Dissecting OCD

Since many of my newsletter followers, blog readers and colleagues are aware that the treatment of OCD (obsessive-compulsive disorder) has been a niche area of mine for years, I often get questions about it. Here’s a recent one:

toilet_paper_roll“I am adamant about toilet tissue being placed on the roller so that the tissue dispenses from the top of the roll, not the bottom. When other family place it on the roller in reverse, I become irritated and immediately change it back.” “Does this mean I have OCD?”

My answer: “No, unless you’re guarding the roller all day as if you were a sentinel keeping watch.”

We all have preferences which can manifest as eccentricities, oddities or habits, if you will, to others. The key is what extent does our way of doing things affect our personal, social or occupational functioning.

OCD is a baffling son-of-a-gun of a disorder. In the literature, it has been referred to as “the full-time companion.” The phrase I’ve coined for it is “a disorder of excessive carefulness accompanied by an exaggeration of possible danger.”


The hallmark presentation is thought and behavior driven. Obsessions are thoughts, images that occur over and over again. Common obsessions are “germophobia” a desire for perfect order, evil or sinful thoughts. Compulsions are ritualistic behaviors performed in response to obsessions. Common compulsions include repeated hand-washing, checking, arranging, hoarding, counting and repeating phrases over and over.

Digging deeper

The disorder emerges early – often in late childhood. It’s accompanied by shame, guilt and self-doubt; severe manifestations can be incapacitating. The cycle of repetition can potentially be hell on earth, and if left untreated, symptoms remain remarkable throughout life. The disorder is very ego-dystonic in that affected people want to break the patterns but can’t – it’s not about won’t. Family effects can be devastating. OCD stirs conflict, anger, and is responsible for more divorces than any other mental health disorder. Initial inquiries for treatment, in my experience, come most often from spouses and other family.

What causes it?

on-off-switchThe best explanation I can offer goes like this: When we humans recognize danger, there is a trigger switch embedded in the basal ganglia which flips into the “on” position. Then, as we begin the process of resolving this danger, the switch transitions to “dimmer” mode and then to the “off” position – with successful resolution. For example, let’s say you’re preparing breakfast and after having done so, you forget to turn off the stove. You may recognize this by the sizzling that continues in the cooking pan, the heat coming from the cooktop, or you may see the flame itself. So, you switch the stove control to the off position, check it once or twice, and proceed with your day. Your trigger switch came on, then dimmed, and moved to off as you snuffed out the potential danger.

The OCD sufferer’s switch unfortunately doesn’t cycle, remaining perpetually in the “on” mode. Thus, their instincts are out of control and they cannot reel in primitive urges and behaviors. As such, OCD may begin as a result of a precipitating event – but not always.

Getting better

I’ll begin with what doesn’t work – and that would be logic. Yet logic is precisely what loved ones tend to employ in an attempt to offer aid. A statement like “the car door is locked, you’ve checked it several times” results in abject failure. OCD affected people know the door is locked, but that doesn’t ameliorate the safety threat.

Treatment pros understand that the threat remains alive in spite of the constant checks and that the repetitiveness of the checking rituals becomes increasingly unnerving. So they work backwards by addressing the ritualistic behaviors first, understanding that as response prevention increases, the intensity of the obsessions will diminish. This strategy is referred to as ERP – exposure and response prevention.  Let’s take the example of someone with “germophobia.” Treatment may resemble something like this: clean the bathtub with gloves at first, gradually reducing the incidence of hand washing after cleaning; then progressively work toward cleaning without gloves and without excessive hand washing. The goal is to get the individual to obsess less about becoming contaminated.

What I do

I also employ the strategy outlined in the previous section, but with a twist. I’ll have the affected individual write himself “fan mail” in advance of treatment – which outlines the changes he’s announced he wants to make. I’ve found this to be an effective way for him to push himself to take the steps that actually generate the actions necessary toward goal attainment. And where applicable, I’ll have him take photos of the situation that is generating so much concern. For the checker who fears that the stove is still on in spite of objective evidence to the contrary, I’ll have him snap a close-up image of the knobs in the “off” position. I’ll have him print the photo and attach his fan mail as a caption – “my stove is off and I can see that is; I choose to believe what I see, and I enjoy feeling relieved.” Then I’ll have him post the photo and look at it several times a day. This type of intervention can also be generalized to excessive hand washing, a need for symmetry or order and hoarding manifestations of OCD.


I am not of a fan of medication for treating this disorder. Yes, all of the SSRI antidepressants are approved for OCD, but I have long thought that their risks outweigh the potential benefits. It’s true that the inhibitory effects of serotonin can potentially reduce the anxiety which fuels the obsessions and compulsions. But it’s also true that these antidepressants are effective only at doses 2-3 times higher than what is typically utilized to treat depression. This means an exacerbation of other side effects such as excitability and sleep disruption, which can discourage behavioral work – the indisputable core of treatment success.


OCD is not only baffling, it’s mysterious also. Those with the disorder tend to pick their poison. Rarely have I encountered a chronic checker who is also a chronic hand washer, thus blurring the lines regarding the recognition of danger. Safety concerns don’t necessarily correlate with contamination concerns.

There is a growing body of credible research indicating that symptoms improve with age – even if untreated. And a little OCD helps us define our uniqueness, so let’s give ourselves permission to be a tad anal-retentive. I did before typing this last sentence; I looked up anal-retentive to see if it had a hyphen.

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.