The "C" in OCD: All About Compulsions

Compulsions
Just as obsessive thoughts can be about anything that comes into the human mind, compulsions can be any possible action or activity that can be performed by a human being. Most people have heard about compulsions that involve excessive cleaning or hand washing. In fact, this stereotypical representation of an OCD compulsion has become so widely known that it is now common for people who are very clean or organized to say, "I'm so OCD." But as any individual who suffers from OCD will tell you, this colloquial usage minimizes the experience of those whose lives are consumed by the disorder. Far from typical fastidiousness with hand-washing, the individual with OCD may feel compelled to wash their hands until their skin becomes raw. Compulsions can be extreme and all consuming. Many individuals with OCD spend much of their day engaging in a repetitive cycle of obsession and compulsion.

Compulsions can include checking, washing, repeating, collecting, ordering, confessing, asking, researching, counting, praying, and avoiding (just to name a few!). These behaviors can look quite different from person to person, which is one of the factors that makes it difficult for untrained clinicians to spot the disorder. For example, checking compulsions can focus on the more common checking of the locks and the stove, but they can also focus on checking almost anything else. Individuals may repeatedly check that they didn't lose something, check for mistakes, they may turn their car around to check that they didn't hit someone, ask numerous questions to check to see if they are perceiving things correctly, check to see if they may have a disease, check on their loved ones, and on and on.

Most individuals with OCD have compulsions that cluster into one or two categories, while others have compulsions that run the gamut. It is not a single behavior or a series of behaviors that defines an OCD compulsion. The best way to identify a compulsion is to understand the purpose that they serve. Individuals with OCD engage in compulsions in order to reduce the uncertainty and doubt that is triggered by their obsession. An individual who fears illness may engage in compulsive hand washing to try to feel "certain" that they will not catch a disease. A person who fears that they might engage in sinful behavior might compulsively confess each small infraction to feel sure they will go to heaven. Someone who fears that they might have unwittingly run someone over with their car may turn their car around and retrace their route, compulsively checking the road for victims, so that they can be 100% sure that they haven’t hurt someone. Someone who fears that they may be “going crazy” may compulsively research mental health on the internet to be sure that they are sane. Someone who fears that they might choke may avoid foods that are sticky and may cut their food into tiny pieces in an effort to attain certainty that they will not choke. An individual who fears that they will make a mistake may read the same part of a book over and over again to feel "sure" that they are understanding it or remembering it properly. Someone who repeatedly asks a loved one how they feel might be trying to be "absolutely positive" that their loved one won't die.

Often times, individuals engage in compulsions to make themselves feel more comfortable or to reduce their distress. At other times, people with OCD won't even report distress or anxiety, they will simply engage in compulsions because something doesn't "feel right." Compulsions may be done until it feels "right" or "clean" or "certain" or "finished" or until the individual's anxiety or distress decreases. But at the very core of all compulsions is the desire to eliminate uncertainty. And for a time, compulsions will make people believe that they can be certain of things, that the doubt has been removed. But invariably, uncertainty creeps back in and the individual finds themselves having to go to greater and greater lengths to feel sure of things. And in this never-ending cycle of compulsions to reduce uncertainty, individuals chase the feeling that things are “right” or “finished”. But this sense of confidence and completeness becomes ever and ever more elusive and the individual experiences greater distress as they go to greater lengths to feel better. And sometimes nothing works. At those times, OCD sufferers may believe they are having a “break down” or they may completely exhaust themselves.

Compulsions May Appear Illogical
While some of the compulsions appear to make logical sense to the observer, others seem to have no logical connection to the obsessive thought and may even look bizarre. But despite the fact that the connection may not be obvious to others, there is generally some explanation for how the compulsion came to be what it is. For example, certain types of repetitive behaviors may start in response to some internal sense that the first try at an action "didn't feel right" and the individual may wonder if they actually completed the activity. This is a common enough experience. Which of us hasn’t locked our car or turned off the stove, only to second guess ourselves and feel compelled to do it again? The action is repeated, and then we confirm that it is done—we feel "certain" and we move on. But the individual with OCD has a different experience. While a single repetition may work well one day, it might not work on another day. They may check a lock once but then continue to have a nagging feeling that it’s not done. So they might check again, or they might do something a little differently—like pull on the door handles just to be certain they are locked. But what if they walk away and it still doesn’t feel quite right? As time goes on, the individual tries different combinations of behaviors that sometimes work and sometimes don’t. They become stuck in a maddening cycle in which the feeling of confidence that “its done” is always just slightly out of reach. They may desperately try to get back the sense of certainty that they could originally achieve with just checking once or twice.

Over the course of months and years, the routine of checking the door locks may bear little resemblance to where it started. In this manner, compulsions may come to look somewhat bizarre to the observer. OCD sufferers may feel compelled to say a certain word or phrase or engage in a particular movement a certain number of times or they may demand that others say or do certain things. They may pray in a very specific and repetitive manner, they may arrange and rearrange their items, they may repeat what others say, repeat various activities over and over, repeating actions a specific number of times and count out loud or to themselves as they are doing things. They may spend considerable portions of their day compulsively trying to "figure out" why they are having certain thoughts, researching the internet or quizzing their friends or family to try to find answers about why they are having certain thoughts or whether or not their thoughts and feelings are normal.