3. The Different Faces of OCD: Common Types and Clinical Presentations

See Additional Resources

The subdivisions of OCD as we know them, be it Incest OCD, Contamination OCD or any other form, are not clinical subdivisions. When psychiatrists diagnose a sufferer with OCD, OCD is OCD. Neither more nor less. Since treatment from a medical perspective is not different for different types of OCD, the distinctions are moot. Even the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not recognize or list the different subtypes of OCD as separate disorders.

However, some common obsessions and compulsions have facilitated the creation of several sub-divisions, referred to as presentations. From a psychotherapeutic standpoint, these presentations are important. OCD affects different people differently. Even within a specific presentation of OCD, there may be elements of various other presentations present. Since it is possible that you may be suffering from some elements of other presentations of OCD as well, do pay attention to the various presentations discussed and see if you can identify any obsessions from those presentations too, along with your Incest OCD.

Contamination OCD: The sufferer may get intrusive thoughts about contamination through germs or becoming sick, or some fear about cleanliness through contact (Rachman, 2004). It could be an aversion to dirt, dust, chemicals, or bodily fluids – anything. It is estimated that 26.5% of OCD cases are of the contamination theme (Foa et al., 2005). In another study, Abramowitz et al. (2008) found that contamination fears are seen in 55% to 58% of the cases.

Checking OCD: This is another common form of OCD (Rachman & Hodgson, 1980), with 28.8% of patients reporting checking as a compulsion (Foa et al., 2005). People with Checking OCD may obsess over making sure that they do nothing that may harm either them or others. They may check if the appliances are turned off, if the gas stove is turned off, if the lights are switched off, if the car is locked, if the door is locked, etc.

Symmetry/Ordering OCD: The person may obsess over symmetry and order (Radomsky & Rachman, 2004); asymmetry or disorderliness may cause discomfort and anxiety (Abramowitz et al., 2008). Thus, if the sufferer has an itch on one side of the face, just to maintain symmetry, they may need to scratch both sides of the face, even though the other side is not itching. Or, if a picture on the wall is not properly centered, it may compulsively need to be straightened.

Just Right OCD: The person may need to repeat an activity until they feel ‘just right’ about it, or experience discomfort (Coles & Ravid, 2016). They may need to open and close doors, walk in and out of the room, read the same sentence in a book, or repeat some other activity multiple times. Unless they get the ‘just right’ feeling, they may not be satisfied and may continue to do the compulsions.

Counting OCD: The person may need to count to a particular number, or do an activity a specific number of times to make bad thoughts go away. Feeling ‘right’ is achieved through counting, even though there may be no rationale (VanDalfsen, 2020). For example, a sufferer may need to do certain activities in multiples of four to make sure that the activities have been done right. If done ‘wrong,’ that is, the activities are not done a specific number of times, like switching the light on and off four times, they may think something bad might happen. At other times, some people may compulsively count everything they can in their environment, a condition called arithmomania (Marais, 2020), which is also an expression of OCD.

Pure-O OCD: Compulsions such as washing, checking, rearranging, counting and repeating are visible to others. But there are presentations of OCD which have intrusive thoughts or obsessions but no apparent compulsions. This kind of OCD has been called Pure-O OCD. Pure-O is short for purely obsessional. This presentation of OCD was once believed to have only obsessive thoughts and no compulsions (Williams et al., 2013). But this belief is wrong. In some presentations of OCD, compulsions may remain hidden or unidentified, or may be mental in nature (Seyfer, 2021). But compulsions definitely exist. Some of the types of Pure-O OCD are:

Relationship OCD: In Relationship OCD the obsessions are related to romantic relationships and can be of three types – where you doubt your love for your partner, where you doubt your partner’s love for you, and where you doubt if the relationship is ‘right’ in general (Doron et al., 2012). Or, ROCD may also be about other relationships such as between parent and child, boss and subordinate, friends, and so on.

Somatic OCD (or Sensorimotor OCD): Sensorimotor OCD may involve bodily functions like breathing, swallowing, blinking, or staring, and the sufferer may not be able to move their focus away from these sensations (Keuler, 2011). There could be hyper attention towards the bladder, or any other part of the body too. Another aspect of this presentation may be an aversion to surfaces like a chalkboard in anticipation of anxiety caused by ‘nails on the chalkboard’ feeling.

Peripheral Staring OCD: The sufferer may repeatedly stare at objects in the periphery of their vision. They may not be able to make eye contact and choose to stare elsewhere. OCD may then create an obsession that they want to stare at the crotch, buttocks, or breasts of the opposite person, and it may create anxiety, leading to compulsions. This is called Ocular Tourettic OCD. In some cases, people think they may stare but don’t. In other cases, people actually do end up staring (Grayson & Price, 2021) and make others uncomfortable.

Existential OCD or Philosophical OCD: The sufferer may become obsessed with existential questions like what is life, what is our purpose on Earth, what is the meaning of our existence, and so on (Penzel, 2013). They may try to seek answers to these questions and not finding the exact answers or answers that satisfy them, may cause distress, leading to compulsions.

Sexual Intrusive Thoughts OCD: Intrusive thoughts may take the form of sexual thoughts or sexual images about various entities. This may make the sufferer hate themselves for being depraved. The prevalence rate of sexual obsessions in OCD could be between 10.5% and 29.6% with males being more affected than females (Tripathi et al., 2018). There could be various forms of this type of OCD.

People could obsess about their sexual orientation, incest, infidelity, genitalia, sexually abusing adults, animals, children, unborn fetuses (Palmer et al., 2019), having sex with or kissing strangers, celebrities, touching people inappropriately, imagining people naked (Lee & Kwon, 2003 and others), having sex with God (Rachman 2007), or changing sexual orientation (Filer & Brockington, 1996).

Grant et al. (2006) state that approximately 24.9% of OCD sufferers have experienced sexual intrusive thoughts at some point during their lives. Williams and Farris (2011) found that 16.8% of OCD sufferers seeking treatment reported current unwanted sexual obsessions.

In POCD, the sufferer may fear that they may be sexually attracted to children and/or may commit sexual crimes against children, either consciously or unconsciously  (O’Neil et al., 2005).

Layers over other subtypes of OCD: There are some subtypes of OCD that may not be independent presentations of OCD but a layer over existing presentations. These layers may complicate the existing presentations and add nuances to the recovery process. Following are some of the layers over existing presentations of OCD.

Magical Thinking OCD (MTOCD): In MTOCD, obsessions may be about superstitions or magical thinking. The belief may be that events that cannot have a causal relationship may do so (Einstein & Menzies, 2004). For example, the sufferer may believe that if they step on cracks in tiles, their mother may die. Or the sufferer may believe in superstitions like bad things happening if a black cat crosses their path.

Guilt OCD or Real Event OCD: People make mistakes and learn to experience remorse, forgive themselves and move on from the episode. A sufferer with Guilt OCD may find it difficult to move on from mistakes committed in the past, sometimes, even from years ago (Farrell, 2021). They may think, ‘While others only think of committing a crime, I already have and I need to be punished for it.’ Accepting that the episode is over and they need to move on, rather than dwell on the past, may be a challenge for them.

False Memory OCD: In False Memory OCD, “people believe that they have experienced an item or event which is actually novel” (Dodson et al., 2000, p. 392). The sufferer may become convinced that the worst has already happened instead of dreading the possibility of it happening. For example, a sufferer with Incest OCD may believe that they have indeed acted sexually inappropriately with their parent/sibling/child (rather than worry about the possibility that they might in the future). They may begin to feel that they may have committed the act but somehow do not remember it enough to be sure.

Mental Contamination: In Mental Contamination OCD, the sufferer may get a sinful, perverted, or dirty thought, which may lead to shame, or guilt. They may then engage in washing rituals to make the thought go away (Coughtrey et al., 2012). The obsession may not be about physical cleanliness; it could be about harm or sexual in nature. But the compulsion may be to physically wash and clean until the thoughts go away.

Meta OCD: Sometimes OCD may make a sufferer obsess about their OCD (Wortmann, 2014). So, the sufferer may begin to have doubts like ‘Do I really have OCD?’ ‘Am I pretending to have OCD?’ ‘Am I obsessing about obsessing?’ or even ‘Have I been diagnosed properly?’ The doubts move between the actual presentation of OCD and Meta OCD, and if this presentation is not identified, recovery may be affected.

There may be dozens of other presentations or manifestations of the same presentations that may not have been covered here. Awareness is critical because a sufferer may be affected by more than one presentation and understanding what aspects of their life are affected by OCD will help in dealing with OCD in a rounded, holistic way. Before proceeding to the next chapter, in Worksheet 1.5, note down if you are experiencing obsessions from any of the other presentations too. The sentence structure will be something like –

I FEEL THAT my partner is cheating on me. Or, WHAT IF my partner is cheating on me? I NEED TO stalk their social media.

I FEEL THAT I am gay. Or, WHAT IF I am gay? I NEED TO check my attraction towards people of all genders.

In the above examples, the first part is the obsession and the second part is the compulsion. Use this structure to fill the worksheet.

  • Chapters
    • Previous: 2.1. WS. Obsessions or Compulsions
    • Next:
Enquire on