In medicine, many conditions are referred to by their subtypes. A good example is diabetes—an illness that affects 38.4 million people in the United States alone. There are several subtypes of the disease, but the ones you probably hear most often, and that affect the most people, are Type 1 and Type 2 diabetes. Both are caused by a problem with insulin, a hormone that helps regulate blood sugar. Each can be chronic, meaning they’re persistent or long-lasting, and lead to severe complications if not properly managed.
So why make such a big distinction between them? Because the way they’re treated differs enormously. Many people living with Type 2 diabetes can manage their symptoms with diet and lifestyle modifications. Type 1 diabetes requires not only being careful about what you eat, but you must also inject yourself with synthetic insulin several times per day or the condition can be fatal.
If you’ve spent even a little time researching obsessive-compulsive disorder (OCD), you know that the condition also has several subtypes, and that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (or DSM) includes specific examples of people’s experience with them, says says Nicholas Farrell, PhD, Director of Clinical Development and Programming at NOCD.
The DSM is considered the authoritative guide to diagnosing and classifying mental disorders, and contains information that influences how these conditions are defined and treated. But in the case of OCD’s many subtypes, the DSM doesn’t list or define them specifically—and for good reason. Let’s learn a bit more about why this is the case.
What are OCD Subtypes?
The way mental disorders are included, excluded, and categorized within the DSM is complicated and, very often, causes heated debates among mental health professionals. Before the latest iteration of the DSM—the DSM-5—was published in May 2013, OCD was categorized as an anxiety disorder. It now has a category of its own, based on research showing that OCD has unique characteristics and underlying mechanisms. It’s an example of how the DSM can change as scientific knowledge grows.
OCD is a condition where you experience repetitive and intrusive thoughts, images, urges, or feelings, called obsessions. These obsessions can be very distressing, causing you to perform compulsions, which are mental or physical behaviors that are done in an attempt to decrease your distress or anxiety, or prevent “bad things” from happening.
Before the release of the DSM-5, some mental health professionals argued that, like other mental disorders, OCD should be divided into various subtypes, which include:
- Existential OCD: This is when you have obsessive thoughts about deep philosophical questions, like the meaning of life, death, or existence, that lead to significant distress and often compulsive overthinking or seeking reassurance.
- False Memory/Real Events OCD involves an obsession with the fear of having done something bad in the past, with compulsions including ruminating or seeking reassurance about these potentially false memories or events.
- Harm/Violent OCD centers around intrusive thoughts or images about harming yourself or others, which understandably cause distress, as well as behaviors like checking or avoiding situations that trigger these thoughts.
- Health Concern/Contamination OCD is an obsession with being contaminated by germs, diseases, or toxins, leading to compulsions like excessive washing, cleaning, or avoiding perceived sources of contamination.
- Perfectionistic OCD has to do with a need for things to be done perfectly. That can cause compulsions such as excessive checking, organizing, or redoing tasks to meet unrealistically high standards.
- Pure OCD is characterized by distressing and intrusive thoughts that don’t have visible compulsions; the compulsions are usually mental, like reassurance-seeking or mental reviewing.
- Relationship OCD (ROCD): This is when you have obsessive doubts about your romantic relationship, leading to constant questioning of your love, attraction, or compatibility with your partner.
- Religious OCD (Scrupulosity) involves intense worry about sinning or violating religious principles, often with compulsions like excessive praying, confessing, or seeking reassurance from others.
- Responsibility OCD is an overwhelming fear that you could be responsible for something terrible happening—like causing an accident. It can lead to constant checking or reassurance-seeking behaviors.
- Sensorimotor OCD: If you have a hyper-awareness of certain bodily sensations or processes, such as blinking, breathing, swallowing, you may have this subtype of OCD. The symptoms may go unnoticed by others, but cause distress and difficulty focusing on anything else.
- Sexual Orientation/Gender OCD is obsessive thoughts about your sexual orientation or sexual identity, often leading to significant anxiety and compulsive behaviors aimed at finding reassurance.
They didn’t get their way.
“Deciding not to include OCD subtypes is an area where I’d say the DSM folks have got it right,” says Dr. Farrell. “The closest thing to a list of subtypes in the DSM-5 are examples of different OCD experiences. If you open the book right now, you can read those examples and have little trouble picking out common subtypes or themes.”
He adds that new kinds of OCD are introduced so often that the DSM—which sees many years between editions—couldn’t keep up.
“10 years ago, the term Relationship OCD was hardly ever used, and nobody recognized Sensorimotor OCD,” explains Dr. Farrell. “Even things that are kind of on the fringes now, like hit and run, retroactive jealousy, or ocular tourettic OCD (formerly called staring OCD), will likely be mainstream in 2034, and I’m sure a whole new batch emerges shortly after that. But here’s the thing: Unlike other conditions with subtypes, we treat any presentation of OCD the same way. That, in a nutshell, is why I think the DSM folks were right not to include them.” (And despite the technicality of not officially being classified as subtypes, they’re often referred to as such, even by many mental health professionals.)
The treatment Dr. Farrell is referring to? It’s called exposure and response prevention (ERP) therapy.
ERP is effective in treating all OCD subtypes
ERP works by helping you gradually face the fears or intrusive thoughts that bother you without resorting to your usual actions to ease them. In this therapy, with the guidance of a therapist, you’re exposed in a controlled way to the situations or ideas that trigger your anxiety.
Let’s say you’re scared of germs, a feature of contamination OCD. Your therapist might encourage you to touch something you consider dirty and then resist washing your hands immediately. This particular exposure is intended to help you confront your fear directly and learn that the anxiety you feel naturally decreases over time, even without the relief provided by the compulsion of washing. Over time, ERP can reduce or eliminate the power that the fear of contamination holds over you.
Here’s another example: Suppose you always doubt your partner’s love—known as relationship OCD. Your therapist might ask you to refrain from seeking reassurance from your partner after expressing your love. This helps you face the anxiety caused by doubt and learn to accept the uncertainty in the relationship without constant reassurance.
Or perhaps you have harm OCD, typified by intrusive thoughts about hurting someone. Your therapist might encourage you to hold a kitchen knife while standing near someone, and then resist the urge to repeatedly check to make sure you haven’t hurt them. This helps you face the fear and learn that having the thought doesn’t mean you’ll act on it.
“There are some kinds of OCD that come with considerations about how ERP is delivered,” explains Dr. Farrell. “For example, if you have false memory OCD, your treatment is probably going to be predicated on imaginal exposures, whereas if you’re dealing with harm OCD, you’re more likely to have physical, actionable exposures. But aside from these relatively minor tweaks, the way ERP is delivered doesn’t change much, regardless of the subtype.”
Why talk about subtypes?
Given that they have little bearing on the way ERP is delivered, you might be wondering why anyone uses the term “subtype” at all.
“While I don’t think they belong in the DSM, there is certainly a benefit to recognizing OCD subtypes,” Dr. Farrell says. “They allow those with OCD to more easily identify their experiences, realizing they have a real condition, and that they’re not alone in their struggle. The drawback of this is that, occasionally, people mistakenly think that each subtype requires a different treatment. Our intake team often receives requests for specialists in specific subtypes like existential OCD, which don’t exist as separate disciplines. This misconception suggests a need for highly specialized experts for each subtype, which isn’t the case, and can cause unnecessary confusion and a delay in getting help.”
Regardless of the subtype you’re experiencing, ERP’s purpose is to show you that you can cope with the anxiety your obsessions provoke and that it diminishes over time—without needing to perform compulsions, which only offer fleeting relief. Through consistent practice, you learn that the feared outcome doesn’t happen, and even if it does, that it’s not as bad as you thought. ERP is about breaking the cycle of fear and the compulsive actions you use to deal with it, helping you lead a more fulfilling life.