#TherapistDiaries: The realities of OCD, today’s ‘urban term’

It’s not uncommon in pop culture to use diseases and illnesses as verbs. This insensitive practice often includes the term Obsessive-Compulsive Disorder (OCD). It’s misused to such an extent that it is almost an urban term these days.

I heard a teenager, in a popular movie, talking about his mom who was concerned about her son not washing his hands before eating, say, “She’s so OCD!”

A designer, whose job focused on geometric and symmetric designs, once told me, “I have OCD”.

She had been diagnosed by her friend, who read a random internet article which said that having an obsession with order and symmetry was a  symptom of OCD. The popular belief is that if one is overly concerned with cleanliness or set patterns, they surely must have OCD.

Recently, I was watching Jack Nicholson’s As Good As It Gets. His character had a fixed pattern of turning the locks a couple of times before opening the door. The very first glimpse of his house introduces the audience to a bathroom cabinet filled with soap bars and towels, which he disposes as soon as he uses them. Moreover, Nicholson eats at a particular restaurant, to which he walks in a particular style, sitting at a particular table. Not only does he bring his own plastic cutlery, but he also demands to be served by a particular waitress, who has been waiting his table for years.

The movie concludes with Nicholson breaking his years-old obsessive compulsive patterns by simply falling in love. This is a reach and the reality of this disorder is much more complex. Much like the ending of the film, our society’s general perception of OCD is very casual and at times insensitive. It is seen as a peculiar personality trait that, according to people, either needs no treatment or can be managed at free will. The truth behind OCD is much more painful and it is about more than just being concerned with neatness or order.

The first facet of OCD includes repetitive thoughts about certain themes. The themes may relate to contamination, order, symmetry and religion. A person may have repetitive thoughts that always seem intrusive and out of control. The thoughts may be related to all the aforementioned themes or could be a combination of them.

But it doesn’t stop here. Therapists meet a number of people engaging in repetitive actions as a part of OCD too. For instance, Lady Macbeth used to repeatedly wash her hands because she had an intrusive and repetitive thought related to blood contamination. Therefore, repetitive acts are the second dimension of OCD. Some may only have intrusive thoughts, some may only perform repetitive acts with no active awareness, and some might be plagued by both intrusive thoughts and actions.

The following examples of Ali*, Bismah* and Khadija* can best elaborate the varied nature of OCD.

Ali, in his early teens, came to me with a complaint of repetitive imagined scenarios about himself running from religious prayer. He would repeatedly tell himself, “I’m not a good Muslim”. In reality, he offered his prayers quite regularly and appeared to be observing his faith. I asked him if he imagined this scenario at will. He replied,

“It’s like some urge, a constant urge which bothers me unless I imagine this scenario. But when I imagine it, I feel obligated to take a bath, three times in one go.”

What was happening with this teenager was that he was having an obsessive thought in the form of an ‘urge’ and ‘visuals’; his repetitive act of washing himself thrice was a compensatory response to reduce the anxiety created by the thought.

Bismah, an artist by profession, was in her late 20s. Things got out of hand when she became pregnant and started having intrusive thoughts, in her own voice, which would say to her,

“You are not relaxed enough. This isn’t working. You’ll never be relaxed.”

She didn’t have any compensatory behaviour (repetitive acts) to relieve the anxiety of this thought, and all she could do was cry and feel helpless.

Khadija, an elderly woman, had a pattern of clapping her hands three times upon waking up, opening doors, and hanging up the phone. Additionally, she checked her main gate a fixed number of times in a day. When asked about this, she revealed that she had no insight about this behavior and outright denied doing it. This means that she only carried out repetitive acts but was not subjected to intrusive thoughts.

The thoughts come in the form of our own voice or a version of it. They come as urges and may come as visuals or imagined situations. Obsessive thoughts can take up any of these forms as shown in the aforementioned cases.

The psychological theories which explore why this disorder may arise point to several factors. Extremely strict parenting, where a child feels pressurised into being perfect, or severe punishment-related experiences upon making mistakes in one’s growing years can often lead to OCD. An experience of sexual abuse can lead to a feeling of contamination or neatness, resulting in OCD. Having a family member who has OCD can also lead to learning it as model behaviour in one’s childhood. A strict emphasis on fear-based morality or religion leads to perceiving oneself as a sinful person which may or may not be rooted in reality. Lastly, having a general bent towards perfectionism is another major cause of the disorder.

Unfortunately, the treatment of OCD is tedious for the patient. It involves them developing an awareness of these thoughts, an exposure to the feared outcome and delaying the compensatory behaviour or repetitive acts.

OCD is one of those disorders that causes great personal distress and severely alters the way people live their lives. OCD brings a lot of scrutiny, bullying and humiliation since one can be seen engaging in these obsessive acts by others. You can be seen doing the ritualistic hand wash. You can be seen checking certain things multiple times and going all the way to check again. You can be seen putting things in a particular order multiple times, and you can be seen dressing up in a certain way. Therefore, this makes it difficult to perform or complete tasks on time, and these factors contribute to severe stress. It is definitely not as casual as pop culture makes it seem by misusing it.

The only message I would want to give people who have or know someone with OCD is that recovery takes time. It takes time to alter cognition and gain control. It takes time to get rid of the repetitive acts and it takes time to treat the childhood experiences that led to this behavioral disorder. But just because it takes time doesn’t mean it never gets better.

(*Names have been changed to protect identities and doctor-patient confidentiality.)