OCD Myths, Debunked #1: Compulsions Are All Visible Behaviors

OCD is a complex mental health condition that is often missed and misunderstood by clinicians and people with OCD alike. The International Obsessive Compulsive Disorder Foundation (IOCDF) estimates that 1 in 40 people in the US will meet the criteria for an OCD diagnosis at some point in their lives. That works out to be around 8.2 million people, or about the population of the state of Washington. That’s a lot of people! Even still, it takes the average person 7 years to get an OCD diagnosis from the time that symptoms emerge.

What makes OCD so tricky to diagnose, if so many people experience it? A major factor is our collective understanding of what OCD is in the first place. Pop culture often depicts OCD as intense cleanliness, a desire for perfectionism, or meaningless rituals that the characters themselves have no real connection to. If this is all you know OCD to be, it’s very easy to not recognize yourself in that portrayal, and never seek support or answers. Further, if clinicians have this narrow view of OCD, they might miss important signs and further extend the amount of time it takes to get real support.

Let’s get into some important misconceptions about OCD, so that we can all move forward with a better understanding of what this very common diagnosis actually is. This series will attempt to provide an overview of topics that deserve further discussion, one myth at a time.

The misconception of the day: Compulsions are all visible behaviors.

Think about stereotypical compulsions that immediately come to mind when you think of OCD. You may think of…

• Hand washing
• Rigorous cleaning and organizing
• Switching lights on and off
• Tapping or blinking rituals

While many compulsions are based on physical activities, it’s just as likely that compulsions are invisible, at least to people on the outside.

You may have heard of the term “Pure O” OCD, as a way of describing OCD that occurs as obsessions without any compulsions. While this label can be affirming for folks who have never experienced physical compulsions, it is more likely that people with “Pure O” OCD do have compulsions, they’re just internal. Some examples of internal compulsions may be…

• Mental reviewing/rumination: thinking through memories or anticipating future events over and over again, scanning for danger/embarrassment/feared outcomes
  • Example: rethinking a conversation with your spouse from last week, for hours and hours, reviewing what you said and how they reacted until you feel totally sure that they aren’t secretly planning on breaking up with you.
• Thought neutralization/blocking: forcing comforting, repetitive, or nonsense thoughts to “drown out” anxiety and obsessions
  • Examples: when having obsessive thoughts about harming a loved one, interrupting those thoughts by thinking “NO, NO, NO, NO” on repeat, imagining a big red stop sign over and over, or repeating the phrase “I am okay” internally until there’s an internal sense of things being “neutralized”.
• Internal checking: responding to a distressing thought or sensation by repeatedly “testing” to see if it’s real, still there, or changing.
  • Examples: noticing a sore throat and repetitively checking to see if it’s getting worse, checking desire to harm a loved one by repeatedly imagining them in a feared scenario and seeing if you have an emotional response

Mental compulsions are very real and often fly under the radar in a way that physical compulsions don’t, simply because other people may not notice they’re happening. However, one of the sneakiest ways OCD reinforces itself is based on behaviors that aren’t happening at all.

Huh? How could something not happening impact OCD? Through avoidance!

Avoidance is one of the easiest signs of OCD to miss, because it relies on having a deep understanding of your personal OCD. Avoidance can keep OCD around in subtle ways for a very long time. Some ways that OCD shows up are…

• Avoiding things because they trigger obsessions
  • Examples: not cooking for fear of triggering anxiety about food poisoning, not dating for fear of worrying that someone is cheating on you, not texting or writing for fear of saying the “wrong thing”.
• Avoiding things because they trigger compulsions
  • Examples: not showering because your hygiene routine is so rigorous/time consuming/painful, not speaking with loved ones because your mental reviewing compulsions are so distressing after the fact, not driving because you’ll feel the need to check and make sure you didn’t hit anyone.
• Avoiding contact with objects, places, or people that seem “contaminated”
• Avoiding contact with kids or animals for fear of pedophilia, beastiality, or other “taboo” OCD themes being triggered

Both avoidance and mental compulsions are often missed during assessments and screeners for OCD, and can contribute to a delay in receiving effective care. It’s important to break the misconception that OCD is all behavioral, because that really only covers a small part of the ways that OCD can impact someone’s life. Getting better at recognizing all the many aspects of OCD ensures that we are better at talking about it and supporting people who are dealing with OCD in the future, including ourselves.