OCD Is More Than Handwashing: What Obsessive-Compulsive Disorder Can Really Look Like

A conversation with Dr. Amanda King of Nevada Mental Health

When many people hear the term OCD, they picture someone who washes their hands repeatedly, keeps a spotless home, or likes things arranged in a very particular way.

Those examples can be part of obsessive-compulsive disorder. But they are not the whole picture.

Dr. Amanda King, a double board-certified psychiatrist in general psychiatry and child and adolescent psychiatry with Nevada Mental Health, said OCD is often misunderstood, missed, or confused with other conditions.

“There are a lot of stereotypes with OCD,” King said.

One of the biggest misconceptions is that OCD is simply about cleanliness or perfectionism. In reality, OCD involves obsessions, compulsions, distress, and impairment. It can affect work, school, relationships, self-esteem, and daily functioning.

OCD Is Not the Same as Being Neat or Organized

OCD stands for obsessive-compulsive disorder. It is a psychiatric condition that can include intrusive thoughts, images, urges, fears, or doubts, followed by compulsions that a person feels driven to do in response.

Those compulsions may be visible, such as washing, checking, arranging, or repeating behaviors. They may also be invisible, such as counting, praying, reviewing events mentally, or trying to “undo” a thought in the mind.

King said OCD is sometimes confused with obsessive-compulsive personality disorder, or OCPD. OCPD is associated more with perfectionism, rigidity, and a strong preference for order. OCD is different because it involves true obsessions and compulsions that are distressing and impairing.

Someone may like their home organized, prefer a certain routine, or double-check the stove once before leaving. That does not automatically mean they have OCD.

The clinical question is whether the symptoms are causing impairment.

“Is this affecting your daily functioning, whether that’s at home, at work, or in any areas of your day-to-day life?” King said.

If the thoughts or behaviors are taking significant time, causing distress, disrupting school or work, damaging relationships, or making daily life harder to complete, it may be time to seek an evaluation.

OCD Can Include Checking, Harm Fears, and Intrusive Thoughts

Contamination fears and excessive handwashing are well-known OCD symptoms, but they are only one possible presentation.

King said OCD may also involve checking behaviors. A person may leave home and worry they left the stove on, the curling iron plugged in, or the door unlocked. They may return to check more than once, even when part of them knows they already checked.

OCD can also include harm-related intrusive thoughts. A person may fear they accidentally hurt someone while driving, then circle back to check whether anything happened. Others may have violent, sexual, or taboo intrusive thoughts that feel deeply upsetting because the thoughts conflict with their values.

King used the term egodystonic to describe this kind of distress. In plain language, that means the thoughts do not feel aligned with who the person is or what they want.

“They don’t want to have the thoughts,” King said. “They are bothersome to them.”

That distinction matters. Having an intrusive thought does not mean someone wants to act on it. In OCD, these thoughts can be terrifying precisely because they feel so opposite to the person’s character.

Because of shame or fear of being misunderstood, many people do not talk about these symptoms. That can delay diagnosis and treatment.

Some Compulsions Are Invisible

Another misconception is that compulsions are always observable from the outside.

King said more than half of patients with OCD may experience mental rituals that are often invisible unless a clinician asks the right questions.

These may include counting, praying, mentally repeating phrases, replaying events, asking for reassurance in subtle ways, or trying to neutralize a distressing thought internally.

From the outside, the person may appear quiet or distracted. Internally, they may be working very hard to reduce anxiety, prevent a feared outcome, or feel certain that something bad will not happen.

That is one reason professional evaluation matters. If a person only looks for visible rituals, they may miss the way OCD is affecting their life.

What OCD Can Look Like in Children and Teens

OCD can affect adults, adolescents, and children. King said parents, caregivers, and teachers are often important observers because symptoms may show up across different environments.

Possible signs in children or teens may include:

• Spending excessive time washing hands or using the bathroom.
• Red, raw, or irritated hands from repeated washing.
• Bedtime rituals that must be completed in a specific order.
• Repeating tasks until they feel “just right.”
• Counting, checking, arranging, or asking for reassurance repeatedly.
• Schoolwork taking much longer than expected because of rituals or intrusive thoughts.
• Significant distress if a routine is interrupted.

King gave the example of an adolescent whose bedtime routine took about two hours, including extended flossing and brushing that had to be repeated if it did not feel right.

The issue was not simply that the routine was unusual. The issue was that it was distressing, time-consuming, and interfering with life.

Nevada Mental Health provides pediatric psychiatry for children and adolescents, as well as adult psychiatry for adults dealing with OCD or related concerns.

Why OCD Is Sometimes Missed or Misdiagnosed

OCD can be missed for years.

King said the average time from onset of OCD symptoms to initial treatment is about eight years for many people.

One reason is that people may hide symptoms out of embarrassment. Another is that OCD can be misdiagnosed, especially when intrusive thoughts are misunderstood.

King said she has seen patients whose intrusive thoughts were mistaken for psychotic symptoms, leading them toward the wrong medications or the wrong type of therapy.

“The first step is getting diagnosed correctly,” she said, “and then the second step is getting the right treatment intervention.”

A psychiatric evaluation can help distinguish OCD from generalized anxiety, depression, trauma-related symptoms, psychosis, OCPD, or other conditions that may overlap. If you are unsure what to expect, Nevada Mental Health explains the intake process in its guide to what to expect at Nevada Mental Health.

OCD Is Treatable

The good news is that OCD is treatable.

King said many patients see meaningful symptom reduction when they receive the right type of treatment.

The gold-standard psychotherapy for OCD is exposure and response prevention, often called ERP. ERP is a specialized form of therapy that gradually helps a person face feared situations, thoughts, or sensations while reducing the compulsive response that keeps the OCD cycle going.

For someone with contamination fears, ERP might involve gradual exposure to feared germs while practicing not washing repeatedly. For someone with checking behaviors, it might involve reducing repeated checking and learning to tolerate the distress that follows.

ERP should be done with a clinician trained in this approach. Not every therapist is trained in ERP, so finding the right type of care matters.

Medications can also help. King said SSRIs, or selective serotonin reuptake inhibitors, are considered first-line medication treatment for OCD. These medications affect serotonin pathways in the brain and may help reduce OCD symptoms for some patients.

If medication is part of the plan, a psychiatric medication evaluation can help review symptoms, diagnosis, medication history, side effects, and treatment goals.

Where TMS Can Fit for Treatment-Resistant OCD

Some people continue to struggle even after trying evidence-based therapy and medication.

King said TMS therapy can be considered for treatment-resistant OCD in certain cases. TMS stands for transcranial magnetic stimulation. It is a noninvasive treatment that uses magnetic pulses to stimulate targeted areas of the brain.

For treatment-resistant OCD, King said TMS typically comes into the conversation after two adequate medication trials have not worked well enough. Those might include two SSRI trials or an SSRI plus another medication option such as clomipramine.

Nevada Mental Health’s overview of interventional psychiatry explains how treatments such as TMS fit into a broader approach for complex or treatment-resistant mental health conditions.

When to Ask for Help

It may be time to seek an OCD evaluation if intrusive thoughts, fears, checking, rituals, washing, reassurance-seeking, or mental compulsions are:

• Taking significant time each day.
• Causing shame, fear, or distress.
• Interfering with school, work, home life, or relationships.
• Leading to avoidance of normal activities.
• Affecting sleep, concentration, self-esteem, or daily routines.
• Making a child or teen’s day harder across home, school, or social settings.

You do not have to know whether it is OCD before asking for help. A professional evaluation can help clarify what is happening and what kind of treatment may fit.

At Nevada Mental Health, OCD treatment may include diagnostic evaluation, therapy referrals, medication management, and, for appropriate patients, advanced options such as TMS.

If you or someone you know is in immediate danger, thinking about suicide, or unable to stay safe, call 911 or call or text 988 for the Suicide and Crisis Lifeline.