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The Four Horseman of OCD

Updated: Aug 31, 2020

Obsessive compulsive disorder (commonly referred to as OCD) is a disorder of thought and behavior. Obsessions are intrusive thoughts that individuals have that create fear based reactions, often referred to as compulsions. Intrusive thought affect 4 out of 5 individuals, or about 80%; however, there is a subset of those individuals who struggle with letting go or dismissing those thoughts. Obsessive compulsive disorder affects about 1 in 100 children and 1 in 40 adults ( Nationwide, this equates to about 2.2 million people (

Intrusive thoughts can present in many different areas, but one things that is typically common is their attack on the value system of each individual. This is known as ego-dystonic thinking which can lead to an intense amount of dissonance and discomfort. Ego-dystonia is a term from prior thoughts in psychological sciences, but still applicable in this sense. This term means that the thoughts are opposite of what the individual might think of themselves or the behaviors that they would espouse. This style of attack allows for the fear response, typically in the form of compulsions or avoidance, because the suffers has to prove to themselves that they ARE NOT that thing, or keep safe individuals that are unknowing of these thoughts. For instance: If a sufferer of OCD suddenly is plagues with violent or harmful images, but views themselves as a kind hearted, non-violent person, they would act in ways to combat the attack to their ego or value system. These compulsions, as having been discussed before in prior articles, only serve to reinforce the obsessions. The cycle looks very similar to this:

Even though there are differences between the four very distinct content areas, the progression of symptoms often is very similar. Small concessions made to concerning intrusive thoughts lead to much bigger concessions in the future. Somebody who stops to pray a second time may lead to longer, more sufficient prayers to alleviate any uncertainty that their prayer wasn't "good enough". Similarly, individuals with contamination phobic OCD, will clean and re-clean areas so they can be "certain" that it was cleaned adequately.

There are a wide variety of presentations of OCD. Some with and without overt compulsions. Some presentations of OCD rely on covert compulsions that serve similar purposes as their overt counterparts. Covert compulsions are unseen ritualized ways of thinking that lead to reduction of anxiety. Since there are so many varieties of distorted, intrusive thinking, the OCD community has identified four main content areas that most obsessions can be categorized within. (infographic found at:

These four content areas may have various forms of intrusive thoughts that may present with catastrophic thinking, generalization, or other thinking fallacies that allow for the introduction and maintenance of OCD thinkings via compulsions and avoidance. Some areas are much more accepted and understood by individuals within our community, whereas many others still remain taboo.

Because of how OCD affects the neurocircuitry, it directs our attention to the fear object or concern at that moment. One such loop (the Cortico-Striatal Thalamo Cortical (CSTC) loop) connects a variety of systems within our brain, particularly the prefrontal cortex, which plays a key role in attentional focus. When a sufferer is experiencing persistent intrusive thoughts, they aim their attention at alleviating the distress they are experiencing at that moment. This is a key function of the orbitofrontal cortex. That attentional focus will hinder their ability to consider safety mechanisms and barriers between them and danger. Their emotional fight or flight engages and they seek safety via avoidance behaviors or compulsive rituals.

Contamination symptoms can present in a number of different ways. One such form lends to catastrophizing thought that may end up in them getting ill, sick, or somebody they love becoming ill or sick because of their “carelessness.” Another form, commonly referred to as “Disgust OCD” is that germs are all over them and their items which leads to compulsive cleaning or avoidance of personal objects until they themselves are clean. We’d often encourage individuals to purposefully “contaminate” themselves and withhold their compulsive response. With regards to disgust OCD, we would have them “contaminate” all of their personal items and sit with that discomfort until they feel less anxiety with regards to those items or area that is infected.

A second content area concerning OCD is symmetry and checking. This form is commonly referred to as tapping or checking OCD as well. The suffer may feel the need to check something until it is “just right” or until it “feels right.” This may be items that are deemed dangerous in nature (I.e. gas stove controls) or something less dangerous (I.e. making sure glasses are laid on their side table, just so...). These individuals are again encouraged to engage with their discomfort and withhold their compulsive behaviors.

Doubt and harm OCD is a content area which we who treat OCD will see often, but much less than the prior two content areas. These intrusive thinking patterns have to do with responsibility for harming somebody, or something. Their doubt in how they have acted, often citing their intrusive thoughts/imagery as “false memories.” Some of our work with individuals who are concerned about harming others, would be allowing them the opportunity to harm somebody by creating situations where if they “lost control”, they would have certain opportunity to harm or maim somebody. I have sat with individuals who have been given sharp objects and even turned my back to them given them the perfect opportunity to “murder” me. Yet, here I am....still kicking.

The last formal content area deals with taboo or unacceptable thoughts. Unacceptable religious thought would fall within this category of OCD. Scrupulousity OCD often relies acceptance and commitment principles to identify negative intrusive thoughts as OCD, rationally identifying them as ego-dystonic ways of thinking, and committing to dismissing or ignoring the thoughts. Another form of treatment, ERP, would encourage the sufferer to engage in blasphemic behaviors (such as drawing upside down crosses or reciting the Mark of the Best 666) in order to challenge the negative intrusive thinking.

Many of the processes from development to maintenance to treatment can be very similar, not all individuals who suffer may seek help, or may be misdiagnosed. Often the more taboo or violent presentations of OCD are often conceptualized incorrectly. From the clients I have worked with who suffer from P-OCD, to violent/harm presentations; they all express a sense of loneliness because they do not, and often cannot, share their struggle with even those close to them. This may lead to many suffering to the point of isolation and debilitation. They often remark, "Why couldn't I just be a germaphobe..?"

Even though OCD can present in many ways, with a variety of different intrusive thoughts, the process of development, maintenance, and treatment of OCD is often more similar than different. Some presentations of OCD are easier to communicate than others, even though those more taboo presentations have similar prognoses. If you or somebody you love is a sufferer of OCD, there are professionals with specific training to help you overcome those intrusive thoughts and compulsive behaviors that take up so much of your, or their time. You can visit the International OCD Foundations website ( for more information, connect with counselors, or educate those close to you. If you're in Oklahoma or Kansas, you can connect with me to begin your journey to an OC-FREE Life!

Chad McCoy, MA, LPC-S


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