Challenges in the diagnosis in Tourette syndrome patients | NDT


According to DSM-5, Tourette syndrome (TS) is defined by the presence of at least one vocal and multiple motor tics persisting for more than 1 year with childhood onset. In almost 80% of patients, psychiatric comorbidities co-occur, the most frequently being attention deficit/hyperactivity disorder (ADHD), obsessive-compulsive behavior (OCB) or obsessive-compulsive disorder (OCD), depression, anxiety, rage attacks, and self-injurious behavior (SIB).1,2 The prevalence of TS ranges – depending on age – from 0.3% to 1%.3–5 Tics are sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations.6 Alternatively to the term vocal tics, the name phonic tic is used. Both motor and vocal tics can be further divided into simple and complex tics. Depending on the movement pattern motor tics, in addition, can be classified as tonic, clonic, or dystonic tics. In addition, some specific types of complex tics include echolalia (repetition of sounds, words or phrases pronounced by others), echopraxia (repetition of gestures executed by others), palilalia (spontaneous repetition of one’s own sounds, words or phrases sometime resembling stuttering or speech blocking tics), palipraxia (repetition of one’s own gestures), coprolalia (shouting of obscene words or phrases), and copropraxia (execution of obscene postures or gestures). Finally, tics are typically characterized by brief preceding premonitory sensations, temporal suppressibility, and a rostro-caudal distribution.

While in the majority of patients the diagnosis of a primary tic disorder is easy to make, in some patients the differential diagnosis is more difficult and complex. Motor tics must be differentiated not only from other hyperkinetic movement disorders, such as stereotypies, myoclonus, paroxysmal disorders, and epileptic seizures, but also hyperactivity due to ADHD and repetitive behaviors and rituals belonging to the OCD spectrum, and, finally, from functional movements. Interestingly, the clinical spectrum of OCB/OCD in TS differs from symptoms in pure OCD. This has been described as “tic-related OCD” mainly associated with “just right” phenomena.7,8 However, tics and “just right” phenomena may also occur coincidentally.

In this review we want to give recommendations for the diagnosis and assessment of tics and OCD in patients with TS. To identify all relevant articles, we conducted a systematic review yielding to find publications reporting about OCD phenomena in TS. Furthermore, recommendations given by the European Society for the Study of Tourette Syndrome (ESSTS) have been taken into consideration.9 Finally, we address challenges that one could encounter in the management of patients with overlapping tics and obsessions and/or compulsions. In this regard, we also outline differences between the OCB/OCD spectrum in TS compared to pure OCD (without tics) and briefly highlight differences in therapeutic interventions.


We conducted both a systematic as well as a narrative review of the most important aspects related to OCB/OCD in TS. Our systematic approach was based on the search in PubMed, Ovid, Web of Science, Embase and APA Psych Info conducted on February 08, 2021. We searched for articles examining the coexistence of TS and OCB/OCD using the search terms “tics” AND/OR “Tourette” AND/OR “obsessive-compulsive disorder” AND/OR “OCD” AND/OR “obsession” AND/OR “compulsion”. Reviews and meta-analyses in the area were further searched for relevant citations.

Titles and abstracts of the studies obtained through this search were examined by both authors in order to determine article inclusion. Each article was also checked for further potential references. Discrepancies were addressed by the authors through discussion. Eligibility for the systematic review was based on the following criteria: (1) studies involving patients with TS and OCD, (2) original articles, and (3) studies in humans. Articles were excluded based on the following criteria (1) meta-analyses or review papers, (2) not investigating patients with TS and OCD, and (3) animal or other preclinical studies. Several studies included data previously reported elsewhere. Data collected on each article included year, study design, number of subjects with TS and/or OCD, mean correlates of OCD in TS and the most important characteristics of OCD in TS in comparison with OCD/OCB. As a result, we identified 628 articles, out of which 57 have been included in this review. Our search strategy is illustrated in a PRISMA flow diagram (Figure 1). While in the subsequent review, we included only the most relevant studies, additionally an extensive list of all 57 publications including the most important findings is shown in Supplementary Table 1.

Figure 1 PRISMA flow diagramMoher 2009.

Diagnosis and Assessment of Tics in Tourette Syndrome

According to the guidelines published by ESSTS,9 the diagnosis of TS should be made according to newest DSM criteria. This includes the exclusion of other phenomena resembling tics as well as secondary tic disorders. Tics are characterized by a number of clinical phenomena useful to distinguish them from other neurological and psychiatric symptoms. In the majority of patients, tics are proceeded by premonitory urges defined as an uncomfortable sensation of twinging, itching, or stretching, partially or completely relieved by the tic execution. This sensation is reported to last only a fraction of a second and occurs immediately before the tic. Based on clinical experience it is believed that the topographic distribution of premonitory urges stays in line with the tic localization. Typically, patients can suppress their tics for a short period of time ranging from seconds to minutes.10 Noteworthy, the presence of premonitory urges and tics suppressibility are highly age dependent as many children do not report premonitory sensations and feel unable to suppress their tics voluntarily.

Another important characteristic is that tics are influenced by environmental factors. The majority of patients reports a temporarily tic increase during stress, emotional tension, but also when talking about tics and seeing others with tics, while tics typically decrease with concentration and relaxation. Finally, the course of tics in TS is typically waxing and waning with respect to frequency, number, intensity, complexity, and phenomenology. The typical age at onset of tics is 5–7 years.11 In most patients, simple tics proceed complex tics and motor tics usually start before vocal tics.1 In almost 70% of cases, peak tic severity is experienced in the early adolescence between 10 and 12 years of age.11–13 Thereafter, tics spontaneously improve in the vast majority of patients, but may persist into adulthood.12–14

The assessment of tics is often challenging due to their waxing and waning nature, suppressibility of tics, as well as great variability regarding their impact on quality of life. It is therefore advisable to take all available information into consideration, including interview, clinical examination, and reports by families and caregivers and – if possible and in more complex cases – home-made video recordings. Because of these well-known difficulties in assessing tics, during the last years several different measurements have been suggested for tic assessment. The authors of a systematic review published in 2017 classified available tic rating scales as “recommended”, “suggested”, and “listed”15 and recommended the following rating scales: the Yale Global Tic Severity Scale (YGTSS),16 the Tourette Syndrome Clinical Global Impression (TS-CGI),17 the Tourette’s Disorder Scale (TDS),18 the Shapiro Tourette syndrome Severity Scale (STSS),19 and the Premonitory Urges for Tics Scale (PUTS).20 Furthermore, six scales were rated as “suggested” and another five as “listed” (for more details refer to Martino et al15). Anyhow, the gold standard to measure tic severity is the YGTSS. However, there is general agreement to use only the “total tic score” (TTS, range, 0–50) of the YGTSS to assess tics. To overcome – at least in part – limitations of the YGTSS, in 2018, McGuire et al21 introduced a revised version of the YGTSS (YGTSS-R). Although only recently we were able to show that further improvements are needed – particularly regarding the complexity of the measurement22 – in future studies the YGTSS-R (instead of the YGTSS) should be used. Most widely used scales helpful in the diagnosis and assessment of tics are summarized in Table 1.

Table 1 Most Widely Used Scales in the Diagnosis and Assessment of Tics Adopted from Martino et al.15 (Listed in Alphabetical Order)

Characteristics of Obsessive-Compulsive Disorder in Patients with Tourette Syndrome

In TS, psychiatric comorbidities are the rule rather than the exception and occur in almost 80% of patients.1,23,24 OCB/OCD is – beside ADHD – the most common comorbid psychiatric comorbidity, particularly in adults with TS. While only a minority of patients with TS suffer from full blown OCD according to DSM (around 30%, however numbers range from 2% to 66% depending on the sample investigated1,4,5,25), a large number of patients (about 60–70%1,26) exhibit mild to moderate OCB.5

Importantly, several lines of evidence suggest that tics and OCD share a common pathophysiology.5,27 Both conditions have familial nature, but while OCB/OCD is found more frequently in females,28 tics are far more common (3–4:1) in males.29 Interestingly, genetic studies indicate that OCB/OCD and TS share a common genetical background.30–32 Como et al33 even suggested that OCB is an alternative expression of the TS phenotype, more commonly affecting female gene carriers. This presumed overlap is also reflected in the clinical manifestation making differentiation between tics and OCD-derived symptoms sometimes very challenging.

When comparing pure OCB/OCD in the absence of tics with comorbid OCB/OCD in the context of TS, a number of differences emerge. Leckman et al34 conducted a cross-sectional study aimed to investigate tic-related and non-tic-related OCD. They investigated 177 patients with OCD, of whom 56 had tic-related OCD. Patients with tic-related OCD more often suffered from obsessions with aggressive, religious, and sexual thoughts as well as compulsions with checking, counting, ordering, touching, and hoarding behaviors compared to those with pure OCD (without tics). Surprisingly, these two groups did not differ regarding the presence of “just right” phenomena. George et al35 prospectively assessed OCD in 10 patients with pure OCD compared to 15 patients with TS and comorbid OCD using the Yale–Brown Obsessive Compulsive Scale (Y-BOCS), the Leyton Obsessional Inventory (LOI) as well as a questionnaire targeting to differentiate between the two disorders. They found that patients with TS plus OCD demonstrated significantly more violent, sexual and symmetrical obsessions and more touching, counting, and self-injurious compulsions. On the contrary, patients with pure OCD suffered more often from obsessive thoughts related to dirt and germs, and – as a consequence of these – more cleaning compulsions. Interestingly, patients with TS-related OCD felt that their compulsions arouse spontaneously, while patients with pure OCD reported that their compulsions are preceded by cognitions.

Alsbrook et al36 conducted a factor analysis of “tic symptoms” in 85 patients with TS. Four significant clinical clusters were identified: (1) aggressive phenomena (eg, kicking, temper fits, argumentativeness), (2) purely motor and phonic tic symptoms, (3) compulsive phenomena (eg, touching of others or objects, repetitive speech, throat clearing), and (4) tapping and absence of grunting. Eapen et al37 reported about clinical features and associated psychopathology in 91 patients with TS and found that OCB was positively correlated with the presence of ADHD and SIB. With regard to psychopathology in adults, principal component factor analysis yielded two factors, “obsessionality” and “anxiety/depression”, which accounted for 72% of the variance. Mathews et al38 presented results of the study examining clinical and genetic data of 133 individuals with TS in the intent to identify clinical/genetic clusters. Using cluster analysis, they identified two distinct groups, those with predominantly simple tics (cluster 1) and those with multiple complex tics (cluster 2). Membership in cluster 2 was correlated with increased tic severity, global impairment, medication treatment, and presence of comorbid OCB and with family history of tics, lower verbal IQ, earlier age of onset, and comorbid OCD and ADHD in the sample of Ashkenazi Jews. Another study trying to tackle the topic of diverse clinical phenotypes in TS was published by Robertson and Cavanna39 who carried out a principal component factor analytic study in 69 patients with TS. The authors identified three significant factors, accounting for approximately 42% of the symptomatic variance: Factor 1: predominantly “pure tics”, Factor 2: predominantly “ADHD and aggressive behaviors”, and Factor 3: predominantly “depression-anxiety-OCB and SIB”. Different kinds of tics occurred in all three factors. Only frowning/raising eyebrows and sniffing/smelling loaded significantly on Factors 1 and 3. In 2010, the same group conducted a follow-up study in a larger sample of 639 patients with TS.40 Using a principal component factor analysis, again three factors were identified: (1) complex motor tics and echo-paliphenomena; (2) ADHD plus aggressive behaviors; and (3) complex vocal tics and coprophenomena. OCB was significantly associated with the first two factors. The three factors accounted for 48.5% of the total symptomatic variance. Similarly, Huisman van Dijk41 reported about a relationship between tics, OCB, ADHD and autism symptoms. Their analysis revealed a five-factor structure including (1) tic/aggression/symmetry, (2) OCB/compulsive tics especially related to numbers and patterns, (3) ADHD symptoms, (4) autism symptoms; and (5) hoarding/inattention symptoms.

Terminology Used to Describe Phenomena Related to Obsessive-Compulsive Behaviors in Tourette Syndrome

Various terminologies are used to describe OCB/OCD related phenomena in TS including OCB, obsessive-compulsive symptoms (OCS), OCD, “just right” phenomena, “not just right experiences” (NJRE), repetitive behaviors, compulsive tics, and cognitive tics. It is important to realize that these symptoms belong to the same spectrum, largely overlap and in part are used synonymously. While OCD is clearly defined – according to DSM-5 as outlined above, for all other term – although often used – clear and generally accepted definitions are missing. In general, a patient is diagnosed with OCB, if obsessions and/or compulsions are only of mild severity and do not fulfil diagnostic criteria for OCD.

In contrast, NJRE specifically involve sensations of “incompleteness” rather than the need to “avoid harm” as typical seen in other OCD symptoms. “Just right” experiences are related to discomfort or tension rather than anxiety.42 Interestingly, they have been reported to proceed or accompany both tics and compulsions.7 Furthermore, Leckman et al8 suggested that premonitory urges (PUs)43 that typical proceed tics in TS show similarities with “just right” sensations. Most typically, PUs are described as an itch, discomfort or pressure. It is believed that PUs make patients execute tics in response to urges. Similarly, Coles et al44 described experiences of “not just-right” in patients with pure OCD defined as a feeling of “incompleteness”, if a specific mental or physical act is somehow performed incorrectly. Accordingly, da Silva Prado et al42 stated that we are still lacking a consensus regarding these different terminologies. Instead of using the term, PU, “just-right” and NJRE, alternatively the umbrella term “sensory phenomena” has been proposed.45

Compared to OCB/OCD, the term “repetitive behaviors” describes a far wider spectrum of symptoms including both impulsions, compulsions, stereotypies and even tics. It is used in the context of a variety of different neuropsychiatric disorders such as autism spectrum disorder (ASD), TS, OCB/OCD, schizophrenia, dementia, epilepsy, and eating disorders. In contrast, the terms “compulsive tics” and “cognitive tics” are used only in context of TS and other tic disorders. Compulsive tics are defined as “repetitive movements performed according to rules (ie, ritualistic) in response to an obsession or to reduce tension”.46 They are believed to represent a specific type of complex tics that share characteristics of both tics and compulsions. In contrast, cognitive tics are defined as mental acts that bear common characteristics with tics and obsessions.47 In clinical practice, both terms compulsive and cognitive tics are used only rarely, presumably because of the not clearly defined underlying concepts. Subsequently, we discuss each of these phenomena in more detail. Finally, also SIB in TS should be differentiated as a part of the spectrum on the verge between tics and OCB/OCD as previous studies have demonstrated that autoaggression in TS is mainly associated with tics or OCD spectrum.48,49

“Just Right” Phenomena: NJRE

The term “just right” has been introduced for the first time in the context of OCD by Janet in 1903 in his work “Les Obsessions et La Psychasthe“ describing the following phenomenon: “The patients feel that actions they perform are incompletely achieved, or that they do not produce the sought for satisfaction”.50 In 1994, Leckman et al8 were the first, who used the term of “just right” sensations in the context of TS. Today, it is generally accepted that “just right” phenomena represent the most common OCB in patients with TS. They are defined as the execution of an action in a certain way in order to achieve internal relief.8,51 In 2013, Neal and Cavanna51 alternatively introduced the term “not just right experience” (NJRE) in TS research after this term has been used since 1992 in studies related to OCD.52 Although semantically more accurately compared to the term “just right”, the synonym NJRE is less commonly used in TS research.

Leckman et al8 carried out a cross-sectional study in 134 subjects aged 9 to 71 to evaluate “just right” phenomena in patients with tic disorders. While 81% of patients with TS and comorbid OCD reported on a need to perform compulsions until a feeling of “just right” is achieved, only 56% of those with TS and comorbid OCB experienced such as feeling. Most of the patients described these sensations as a visual or tactile feature of the compulsion. Because of this overlap, the authors speculated that brain regions involved in sensorimotor processing are also involved in the pathophysiology of tics. In a large single-center study including 1032 patients with tic disorders, 10% and 62% were diagnosed with OCD and OCB, respectively (based on a structured clinical interview) with NJREs being the most common symptom followed by checking, ordering, washing, and counting.1

Neal and Cavanna51 for the first time used the “Not Just Right Experiences Questionnaire-Revised” (NJRE-QR) to systematically investigate NJRE in 71 adults with TS. This scale was originally introduced by Coles et al53 to assess NJREs in patients with OCD. They found that 80% of patients with TS report at least one NJRE. However, patients with comorbid OCB/OCD experienced significantly more NJREs compared to those without. The strongest correlation was found between NJRE-QR scores and self-report measures of compulsivity. The authors’ final conclusion was that NJREs are presumably more related to OCD than to tics. This hypothesis is in line with results of studies in pure OCD reporting an incidence of 95% of NJREs in OCD patients.44,54,55

Taken together, the clinical spectrum of OCB in patients with TS is broad. In any case, it is vital to actively inquire about OCB-related phenomena in order not to overlook these symptoms, particularly, because patients often do not report about it spontaneously. This procedure is of clinical importance, since “full blown” OCD often impairs patients’ quality of life to a greater extent than the tics. Compared to pure OCD, patients with TS and comorbid OCB/OCD more frequently suffer from “just right” phenomena, which is the most typical OCB in TS. More precisely, we suggest to use the term NJRE.

Repetitive Behaviors Related to Tourette Syndrome

Cath et al56 investigated the relationship between types and severity of repetitive behaviors in patients with TS plus OCD and pure OCD. They enrolled 14 subjects with TS and comorbid OCD, 18 with “TS only” (without comorbidities), 21 with pure OCD, and 29 healthy controls. Across the study groups, obsessions were more severe than impulsive behaviors and compulsions. Compared to pure OCD, patients with TS and comorbid OCD reported more “Tourette-related” impulsions such as mental play, echophenomena, impulsive, and SIB, but less obsessions and particular types of compulsions including washing. The authors concluded that patients with TS and comorbid OCD are phenomenologically more similar to TS than to pure OCD. Banaschewski et al57 analyzed data of a worldwide database on TS including 4833 individuals. OCB co-occurring with TS was associated with impulsive and aggressive behavior as well as with depression and anxiety. Worbe et al58 studied 166 patients with TS aged 15–68 to investigate whether repetitive behaviors represent a manifestation of OCD or belong to the tic spectrum. In their cohort, they found repetitive behaviors in 65% of patients. Based on clinical phenomenology, they identified three types of repetitive behaviors: a “tic-like” type (in 24% of patients) presenting with symptoms such as touching, counting, “just right”, and symmetry; an “OCD-like” type (in 20% of patients), manifesting with repetitive behaviors such as washing and checking rituals; and finally, a “mixed group” suffering from both “tic-like” and “OCD-like” types of repetitive behaviors (in 13% of patients). Only 6% of patients could not be classified in any of these groups. The authors concluded that in TS, different types of repetitive behaviors can be distinguished: “tic-like” behaviors, which seem to be an integral part of TS and “OCD-like” behaviors correlating with a higher score of complex tics and more frequent treatment with antipsychotics and selective serotonin reuptake inhibitors (SSRIs) as well as worse socio-professional functioning.

Eddy and Cavanna59 reviewed the literature in order to explore the nature of TS and OCD in more detail. They suggest that both disorders represent a continuum with contamination worries being more indicative for “full-blown” OCD, while repetitive behaviors are more linked to echophenomena, ordering, symmetry, and counting as typically seen in TS. Based on their research it is less clear, whether there is a difference between OCD- and TS- specific checking behaviours. They also postulate that patients with OCD are mainly focused on avoiding harm as much as possible, while in patients with TS repetitive behaviors such as self-defeat and SIB (eg, touching very hot or sharp objects) or socially dangerous acts (ie, non-obscene socially inappropriate symptoms, NOSI) are more characteristic.

All in all, distinction between “tic-like” and “OCD-like” repetitive behaviors can be very challenging. However, “tic-like” repetitive behaviors are usually preceded by premonitory urges, are ego-syntonic, and are not accompanied by intrusive thoughts, while “OCD-like” repetitive behaviors are typically anxiety-driven, are accompanied by obsessions, and are ego-dystonic.

Compulsive Tics

According to Palumbo and Kurlan,46 compulsive tics represent repetitive behaviors in patients with TS that comprise features of both compulsions and complex tics making it impossible to classify the particular symptom either as a tic or as a compulsion. Alternatively to the term compulsive tics, they suggested the term “compultics”. Thus, compulsive tics are defined as repetitive movements performed according to rules, in response to an obsession, or to reduce tension, for example touching a door a certain number of times. The author highlight that compulsive tics most typically have to be performed according to specific rules, ritualistic behaviors, in a certain number of times, in a certain order or at a certain time of day (eg, bedtime rituals).

To distinguish tics from compulsions, a thorough clinical interview may be helpful: While compulsions aim at neutralizing an anxiety-driven worry, compulsive tics are not executed with the aim of anxiety reduction. Instead, they help to neutralize the feeling of sensory discomfort until a “just right” feeling is achieved or a “not just right feeling” is diminished. Whilst tics usually start at age of 5–7 and tend to exacerbate in the adolescence and decrease during adulthood, OCD initiates at the age of 10–12 and patients often experience symptom deterioration while getting older.60

Cognitive Tics

Some researchers postulate the existence of so-called “cognitive tics” or “mental tics” (both terms are used synonymously), a symptom resembling obsessions.47,61 In 2005, O’Connor62 first suggested the presence of cognitive tics. In his article, he defined cognitive tics as thoughts, phrases, urges, songs, words, and scenes that intrude into consciousness, are difficult to remove, and consecutively cause irritation to the person. Until today, it is a matter of discussion, whether this is a meaningful concept as by definition tics are classified as motor or vocal phenomena. However, obsessions are defined as coherent doubts or images about aversive events or thoughts, while cognitive tics are neutral or pleasant or even stimulating. Accordingly, obsessions are part of the OCB/OCD spectrum and – in the patients’ mind – are linked to bad consequences. In contrast, cognitive/mental tics are isolated sequences unrelated to any consequences.

Alternatively, cognitive tics could be interpreted as a part of a much broader spectrum of intrusive thoughts defined as thoughts, images or impulses that (1) interrupt an ongoing activity, (2) are of internal attribution, and (3) are difficult to control.63 Based on this concept, the authors suggest that intrusive thought and cognitive tics share a number of common characteristics: (1) they are generally conceptualized as unwanted, (2) are hardly ever considered a one-time occurrence, but rather refer to thoughts, images, or impulses that have the tendency to repeat themselves, and (3) they have intrusive nature, which means that they interrupt regular activity.

The construct of cognitive tics is another example that illustrates the overlap of tics and obsessions and the difficulties to differentiate one from the other. In patients reporting impairing cognitive tics, treatment-specific response – to either (selective) serotonin-reuptake inhibitors ((S)SRI) or antipsychotics – may facilitate the final diagnosis of either a tic-related or an OCD-related symptom. Common and distinguishing features of tics and obsessions/compulsions are summarized in Table 2.

Table 2 Similarities and Disparities Between Tics and Compulsions/Obsessions

Self-Injurious Behavior (SIB)

Another phenomenon on the frontier between tics and compulsions is SIB found in about 40% of patients with TS.1,48,49,64,65 SIB is defined as auto-aggressive behavior directed against oneself. It is carried out although its senselessness and the risk of injury are recognized. SIB either consists merely of an urge to injure oneself against one’s will or are accompanied by actual damage to one’s own body against one’s will. Thus, injuries caused by auto-aggressive actions are not accidental and SIB is not accompanied by suicidal intent. Until today, it is unclear whether SIB is more related to tics or to OCD or represents an independent phenomenon. From previous studies it is suggested that SIB is associated with both complex motor tics and coprophenomena, but also different psychiatric comorbidities.1,48,49 In a recent study, our group66 developed a specific diagnostic instrument for rating complexity and severity of SIB in patients with TS, the Self-injurious Behaviour Scale (SIBS). In a large sample, 103 of 123 adult patients (84%) reported SIB. Remarkably, SIBS scores correlated with tic severity as assessed by the Adult Tic Questionnaire (ATQ), but not with the severity of OCD or any other psychiatric comorbidity (unpublished data). From these results therefore it is suggested that SIB represents a specific type of tic rather than an OCD-related phenomenon.

SIB must be differentiated from severe and/or complex motor tics that cause physical impairment (eg, because of the intensity or high frequency of the tics). In addition, harm caused by OCD with excessive washing and grooming must be differentiated. Finally, also impulsive behavior related to ADHD and rage attacks may result in physical injury that must be differentiated from SIB.48

Scales Used for the Diagnosis and Assessment of Obsessive-Compulsive Disorder

According to ESSTS guidelines,9 it is recommended to actively inquire about psychiatric comorbidities in every patient with TS as type and severity of clinical symptoms determine the therapeutic approach. Although in any case the diagnostic interview should cover the whole spectrum of common comorbid disorders, it should be oriented differently depending on the patient’s age. While in children the primary focus should be on ADHD followed by ASD, oppositional defiant disorder (ODD), learning disorders, anxiety disorders, and rage attacks, in adults predominant comorbidities are OCB/OCD and mood disorders followed by anxiety disorders, ADHD, rage attacks, and SIB.

For diagnosing comorbid OCB/OCD we recommend to use DSM-5 criteria, but also structured interviews can be used, particularly, the Mini International Neuropsychiatric Interview,67 the Structured Clinical Interview for DSM Disorders (SCID)68 in adults, the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI KID),69 and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL)70 for children, respectively. When it comes to further evaluation of OCB/OCD, the best investigated, most widely used, and, therefore, recommended scale is the Y-BOCS71 and equivalently, for children, the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS).72 Y-BOCS and CY-BOCS are 10-item, clinician-administered scales created to rate symptom severity, but not to establish a diagnosis. They contain symptom checklists and provide five rating dimensions for both obsessions and compulsions: time spent or occupied, interference with functioning or relationships, degree of distress, resistance, and control (ie, success in resistance). Each item is rated from 0, meaning “no symptoms”, to 4, “extreme symptoms”. As the (C)Y-BOCS is considered the gold standard for the assessment of OCB/OCD, we strongly encourage to use this scale in clinical practice. However, a number of other validated and well-established rating scales is available including the Obsessive-Compulsive Inventory (OCI)73 and the OCI-Child Version,74 the LOI75 and the LOI – Child Version Survey,76 and the Children’s Obsessional Compulsive Inventory (CHOCI).77 Scales helpful in the diagnosis and assessment of OCB/OCD in patients with TS are summarized in Table 3.

Table 3 Most Often Used Scales in the Diagnosis and Assessment of OCD (Listed in Alphabetical Order)

While in the context of clinical studies, use of well-established standardized assessments is of utmost importance, in daily clinical routine practice, a structured interview represents the gold standard to capture the whole clinical symptom spectrum. Up to now, none of the available measurements can be used to unequivocally classify phenomena on the borderline between tics and OCB/OCD as one of these. Unfortunately, “tic-like” as well as “OCD-like” repetitive behaviors are included in rating scales for both tics and OCB/OCD including the gold standard measurements. For example, SIB is mentioned in the symptom lists of both YGTSS and Y-BOCS. In other words, up to now differentiations between one and the other solely relies on clinical judgement. This in turn underlines the importance of centers of excellence for TS with extensive clinical experience. For all clinicians treating patients with TS, it is of importance to know that tics and OCB/OCD often co-occur. Not quite rarely, patients themselves may be able to assist disentangling “tic-like” from “OCD-like” repetitive behaviors, when comparing the phenomenon at issue to unequivocal tics (such as eye blinking) or unequivocal OCB/OCD (such as checking). Finally, treatment-specific response to either SSRI or antipsychotics may help to make the final diagnosis.

Treatment of Tics and Comorbid Obsessive-Compulsive Disorder in Patients with Tourette Syndrome

It is important to bear in mind that comorbidities – and in particular comorbid OCD – often cause greater impairment in patients’ quality of life than tics.78–81 In general, treatment of OCB/OCD in patients with coexisting tics/TS is based on the same premises as the treatment of patients with (pure) OCD without tics. Unfortunately, until today there is no treatment known that improves both tics and OCB/OCD. Regarding behavioral therapy (BT), for the treatment of OCB/OCD, Exposure and Response Prevention (ERP) is preferred,82,83 while in the therapy of tics Cognitive Behavioral Intervention for Tics (CBIT) is recommended.84,85 Alternatively, for OCB/OCD pharmacotherapy with SSRI can be initiated,86–89 while first choice treatment for tics are antipsychotics such as aripiprazole. Since ERP and pharmacotherapy with SSRI have similar efficacy on OCD,90 BT should be recommended as first-line treatment. If monotherapy with either ERP or pharmacotherapy is insufficient, combined treatment should be offered. If OCB/OCD responds partially to pharmacotherapy with SSRI, alternatively, augmentation with antipsychotics such as aripiprazole can be taken into consideration.88,91 If all these interventions fail to significantly improve OCD, gradual dose up-titration of the SSRI should be considered until intolerable adverse events occur. In refractory patients experimental treatments including cannabis-based medicines92–99 and finally surgical treatment with deep brain stimulation100 may be considered.


All in all, OCB and OCD are one of the most frequent comorbid psychiatric symptoms co-occurring in patients with primary tic disorders including TS. Since patients often do not spontaneously report on these symptoms – either because they are unaware of the relationship to TS or they are ashamed of their behaviors and thoughts – it is recommended to actively ask all patients about obsessions and compulsions not only at first consultation, but also at follow-up visits. Depending on the clinical context – as well as in clinical studies – it may be helpful to assess severity of OCB/OCD using the (C)Y-BOCS. By far the most frequent and most typical obsessions in patients with TS are “just right” phenomena, which more accurately should be named NJER, followed by compulsions with violent and sexual thoughts as well as symmetrical obsessions, touching, and counting. Differential diagnosis of OCB/OCD in TS includes tics, especially complex motor tics performed in the sequence, SIB, and mental phenomena on the frontiers between tics and obsessions, called cognitive tics. In patients with impairing OCB/OCD treatment with either ERP or SSRI should be offered depending on the preference of the patient.

Mental health awareness cannot be confined to the month of May

I’m plagued by a crippling case of generalized anxiety, obsessive-compulsive disorder, addiction, and an abyssal, recursive case of depression. I also never talk about this publicly. My illness, it seems, is the desolate burden of me and my psychiatrist alone. Not that any of this makes me special or unique — it’s been my general attitude that if my mental ailments are all I have to complain about, then I’m doing something right. That being said, this burden can be a grim and solipsistic one. Moreover, the fact that tens of millions of people are affected by mental illness year after year, with cases spiking and no real causation being addressed, it’s a plight we, as a society, ought to concern ourselves with on a more rigorous, consistent basis. 

We all share in the gauntlet of the human psychic condition; playing dice with fate, seeing how we’ll react to the stimuli and phenomena of social and economic life. And nowadays, more often than not, such a game concludes in at least some degree of mental illness. According to The National Institute of Mental Health, an estimated 31.1% of U.S. adults experience an anxiety disorder at some point in their lives and an estimated 11 million U.S. adults experienced a severe depressive episode in the year the study was released, with 35% of that group not receiving treatment for their ailment. Moreover, 4.4% of U.S. adults experience bipolar disorder at some point in their lives. Equally critical to consider, according to the Centers for Disease Control and Prevention, in 2019, 70,630 drug overdose deaths occurred.

What’s more, from 2018 to 2019, the U.S. saw a 67.9% increase in synthetic opioid-related overdose deaths — a figure that, for me, isn’t just another number. I’ve personally experienced the deaths of nine of my friends from drug-related overdoses and, sadly, there are countless others who I’ve seen pass along the way. Furthermore, when the aforementioned statistics are aggregated — anxiety, bipolar and depression included — such a figure accounts for an inordinate swath of the population. In other words, there’s an epidemic of Bubonic proportion unfolding like soundless fallout right before our eyes. And, save the studies, gradual destigmatization and psychiatric care, not much is being done to curb or alter this trend. From my perspective, it’s only getting worse.

“The depressed person is in terrible and unceasing emotional pain,” author David Foster Wallace wrote, “and the impossibility of sharing or articulating this pain is itself a component of this pain and a contributing factor in its essential horror.” What may very well come across as some pithy Twitter quote about depression, is in fact a core insight into individuals suffering from mental illness. Assuredly, the “impossibility of sharing or articulating” the anguish of the experience of mental illness is the crux of suffering, as Wallace notes. And in the context of our social rituals and values, it is the crux of our societal ills too. 

See, we are living in what the social theorist Byung-Chul Han has termed as the “Burnout Society.” According to Han, we are a culture that resists negative interpretations of the self and our world, leading to an ethics of achievement, positivity and activity. In another sense, we are constantly being told that we can achieve anything, and therefore, we have to achieve something. This persistent pressure to “do,” alongside the achievements of others around us, logically leads to tiredness, exhaustion and burnout — to illness. “Tiredness of this kind proves violent,” Han wrote in his book “Burnout Society,” “because it destroys all that is common or shared, all proximity, and even language itself.”

We cannot effectively share or articulate our suffering, as Wallace noted. We must instead “hustle,” “never quit,” “believe in ourselves,” “dream big,” “start something,” ad infinitum. Per the parameters of our societal norms — visible through social media outlets such as Instagram, the echo chamber of positivity and influencer-driven virtue — individuals suffering from mental illness must cloak their condition with a thin shroud of placid social niceties. It’s hard, if not impossible, to articulate the experience of mental illness via the coordinates of these social rituals and values we have constructed. In this sense, mental health awareness is not simply an individualistic, clinical concern. It is a societal concern, and our awareness of it and our collective efforts to address it ought to persist past the month of May.

The point of delineating causation as opposed to the normal pharmacological or pop-psychology narratives is not to discredit or argue against them — I take medication and undergo psychotherapy myself. The point is to explain that there is much more to it than popping a few pills and talking about your feelings. A tangible degree of social consciousness is required if we are to truly start saving lives. Mental health awareness is a massive societal concern. So keep us in mind — because we would, but it’s a mess for us up there.

6 Ways anxiety disorders develop and how to cope with them

Anxiety disorder is a type of mental health disorder that is characterised by excess fear, worry, or anxiety. This disorder includes panic attacks, obsessive-compulsive disorder, and post-traumatic stress disorder. The symptoms of this disorder are excess stress, constant worrying, and fear, etc. There are many ways in which anxiety disorders develop. So, psychologist, Dr. Malini Saba, Founder and Chairman, Saba Group talks about the red flags that can trigger anxiety disorder and how to cope with it.

Lack of Quality Sleep

A lot has been said about getting 6-8 hours of sound sleep for a healthy mind and body. While not many will concur with this, however, sleep and mental health are closely interlinked. Sleep deprivation can severely impact one’s psychological state and mental health, leading to anxiety issues. One should keep an eye on their sleeping pattern, and seek help if they face insomnia, frequent nightmares, etc. Catching these early warnings can help eliminate the chances of developing anxiety.

Mulling over things that are beyond the control

In the current scenario, with the pandemic raging on, all of us are doing everything in our power to keep ourselves and our loved ones safe from the wrath of Covid-19. However, in some cases, in spite of the best efforts, the situation can deteriorate and can cause anxiety. In such times, it is better to focus on the situation at hand instead of dwelling on the negatives. This will help create a positive attitude and can lessen the chances of developing anxiety.

Alcohol abuse

Unwinding with a glass of wine or beer after a long day may sound tempting to many, however, alcohol dependence and subsequent abuse can be the reason for alcohol-induced anxiety. Also using alcohol as a crutch to overcome social anxiety, in reality, can worsen the symptoms. Since alcohol hampers the normal functioning of an individual, long-term abuse can induce panic attacks and even lead to PTSD.  The best way to deal with alcohol-induced anxiety is to be mindful of your consumption and reach out for support from family and friends to tackle these difficult times.


One of the biggest contributors to the development of anxiety disorder is stress. In our day-to-day life, all of us endure stress. While we can’t completely eliminate it, however, it is necessary that we do not fall victim to it. Stress and anxiety go hand in hand where one heightens the symptoms of the other. If you suddenly have any of the physical symptoms ranging from severe headaches to unexplained spells of dizziness, it is time to take a breather and focus on calming your mind and relaxing your body. Breathing exercises are the best ways to do this.

Zero self-love

Treating your mind and body with a day of relaxation can do wonders and can also reduce the chances of developing any anxiety disorders. So, take a day off and indulge yourself in activities you enjoy and refresh your mind.

Side effects of medication

Every medication has side effects and it’s best to avoid them until absolute necessity. Few medications also contribute to the development of stress and can even induce panic-like symptoms. In such cases, it’s best to consult your doctor and consider changing the medication.

Also Read: Can breathing techniques improve your mental health? An expert opines

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Perfectionistic cognitions appear to play a key role in clinical anxiety

A new study found that perfectionist thinking patterns contributed to posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD) symptoms, over and above several known control variables. The findings were published in Cognitive Behaviour Therapy.

Perfectionism involves a desire to perform to the highest standards without allowing room for failure. People with perfectionist beliefs tend to be overly self-critical and put pressure on themselves to perform flawlessly at all times. While perfectionism is often seen as a favorable trait, the attribute has been linked to numerous anxiety disorders such as obsessive compulsive disorder (OCD) and social anxiety disorder (SAD).

Researchers have recently begun exploring the thought patterns that characterize perfectionism — called perfectionist cognitions (PC). As study author Jeremy Tyler and his team say, perfectionist cognitions include expectations about achieving perfection such as, “I can’t stand to make mistakes.” These cognitions have been linked to dysfunctional mental health symptoms like obsessions, distress, and anxiety. However, these associations have yet to be explored among a clinical population.

In a new study, Tyler and his colleagues wanted to extend the current findings by exploring perfectionist thought patterns among a sample of patients with diagnosed anxiety or anxiety-related disorders.

A total of 356 adults between the ages of 18 and 69 participated in the study. The most common primary diagnoses were OCD, SAD, and GAD. More than half (52%) of respondents had more than one mental health disorder diagnosis.

In a self-report survey, the subjects completed the Perfectionism Cognitions Inventory (PCI), which included a list of 25 perfectionist cognitions (e.g., “No matter how much I do, it’s never enough.”). Subjects were asked to rate how often they had experienced each of these thoughts in the last week. They also completed assessments of symptoms of GAD, OCD, SAD, depression, panic disorder, and PTSD. Finally, they completed assessments of emotion regulation difficulties and anxiety sensitivity.

The researchers found that perfectionist cognitions were positively linked to anxiety disorder symptoms across a range of diagnoses. More importantly, scores on the PCI still accounted for a significant percentage of variance in GAD symptoms and PTSD symptoms after controlling for symptoms of depression, anxiety sensitivity, and difficulties in emotion regulation — three factors that are known to relate to both perfectionist thinking, anxiety, and PTSD.

“These findings imply that treatment-seeking individuals experiencing more frequent thoughts about striving towards perfection were more likely to endorse more severe symptoms of GAD and PTSD beyond the contribution of anxiety sensitivity, deficits in emotion regulation, or depressive symptoms,” Tyler and colleagues report.

The authors discuss a few reasons why perfectionist cognitions might lead to increased anxiety. One possibility is that perfectionist thought patterns increase vulnerability to anxiety by encouraging a hyper-focus on perfection and acute awareness of failure that then leads to negative emotions like anxiety. The researchers say their findings suggest this pathway may be even more likely to occur among people with a GAD or PTSD diagnosis.

Tyler and team say their findings provide a basis for future studies regarding the role of PC in anxiety-related disorders. The findings also suggest that the treatment of anxiety disorders might benefit from a focus on addressing the presence of perfectionist cognitions.

The study, “The unique contribution of perfectionistic cognitions to anxiety disorder symptoms in a treatment-seeking sample”, was authored by Jeremy Tyler, Wenting Mu, Jesse McCann, Gina Belli, and Anu Asnaani.

Anxiety: Physical symptoms and how to cope with them

Although anxiety disorders come under the umbrella of mental health conditions, they can also cause physical reactions.

In addition to distress, fear, and worry, a person may have physical symptoms of anxiety, including:

Panic attacks can occur suddenly. If a person experiences a panic attack, they may feel that they are in extreme danger or are losing control.

People can have strong physical reactions during a panic attack, and they may even feel as though they are having a heart attack.

Some symptoms of a panic attack may include:

  • chest pain
  • chills
  • difficulty breathing
  • problems swallowing, or a feeling of choking
  • excessive sweating
  • a racing heart rate
  • feeling faint and nauseous
  • feeling that death is imminent
  • hot flashes
  • hyperventilation
  • numbness or tingling in the fingers, arms, or toes
  • shaking
  • stomach pain
  • a feeling of cold in the hands and feet
  • feeling detached from the body
  • dizziness or lightheadedness
  • blurry vision

Learn more about the differences between anxiety and panic attacks here.

Why the body responds to anxiety

Stressful life events can trigger panic attacks. However, panic attacks do not always have an obvious cause.

The physical symptoms of panic attacks are due to the body’s fight-or-flight response, which generates fear and anxiety.

During the fight-or-flight response, an individual responds to authentic and unreal danger in the same way and with the same physiological reactions. For example, their heart and breathing rates increase, they have a surge of adrenaline, and their senses become hyperalert.

A person’s body responds in this way because it is preparing to either fight the threat or run away from it.

The increase in blood flow prepares the muscles to flee from danger and allows the brain to focus and make quick decisions. The rapid breathing provides the body with more oxygen, ready to escape.

However, these things may cause the individual to feel as though they cannot get enough air, which may result in further feelings of panic.

The long-term effects

Anxiety disorders can cause people to avoid situations that they know trigger negative emotions. They may feel ashamed that they cannot live their lives as everyone else does. In turn, this may lead to increased social isolation and further withdrawal.

When this happens, a person may enter a cycle of living in fear of fear, meaning that the fear of a panic attack causes them to have more panic attacks.

If someone has chronic anxiety, they are always on high alert. This may negatively affect their cardiovascular, digestive, immune, and respiratory health.

No, OCD in a pandemic doesn’t necessarily get worse with all that extra hand washing

At the beginning of the COVID-19 pandemic, we were concerned infection control measures such as extra hand washing and social distancing might compound the distress of people living with obsessive-compulsive disorder (OCD).

Early anecdotal evidence and case studies reported an apparent increase in OCD relapse rates and symptom severity.

But a year on, we’re learning this is not necessarily the case, and research is giving us a more nuanced understanding of what it’s like to have OCD during a pandemic.

Read more:
Hoarding, stockpiling, panic buying: What’s normal behavior in an abnormal time?

What is OCD?

OCD is a common and disabling condition, affecting roughly 1.2% of Australians.

It’s characterised by obsessions (repetitive intrusive thoughts) and compulsions (physical actions or mental rituals) that attempt to quell these preoccupations.

There are several subtypes of OCD, including:

  • contamination: characterised by obsessions and compulsions centred around washing, cleaning and concerns around personal hygiene and health

  • overresponsibility: encompassing pathological doubt, concerns over unintentional harm to others or oneself, and persistent urges to check things

  • symmetry: obsessions about things feeling “just right” (for example, uniform and/or symmetrical), resulting in ritualistic behaviours including counting and ordering

  • taboo: characterised by unwanted intrusive thoughts that are often violent, sexual or religious in nature.

Although we don’t fully understand what causes OCD, research points to abnormal activity of specific brain networks, including a network called the cortico-striatal-thalamo-cortical loop.

This network connects key emotional, cognitive and motor hubs in the brain, and it’s particularly important for higher-order cognitive tasks such as thinking flexibly.

No, people with OCD aren’t ‘quirky’

There are several prevailing stereotypes about what it means to live with OCD, such as a belief people with the disorder are just a bit quirky, overly particular, “neat freaks” or “germ-phobic”.

Such ideas are frequently promulgated in popular culture. For example, in 2018 Khloe Kardashian promoted her “KHLO-C-D” branding for an online miniseries in which she gave tips on home organisation and cleanliness. The campaign was widely criticised.

While contamination fears and an affinity for symmetry are better recognised in the community (perhaps owing to portrayals in TV and film), the “taboo” and “overresponsibility” dimensions of OCD are far less understood and are therefore subject to higher levels of stigma.

Are we all OCD now?

The global response to COVID-19 has blurred the line between pathological behaviours and adaptive health and safety measures.

Behaviours that were previously linked to psychiatric illnesses, such as repetitive washing and sanitising rituals, are now encouraged (at least to some extent) by health authorities.

While infection control directives such as social distancing and hand hygiene play an essential role in our fight against the virus, they take a psychological toll too.

The pandemic has had a profound effect on mental health due to increased stress and lifestyle changes. Indeed, scientists have recently proposed a condition called “COVID-19 stress syndrome”. Some of the symptoms significantly overlap with anxiety disorders and OCD.

While we don’t all have OCD now, it’s unquestionable our collective behaviour has changed in ways that make the distinction between “normal” and “pathological” much more complex.

In this light, the International College of Obsessive–Compulsive Spectrum Disorders has highlighted the unique challenges the pandemic poses for accurately diagnosing OCD.

Read more:
You can’t be ‘a little bit OCD’ but your everyday obsessions can help end the condition’s stigma

Living with OCD in a pandemic

Having a pre-existing mental health condition appears to be the single most influential predictor of high stress levels during COVID-19.

However, recent evidence from well-controlled studies doesn’t find compelling evidence that people with OCD have been affected by COVID-19 to a greater extent than those with other psychological conditions (such as depression or general anxiety).

One study published in January compared OCD severity in a large group before and during the pandemic. It found the stress induced by COVID-19 increased measures of mental distress across all OCD symptom dimensions (not only those directly related to a public health crisis).

The authors suggested the increase in OCD symptom severity was likely a “non-specific stress-related response”. In other words, it’s the general stress of the pandemic that has worsened OCD in some cases; not the increased focus on infection control.

A woman sitting on the couch, appears pensive or unhappy.
Having a pre-existing mental health condition is the biggest risk factor for having high stress levels during the pandemic.

Another recent study found the pandemic didn’t lessen the benefits of treatment in a large outpatient group with OCD in India.

Interestingly, the researchers from this study also found prior incomplete disease remission (cases of OCD that persisted even with treatment) and general stress were the best predictors of OCD relapse during the pandemic, rather than “COVID-specific” stress, per se.

After the pandemic

These findings don’t suggest there’s a specific vulnerability to COVID-related stress for people with OCD.

But it’s worth noting cognitive inflexibility, a symptom often seen in OCD, may make it more difficult for people with the disorder to “unlearn” temporary public health directives.

So it’s important we continue to monitor the effects of COVID-related stress on OCD and similar disorders, particularly as we slowly transition from the pandemic.

There’s much we can learn from the study of OCD during COVID-19. Most notably, it appears an “intuitive” understanding of the disorder doesn’t sufficiently capture the breadth of individual OCD experiences.

A deeper understanding of the variability of OCD presentations, and a move away from stereotyped perceptions, may encourage more people to openly discuss their own OCD experience and seek treatment.

Read more:
My skin’s dry with all this hand washing. What can I do?

Need support?

If you live in Australia, call Lifeline (13 11 14), Kids Helpline (1800 551 800) or BeyondBlue (1800 512 348). Alternatively, “OCD STOP!” is a free online program designed to help you better understand and manage OCD.

If you simply want to learn more about OCD, online resources are available at SANE Australia and Beyond Blue.

Treating the Compulsive Personality: Transforming Poison into Medicine

One summer during my analytic training, I committed myself to study, outline, and completely internalize Nancy McWilliams’s Psychoanalytic Diagnosis (1994). The idea that you could be more effective with clients by understanding their specific patterns ran contrary to the anti-diagnosis attitude at my training institute. But it appealed to my eagerness to be helpful.

Not long after I began, I recognized myself in the chapter on the obsessive-compulsive personality. While I didn’t meet the DSM-5 criteria for obsessive-compulsive personality disorder (OCPD), I certainly had my compulsive traits: perfectionism, over-working, and planning, just to name the obvious. McWilliams’ description elucidated who I could have become, had I not had a supportive family and lots of analysis to rein in those tendencies.

But this wasn’t just personal or theoretical. I recognized the collection of traits found in the personality style in my many driven, Type A, and perfectionistic clients working in law, finance, and publishing in work-crazed midtown Manhattan. And I saw the suffering it caused.

The Unrecognized Stepchild of Personality Disorders

Captivated by the subject, I eventually got involved in some online OCPD support groups. There, I read many stories of people who thought they had OCD for years before finally realizing that their entire personality was characterized by compulsive tendencies. They had known that their struggles weren’t just with specific obsessions and compulsions, but that was the only diagnosis they were aware of that was even close to describing them. And in many cases, OCD was the diagnosis a clinician had given them.

This pattern of misdiagnosis became even clearer once I began receiving comments and emails from people reading my new blog, The Healthy Compulsive Project, and my book, The Healthy Compulsive.

While OCPD is one of the most frequently occurring personality disorders of the ten listed in the DSM, it is under-recognized and probably underdiagnosed (Koutoufa Furnman, 2014). Far too often, it’s confused with OCD by both the public and clinicians. One study indicates that the lack of recognition of the condition leads to a lack of empathy for it (McIntosh Paulson, 2019). And far more people suffer from obsessive-compulsive personality traits than those who meet the full criteria.

It doesn’t help that it’s ego syntonic not just for the sufferer, but to some extent for our culture as well. Capitalism doesn’t care if you work too hard. According to psychologist and researcher Anthony Pinto (2016), there is no empirically validated gold standard treatment for OCPD. I suspect that this is a function both of our tolerance of it and of the difficulty in treating it.

What’s the Meaning of This?

As I filtered all of this through my training as a Jungian analyst, my curiosity about the underlying meaning of the disorder was piqued. Jung emphasized the importance of asking what symptoms and neuroses were for. What potentially adaptive purpose did symptoms serve in the patient’s life, or for humankind at large? Could there be meaning under something so destructive? Was there some underlying attempt to move toward individuation gone awry?

Looking up the etymology underlying the word “compulsion,” I realized that it wasn’t originally a bad thing. A compulsion is an urge that’s almost uncontrollable. A drive or force. And that’s not all bad. Many of these urges lead to creative and productive behavior. But

before I could find any possible light in the condition, I had to acknowledge how dark it could be.

The Cost of OCPD

The more I observed the world of the obsessive-compulsive personality, the more I came to see its destructive potential. A review of OCPD by Deidrich Voderholzer (2015) tells us that people who have OCPD often have other diagnoses as well, including anxiety, depression, substance-abuse, eating disorders, and hypochondriasis. OCPD amplifies these other conditions and makes them harder to treat. People with OCPD have higher than average rates of depression and suicide and score lower on a test called the Reasons for Living Inventory (Deidrich Voderholzer, 2015).

Medical expenses for people with OCPD are substantially higher than those with other conditions such as depression and anxiety. And the study indicating this only included people who had sought treatment—which excludes the many with more serious cases who don’t (Deidrich Voderholzer, 2015).

The cost for couples and families is great. People who are at the unhealthy end of the compulsive spectrum can be impossible to live with. They can become mean, bossy and critical, and their need to control often contributes to divorce. Much of the correspondence I receive is from partners of people with OCPD who are at the end of their rope, looking desperately for hope that their partner can change.

Parents with OCPD often place unreasonable demands on their children. This can interfere with developing secure attachment and may also increase the chances of a child’s developing an eating disorder.

It also causes problems in the workplace. While some compulsives are very productive, others become so perfectionistic that they can’t get anything done. Still others prevent their coworkers from getting anything done because their criticism disrupts productivity.

Similar problems happen in other organizations such as volunteer groups and religious institutions. People with compulsive tendencies often become involved in community groups, and they’re so convinced that they’re completely right, and that they should control everything, that they contribute to the deterioration of the organization, partially because others don’t want to work with them (Deidrich Voderholzer, 2015).

Just as disturbing is knowing of the many personal, community, and cultural benefits that the condition prevents when it hijacks energy that would otherwise have led to leadership, creativity, and productivity. Compulsives can be movers and shakers, but instead they often end up being blockers and disruptors.

The people who shape the world are the ones with the most determination, not the ones with the best ideas. And compulsives have lots of determination.

The Adaptive Perspective on OCPD

As I looked more deeply into the condition, I could see that the original intention beneath compulsive control is positive: compulsives are compelled to grow, lead, create, produce, protect, and repair. It seemed to me that the obsessive or compulsive personality is not fundamentally neurotic, but a set of potentially adaptive, healthy, constructive, and fulfilling characteristics that have gone into overdrive.

I’m certainly not the only one to make this observation. A dimensional perspective of personality disorders is gaining momentum (Haslam, 2003). But this viewpoint is still sorely needed for sufferers, partners, and clinicians.

Realizing that evolutionary psychology might provide an understanding of the adaptive potential of obsessive-compulsive tendencies, I contacted psychologist Steven Hertler, who has been on the front lines of thought in this area. His ideas resonated with what I had suspected about the survival benefits of obsessive-compulsive tendencies: the behavior that those genes led to made it more likely that the offspring of those with the genes would survive (Hertler, 2015). For instance, being meticulous and cautious is part of what Hertler (2015) refers to as a “slow-life strategy,” which increases the likelihood that those genes will be handed down.

Most importantly, though, a perspective which highlights the possible benefits of a compulsive personality style has significant clinical benefits. Conveying the possible advantages of this character style to clients lowers defensiveness and encourages change.

There is a wide spectrum of people with compulsive personality, with unhealthy and maladaptive on one end, and healthy and adaptive on the other end. Clients on the unhealthy end of the spectrum can be very defensive about their condition. They tend to think in black-and-white terms, good and bad, and their sense of security is dependent on believing that they are all the way on the good side. This makes it hard for them to acknowledge their condition, enter therapy, and get engaged in treatment. When they do come in, it’s usually because their partner is pressuring them, or because they have become burned-out or depressed.

If we are to help people suffering from obsessive-compulsive personality disorder, we need to find a way to get under their defenses so that they can make use of therapy. When we understand and convey that OCPD is a maladaptive version of something much more positive, we begin to forge a good working relationship.

But as therapists, we should also acknowledge that some individuals are so far to the unhealthy end of the continuum that even if they were to enter therapy, we might not be able to help them. It was important for me, at least, to be realistic, so that I didn’t set myself up to feel that I had failed if I wasn’t able to help someone.

Characteristics of the Obsessive-Compulsive Personality

The DSM-5 says that OCPD is defined by a “preoccupation with orderliness, perfectionism, and mental interpersonal control at the expense of flexibility, openness, efficiency” (American Psychiatric Association, 2013). It goes on to list eight criteria; since these criteria are readily available, I won’t list them here. But I do want to emphasize what the DSM-5 (2013) points out in the first criteria: people with OCPD are preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. I have found this to be a defining characteristic of people on the unhealthy end of the compulsive spectrum—they’ve lost the point of their rules and efforts to control. They’ve lost their original intention, the thing they first felt compelled to do.

I remember being struck the first time I noticed this. A female client was talking about how she had berated some people for not following the rules. It struck me that she was so adamant about the rules that she had forgotten who the rules were meant to help and protect—the very people she was berating.

One goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled them. [editquote:ne goal of treatment should be to help clients recover, or uncover for the first time, the original impulse, the deeper motivation that has compelled themThat original impulse could be service to others, creation of many sorts, or repairing the world. Ideally, identifying these original impulses allows the individual to fulfil them productively, rather than obsessively or repeatedly try to carry them out in distorted ways.

Four Types of Compulsives

The more I treated people with OCPD the more I came to recognize that while there were certainly significant differences amongst them, those differences seemed to fall into a few patterns. The desire for control and perfection was the same, but the strategies they used to relieve their anxiety or to prove their worth were different. Eventually I identified four primary, overlapping styles, with both adaptive and maladaptive possibilities:

  1. Leader/Authoritarian Boss or Bully
  2. Doer/Workaholic
  3. Follower/People-Pleaser
  4. Thinker/Procrastinating Obsessive Perfectionist

This helped me to recognize clients’ dominant strategy and what was needed for balance.

In Search of a Treatment Approach

According to psychologist and researcher Anthony Pinto (2016), while we have reason to believe that psychotherapy is the treatment of choice for OCPD, we don’t have a form of treatment which has been verified by research at the “gold standard” level for evidence-based treatment of OCPD. Most of the studies we do have are either not specific to OCPD or are not rigorous enough to be certain that a particular approach is effective.

I may be biased because I practice psychodynamic treatment, but it seems to me that because OCPD affects the entire personality, psychodynamic treatment will be the most effective. I say this because cognitive and behavioral treatments are most effective for very specific issues, less so for the sort of global issues that characterize OCPD.

But those of us who work psychoanalytically may need to budge a little on maintenance of the frame, disclosure, the use of goals, and our reluctance to diagnose. Just as the saying “the only way to peace is peace” goes, “the only way to flexibility is flexibility.” We need to be mindful of our own personal need to control, and a certain rigor that our training may have encouraged: we might think or feel that we are doing the “right” thing by following the rules. But in particular aspects of the work with compulsives, we may gain more through example than through analysis.

Eight Key Points

I’ve found that there are particular themes and tasks that I usually need to work through with compulsive clients over time. I don’t believe that these are unique to OCPD, but rather that they usually require more emphasis than might with other conditions. I outline these below with the suggestion that they be used in a flexible and organic way, rather than as hard and fast steps.

In each of these steps I try to enlist clients’ adaptive compulsive characteristics to foster change.

  1. Create a narrative respecting inborn characteristics. To help compulsives diminish insecurity and develop self-acceptance, I’ve found that it is important to create a narrative which distinguishes authentic, organic aspects of their personality from those which were the result of their environment. Compulsives are born with traits such as perfectionism, determination, and attention to detail. They usually like constructive projects, and this can be a joint project that nurtures the working therapeutic relationship.
  2. Identify the coping strategy they adopted. If there was a poor fit between the client and his or her parents, the child may have used their inborn tendencies, such as perfectionism, drive, or self-restraint, to find favor and to feel more secure. Most unhealthy compulsives become so when their energy and talent are hijacked and enlisted to prevent feelings of shame and insecurity, and to prove that they are worthy of respect, inclusion, and connection.
  3. Identify when their coping strategy is still used to cope with anxiety. Recognize if and how they still use that coping strategy as an adult. Most coping strategies used to ward off anxiety will diminish if the anxiety is faced head on rather than avoided with compulsions.
  4. Address underlying insecurity. Question their self-criticism and replace it with appreciation for their inherent individual strengths, rather than pathologizing or understanding them as reactive or defensive. Reframe their personality as potentially constructive. I’ve seen this perspective help many people as they participate in OCPD support groups.
  5. Help clients shift to a more “bottom-up” psychology. Nurture their capacity to identify emotions and learn from them rather than use compulsive behavior to avoid them. Help them to identify and live out the original sources of their compulsion, such as service, creation, and repair, actions that would give their lives more meaning. Help them to make choices based on how things feel rather than how they look.
  6. Identify what’s most important. Most compulsives have either lost track of what’s most important to them, or never knew. Projects and righteousness that they imagine will impress others fill the vacuum. Instead, once they can feel what they were naturally compelled to do, they can use their determination to fulfill it in a more satisfying way.
  7. Identify personality parts. Compulsives try to live in a way that is entirely based on direction from the superego, and they attempt to exclude other aspects of their personality. I have found it very helpful to have them to label the dominant voices in their head (Perfectionist, Problem Solver, Slavedriver), and to identify other personality parts that have been silenced or who operate in a stealth way. Depending on what the client is most comfortable with, we can use terms from Transactional Analysis (Parent, Adult, Child), Internal Family Systems (Exiles, Managers, Firefighters), or a Jungian/archetypal perspective (Judge, Persona, Orphan).
  8. Use the body, the present moment, and the therapeutic relationship. Compulsives rarely experience the present and usually drive their bodies as vehicles rather than nurture them. Bringing their attention to their moment-to-moment experience and using their experience of you as their therapist can help. For instance, bring their attention to tension in their body and, if possible, connect that with any feelings that they have about you. For instance, do they feel a need to comply with you, or any resentment about complying with you?

The Case of Bart


A man in his early forties, whom I will call Bart, came to see me when his wife said she could no longer tolerate his worrying and unhappiness. To his own surprise, he found himself tearing up as he described his life to me. He didn’t do that kind of thing. Ever.

Bart was handsome, fit and bright. Yet he was very self-deprecating.

He told me that he worked in finance and had done well enough to provide comfortably for his family. But his success didn’t register with him at all. He worried about what others thought of him. He feared that people would discover that he was a hoax at his job; he believed his success was accidental and that he could lose it all at any time. At this point in his career, he was just coasting and didn’t find any meaning or challenge in it.

Bart imagined that his family tolerated him only because he provided for them. During our initial consultation, he said he wasn’t feeling bad. But it was clear that he had experienced serious depression in the past, and I suspected that he was still depressed but couldn’t acknowledge it.

His wife was lively, talkative, and highly social, but their relationship was flat at best. He made it a point to say that he did not want to blame her for any of his problems or theirs as a couple. Nor did he want to assign any blame to his parents. Any problems he had were of his own making.

He admitted that he found it difficult to engage feelings. He avoided reflection, journaling, and talking. Like most compulsives, he controlled not just the outer world, but also his inner world. It was hard for him to tolerate uncertainty.

He played organized sports about four days a week, and he had great difficulty tolerating any mistakes on the field or court. He constantly monitored success and failure with a scoreboard in his head. He had quit playing golf because he got too upset when he didn’t play well.

At the end of our initial consultation, I told him that it seemed to me that while he had adapted very well to the external world, he had not adapted well to his inner world.

Achieving that would be one of the goals of our work together. I was confident that if he could put the same energy and attention that he had put into career success into his psychological well being, he would see change.

He told me that his impressions of therapy were based on media examples and that he didn’t have any idea how this worked. I told him that I was glad he was asking because we as therapists don’t always do a good job of explaining how the therapeutic process works. I agreed to be transparent about the course of our work, to share how I believed we needed to proceed, and to explain the rationale behind my suggestions. In particular, I would try to be clear about his role in the work.


His mother was depressed and a classic martyr. Masochistic, even. She seemed to enjoy her suffering. His father worked as a salesman and was willful, driven, and judgmental. He insisted on success: winning was his religion. For Bart this meant that if his behavior didn’t lead to points on the scoreboard in terms of some productivity or success, it was meaningless. His father said, “it’s good to win.” Bart extended this to “it’s terrible to lose.”

Bart internalized the strategies of both parents, and it caused a terrible conflict: he had imperatives both to lose and suffer (his mother’s masochism), and to win and achieve (his father’s need to triumph). He chose to be more like his father from his teens until he was 25; then he switched and became more like his mother. But he couldn’t let go of the feeling that he should still be winning all the time, in addition to learning, producing, and working all the time. He had lots of “shoulds.”

He had concluded that people want compliance rather than authenticity. He was raised Roman Catholic, and he’d make up things he had done wrong to have something to admit when he went to confession. He told me that he no longer believed in God, so he had to punish himself now. He felt guilty about any sort of self-assertion. He loved post-apocalyptic films because “in that setting, you don’t have to worry about being good anymore.”

Yet Bart didn’t feel that his parents or his environment had any bearing on his current struggles. So I said that the most important thing for us now was to understand how he had adapted to the situation he was raised in.

Coping Strategy

One aspect of Bart’s strategy was trying to control people by giving them what they wanted. Meeting his father’s expectations was only the beginning. Among the four types of compulsives, he was clearly a follower/people-pleaser. He tried to achieve self-acceptance through others’ opinions of him, but it didn’t work, even when he did get accolades.

Another aspect of his strategy was to not depend on others. To do so would rob him of control. It would take time for him to realize that he actually did have social needs, but that, so far, those needs had only gone into impressing others, rather than relating to them. As with many compulsives, Bart felt it was safer to seek respect than to want love.

In his martyr mindset, being a victim implied that he was good. So he often became very negative about his life to prove to himself that he was a victim. He wouldn’t complain verbally to others, but he did need to show himself, at least, how bad his life was. Later he came to realize that his depressed moods were also unconscious attempts to communicate the misery that he could not reveal directly.

He was aware that he had adopted a strategy of planning and perfecting to try to pre-empt the utter self-contempt he unleashed on himself when things didn’t go well. “But why the self-contempt?” I asked. “If I’m self-critical, it will show other people that I won’t tolerate mistakes. But it’s become habitual. I do it even when other people aren’t looking.”

Engaging Feelings

Much of our work involved learning to identify feelings and excavating different levels of feeling so that he could operate from a more “bottom-up” approach. We spoke of therapy as a gymnasium for exercising his capacity to tune into feelings. As with many compulsives, framing our work in terms of a project was helpful in engaging him. I tried to bring attention to what he was feeling in his body and to the present moment.

Most of his feelings were about “shoulds.” Desires were few and far between. Tuning in to desires was a heavy lift for him, but with time he began to be more aware of the difference between acting on fears versus acting on desires.

At times Bart felt like giving up, whatever that might mean. I recommended that he take that seriously but not literally: What is it that you really need to give up? What is the control that you would be happier without?

As he let go of self-control, anger began to surface and eclipsed his sadness and anxiety. Part of him believed that he always did the right thing, and he got angry at those who didn’t. While he was typically self-effacing, it was new for him to acknowledge that in some ways he felt superior.

But we also needed to continue to excavate even more deeply beneath his anger and judgement to see if there were yet other levels of fear or sadness. While it was scary and sad to acknowledge how much was out of his control, it was a relief not to be avoiding it.

When he first came into treatment he had imagined that therapy would remove all his uncomfortable feelings. But with time he came to realize that it was okay to have feelings—sad, anxious or angry—and that he could learn not to amplify those feelings or carry them needlessly. With time, he didn’t need to avoid them so thoroughly.

Identifying What’s Important

Even as he learned to turn his focus inward, he found it hard to articulate his goals in life, career, and therapy. He had lost track of himself and what he really wanted long ago.

Because he had little access to feeling, he was unable to find direction. He obsessed about his job and whether to change companies or even careers. He liked the idea of a new career, especially one with a new identity, but he couldn’t follow through on that. He feared losing the fantasy of what it would be like if he did change.

As he navigated his professional and personal world, I often had to ask him what was most important to him. At first this was distressing, since he had no idea who he was or what he wanted. He was always climbing mountains, but he wasn’t sure whether taking on challenges was something he felt he was supposed to do or something he wanted to do. This skill of distinguishing how something looks from how it feels has been essential to the improvement of most of the people I work with. He couldn’t tell the difference, and we kept revisiting the distinction.

In his efforts to succeed, he’d lost track of why he wanted to succeed.

Any sense of fulfillment in accomplishments was replaced by the need to achieve to prove to others and himself that he wasn’t a fraud. Over time he came to recognize that taking on challenges was fulfilling, that he genuinely enjoyed it, and that it was vital to his feeling better. But to enjoy it, he had to let go of using the challenges to prove his worth.

He had similar realizations when telling me about learning: this wasn’t just something he should do to silence his father’s demanding voice, it was something that was very satisfying. He didn’t have to do it, he wanted to do it. And that made it more pleasurable.

We explored his feelings about his marriage. He did value his marriage but was reluctant to depend on his wife: “I’d like to think that I don’t need my wife, but I do. And because I don’t want her to be too important, I don’t take in her support.” This would have made him too vulnerable and would have gone against the masochism he adopted from his mother.

It was a small revelation to him when he was recounting his weekend and noticed that spending time with his son had actually been pleasurable. It wasn’t just a “should.” Noticing this feeling of pleasure was a small window into what was most important for him. “I’ve been putting points in the wrong basket all along, thinking that making money was most important…I have to challenge the idea that piling one more dollar on the stack will make me feel better.”

He came to value more peaceful emotional states—being more present and accepting, and less regretful and judgmental.

Transference Countertransference

Coming to therapy was not comfortable for Bart, partially because he felt he wasn’t “good” at it.

I remembered that he had quit playing golf because he wasn’t good at it and wondered to myself if the same could happen with therapy. Still, his ability to speak to me directly about his discomfort was a success. Doing so served as a sort of psychoanalytic exposure therapy, staring down his deep fear of being real and of being known, with the added advantages of eventually understanding the causes and functions of those fears.

He once asked whether therapy was like confession. I explored what it was like in that regard for him and reminded him that when he was young he would make up sins to take to confession. Would he need to do that here? He didn’t think so.

He admitted that he wanted to learn the language of psychotherapy to please me. “Sometimes I tell you what I think you want to hear. I never lie to you, but I do try to figure out what you want.” He felt pressure in the silence to figure out what he was supposed to say. We explored this as a good example of his strategy.

“I’m afraid you think I’m a dick,” he said. “I’ve got so much, what’s my problem? Why am I complaining? You must think I’m just indulging here.” Was this feeling unique to our situation, or was this actually typical of how he felt with most people? He acknowledged that he never felt that it was okay to feel even tolerably accepting of himself, much less feel really good. That would be indulgent and arrogant. And it would invite humiliation.

He had imagined that I would give him a thumbs up at some point, certify him as mentally healthy, and send him on his way. We used this as an opportunity to distinguish what was more important: what I thought about him or how he felt about himself.

Allowing me to know him, and questioning how he imagined I saw him, was a step in the direction of being more open with people in general. Looking for parallels with what he imagined I thought of him, we explored the difference between what he imagined his wife thought of him, and what she really thought of him. As he felt less criticized, anxious, and depressed, she scrutinized him less, and he began to feel more comfortable with her.

I also experienced my own discomfort with him. I feared that he would run out of things to say and that I would be exposed as not having anything to offer him. I was not able to work this through completely, but in retrospect I suspect that my fears of being found inadequate were both induced and my own.

He missed a fair number of sessions. Even accounting for the fact that business meetings came up last minute, it still seemed that he avoided his issues at times by not coming. I thought it might be fitting for this to be an imperfect therapeutic process, and that my accepting that was going to be instrumental in his progress.

Despite how imperfect it was, he did make progress. Candor, which had been ego dystonic, was becoming ego syntonic. His coping strategy was changing, and we both came to enjoy his increasing freedom to be himself in the sessions.

Treatment Process: The Agents of Change

My goal in treatment with most compulsives is to enlist their natural impulse to become a “better” person and put it in service of their psychological growth. With Bart I never used the word compulsive, much less mention the diagnosis “OCPD.” But I did note his strong, natural drive to succeed and to be a good person.

Bart did seem to get this eventually: “It’s kind of like I’m waking up and realizing that the game I was playing, putting points on the scoreboard, was meaningless, but this process of understanding myself and feeling better is more important. It feels good when I get it, when I master it.”

These realizations included questioning the narrative that he had to be like either of his parents. Near the end of his treatment he told me, “I want to take the best of my mother and father, and not be so black-and-white about it.”

Another aspect of his narrative that we needed to question was whether his family needed him only for money.

Maybe they wanted him to be happy as well. Accepting this as a possibility required some vulnerability on his part. He couldn’t remain aloof if they actually cared about him. I believe that his work on opening to feelings in our sessions was instrumental in allowing him to feel closer to his family.

On occasion he wanted assignments for the week. I chose exercises to help him become more aware, in the moment, of how his old coping strategy affected him. For instance: “Try to notice when you stop yourself from feeling good. Count the times you do it. Just noticing it is great.” And, “Notice how many times perfectionism leads you to attack yourself.” Compulsives love to count. What he counted was changing.

We explored different parts of his personality. “What if I’m an asshole that just likes money? What if I just like being seen as generous but I’m really not?”

“Yes, part of you likes money, and part of you likes being seen as generous. Those are both okay. And there is more to you. There is also a part that genuinely likes to be generous whether anyone sees it or not.”

He wondered if it was okay to be ambitious. Somehow it didn’t feel right. The more we processed this, the clearer it became that it wasn’t so much money that was important to him, but achievement and mastery. There was a part of him that loved challenges. To say what he loved was a new expression and marked acceptance of a part of him that he had only vaguely recognized before.

Accepting his introversion was another challenge. He definitely liked his time alone but felt guilty about it, which of course meant that spending time with his wife and others felt like it was in the “should do” column, not the desire column. In the long run, he came to appreciate both being alone (without guilt) and spending time with his family, because it was no longer a “should.” As different parts of him came out of hiding, it became clearer what was important to him.

All these elements served to reduce the insecurity he felt, so that he didn’t need to prove himself…as much.


After 19 months Bart felt well enough to end treatment. We spent a few weeks processing the termination, especially what it was like for him to end it rather than me. I would have liked to see him longer, but that may have come out of my own perfectionist ideas about how long treatment should go on and what it should accomplish.

I would like to have seen him develop more comfort with the therapeutic process itself, but that too comes from someone whose intense interest in psychology developed when he was a teenager. Maybe not everyone needs to be comfortable with therapy, much less actually enjoy it. It was a very good sign that he decided to end treatment rather than feel he needed to stay to please me. I hope my acceptance was healing.

I will never know how much, if any, of his progress was a well-performed recovery. But I suspect that even if his first efforts to be authentic were to please me, they eventually became truly authentic. I suspect that he had experiences and insights that will help him change and be more fulfilled, even well after our work is finished.

Working with compulsives has forced me to examine my own biases, my own need to control, and my own rigidity. If nothing else, I learned that I can’t expect my patients to become any more flexible than I am myself. This includes challenging my own fixed ideas of how treatment should go with each new client.

Conclusion: Poison as Medicine

Jung said that individuation is a compulsive process, that we are compelled to become our true, authentic selves. When that process is blocked, neurotic compulsion ensues.

When we recognize the constructive potential of the obsessive-compulsive personality, we can help make it less “disordered.”

When we recognize the energy that’s gotten off track, we can help direct that energy back toward its original, healthier path. The adamancy about doing the “right thing” that turned against the client and the people around them can be enlisted to help them find their way to a more satisfying way of living.

The alchemists were known for trying to transform lead into gold, which was really only a metaphor for transforming the poisonous, dark struggles of our lives into the incorruptible gold of character. But I think that this metaphor works best when we understand that the gold was there all along, obscured and waiting to be released.


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evidence. Clin Psychol Rev, 23(1), 75-93.

Hertler, S. C. (2015). The evolutionary logic of the obsessive trait complex: Obsessive
compulsive personality disorder as a complementary behavioral syndrome. Psychological
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Koutoufa, I., Furnham, A. (2014). Mental health literacy and obsessive–compulsive personality disorder. Psychiatry Research, 215(1), 223-228.

McIntosh, P., Paulsen, L. Mental health literacy of OCD and OCPD in a rural area. The Journal of Counseling Research and Practice, 4(1), 52-67. Available at

McWilliams, N. (2014). Psychoanalytic Diagnosis. The Guildford Press.
Pinto, A. (2016). Treatment of obsessive-compulsive personality disorder. In E. A. Storch A. B. Lewn (Eds.), Clinical handbook of obsessive-compulsive and related disorders (pp. 415-429). Springer International Publishing AG. 

© 2021, LLC

Obsessive-Compulsive Disorder (OCD) Latest Facts: Types, Causes, Symptoms and Treatments

What is OCD?

We’ve all experienced that feeling of doubt that makes us go back and double-check if we turned off the stove. You’ve also probably had an unpleasant or even violent thought from time to time that makes you wonder where it came from. But people with obsessive-compulsive disorder experience obsessive thoughts like this followed by compulsive behaviors so frequently and intensely that it interferes with their daily life.

Washing Hands

OCD falls under the umbrella of anxiety disorders and it is characterized by unwanted, uncontrolled thoughts and repetitive, ritualized behaviors that people feel forced to perform. People are aware of the irrational nature of these thoughts and behaviors, but they feel like they are unable to control and resist them.

Obsessions and compulsions – a vicious cycle

Obsessions are thoughts, images, or impulses that occur involuntarily. They are unpleasant and feel forced, i.e. the person doesn’t have control over them. People don’t want to experience these thoughts, they are often disturbing and distracting, but they feel powerless to stop them from occurring continually.

Read Also: Mental Health During Childhood and Adolescence Influences Health and Life Expectancy in Adulthood

Compulsions are behaviors or rituals usually performed to eliminate obsessions. People feel driven to do certain things repeatedly and excessively to make intrusive thoughts go away. For example, if a person is terrified that they might cause a fire and burn down their building, they can develop a compulsion of checking their stove over and over again. They feel certain relief when they perform the act, but that feeling usually does not last for long. Obsessive thoughts come back and people often feel even more compelled to perform the ritual or behavior. This makes the person even more anxious because obsessions and compulsions take more energy and can become very time-consuming. This is called a “vicious cycle of OCD”.


People suffering from OCD can experience obsessions, compulsions, or a combination of both. Usually, the symptoms interfere with daily life and personal performance at work, in school, and in personal relationships.

Common obsessions

1. Contamination
Germs and/or disease
Household chemicals
Body fluids (feces, urine)
Environmental contaminants (radiation, asbestos)

2. Perfectionism
The pressure that things need to be even or exact
Worry of losing an important item or forgetting important information when they throw something out
Difficulty deciding whether to keep things or discard them
Worry of losing things

3. Losing control – fear of:
Harming oneself
Harming other people
Disturbing and violent mental images
Saying insults or vulgarities out loud
Stealing something

4. Harm – fear of:
Being the cause of a terrible event (for example, causing a fire or burglary)
Harming others by their negligence (for example, infecting someone with germs if they touch them)

5. Religious obsessions
Fear of offending God and blasphemy
Extreme attention to morality and worry about right and wrong

6. Undesired sexual thoughts
Inappropriate or perverted sexual ideas and images
Inappropriate or perverted sexual impulses concerning others
Taboos involving children or incest
Thoughts about violent sexual behavior

7. Other
Concerns about personal sexual orientation
Fear of getting sick not by contamination (for example, getting cancer)
Superstitions about (un)lucky numbers, colors, etc.

Read Also: Thyroid Inflammation May Be One of the Causes of Anxiety According to Ukrainian Study

Common compulsions

1. Cleaning
Washing hands excessively or in a certain manner
Showering, tooth-brushing, etc. excessively
Cleaning household or other items excessively
Other acts to prevent or remove contaminants

2. Checking
Checking if they harmed others or themselves
Checking that nothing terrible happened
Checking that they did not make a mistake

3. Repeating:
Routine activities (for example, going through the doors)
Body movements (touching, crossing, stepping, etc.)
Activities certain amount of times (for example, turning lights on and off three times in a row)

4. Mental compulsions
Going over events mentally to prevent harm to others or themselves
Praying or other religious rituals to prevent harm
Counting items or counting while doing something until they feel “right”
“Cancelling” or “undoing” (for example, saying a good word after a bad one to cancel it out)

5. Other
Arranging things in order until they feel “right”
Avoiding triggering situations

People usually begin experiencing symptoms in their teen or young adult years, but OCD can start even in early childhood. Symptoms typically develop over time and they vary in frequency and severity throughout life. Specific obsessions and compulsions can also vary and change as time passes. Symptoms usually become worse when a person experiences a lot of stress. OCD is often a lifelong struggle for people, but there are treatment options out there to help manage the disorder.

If your symptoms are affecting your ability to function on a daily basis, you should consider seeing a doctor or mental health professional.

Read Also: Simulating Exposure to Feces to Treat OCD Shows Promise


Professionals do not fully understand how and why OCD develops. There are several theories about what causes the disorder:

  • Biological – OCD is a result of a change in brain chemistry or function.
  • Genetic – Obsessions and compulsions have a genetic component, but specific genes have not been identified yet.
  • Learning – Fears and behaviors associated with OCD can be learned over time or by watching people close to us.

Scientific research supports each theory to some degree, so it is likely that we need to consider multiple factors when it comes to the development of OCD. Further research is needed to bring us closer to understanding the causes of this disorder.

Risk factors

There are certain factors to be considered because they may increase the risk of developing OCD. Some of them are:

  • Family history – having biological relatives with OCD increases the risk of developing it.
  • Life events – stressful and traumatic events can cause emotional distress, which can act as a trigger for intrusive thoughts and repetitive behaviors typical for OCD.
  • Other mental health issues – it is possible that OCD can be related to other disorders like anxiety, depression, tic disorders, or disorders with substance abuse.

Treatment options for OCD

Psychotherapy, medication, or a combination of the two are the most common options to treat OCD. Most patients respond well to treatment, however, there are cases in which symptoms persist after getting treated.

An important thing to consider when making decisions regarding treatment is the presence of other mental health disorders.

Read Also: Deep Sleep Reduces Anxiety Levels Considerably During The Day, UC Berkeley Study Shows


Research shows that some types of psychotherapy, such as cognitive-behavioral therapy (CBT) and others related to CBT (for example, habit reversal training) are more effective than others when it comes to OCD treatment. CBT appears to be as effective as medication for many patients, according to research.

The most effective type of CBT for compulsive symptoms reduction is called Exposure and response prevention. The process of this approach includes exposure to triggering situations (for example, touching dirty items) and being prevented to act out the compulsive behavior that usually follows that situation (washing hands). It appears that even patients who did not respond to medication therapy benefit from this approach.


Medications used to treat and reduce obsessive-compulsive symptoms are called serotonin reuptake inhibitors. This class of medication is used to treat depression as well, but doses are usually higher when treating OCD and may take eight to twelve weeks before patients start to notice the difference in symptoms. Sometimes, if a patient does not respond well to this type of treatment, professionals prescribe antipsychotic medication. Research shows that this approach can help manage symptoms of OCD, but there are mixed results when it comes to research about the effectiveness of antipsychotics on this disorder.

Read Also: Researchers May Have Found A New Cure For Anxiety

Treatment should be personalized with most mental health disorders. The same goes for OCD as well. The process might begin with medication or psychotherapy only, and the other option can be an add-on treatment to assure a better outcome for the patient.








NYC Youth Struggling with OCD Face Compounded Challenges in Pandemic

‘I don’t know that the diagnostic incidents of OCD has gone up, but the symptom occurrence and the severity has exacerbated with the pandemic,’ says Theresa Hsu-Walklet, a psychologist and the assistant director of the Pediatric Behavioral Health Integration Program at Montefiore Medical Center.

Adi Talwar

Teresa Hsu-Walklet, PhD, is an attending psychologist for the Behavioral
Health Integration Program (BHIP) at Children’s Hospital at Montefiore.

A teen of color, overwhelmed by fears of contamination, closed themselves in their bedroom at the start of the COVID-19 crisis. As time went on, they became increasingly depressed and disconnected from the world, alarming family members.

Another adolescent of color attended therapy on their parent’s phone but was not able to look into the camera; they were too afraid to touch the phone. 

Both of these young people live in New York City and suffer from Obsessive Compulsive Disorder (OCD), in which a person experiences obsessions, which are intrusive and unwanted thoughts that cause distress, and/or urges to perform compulsions, which are behaviors or thoughts a person uses to avoid or reduce anxiety or get rid of an obsession. While in the U.S., the acronym OCD is often used as a synonym for characteristics like “detail-oriented” or “organized,” experts say the actual disorder is highly distressing and sometimes debilitating. 

Read our coverage of
New York City’s
Coronavirus crisis.

For several reasons, the pandemic has been particularly challenging for OCD patients. Scientists and news reports have found that many sufferers of OCD—both children and adults—experienced exacerbated symptoms. Clinicians who spoke with City Limits mentioned isolation, stress, or a lack of access to normal coping mechanisms as factors that could have contributed to this worsening. In addition, while OCD can appear in many forms, fear of contamination and germs is a common type, and some sufferers have struggled with excessive worry about COVID-19 contamination and spreading the illness. These, in turn, can manifest in a rise in compulsions, such as excessive cleaning. Some people have also experienced other types of OCD exacerbated by the pandemic, such as somatic obsessions or health OCD (concern with fearing something is wrong with the body) and harm OCD (fear one will be responsible for something terrible happening).

“I don’t know that the diagnostic incidents of OCD has gone up, but the symptom occurrence and the severity has exacerbated with the pandemic,” says Theresa Hsu-Walklet, a psychologist and the assistant director of the Pediatric Behavioral Health Integration Program at Montefiore Medical Center in the Bronx. She adds that the pandemic has led to new complexities for therapists providing treatment.

“Pre-pandemic, we might ask youth to stop washing hands as part of treatment…but due to COVID19, we want our patients to be safe and don’t want them to stop washing their hands completely,” she wrote in an email. “Moreover, the media, parents, and schools are now reinforcing the idea of washing hands, which makes treatment harder when the severity of compulsions is greater.” While in the past, a psychologist might ask a youth to touch a public doorknob and not wash their hands, now they might aim to limit the number of times a young person washes their hands once they are already in their home, she explains.

Dr. Rebecca Berry, a licensed psychologist who coordinates the intensive OCD treatment at the  Child Study Center, part of Hassenfeld Children’s Hospital at NYU Langone, says she didn’t see worsened contamination symptoms at the very start of the pandemic, but as the pandemic progressed and children were left isolated and without access to pleasurable activities, many patients’ OCD worsened, with some experiencing contamination fears but others experiencing different obsessions and compulsions. Many also became more depressed.

“For some youth, it was sort of like, which is [it], the chicken or the egg? Did the OCD contribute to a worsening depression during the pandemic, or did depression intensify the OCD?” says Berry. “I don’t think we can necessarily answer that.”

Experts say genes likely play a role in the development of the disorder, but that it can be triggered and exacerbated by stress. OCD often begins either between the ages of 8 and 12 or in late adolescence to early adulthood. At any given time there are roughly one in 100 adults and at least one in every 200 children living with OCD in the United States. To put the latter in context, this is less than the rate of children who experience anxiety (seven in every 100) and depression (three in every 100) but comparable to the rate of children who suffer from diabetes.

Much has already been written on the mental health crisis facing New York City’s youth—particularly its Black and brown children, who lost parents during the pandemic at twice the rate of white children, and who, prior to the pandemic, were twice as likely to live below the poverty line.

Yet there’s little public information available on how OCD impacts the city’s young residents. The New York City Health Department Epiquery database reports that 3 percent of parents with a child between the ages of 2 and 12 answered yes when asked if a health professional had ever said their child had “anxiety problems,” but the database doesn’t offer data about OCD specifically.

At the same time, for low-income youth and youth of color, there are compounded barriers to receiving treatment for this disorder.

When OCD meets racism

Experts acknowledge that the typical media representation of an OCD sufferer isn’t a non-white child.

“A pretty common public perception is that the OCD sufferer is a white male who has a certain level of exactness in their behavior and whose diagnosis is probably more appropriate to call OCPD [Obsessive Compulsive Personality Disorder, a different illness],” says Dr. Dean McKay, a professor of psychology at Fordham University who runs the Compulsive, Obsessive, and Anxiety Program (C.O.A.P.).

Before 2008, there were few published studies focused on the presentation or treatment of OCD in African Americans and a low rate of participation in OCD studies by non-white Americans, writes psychologist Monnica Williams, a professor at the University of Ottawa and an expert researcher in OCD among Black Americans. She says that to her knowledge, there are still no studies truly focused on African American children with OCD, and that it’s difficult for researchers to obtain funding for studies of depression and anxiety-related disorders in the Black community.

“Black people specifically are often stereotyped as being strong and sturdy and impervious to pain,” says Williams, who adds this stereotype has its roots in rationalizations of slavery.”That stereotype also extends to emotional pain,” she says, adding that research funders “aren’t looking for problems like depression and anxiety, because of the stereotypes of what the problems actually are.”

But it’s not just funders: overwhelmed mental health clinics in disenfranchised communities struggling with violence sometimes treat people who suffer from anxiety or depression as a low priority for care, according to Williams.

While Black American adults and white Americans have a similar chance of getting OCD in their lifetimes, Black Americans are more likely to have a more severe case and stay ill longer, Williams says. (One study found similar severity rates among all populations, but that minority populations were less likely to get treatments.)

People of color with OCD are also often misdiagnosed with other illnesses, including schizophrenia and psychosis—disparities in care that help fuel distrust in the mental health care system, experts say. “I think there’s a certain measure of awareness in some communities of color and low income communities [of this]. Not only is there a stigma around mental illness, but also there’s a hazard that they could be given a course of treatment that is inappropriate or may even be harmful,” says McKay.

Of course, for any person regardless of race, OCD is not always easy to diagnose. Sufferers’ obsessions and compulsions can be quite heterogeneous, and some are easier to identify than others.

“The compulsions associated with OCD can manifest in different ways. Whereas some compulsions are easily observable (e.g., excessive hand washing, tapping a certain number of times), internal compulsions are more difficult to detect. For example, a child or teen may repeat a reassuring statement or count to a specific number internally,” wrote Dr. Michelle Fenesy, a postdoctoral fellow at the Washington Heights Youth Anxiety Center, in an email.

OCD sufferers may also try to hide their OCD symptoms. “In regards to OCD specifically, children and teens may experience shame related to some obsessions (e.g., harming others) and therefore not disclose having these intrusive thoughts,” Fenesy continued. In one form of OCD, a sufferer may have intrusive sexual or violent thoughts along with a fear of acting impulsively, even though the sufferer has no desire to act upon the thoughts.

Some argue for greater cultural awareness to the range of racially and culturally specific manifestations of OCD symptoms. McKay worked with one child who feared a classmate’s touch would turn the child into a zombie. Though this might have seemed strange to many practitioners, the child was of Haitian descent, and this was simply an obsession focused on the zombie of Haitian cultural mythology.

Williams also says therapists need a better understanding of the impact of racism on their clients. Her study found that both material hardship (the degree to which an individual cannot meet basic expenses) and exposure to racial discrimination were positively correlated with the exacerbation of OCD symptoms. She also writes that, “OCD symptoms may be influenced by negative racial stereotypes.” Take, for instance, the false and racist stereotypes about Black Americans being unclean and violent. These stereotypes might cause some Black people predisposed for OCD to worry excessively about presenting as clean, or about having intrusive violent thoughts. Concern over such stereotypes might also cause Black patients with OCD to not share and get treatment, for fear of being seen as unclean or violent by others. Therapists need to invest extra time into ensuring their clients of color understand their obsessions and compulsions are quite normal for OCD, Williams says, and they also have to take seriously the stress their clients face from living in a racist society.

“Experiences of racialization may be embedded into the client’s symptoms, but when therapists dismiss or minimize challenging race-based experiences, they can do more harm than good,” wrote Williams in an online editorial.

Stigma and community access

There are multiple other barriers that can prevent a family from seeking treatment.

“Systemic barriers that prevent youth with OCD from accessing treatment are not largely different from barriers that prevent access to mental health treatment for common disorders like anxiety or depression,” wrote Carolina Zerrate, medical director of the Washington Heights Youth Anxiety Center, in an email. “There is still significant stigma about having mental illness and receiving psychological or psychiatric treatment. Students in the public schools we serve in upper Manhattan mostly identify as Latines, black, or mixed race. Stigma is not exclusive though highly prevalent among BIPOC communities.”

Other barriers in marginalized communities can include limited knowledge about mental health disorders and how to get treatment as well as language barriers and cultural beliefs, such as a reliance solely on religious solutions. Furthermore, even if a family has obtained affordable health insurance, other financial hurdles can hinder a family from seeking treatment for their child, such as the cost of subway rides or the price of internet to access telehealth appointments.

Many communities still lack information about OCD. While in 2017 New York State passed a law mandating that mental health issues be incorporated into the curriculum for grades K-12, there is some variability by school in the implementation of the law, and most school curriculums likely don’t go into much depth about OCD specifically, according to John Richter, director of public policy at the Mental Health Association in New York State.

“What would be useful … is if there was some outreach to schools, particularly in some low-income communities and other communities of other under-represented people and communities of color, to disseminate some information about OCD,” says McKay, “and also, in consultation with members of those communities, to develop an understanding of culturally relevant symptoms.”

There can also be varying levels of knowledge about the disorder among health care professionals themselves, including medical practitioners, school counselors and others who interact regularly with children. OCD experts say the more these professionals know about OCD, the better, as they can play a crucial role in helping families overcome stigma and other barriers to care.

In response to a request for comment on how schools are supporting students with OCD, the city’s Department of Education emphasized that every student currently has access to either a social worker, a guidance counselor or a mental health clinic, and that the DOE has additional partnerships with Health + Hospitals to provide clinical mental health care.

“Through deep investments in services and resources, we’ve put mental health at the core of our work with young people,” said Nathaniel Styer, a DOE spokesperson, in an email. “They are trained to work with children to identify issues like OCD, and to develop a plan that identifies appropriate next steps and supports, like supplementary aids or tailored in-school supports.”

The number of social workers in the city’s public schools has increased over the past decade, and in December the de Blasio administration announced it would hire an additional 150 new social workers and expand the community school program in the 27 neighborhoods hit hardest by the pandemic. Still, teachers say far more school mental health professionals are needed.

Asked to comment on how the city was working to address barriers to treatment for OCD, the Health Department referred City Limits to its Community Supports and Services web page, which lists hotlines, resource centers, and programs for families and children pertaining to multiple mental health conditions.

Affording the best treatment

Even though New York City is known as a home for many of the nation’s preeminent mental health specialists, it can be difficult to find practitioners who can properly treat OCD. Many therapists are focused on psychodynamic therapy, which emphasizes gaining insight about oneself through a longer-term process of discovering an underlying emotional narrative. For OCD patients, however, another form of treatment is widely thought to be more effective: Cognitive Behavioral Therapy, which aims to immediately identify negative thinking patterns and create new thinking skills to change feelings and behaviors.

The type of cognitive therapy considered the most important for treating OCD is Exposure and Response Prevention (ERP) therapy, which requires patients to purposefully expose themselves to things that make them anxious. According to McKay, not enough therapists undertake the intensive training needed to become a practitioner of ERP, and some psychodynamic therapists are uncomfortable with the idea of pushing clients to be uncomfortable. “[ERP] has a lingering public relations problem,” he says. “Fortunately, that seems to be changing.”

To add to the problem, many ERP specialists do not accept health insurance. “I think the challenge in the therapy world is the reimbursement rates to take insurance are just abysmal. It’s really difficult for a practitioner to make it [if they take insurance],” says Dr. Eric Storch, a psychologist who oversees the Cognitive Behavioral Therapy for OCD and related disorders program at Baylor College of Medicine in Texas.

City Limits used the Psychology Today website to search for therapists within 30 miles of central Manhattan who treat OCD and use ERP, retrieving 185 results. Filtering those searches to psychologists who take Medicaid reduced those results to three, plus a telehealth therapist in Rochester. Filtering instead to psychologists who take Healthfirst, a no-to-low-cost health insurance and a Medicaid managed care organization, reduced results to five psychologists.

City Limits also called the NYC Well hotline developed under the city’s ThriveNYC initiative to see if the city could provide referrals to ERP specialists who accept health insurance, but the hotline database is unable to filter according to treatment method, leaving callers to comb through lists of clinics that offer treatment for OCD to see if any offer ERP.

“This is a training problem, and we need to be able to disseminate the treatment more widely because it does require a level of expertise that’s not usually present in Medicaid or Medicare-based settings,” says McKay.

There’s reason to have hope; Williams, who is the co-founder of the diversity council for the International OCD Foundation (IOCDF), says the organization has begun offering scholarships to clinicians of color to participate in trainings, and she’s working on an initiative to bring trainings lead by OCD specialists of color to more communities of color.

There are also certain places that do accept patients with insurance and Medicaid. For instance, Hsu-Walker at Montefiore works in a primary care setting, so patients can walk down the hall to get mental health treatment, with Montefiore itself eating the insurance cost difference. In addition, some university externs will see patients for a reduced fee.

Health insurance companies are actually required under New York law to provide treatment for patients with OCD, so patients can try petitioning their insurance company to cover a specialist who is out-of-network, says McKay, though he notes some companies are more amenable than others. Williams finds insurance companies are often not willing to reimburse for two 90-minute sessions per week—the golden standard treatment for OCD. “There needs to be a lot more priority given to what the clinician says…rather than barriers and roadblocks to actually getting that treatment,” she says.

One silver lining of the pandemic for OCD patients is increased access to telehealth medicine in New York State, which has allowed OCD patients to seek specialists beyond the city’s limits. ERP is also often more effective when done in the space of the home.

“Telehealth practice has allowed for exposure to be done in ways that are more relevant to the individual,” says McKay. “You can walk around the house! You can be on a secure network via telehealth-based intervention and the [therapist] can guide you right there in real time.”

Are you or someone you know seeking treatment for OCD? Here are some suggestions for New Yorkers seeking help.

  • Use the Psychology Today search engine to find a therapist, specifying your health insurance, disorder, age range, and the specific treatment you are seeking.
  • Use the IOCDF database to find a therapist or practice. You can’t search by your specific insurance, but you can narrow by those who take private insurance, Medicare or Medicaid, a sliding fee, etc, and you can search by specialty, age, and other criteria.
  • Some hospitals are also affiliated with OCD clinics or specialists who accept some, or many, insurance types.
  • You might also find universities that are conducting studies that offer treatment for free.
  • Check out New York specialty practices that say they don’t accept insurance or only as an out of network provider, but do provide a sliding scale of fees, especially if you’re working with an extern, masters or doctorate student.

City Limits’ series on behavioral health and NYC’s children is supported by the Citizens’ Committee for Children of New York. City Limits is solely responsible for the content and editorial direction.

Encouraging Women to Report Perinatal-Specific Symptoms of OCD and Using DSM-5 Leads to Higher Prevalence Estimates

Point prevalence of perinatal obsessive-compulsive disorder (OCD) gradually increases and peaks at close to 9% at about 8 weeks postpartum before declining, researchers found in a study published in the Journal of Clinical Psychiatry.

The researchers collected data from February 2014 through February 2017 from 580 women living in British Columbia, Canada. Women completed online questionnaires and a telephone interview in late pregnancy (mean=36.89 weeks, standard deviation (SD)=1.96) and twice postpartum: at a mean of 9.9 weeks (SD=1.94) and at a mean of 21.27 weeks (SD=3.83). They were followed from late pregnancy (at 32 weeks gestation or later) through up to 38 weeks postpartum.

Of the 580 participants, 270 provided data for 3 interviews, 182 for 2 interviews and 122 for only 1 interview. Diagnostic data were collected retrospectively for 101 patients who missed the prenatal interview and 49 who missed the early postpartum interview.

They were assessed for OCD using the Structured Clinical Interview for DSM-5 (SCID-5).

Researchers asked participants about OC symptoms they had experienced in the past 2 weeks at each interview. Participants also were asked to identify the 2-week period during pregnancy or afterward when their OC symptoms were the most intense. They were asked about infant-related harm thoughts and associated behaviors postpartum.

Estimated point prevalence of OCD diagnosis from the model was 2.6% (95% CI .4-4.8) at 6 weeks prior to delivery, 8.3% (95% CI 5.4-11.2) at 10 weeks postpartum and 6.1% (95% CI 3.3-8.8) at 20 weeks postpartum. Estimated average point prevalence during the prenatal period was 2.9% (95% CI 2.7-3.2) and 7.0% (95% CI 6.9-7.2) during the postpartum period. Weighted period prevalence during pregnancy (n=375) was estimated at 7.8% (95% CI 5.1-12.0).

At the beginning of the postpartum period, 93 of 535 participants had a diagnosis of OCD. The period prevalence through the final postpartum interview at 38 weeks was estimated with logistic regression as 16.9% (95% CI 14.0-20.2). Period prevalence through 8.8 weeks was 6.9%. Up to 13 weeks, it was 7.8%.

Incidence of new OCD diagnoses was estimated at 4.7 (95% CI 3.2-6.1) new cases per 1,000 women per week postpartum, with a total of 49 new cases reached by 22 weeks postpartum. The average person time of follow-up was 18 weeks. Cumulative incidence of new cases of OCD was 5% for 4 weeks, 6% for 8 weeks, 7% for 12 weeks, and 8% for 16 weeks postpartum, respectively. By 6 months postpartum, cumulative incidence rose to 9%.

Of the 100 women who reported symptoms during the perinatal period that were consistent with a diagnosis of OCD, 60 reported that clinical levels of OCD began during the pregnancy or postpartum.

These prevalence estimates are higher than those found in previous studies, which the researchers attributed to more comprehensive evaluation of perinatal-specific OC symptoms and differences between DSM-IV and DSM-5 diagnostic criteria. This study was the first to use DSM-5 diagnostic criteria.

Limitations included the fact that some women joined the study after childbirth and may have been attracted to the study because of their experience of postpartum intrusive thoughts and that the history of OCD prior to participation was collected only for participants who experienced OCD symptoms.

The study authors said, “Our study suggests that when women are encouraged to report their perinatal specific symptoms, and current diagnostic criteria are applied, estimates for perinatal OCD may be higher than previously believed.”


Fairbrother N, Collardeau F, Albert AYK, et al. High prevalence and incidence of obsessive-compulsive disorder among women across pregnancy and the postpartum. J Clin Psychiatry. Published online March 23, 2021. doi: 10.4088/JCP.20m13398

The impact of anxiety disorders and how to manage them

Alice Bertoldo, psychologist (GGZ, NIP) and psychosomatic psychotherapist, trained in Cognitive Behaviour Therapy and Psychodrama, tells us how to deal with an anxiety disorder.

Anxiety disorders are among the most common mental health conditions. Often, they are paired with other mental health issues, such as major depressive disorder or personality disorders. Most people who are experiencing anxiety disorders try to cope with life using alcohol or drugs.

Cognitive schema

A cognitive schema is a mental framework that helps individuals to process and organise information. Cognitive schemas come from Core Beliefs; the way we see the world, ourselves and our future. When Cognitive schemas are biased they process ambiguous stimuli from the environment as a “catastrophe” or as a “threat”. Thus, the mind perceives as ‘dangerous’ stimuli that otherwise might be neutral.

How an anxiety disorder can impact your life

Anxiety disorders can impact life in a variety of ways, such as:

  • You avoid feared places and situations
  • You can’t sleep, suffer from insomnia
  • You postpone tasks
  • You isolate yourself socially
  • You suffer from indecisiveness
  • You overthink everything
  • You have difficulty trying new things

Key factors

There are several factors that play a part in developing anxiety such as:

  • Genes
  • Chemical imbalance in the brain
  • Trauma
  • Social media and isolation
  • A lifestyle that does not suit your needs and wants

Four types of fear

Anxiety can be grouped into four different conceptualisations of fear:

1. Catastrophic

The fear that something very negative and catastrophic like the “worst-case scenario” is going to happen. It includes separation anxiety, arachnophobia (the fear of spiders), ophidiophobia (the fear of snakes).

2. Evaluation

The fear of being watched and judged, such as in social anxiety, selective mutism and glossophobia (fear of public speaking).

3. Losing control

The fear of losing control (panic attacks and agoraphobia).

4. Uncertainty

Feeling uncertain (generalised anxiety disorder and obsessive-compulsive disorder).

How to overcome and manage anxiety

Let’s have a look at the different ways you can help overcome and manage anxiety:

Cognitive Behaviour Therapy (CBT)

This is particularly useful to treat anxiety disorders. In particular, exposure techniques (in-vivo or imaginal) have proven to be highly effective.


This is the very first step to help the person realising that avoidance of feared situations and places maintains anxiety.


This can help as it will teach you to pay attention to the present moment, to accept thoughts and feelings without judging them and focusing on breathing.


When you lay or sit comfortably, close your eyes and start to scan your body from your toes to your head and whenever you feel tension, relax that spot. Focus on your breathing and on the present moment.

Walking meditation

While you walk, slowly focus on the sensations you are experiencing while walking. Focus on your toes, and feet and your legs’ movement. Do this for 15 minutes.

Deep breathing

This is a fantastic tool to thin out the “white fog” (anxiety) in your mind and to feel grounded. Sit comfortably and breathe for six seconds, making sure that your stomach fills in with air. Leave your shoulders and chest still and relaxed. Let the air in via your stomach only. Breathe out the air from your stomach and then breathe in again. 


Exercising can reduce anxiety.

Walks in nature

Exercising while being in nature can help reduce anxiety even more.

Alcohol smoking

Limit your intake of alcohol (especially in the evening) and smoking.

Do something fun and creative!

Use your passions to momentarily distract yourself from the problem. Do activities in which you can use your hands such as painting for instance.

Don’t be afraid to seek professional help

In conclusion, to overcome anxiety disorders, it’s advisable to ask for professional help. Therapy allows you to get to know yourself and your vulnerabilities and acquire a different and more healthy perspective of yourself. Moreover, there are several ways through which it’s possible to manage anxiety, for instance with mindfulness, sports, art, and by surrounding yourself with nice people.

Alice Bertoldo, psychologist and psychosomatic psychotherapist, offers in-person and online therapy sessions to treat anxiety disorders, depression and trauma. 

Seeking Help: My Orthorexia Journey

I thought I was done with the dating game when I met my husband Matt in 2010. I was wrong! Make no mistake, we’re happily married. What I’m talking about is finding a therapist. When my primary care physician diagnosed my anxiety, obsessive-compulsive disorder and an unspecified eating disorder, I figured he would provide me with several resources. At this point, I thought I had already taken the biggest step forward by admitting I needed help. I didn’t know what that help would look like and apparently neither did my doctor. He advised me to just “look online” for resources.

Having never looked for a therapist before I told myself it couldn’t be that hard. I’ll just do what I always do, turn to Google. However, when you type in “male therapist for eating disorders, OCD and anxiety,” you don’t really find what you need. There were several local eating disorder clinics for in-patient care, their websites were painted with images of women, who spoke about their battles with anorexia and bulimia but none of this was relatable to me.

I was a 34-year-old male with an eating disorder that didn’t even have a label. I often questioned whether or not I actually had an eating disorder since I was still eating food and not purging. I didn’t see the need for in-patient care but what other options were there? Nothing matched my needs, plus I had no idea exactly what I even needed at that point.

Talk about feeling lost! I was frustrated, angry and alone. I felt invisible to our country’s mental health care system, especially as a guy who has some weird relationship with food. Already at my lowest point mentally, physically and emotionally, I gave up my search for a couple of days. I couldn’t handle it. Finding a therapist felt like the straw that broke the camel’s back. Maybe I would just have to face the fact that I’m just not fixable. Perhaps, I’m sentenced to this hell I’ve been living in for so long. And who knows, this unspecified eating disorder thing sounds made up so maybe I’m not really that sick.

I didn’t want to waste mental health resources on my situation when there are other people out there a lot worse off than me. Man, talk about being unable to see the gravity of my own situation. This disillusionment was the result of two major factors: being a male with one of the “other” eating disorders and the simple lack of available mental health resources.

I resumed my search after a couple of days. My results revealed I was only going to be able to address some of my issues with a therapist. So I focused on my anxiety and OCD first. I’ve later learned this was the right decision for my specific situation but I stumbled across that revelation on my own, not with any medical guidance. I sent out over twenty messages to prospective therapists, but the majority resulted in the following responses:

“We’re currently not accepting new patients.”

“We can schedule you for a consultation in 3 months.”

“We’re unable to help you with regards to your specific conditions.”

At least they responded because some of these therapists never even returned my message. Then one day, a counselor named Sean replied. We connected over video chat for a 15-minute consultation. His approach felt like the perfect fit for my anxiety and OCD issues, which ultimately stemmed from unresolved pain during my adolescence. Sean admitted he hadn’t dealt with many eating disorder cases but was still willing to work with me. I am forever grateful for his willingness to grow with me.

We reconnected the following week for my first appointment. could not have made a better connection. A few sessions into therapy with Sean, my anxious and obsessive thoughts were starting to subside. My mind cleared just enough for me to tackle the next obstacle in my way, that unspecified eating disorder.

I started looking for nutritionists in my area. The eating disorder recovery clinics just were not a fit for me. Again, I felt like I wasn’t sick enough to go plus I felt I didn’t meet their demographic. I was a guy with an “other” eating disorder, whatever that is. I knew I was sick. I was at my lowest weight ever, always cold with a low pulse and constant body pain. Yet, I couldn’t wrap my mind around what was wrong with me, which escalated when it seemed professionals couldn’t either.

The first nutritionist I spoke with seemed well-versed in sports nutrition. She could develop a nutrition plan to build muscle but she was clueless when it came to my eating disorder. Her focus was macronutrients and lots of protein, not the disordered mind. Yes, I needed someone who was going to help repair my body but I also needed someone who held the basic human compassion to understand my mental turmoil around food.

I thanked her for the consultation and resumed my search. I repeatedly told Matt how tired I was of this. Maybe I’ll just work with my therapist on the other issues and hope the eating disorder fixed itself. Then one day I stumbled across my RDN’s website. I liked her approach to intuitive eating and set up a consultation. She seemed like the perfect match for me. She knew her nutrition but she was always willing to work through me and my orthorexic thoughts. Kassandra is not a therapist, but she is a human. I knew her and Sean were my dynamic duo.

One catch, though, the nutrition program costs thousands out of pocket. Insurance wouldn’t cover it. Don’t even get me started on that!

I instantly flung myself on the bed in a fit of tears. I didn’t want to put that financial strain on us for some stupid non-descript eating disorder. Matt, like he always does, reassured me that I was worth it. He said, “The most important thing is helping you get better.” The next day I enrolled in my nutrition program with Kassandra who has been by my side each step of the way. She has helped to restore me physically while Sean has helped repair my mind and soul.

Admitting I needed help was hell. I initially felt like a failure to myself and those around me. Finding help was even harder. This time I felt invisible or unimportant to the system. I’ve seen several friends struggle with finding help but I constantly reassure them that they can’t give up hope. They’re worth it, just like I am.

Our mental health professionals are overwhelmed and I worry the situation will worsen. We must change the narrative and make sure everyone’s voice is heard and understood so nobody has to feel invisible or like their problems don’t matter. Mental illness does not discriminate. We are always told to embrace our uniqueness. My hope is that we can fully live up to that expectation so that one day we can live in a world where everyone feels worthy of help and most importantly, can find it!


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