Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder is characterized by the presence of obsessions and/or compulsions which cause significant distress and interference with functioning.
Obsessions are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. At times the person may attempt to ignore or suppress such thoughts, impulses, or images, or neutralize them with some other thought or action.
Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are either not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
Common Themes in Obsessive-Compulsive Disorder:
Aggressive Obsessions: Fear might harm self, fear might harm others, violent or horrific images, fear of doing something embarrassing, fear will act on unwanted impulses (e.g., stabbing someone), fear will steal things, fear of accidentally harming others (e.g., hit/run), fear will be responsible for something bad happening (e.g., fire/burglary). Individuals may engage in significant avoidance to reduce the likelihood of them acting impulsively (e.g., avoiding use of sharp objects). This may also include Perinatal/Postpartum OCD symptoms, such as intrusive thoughts about harming one's baby.
Checking Behaviors: Checking locks, stove, appliances, checking that you did not/will not harm yourself or others, checking that nothing terrible did/will happen, checking that you didn't make a mistake, checking tied to somatic obsessions, mental analyzing or checking behaviors.
Contamination Concerns: Concern or disgust with bodily waste or secretions (e.g., urine, feces, saliva, blood), excessive concern with dirt or germs, excessive concern with environmental contaminants (e.g., asbestos, radiation), excessive concern with household items (e.g., cleansers, chemicals), excessive concern with animals (e.g., insects), bothered by sticky substances or residues), concerned that you will become sick because of germs/contaminants, concerns that you will spread contaminants and get others sick, concerned with how it will feel to be contaminated (e.g., feeling dirty, experiencing disgust). Common compulsions include excessive or ritualized handwashing, showering, bathing, toothbrushing, grooming, or toilet routine, excessive cleaning of household items or other objects, excessive measures to prevent or remove contact with contaminants.
Counting Symptoms: Rituals in which one feels the urge to count while engaging in compulsive behaviors.
Mental Compulsions: Rituals that are done in one's own mind. Examples include analyzing or reviewing past events, attempts to neutralize intrusive/distressing thoughts to "cancel them out," and analyzing one's thoughts/feelings. See this LINK on types of mental compulsions for a discussion of other examples.
Hoarding / Saving: Thoughts of needing to save/keep things that others would likely throw away (e.g., trash, wrappers, ribbons, string), excessive concern with discarding items of sentimental value.
"Just Right" Obsessions / Need for Symmetry or Exactness: Thoughts that things have to be in the right place or else something bad could happen, feeling that things have to be a certain way or "just right" or else person experiences distress. They may report that things feel "wrong" unless they are done a particular way. May involve compulsions in which a person feels the urge to touch, tap, or rub things in a particular way.
Perfectionism: Marked by difficult to attain standards that leave the person feeling distressed and overwhelmed. There is a focus on needing to be productive and judged as successful and competent by others. There is often an "all-or-nothing" mentality, where the person feels less than if the product isn't perfect or their absolute best, as that may feel unacceptable or like a failure to them. While high standards and goals may often drive someone to achieve excellence, perfectionism in OCD is often associated with distress, interference, and diminishing returns. Individuals are often overwhelmed and exhausted as they strive to meet unrealistic standards.
Ordering/Organizing/Arranging Symptoms: Thoughts that things have to be organized in a certain way or else something bad could happen or it could interfere with functioning in some way.
Religious Obsessions / Scrupulosity: Excessive concern with sacrilege and blasphemy, fear of offending God, fear of going to hell, excessive concern with right and wrong, heightened sense of morality. Symptoms may be associated with excessive prayer, reassurance-seeking behavior, and urges to confess obsessive thoughts.
Relationship Obsessions: Pre-occupation with current or past relationships (usually romantic, but could also be other relationships as well). Obsessions are typically either relationship focused (e.g., concerns about whether one is in the "right" romantic relationship) or partner-focused (e.g., pre-occupation with perceived flaws, such as physical features or personality characteristics/traits). Individuals may also be preoccupied with their partner's previous relationships
Repeating Rituals: Re-reading or re-reading, need to repeat routine activities (e.g., going in and out of the door).
Sexual Obsessions: Forbidden or perverse sexual thoughts, images, or impulses, intrusive sexual thoughts involving children or incest, intrusive sexual thoughts with content involving homosexuality, intrusive thoughts of aggressive sexual behavior towards others (e.g., molestation, sexual violence). Individuals with these thoughts may engage in efforts to try to suppress these thoughts, or avoid situations that trigger these thoughts.
Somatic Obsessions: Excessive concern with illness or disease, excessive concern with body part or aspect of appearance.
Sensorimotor Obsessions: A hyperawareness of bodily processes (e.g., breathing, swallowing).
Existential & Philosophical Symptoms: These symptoms often focus on big-life questions, such as "what is the meaning of life," or "what's my purpose?" Other common symptoms may obsessions about the origin of the earth or the massive size of the universe, or a preoccupation with what is "real." Those with these symptoms often spend excessive time trying to answer unanswerable questions.
Miscellaneous Symptoms: Need to know or remember, fear of saying certain things, fear of not saying just the right thing, fear of losing things, intrusive nonsense sounds, words, or music, bothered by certain sounds/noises, lucky/unlucky numbers, colors with special significance, superstitious fears, excessive listmaking, blinking or staring rituals, avoidance, ritualized eating behaviors.
Obsessions are recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. At times the person may attempt to ignore or suppress such thoughts, impulses, or images, or neutralize them with some other thought or action.
Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are either not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
Common Themes in Obsessive-Compulsive Disorder:
Aggressive Obsessions: Fear might harm self, fear might harm others, violent or horrific images, fear of doing something embarrassing, fear will act on unwanted impulses (e.g., stabbing someone), fear will steal things, fear of accidentally harming others (e.g., hit/run), fear will be responsible for something bad happening (e.g., fire/burglary). Individuals may engage in significant avoidance to reduce the likelihood of them acting impulsively (e.g., avoiding use of sharp objects). This may also include Perinatal/Postpartum OCD symptoms, such as intrusive thoughts about harming one's baby.
- Violent Obsessions: How I Treat OCD Killer Thoughts
- Perinatal OCD: Beyond the Blues
- Harm OCD - Afraid You Are Going to Hurt Someone?
- OCD and Acting Out: Afraid You Will Really Do it?
Checking Behaviors: Checking locks, stove, appliances, checking that you did not/will not harm yourself or others, checking that nothing terrible did/will happen, checking that you didn't make a mistake, checking tied to somatic obsessions, mental analyzing or checking behaviors.
Contamination Concerns: Concern or disgust with bodily waste or secretions (e.g., urine, feces, saliva, blood), excessive concern with dirt or germs, excessive concern with environmental contaminants (e.g., asbestos, radiation), excessive concern with household items (e.g., cleansers, chemicals), excessive concern with animals (e.g., insects), bothered by sticky substances or residues), concerned that you will become sick because of germs/contaminants, concerns that you will spread contaminants and get others sick, concerned with how it will feel to be contaminated (e.g., feeling dirty, experiencing disgust). Common compulsions include excessive or ritualized handwashing, showering, bathing, toothbrushing, grooming, or toilet routine, excessive cleaning of household items or other objects, excessive measures to prevent or remove contact with contaminants.
Counting Symptoms: Rituals in which one feels the urge to count while engaging in compulsive behaviors.
Mental Compulsions: Rituals that are done in one's own mind. Examples include analyzing or reviewing past events, attempts to neutralize intrusive/distressing thoughts to "cancel them out," and analyzing one's thoughts/feelings. See this LINK on types of mental compulsions for a discussion of other examples.
Hoarding / Saving: Thoughts of needing to save/keep things that others would likely throw away (e.g., trash, wrappers, ribbons, string), excessive concern with discarding items of sentimental value.
"Just Right" Obsessions / Need for Symmetry or Exactness: Thoughts that things have to be in the right place or else something bad could happen, feeling that things have to be a certain way or "just right" or else person experiences distress. They may report that things feel "wrong" unless they are done a particular way. May involve compulsions in which a person feels the urge to touch, tap, or rub things in a particular way.
Perfectionism: Marked by difficult to attain standards that leave the person feeling distressed and overwhelmed. There is a focus on needing to be productive and judged as successful and competent by others. There is often an "all-or-nothing" mentality, where the person feels less than if the product isn't perfect or their absolute best, as that may feel unacceptable or like a failure to them. While high standards and goals may often drive someone to achieve excellence, perfectionism in OCD is often associated with distress, interference, and diminishing returns. Individuals are often overwhelmed and exhausted as they strive to meet unrealistic standards.
Ordering/Organizing/Arranging Symptoms: Thoughts that things have to be organized in a certain way or else something bad could happen or it could interfere with functioning in some way.
Religious Obsessions / Scrupulosity: Excessive concern with sacrilege and blasphemy, fear of offending God, fear of going to hell, excessive concern with right and wrong, heightened sense of morality. Symptoms may be associated with excessive prayer, reassurance-seeking behavior, and urges to confess obsessive thoughts.
Relationship Obsessions: Pre-occupation with current or past relationships (usually romantic, but could also be other relationships as well). Obsessions are typically either relationship focused (e.g., concerns about whether one is in the "right" romantic relationship) or partner-focused (e.g., pre-occupation with perceived flaws, such as physical features or personality characteristics/traits). Individuals may also be preoccupied with their partner's previous relationships
Repeating Rituals: Re-reading or re-reading, need to repeat routine activities (e.g., going in and out of the door).
Sexual Obsessions: Forbidden or perverse sexual thoughts, images, or impulses, intrusive sexual thoughts involving children or incest, intrusive sexual thoughts with content involving homosexuality, intrusive thoughts of aggressive sexual behavior towards others (e.g., molestation, sexual violence). Individuals with these thoughts may engage in efforts to try to suppress these thoughts, or avoid situations that trigger these thoughts.
- Am I a Monster? An Overview of Common Features, Typical Course, Shame, and Treatment of Pedophilia OCD
- Sexual Orientation Obsessions: How Do I know I'm Not Really Gay/Straight?
Somatic Obsessions: Excessive concern with illness or disease, excessive concern with body part or aspect of appearance.
Sensorimotor Obsessions: A hyperawareness of bodily processes (e.g., breathing, swallowing).
Existential & Philosophical Symptoms: These symptoms often focus on big-life questions, such as "what is the meaning of life," or "what's my purpose?" Other common symptoms may obsessions about the origin of the earth or the massive size of the universe, or a preoccupation with what is "real." Those with these symptoms often spend excessive time trying to answer unanswerable questions.
Miscellaneous Symptoms: Need to know or remember, fear of saying certain things, fear of not saying just the right thing, fear of losing things, intrusive nonsense sounds, words, or music, bothered by certain sounds/noises, lucky/unlucky numbers, colors with special significance, superstitious fears, excessive listmaking, blinking or staring rituals, avoidance, ritualized eating behaviors.
References
Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.
Journal of the American Academy of Child & Adolescent Psychiatry. 2012 Jan;51(1):98-113. doi: 10.1016/j.jaac.2011.09.019. LINK TO PDF
Practice Guideline for the Treatment of Patients With Obsessive-Compulsive Disorder (Koran et al., Work Group on OCD; 2010). LINK TO PDF
Efficacy and acceptability of cognitive-behavioral therapy and serotonin reuptake inhibitors for pediatric obsessive-compulsive disorder: a network meta-analysis (2024).
Matti Cervin, Joseph F. McGuire, Johann M. D’Souza, Alessandro S. De Nadai, Kristina Aspvall, Wayne K. Goodman, Per Andren, Sophie C. Schneider, Daniel A. Geller,David Mataix-Cols, and Eric A. Storch. Journal of Child Psychology & Psychiatry, 65, pp 594–609. LINK TO PDF
A meta-analysis of dropout rates from exposure and response prevention and pharmacological treatment for youth with obsessive compulsive disorder.
Johnco, C., McGuire, J.F., Roper, T., & Storch, E.A. (2019). Depression & Anxiety, 37, 407-417.
Randomized, placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the treatment of pediatric obsessive–compulsive disorder.
Storch, Eric A.; Bussing, Regina; Small, Brent J.; Geffken, Gary R.; McNamara, Joseph P.; Rahman, Omar; Lewin, Adam B.; Garvan, Cynthia S.; Goodman, Wayne K.; Murphy, Tanya K.; Behaviour Research and Therapy, Vol 51(12), Dec, 2013 pp. 823-829.
Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: A pilot randomized controlled trial.
Lewin, Adam B.; Park, Jennifer M.; Jones, Anna M.; Crawford, Erika A.; De Nadai, Alessandro S.; Menzel, Jessie; Arnold, Elysse B.; Murphy, Tanya K.; Storch, Eric A.; Behaviour Research and Therapy, Vol 56, May, 2014 pp. 30-38.
Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS JR) - a randomized clinical trial.
Freeman, J., Sapyta, J., Garcia, A., Compton, S., Khanna, M., Flessner, C., FitzGerald, D., Mauro, C., Dingfelder, R., Benito, K., Harrison, J., Curry, J., Foa, E., March, J., Moore, P.., & Franklin, M. Journal of the American Medical Association, (2014 Jun; 71(6): 689-698.
Rage attacks in pediatric obsessive-compulsive disorder: Phenomenology and clinical correlates.
Storch, Eric A.; Jones, Anna M.; Lack, Caleb W.; Ale, Chelsea M.; Sulkowski, Michael L.; Lewin, Adam B.; De Nadai, Alessandro S.; Murphy, Tanya K.; Journal of the American Academy of Child & Adolescent Psychiatry, Vol 51(6), Jun, 2012 pp. 582-592.
The role of comorbid disruptive behavior in the clinical expression of pediatric obsessive-compulsive disorder.
Storch, Eric A.; Lewin, Adam B.; Geffken, Gary R.; Morgan, Jessica R.; Murphy, Tanya K.; Behaviour Research and Therapy, Vol 48(12), Dec, 2010 pp. 1204-1210.
Parental experiences of having a child with obsessive-compulsive disorder: Associations with clinical characteristics and caregiver adjustment.
Storch, Eric A.; Lehmkuhl, Heather; Pence, Steven L. Jr.; Geffken, Gary R.; Ricketts, Emily; Storch, Jill F.; Murphy, Tanya K.; Journal of Child and Family Studies, Vol 18(3), Jun, 2009 pp. 249-258.
A meta‐analysis of cognitive behavior therapy and medication for child obsessive–compulsive disorder: Moderators of treatment efficacy, response, and remission.
McGuire, Joseph F.; Piacentini, John; Lewin, Adam B.; Brennan, Erin A.; Murphy, Tanya K.; Storch, Eric A.; Depression and Anxiety, Vol 32(8), Aug, 2015 pp. 580-593.
Medications
How do SSRI's Work? SSRI's Explained
Meta-Analysis of the Dose-Response Relationship of SSRI in Obsessive-Compulsive Disorder. (2011). Bloch, M.H., McGuire, J., Landeros-Weisenberger, A., Leckman. J.F., & Pittenger, C. Molecular Psychiatry
Optimal Dose of Serotonin Reuptake Inhibitors for Obsessive-Compulsive Disorder in Adults: A Systematic Review and Dose–Response Meta-Analysis (2021), Xu et al. Frontiers in Psychiatry
Systematic Review and Meta-Analysis: Early Treatment Responses of Selective-Serotonin Reuptake Inhibitors and Clomipramine in Pediatric Obsessive-Compulsive Disorder (2020), Varigonda, A. L., Jakubovski, E., Bloch, M.H., Journal of American Academy of Child & Adolescent Psychiatry
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Jacob Center for Evidence-Based Treatment
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Copyright © 2015-2025 Marni L. Jacob, Ph.D., LLC
Jacob Center for Evidence-Based Treatment
7900 Glades Road, Suite 615, Boca Raton, FL 33434
(561) 290-9080