Obtaining an accurate Obsessive Compulsive Disorder (OCD) diagnosis and treatment can take upwards of 11 years for many. One of the biggest barriers to accessing help sooner stems from a lack of education and awareness about the various ways that OCD can manifest. Trained mental health professionals frequently lack understanding about the disorder, leaving it undetected or misdiagnosing symptoms. When OCD is portrayed accurately, which it so often is not, we tend to see stereotypical representations: somebody with fears of contamination who washes their hands compulsively or somebody repeatedly checking the stove for fear that they left it on and will burn the house down. These are very real and painful realities of OCD, but they are not the only reality.
For many, OCD obsessions take the form of taboo subjects that are difficult to speak openly about…let alone even think about: paedophilia, incest, violence, bestiality, rape, suicide, and more. Their brains latch onto the last thing they would ever want to enter their minds and assault them with these thoughts on repeat. For example, someone with sexual obsessions might experience unwanted sexual thoughts about children that lead them to fear they are a paedophile–despite how disgusted they are by the thoughts.
OCD is egodystonic, meaning that the obsessions are not in alignment with the person’s values, beliefs, and self-concept. This is part of what makes living with OCD so distressing.Alegra Kastens
I know what you might be thinking: what is the difference between someone with OCD and a paedophile, rapist, murderer, or [insert taboo fear]? There is a world of difference. OCD is egodystonic, meaning that the obsessions are not in alignment with the person’s values, beliefs, and self-concept. This is part of what makes living with OCD so distressing. The sufferer is ambushed by thoughts that disturb them—thoughts that they do not want to carry out. In fact, they perform compulsions (in response to obsessions) to attempt to get rid of the thoughts, prevent something bad from happening, and alleviate anxiety. Someone with unwanted sexually intrusive thoughts about kids might compulsively avoid being around their own children because of how petrified they are by the thoughts. Someone with unwanted violent intrusive thoughts might compulsively hide the kitchen knives in the trunk of their car because they’re so fearful of being around them. This vastly differs from a paedophile who is attracted to children and aligns with the sexual thoughts or a murderer who has a desire to kill.
If this is new to you, you’re not alone. It is often new to the very people who experience these symptoms and live for years without a name for the torment happening in their brains. I was one of them. When I finally gathered the courage to take to the internet and search for the reason I was having such thoughts (the taboo kind), I didn’t believe what popped up multiple times on my screen—that they were symptoms of Obsessive Compulsive Disorder. I could not reconcile the kinds of thoughts I was having with the only things I knew about OCD: that people compulsively wash their hands or tap and count things.
As a therapist who now specializes in the treatment of OCD, this dissonance shows up in my office almost daily as I treat clients who went undiagnosed or misdiagnosed for years because of the gross misrepresentation and stereotyping of OCD.
What is an obsession?
In pop culture, “obsessed” is a word used to describe someone’s love and adoration for something. Think: “I’m so obsessed with this TV show! I binge it daily.” This connotation opposes the psychological definition of an obsession, which is a crucial distinction to make when understanding OCD.
People with OCD do not love or adore their obsessions. They are terrorized by them. An obsession is a repetitive, unwanted thought/image/urge/sensation that causes a person distress and is often experienced as intrusive. It is not simply the cringy passing thought that we all have from time to time, but a recurring thought that pops into a person’s mind, sticks, and takes over.
Can’t the person just stop thinking those thoughts or choose different thoughts? This is a maddening question often posed to those with OCD who would love nothing more than to stop having such thoughts. The truth is that we are not in control of what pops into our mind, and attempts to suppress such thoughts exacerbate the intensity and frequency of the thoughts.
Try to pose for yourself this task: not to think of a polar bear, and you will see that the cursed thing will come to mind every minute.Fyodor Dostoyevsky
Studies have shown that the more we attempt to stop thinking about something, the more we actually think about it.
What is a compulsion?
A compulsion is a physical or mental act that a person feels compelled to carry out in response to an obsession. They do not want to perform the compulsion, but feel the urge to do so in order to seek certainty that the obsession is not true, alleviate discomfort, or prevent a dreaded outcome from occurring.
The most widely recognized compulsions are overt, physical compulsions like excessive sanitization and re-doing something until it feels “right.” Compulsions that are just as pervasive but commonly missed are covert, mental compulsions. Examples include mental rumination about the content of obsessions, mentally reviewing the past, attempting to neutralize an obsession by replacing a “bad” thought with a “good” thought, mentally checking one’s feelings and bodily sensations in response to obsessions, and more. Avoidance and reassurance-seeking behaviors are also compulsions that those with OCD carry out.
What makes OCD different?
Don’t we all have an odd intrusive thought from time to time? Don’t we all perform a ritual from time to time? Yes and yes, but that does not mean that we all have OCD. Obsessions and compulsions are time-consuming for the OCD sufferer and take up at least an hour of their day. Obsessions are repetitive and sticky because of the way a person’s brain is wired. Whereas someone without OCD might be able to let the thought go and move on, obsessions are all-consuming for those with OCD. A person’s symptoms also impair their functioning across various domains: work, education, relationships, sexual intimacy, etc.
(Taboo) Obsessional Themes
Now that we’ve defined Obsessive Compulsive Disorder, we can take an in-depth look at the various taboo ways that it shows up for people.
A few important things to note:
- The below lists of obsessions and compulsions are not exhaustive. I’ve provided common examples.
- What is taboo can be both objective and subjective. The obsessions I’ve expanded on are objectively taboo subjects that society often deems unspeakable. They are subjects that make it difficult for a person to access treatment out of fear that a clinician who does not understand OCD will report them to authorities. There are other obsessional themes, such as blasphemous obsessions (ex. intrusive thoughts about worshiping Satan), that might feel taboo for those who are religious but may not be experienced as taboo for those who are not religious.
Taboo sexual obsessions include unwanted intrusive thoughts, images, or urges about pedophilia, incest, bestiality, rape, and necrophilia. People with such obsessions often avoid seeking treatment out of fear that a therapist will misunderstand their symptoms and report them to child protective services or law enforcement.
Common sexual obsessions include:
- A relentless fear that one is a pedophile or attracted to a family member, animal, or dead person/animal
- Unwanted sexual thoughts, images, or “mental movies” that play out in a person’s mind (ex. image of a sexual act with a family member)
- Relentless “What if” thoughts → What if I am attracted to children or animals? What if I snap and have sex with my mom? What if I am aroused when my child sits on my lap? What if I sexually assaulted someone in the past and blocked it out of my memory? What if I secretly want to have sex with my sister?
- The fear that a person will become a pedophile because there is a history of child sexual abuse in their family
- The (unfounded) fear that someone close to them is a pedophile, rapist, incestuous, or is into bestiality and necrophilia
Common compulsions include:
- Avoidance of the subjects of obsessions (children, family members, animals, etc.)
- Replacing unwanted thoughts with more desirable thoughts (ex. replacing an unwanted sexual thought about a child with “I love children”)
- Staring at the subject of the obsession to check and ensure that there is not arousal
- Mentally saying the word “stop” when a thought pops in
- Avoidance of activities related to the subject of the obsession (ex. avoiding hugging one’s mom, changing their baby’s diaper, petting one’s dog, etc.)
- Mentally reviewing the past to ensure that one has not acted in a sexually inappropriate way
- Sanitizing after touching a kid, family member, or animal to avoid being “contaminated”
- Avoidance of sex for fear that the thoughts will arise during
Another common manifestation of OCD involves unwanted violent intrusive thoughts, images, or urges. As for those with sexual obsessions, people with harm obsessions often avoid seeking treatment out of fear that a clinician will misconstrue obsessions as homicidality.
Common harm obsessions include:
- A relentless fear that one will harm (stab, shoot, push in front of a car, etc.) a person or animal
- Unwanted violent thoughts, images, or “mental movies” that play out in a person’s mind (ex. intrusive image of a person stabbing someone)
- Relentless “What if” thoughts → What if I am a murderer? What if I lose control and stab my partner while cooking? What if I am attracted to these violent thoughts? What if I push someone in front of the subway? What if I want to harm someone?
- The fear of snapping and acting in a violent way
Common compulsions include:
- Not using/hiding sharp objects (knives, scissors, etc.)
- Avoidance of television shows, movies, news articles, etc. that involve violence
- Mentally reassuring oneself (ex. repeating “I am not a killer” after having violent intrusive thoughts)
- Researching serial killers and others who have carried out violent acts to compare and seek reassurance that they are not like them
- Re-doing an activity after having an intrusive thought so that the activity is not “contaminated”
Postpartum OCD, a nickname for obsessions that arise after child birth, is common but not as well-recognized as Postpartum Depression. The sufferer experiences unwanted intrusive thoughts, images, and urges about harming their baby or something bad happening to their baby. These parents are often fearful of accessing help because they do not want their baby to be taken away. While they know that they would never carry out such thoughts, they are unsure that a clinician will understand this.
Common postpartum obsessions include:
- Intense fear of harm befalling a baby (ex. the baby stops breathing in its sleep, dies of SIDS, drowns, etc.)
- Unwanted thoughts, images, and urges about a baby that are of a violent or sexual nature (ex. intrusive images of throwing the baby down the stairs, thoughts about performing a sexual act while changing its diaper, images of purposely drowning the baby, etc.)
- Relentless “What if” thoughts → What if I sexually abuse my baby while giving them a bath? What if my baby stops breathing in their sleep? What if I throw my baby out the window?
- Fear that one will snap and harm their baby
Common compulsions include:
- Repetitive checking of a baby at night to ensure they are breathing (by staring at the baby, staring at the baby monitor, etc.) to a degree that impairs the sufferer’s functioning
- Avoidance of coming into contact with one’s baby (ex. not holding the baby, making their partner change the diaper or give the baby a bath, etc.)
- Putting up an excessive amount of cameras in one’s home that a person checks repetitively (to an unhealthy degree)
- Not being alone with their baby unless someone else is in the room
- Excessive visits to the doctor to check the baby’s health
People with OCD can experience unwanted intrusive thoughts, images, and urges about suicide. Whereas someone with active suicidal ideation aligns with the thoughts, the person with OCD does not want to be having them and does not want to die by suicide. Those with suicidal obsessions commonly fear accessing help. They worry that their therapist will treat suicidal obsessions as suicidal ideation and initiate involuntary hospitalization.
Common suicidal obsessions include:
- Intrusive and unwanted thoughts, images, and urges related to suicide (ex. an unwanted urge to jump off of a roof when standing near the ledge)
- The fear that one will “snap” and kill oneself
- Relentless “What if” thoughts → What if I slit my wrists while chopping these onions? What if I jump in front of the subway? What if I drive my car into the median?
- Intrusive thoughts in the form of commands: “Kill yourself!” “Do it!”
Common compulsions include:
- Not using/hiding knives and other objects that could lead to death
- Avoidance of activities that could lead to suicide (ex. driving, standing near high ledges, etc.)
- Not being alone for fear that one will kill oneself
- Mental rumination about the obsessions (ex. trying to analyze whether it is a suicidal obsession or suicidal ideation)
Regardless of the obsessional theme/the content of obsessions, it is all OCD and is treated the same. That being said, not all obsessions are experienced in the same way. People with taboo obsessions often carry an added layer of shame and stigma because of the content of their obsessions. It is objectively more difficult to disclose to someone that you are living with sexual obsessions about children as opposed to disclosing a fear of contracting an illness by touching a doorknob. Some go years, or even a lifetime, without telling another soul about their obsessions, which can exacerbate the shame and compound a person’s suffering.
It is imperative to find a mental health clinician who specializes in the treatment of Obsessive Compulsive Disorder and understands how to treat it effectively. The gold standard treatment for OCD is Exposure and Response Prevention (ERP), during which a person actively faces triggers head-on and learns how to tolerate anxiety and discomfort without performing compulsive rituals. Cognitive therapy, mindfulness skills training, and Acceptance & Commitment Therapy (ACT) are helpful adjunctive treatments to utilize.