What is obsessive-compulsive disorder (OCD)?

Previously categorised as an anxiety disorder, OCD now sits within the ‘obsessive-compulsive and related disorders’ category in DSM-5-TR, which also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin picking disorder).

OCD is characterised by the presence of obsessions, compulsions, or both (see Table 11 and Table 12). It is distinct from feeling a need for neatness, cleanliness, or order (which is sometimes referred to as ‘obsessive-compulsive’ or ‘OCD’). OCD is often long-lasting and debilitating with people feeling compelled to prevent disasters befalling loved ones or alleviate anxiety by performing rituals which cause significant distress.

Table 11: Predominant symptoms associated with OCD

Obsessions and compulsions
Obsessions (often referred to as ruminations) are recurring, persisting thoughts, urges, or images that are intrusive and unwanted, and cause anxiety or distress in most people. The person attempts to ignore or suppress their obsessive thoughts, urges or images, or counteract them with another thought or action (i.e., by performing a compulsion). Examples of obsessions include persistent fears of contamination, thinking they are to blame for something, or an overwhelming need to do things perfectly.
Compulsions (often referred to as rituals) are repetitive mental acts or behaviours that a person feels driven to perform, in response to an obsession or according to rules that must be strictly followed. The mental acts or behaviours are aimed at preventing or reducing anxiety or distress, or preventing a dreaded event; however, the behaviours or mental acts are not connected to what they are designed to counteract in any realistic way, or they are clearly excessive. Examples of compulsive behaviours include the need to repeatedly wash one’s hands due to the fear of contamination, check that things have been done (e.g., whether doors or windows have been locked, appliances switched off), or avoid certain objects and situations (e.g., holes in the road, cracks or lines in the pavement). Examples of mental acts include counting or repeating words silently.

Obsessions and compulsions

Obsessions (often referred to as ruminations) are recurring, persisting thoughts, urges, or images that are intrusive and unwanted, and cause anxiety or distress in most people. The person attempts to ignore or suppress their obsessive thoughts, urges or images, or counteract them with another thought or action (i.e., by performing a compulsion).

Examples of obsessions include persistent fears of contamination, thinking they are to blame for something, or an overwhelming need to do things perfectly.

Compulsions (often referred to as rituals) are repetitive mental acts or behaviours that a person feels driven to perform, in response to an obsession or according to rules that must be strictly followed. The mental acts or behaviours are aimed at preventing or reducing anxiety or distress, or preventing a dreaded event; however, the behaviours or mental acts are not connected to what they are designed to counteract in any realistic way, or they are clearly excessive.

Examples of compulsive behaviours include the need to repeatedly wash one’s hands due to the fear of contamination, check that things have been done (e.g., whether doors or windows have been locked, appliances switched off), or avoid certain objects and situations (e.g., holes in the road, cracks or lines in the pavement). Examples of mental acts include counting or repeating words silently.

A case study example of how a person experiencing co-occurring OCD and AOD use disorder may present is illustrated in Box 6.

Table 12: Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD)
OCD is characterised by the presence of obsessions, compulsions, or both. The obsessions or compulsions are time-consuming, taking at least one hour per day, or cause significant distress. As the performance of these rituals is time-consuming, they can significantly interfere with the person’s social and occupational functioning.

Box 6: Case study F: What does co-occurring OCD and AOD use look like? Ayla’s story

Case study F: Ayla’s story

Ayla is a 19-year-old who is currently living with her parents. She presented to her local AOD service at the insistence of her parents who came across her stash of cannabis when her mother was straightening her room. Although her mother has brought Ayla to her appointment, she has remained in the waiting room while Ayla speaks to the AOD worker.

On assessment, Ayla was at first quiet and appeared to be withdrawn. She told the AOD worker that she had been using cannabis daily to slow down or dampen her thoughts. Ayla eventually broke down in tears and told the AOD worker that she had been having obsessive thoughts and behaviours that she had to perform, for a long time. Ayla said that when she was in school, she was always the last one to leave the classroom because she had to make sure that every letter on the whiteboard had been copied down in her notebook exactly right. She was usually late to the next class because of this repetitive checking, and she often had difficulty sleeping because she was reliving the day’s classes in her mind, trying to remember if she had copied down all the notes correctly. On one occasion, she was called in to see the school counsellor because of her continual lateness. The counsellor told Ayla that she thought Ayla might have generalised anxiety disorder and should try to ‘forget’ about her obsessive thoughts and stop worrying so much. The counsellor told her to focus on what she wanted to do after she left school.

Ayla told the AOD worker that as she got a bit older, she started having intrusive negative thoughts about harm befalling her family. Ayla said that if she didn’t tap her bedroom door handle seven times every time she entered or left the room, her family would die. Seven was a meaningful number for Ayla, because she had two parents plus two sisters plus two dogs (and herself). If Ayla didn’t feel ‘right’ about the tapping, or if she thought she tapped eight times instead of seven, she had to start again. Ayla told the AOD worker that her tapping then extended to a need to check and recheck all the lights in her room before leaving her room and when going to bed. Ayla tried to explain that even when the lights were off, she would have to carefully check the bulb and the light switch, not believing or trusting her eyes that they were off, so needing to turn them on and back off again. When she left home, she would take pictures of the switches and the globes and keep looking at them and also replay the ritual of turning them off over and over in her mind.

Ayla told the AOD worker that tapping or turning the switches would provide her with a few seconds of relief, but this was always short-lived, and she would need to repeat it to alleviate her obsessive thoughts. Ayla said it was like ‘an itch that I just have to scratch’. She told the AOD worker that she understood that there was no logic or rationality to her thoughts and behaviours, but she couldn’t stop herself from performing her rituals. Ayla said she was lonely but had trouble forming and maintaining friendships because she was always distracted by her thoughts and couldn’t engage with another person.

Since leaving school she had tried several different part-time jobs, but because she took several hours to leave the house, she was unable to keep any of them. Her sisters and a couple of old school friends had told her to relax, and Ayla had tried yoga, meditation, and mindfulness – all of which she found frustrating and of little benefit. Ayla told the AOD worker that smoking weed was the only thing she has found useful, as it dulled and slowed her thoughts. She said that smoking a ‘ton’ of weed was the only way she could now get to sleep.

Ayla told the AOD worker that she was completely exhausted and just wanted the obsessions and compulsions to stop. She said the only way she could realistically see that happening was if she ended her life.

Key Points

What are the primary concerns for Ayla?
Where to from here?

Case study F continues in Chapter B7.