Verified by 
Public and professional understanding of obsessive-compulsive disorder (OCD) has dramatically improved within the last decade. GPs are now more likely to pick up that a patient may be living with OCD and refer them appropriately. Though people do still misuse the term OCD ("I’m so OCD about my pencil case!" etc.), a search under the OCD hashtag on a social media platform is now far more likely to bring up actual OCD-related content posted by sufferers, rather than pictures of wonky paving stones and "arghhh! My OCD!" captions or jokes about "obsessive cat disorder."
Nevertheless, it is still not unusual for someone with OCD to wait a long time before seeking help or getting a diagnosis. The average time between symptom onset in OCD and receiving help varies according to which source you read, but most put it in the region of over a decade. Anecdotally speaking, as someone who knows many people with OCD through both attending and facilitating support groups and workshops, it often seems to me that the delay in accessing support or receiving a diagnosis is greatest where the sufferer experiences mental compulsions rather than overt, physical compulsions. But what, you may wonder, are mental compulsions?
All OCD involves experiencing obsessions (unwanted thoughts that cause you significant distress, such as "something bad is going to happen to my family") followed by compulsions, which are the action taken in response to the distressing thought (e.g., "I must touch my toes 20 times to stop this bad thing from happening to my family"). What is often not properly understood, even by doctors and mental health professionals, is that the action taken does not have to be physical. A person who begins to count in their head, or internally repeat a phrase that feels like it "neutralises" or "fixes" their thought about something bad happening to their family, is just as actively performing a compulsion as the person who touches their toes in response.
As Patricia Zurita Ona, Psy.D. (also known as Dr. Z.), author of Living Beyond OCD Using Acceptance and Commitment Therapy, comments: "Mental compulsions are mental actions that vary from simple to complex; they’re equally distressing as public compulsions, can be triggered by any type of obsession, and serve the purpose of getting rid of the fear, terror, and dreadful feelings, even just for a little bit." My observation that those who mainly or entirely experience mental compulsions may take longer to receive help probably makes intuitive sense. In my experience, the greatest upside of doing compulsions in your head is that no one will notice. The greatest downside of doing compulsions in your head is that no one will notice.
On the one hand, this means you will be less likely to attract stares or be viewed by others as "abnormal" or "weird." On the other hand, it also means your OCD is more likely to fly under the radar and remain unnoticed by family, friends, and professionals, even if it causes you significant distress.
When I performed mental compulsions as a child and teenager, which mainly involved making mental lists of things I might have done wrong and then chanting them internally, people described me as "glazed over" or "far away." Far from being seen as symptoms of a debilitating condition, they simply earned me the fairly coveted status of "dreamy thinker" (it probably helped that I was a keen member of the school’s creative writing club). This is very different from the responses (namely, "that is clearly a Mad Person") I have received from strangers when I experience physical compulsions that tell me to try out every seat in a train carriage until I find the one that "feels right." In the words of Dr. Z, "mental compulsions are less easily identifiable than public ones primarily because they’re so well hidden."
The nature of mental compulsions probably means that while the onus is still on therapists, psychologists, and psychiatrists to ask questions that allow room for people to identify and report them, you are often the first step in the process of spotting them. This is of course particularly relevant if you are not receiving any mental health support. A GP is likely to notice if you can’t stop touching your toes during your appointment. But they are not psychics, so they are far less likely to notice if you spend the majority of the appointment internally chanting the words "without sloths, there would be no avocados" so that your family members don’t spontaneously combust (yes, mental compulsions can be this random).
To help you get better at spotting potential mental compulsions, below is a list of some of the different types that sufferers may experience, provided by Dr. Z:
- Saying words, numbers, or phrases
- Counting words, letters, numbers, or objects
- Repeating/making lists of individual items or categories
- Replacing an obsession with a different image or word
- Saying prayers
- Scanning thoughts, sensations, feelings, reactions, or emotions
- Reviewing and replaying past situations
- Dissecting and scrutinising past situations with potential what-if scenarios
- Anticipating future situations with or without potential what-if scenarios
- Trying to figure out the meaning of internal experiences such as thoughts, images, sensations, and feelings
- Trying to figure out major life issues or existential matters
It’s important to note that simply experiencing one of the above examples does not mean you have OCD or that you are experiencing mental compulsions. Clearly, the average person who is praying or wondering about existential matters probably does not have OCD. Like with all OCD, the important thing to consider is how much time these actions take up, and, significantly, how much distress they cause you. The experience of compulsive praying as a safety behaviour (to come back to the early example, repeating "please God do not let my family die" a great number of times), feels very different from the experience of praying because you are engaging in a spiritual practice that adds meaning to your life.
That said, if you do have OCD or are questioning whether you might, the above list offers a helpful starting point from which to consider your experience.
For further information on mental compulsions, as well as a detailed explanation and examples of all of the above-listed mental compulsions, you can visit Dr. Z’s blog.
LinkedIn Image: tommaso79/Shutterstock. Facebook image: JuliSavel/Shutterstock
