"I think I might be going mad."

Daniel sat forward in the chair, hands clasped tightly together, speaking just above a whisper. For weeks, he'd been having thoughts that terrified him—violent images of harming his young daughter, sexual thoughts about family members, fears that he'd somehow caused accidents through negligence.

The thoughts came unbidden and felt completely alien to his values. He'd never hurt anyone, would never want to, considered himself a gentle and caring person. But the thoughts persisted, and with them came crushing anxiety and shame.

"I can't tell anyone about this," he said. "They'd think I was dangerous. Sometimes I think I am."

Daniel was experiencing OCD—Obsessive Compulsive Disorder. But it looked nothing like the hand-washing, light-checking stereotype that dominates popular understanding. His compulsions weren't visible behaviours but mental rituals: replaying events to check for evidence he'd caused harm, seeking reassurance from himself that he wasn't a bad person, analysing his thoughts to determine their meaning.

This is the OCD that many people suffer with in silence, convinced they're uniquely disturbed, unaware that what they're experiencing has a name and effective treatments.

TL;DR: Key Takeaways

OCD involves intrusive obsessions (unwanted thoughts/images) and compulsions (behaviours or mental acts to reduce anxiety)
It affects 1-2% of the population and goes far beyond cleaning and checking stereotypes
Common themes include contamination, harm, sexuality, relationships, and "just right" feelings
OCD is driven by intolerance of uncertainty and inflated sense of responsibility
Compulsions provide temporary relief but strengthen the OCD cycle long-term
ERP (Exposure and Response Prevention) is the gold standard treatment
OCD is highly treatable—recovery is possible

What OCD Actually Is

Obsessive Compulsive Disorder involves two components:

Obsessions

These are intrusive thoughts, images, or urges that:

Appear unwanted and repeatedly
Cause significant distress or anxiety
Are ego-dystonic (feel inconsistent with your values and self-concept)
Are difficult to dismiss or control

Important: Obsessions aren't fleeting worries or preferences. They're persistent, distressing, and feel impossible to shake.

Compulsions

These are repetitive behaviours or mental acts that:

Are performed in response to obsessions
Aim to reduce anxiety or prevent feared outcomes
Provide temporary relief but make the problem worse long-term
Are excessive or not realistically connected to the feared outcome

Important: Compulsions can be visible (washing hands, checking locks) or entirely mental (counting, praying, reviewing thoughts).

The OCD Cycle

Understanding the cycle helps explain why OCD persists:

Trigger: Something activates an intrusive thought (touching a door handle, seeing a knife, having a "bad" thought)
Obsession: The intrusive thought/image/urge appears and causes anxiety
Misinterpretation: The OCD brain says "This thought is important/dangerous/meaningful"
Anxiety spike: Fear increases dramatically
Compulsion: You perform a ritual to reduce anxiety (washing, checking, mental review, seeking reassurance)
Brief relief: Anxiety drops temporarily
Strengthening: The OCD learns that the thought WAS dangerous (because you had to neutralise it)

This cycle reinforces itself. Each compulsion confirms to the OCD brain that the obsession was a genuine threat—otherwise, why did you need to respond?

Beyond the Stereotypes: Types of OCD

Media portrayals have given most people a narrow view of OCD. In reality, it takes many forms:

Contamination OCD

This is the most recognised type but still often misunderstood.

Obsessions: Fear of germs, illness, contamination, spreading disease to others, being contaminated by toxic substances

Compulsions: Excessive washing, cleaning, avoiding "contaminated" spaces, following rigid hygiene rituals, seeking reassurance about cleanliness

What it's really like: Not just liking things clean. It's debilitating fear that touching something will cause serious harm to yourself or loved ones, followed by hours of washing that never feels complete.

Checking OCD

Obsessions: Fear of having caused harm through negligence (leaving the stove on, not locking the door, hitting someone while driving)

Compulsions: Repeatedly checking appliances, locks, routes; retracing steps; seeking reassurance; reviewing memories

What it's really like: Driving the same route five times to check you didn't hit a pedestrian you never saw. Leaving for work but turning back repeatedly to check the straighteners are off.

Harm OCD

This is one of the most distressing and misunderstood forms.

Obsessions: Intrusive thoughts/images of harming others (particularly vulnerable people like children), fears you'll "snap" and act on violent urges, fears you're a dangerous person

Compulsions: Avoiding situations where harm could occur, avoiding knives or other "weapons," mentally reviewing to check for dangerous intent, seeking reassurance you're not dangerous, avoiding the people you're afraid of harming

What it's really like: Parents terrified of their love for their children because they have intrusive images of harming them. People avoiding loved ones because presence triggers horrifying thoughts. Living in constant fear you're secretly a monster.

Critical point: People with harm OCD are not violent. The thoughts are ego-dystonic—they cause distress precisely because they contradict the person's values. Research shows people with OCD are no more likely to act on violent thoughts than anyone else.

Sexual Orientation OCD (SO-OCD)

Obsessions: Intense anxiety about one's sexual orientation, constant questioning and doubt, fear of being attracted to the "wrong" gender

Compulsions: Checking for arousal, analyzing past experiences, comparing attraction levels, seeking reassurance, avoiding situations that trigger doubt

What it's really like: Not actually questioning sexual orientation. It's obsessive doubt that hijacks the question. People with SO-OCD often have clear sexual orientation histories but can't tolerate the uncertainty that absolute certainty is impossible.

Relationship OCD (R-OCD)

Obsessions: Doubts about whether you love your partner, whether they're "the one," comparing your relationship to others, intrusive thoughts about leaving

Compulsions: Seeking reassurance from partner or others, testing your feelings, analyzing the relationship, comparing to past relationships

What it's really like: Loving your partner but being hijacked by doubt. Every interaction becomes evidence gathering: "Did I feel enough love during that conversation? What does it mean that I felt annoyed?"

"Pure O" OCD

"Pure O" is a misleading term—there's no such thing as OCD without compulsions. But this form involves predominantly mental compulsions.

Obsessions: Often related to harm, sexuality, religion, or relationship themes

Compulsions: Mental review, mental checking, thought suppression, mental reassurance, analysis, neutralizing "bad" thoughts with "good" ones

What it's really like: Invisible suffering. People appear fine externally while experiencing constant mental rituals that exhaust them.

Just Right OCD

Obsessions: Powerful discomfort when things aren't "just right," need for symmetry, specific ordering, or particular sensations

Compulsions: Arranging, ordering, repeating actions until they "feel right," evening up (e.g., touching right side because you touched left)

What it's really like: Not aesthetic preference. It's distressing compulsion to achieve a feeling that may never come, leading to hours spent arranging or repeating.

How OCD Differs from Other Experiences

Normal Intrusive Thoughts vs OCD Obsessions

Studies show that about 90% of people experience intrusive thoughts. The difference is in the response:

Normal Intrusive Thoughts	OCD Obsessions
Occasional and easily dismissed	Frequent and difficult to dismiss
Mildly uncomfortable	Highly distressing
Don't significantly impact life	Significantly impair functioning
"That's a weird thought" (move on)	"What does this mean about me?" (ruminate)
Don't lead to compulsions	Trigger compulsive responses

Example: Most people have fleeting thoughts like "I could push someone onto the tracks." The non-OCD brain notes it briefly and moves on. The OCD brain says: "Why did I think that? Does it mean I'm dangerous? What if I lose control?"

Anxiety Disorders vs OCD

OCD was classified as an anxiety disorder until 2013, when it got its own category in the DSM-5. While anxiety is central to OCD, several features distinguish it:

OCD has the specific obsession-compulsion cycle
Compulsions provide temporary relief (unlike generalised anxiety)
The content tends to be ego-dystonic and intrusive
Treatment approaches differ (ERP for OCD; other approaches for anxiety disorders)

OCPD vs OCD

Obsessive Compulsive Personality Disorder (OCPD) is frequently confused with OCD but is quite different:

OCD	OCPD
Ego-dystonic (thoughts feel wrong)	Ego-syntonic (thoughts feel right)
Causes distress	May not cause distress
Recognised as a problem	Often viewed as "just how I am"
Intrusive obsessions	Personality-wide perfectionism
Specific compulsions	General rigidity and control
Wants relief from symptoms	Sees approach as correct

What Drives OCD?

Understanding the cognitive patterns underlying OCD helps explain why it persists:

Intolerance of Uncertainty

Most people can tolerate: "I'm 99% sure I locked the door." The OCD brain demands 100% certainty—which is never truly achievable. This intolerance drives compulsions that seek impossible certainty.

Inflated Responsibility

OCD involves believing you have more power to cause or prevent harm than you actually do. "If I don't check perfectly, I'll cause a fire" or "If I have this thought, I might act on it."

Thought-Action Fusion

The belief that:

Having a thought makes it more likely to happen (likelihood TAF)
Having a thought is morally equivalent to doing it (moral TAF)

Example: "Thinking about harming my child means I might do it" or "Having a sexual thought about someone means I'm guilty of that act."

Overestimation of Threat

OCD magnifies the actual danger of situations. The likelihood of serious illness from touching a door handle is assessed as much higher than reality.

Need to Control Thoughts

The belief that you should be able to control all your thoughts, and that having disturbing thoughts means something is wrong with you.

Treatment That Works: ERP and Beyond

The good news about OCD is that it's highly treatable. The gold standard treatment is Exposure and Response Prevention (ERP):

How ERP Works

ERP involves two components:

Exposure: Deliberately confronting feared situations or thoughts rather than avoiding them. This might mean:

Touching "contaminated" objects
Sitting with intrusive thoughts without neutralizing
Not checking the lock
Tolerating uncertainty

Response Prevention: Resisting the compulsion that normally follows the obsession. This means:

Not washing after touching something "contaminated"
Not mentally reviewing to check for danger
Not seeking reassurance
Sitting with the anxiety instead of reducing it

Why ERP Works

OCD maintains itself through avoidance and compulsions. ERP breaks the cycle by teaching:

The feared catastrophe doesn't occur (or is tolerable if it does)
Anxiety decreases on its own without compulsions (habituation)
Obsessions don't require action—they're just thoughts
Uncertainty is tolerable
You can experience distress without being destroyed by it

The ERP Process

ERP is typically done gradually through a fear hierarchy:

List situations that trigger OCD, rated by difficulty (0-100)
Start with moderately difficult exposures (30-40 range)
Repeat exposures until anxiety drops significantly
Progress to more difficult exposures
Practice response prevention consistently

Example hierarchy for contamination OCD:

30: Touch outside of rubbish bin, wait 30 min before washing
50: Touch toilet seat, wait 2 hours before washing
70: Touch floor of public toilet, touch face, wait until end of day
90: Touch outside of public bin, eat food without washing

This looks extreme to those without OCD, but for someone with contamination OCD, these are the exposures that retrain the brain.

Other Helpful Approaches

While ERP is the gold standard, other approaches support treatment:

Cognitive therapy: Identifying and challenging OCD thinking patterns (thought-action fusion, inflated responsibility)

Acceptance and Commitment Therapy (ACT): Learning to notice thoughts without needing to change or respond to them

Mindfulness: Building capacity to observe thoughts without judgment or engagement

Medication: SSRIs (at higher doses than used for depression) can reduce OCD symptoms, often used alongside therapy

Compassion Focused Therapy: Addressing shame that often accompanies OCD

Living with OCD: Practical Strategies

While professional treatment is strongly recommended, some strategies can help:

Stop Seeking Reassurance

Reassurance is a compulsion—it temporarily reduces anxiety but strengthens the OCD. When you find yourself seeking reassurance (from others or yourself), notice it and resist.

Label It as OCD

When obsessions appear, try: "This is OCD talking, not reality." This creates distance between you and the thoughts.

Accept Uncertainty

Practice phrases like:

"Maybe, maybe not"
"I can live with not knowing for sure"
"Uncertainty is part of life"

Delay Compulsions

If you can't resist entirely, try delaying: "I'll check the lock in 10 minutes if I still need to." Often the urge diminishes.

Practice Self-Compassion

OCD is not your fault. You're not weak, damaged, or dangerous. You're experiencing a treatable condition.

Frequently Asked Questions

Can you have OCD about more than one thing?

Yes, it's common to have multiple obsession themes. They may occur simultaneously or shift over time. Treatment principles remain the same across themes.

Is OCD curable?

Many people achieve significant symptom reduction or remission with treatment. Some experience occasional flare-ups during stress. The goal is typically not zero symptoms but manageable symptoms that don't impair life.

What if ERP feels impossible?

ERP should feel challenging but not overwhelming. A skilled therapist creates a gradual hierarchy and supports you through the process. If one exposure feels too much, start with an easier one.

Can OCD develop suddenly?

Sometimes OCD appears suddenly, often triggered by stress, trauma, illness, or major life changes (e.g., becoming a parent). Other times it develops gradually.

What if I can't afford private therapy?

The NHS offers OCD treatment, though waiting times can be long. IAPT services provide evidence-based therapy. OCD Action and OCD-UK offer support, resources, and information about accessing treatment.

Is it OCD or am I just anxious?

The key distinguishing feature is the obsession-compulsion cycle. If you have intrusive thoughts that drive specific behaviours (visible or mental) to reduce anxiety, and this cycle is impairing your life, professional assessment is warranted.

Finding Hope

Daniel, the father from the beginning, was convinced his thoughts meant something terrible about him. The intrusive images of harming his daughter felt like evidence he was dangerous, unfit to be a parent, maybe even evil.

Through therapy, he learned that:

Harm obsessions are common, especially in new parents
The thoughts distressed him because he loved his daughter, not because he wanted to harm her
His compulsions (avoiding being alone with her, mentally checking for dangerous feelings) were maintaining the OCD
He could observe the thoughts without needing to figure out what they meant

Treatment wasn't easy. ERP meant sitting with intrusive thoughts without neutralizing them—tolerating the anxiety that he might be dangerous. But gradually, the thoughts lost their power. They became background noise rather than evidence of his character.

"I still get the thoughts sometimes," he told me months later, "but they don't terrify me anymore. I know what they are. They're just OCD—not truth, not prophecy, not my secret desires. Just noise."

If you're experiencing symptoms of OCD, please know:

You're not alone
You're not going mad
You're not a bad person
OCD is not your fault
Treatment works

The thoughts feel powerful and meaningful. They're neither. They're symptoms of a treatable condition.

Ready to Address OCD?

Our integrative counselling approach can help you understand OCD patterns and develop strategies for managing symptoms. While we don't specialise exclusively in OCD, we can provide support and refer you to specialist OCD therapists when needed.

Sessions are available in person in Fulham (SW6) or online across the UK. Book a free 15-minute consultation to discuss how we might support you.

For specialist OCD treatment, we recommend:

OCD Action: ocdaction.org.uk (support, resources, therapist directory)
OCD-UK: ocduk.org (information and support)
Your GP: for NHS referral to specialist OCD services

If you're struggling with thoughts of self-harm or suicide, please contact Samaritans immediately on 116 123, available 24/7.

Understanding OCD: More Than Just Cleaning and Checking