Mental checking can involve mentally analyzing whether or not a behavior was completed properly.

Behavioral Checking (Overt Checking)

Many examples of compulsive checking rituals in OCD involve direct inspection of a target stimulus by sight, sound, or feel.

Common OCD checking behaviors include relocking doors, visually examining the position of one’s parking brake, or holding one’s hands above stove burners in order to detect warmth.

Behavioral checking is often accompanied by the thought, “Did I do it the right way?”

These checking behaviors are often referred to as behavioral checks, manual checks, or overt checks. Overt rituals (by definition) are visible behaviors that can be perceived by external observers. However, in some cases, overt rituals may be subtle or purposefully hidden in order to avoid embarrassment.

Mental Checking (Covert Checking)

In contrast, other compulsive checking rituals can only be perceived by the individual engaging in the behavior. These types of OCD rituals are thought-based and are sometimes referred to as mental checking or covert checking rituals.

Mental checks are often accompanied by thoughts such as, “Did I do it the right way?”, “Am I feeling the right way?”, or “Did I do this for the right reason?”

Mental checking is the cognitive counterpart of behavioral checking, and many covert checking rituals overlap extensively with the mental rituals that characterize Pure-O OCD.

Whereas overt checking involves obtaining evidence directly from the current physical environment (i.e., obtaining visual, auditory, or tactile feedback from physical objects or behaviors), mental checking typically involves an evaluation (or reevaluation) of information already obtained. This information may exist in the form of memories, feelings, motivations, or other internal states of being.

Mental checks can occur both in the presence and absence of a given target stimulus. Individuals may engage in mental checking rituals shortly after an event, but covert checking is not bound by time or space. Some people with OCD continue to check hours, days, or even years after the original event. For example, some individuals may review or check the content of conversations that occurred many years ago.

Let’s identify some examples of mental checking. This list is not exhaustive but is intended to illustrate the diversity of situations in which mental checking might be present.

Examples of Mental Checking

1. Memory Checking Rituals – Reviewing one’s memory to “make sure” or verify that a behavior was completed properly.
Did I lock the door?  Was the stove really off? Was the “H” on the faucet handle facing the way it normally does when it’s off? I know the answer was “B”, but did I circle “A”? Was that sound similar to the sound of a stick hitting the underside of my car, or did it sound “wet”?

This mental ritual involves retrieving memories or trying to recreate mental pictures of past events. These images are then mentally examined, checked, or scrutinized to determine if a specific criterion has been met. For example, one might try to remember the exact angle of a stovetop dial in order to obtain reassurance that the gas valve has been closed. Memories in any sensory modality can be mentally retrieved and checked – sights, sounds, or physical sensations. Because there is often OCD doubt about whether these mental images do, in fact, represent what one has actually seen, mental checks often fuel additional behavioral checks.

Other memory checking rituals involve categorization and probability estimation, which are more complicated processes than when one evaluates a simple dichotomy. With these more complex rituals, multiple possible outcomes are considered, each of which differs with regard to its undesirability. These checks occur in nearly all forms of OCD, including contamination OCD and hit-and-run OCD.

2. Feeling Checking Rituals – Comparing current feelings to how they “should” feel.
Do I feel as secure in my relationship with God as I should?  Did my prayer feel genuine?

This mental checking ritual is based around comparing one’s current emotions to an idealized version of how they should be. This desired feeling state may be based on history (i.e., previous feeling states) or on aspirational feeling states. These symptoms often characterize scrupulosity, ROCD, and HOCD. For example, scrupulosity often involves a discrepancy between how “close” or “connected” one should feel in their relationship with God vs. how they actually feel at a given moment. There may also be perceived discrepancies related to feelings of “genuineness” about one’s prayers.

3. Relationship Checking Rituals – Comparing current relationships to how they “should” be.
Am I still in love with my partner?  Does the fact that I found that other person attractive or had that dream mean that I should end my current relationship?  Do doubts about my current relationship mean that there’s somebody better out there for me?

These checking rituals are often based around the premise that if one is in the “right relationship,” one shouldn’t experience any doubts about their relationship or their partner. Individuals with these types of OCD checking rituals compare current relationships to past relationships or to potential idealized future relationships. They often experience significant doubt and distress about their personal relationships and may have a history of relationship “ping pong.” They may worry about “missing out,” hurting their partner’s feelings, or not “being on the right path.”

These types of symptoms often characterize ROCD. In addition to the symptoms described above, ROCD may also involve making faulty inferences about one’s future behavior on the basis of their current doubts (see Intention Checking rituals below). For example, one might infer that having doubts about one’s current relationship might mean that they secretly want to cheat (or will cheat) on their partner (despite having no desire to do so). Parallel symptoms can also characterize scrupulosity, in which individuals may worry that they secretly want to reject God and/or worship the devil.

4. Intention Checking Rituals – Examining one’s own motivation for engaging in particular behaviors.
Am I changing my child’s diaper because I thought it was really soiled or because I wanted to look at my child’s private parts? Does the fact that I noticed that person’s attractiveness mean that I want to have a relationship with them? Does the fact that I’m clenching my fists in anger mean that I want to punch or harm that person? Does the fact that I’m having suicidal thoughts mean that I want to kill myself? What kind of person would be having these kinds of thoughts?  

These checking rituals cause one to question their own motivations for engaging in certain behaviors which commonly results in extreme guilt, shame, or confusion. These types of checking rituals are often present in OCD characterized by harm, sexual, or suicide obsessions, as well as in cases of HOCD, ROCD, and scrupulosity.

Individuals with these types of rituals often assume that their thoughts have significant meaning. They might think that all thoughts are purposeful or may reflect one’s “true” character or desires. This is problematic in that these types of rituals often involve morally taboo topics or unwanted thoughts.

These rituals are sometimes called “figuring out” rituals, as they involve trying to understand the “real” reason for doing something. They also are frequently accompanied by reassurance seeking rituals. Reassurance seeking rituals may involve other people (“Do you think I could ever do that?”) or may consist of personal attempts to convince oneself that one’s behavior is motivated by sound reasons.

5. Sensation Checking Rituals – Attempting to understand the meaning of physical sensations in one’s body.
Does that tingling sensation in my groin mean that I want to have a sexual relationship with that person? Does that fluttering in my chest mean that I’m about to lose control and scream something inappropriate?

This type of mental ritual involves trying to figure out the meaning of specific bodily sensations. Individuals with these types of compulsions often become hyper-attuned to small changes in their own physiology. Sensations associated with this type of ritual are often sexual, violent, or frightening in nature.

6. People Checking Rituals – Mentally reviewing the meaning of other people’s behaviors, words, or facial expressions.
Did his expression indicate that I insulted him? Did she invite me to lunch because she really wanted to see me, or because she thinks I’m pathetic? If I hadn’t locked the door, wouldn’t my spouse have said something? If I had left the gas stove on, wouldn’t my kids have commented on the smell?

These rituals involve reviewing other people’s actions, words, or facial expressions in order to better understand their reactions or intentions. These rituals can also involve establishing the safety of current situations by reducing doubt and uncertainty through reassurance or diffusion of responsibility. For example, “If that person wasn’t concerned, then I shouldn’t be concerned either” or “If this situation is really dangerous, then that person would have taken proper precautions.”

7. Understanding/Information Checking Rituals – Mentally replaying conversations or reviewing written materials to check their content.
Did I really understand their advice? Did I express myself properly? Did I leave any important information out that could cause something bad to happen? Did I understand what I just read?

These rituals involve a fear of misunderstanding and/or miscommunicating information. Individuals with these types of rituals may fear that they have misunderstood something that was said to them, or they may be afraid of mispeaking or leaving out essential details when talking to others. This fear is based around the idea that something important might be missed, or that there is a moral imperative to avoid misleading other people.

Common forms of OCD that are based around this ritual include OCD perfectionism (rereading, rewriting rituals), and moral OCD based around the fear of unintentionally lying to others. Many individuals with these types of compulsions do not recognize that they have OCD.

As you can see, covert checking is incredibly diverse and can be easily overlooked.  Whether behavioral or mental, checking rituals provide short-lived reassurance that ultimately backfires and reinforces OCD. The most effective treatment for OCD is exposure and response prevention (ERP). In my South Florida psychological practice, I treat individuals with OCD by helping them learn to recognize and resist their behavioral and mental checking rituals.

Questions? Comments? Do you engage in covert checking rituals? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Checking & OCD: Part 1 (Checking for Safety)
2. “Pure-O” OCD: Common Obsessions & Mental Rituals
3. Hit-and-Run OCD

This article, OCD & Checking: Part 2 (Mental Checking), was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Checking-related OCD takes innumerable forms, and includes checks for safety, understanding, and mistakes.

But OCD’s greed knows no bounds.

What starts out as a simple check “just to make sure” eventually spirals into disabling OCD doubt that can come to predominate innumerable situations and scenarios.

Checking behaviors often emerge in situations in which “being irresponsible” might result in catastrophic outcomes, guilt, anxiety, or regret. OCD-related checking is usually driven by a need to obtain absolute certainty that nothing bad will happen. Compulsive checking is typically harder to control in “high stakes” scenarios and in situations in which you perceive that you have personal responsibility for the outcome.

Unfortunately, at least some degree of personal responsibility is present in most situations. Moreover, many people with OCD often feel that safety is tenuous or that disasters are lurking just one mistake away. Consequently, people with severe checking-related OCD may experience very little solace in their day-to-day lives.

Compulsive checking behaviors are probably the most diverse of all OCD rituals. Variations in checking-related behaviors dominate in most forms of OCD, even types of OCD that you might not necessarily consider checking-related variants of the disorder (e.g., hit-and-run OCD, scrupulosity, perfectionism, HOCD, other sexual obsessions). In this multi-part post, we’ll talk about some of the goals of checking and the different types of situations in which checking-related symptoms are present. We’ll begin by discussing OCD checking compulsions related to safety/danger.

OCD Checking for Safety/Danger

When people think of checking-related OCD, they most often think of situations that involve issues of potential danger. People who check for safety may check locks, stoves, light switches, or virtually any appliance or item with an electrical cord. Other common household items that are commonly checked include toasters, washing machines, dryers, ovens, curling irons, coffee machines, computers, televisions, candles, and fireplaces.

Thoughts that often drive these types of compulsive OCD checking behaviors are fears of fires, which may destroy homes or result in injury or death. Some individuals with anxiety about safety issues have very restricted, specific fears. For example, some individuals fear that their “careless” behavior will result in the death of a beloved pet.

Some people with safety-related OCD think, “If I have a thought and don’t take preventative action, then that’s almost as ‘bad’ as directly causing the feared outcome myself.” Others think, “If I have a thought and don’t do whatever I can to eliminate the threat, that must mean that deep down I want this bad thing to happen.”

Maladaptive thoughts like these make it very difficult to overcome anxiety and resist or limit checking behaviors.

Checking for safety may also be driven by fears of crime, theft, violence, or vandalism. These checkers may check locks, gates, windows, doors, garage doors, and other household entry points before leaving the house or going to bed. Often, the fear is that an intruder will enter the house via an unlocked door or window, which will result in murder, rape, or another dangerous situation. Upon returning home, individuals with this fear will often look in closets, under beds, behind doors, in basements, and in other “hiding places” to make sure that a criminal has not entered the home. These checking rituals may span minutes or hours; however, if left untreated, these rituals typically increase in complexity and length.

Types of Checking Behaviors for Danger/Safety

Compulsive checking behaviors are diverse in form and function. Specific OCD checks may focus on whether electrical appliances are “off”, whether they’ve been unplugged, or whether their electrical cords are free from damage. Ironically, some individuals with OCD may inspect cords for signs of damage or fraying so frequently that they cause these items to wear out more quickly.

Rituals may involve visually inspecting items or turning these items on or off repeatedly until it “feels right.” Similarly, doors may be locked and unlocked multiple times in accordance with these “not just right” feelings. Compulsions are also sometimes driven by lucky or unlucky numbers, in that the individual may fear that checking something the “wrong” number of times may somehow affect the probability that the dreaded situation or event will occur.

Checking behaviors related to anxiety about potential danger often involve a combination of checking visual cues (does the item’s dial look like it’s in the off position?), auditory cues (did I hear it click “right?”), and tactile cues (did I feel it click “right?”). Certain individuals may also engage in checking compulsions related to odors or smells (olfactory checking). These individuals may have sniffing rituals used to detect dangerous smells (e.g., the odor of natural gas, the smell of smoke or fire). Similarly, some individuals have tasting/licking rituals used to determine if one’s food or drink has become tainted/poisoned. If any of these factors are ambiguous or if the person gets distracted while checking, the behavior is typically repeated.

Objects that require regular use or maintenance can be especially distressing for individuals who check. Some individuals have a difficult time removing lint from their clothes dryer (e.g., What if I missed some lint or a small piece of lint has fallen behind the dryer?). Other individuals have similar fears relating to coffee machine cleaning and maintenance (e.g., What if I didn’t remove the coffee filter properly and it starts a fire?). Another common stressful situation involves checking to make sure that your car’s gear is in “Park” before leaving your vehicle.

Some individuals may compulsively check the placement of objects relative to other objects. They may be concerned about the proximity of appliances to paper, curtains, furniture, or other flammable objects. These individuals may have rituals that involve moving or adjusting the positions of these objects. Compulsions can become particularly time-consuming in multi-member households (or in households with children), in which the individual with OCD feels responsible for neutralizing threats that may arise due to the behavior of others.

One of the things that is so frustrating for individuals with these types of OCD symptoms is that the checker may consider these behaviors illogical, but may still feel compelled to check anyway. Individuals may have gas fireplaces that are never used, and yet they feel urges to check these items whenever leaving the house. Paradoxically, these checks may increase the likelihood that these items will be left in the “on” position.

Compulsive checking can affect individuals at any age, but in my Palm Beach, Florida, psychological practice, I often see these fears develop quite early in children and teens. These checking behaviors may be obvious to all family members (parents, siblings), but sometimes the child or teen may engage in these behaviors secretly. Sometimes checking behaviors are part of a larger bedtime ritual, or a regular ritual that precedes leaving the household (e.g., before leaving for school/work). Common checks include returning home to make sure that the garage door is shut and that doors have been locked properly. Individuals may repeat these checks multiple times or may leave work/school to return home “just to make sure.” If one is leaving the household for a longer interval (e.g., if one is going on vacation), these compulsions may be even more exaggerated and time-consuming.

Checking for safety does not only involve manual checks of objects. Checking also encompasses other reassurance-seeking behaviors designed to see if loved ones are safe. For example, checks also include phone calls or texts to family members to make sure they’re okay. Checks can be overt (“Are you okay?”) or information-based (“When will you be home tonight?”). Feared outcomes may focus on disasters, crimes (murder, rape, assault, abduction, muggings), accidents (car accidents, plane crashes), injuries (falling down the stairs), or other dangerous situations.

Subsequent posts will discuss compulsive checking in different contexts. Topics addressed will include checking to prevent loss, checking to prevent mistakes, checking for understanding or comprehension, checking your own morality, and checking your relationships with others. Read part 2 which focuses on mental checking.

Questions? Comments? Do you have OCD and have rituals related to checking for safety/danger? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. OCD & Checking: Part 2 (Mental Checking)
2. Hit-and-Run OCD
3. OCD symptoms: the obvious (and the not so obvious)

This article, Checking & OCD: Part 1 (Checking for Safety), was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Homosexual OCD (HOCD) involves obsessions related to one's sexual orientation. Straight people with HOCD fear they may become gay (or are secretly gay); gay people may fear becoming straight.

Fear of Being Gay (Homosexual OCD / HOCD)

Emerging sexuality can be confusing for any teen or young adult, and gay teens face a variety of unique challenges over the course of adolescence.

In addition to learning to understand their own sexuality, gay teens must navigate complex situations and pressures that may not be relevant for straight teens. They must also deal with opinionated parents, friends, and others who sometimes hold differing views about sexuality. Anxiety, distress, and confusion are often part of this process.

This post is not about the anxiety associated with being gay or with “coming out” but instead discusses homosexual OCD (“HOCD”), an anxiety disorder that affects a small number of individuals. HOCD is not unique to teens but can occur at any age.

What is HOCD?

Homosexual OCD (“HOCD”) is a specific subtype of obsessive-compulsive disorder (OCD) that involves recurrent sexual obsessions and intrusive doubts about one’s sexual orientation.

Straight individuals with homosexual OCD experience obsessive fears about the possibility of being gay. Their HOCD obsessions often consist of unwanted thoughts, impulses, or images that uncontrollably pop into consciousness. To reduce the anxiety brought on by their obsessions, individuals with HOCD engage in a variety of rituals that focus on “proving their true sexuality” or reducing their perceived “vulnerability” to becoming gay.

Sexual obsessions can also affect gay men, lesbians, or bisexual individuals with OCD, who may become fearful about the possibility of becoming straight (“Straight OCD”). The common element that unites these seemingly opposite sexual obsessions is the fear of being attracted to something unwanted, taboo, or “unacceptable” based on one’s particular worldview. For the sake of simplicity, I’ll be using HOCD-centric language in this post. However, the same basic elements are directly applicable to all people with obsessive doubts about their sexual orientation.

People with HOCD worry that they might secretly be gay or might become gay, despite not questioning their sexuality in the past. Prior to the onset of HOCD, they might have had few doubts about their sexual orientation. Many people with homosexual OCD also have a history of having enjoyed heterosexual relationships in the past.  It was only after the first unwanted thought “popped” that they became overly concerned about the prospect of being gay. The occurrence of this unwanted thought then causes them to question their sexual identity and reanalyze previous experiences, in light of the possibility that they might possibly be gay.

Individuals with homosexual OCD want to know “for sure” that they are not gay and often go to great lengths to prove to themselves that they are straight.  However, due to the way OCD is strengthened and reinforced by rituals, these attempts ultimately backfire.  The result is that some people with HOCD become extremely disabled.  In order to avoid symptom triggers, it’s not uncommon for people with homosexual OCD to become depressed and drop out of school, quit their jobs, end relationships, or make other life-altering decisions that paradoxically make their symptoms worse.

In some cases, individuals with HOCD experiment with homosexual relationships or adopt gay lifestyles because of doubt about their heterosexuality. This doubt causes them to leave their current spouses/partners, “come out,” and begin to date same sex individuals. However, in contrast to lesbians and gay men who “come out” and find happiness, individuals with HOCD find their new lives distressing, confusing, and dissatisfying. Moreover, they continue to experience doubt and uncertainty about their sexuality.

HOCD Symptoms

Homosexual OCD typically has elements that parallel checking, contamination, and Pure-O OCD.  Some individuals with HOCD have a predominantly checking-related variant of OCD.  When around same sex individuals, they “check” their own bodies for signs of sexual arousal.  Other people with homosexual obsessions have a contamination-related variant of HOCD and worry that contact with gay men, lesbians, bisexual individuals, or effeminate/androgynous people is “contagious” or may somehow “activate” their latent homosexuality.  Still others worry about acting on unwanted sexual impulses.  They worry that if they’re around gay people or same sex individuals that they might lose control and act out sexually. Some people with HOCD worry that other people will think they’re gay, and they spend excessive time and energy trying to “act straight.” Many people with HOCD experience all of the symptoms above.

What maintains intrusive sexual obsessions? Like any form of OCD, symptoms of HOCD are maintained by faulty beliefs, rituals, and avoidance behaviors. Faulty beliefs about sexuality and sexual orientation perpetuate fear about the possible consequences of resisting OCD-related compulsions. This is harmful because every time an unwanted thought is avoided or neutralized, it is reinforced and becomes more likely to become activated again in the future. Avoidance and rituals thus prevent the occurrence of corrective learning experiences that would ultimately cause these unwanted thoughts to decrease in frequency and intensity.

Rituals associated with homosexual OCD include mental rituals and behavioral rituals.

Homosexual OCD Mental Rituals

• Asking self, “Do I find that person attractive?” (often applied to both opposite sex and same sex individuals).
• Asking self, “Am I currently aroused?”
• Asking self, “Am I appropriately disgusted by this?” when seeing same sex couples.
• Other questions like the above that are designed to “figure out” or determine one’s sexual orientation.
• Re-analyzing previous romantic or sexual experiences to make sure that one is straight.
• Trying to convince oneself definitively of one’s sexuality.
• Reassuring self about one’s sexual orientation (“I’m definitely straight”).
• Mentally comparing self to straight people vs. gay men (or lesbians).
• Repeatedly redirecting attention away from same sex individuals to opposite sex individuals.
• Other mental rituals designed to “reset” or neutralize unwanted thoughts (e.g., mental washing rituals).
• Repeatedly telling yourself that you’re not gay.
• Trying to figure out why previous relationships failed (to make sure it wasn’t related to your partner thinking you were gay).
• Planning for and anticipating all the likely consequences of “coming out,” even though you have no desire to “come out” or have gay relationships.
• Planning how to leave your spouse or significant other (when you don’t actually want to do this).
• Neutralizing “gay thoughts” with “straight thoughts.”
• Mentally picturing opposite sex genitals or heterosexual acts to reduce anxiety about intrusive thoughts.
• Scanning the environment to identify people who might be gay.
• “Magical” rituals designed to distance oneself from unwanted thoughts (e.g., imagining oneself getting sick or vomiting when having unwanted thoughts).
• Escaping from unwanted thoughts by recalling/reviewing pleasant past sexual experiences.
• Replacing unwanted gay thoughts with violent thoughts.

HOCD Rituals & Compulsions (Behavioral)

• Checking one’s own body for physical signs of arousal (can also be a mental ritual).
• Walking in an overly masculine (if a man) or feminine (if a woman) way in order to “appear straight.”
• Interacting in a overly masculine or feminine way.
• Talking only about “appropriately” masculine or feminine topics.
• Washing rituals (hands, etc.) if one comes into contact with gay men, lesbians, or bisexual individuals.
• Watching straight pornography in order to reassure self that your’re aroused by it.
• Watching gay porn in order to “prove”  that your’re disgusted by it or not aroused by it.
• Asking other people if they ever find same sex people attractive.
• Asking other “Is it normal to…?”- type questions over and over again to obtain reassurance.
• Asking other people for reassurance about your sexuality.
• Repeatedly asking ex-girlfriends/boyfriends why your relationship ended.
• Dating excessively to “prove” that one is straight and/or that one is attracted to the opposite sex.
• Compulsive masturbation to straight pornography in order to “prove” that one is attracted to the opposite sex.
• Interacting in a way that is aggressive, insulting, or disrespectful to gay people.
• In some cases, adopting a gay lifestyle because it feels like it is inevitable (due to OCD doubt). However, finding this lifestyle distressing and unwanted.
• In some cases, dating same sex individuals or engaging in homosexual acts to figure out the meaning of these experiences, but finding these activities distressing and unwanted.

Homosexual OCD Avoidance Behaviors

• Avoiding gay men, lesbians, and bisexual people.
• Avoiding things that have been touched by gay men, lesbians, or bisexual people.
• Avoiding physical contact with same sex individuals (handshaking, hugs).
• Avoiding being alone with same sex individuals.
• Avoiding conversations with same sex individuals.
• Avoiding places frequented by gay people.
• Avoiding public restrooms, locker rooms, and other situations potentially involving same sex nudity.
• Avoiding attractive same sex individuals or pictures/movies featuring attractive same sex individuals.
• Avoiding activities that aren’t stereotypically masculine (if a man) or feminine (if a woman).
• Dressing in a stereotypically masculine or feminine way (e.g., wearing pink [for men]).
• Avoiding music by gay individuals or movies featuring gay actors or characters.
• Avoiding romantic relationships and sexual activity for fear of unwanted thoughts “popping in” during sex.
• Avoiding eye contact with same sex individuals.
• When in public, trying to avoid looking at the groin, backside, or chest areas of same sex individuals.
• Avoiding masturbation due to fear about an unwanted thought occurring.
• Avoiding TV shows with gay characters or gay themes.
• Avoiding purple items, rainbows, and other symbols associated with homosexuality.
• Avoiding androgynous or flamboyant clothing.
• Manipulating your voice so that it sounds more masculine or feminine.
• Not eating in public (in case food was prepared by a gay person).

Homosexual OCD Maladaptive Beliefs

• Straight individuals shouldn’t find same sex people attractive.
• Straight people shouldn’t have any doubts about their sexuality.
• Every thought means something. I wouldn’t be having these thoughts over and over again if they weren’t meaningful.
• If I turned out to be gay, it would ruin my life.
• Straight people should only have straight thoughts. Gay people should only have gay thoughts.
• If I’m not 100% straight, it means I’m gay.
• If I have a thought that’s inconsistent with my desired orientation, it means I’ve “crossed over.”
• Sexuality can be contagious.
• Every time I feel sexually aroused, there must be a reason for it.
• Feeling sexual arousal must mean that I want to have sex with this person.
• If my current partner found out I was having these thoughts, s/he’d leave me.
• If I keep having this thought, I’m going to have to act on it eventually.
• Maybe the only way I can be free of these thoughts is to act on them.

Treatment of HOCD (Homosexual OCD)

“What if this isn’t OCD? What if I’m really gay?” These are important questions that you might wish to discuss with your therapist. If you have HOCD, doubt about your sexuality reflects an OCD-related “false alarm” that has nothing to do with your actual sexual orientation. If you are gay, your gay thoughts will be associated with pleasure rather than with fear (although you might experience anxiety about the social repercussions of “coming out”).

If you have homosexual OCD, what-if questions about sexuality are ultimately unanswerable in the way that OCD demands they be answered. In my South Florida (Palm Beach County) psychological practice, people seeking HOCD treatment are preoccupied with attempts to know the unknowable.  Unfortunately, there simply is no objective way to determine your “true” sexuality.  If there was a simple solution, you would’ve found it by now.

Because there is no objective way to prove your “true” sexuality to your OCD (it will always ask, “What if…?” and “How do you know for sure…?” questions), your HOCD treatment must focus on the goal of learning to live with the doubt. In other words, treatment should not focus on “proving” whether or not you are straight or gay but rather focus on providing you with better skills for tolerating the unknowable. Remember that HOCD operates just like other versions of Pure-O OCD: the more you analyze your thoughts and body to try to “figure out the truth”, the more likely you are to unknowingly reinforce your symptoms.

The best strategy for reducing your symptoms will be based on exposure and response prevention for HOCD. Exposures for HOCD are built around purposefully seeking out situations you avoid and then resisting mental and behavioral rituals. Developing a good exposure hierarchy can be confusing, so find a good HOCD therapist to guide you. Moreover, your HOCD therapist will also help you stay consistent in the goal of learning to live with uncertainty. Because you have probably spent significant amounts of time trying to prove your sexual orientation once and for all, it’s easy to fall back into this unhelpful goal.

If you’re interviewing potential therapists and one suggests that they can “cure you of your gay thoughts” or help you “know for sure that you’re straight”, consider this a red flag. That person is not an HOCD specialist. These types of promises are inconsistent with how effective HOCD treatment actually works. Although everyone with HOCD wants to get rid of their gay thoughts, thought suppression techniques will be ineffective in the long-run.

To understand why, or to read more about my general treatment approach in my South Florida (Palm Beach) psychological practice, see my posts on sexual obsessions, thought control and thought suppression. Overcoming symptoms of HOCD requires hard work, but people recover from this challenging form of OCD every day.

Questions? Comments? Living with HOCD or another sexual orientation obsession? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Sexual Obsessions in OCD (Obsessive-Compulsive Disorder)
2. “Pure-O” OCD: Common Obsessions & Mental Rituals
3. Treatment of Unwanted Thoughts & Sensations in OCD

This article, HOCD: Homosexual OCD & Sexual Orientation OCD, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Sexual obsessions involve unwanted sexual thoughts, such as the fear of being attracted to something unwanted, taboo, or morally "unacceptable."

In addition to anxiety, which characterizes most obsessions, individuals with sexual obsessions often experience extreme guilt, shame, hopelessness, and depression.  Individuals with OCD with sexual symptoms often mistakenly consider themselves deviant, disgusting, or evil.

Moreover, incorrect assumptions about the true causes of their unwanted sexual thoughts make them less likely to seek treatment or to share their symptoms with others.  In my Palm Beach County, South Florida psychological practice, I treat many individuals who have lived with sexual obsessions for many years before seeking treatment.

Sexual obsessions often leave one feeling isolated and alone.  Moreover, in efforts to avoid symptom triggers, people with unwanted sexual thoughts often drop out of school, quit their jobs, end relationships, or make other life-altering decisions that paradoxically make their symptoms worse.

What are Sexual Obsessions?

Sexual obsessions in OCD can take many forms. Most sexual obsessions involve unwanted thoughts, ideas, impulses, or images focusing on sexual content.  Some individuals with sexual obsessions are bombarded by unwanted urges to act in a sexual way toward children, animals, or other populations.  They might experience intrusive images of sexual organs, envision themselves performing unwanted sexual acts, or have persistent doubts about their own sexual identity.

They experience repetitive thoughts like:

• What if I’m attracted to that person?
• What if I lose control and act out sexually?
• What if I expose my genitals to that person?
• What if I secretly want to have sex with that person?

Sexual obsessions often involve the fear of secretly being gay (if one is actually straight), being sexually attracted to children (fear of pedophilia), being sexually attracted to animals (fear of bestiality), or being sexually attracted to dead things (fear of necrophilia).  In fact, the variety and forms that unwanted sexual thoughts can take are limited only by the breadth of the human imagination. Societal and personal beliefs about these topics often lead to extreme distress whenever these obsessions occur.  

Here are some common sexual obsessions / thoughts.

Types of OCD Sexual Obsessions / Thoughts

• Fear of being a pedophile or becoming a pedophile.
• (parents often fear being sexually attracted to their own children).
• Fear of being sexually attracted to animals.
• Fear of being sexually attracted to dead things.
• Fear of becoming gay (if straight) or fear of becoming straight (if gay).
• May also involve a fear of secretly being gay (or straight).
• Fear of being sexually attracted to religious persons.
• Fear of being sexually attracted to God.
• Fear of being sexually attracted to siblings, parents, or other relatives.
• Fear of becoming aggressive or violent during sex.

Many individuals with sexual obsessions spend significant amounts of time either berating themselves for having such thoughts or trying to convince themselves that the thoughts aren’t true.  In most cases, efforts to convince oneself that the thoughts are untrue is a form of mental reassurance, a ritual/compulsion that maintains the OCD cycle.

In cases of severe OCD, individuals may become confused about whether or not they have actually acted on their thoughts.  They may know logically that these events have not occurred, but OCD may cause them to doubt their memories.

Ways to Identify Sexual Obsessions in OCD

• What is the prevailing emotion you experience when having these thoughts?  Dread/guilt or desire/lust?  Dread, confusion, guilt, and despair commonly accompany sexual obsessions.
• What’s the difference between being a pedophile and having obsessions focusing on pedophilia?  Pedophiles enjoy the idea of having sex with children, whereas individuals with pedophilia related obsessions are often scared by the prospect of acting on their thoughts.
• Also regarding pedophilia: If you could be guaranteed that you wouldn’t get caught, would you want to act on your thoughts?  Pedophiles answer “Yes” to this question.  People with OCD answer “No” or “I don’t know” (due to OCD-related doubt).
• What’s the difference between being gay and having homosexual obsessions (HOCD)?  Gay individuals experience pleasure when having sexual thoughts involving same sex partners, whereas individuals with homosexual obsessions become scared or disgusted by these thoughts.
• It’s also important to recognize cases in which individuals with OCD fear that they might have to inevitably give into their impulses in order to keep “from going crazy”.  They might not want to act on their thoughts but they think, “What if my mind is never at peace until I act on my thoughts?”  The idea of having relief from their thoughts can then make them feel unsure about whether or not they want to act on them.

Please note that the above questions are over-simplifications of complex ideas.  If you have sexual obsessions, you would likely experience doubt and confusion over the answers to many of these questions.

Treatment of Sexual Obsessions / Thoughts in OCD

Treatment of sexual obsessions is complex and individualized.  In my Palm Beach Gardens, FL practice, I treat many individuals with OCD sexual obsessions using exposure and response prevention (ERP) and cognitive-behavioral therapy (CBT). Treatment involves confronting fear triggers in a systematic way while resisting rituals and avoidance behaviors. With consistent practice, these fear triggers lose their power over you.

Overcoming sexual obsessions is not based on definitively proving that these obsessions are unfounded. Although this outcome would be desirable (if possible), someone with a strong tendency toward OCD doubt can never eliminate all traces of doubt in a way that is fully satisfying. After all, if you have these types of symptoms, you’ve probably already spent months or years trying unsuccessfully to accomplish this goal.

Am I sure that I don’t secretly want to have sex with _________? Trying to answer this question with a resounding “No” is ultimately doomed to fail. It’s not the question itself that is the problem. It’s actually your exhaustive attempts to disprove the possibility that perpetuates your symptoms. I have discussed this idea in more detail in my posts on thought control and unwanted thoughts.

Instead, successful, effective treatment of OCD is based on learning to accept uncertainty about the things we can’t know for sure. You might not know with 100% certainty whether or not you could become a pedophile, but neither does anyone else. People without OCD-related sexual obsessions accept this doubt, without engaging in efforts to avoid or neutralize. This is the goal of treatment: to accept doubt without avoidance or neutralization. This is the key to breaking free from sexual obsessions and living a happy, healthy life.

My next post will discuss symptoms of homosexual OCD (HOCD), or the fear of becoming gay (or secretly being gay).

Questions? Comments? Struggling with OCD-related sexual obsessions? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Thought Control & OCD (Obsessive-Compulsive Disorder)
2. Obsessive-Compulsive Disorder (OCD) – Overview
3. Obsessive-Compulsive Disorder (OCD) – Cognitive Deficits

This article, Sexual Obsessions in OCD (Obsessive-Compulsive Disorder), was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Body dysmorphic disorder symptom areas vary between individuals but commonly focus on the skin, hair, weight, and specific facial features.

Symptoms of Body Dysmorphic Disorder (BDD)

Body dysmorphic disorder (BDD) is a somatoform disorder that closely resembles obsessive-compulsive disorder (OCD). Symptoms of body dysmorphic disorder include excessive concern about perceived physical flaws, defects, or imperfections.

Individuals with body dysmorphic disorder become obsessed with these unwanted aspects of their appearance and perform a variety of rituals and avoidance behaviors in order to disguise or conceal these “flaws.” BDD symptoms typically result in extreme distress and a variety of social and occupational difficulties.

Body dysmorphic disorder symptom areas vary between individuals and commonly focus on the skin, hair, weight, and specific facial features, such as the nose (Philips, 2005).

In The Broken Mirror (2005), Dr. Philips breaks down the frequency of different types of BDD concerns:

In my South Florida (Palm Beach County) psychological practice, I often treat individuals with body dysmorphic disorder whose BDD symptoms focus on specific facial features or skin quality.  They often worry about facials scars, pores, dimples, moles, birthmarks, skin tags, hair, wrinkles or lines, under-eye circles, or general facial symmetry.  Some men have symptoms that include a preoccupation with muscle growth and development. This is sometimes referred to as muscle dysmorphia, or “manorexia”, and often involves a preoccupation with muscle symmetry and fears about being “too skinny” or “too small”. Regardless of the body area of concern, BDD involves appearance-related perfectionism.

For people with body dysmorphic disorder, concerns about body symmetry are quite common.  Individuals may worry about the symmetry of specific body parts (breasts, buttocks), facial features (eyes, eyebrows, ears), or the distribution of body hair.  Other individuals experience excessive concern about scarring from elective cosmetic procedures or enhancements (e.g., over-concern about the appearance of one’s breasts following breast augmentation).

Symptoms of body dysmorphic disorder are maintained by rituals and avoidance behaviors. These behaviors are often targeted in treatment of BDD in the context of exposure and response prevention (ERP). Although ERP is traditionally considered a treatment for obsessive-compulsive disorder, ERP is also an effective treatment for BDD.

Body Dysmorphic Disorder (BDD) Avoidance Behaviors & Rituals

• Social anxiety, isolation, and avoidance.
• Avoidance of dating and sexual intimacy.
• Avoidance of places with bright, intense lighting that might highlight or reveal perceived flaws.
• Avoiding particular activities like swimming.
• Avoiding exercise (or other sweat-inducing activities) or (in other cases) over-exercising.
• Performing facial exercises or other exercises targeting specific BDD concerns.
• Staying at home during rainy or windy days.
• Limiting or avoiding eye contact with others.
• Keeping the face in profile to prevent others from noticing assymetries.
• Spending excessive time in preparing to go out.
• Repeatedly checking in the mirror or inspecting one’s appearance.
• Repeatedly applying/reapplying make-up to modify or disguise any perceived defect.
• Repeatedly brushing or styling the hair.
• Repeatedly shaving the skin.
• Wearing bulky/oversized clothing to disguise the defect.
• Limiting contact with real-life friends (but potentially not online friends).
• Avoidance of situations where photographs or videos will be taken.
• Checking appearance in mirrors and reflective surfaces.
• Touching or inspecting perceived flaws.
• Wearing hats or wigs.
• Use of hair-growth products like Rogaine.
• Reassurance-seeking (asking other people if they can see the defect).
• Trying to convince other people of the defect’s existence.
• Closely monitoring other people’s reactions and eye movements in social situations.
• Skin-picking, rubbing, or smoothing the skin.
• Tweezing and plucking hair.
• Getting frequent haircuts or frequently trimming one’s own hair.
• Avoiding form-fitting clothing or any clothing that feels restrictive or puts pressure on the skin.
• Excessively dying the hair.
• Repetitive surgical alterations of one’s appearance.
• Excessive use of products designed to prevent aging or restore one’s appearance.
• “Flexing and checking”, excessive exercise, excessive eating, and the use of anabolic steroids or growth hormones (in muscle dysmorphia).

Want to learn more about BDD? Read my previous post that provided an overview of body dysmorphic disorder.

Questions? Comments? Do you experience symptoms of body dysmorphic disorder (BDD) that weren’t included above? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Body Dysmorphic Disorder (BDD)
2. Symptoms of Depression / Major Depressive Disorder (MDD)
3. Sensorimotor OCD Body-Focused Obsessions & Compulsions (Swallowing, Breathing)

This article, Body Dysmorphic Disorder (BDD) Symptoms, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Body Dysmorphic Disorder (BDD) is an OCD-like syndrome that involves hyper-attention to one or more perceived bodily defects, imperfections, or flaws.

What is Body Dysmorphic Disorder (BDD)?

Body dysmorphic disorder (BDD) is not formally classified as an anxiety disorder; however, it shares many overlapping features with anxiety disorders like obsessive-compulsive disorder (OCD).

In contrast to OCD which typically focuses on specific external feared outcomes, body dysmorphic disorder involves hyper-attention to one or more perceived bodily defects, imperfections, or flaws.  BDD “flaws” are experienced as distressing and intolerable.

In some cases, the imperfections that bother individuals with body dysmorphic disorder can be perceived by other people, but BDD magnifies and distorts these imperfections in the eyes of the sufferer.  In other cases, individuals with BDD notice and attend to “flaws” that cannot be readily perceived by others.  Regardless of the form of one’s symptoms, body dysmorphic disorder is associated with extreme distress and shame.  Moreover, because BDD-related “flaws” are often perceived as being permanent, inescapable, or un-fixable, many individuals with body dysmorphic disorder experience hopelessness, depression, self-loathing, and suicidal thoughts. Due to shame about their appearance, many people with BDD go to great lengths to keep their symptoms a secret.

Individuals with body dysmorphic disorder often use mirrors to check or scrutinize their appearance.  They also engage in a variety of avoidance behaviors in order to mask or hide their perceived defect(s) from others.  They often avoid going out in public (e.g., skipping class or work), limit involvement in situations in which they might be the center of attention (e.g., dating), or spend excessive time trying to camouflage, disguise, or alter their appearance.  Preparation for leaving the house may involve elaborate grooming behaviors that span hours every day.

Although many people have sensitivities about certain aspects of their appearance, typical sensitivities do not reflect BDD.  By comparison, symptoms of body dysmorphic disorder are extremely distressing and potentially disabling.

The checking and grooming rituals that characterize body dysmorphic disorder resemble the compulsive behaviors found in obsessive-compulsive disorder.  However, there are some notable distinguishing features between individuals with OCD and BDD.  One of the major differences between OCD and BDD is the degree to which one recognizes his/her rituals as excessive or unreasonable.  Although individuals with OCD experience extreme anxiety about their particular feared outcome (e.g., fear of getting sick, fear of hitting someone with their car), they often recognize that their rituals are excessive.  This is particularly true when the individual is not actively exposed to a symptom trigger.

In contrast, body dysmorphic disorder tends to be associated with poorer insight (Veale, 2004).  Most individuals with BDD are convinced that their “defects” are obvious to everyone. They often are quite certain that these “flaws” make them appear hideous, ugly, or deformed to other people.  Because these beliefs are so strongly held,  the need to disguise or mask the appearance transcends most situations and feels nearly impossible to resist.  People with body dysmorphic disorder fear that if they do not hide their perceived defect, they might suffer extreme embarrassment or shame. Regardless of how others might actually react, feeling physically exposed is experienced as being intolerable.

Is Body Dysmorphic Disorder (BDD) a form of vanity?

Absolutely not.

Individuals with body dysmorphic disorder are not vain, although individuals unfamiliar with the condition might mistakenly assume so on the basis of the amount of time individuals with BDD spend primping and grooming.

Vanity involves taking pride in one’s appearance. In contrast, BDD involves hating one’s appearance.

Whereas grooming behaviors in vain people are attempts to appear more attractive or desirable, BDD compulsions reflect attempts to escape or control unwanted feelings of ugliness.  The checking and grooming rituals common in BDD are experienced as distressing rather than enjoyable.

Many people with BDD are humble, likeable people who experience perceptual anomalies that cause them to misprocess information about themselves.  Unfortunately, these perceptual abnormalities cause them to mistakenly consider themselves ugly, deformed, or hideous.

What causes Body Dysmorphic Disorder (BDD)?

Why do people develop BDD?  It is thought that people with body dysmorphic disorder have information processing abnormalities (Yaryura-Tobias, Neziroglu, & Torres-Gallegos, 2002).

People with BDD appear to misprocess information about their own appearance. Essentially, when they look in the mirror, they over-attend to information about flaws.  They have a hard time processing reflections holistically and instead get stuck in over-analyzing and trying to “fix” one specific aspect of their appearance.  Because they themselves over-attend to information about their own appearance, they assume that other people will do likewise.

People with body dysmorphic disorder also appear to incorrectly process emotional information about other people.  In comparison to people without BDD, people with BDD are more likely to perceive neutral expressions as being angry, hostile, or rejecting (Buhlmann, Etcoff, & Wilhelm, 2006).

BDD is also associated with learning-related factors. The avoidance behaviors and excessive grooming rituals that characterize BDD prevent people with the disorder from having the types of “corrective learning experiences” necessary to resolve their symptoms.  Because individuals with BDD only get social feedback about their appearance after they have spent hours doing “damage control”, they mistakenly assume that their rituals are necessary to keep others from noticing their flaws.  These compulsions are thus reinforced and perpetuated.

Body dysmorphic disorder also appears to be genetically-linked. Although BDD affects only about 2% of the general population (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brahler, 2006), about 8% of individuals with BDD have another family member with BDD (Bienvenu et al., 2000). Moreover, about 7% of individuals with BDD have a first-degree family member with OCD (Phillips, Gunderson, Mallya, McElroy, & Carter, 1998).

How is Body Dysmorphic Disorder (BDD) treated?

Effective treatment of body dysmorphic disorder typically addresses all of the above factors through a combination of cognitive therapy and behavioral exposure.  BDD treatment often has elements that resemble exposure and response prevention for OCD.

When I treat BDD in my South Florida psychological practice in Palm Beach County, we begin with cognitive therapy. We then progress to building an exposure hierarchy that involves gradually decreasing avoidance behaviors and resisting rituals while increasing activities that reflect one’s goals and values.

In future posts, I’ll talk more about the symptoms of BDD and the approach to treatment I use in my Palm Beach practice.

Questions? Comments? Struggling with body dysmorphic disorder (BDD)? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Body Dysmorphic Disorder (BDD) Symptoms
2. Sensorimotor OCD Body-Focused Obsessions & Compulsions (Swallowing, Breathing)
3. OCD Core Fears Related to Body-Focused Obsessions & Compulsions (e.g., Swallowing, Breathing, Blinking)

This article, Body Dysmorphic Disorder (BDD), was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Answering "What If...?" questions is an anxiety-related avoidance behavior that involves overpreparation.

Anxiety, Worry, & What If Questions

If you have anxiety, it’s likely that you wrestle with worry and “what if” questions. Many what if questions are easily recognizable and start with the obvious, “What if…?” Others are more subtle and begin with phrases like “How am I ever going to…?”

By definition, what if questions prompt us to solve problems that haven’t actually happened yet. The possibilities are truly endless. These worries may involve fears about current situations or about situations set far in the future.

What if questions are often difficult to resist because by answering them, we often feel that we become more mentally “prepared” or “ready” to deal with life’s uncertainties. In fact, many individuals feel stressed out if they ignore their worries. They think that because what ifs involve potentially dangerous situations, it’s irresponsible or reckless to ignore these worries. By answering what ifs, they hope to have a better degree of control if and when these situations actually arise.

Many individuals with anxiety disorders like obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD) struggle with what if questions and other worries for hours each day.

How often does this “mental preparation” actually pay off for people with anxiety?

Almost never.

That’s because mental reassurance (a type of mental ritual) is capable of providing only transient relief. We may feel prepared for a few seconds, minutes, or hours, but the feeling eventually wears off and then we feel compelled to re-board the what if train.

Because life involves infinite possibilities and our current situation is constantly changing, the scope of potential what if questions is limitless. You could literally spend the rest of your life preparing for every possible contingency in the hopes that you would be in a better position to deal with it (if and when it actually happens).

However, you can never be fully prepared.  Perfect preparation is only a mirage.

Providing specific answers to your anxiety’s what-if questions is like trying to fill a colander with water. You can spend time doing it, but it’s never going to get you anywhere. Moreover, you’ve wasted a lot of water in the process.

Similarly, there are consequences to answering what ifs.

What are the consequences of answering what if worries?

• Answering what if questions substitutes thoughts for action. Because only action can create lasting change, answering what ifs is an avoidance behavior.
• Time spent answering what ifs is time wasted. How would you rather spend your time? Rehashing answers to (likely) irrelevant questions, or doing something that will actually help you recover from your anxiety disorder?
• What ifs multiply when you engage with them. The more you answer what ifs, the more what ifs will pop up to take their places (think about the paintbrushes in the Sorcerer’s Apprentice).
• You never learn to trust yourself.  Over-preparation reinforces the idea that you won’t be capable of dealing with stressors when they spontaneously arise.  As such, in the long run, answering what ifs increases feelings of helplessness and dread.

Worry and what if questions do not actually prepare you to deal more effectively with situations; they just temporarily make you feel better.  The only real consequence of exhaustive preparation is that you miss out on experiencing the current moment. Instead, you’re living in (and engaging with) a fantasy.

Time is finite.

The most unfortunate consequence of catering to what-ifs is that you end up spending your life preparing for disasters that may never materialize.  Moreover, the sacrifices you make to “feel prepared” never actually work. You never feel adequately ready…in fact, you likely feel even more out of control.

How to Deal with What If Questions & Worry

The best way to deal with what-if’s is to acknowledge them but resist efforts to mentally solve them.  The reason this is helpful is because it’s based on acceptance of uncertainty.

When you feel an urge to answer a what if, avoid coming up with potential solutions and work on accepting that you’ll cope with the situation when it actually arises.  It’s also helpful to develop a script like the following (note: this script was written to help deal with symptoms of sensorimotor OCD):

“Thank you, OCD, for pointing out that I might have these symptoms forever. It’s certainly possible. I guess I’ll just have to deal with that when it happens. In the meantime, if I have to live with these symptoms, I might as well work on becoming less frightened/annoyed by them.”

That’s it.  If the script feels too abrupt, that’s good.  It’s supposed to be brief so that it doesn’t sideline you from your life.

Write out your script on a coping card and review it when needed.  You could also make an audio recording of your script and load it on your iphone/ipod, smartphone, computer, or car stereo.

If you find yourself asking, “What if I write the wrong script and it doesn’t work?” reread the above section “How to Deal with What If Questions & Worry.”

Questions? Comments? Struggling with anxiety related to what ifs and life’s other worries? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Fear, Doubt, Uncertainty, ERP, & the Monster Under the Bed
2. OCD Treatment: OCD vs. Me. How do I Tell the Difference?
3. Sensorimotor OCD & Social Anxiety Differential Diagnosis: “Obsessive Swallowing”

This article, Worry & “What If” Questions, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Hit-and-run OCD involves the fear of causing accidental injury or death while driving.

Fear of Driving

Hit-and-run OCD, or motor vehicle accident OCD, is distinct from other syndromes that involve anxiety about driving or the fear of car accidents. Hit and run OCD differs from panic- or agoraphobia-related driving avoidance, in which individuals fear driving due to the possibility of having a panic attack while in the car. Diagnosis of hit and run OCD is slightly more complicated in cases in which one fears “losing control” while driving, as this symptom can reflect either panic or OCD. In the case of panic, this fear is based on panicking and “losing control” or “going crazy”, whereas in OCD this fear is based on acting on an unwanted impulse (e.g., impulsively swerving).

Hit and run OCD differs from “driving phobia” largely in terms of the rituals/compulsions that are present in OCD. Driving phobia involves more generalized fears. MVA-OCD also has a different symptom profile than post-traumatic stress disorder (PTSD) which might develop following a car accident and include flashbacks and other PTSD symptoms.

Symptoms of “Hit and Run” OCD

Hit-and-run OCD resembles other forms of checking OCD.  Just as checking a stove is used to prevent fire, checking for accidents while driving is a way of preventing (or reducing the severity of) accidental injury or death.  A common form of checking is driving back along the same route in order to scan for victims.

Unfortunately for sufferers, this compulsion actually creates yet another opportunity for having caused an accidental death or injury.  Despite driving along the same road multiple times, the potential for having missed something remains.  Relentless OCD doubt and uncertainty persist.  Many individuals get stuck in checking loops that span many minutes or hours until exhaustion and/or distress make further checking impossible.

Symptoms of hit and run OCD are time-consuming, distressing, and often debilitating.  Let’s review some of the most common symptoms of hit and run obsessive compulsive disorder (OCD).

Common Rituals in Hit-and-Run OCD

Similar to other forms of checking OCD, hit-and-run OCD involves checking and reassurance rituals. These rituals include:

• Circling back and checking for victims/bodies.
• Looking in the rear-view mirror for signs of an accident.
• Looking in the rear-view mirror to assess the reactions of other drivers (e.g., to see if other cars have swerved or pulled over).
• Listening intently while driving in order to hear screeching tires or the sounds of someone who has been hurt.
• Listening for emergency sirens (i.e., from ambulances, police cars, or other emergency vehicles).
• Monitoring the road for bumps that might signal having hit someone.
• Pulling over to the side of the road to look into ditches or gullies for injured people.
• Holding the steering wheel tightly in order to be able to react more quickly.
• Compulsively checking/readjusting mirror positions.
• Compulsive car maintenance (e.g., checking tire pressure).
• Reassurance rituals involving other passengers.
• Asking other passengers questions about whether or not someone has been hit.
• Watching other passengers’ reactions as a way of reassuring oneself that no pedestrians have been injured.
• Mental Rituals.
• Reassuring self, “No one was hit.”
• Reassuring self, “I’m a safe driver.”
• Reassuring self, “Nothing bad is going to happen.”
• Reassuring self, “I’ve driven this route a million times and nothing bad happened.”
• Mentally replaying, reviewing, or retracing one’s driving route.
• Mentally reviewing evidence that indicates that no accident has occurred.
• Praying.
• Thinking “safe thoughts.”
• Replacing “dangerous” thoughts with “good” thoughts.
• Planning what to say to the police if they show up investigating a hit-and-run incident.
• Planning what to say to your victim is s/he survives.

Avoidance Behaviors in Hit and Run OCD

Hit and run OCD is often associated with a wide range of avoidance behaviors. Common avoidance behaviors include:

• Avoiding driving entirely.
• Avoiding schools or neighborhoods where children play.
• Driving only when other people are in the car (to get reassurance that no one was hit).
• Driving only when one is alone (to prevent distraction).
• Driving in silence (i.e., without the radio on) in order to hear the cries of someone who might be injured.
• Avoiding night driving or driving in the rain.
• Avoiding “dangerous lanes” on the highway.
• Driving only on back roads.
• Not driving in unfamiliar places.
• Consolidating errands so that one doesn’t have to leave the house as often.
• Limiting driving distances and staying close to home.
• Avoiding cell phone use or other forms of distracted driving.
• Driving below the speed limit.
• Avoiding parking lots.
• Avoiding busy intersections.
• Avoiding seeing or hearing about car accidents in movies or on TV.

Feared Consequences in Hit-and-Run OCD

Feared consequences associated with hit and run OCD vary. Although the most obvious feared consequence is the actual death or injury of a victim, potential emotional consequences may cause even more distress. For example, individuals often fear the prospect of harming someone because they can’t imagine living the rest of their lives with unrelenting guilt. Common feared consequences include:

• Fear of something falling off your car and causing an accident.
• Fear of killing someone.
• Fear of maiming someone.
• Fear of going to jail.
• Fear of feeling unrelenting guilt over having killed someone.
• Fear of being “irresponsible” or “negligent”.
• Fear of having your life “ruined.”
• Fear of being perceived as “a horrible person.”
• Fear of getting convicted of manslaughter and “ruining” the lives of your friends and family.
• Fear that others will condemn you for what you’ve done.
• Fear of having to face the family members of your victim.
• Fear that life will never be the same.
• Fear of committing an unforgivable crime.
• Fear of unrelenting depression and possible suicide.
• Fear of having to face your victim (if s/he survives).

Effective treatment of hit and run OCD should be based on exposure and response prevention for OCD.  In my South Florida (Palm Beach) psychological practice, I treat many individuals with hit and run OCD and other harm-based obsessions. Treatment involves eliminating avoidance behaviors, resisting rituals, and purposefully tackling your feared consequences according to a personalized anxiety hierarchy.

Questions? Comments? Do you experience symptoms of hit-and-run OCD? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Checking & OCD: Part 1 (Checking for Safety)
2. OCD & Checking: Part 2 (Mental Checking)
3. Obsessive-Compulsive Disorder (OCD) – Overview

This article, Hit-and-Run OCD, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Scrupulosity is a form of religious OCD that often involves having blasphemous or unacceptable thoughts about God.

What is Scrupulosity?

Scrupulosity is a form of obsessive-compulsive disorder (OCD) characterized by religious and/or moral obsessions. Scrupulosity can sometimes be difficult to recognize because even within a single faith community, religious beliefs and practices vary widely. There is no singular belief or behavior that is diagnostic for scrupulosity.

Instead, scrupulosity is best regarded as a pattern of beliefs and behaviors associated with excessive worry about having committed a sin or engaging in immoral acts. Concern may focus either on thoughts or actions already taken or the possibility of committing sins in the future. This results in significant emotional distress, guilt, and despair.

Scrupulous individuals also worry about the sinfulness of having bad thoughts. This experience is very similar to individuals with OCD who experience harm-related obsessions (e.g., the fear of harming a child or loved one). People with scrupulosity often wonder why they’re having bad thoughts and worry that these thoughts have special meaning. They also mistakenly assume that they wouldn’t be having these thoughts if the thoughts weren’t true.

Because the sinfulness of thoughts is discussed in the Bible and other religious texts, many scrupulous individuals take this as “proof” that they should be able to control their thoughts at all times. For individuals who hold this belief, it is especially important that treatment includes steps related to belief clarification. Treatment of scrupulosity may also include consultations with religious professionals. When I treat individuals in South Florida (Palm Beach Gardens, West Palm Beach, Jupiter) with scrupulosity, I typically incorporate these elements in my treatment plan.

Feared consequences associated with scrupulosity often focus on damnation, estrangement from God, making God angry, or living an empty existence. There may also be the fear that one may “corrupt” others or experience uncontrollable feelings of guilt forever.

In order to prevent these outcomes from occurring, individuals with religious scrupulosity engage in a variety of rituals. These compulsions typically involve taking preventative action to keep a sin from occurring or engaging in some type of restoration ritual to repair their relationship with God. People with scrupulosity also commonly engage in a variety of mental rituals.

How is Scrupulosity Diagnosed?

Diagnosis of scrupulosity is complicated because symptoms of scrupulosity exist at the intersection of spirituality and mental health.  This results in symptoms of scrupulosity frequently going undetected. Psychologists may not sufficiently inquire about one’s faith tradition and overlook scrupulous symptoms.  Similarly, religious professionals may have less experience in recognizing signs of obsessive-compulsive disorder (OCD).  Parents of scrupulous children often take pride in their children’s seemingly strong faith and fail to recognize that their “faith” is predominantly fear-based. Because of these challenges, it is especially important to foster better public awareness about scrupulosity and how it relates to OCD.

Here are some common obsessions and compulsions associated with scrupulosity.  Because many of these behaviors are normal within certain faith traditions, it can be useful to consult with an OCD specialist if you’re concerned about these (or other) symptoms.

Symptoms of Scrupulosity (OCD)

• Fear of committing blasphemy or having blasphemous thoughts.
• Excessive fear of hell and/or damnation.
• Excessive doubt about “being saved.”
• Excessive fear and doubt about the existence of God.
• Fear of committing (or having committed) an “unpardonable sin.”
• Excessive worry that one’s life is on the “wrong path.”
• Fear of being responsible for creating a rift in your relationship with God.
• Fear of God not listening to your prayers.
• Excessive fear and doubt about choosing the “right” church/religion or having the “right” beliefs.
• Excessive concern about doing the “right thing.”
• Applying different moral standards to one’s own behavior than to the behavior of others.
• Excessive concern about clothing choices (i.e., not wanting to dress provocatively).
• Excessive concern about child-rearing practices.
• Afraid that one will (or has) sold one’s soul to the Devil.
• Afraid that one is secretly a Satanist.
• Intrusive images of sex or violence related to religious figures (God, Jesus, Mary, saints, etc.)
• Repetitive thoughts about being sexually attracted to God, Jesus, Mary, saints, or other religious figures.
• Intrusive images of inverted crosses, pentagrams, or other sacrilegious icons.
• Fear that one may secretly be possessed by demons.
• Fear that one’s children may be possessed by demons.
• Fear of future actions (e.g., worry that one will have to murder their children if they are possessed).
• Fear of being (or becoming) the Antichrist.
• Fear that one’s kids may be the Antichrist.
• Worry about whether one is fundamentally good or evil.
• Afraid of repeating prayers backwards.
• Fear of secretly wanting to go to hell.
• Fear of impulsively or intentionally praying to the Devil.
• Intrusive thoughts related to loving the Devil (e.g., Satan is Lord).
• Fear of secretly being controlled by the Devil and carrying out his wishes.
• Intrusive thoughts about rejecting the Holy Spirit.
• Intrusive thoughts about impulsively committing suicide and going to hell.

Compulsions Related to Scrupulosity (OCD)

• Repeating or restarting prayers.
• Praying excessively.
• Compulsively seeking out information online about the sinfulness of certain activities.
• Excessively attending confession.
• Compulsive reassurance-seeking from family members or members of one’s faith community.
• Did I do the right thing?
• Do you think it’s okay if I…?
• Compulsive self-reassurance
• Repeatedly saying: “I’m a good Christian person” after experiencing an unwanted thought.
• Repeatedly saying: “God loves me” after having an unwanted thought.
• Compulsive writing (e.g., Jesus loves me).
• Mentally reviewing or analyzing events to determine if a sin was committed.
• Taking religious practices to extremes.
• “Observing the Sabbath” in a way that’s not typical for others in one’s faith tradition.
• Fasting in a way that’s not typical for other members of one’s religious community.
• Engaging in self-punishing atonement practices that are not characteristic of one’s faith.
• Making deals with God.
• Planning and preparing for future religious problems (e.g., researching exorcisms).
• Replacing unwanted thoughts or images with safer or holier images.
• Thinking of images of the cross, doves, Jesus’s face, Mary’s face.
• Mentally inverting unwanted images.
• Inspecting one’s body for “signs” from God or the Devil.
• Examining birthmarks or looking for moles that indicate whether one is good or evil.
• Restarting or cleansing rituals.
• Getting out of bed again.
• Taking showers.
• “Renewing” oneself through mini-Baptisms.
• Asking for forgiveness excessively.
• Excessive study of religious texts (i.e., Bible, Torah, or Koran).

Avoidance Behaviors Related to Scrupulosity (OCD)

• Avoiding religious services (if one is afraid of God’s judgment for having bad thoughts while attending a service).
• Avoiding communion (if afraid of dropping a communion wafer).
• Avoiding triggers related to other spiritual or secular belief systems.
• Avoiding books, movies, or magazines that mention evolution.
• Avoiding yoga or other practices that developed out of a different faith tradition.
• Avoiding numbers that are unlucky or have religious significance (e.g., 13, 666).
• Avoiding reading the Bible, Torah, or Koran.
• Postponing decisions until they “feel right” or until God gives a clear sign about what to do.
• Avoiding prayer (if afraid of having a bad thought while praying).
• Deferring decisions to other people.
• Avoiding eye contact with members of the opposite sex (if afraid of committing adultery).
• Avoiding conversations with atheists (or people of other religions) for fear that their beliefs may pollute or corrupt your own belief system.

Remember, effective treatment for scrupulosity is based on exposure and ritual prevention, a type of behavioral therapy that was designed to treat obsessive-compulsive disorder (OCD). However, ERP will typically be augmented with steps related to belief clarification.

Questions? Comments? Do you experience scrupulous symptoms that were not mentioned above? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Scrupulosity & OCD: Religious/Moral Symptoms
2. OCD symptoms: the obvious (and the not so obvious)
3. Pure-O OCD Rituals: Starting Over, Resetting, & Undoing

This article, Scrupulosity, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.

Treatment of scrupulosity (religious/moral OCD) is based on exposure and response prevention (ERP), but pre-treatment goals often focus on belief clarification.

Any suggestions for treating scrupulosity (religious OCD)?

Religious Scrupulosity/OCD

For many people with OCD/scrupulosity, treatment can be especially confusing at first. Every action or inaction can feel potentially dangerous, which is why scrupulosity often goes untreated for so long. The very fact that you recognize that this is related to obsessive-compulsive disorder is excellent. It also sounds like you have insight about your OCD symptoms and the OCD positive feedback loop. Many people with religious obsessions don’t realize that obsessions can target religious/moral topics. Their OCD tells them that it’s impossible to engage in religious practices “too much” or “too frequently.”

Scrupulosity/OCD Belief Clarification

The first step in your recovery is to clarify your religious beliefs. If you don’t do this, exposure and response prevention for your scrupulosity will likely be unhelpful. The types of questions you should ask yourself are:

• Does God expect me to be perfect?
• If I make a mistake or commit a sin, does my religion have procedures for obtaining forgiveness?
• Would God want my behaviors to be largely driven by obsessive-compulsive disorder?
• Would God want my relationship to my religion to be OCD-based or faith-based?
• Would God understand what’s going on in my head and want me to fight my OCD?
• If my treatment involves doing things that might be considered potentially sinful, would God understand?

Although you cannot have complete confidence when answering many of these questions, your answers to these questions will help frame your treatment efforts. For those whose symptoms distort their view of God, these questions can be especially tricky. These individuals sometimes base their answers on how they would like to think about God. When I treat people who have religious scrupulosity in my South Florida (Palm Beach County) psychological practice, my intention is not to change their religion or create more guilt for them…but rather to help them determine if there are aspects of their current relationship to God/religion that are dysfunctional. If this is the case, it’s not the person’s fault; this simply reflects a common symptom of scrupulosity.

Treatment is then designed to help them develop a more functional and healthy relationship with God.

Once you’ve clarified your beliefs, the next step is to define appropriate treatment goals.

Moral/Religious OCD Treatment Goals

For anyone with scrupulosity/OCD, it’s unhelpful to define your goals in terms of impossibilities. You must set achievable treatment goals. For example, it would be unwise to select the goal of knowing for sure that you did the right thing or handled the situation the right way. Moreover, it would also be unhelpful to adopt the goal of trying to be 100% sure that God isn’t mad at you. For other people with scrupulosity, there may be the fear of hell/damnation and the unattainable goal of wanting to know 100% that you are saved. These types of goals just feed obsessive-compulsive symptoms.

No matter what we do, we can never know these things in the ways that OCD tells us we should know them. Perfect certainty about faith and morality just isn’t possible.

If you think about it, you’ll realize that these types of OCD-driven goals take faith completely out of religion.

Obsessive-compulsive disorder (OCD) often tells us that the only acceptable way to practice religion is to practice it with a perfect sense of knowing. This is actually incompatible with the idea that faith involves believing in something that can’t be seen or verified.

Appropriate treatment goals involve learning to live more comfortably in a world that is often gray, muddied, and confusing…to better tolerate OCD doubt, uncertainty, and ambiguity regarding our actions and intentions. This involves accepting yourself as an imperfect person who will inevitably mess up and learning to rely more on faith and less on certainty.

Exposure and Response Prevention (ERP) for Scrupulosity/OCD

Once you’ve set your goals, you then practice exposure and response prevention (ERP) for scrupulosity. You intentionally enter situations that trigger your doubt and uncertainty and resist the urge to escape or perform your rituals. For you, with the symptoms you’ve described, this would involve resisting the urge to cross-post religious topics on Facebook. Although this will feel dangerous at first, the more practice you get, the easier it will become.

There are also a variety of other exposures that might be helpful to you, such as thinking a bad thought on purpose. Again, this likely sounds dangerous if you’ve never done it before. However, after you’ve clarified your beliefs and defined appropriate treatment goals, you might determine that this territory is an important step in your recovery.

Would God understand and support your efforts to fight OCD?

Only you can answer this question.

Scrupulosity & Mental Rituals

It’s also important to note that when people have symptoms like yours, they often have a variety of mental rituals that accompany their obsessions. These include:

• Reviewing/re-analyzing/replaying scenes from the day to figure out if you did the “right” thing.
• Trying to figure out (i.e., questioning) your own motives in various situations.
• Compulsive praying (which often includes repeating/restarting prayers multiple times)
• Repeating prayers or restarting prayers if you get distracted or lose focus.
• Repeating prayers or restarting prayers if you are not concentrating 100% on the words of your prayer.
• Repeating prayers or restarting prayers if you had a bad thought during them.
• Repeating prayers or restarting prayers if you felt they weren’t 100% genuine.
• Reassurance-seeking behaviors.
• Asking others if you did the “right” thing.
• Excessively reading/studying religious texts (e.g., Bible/Torah/Koran) in order to inform current behavior.
• Asking for forgiveness excessively.

It’s important that you resist these rituals, as they will interfere with your progress in treatment. If you have a hard time determining if a certain behavior is problematic (e.g., praying, studying the Bible/Torah/Koran), it can be helpful to consult with a religious professional (e.g., pastor, priest, rabbi) in order to get feedback. Because not all clergy are familiar with OCD/scrupulosity, I would recommend that you have your therapist join you at this meeting.

After this consultation, it may be helpful to set parameters for your prayer. For example, you may decide to pray at specific times, limit the amount of time you spend praying, and resist urges to repeat/restart prayers. If these behaviors reflect symptoms of scrupulosity, they can actually interfere with being able to establish a healthy relationship with your religion.

Just like any form of OCD, scrupulosity can be effectively treated through exposure and response prevention (ERP). Given the complexity of these symptoms, I would recommend getting the assistance of a therapist who specializes in treating OCD. If you live in a remote area and there are no local providers, there are probably providers in your state who would be willing to do therapy by phone or over Skype. If you use a screen-sharing program, you could even do some of the Facebook exposures “together.”

Wishing you the best in your recovery from religious scrupulosity!

Questions? Comments? Experience with recovering from religious obsessive-compulsive disorder? Sound off below.

…or continue the discussion on Facebook, Twitter, or Google+.

Related posts:

1. Scrupulosity
2. OCD symptoms: the obvious (and the not so obvious)
3. Fear of Saliva Swallowing & Choking: Treatment & Symptoms (OCD)

This article, Scrupulosity & OCD: Religious/Moral Symptoms, was originally published on Steven J. Seay, Ph.D. You may read more about the author here.