OCD Themes: The Many Faces of OCD
Obsessive Compulsive Disorder, or “OCD,” tends to get a bad rap in the mental health world, where it presently reigns as anxiety’s even more perverse cousin. There are many myths that surround this disorder, and it is because of these misconceptions that a diagnosis of OCD can feel more like a life sentence than a disorder. Although OCD can be challenging and difficult to treat at times, it is most often amenable to intervention when brought to the attention of a trained professional, especially when the client is willing to learn about this disorder and step outside of their comfort zone to address the symptoms.
Believe it or not, the trickiest part of treating OCD can be identifying it, and this is the case for a few reasons:
OCD, just like its counterpart, Worry, is sneaky. It likes to cause trouble, but it does not like to get called out. Part of this stealth is hanging out underneath the surface through the use of mental compulsions, which cannot be observed by the naked eye, or discrete compulsions, that are embedded within “normal" behaviors, making them all the more elusive and difficult to detect.
OCD can also be a bully, convincing its victims to keep obsessions to themselves as opposed to sharing their thoughts with trusted peers or family members. An example of this can be “protecting” OCD by denying its presence. If I had a dollar each time I heard, “That’s not my OCD,” I’d be living in Monaco!
Another factor that makes OCD recognition difficult is that some obsessions and compulsions are considered “normal” and part of our societal fabric. A football athlete who will only wear a certain pair of underwear on game day because THAT is the pair they wore when they made their first touchdown gets a giggle. Seeing matching numbers on a clock, such as 5:55 or 4:44 and making a wish, feels validating and even evocative of a “sacred geometry” buried deep within spacetime. Asking a friend for reassurance is a normal interpersonal exchange, and not problematic–until it is.
It is important to keep in mind that children and teens have an extremely personal, detailed and historical relationship with their individual OCD. Regardless of how much a youngster shares with their parents about this disorder, there is no way they can accurately capture the entire essence of the toxic dynamics that exists between them and their OCD. Furthermore, trying to figure out what is OCD and what is not, alongside differentiating between disorder and plain old Worry, are not easy tasks, and without professional guidance, someone living with OCD can be likely to get passed off as merely superstitious, which does not meet diagnostic criteria for OCD, even if it does.
Obsession + Compulsion = OCD
OCD always involves the same two components: an obsession and a compulsion. An obsession is a thought that gets stuck, and a compulsion is an action, either behavioral or cognitive, that is intended to alleviate the emotional distress that stems from the obsession. The compulsion always strengthens the obsession, which in turn grows OCD over time in a self-destructive feedback loop.
Parents, beware: not all compulsions are observable. Some compulsions are mental, which means a child or teen could be engaging in them without their parents’ awareness, and other compulsions have chameleon-like features, seamlessly blending into the environment without calling any attention to their nature. Repetitive compulsions that require parental accommodation tend to get noticed much more quickly than mental or discrete compulsions, but it is important to keep in mind that there can more than meets the eye when it comes to OCD.
Common OCD Themes
OCD has many themes, and someone dealing with this disorder is likely to have multiple themes that shift and change over time rather than one set theme that remains the same regardless of age or environment. Additionally, themes tend to take on the developmental challenges or tasks a youngster might be immersed in such as appropriate risk-taking, changing bodies or identity development. Here are some common themes and examples of how they can present:
Contamination OCD involves a fear of contamination, duh! What makes this theme tricky, however, is that contaminants can include anything from germs to chemicals to fecal matter–and these are only a few of the viable options OCD may target, to name a few. Someone with this theme may refuse to eat certain foods that they think are “bad,” wipe excessively after bathroom usage to be sure that no known contaminants are left behind or may wash their hands until they can feel “sure” all of the germs have been eliminated.
Sexual Identity OCD involves doubtfulness around sexual identity. Sexual identity is based upon feelings of romanticism and/or sexual arousal. Individuals with this theme worry that they may have a different sexual identity than that which they believe to be true. Compulsions can include checking arousal when around the same or different gender, reassurance-seeking and mental gathering of evidence confirming one’s sexual identity.
Health OCD entails obsessions around being sick or having an illness such as cancer, an autoimmune disorder or AIDS. Compulsions include reassurance-seeking from mental health professionals, going down the Google wormhole of searching up symptoms or checking to see if certain sensations are present.
Just Right OCD involves a need to feel the “right” way about something. Obsessions can be around bad things happening if that “just right” feeling is not achieved, or a rigid need for something to feel “right” and an intolerance of anything that does not meet this criteria. This theme is quite broad and can include the physical arrangement of objects, the scanning of songs on a playlist until the “right” song is played or needing a parent to repeatedly say something in a certain way, such as “I love you” or “goodnight.”
Responsibility OCD is a fear of being responsible for something and not being able to tolerate the consequential emotion, which is usually some form of guilt. People with this theme may pick up random objects as they are walking to ensure another person does not trip, excessively check that they have turned off a certain object, or express a fear that they hurt a friend at recess, even if they do not recollect doing so.
Harm OCD includes obsessions around hurting oneself or another, despite a lack of intention to engage in such acts. Examples of compulsions can be avoiding sharp objects, out of fear that the individual may grab one and not be able to control their urge to hurt another, reading or watching stories of people who have “snapped” and comparing themselves to them, or avoiding situations OCD deems “risky,” such as being alone with someone or spending time in a location where sharp objects are located.
Moral OCD is a fear of being a bad person. OCD has a lot of fun with this theme, as being “bad” is an umbrella term under which a broad range of acts can ethically fit. People with this theme may excessively apologize, mentally attempt to replace “bad” thoughts with “good” ones or refuse to engage in activities that involve any form of social risk-taking, such as attending parties or low-key social gatherings.
Disclaimer: A youngster can engage in some of the compulsions mentioned above without having OCD. Most of us have questioned whether we are good or not or worried about being sick at one time or another–this is totally normal and not a cause for concern. The key in determining whether or not someone has OCD is duration and frequency. If your child or teen has been engaging in known compulsions for over a year (duration) or multiple times a day (frequency), there is a chance that more may be residing underneath the surface than meets the eye, which warrants investigation.
Worry vs. OCD
Worry and OCD can look similar, especially in the absence of obvious repetitive compulsions. Despite their catastrophic qualities, there are key differences that are important to note:
Worry jumps around from topic to topic, while OCD is myopic and hyper fixates on a limited range of fears.
Worry, believe it or not, is rooted in possible outcomes, such as failing a test or losing a friend, whereas OCD is connected to conclusions that are more irrational in nature and that are often far from probable (accidentally pushing a friend down the slide, ingesting a toxic amount of antibacterial sanitizer after wiping down a table, a parent dying if the correct song is not played, etc.).
Worry tends to be related to something relevant, while OCD is intrusive. An example of Worry is feeling anxious at a party that no one will talk with you (relevant). An example of OCD is feeling anxious at a party that the headache you had last week was a sign of cancer (intrusive).
When in doubt, seek the support of a trained mental health profession who has expertise with OCD to learn more about your child or teen’s symptoms.
Resources
We are quite fortunate in 2023 to have so many resources around the topic of pediatric and adolescent OCD. Not only are there more books, podcasts and dialogues around this disorder, there is more hope, as continual research is being performed to help professionals, families and individuals better understand OCD, treatment modalities and the impact of parental accommodation on symptoms.
Below are some reads and podcasts that parents may want to consider to learn more about this topic:
What to Do When Your Brain Gets Stuck: A Kids’ Guide to Overcoming OCD by Dawn Huebner, Ph.D.
Stuff That’s Loud: A Teen’s Guide to Unspiraling when OCD Gets Noisy by Ben Sedley and Lisa Coyne
AT Parenting Survival Podcast with Natasha Daniels (a podcast dedicated to pediatric/adolescent OCD)
