The subdivisions of OCD as we know them, be it Harm OCD, contamination OCD or any other form, are not clinical subdivisions. When psychiatrists diagnose a person 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. 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 Harm OCD.
Contamination OCD: In Contamination OCD, the person 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.
Mental Contamination: In Mental Contamination OCD, the person may get a thought that he may consider sinful or pervert or dirty, which may lead to shame, or guilt. He may then engage in washing rituals to make the thought go away (Coughtrey et al., 2012). The obsession may not be about physical cleanliness, but the compulsions may be physical. The thoughts could be about harm or they could be sexual in nature. But the compulsion may be to physically wash and clean until the thoughts go away.
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: In this presentation, 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 person has an itch on one side of the face, he might scratch that and then, just to maintain symmetry, he may need to scratch the other side as well. Or, if there is a picture on the wall that is not properly centered, it may cause distress, until it is straightened.
Just Right OCD: In this, the person may need to repeat an activity until he feels ‘just right’ about it, or else he may feel uncomfortable (Coles & Ravid, 2016). He may need to open and shut doors, walk in and out of the room, read the same sentence in a book, or repeat some other activity multiple times. Unless he gets the ‘just right’ feeling, he may not be satisfied and may continue to do the compulsions.
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., 2012a). Or ROCD may also be about other relationships such as between parent and child, boss and subordinate, friends, and so on.
Religious OCD or Scrupulosity OCD: This subtype affects the believers. They have a strong desire to do right by God. They may begin to fear doing anything wrong that may be considered sinful and may lead to their getting punished (Greenberg & Huppert, 2010). Obsessions may include immoral thoughts about God or doubts about their faith. Their devotion may become their bane.
A variation of Scrupulosity OCD is Secular Scrupulosity OCD or Moral Scrupulosity OCD, which is not governed by religion but a strong sense of right or wrong (Siev et al., 2011). In this presentation, the person may worry about morality or ethics, and may become obsessed with the rights and wrongs. He may find using abusive language incorrect. He may also be unable to lie, or exaggerate, and may also feel the need to confess repeatedly. He could also develop hyper-responsibility and try and set even those things right which may not concern him either too much, or at all.
Sexual Intrusive Thoughts OCD: Intrusive thoughts may take the form of sexual thoughts or sexual images about people, including family members, friends, kids, or even God. This may make the person hate himself for being depraved. 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 other 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).
Somatic OCD (or Sensorimotor OCD): Sensorimotor OCD may involve bodily functions like breathing, swallowing, blinking or staring, and the person may not be able to move his 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 person may repeatedly stare at objects in the periphery of his vision. He may not be able to make eye contact and choose to stare elsewhere. OCD may then create an obsession that he wants 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 making others uncomfortable.
Existential OCD or Philosophical OCD: This is a rare subtype of OCD. The person 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). He may try to seek answers to these questions and not finding the answers may cause distress, leading to compulsions.
Guilt OCD or Real Event OCD: People make mistakes and learn to experience remorse, forgive themselves and move on from the episode. A person with Guilt OCD may find it difficult to move on from mistakes committed in the past, sometimes, even from years ago (Farrell, 2021). He may think that the ‘crime’ that he has committed is not pardonable and often believes that he deserves to be punished for the crime. The rationale that his brain may provide him is that ‘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 he needs to look ahead, rather than dwell on the past, may become a challenge for him.
Counting OCD: The person may need to count up to a particular number, or do an activity a specific number of times to make the bad thoughts go away. Feeling ‘right’ is achieved through counting behavior, even though there may be no rationale (VanDalfsen, 2020). For example, a person 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, he 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.
Magical Thinking OCD: In the case of magical thinking OCD, obsessions may be about superstitions or magical thinking. The belief may be that events that cannot have a causal relationship may do so (Einstien, & Menzies, 2004). For example, the person may believe that if he steps on cracks in tiles, his wife may die. Or the person may believe superstitions like bad things happening if a black cat crosses his path.
False Memory OCD: This is not a separate sub-type but a different layer of obsession that may develop in any of the subtypes. 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 person may become convinced that the worst has already happened instead of dreading the possibility of it happening. For example, a person with pedophilia OCD may begin to believe that he has indeed molested children (rather than worry about the possibility that he might). He may begin to feel that he may have committed the crime but somehow does not remember it enough to be sure.
Meta OCD: This is another layer over existing presentations of OCD. Sometimes OCD may make a person obsess about his OCD (Wortmann, 2014). So, the person 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 person may be affected by more than one presentation and understanding what aspects of his life are affected by OCD will help in dealing with OCD in a rounded, holistic way. Before proceeding to the next chapter, discuss with your caregiver and 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 / WHAT IF my partner is cheating on me AND I NEED TO stalk his social media.
I FEEL THAT / WHAT IF I am gay AND 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.