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If you’ve delved into information about Obsessive-Compulsive Disorder (OCD), you might have encountered discussions on various themes or subtypes associated with this condition. Obsessive fears and compulsions are often categorised into themes such as those below:
Common subtypes of obsessions include:
- Contamination, dirt, germs, hygiene
- Harm to other people (manifested as “If I don’t do this, something bad will happen…”)
- Doubt and uncertainty (leading to repetitive checking)
- Blasphemous or offensive religious thoughts (often considered as “taboo thoughts”)
- Symmetry and perfection
Common subtypes of compulsions include:
- Washing and cleaning
- Checking
- Counting
- Arranging or ordering
- Hoarding
The grouping of themes has been certainly helpful in helping individuals identify and discuss their experience of OCD and in showing the wide range of symptomology beyond the stereotyped ones. The understanding and knowledge of OCD have certainly improved over the years, which is a move in the right direction given the treatment delay of 11 years in Singapore for OCD. This means that there is 11-year gap between when a person starts experiencing symptoms and when they finally receive help.
While these categories have been instrumental, they may not encapsulate the entirety of the disorder. If you can’t relate to a specific theme, it might lead to doubt regarding whether you truly have OCD. OCD has the capability to cast doubt on any aspect, including one’s own diagnosis.
In practice, individuals rarely fit neatly into one category. Even within a specific subtype, not all aspects may be applicable. For example, an individual who is worried about contamination might be fearful of sharing food with others, but be perfectly fine with touching the rubbish bin. Moreover, the content of the obsessions shift and change over time, making it challenging to confine them within predefined themes.
In my clinical experience, it’s more beneficial to explore the underlying fears that OCD focuses on, rather than fixating solely on the subtypes. At the core of OCD often lie doubts and uncertainties, questioning one’s identity, feelings, memories, capabilities, and senses. OCD uses these doubts to “hold us hostage”, threatening us that our underlying fear might be true.
Common underlying fears associated with OCD:
- Being a bad person
- Facing abandonment or rejection by others
- Fear of death
- Concerns about suffering indefinitely
- Belief that the future will be irreversibly ruined
In therapy, understanding these underlying fears becomes essential. I often guide individuals to envision their obsessions, allowing the worst-case scenario to unfold. By exploring the potential consequences of not engaging in compulsions, the underlying fear typically surfaces.
For instance, a person with perfectionism-related OCD might express persistent worries about making mistakes at work, leading to repetitive checking behaviours. However, upon deeper exploration, the core fear emerges as the worry of being fired, which, in turn, is linked to the fear of becoming a burden and facing abandonment and rejection from friends and family.
The gold standard psychotherapy for OCD is exposure-response prevention (ERP). This approach involves gradual exposure to feared situations, fostering increased tolerance for doubts and uncertainty. The most effective treatment targets specific underlying fears, allowing individuals to confront their fears and live with uncertainty, even if the themes of their obsessions evolve over time.