulsions…

o   Mental Review – A person examines past memories and events to determine if the feared obsession occurred or to make sure there isn’t any historical evidence that supports the OCD fear.  For example, a man with HOCD may mentally review all of his positive, heterosexual experiences to feel more certain about being straight.  A woman may lie in bed mentally reviewing all of the physical actions she took when placing her infant in the crib, to ensure she didn’t suffocate her baby with the pillow.  “I remember placing the pillow on the rocking chair before bringing the baby to her room.”  An individual may also review his past thoughts and events to gain certainty he is not in denial of the existence of his sinister inner core.

An example of a mental review process may look something like this, “My niece was over the other day and she sat on my lap.  Why did I let her do that?  What if I wanted her to sit on my lap because I am sexually aroused by her?  I think she may have initiated the contact though.  Yes, she got up off the floor and approached me.  Did I pick her up or did she climb up herself?  I’m pretty sure she climbed up herself.  Okay, well what if it doesn’t matter that she climbed up herself?  What if it is still creepy that I allowed it or that I didn’t ask her to get down sooner?  I am the adult after all.  Okay well many people allow kids to sit on their laps.  Was I aroused during this?  I think I felt something.  Well I did let her down when I felt the tingling sensation.  She said goodbye to me and so she must not have been traumatized by what I did.”

o   Mental Checking – Checking the brain is just a non-physical way to ensure an OCD fear is not realized, and serves the same purpose as door or stove checking.  A mental checklist may be recited to be sure all bases are covered.  The OCD sufferer may bring up OCD thoughts intentionally for the purpose of checking if the thoughts still bother them.  They may fear that the presence of uncertainty and anxiety mean that the thought is therefore true.  The intensity of OCD thoughts and feelings can fluctuate from day to day and moment to moment.  Because of the good feeling sufferers get when intrusive thoughts don’t produce as much anxiety or uncertainty as usual, they may compulsively “check” their reactions to thoughts to hopefully replicate this experience.  The problem is continued checking becomes the reinforcement for OCD thoughts and feelings.

o   Mental Rehearsal – A person spends time mentally preparing or rehearsing a future situation to determine it is safe for themselves or others in this compulsion type, which is the exact opposite of mental review where the past is examined.  Examples include rehearsing a future medical appointment to be sure the all right medical information will be provided and all the right questions are asked to guarantee health.  A groom with ROCD fears may mentally rehearse the upcoming wedding vows to examine if he feels strongly enough about each point to marry his future wife.

A teacher may fear she is not adequately understood when she speaks and never feels she can explain things perfectly enough.  She may engage in a mental ritual where she rehearses her lesson plans mentally to ensure the children succeed.  Mental rehearsal might look something like this for someone suffering from ‘hit and run’ OCD, “I know Main Street has a lot of mothers pushing strollers in the afternoon.  I will have to take another street since I will be going out for lunch today.  Second Street might be less congested.  How will I know if it is safe for me to drive?  I can ask my co-worker to ride along with me and he will be able to hear if I hit someone.”

o   Self-Reassurance – Just like reassurance-seeking from others, the purpose of self-reassurance is to mentally provide certainty that the feared outcome won’t occur or that one is not as bad or evil as the OCD leads them to believe.  A person may tell themselves positive affirmations about being a good person when their OCD produces thoughts about harm, pedophilia, etc.  They commonly run through a mental list of reassurances they have received from family, friends or professionals.  An example off the self-reassurance process may look something like this, “My priest said I did not sin when I accidentally took home the song book from mass.  But wait, did he know that I was the one who put it the bag and not my child?  Yes, he told me that it didn’t matter if I did it or my child did it.  I returned it to the church the next day and it was an accident.  I am a good person.  I’ve never stolen anything in my life!”

o   Thought neutralization – This occurs when a person mentally replaces unwanted, unpleasant thoughts or images with pleasant or more neutral ones.  A woman tries to imagine her child sitting in a field of flowers after having a thought about him getting kidnapped from the playground at daycare.  Another woman brings in an image of herself beside her neighbor, a woman still healthy and vibrant at age 83, to neutralize an intrusive thought about potentially getting cancer. A young man with HOCD may imagine a sexy girl in a short dress after noticing an attractive man walk by him on the street.

o   Prayer, mantras, and special phrases – A person may repeat a prayer or phrase to neutralize an intrusive thought.  Clients with intrusive thoughts may say a prayer, “God is good,” or a compulsively say a phrase, “Good conquers evil,” following any panic-inducing OCD thought.  The phrase, “It’s not me, it’s my OCD” is a good way to recognize and categorize intrusive thoughts as OCD brain blips that don’t need attention.  It is a helpful reminder to avoid responding to OCD thoughts compulsively.  Any phrase can become compulsive, however, if it is used repeatedly and excessively with the motive of convincing oneself with certainty that a bad outcome will not occur, seeking comfort or attempting to rid oneself of thoughts.  Have awareness of your motive for using any phrase, even the helpful ones provided by your OCD specialist.  Normal religious prayer may also be repeated compulsively to neutralize fears about having done the prayer incorrectly or that they have sinned by having inappropriate thoughts while praying.

o   Solving and wishing – Sometimes people become less concerned with the possibility of acting out their thoughts and more concerned that the thoughts will plague them forever and will cause of life of misery.  This has been referred to as “Obsessing about Obsessing.”  Individuals often spend time “wishing” for the thoughts to go away and comparing their life to a life they would have if they weren’t obsessing.  An OCD sufferer’s compulsions may also be focused on “solving” their OCD puzzle by excessively thinking about what they need to do to fix their OCD.  These compulsions send a message that the OCD is more important than it is, and as a result makes OCD more powerful.

o   Self-punishment – A person who has fears of being a bad person which results in excessive amounts of guilt may engage in a mental ritual called self-punishment.  The person will abuse themselves mentally in order to feel they are not getting away with a crime that has gone unpunished.  The self-abuse temporarily relieves some guilt because they feel they haven’t gotten away with something they ‘should’ be punished for.  It also leads to a sense that they are on the same side of the population as people who hate killing, pedophilia and incest, etc.  Just letting these ideas sit around is not acceptable.  Obviously, putting oneself through this process is uncomfortable and often very depressing, but letting oneself off the hook does not feel like an option.  “I am a horrible person for having these thoughts.  What kind of good person would think about sex with his sister?  This is really sick.  I am a demented and depraved individual and don’t deserve to live!”

If you don’t see your compulsions listed above, there is no need to panic.  There are millions of different and creative ways to run from OCD.  You may be so innovative that you have invented compulsions that you can’t find in any book or on any website.  As long as you have an obsession that is followed up by some physical or mental behavior to gain certainty, reduce distress or prevent thoughts you are playing the OCD game.  It is quite amazing however, that even the most obscure compulsions I have ended up seeing in more than one client through the years.  There is someone out there like you…believe me!

Stacey Kuhl Wochner, LCSW is a psychotherapist in private practice in Los Angeles, CA specializing in the treatment of OCD.  Follow her on Facebook.

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