Causes of OCD

Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by unwanted, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) aimed at reducing the anxiety caused by the obsessions.

The Obsessive Compulsive Cognitions Working Group (OCCWG; Steketee et al., 2003) identified six key types of appraisals and beliefs that play a crucial role in the development and maintenance of OCD.

These factors can interact with each other and with other biological, psychological, and environmental influences to contribute to the development and maintenance of OCD symptoms.

Understanding these underlying causes can help inform treatment approaches and support individuals in managing their symptoms.

1. Inflated Responsibility

People with OCD often have an overvalued sense of responsibility for preventing harm to themselves or others. They may believe that failing to prevent harm is morally equivalent to causing harm directly.

This belief can lead to excessive guilt and an overwhelming need to take action to prevent negative outcomes, even when the likelihood of such outcomes is low, or the individual’s ability to prevent them is limited.

People with inflated responsibility may worry that their actions or inactions could lead to harm, such as a fire, burglary, or injury to others.

They may repeat checking behaviors to prevent these perceived negative outcomes, such as ensuring that appliances are turned off, doors are locked, or loved ones are safe.

2. Overimportance of Thoughts

Individuals with OCD tend to overestimate the importance and meaning of their intrusive thoughts.

They may believe that having a thought increases the likelihood of the event occurring in reality (thought-action fusion) or that having a morally repugnant thought is equivalent to committing a morally repugnant deed (moral thought-action fusion).

These beliefs can cause significant distress and lead to attempts to suppress or neutralize the thoughts through compulsions.

Compulsions

Compulsions, which can be observable actions or mental rituals, are performed by individuals with OCD to neutralize obsessive thoughts and alleviate distress. These compulsions are often carried out in a rigid or ritualized manner.

While compulsions may provide short-term relief, they ultimately contribute to the maintenance of OCD symptoms by preventing the individual from learning that their fears are unfounded and that they can tolerate the distress without resorting to compulsive behaviors.

Avoidance

People with OCD often try to avoid things that might trigger their obsessive thoughts. They do this for a few reasons:

1. To stop the obsessive thoughts from happening in the first place
2. To prevent something bad from occurring
3. To feel less distressed when they can’t completely avoid the things they fear

For example, someone with OCD might avoid certain places (like hospitals or public bathrooms), objects (like knives), situations (like being alone with a child), or people (like those who are sick).

If they can’t avoid these things entirely, they might try to avoid direct contact, like wearing gloves or using their sleeve to open a door.

People with OCD related to disturbing thoughts (like harming others) might also avoid talking about their thoughts. They worry that revealing the thoughts could make them happen, or they feel ashamed and scared of the consequences (like having their child taken away).

Another way people try to avoid their obsessive thoughts is by pushing the thoughts out of their mind. But as they continue to see the thoughts as dangerous, more and more things in their environment can start to trigger the thoughts. This means they have to avoid more things, which can really disrupt their lives.

While it’s understandable that people want to avoid things that make them anxious, avoiding doesn’t help in the long run.

It stops them from learning that their fears won’t necessarily come true and that they can handle the distress. Avoidance also takes up a lot of time and energy, making OCD an even bigger problem in their lives.

3. Mental Control of Thoughts

People with OCD often overvalue the importance of exerting complete control over their intrusive thoughts, images, or impulses.

They may believe that complete mental control is both possible and desirable and that any failure to control their thoughts is a sign of weakness or moral failing.

This can lead to excessive attempts to monitor and control their thoughts, paradoxically increasing the frequency and intensity of the intrusive thoughts.

Thought Suppression

People with OCD often try to push away or ignore their obsessive thoughts. They do this for a few main reasons:

1. They don’t want the thoughts to get so bad that they feel they have to perform compulsions, such as checking or making items symmetrical.
2. They want to stop their anxiety from getting worse.
3. They’re afraid the thoughts might lead to something bad happening.

Researchers think that trying not to think about something actually makes you think about it more. It’s called the “white bear effect” – if I tell you “don’t think about a white bear,” it’s hard not to picture one.

But for people with OCD, studies don’t really show that pushing away thoughts makes them happen more often.

In the study by Purdon, they found that around 30-50% of the time, ignoring obsessive thoughts actually helped people feel better and focus on other things.

So while trying to control or get rid of obsessive thoughts fully might not always work, it’s not necessarily true that it always backfires and makes the thoughts more frequent or intense.

The effects can vary from person to person and situation to situation.

4. Overestimation of Threat

Individuals with OCD tend to overestimate the severity and likelihood of negative events occurring.

They may believe that the world is a dangerous place and that bad things are more likely to happen to them than others.

This heightened perception of threat can fuel anxiety and drive compulsive behaviors aimed at reducing the perceived risk.

Hypervigilance

People with OCD often overestimate the likelihood and severity of potential threats, which leads to hypervigilance, a heightened state of alertness and sensitivity to triggers related to their obsessive concerns. This hypervigilance can manifest in several ways:

1. Monitoring for triggers: Individuals with OCD may constantly scan their environment for triggers that could provoke their obsessive thoughts, ironically even when trying to avoid these triggers.
2. Vigilance for harm: They may be on high alert for any information suggesting that harm has occurred or will occur, as well as signs that their compulsions have not successfully prevented harm.
3. Attention to internal and external cues: Hypervigilance can involve monitoring both internal (e.g., bodily sensations, thoughts) and external (e.g., environmental) information.
4. Specific manifestations: The focus of hypervigilance varies depending on the type of OCD. For example, those with contamination concerns may track “contaminated” objects, while those with repugnant obsessions may monitor their body sensations or thoughts for signs of arousal or recurrence of the obsession.

Although hypervigilance is understandable, it is ultimately unhelpful because it ensures that even minor threat indications are noticed, possibly at the expense of important safety information.

Monitoring bodily sensations can lead to misattribution of normal physiological changes, while attempting to prove that harm has not occurred is futile, as the absence of evidence is not evidence of absence.

Furthermore, repeatedly monitoring oneself can undermine confidence in one’s own sensory experiences.

Hypervigilance and avoidance are important markers of OCD severity and treatment progress, even though they are not always included in symptom measures.

5. Intolerance of Uncertainty

People with OCD often have difficulty tolerating uncertainty and may believe that they must be absolutely sure of something to avoid making mistakes.

They feel a strong need to consider all possible outcomes of a situation, leading to excessive doubting, checking, and seeking reassurance.

The inability to tolerate uncertainty can maintain the cycle of obsessions and compulsions.

When faced with unpredictable situations or unknown outcomes in the future, individuals with OCD may react with heightened feelings of anxiety, an overthinking process characterized by repetitive, unrealistic worry.

This might include worrying about a future event, thinking of all the worst-case scenarios, replaying a past scenario, predicting how something will play out, or planning something to every last detail.

Compulsive rituals, avoidance behaviors, and safety behaviors in OCD can be understood as ways for individuals to seek certainty when faced with uncertainty.

6. Perfectionism

Individuals with OCD may believe that there is a perfect solution to problems and that even minor errors will have serious consequences.

They may tend to believe that they must be perfect at everything to be a worthwhile person.

This perfectionism can drive compulsive behaviors aimed at ensuring that tasks are completed flawlessly and can contribute to a fear of making mistakes or being judged negatively by others.