While there are certain themes of obsessive-compulsive disorder (OCD) that commonly arise—some of them, like symmetry and contamination, are likely familiar to you—it’s interesting to know that OCD can look wildly different for everyone.
“At its core, OCD is defined by a perceived inability to accept unwanted mental events,” says Nicolas Farrell, PhD, Regional Clinical Director at NOCD. He explains that we all have extremely powerful brains that can churn out endless possibilities of mental content, and it’s not always pleasant or expected.
In many instances—inventions, artistic creativity, everyday problem solving—the mysteries of our minds can be a very good thing. But for some people, the whole thing goes sideways. Why? “We all have our own personal perspectives, outlooks, and moral standards on what’s acceptable or not,” Dr. Farrell says. “And no one can fully control the thoughts they have.”
Case in point: Intrusive thoughts, images, or urges, can pop into your brain at any given time. Some people will brush them off and move on, others may feel disturbed but still move on, and some people can feel absolutely overcome by them. As a result, the distress will cause them to try to avoid or push those thoughts away, Dr. Farrell says. Compulsions then develop to neutralize those thoughts or prevent something bad from happening. And this process is how OCD works.
Due to the uniqueness of our brains and the variety of content they can create, as well as how that mental landscape affects you, OCD can look incredibly different from person-to-person. “I think there are so many different shapes and forms that OCD can take because of the seemingly endless list of ideas and variety of attitudes people have about their thoughts,” Dr. Farrell says.
With an almost endless number of subtypes of OCD, it’s possible to bucket them into four main categories. Keep in mind that these are not clinically validated, but that summarizing common themes of OCD helps to understand just how many forms the condition can take. This also helps normalize and de-stigmatize them, Dr. Farrell explains. “It’s common for someone in treatment to say that they know intrusive thoughts are common, but let me tell you, you have not heard what I’m about to say!” Dr. Farrell points out. Rest assured, “we’ve heard it all—or it’s a very slight variation of these main common themes,” he says.
What are the four different types of OCD?
Though there are many OCD subtypes, these themes can be generally combined into four categories:
- Harm or serious misfortune
- “Just Right” or perfectionism
- Unacceptable/taboo thoughts
The four main types of OCD, explained
In the following sections, we’ll dive into what these types of OCD look like, including the common obsessions and compulsions that fit with each. Remember, OCD is extremely individualized, so while you may identify with one of these categories, not every obsession or compulsion will apply to you.
“Contamination is a big theme in OCD,” says Dr. Farrell. If you have Contamination OCD, you may fear that you could become sick or contaminated in a certain situation, or fear that you will contaminate someone else by unintentionally spreading harmful contaminants that cause others to be sick.
While the most common presentation of Contamination OCD is a fear of physical contamination (such as touching something), there’s also emotional contamination in OCD where you fear that people, places, or objects are contaminated, and so, you have to perform compulsions so that you are not “dirty.” So, if you have a bad thought that makes you feel “dirty” you might now have to wash your hands a certain number of times or change your clothes to avoid being contaminated. You may also fear that having an impure or disturbing thought like this will contaminate or harm someone else.
Compulsions in contamination OCD might look like:
- Excessive cleaning of objects and surfaces
- Excessive hand washing
- Using harsh chemicals
- Frequently changing your clothes
- Avoidance of objects, surfaces, or places where you feel as if you can be contaminated
- Seeking reassurance that something is not contaminated
- Mental review to keep track of things that are clean versus dirty
- Excessive research about illness or contaminants
Harm or serious misfortune OCD
Harm OCD involves the fear that you will harm someone else. “People with this type of OCD will do a lot to try to verify or get assurance that they were not responsible for harm or serious misfortune of another person,” Dr. Farrell says. For example, you might be driving and become fearful that several intersections ago you unknowingly hit a pedestrian, so you go back to check that there are “no bodies lying around,” he explains.
Other times, checking can be more discreet because it occurs in your head. You might repeatedly mentally review—or check—a conversation you had with a colleague or a friend to make sure you didn’t say anything offensive or inappropriate, which could emotionally harm someone.
OCD also has a way of closing your world via avoidance, and it’s also very prevalent in harm OCD. “People who struggle with this theme of OCD commonly overestimate the probability that they will be responsible for harming someone. Because of this, a common behavioral response is that they will just avoid a situation entirely,” says Dr. Farrell. If you believe that you might impulsively stab your partner when you’re chopping veggies, well, then you’re probably not going to cook with knives. If you think you’re going to run someone off the road with your car, you might not drive at all.
- Checking to make sure they did not cause harm
- Reassurance seeking by asking people close to them if they think they’d cause harm
- Mentally reviewing past experiences.
- Thought cancellation
- Avoidance of situations or people that they fear they will cause harm to
- Avoidance of objects that could cause harm to self or others
“Just Right” OCD
Here’s where themes focused on perfectionism come in—the sorts of symptoms that most people tend to associate with the condition. “This is the belief or worldview of a person who can’t handle or live with things not being just so,” Dr. Farrell explains.
This type of OCD might be outcome-based, such as needing to score perfect on a test or pass a performance review with perfect feedback from your boss with nothing to work on in the future. Or, you may focus on a perfect appearance: “There may be a need for objects or things in the environment to be arranged or ordered in a certain way,” Dr. Farrell explains. As with all themes of OCD, it can impact absolutely anybody—perfectionism OCD is something David Beckham has opened up about in his life.
Another way “Just Right” OCD can manifest is the physical need for things to be complete or exact, says Dr. Farrell. This is the person who walks through a doorway and bumps his left elbow needing to bump his right elbow to even things out, he explains.
Compulsions in “Just Right” OCD include:
- Repeating or fixing actions until something is done “just right”
- Avoidance of things or situations that can’t be perfect
- Seeking reassurance that something appears perfect to others
Unacceptable/taboo ideas or thoughts
This OCD theme “includes any kind of mental phenomena that a person might experience that runs counter to who they believe themselves to be,” Dr. Farrell says. This speaks to the ego-dystonic nature of OCD, which means that your intrusive obsessions are not aligned with your actual values or desires.
Examples of taboo themes of OCD would be obsessions related to pedophilia (sexual intrusive thoughts about children), postpartum (fears of harming your newborn intentionally or unintentionally), incest, or bestiality/necrophilia (unwanted thoughts about a pet, animal, or dead body).
What’s important to keep in mind is that people experiencing taboo thoughts do not want these things to happen, and they don’t want these thoughts to occur. They are horrified by them and want to get rid of them as quickly as possible.
Compulsions related to taboo thoughts include:
- Hiding things that could be used as weapons
- Researching murderers or pedophiles to reassure yourself that you’re not like them
- Compulsive prayer
- Avoiding being around children or animals
- Thought replacement, where you replace “bad” thoughts with “good” thoughts
Why these four types of OCD aren’t precise
Intrusive thoughts and fears don’t come in tidy packages—there is variability to how everyone experiences their OCD. What’s more, it’s common to have more than one theme of OCD. “An unwanted thought, image, or idea a person experiences may beget multiple feared consequences or outcomes,” says Dr. Farrell. For example, someone might fear harming another person but also fear what that thought means about their identity or religious morality.
In general, clinicians don’t recommend self-diagnosing OCD. “The landscape of OCD is misunderstood enough, even by trained professionals. However, it’s helpful to know where your symptoms fall from the standpoint of normalizing your OCD,” he explained. Knowing that there are enough people experiencing similar symptoms and themes to your own can help reduce the guilt and blame that accompany the condition.
Bottom line: Seek out a diagnosis from a clinician who is trained in OCD. While you won’t be diagnosed with a specific type, or theme, of OCD, you will address your specific thoughts and compulsions in treatment (more on this below).
What’s the best treatment for OCD?
OCD is best treated with a type of behavioral therapy called exposure and response prevention, or ERP. During ERP therapy, you will meet with a clinician to talk about your obsessions and compulsions.
Through that discussion, you’ll develop a plan for your therapy exercises. For example, if you have contamination fears and are afraid of needles, a photo of a needle may trigger a small amount of anxiety, whereas touching an actual needle causes skyrocketing distress. In that event, your clinician may start working with you as you look at photos of needles, resisting the urge to wash your hands or distract yourself for relief. As time moves on, you’ll build to bigger triggers, learning that you can handle higher amounts of discomfort—eventually, you might even go to the pharmacy to get a flu shot.
Ultimately, ERP takes the power away from your thoughts. You learn to realize that you can handle your intrusive triggers without relying on compulsions. Some people experience benefits from ERP in a matter of weeks. And you don’t even need to do this treatment in-person—virtual therapy has been found to be extremely effective for all types of OCD.
You can conquer any subtype of OCD OCD, starting today
In other words, ERP makes a real difference for OCD and beyond. However, in order for OCD treatment to be effective, it needs to be done by a therapist who has received special training in ERP. NOCD therapists are all specialized in ERP and are here to help you—I recommend learning more about NOCD’s accessible approach to OCD treatment.