4 types of OCD explained

Obsessive-compulsive disorder (OCD) is a mental health condition that causes intrusive and unpleasant thoughts that result in compulsive behaviors. The symptoms of OCD can vary significantly, so the condition is often described in 4 subtypes, which can be treated with therapy, medication, and self-care.

What are the four types of OCD?

OCD is defined as a single condition in the DSM-5 ^[1] with a list of criteria that can present as several different symptoms. As such, any two people diagnosed with OCD could display different variations of symptoms. OCD-related fears and anxieties commonly fall under different categories. For this reason, many have attempted to define OCD subtypes, which may occur alone or in combination ^[2][3].

Although these four subtypes are not listed separately in the DSM-5, many researchers consider this list a valid representation of OCD ^[1][4].

Contamination

This is the most common type of OCD and affects around half of those with the condition. It is characterized by intense fear or disgust of uncleanliness, dirt, germs, or illness. People with this type of OCD might engage in excessive cleaning rituals, which can lead to physical harm, such as irritated, chapped, or bleeding skin on the hands or body ^[3].

Symptoms of contamination OCD can include ^[3][5][6]:

• Fear of dirt and germs.
• Fear or distress caused by substances, items, doorknobs, food, animals, clothing, or even cleaning products that are viewed as contaminated.
• Feelings of fear, distress, and disgust when touching contaminated things.
• Feelings of shame or guilt about the belief of contaminating others.
• Excessive cleaning rituals, such as handwashing, disinfecting surfaces, changing clothes, or throwing items away.
• Having a ‘clean zone’ and ‘dirty zone’; for example, contaminated clothes and items can be stored or used in the dirty zone and must not enter the clean zone.
• Avoidance of people or places that are considered to be contaminated.

Symmetry and arranging

This subtype of OCD is characterized by the obsession with things being perfect or ‘just right’. People with this type of OCD may engage in counting, arranging, and tapping rituals.

While many people may prefer things to look a certain way, this type of OCD causes an overwhelming need rather than preference. It can cause intense unease or discomfort if items are not aligned or arranged correctly ^[7].

Research shows that this type of OCD may be linked to more severe and long-lasting symptoms of OCD ^[8].

Symptoms of this type of OCD can include ^[3][7][8]:

• Discomfort and distress caused by a lack of symmetry or alignment.
• Regularly rearranging items to form symmetry, such as articles of stationery on a desk lined up to be parallel or in a specific order.
• In some cases, it is associated with persistent worries, such as bad things happening to loved ones if items are not arranged perfectly.
• Engaging in rituals, such as arranging items, ensuring a specific number of items are present, and tapping or touching things a particular number of times.
• Avoiding places with geometric shapes, asymmetry, or other shapes or patterns that may trigger a ritual behavior or distress.

Doubt, accidental harm, and checking

Often referred to as ‘checking OCD’, this subtype is characterized by repeated thoughts of accidental harm resulting from careless actions or negligence. People with this type of OCD may spend several hours per day engaging in checking rituals due to persistent doubts and fears around safety ^[9][10].

Symptoms of checking OCD can include ^[3][9][10]:

• Persistent and excessive fear of causing harm to another person by accident, such as accidentally hitting someone while driving or the house burning down because of the stove being left on.
• Feelings of guilt, responsibility, distress, doubt, and anxiety.
• Compulsive rituals around checking, such as checking that the front door is locked, the stove is turned off, taps are closed, or light switches are off.
• May involve performing checking rituals a specific number of times.
• Recurrent doubts about having checked something, causing repeated checking,or retracing of steps.
• Spending several hours engaging in checking rituals, which can cause a great deal of disruption to life and functioning.

Unacceptable or taboo thoughts

This type of OCD is characterized by intense intrusive thoughts that go against the individual’s moral values, such as thoughts of a violent, sexual, or blasphemous nature. The individual does not wish to act upon these thoughts and tries to avoid thinking about them, thereby drawing further attention to them, and increasing their severity ^[3][11].

People with this type of OCD may be less likely to engage in rituals, although they often experience more severe obsessions than the other subtypes ^[12].

Symptoms of this type of OCD can include ^[3][11][12]:

• Intrusivemental images, thoughts, or impulses that do not align with the individual’s morals, beliefs, or desires.
• Taboo thoughts, such as sexually assaulting a child or severely harming or killing someone.
• Becoming obsessed with these thoughts and fighting to suppress them, thus usually intensifying the idea or image.
• Intense feelings of distress, guilt, shame, fear, threat, and responsibility.
• Decline in confidence and self-esteem, believing that intrusive thoughts represent hidden desires.
• Covert rituals, such as trying to ‘undo’ a thought by replacing it with a more positive idea or trying to force the suppression of a thought.
• Avoiding situations related to intrusive thoughts, such as avoiding family members, children, or knives.
• Regular seeking of reassurance about morality.

Are there any other OCD-related disorders?

Several conditions may share similarities with OCD. For example, anxiety and stress-related disorders may share symptoms such as intense fear, avoidance, and unwanted obsessions or thoughts ^[13].

There are also conditions listed in the DSM-5 as OCD-related disorders, which can cause similar symptoms to OCD, such as compulsive behaviors. This includes ^[1][14][15]:

• Body dysmorphic disorder (BDD): BDD is characterized by a preoccupation with a perceived flaw in appearance and can include compulsive behaviors such as mirror checking, hiding the flaw with clothing or make-up, and comparisons with others’ appearances. BDD may cause intrusive and unpleasant thoughts about the self and can impact functioning.
• Hoarding disorder: Hoarding disorder is characterized by compulsively collecting or keeping items, either one specific type of item or a range of items, such as newspapers, junk mail, and plastic bags. It can result in impaired daily and social functioning and create serious safety issues within the home.
• Trichotillomania (hair-pulling disorder): Trichotillomania is characterized by the compulsive pulling of hair, usually from the head, eyelashes, or eyebrows. It can cause increasing distress, avoidance of others, and self-esteem issues.
• Excoriation (skin-picking disorder): Excoriation is characterized by the compulsive picking of the skin, which can cause lesions, irritation, or bleeding. It can result in social withdrawal, emotional distress, and impaired functioning.

How are the different types of OCD treated?

Currently, there is limited research and evidence relating to treatments specific to various subtypes of for OCD. As such, interventions for OCD aim to generally treat the condition, as opposed to specific symptoms or subtypes ^[5].

While these treatments can be very effective for some, there are a large proportion of individuals with OCD who do not respond well to treatment. Therefore, further research into individualized treatment options is required, focusing on subtype symptoms and presentations ^[4][5].

OCD is typically treated with medication, therapy, or both.

Medication

A type of antidepressant medication called selective serotonin reuptake inhibitors (SSRIs) is often the first choice of medication to treat OCD. Studies show that SSRIs are effective in around 40-60% of people with OCD ^[2][5].

In some cases, antipsychotic medications are prescribed to treat OCD. Antipsychotics may be used alongside an antidepressant to improve treatment response ^[5][13].

Therapy

Typically, cognitive behavioral therapy (CBT) is used to treat OCD, as it can help to restructure thought processes and associated behaviors. A type of CBT called exposure and response prevention therapy (ERP) is considered the most effective treatment plan for many with OCD and can be applied to the various subtypes ^[4][6][12].

ERP works by gradually exposing the individual to their fear or cause of distress while avoiding the use of compulsive behaviors as a solution or safety mechanism. This helps the individual to become increasingly tolerant of their fear, gradually reducing their anxieties and OCD symptoms ^[13][14].