OCD Symptoms: Obsessions, Compulsions and the Four Subtypes

OCD symptoms are obsessions, compulsions or both: repeated thoughts, urges or mental images that are intrusive and unwanted, and repetitive behaviors a person feels the urge to do, often in response to those thoughts^[1]. In obsessive-compulsive disorder (OCD), these symptoms are time-consuming and cause significant distress or interfere with daily life^[1].

The DSM-5 threshold is specific: the obsessions or compulsions take more than 1 hour per day, or they cause clinically significant distress or impairment in social, occupational or other important areas of functioning^[6]. Compulsions can be visible behaviors such as hand washing, ordering and checking, or mental acts such as praying, counting or repeating words silently^[6].

Obsessions typically provoke anxiety, fear or disgust, and most people with OCD recognize that the thoughts come from their own mind and are excessive^[7]. Compulsions ease that distress only temporarily, which makes the person more likely to repeat them^[7].

Avoidance is part of the picture. People with OCD may avoid people, places or situations that trigger obsessions, for example staying home to avoid bringing contamination back to the house and family^[7].

DSM-5 does not divide OCD by symptom content; its two specifiers record level of insight and tic history instead^[6]. The "types of OCD" that people search for usually correspond to symptom dimensions identified by factor analysis of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist^[3].

The largest synthesis, a 2008 meta-analysis of 21 studies with 5,124 participants, found four factors that together explained 79.0% of the variance in symptoms^[3]:

• Symmetry: symmetry obsessions with repeating, ordering and counting compulsions (26.7% of variance)^[3].
• Forbidden thoughts: aggressive, sexual, religious and somatic obsessions with checking compulsions (21.0%)^[3].
• Cleaning: contamination obsessions and cleaning compulsions (15.9%)^[3].
• Hoarding: hoarding obsessions and compulsions (15.4%)^[3].

Two pairings held almost everywhere: 20 of the 21 studies linked contamination with cleaning and hoarding obsessions with hoarding compulsions^[3]. Checking was the least stable symptom, grouped with every other category in at least one study^[3].

Since DSM-5, persistent hoarding is usually diagnosed as a separate condition, hoarding disorder, rather than as an OCD symptom^[6].

"Pure O" is an informal label for OCD that appears to involve only obsessions. Because the DSM-5 definition counts mental acts such as counting or silently repeating words as compulsions, obsessions paired with purely mental rituals still meet the compulsion criterion^[6].

Intrusive thoughts and double-checking are common in the general population. In the National Comorbidity Survey Replication, more than one quarter of 2,073 U.S. adults assessed reported obsessions or compulsions at some time in their lives, but only 2.3% met full criteria for lifetime OCD^[4].

NIMH lists four features that generally separate OCD from ordinary habits^[1]:

• The obsessions or compulsions cannot be controlled, even when the person knows they are excessive.
• They take more than 1 hour a day^[1].
• The compulsions bring no pleasure, only temporary relief from anxiety.
• They cause significant problems in daily life.

The American Psychiatric Association draws the same line: many people without OCD have distressing thoughts or repetitive behaviors, but these are not time-consuming, distressing or impairing^[7]. In OCD the behaviors feel rigid, and not performing them commonly causes great distress^[7].

Severity varies widely. Among U.S. adults with past-year OCD in 2001-2003 survey data, 50.6% had serious impairment, 34.8% moderate and 14.6% mild, measured with the Sheehan Disability Scale^[2].

DSM-5 added two specifiers to the OCD diagnosis: the person's level of insight, and whether they have a current or past tic disorder^[6]. Both describe how symptoms present, and both have been studied for links to treatment response^[6].

Insight varies more than the stereotype suggests. In one study of 211 outpatients with OCD rated on the Brown Assessment of Beliefs Scale, 28.9% had excellent insight, 26.5% good, 28.9% fair, 13.3% poor and 2.4% delusional beliefs^[6]. Insight can also shift within a single episode and across episodes^[6].

Research findings are mixed, but poor insight has been associated with earlier onset, longer illness, greater symptom severity and more co-occurring major depression^[6]. The National Comorbidity Survey Replication also linked more severe OCD with poor insight^[4].

Some people with OCD also have a tic disorder: motor tics such as eye blinking, facial grimacing and shoulder shrugging, or vocal tics such as throat-clearing, sniffing and grunting^[1]. One study estimated that 30% to 50% of children with a tic disorder go on to develop OCD^[6]. Data on tics are on the Tourette syndrome and tic disorders page.

OCD symptoms can begin at any age but usually start between late childhood and young adulthood, and most people with OCD are diagnosed as young adults^[1]. A meta-analysis of 192 epidemiological studies put the median onset age for obsessive-compulsive and related disorders at 19 years, with a peak at 14.5 years^[5].

In that analysis, 24.6% of cases began before age 14, 45.1% before age 18 and 64.0% before age 25^[5]. Studies of adolescents have tended to find more boys than girls with OCD, which points to earlier onset in males^[6], and the National Comorbidity Survey Replication found a preponderance of early-onset cases in men^[4].

Children often present differently from adults. Many adults recognize that their compulsions do not make sense, while children may not realize their behavior is unusual and often fear that something terrible will happen if they skip a ritual^[1]. Parents or teachers typically notice the symptoms first^[1].

Symptom clusters also differ by age. In child-only studies, checking grouped with symmetry rather than with forbidden thoughts, and somatic obsessions grouped with cleaning^[3].

Children whose OCD symptoms appear suddenly or worsen after a streptococcal infection may be diagnosed with PANDAS^[1]. Data for teens are on the OCD in adolescents page.

They can. NIMH describes OCD symptoms as often starting slowly, easing for a while or worsening as time passes^[1]. Symptoms often get worse during stressful periods, and the content of obsessions and compulsions can change over time^[1].

Some people with OCD use drugs or alcohol to cope, and many also have a diagnosed mood or anxiety disorder^[1]. The National Comorbidity Survey Replication found OCD associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders^[4].

Anxiety disorders: Earlier DSM editions classified OCD as an anxiety disorder; DSM-5 moved it into its own chapter, Obsessive-Compulsive and Related Disorders, although anxiety remains a central feature^[6]. Anxiety symptoms outside OCD are covered in signs of anxiety.

OCPD: Obsessive-compulsive personality disorder centers on perfectionism and rigidity that the person experiences as egosyntonic, or consistent with how they see themselves^[6]. Its DSM-5 criteria include preoccupation with details, rules and lists, perfectionism that interferes with finishing tasks, and excessive devotion to work^[6]. OCD obsessions, by contrast, are experienced as intrusive and unwanted^[6].

Related disorders: The same DSM-5 chapter includes hoarding disorder, body dysmorphic disorder, trichotillomania and excoriation (skin-picking) disorder^[6]. Hair-pulling and skin-picking involve recurring body-focused repetitive behaviors and repeated attempts to stop them^[7]. Body dysmorphic disorder centers on preoccupation with perceived flaws in appearance that others see as slight or not noticeable^[7].

Psychotic disorders: OCD with absent insight can resemble psychosis. The key difference is that an OCD compulsion is performed to reduce anxiety provoked by a thought, image or impulse; hallucinations, disorganized speech and flattened affect point toward schizophrenia instead^[6].

Diagnosis usually starts with a health care provider who examines the person and takes a health history to rule out other causes, then may refer to a mental health professional^[1]. It can be difficult because worry, anxiety and low mood overlap with other conditions, and people may not disclose obsessions for fear of judgment^[1].

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) remains the gold standard for rating OCD severity, and it includes an insight item scored from 0 to 4^[6]. Its symptom checklist covers 13 main categories: seven types of obsessions and six types of compulsions^[3].

Exposure and response (ritual) prevention, a form of cognitive behavioral therapy, is the first-line psychotherapy for OCD, with more research support than other therapies^[7]. The medications most often prescribed are selective serotonin reuptake inhibitors, which can take 8 to 12 weeks to improve symptoms and may require higher doses than are used for depression^[1].

Many patients remain refractory to serotonergic medication, with some estimates as high as 50% to 60%^[6]. For severe OCD that has not responded to other treatments, the FDA approved deep repetitive transcranial magnetic stimulation in 2018 and extended the approval to standard TMS devices in 2022^[1]. Deep brain stimulation is considered experimental and is allowed for severe OCD under a Humanitarian Device Exemption^[1].