Yesterday, in the language matters segment, we discussed what Obsessive-Compulsive Disorder is not. Why is this important? I find that a large driver of stigma against mental illness, is the emergence of medical and psychiatric language in common speech. When this language is used carelessly, a false image of a world where everyone has a mental illness can develop, and people become jaded to the topic. By discussing what mental illness is not, I’m hoping to dispel at least some of the myths and stigma surrounding the field.

OCD is real, and it’s debilitating – but it’s not all doom and gloom! OCD happens to be treatable, and the first step towards treatment is diagnosis. OCD happens to be one of the most underdiagnosed and missed psychiatric illnesses, so getting the diagnosis can be harder than you’d think.

Before we begin, I’ll reiterate a point from yesterday’s discussion – for it to be OCD, or any mental illness, there has to be a functional impact. In other words, if it doesn’t cause you a significant problem, it isn’t an illness! I’m not in the business of policing thoughts and behavior.

The four kinds of OCD

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Contamination

Perhaps the most widely known manifestation of OCD is contamination fears. People with contamination-based OCD will have obsessional thoughts of contamination, meaning they are extremely preoccupied with the idea that germs, disease, or some contaminant substance, will spread through some form of contact. These fears can go both ways, meaning the individual may have fears they will become contaminated, as well as fears they will contaminate others. These thoughts can consume hours a day and make thinking about anything else near impossible. Importantly, these fears typically do not make sense to the person experiencing them. I person with an obsessional thought that they will develop cancer from touching doorknobs knows this doesn’t make a whole lot of sense. But alas, their brain obsesses over it. This kind of thought is called an egodystonic thought, meaning that the thought or belief is different from how you actually feel.

Contamination obsessions may manifest with compulsions. An important point here is that for a diagnosis of OCD, you do not need both obsessions or compulsions, just one or the other (both tend to be present but one or the other may go under-recognized). Examples of contamination compulsions may be wearing many layers of clothing and gloves, despite it being a warm day. People may have to wash their hands thirty times or more after touching food, just until it feels right.

Contamination-based OCD is not being a neat freak, though being too much of a neat freak can be a mental illness. What am I talking about? To be honest, it’s a difficult topic to relay in words, but essentially, it gets down to what is driving the neatness. If someone has true obsessions (best elicited by a physician in their office), they will probably be having a thought more akin to, “I’m going to get AIDS from these scattered papers,” than someone who is just very neat, who would be having a thought like, “I need the room to be clean otherwise I won’t be calm.” The very neat person is displaying cognitive rigidity, which can looks like OCD, but is distinctly different. Rigidity is more alike what we would call a personality trait.

Editor’s Note: Stay tuned for the remainder of, “The four kinds of OCD.”

Dr. Travis Barron is a resident physician in Toronto, Canada.