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OCD can take many forms: three cases involving contamination, symmetry and checking

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The same OCD pattern can involve different themes

A person with OCD may be preoccupied with dirt, responsibility, order, sexuality, religion or something else altogether. OCD can take the form of intrusive thoughts, mental images, urges or doubts. For some people, what feels most pressing is a strong sense that something is wrong or incomplete.

The person may try to find relief or make everything feel as it should by washing, checking, arranging, avoiding or analysing. This helps for a while but also makes it more likely that the person will do the same again the next time doubt or discomfort appears.

Most people are familiar with unwanted thoughts. The fact that a thought appears is not in itself a sign of OCD. In OCD, the thoughts, doubt, discomfort or urge to act become so persistent that the pattern becomes time-consuming, causes distress or restricts everyday life.

OCD affects Bente, Peter and Lis in three very different ways. For Bente, it centres on dirt and contamination; for Peter, on order and symmetry; and for Lis, on repeated checking.

When OCD centres on dirt and contamination

Bente

From an early age, Bente was very particular about cleanliness and careful to wash her hands. She could become angry and upset if she was unable to wash them before and after a meal. This happened especially on outings when the family ate packed lunches outdoors. When Bente moved away from home as a young woman, thoughts about cleaning began to occupy more of her mind. It was only several years later that OCD began to take control of her everyday life.

When Bente was dismissed from her job as an early years educator at a childcare centre, her fear of dirt and contamination grew. She was afraid of catching a dangerous infection and passing it on to people around her, causing them to become seriously ill because of her. She therefore washed her hands until they felt completely clean, often up to 15 times in a row. Cleaning the house could take most of the day. The task felt overwhelming, yet Bente still felt it was necessary.

For Bente, OCD centres on dirt, contamination and illness. She fears both becoming ill herself and being responsible for other people becoming infected.

The handwashing and cleaning are intended to ensure that she does not pass anything dangerous on. However, the washing has no fixed endpoint. It is not enough that she has washed her hands; they must feel completely clean. Bente may therefore start again even though she has already washed them thoroughly.

For other people, contamination OCD may centre on bodily traces, chemicals or a sense of being unclean without a specific fear of illness.

When OCD centres on order and symmetry

Peter

As a child, Peter’s room was unusually tidy compared with those of his peers. His older sister, Karen, did not share his sense of order. According to Peter, her room usually looked as though a bomb had gone off in it, although Karen did not think it was that bad. Every now and then, she teased him by mixing up his colour-sorted Lego bricks. Peter usually became furious and immediately sorted all the bricks again, even if he was meant to be doing something else.

When Peter attended a residential college as a young adult, his discomfort with disorder grew. He shared a room with three other young people who did not have the same need for order. At first, he repeatedly urged them to tidy up at least once a day, but they often laughed it off with a “Yeah, yeah, Peter.” He felt stressed and surrounded by chaos and did not feel that the others were being considerate. Over time, he became homesick and missed his family.

One day, Peter was sitting in his room sorting some notes. He suddenly had the thought that something terrible might happen to his family if the notes were not arranged in one very particular way. Soon, the same requirement appeared in other situations. After brushing his teeth, for example, his toothbrush had to be positioned exactly right. Peter withdrew from activities at the college and spent more time in his room. One of the tutors noticed his absence and asked how he was doing. Peter trusted the tutor and told them about the thoughts.

Enjoying order or having an eye for detail is not in itself OCD. Peter’s need for order becomes compulsive when it is linked to intense discomfort and the fear that something terrible might happen to his family.

The thought that the position of the notes can protect his family has a magical quality. Peter sees a connection even though the notes’ position has no actual bearing on his family’s safety. When his toothbrush has to be positioned exactly right, he is instead trying to achieve a particular sense of things being right.

People experience the need for order and symmetry in different ways. Some people fear that something serious will happen if objects are not positioned correctly. Others primarily experience unease or incompleteness and continue until it feels right.

When checking becomes a compulsion

Lis

When Lis was a child, her family’s home was burgled. It happened at night while everyone was asleep. She woke with a start when she heard the burglar but did not dare call out to her parents for fear that he would become violent.

In the weeks that followed, Lis was plagued by guilt because she had not woken her parents. They often reassured her that she had done exactly the right thing, but she still felt that it was her fault the burglar had been able to steal from the house. At the same time, she became afraid that he would return.

Lis began checking every evening that all the doors and windows were properly closed and locked. The routine gradually took longer, and soon she was repeating it up to five times. If she began to doubt whether something was properly closed, she would get up in the middle of the night to check again.

In the mornings, Lis was tired and lacked energy at school, and her parents became concerned. After about a year, the checking also began to delay the family whenever they were trying to leave the house. Her parents therefore made an appointment with a psychologist. Lis was unhappy about the decision because she regarded the checking as absolutely necessary. At the same time, she was tired of it taking time away from the things she wanted to do.

Checking behaviour occurs across many OCD themes. The checking may be visible, as when someone checks a lock or a cooker. It may also take place mentally when the person reviews an action, a conversation or a memory.

An ordinary check has a practical purpose and ends when the task is complete. For Lis, seeing the locked door is not enough to end the checking. The doubt returns, along with a sense of responsibility for what might happen if she does not check the door again.

Each recheck provides a brief sense of certainty. Because the feeling does not last, Lis has to check again. The repetitions can also weaken her confidence in what she has just seen and done. The routine grows from one check to several and eventually costs her sleep, time and freedom.

Mental checks are harder for other people to notice. The person may review what happened, look for errors in their memory or check their thoughts to determine whether there is any reason for concern. Here too, the person is trying to achieve a sense of certainty that does not last.

Different content, a recognisable pattern

Bente, Peter and Lis are troubled by different things. Even so, they are all trying to achieve certainty or make things feel completely right. Washing, arranging and checking bring short-term calm but also make it more likely that they will repeat the strategy the next time discomfort appears.

The burglary is an important part of Lis’s story, but a specific event rarely explains on its own why OCD develops. Often, there is no single, simple explanation for why the disorder takes this particular form. The content can also change over time, and several OCD themes may be present at the same time.

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