OCD is characterised by:

• recurring, persistent, and distressing thoughts, images or impulses, known as obsessions
• the need to carry out certain repetitive behaviours, rituals, or mental acts, known as compulsions.¹

Many people with OCD experience both obsessions and compulsions, whilst others have only one or the other.

Obsessions are not merely worries about everyday concerns, and compulsions are not simply habits. The symptoms of OCD are often upsetting or embarrassing to the individual, and can lead to significant avoidance of situations which trigger their OCD thoughts or behaviours.

The repeated behaviours or rituals are generally carried out to reduce anxiety or with the idea that it will prevent a feared situation, however the temporary relief provided by these behaviours and the individual’s reliance on them to manage anxiety is actually part of the OCD cycle. As the worrying thought returns, anxiety or distress increases, and the individual feels the urge to repeat the OCD behaviour to experience the same relief.² This doesn’t provide a long term solution however and the cycle repeats itself.

Common obsessive thoughts include: ^1,3

• contamination from dirt or germs
• concern with personal safety or the safety of others
• concern with order or symmetry
• thoughts inconsistent with the individual’s values, such as aggressive, sexual, or blasphemous thoughts.

Common compulsive behaviours include excessive or repeated:³

• cleaning, for example, washing hands or scrubbing household surfaces
• checking, for example, whether doors are locked or appliances are switched off
• ordering, for example, placing objects in a particular pattern or making things look symmetrical
• mental acts, for example, reciting phrases in one’s head or counting
• hoarding, for example, collecting old newspapers or other things that aren’t useful or of value.

In certain individuals, a major life event such as a relationship breakdown, the loss of a loved one, or the birth of a child may be associated with the onset of OCD, though for others onset can be gradual with no identifiable trigger.^1,4,5

Factors linked to an increased risk of developing OCD include:

• A family history of OCD: People with OCD are more likely to have a family member who has had this condition.⁴
• Personal psychological factors: Unhelpful thinking styles such as perfectionism are thought to increase a person’s risk of developing OCD.^5-7
• Neurological or biological factors: Brain circuitry related to anxiety responses and the ‘turning off’ of repeat thoughts may be different between individuals with and without OCD.^8,9

Identify your triggers

The first step to managing your OCD symptoms is to recognise the triggers—the thoughts or situations—that bring on your obsessions and compulsions.

Record a list of the triggers you experience each day and the obsessions they provoke. Rate the intensity of the fear or anxiety you experienced in each situation and then the compulsions or mental strategies you used to ease your anxiety.

For example, if you have a fear of being contaminated by germs, touching a railing at the mall might generate a fear intensity of 3, whereas touching the restroom floor in the mall might generate a 10 and require 15 minutes of hand washing to ease your anxiety.

Keeping track of your triggers can help you anticipate your urges. And by anticipating your compulsive urges before they arise, you can help to ease them. For example, if your compulsive behavior involves checking that doors are locked, windows closed, or appliances turned off, try to lock the door or turn off the appliance with extra attention the first time.

• Create a solid mental picture and then make a mental note. Tell yourself, “The window is now closed,” or “I can see that the oven is turned off.”
• When the urge to check arises later, you will find it easier to re-label it as “just an obsessive thought.”

Identifying and recording your triggers also provides an important tool for learning to resist your OCD compulsions.

Learn to resist OCD compulsions

It might seem smart to avoid the situations that trigger your obsessive thoughts, but the more you avoid them, the scarier they feel. Conversely, by repeatedly exposing yourself to your OCD triggers, you can learn to resist the urge to complete your compulsive rituals. This is known as exposure and response prevention (ERP) and is a mainstay of psychological therapy for OCD.

ERP requires you to repeatedly expose yourself to the source of your obsession—and then refrain from the compulsive behaviour you’d usually perform to reduce your anxiety. If you are a compulsive hand washer, for example, that could mean touching the door handle in a public restroom and then not allowing yourself to wash your hands. As you sit with the anxiety, the urge to wash your hands will gradually begin to go away on its own. In this way, you’ll learn that you don’t need the ritual to get rid of your anxiety and that you have some control over your obsessive thoughts and compulsive behaviours.

Tackling your biggest fears straight off might be too extreme, so ERP exercises start with you confronting lesser fears and then working your way up the “fear ladder.” Confront those situations that generate a low fear intensity and once you’re able to tolerate the anxiety you can move on to the next, more difficult exposure challenge.

Building your fear ladder. Think about your end goal (to be able to use a public restroom without fear of contamination, for example, or to drive to work without stopping to check if you’ve hit something) and then break down the steps needed to reach that goal. Using the information you recorded in identifying your triggers, make a list of situations from the least scary to the most scary. The first step should make you slightly anxious, but not so frightened that you’re too intimidated to try it.

Sample fear ladder

Using your fear ladder

Work your way up the ladder. Start with the first step and don’t move on until you start to feel more comfortable doing it. If possible, stay in the situation long enough for your anxiety to decrease. The longer you expose yourself to your OCD trigger, the more you’ll get used to it and the less anxious you’ll feel when you face it the next time. Once you’ve done a step on several separate occasions without feeling too much anxiety, you can move on to the next step. If a step is too hard, break it down into smaller steps or go slower.

As you’re resisting your compulsions, focus on the feelings of anxiety. Instead of trying to distract yourself, allow yourself to feel anxious as you resist the urge to engage in your compulsive behavior. You may believe that the discomfort you’re feeling will continue until you engage in the compulsion. But if you stick with it, the anxiety will fade. And you’ll realize that you’re not going to “lose control” or have some kind of breakdown if you don’t perform the ritual.

Practice. The more often you practice, the quicker your progress will be. But don’t rush. Go at a pace that you can manage without feeling overwhelmed. And remember: you will feel uncomfortable and anxious as you face your fears, but the feelings are only temporary. Each time you expose yourself to your trigger, your anxiety should lessen and you’ll start to realize that you have more control (and less to fear) than you thought.

Challenge obsessive thoughts

Everyone has troubling thoughts or worries from time to time. But obsessive-compulsive disorder causes the brain to get stuck on a particular anxiety-provoking thought, causing it to play over and over in your head. The more unpleasant or distressing the thought, the more likely you are to try to repress it. But repressing thoughts is almost impossible and trying usually has the opposite effect, causing the unpleasant thought to resurface more frequently and become more bothersome.

As with resisting compulsions, you can overcome disturbing, obsessive thoughts by learning to tolerate them through exposure and response prevention exercises. It’s also important to remind yourself that just because you have an unpleasant thought, that doesn’t make you a bad person. Your thoughts are just thoughts. Even unwanted, intrusive, or violent thoughts are normal—it’s only the importance you attach to them that turns them into damaging obsessions.

The following strategies can help you see your thoughts for what they are and regain a sense of control over your anxious mind.

Write down your obsessive thoughts. Keep a pad and pencil on you, or type on a smartphone. When you begin to obsess, write down all your thoughts or compulsions.

• Keep writing as the OCD urges continue, aiming to record exactly what you’re thinking, even if you’re repeating the same phrases or the same urges over and over.
• Writing it all down will help you see just how repetitive your obsessions are.
• Writing down the same phrase or urge hundreds of times will help it lose its power.
• Writing thoughts down is much harder work than simply thinking them, so your obsessive thoughts are likely to disappear sooner.

Create an OCD worry period. Rather than trying to suppress obsessions or compulsions, develop the habit of rescheduling them.

• Choose one or two 10-minute “worry periods” each day, time you can devote to obsessing.
• During your worry period, focus only on negative thoughts or urges. Don’t try to correct them. At the end of the worry period, take a few calming breaths, let the obsessive thoughts go, and return to your normal activities. The rest of the day, however, is to be designated free of obsessions.
• When thoughts come into your head during the day, write them down and “postpone” them to your worry period.

Challenge your obsessive thoughts. Use your worry period to challenge negative or intrusive thoughts by asking yourself:

• What’s the evidence that the thought is true? That it’s not true? Have I confused a thought with a fact?
• Is there a more positive, realistic way of looking at the situation?
• What’s the probability that what I’m scared of will actually happen? If the probability is low, what are some more likely outcomes?
• Is the thought helpful? How will obsessing about it help me and how will it hurt me?
• What would I say to a friend who had this thought?

Create a tape of your OCD obsessions or intrusive thoughts. Focus on one specific thought or obsession and record it to a tape recorder or smartphone.

• Recount the obsessive phrase, sentence, or story exactly as it comes into your mind.
• Play the tape back to yourself, over and over for a 45-minute period each day, until listening to the obsession no longer causes you to feel highly distressed.
• By continuously confronting your worry or obsession you will gradually become less anxious. You can then repeat the exercise for a different obsession.

Reach out for support

OCD can get worse when you feel powerless and alone, so it’s important to build a strong support system. The more connected you are to other people, the less vulnerable you’ll feel. And just talking to an understanding person about your worries and urges can make them seem less threatening.

Stay connected to family and friends. Obsessions and compulsions can consume your life to the point of social isolation. In turn, social isolation will aggravate your OCD symptoms. It’s important to invest in relating to family and friends. Talking face-to-face about your worries and urges can make them feel less real and less threatening.

Join an OCD support group. You’re not alone in your struggle with OCD, and participating in a support group can be an effective reminder of that. OCD support groups enable you to both share your own experiences and learn from others who are facing the same problems.

Manage stress

While stress doesn’t cause OCD, it can trigger symptoms or make them worse. Physical exercise and connecting with another person face-to-face are two very effective ways to calm your nervous system. You can also:

Quickly self-soothe and relieve anxiety symptoms by making use of one or more of your physical senses—sight, smell, hearing, touch, taste—or movement. You might try listening to a favourite piece of music, looking at a treasured photo, savouring a cup of tea, or stroking a pet.

Practice relaxation techniques. Mindful meditation, yoga, deep breathing, and other relaxation techniques can help lower your overall stress and tension levels and help you manage your urges. For best results, try practicing a relaxation technique regularly.

Make lifestyle changes to ease OCD

A healthy, balanced lifestyle plays a big role in easing anxiety and keeping OCD compulsions, fears, and worry at bay.

Exercise regularly. Exercise is a natural and effective anti-anxiety treatment that helps to control OCD symptoms by refocusing your mind when obsessive thoughts and compulsions arise. For maximum benefit, try to get 30 minutes or more of aerobic activity on most days. Ten minutes several times a day can be as effective as one longer period especially if you pay mindful attention to the movement process.

Get enough sleep. Not only can anxiety and worry cause insomnia, but a lack of sleep can also exacerbate anxious thoughts and feelings. When you’re well rested, it’s much easier to keep your emotional balance, a key factor in coping with anxiety disorders such as OCD.

Avoid alcohol and nicotine. Alcohol temporarily reduces anxiety and worry, but it actually causes anxiety symptoms as it wears off. Similarly, while it may seem that cigarettes are calming, nicotine is actually a powerful stimulant. Smoking leads to higher, not lower, levels of anxiety and OCD symptoms.

Cognitive behavioural therapy

CBT and exposure and response prevention (ERP), is considered the most effective treatment for OCD. In ERP, a series of goals are developed between the psychologist and the client, based around the situations which trigger obsessions, compulsions or avoidance. With the psychologist’s help, the client confronts these situations (exposure), without using their usual OCD behaviours or rituals (response prevention). Through a gradual process the client learns to ‘sit with’ their anxiety and as they do so, the distress and the obsessions decrease naturally, and more adaptive ways of responding to anxiety develop.

Cognitive therapy (CT)

CT has also been found to help individuals with OCD identify and challenge unhelpful thoughts that contribute to anxiety and their beliefs around the utility of compulsive behaviours.¹⁰

Stress Management

Managing stress more effectively may also reduce symptoms of OCD. Strategies include structured problem-solving and addressing sources of stress directly, increasing enjoyable and relaxing activities, maintaining a healthy lifestyle through regular exercise, getting sufficient sleep, maintaining a balanced diet, reducing or eliminating stimulants such as caffeinated beverages and cigarettes, and increasing social supports.¹¹

In many cases, psychological approaches alone will be effective in treating OCD. However, some people respond better to a combination of psychological treatment and medication.¹²

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