There are so many subtypes of OCD that people speak about nowadays. There are often the most common ones that quickly come to mind, such as contamination-related OCD, harm-related OCD and “just-right” OCD. But now there are also many other subtypes that people will speak about. A quick internet search turns up a whole variety of other subtypes, including: real events OCD, suicidal OCD, pedophilia OCD, sexual orientation OCD, magical thinking OCD and the list goes on. I want to speak about whether we really need to categorize OCD in so many ways and how it is likely not necessary from a treatment perspective.
Of course people want to better understand their OCD and why they are experiencing intrusive thoughts that are distressing and impacting their lives and affecting their quality of life. Information is powerful and I always say that when working with my clients. There is an excellent book on subtypes written by Dr. David Clarke that I often reference when working with clients. Within this book, he explains different subtype treatment protocols for OCD. However, he has broken this into 4 types of subtype categories (contamination; doubt checking and repeating; harm, sex and religious; symmetry, ordering and arranging), as opposed to multiple categories of subtypes that are ever-expanding.
We can also think about the idea that what drives one’s OCD can be a very impactful way of understanding your OCD and beginning to face your fears. For example, If I experience intrusive thoughts that I must walk through doorways until it feels just right because I believe harm might come to my family, we might call that “just right” OCD? But what if I also feel uncomfortable touching doorknobs and light switches without sanitizing excessively afterwards? Do I also have contamination-related OCD? Perhaps I also have intrusive thoughts of walking into the road and fear that I might harm myself. Could this be suicidal OCD? As a therapist, I would ask my client – what is driving all these fears? What is your core belief? You might say that you can’t tolerate the uncertainty of not knowing where these thoughts will take you and your compulsions provide you with short-term relief and the belief (in that moment) that everything will be okay.
Intolerance of uncertainty is a significant driver of our intrusive thoughts in OCD. It compels us to engage in our rituals and compulsions as they often bring with them a short-term feel of certainty or belief that things will somehow be okay, in that particular moment.
In order to push back against your OCD, you really have to accept that nothing is 100% certain. And I often tell my clients that your OCD wants to be 101% certain which is, in fact, impossible.
The Obsessive Compulsive Cognitions Working Group established 6 belief systems that we can actually consider to be important domains in OCD as they drive many different types of intrusive thought. These domains describe beliefs pertaining to: (1) inflated responsibility; (2) overimportance of thoughts; (3) excessive concern about the importance of controlling one’s thoughts; (4) overestimation of threat; (5) intolerance of uncertainty; and (6) perfectionism
When we create subtype after subtype of OCD, we divide up a mental health issue that can often already feel very complex in its presentation. Therefore, I am not convinced all this extra subtyping is either helpful for the client or the therapist. Themes upon which your OCD has latched onto can definitely be important to pay attention to and work on. This can be helpful in terms of broad strokes conceptualization. However, our treatment approach remains the same. We always will turn to our gold standard of Cognitive Behavioural Therapy (CBT), with an emphasis on Exposure and Response Prevention (ERP). We will work together to face your fears and triggers without engaging in rituals and compulsions. In doing so we will actively discuss the importance of tolerating uncertainty and accepting that nothing in life truly comes without costs. Does it really matter if your OCD is about uncertainty with respect to contamination or harm-related thoughts or something you might or might not have done in the past? I would argue that part does not matter. What matters the most is that you begin to understand that tolerance of uncertainty is key to your OCD no longer making the decisions about how you will live your life. At the end of the day, OCD can actually be about anything and everything. How can we ever create a subtype about that?
Are you experiencing intrusive thoughts and symptoms of OCD? Reach out to us at Forward Thinking Psychological Services, where we work with many people with OCD, using CBT and ERP and look forward to working with you!