Below are 5 signs someone might be experiencing OCD.

1. Unwanted thoughts or images that keep popping up in your mind and won’t go away. They’re often disturbing and cause intense anxiety, guilt, disgust, or discomfort.

2. Behaviors you feel that you have to keep doing when intrusive thoughts come up. You may know that the actions don’t even make sense, but you keep doing them because you keep thinking, “but what if it’s true?”

3. Excessive need for certainty or reassurance. You feel a powerful urge to be 100% sure, without a shadow of a sliver of doubt, that your fear is not or won’t come true.

4. You keep trying to suppress or control your thoughts. The more you try to suppress, control, or ‘get rid of’ the intrusive thoughts, the more persistent and severe they become.

5. You start avoiding things you need to do to function at work, school, home, or in your relationships. OCD takes at least an hour or more per day and interferes with daily functioning.

I get this question a lot, and it makes sense to want to know why we are experiencing all this pain and suffering. It’s part of how we make sense of what is happening to us. What we know at this time is that the causes of OCD are some combination of genetics, biology, and experience. Current models of mental illness suggest that some people have a genetic predisposition for developing OCD. In other words, to develop OCD, there must be some vulnerability to OCD. However, the vulnerability alone cannot cause OCD. There also needs to be some environmental trigger, like a stressful event, that activates the vulnerability. Depending on how strong a person’s vulnerability to OCD is, the stressful event may need to be intense (for example, a traumatic event or loss) or it may be something minor or even positive (for example, lack of sleep or a new job).

Clients sometimes want to figure out exactly what it was that triggered their OCD to develop, but it is often impossible to identify. The good news is, most of the time, we don’t need to know how or why it developed in order to treat it! In treatment, we can focus on identifying what is feeding the OCD now, and starving the OCD monster.

The answer to this is: it depends. It depends on how severe a person’s symptoms are, what is going on in a person’s life, and how long a period of time we are talking about. There are three things that can happen: Symptoms can pretty much stay the same, they can get worse, or they can (rarely) resolve without formal treatment (this is called spontaneous remission). A meta-analysis of 12 studies revealed that only 4% of participants experienced spontaneous remission across an average of about 11 weeks. In another study, researchers found that only about 14% experience full remission over a period of 6 years, meaning they no longer met criteria for OCD, and the symptoms did not return. They also identified risk factors for a chronic course, meaning their OCD symptoms stay the same or worsen over time.

Those who started with more severe symptoms and those who developed OCD at a young age were more likely to have a chronic course of symptoms. However, those who were assigned male at birth and those who were younger at the start of the study were less likely to have a chronic course. Many people experienced an episodic course, meaning that their OCD symptoms may wax and wane. Stressful periods of life can increase symptoms, and calmer periods may reduce them. This can look like getting better, but the underlying problem remains. Overall, research thus far has shown that people with OCD are unlikely to see a consistent improvement in symptoms if left untreated. For those who do have spontaneous remission, this could be because of a few reasons: It could be because they reduced their compulsions on their own without going to treatment to do it, or it could be because of life changes that result in fewer stressors that trigger their symptoms. Full remission without making intentional changes is rare.

It’s also important to recognize that OCD can become VERY severe for some people. I have worked with individuals who spend upwards of 8 hours in the shower or who have not bathed or brushed their teeth for months due to their OCD symptoms. People with OCD also experience high rates of depressive disorders and suicidal thinking and behavior. The odds of experiencing suicidal thoughts are 1.9 to 10.3 times greater in people with OCD than in the general population. It’s important to seek treatment before things get to that point, but there is hope for even very severe cases of OCD.

OCD symptoms can often wax and wane over time, depending on several factors, such as stress, the presence of triggers, and potentially even hormonal changes. People use different terms for this, such as “episodes,” “flare-ups,” or “spikes.” Any kind of stress, even with positive changes like a new job, can trigger an increase in OCD symptoms. This is similar to other mental health conditions. General levels of stress make us more psychologically vulnerable and can result in an OCD episode. The presence of an intense, unexpected trigger can also cause a flare-up. For example, if I’m afraid of harming children and I accidentally hurt my nephew when playing, I might experience a sudden increase in symptoms because my brain is telling me the lie that this event is proof that I am dangerous to children. I might then experience a lot of distress and anxiety and go into an OCD spiral of avoidance, compulsions, and an increase in intrusive thoughts. Similarly, both male and female individuals can develop or have more severe obsessive-compulsive symptoms when first becoming parents.

For those who have uteruses, there is some evidence that hormonal fluctuations may influence the onset or severity of OCD symptoms. There is a lot of evidence for new or worsened OCD symptoms in the perinatal or postpartum period for some. Perinatal OCD tends to involve a lot of harm-related intrusive thoughts about the baby, as well as contamination concerns and checking and cleaning behaviors. However, more research is still needed to determine if the cause is biological/hormonal or if it is more related to psychological concerns for their child’s well-being.

Scrupulosity (also called “scrupulous OCD” or the nickname “scrup”) is one of many symptom themes of OCD. This theme involves religious- or moral-based obsessions and compulsions. While I treat all symptom themes and presentations of OCD, I have a special interest in scrupulosity. OCD tends to attach to the things we value most, and religion and morality are important to many people. However, you don’t have to be religious to have scrupulous OCD. Some people are religious and have religious themes, some people are not religious or no longer believe in a religion but have religious themes because they were brought up that way, and others are not religious and have secular moral OCD themes that are not related to religion.

Scrupulosity functions the same as all the other themes of OCD, and the same OCD cycle described above applies. But there are some differences. For example, people with scrupulosity tend to have lower insight. This means that it is harder for the person with OCD to realize that their obsessions or compulsions are excessive, irrational, or unreasonable. They are more likely to resist the idea that their compulsions are unnecessary or unhealthy and may be less willing to engage in exposures or response prevention, which can impact treatment. Additionally, guilt and shame are very common in scrupulous OCD and can be difficult emotions to sit with. These things can make scrupulosity more difficult to treat, but with the right clinician who you trust, treatment can be very effective.