Obsessive compulsive disorder (OCD) is a complicated and heterogeneous disorder, characterised by the presence of unwanted thoughts, known as obsession, and repetitive behaviours, labelled compulsions (American Psychiatric Association, 2022). Despite the various manifestations of OCD, public knowledge of these differing presentations is often very limited. Modern media often depicts very specific themes seen in OCD such as fears of contamination, or a need for order and cleanliness, whilst neglecting to showcase other subtypes of OCD. This provides a very limited scope and general understanding of the heterogeneity of OCD presentations. In turn, this may result in individuals who experience less common themes of OCD to be less likely to recognise their own symptoms, thus not seeking help. Furthermore, OCD involving harm or taboo content is often less represented, and more heavily stigmatised (McCarty et al., 2017). The combined effect of poor OCD representation, and stigmatisation increase the risk of individuals not seeking professional help. Thus, to address this lack of representation, this blog will discuss three lesser-known OCD subtypes, including relationship OCD, Scrupulosity OCD, and Tourettic OCD. However, it is important to note that, although different themes or subtypes may be present in OCD, they are not classified as separate diagnosable categories but instead provide important context for an individual’s experience of living with this disorder.
Obsessive compulsive disorder affects people in many different ways, yet awareness of its diverse presentations remains limited. Understanding OCD symptoms and recognising when professional OCD treatment may be needed can help individuals access support sooner. While evidence-based approaches such as cognitive behavioural therapy (CBT) and medication remain first-line interventions, newer treatments such as Transcranial Magnetic Stimulation (TMS) are increasingly being explored for individuals with treatment-resistant OCD, as well as those experiencing co-occurring anxiety or depression.
Seeking professional support through evidence-based OCD therapy can help individuals better understand and manage symptoms, regardless of the specific subtype they experience.
A prime example of a lesser-known subtype of OCD is relationship OCD (ROCD). To gain a better grasp of ROCD, this blog will aim to first provide some basic information on the mechanisms underpinning this OCD subtype, followed by discussing its potential long-term consequences. This is a subtype of OCD where the focus of unwanted thoughts and subsequent compulsions are focused on intimate relationships (Doron et al., 2014). Individuals with ROCD may experience frequent intrusive thoughts concerning the “rightness” of the relationship, doubts about love, or their partner’s feelings, and may be preoccupied with thoughts regarding perceived flaws in their partner. Importantly these thoughts are entirely unwanted and uncontrollable and are not consistent with the values of the individual experiencing ROCD. In turn, this may lead to compulsions such as reassurance seeking from the partner, constantly monitoring their own feelings, comparing partners to others, and general rumination (Doron et al., 2014). This often results in significant distress to the individual with ROCD, as well dysfunction in their romantic relationship. ROCD, much like OCD, involves significant maladaptive self-monitoring, constantly checking in with one’s internal state regarding love and attraction. Paradoxically, this produces the opposite effect, as constant self-monitoring generates anxiety that clouds access to genuine feelings and emotions (Doron et al., 2014).
Furthermore, the long-term consequences of ROCD result in negative impacts on both the relationship, as well as the individual with ROCD. In terms of the relationship, ROCD may lead to lower relationship satisfaction, increased conflicts, and a higher risk of a breakdown in the partnership. On the other hand, when considering the impact on the individual level, people with ROCD can experience very high levels of anxiety, guilt and shame (Doron et al., 2014). Additionally, ROCD much like OCD shows high comorbidity with depression, and general reduced wellbeing, with impaired social functioning (Doron et al., 2014). To conclude, ROCD has detrimental impacts on a multitude of levels, with obsessions and compulsions clustered around relationship themes. Whilst ROCD is not a distinct diagnosis, being able to recognise these symptoms increase the likelihood of individuals seeking professional help.
Like other forms of OCD, ROCD can have a significant impact on quality of life and may benefit from professional OCD therapy and treatment tailored to the individual's symptoms and circumstances.
A second subtype that will be discussed in this blog is Scrupulosity OCD, linking obsessions and compulsions to a central theme of religion. The International OCD Foundation (IOCDF) characterises scrupulosity OCD as experiencing religious or moral obsessions, as well as constant fears surrounding violating religious principles or ethical systems. Examples of religious compulsions may include excessive or intensely ritualised prayer, mental neutralizing of unacceptable thoughts, excessive confessing or need to consult with the clergy, as well as excessive mental checking or washing (Siev et al., 2011). Interestingly, often times individuals with this subtype of OCD initially desire to be scrupulous and exhibit this behaviour in a nonpathological way, but through time the ritualised behaviour becomes more excessive, until functioning is severely impeded (Greenberg & Huppert., 2010). Whilst the initial amount of concern is considered appropriate, normal religious rituals become compulsions that elicit inappropriate levels of fear and anxiety.
A key difficulty faced when trying to identify scrupulosity OCD lies in being able to distinguish it from normal religiosity. Previous research has shown that secular individuals are not able to accurately distinguish between regular Jewish rituals from OCD rituals (Rosmarin et al., 2010). On the other hand, religious individuals showed significantly more accurate results, being capable of distinguishing the two (Rosmarin et al., 2010). This highlights the importance of mental health professionals being well-informed and knowledgeable of various religious practices and norms. A lack of awareness and understanding of scrupulosity OCD, both among mental health professionals and individuals affected by the condition, represents a significant barrier to achieving positive treatment outcomes (Greenberg & Huppert., 2010).
Early recognition of Scrupulosity OCD is important, as appropriate OCD treatment can help individuals distinguish between healthy religious practice and compulsive behaviours driven by anxiety and obsessional thinking.
A final lesser-known subtype emerging in current research is Tourettic OCD (TOCD). Similarly to ROCD or Scrupulosity OCD, TOCD is not a separate subtype diagnosable through the DSM-5, but rather an intermediate psychiatric condition encapsulating elements from both OCD and Tourette Syndrome (TS) (Katz et al., 2022). A common element seen in both OCD and TS is the feeling of discomfort that precedes a particular behaviour. In the case of OCD, the behaviour refers to the compulsive ritualized actions used to alleviate emotional discomfort, usually intense feelings of anxiety (Katz et al., 2022). On the other hand, in TS, the discomfort is not emotional, but rather a physical or sensory premonitory urge that precedes tic behaviours (e.g., facial grimacing, blinking, vocalisations, etc). Both conditions involve repetitive behaviours, yet suppression of these behaviours differ between OCD and TS. In OCD, suppression of a compulsion involves much higher order cognitive control and awareness, whilst in TS tics are entirely involuntary and require motor control to suppress (Katz et al., 2022).
Interestingly, TOCD presents slightly differently than OCD or TS alone, instead incorporating elements from both conditions. In TOCD, individuals experience a somatic premonitory urge prior to the behaviour, this urge often being associated with OCD-like cognitions such as something feeling “not right” or needing things to be “just right”. Furthermore, the behaviour itself also blends elements from both conditions, presenting as repetitive complex motor movements, often incorporating several steps such as tapping, arranging, or completing the action a certain number of times. Interestingly, the ability to suppress this behaviour has been found to be more difficult than OCD or TS alone. Neuropsychology provides further evidence for the overlap between OCD and TS, with both conditions sharing a core neurocircuitry mechanism, the cortico-striatal-thalamo-cortical pathway (Katz et al., 2022). Therefore, when treating an individual with TOCD it is crucial that elements from both conditions are simultaneously addressed to increase the potential for a positive treatment outcome.
Due to its overlap with both OCD and Tourette Syndrome, effective treatment often requires a comprehensive and individualised approach that addresses both obsessive-compulsive symptoms and tic-related difficulties.
To conclude, whilst OCD is often portrayed through a very narrow lens, this oversimplifies and undermines the true complexity and heterogeneity of the condition. Subtypes such as Relationship OCD (ROCD), Scrupulosity OCD, and Tourettic OCD (TOCD) highlight the many ways obsessive compulsive disorder can present, showing why OCD symptoms are often misunderstood or overlooked. Increasing awareness of these experiences can help improve early identification, reduce stigma, and encourage individuals to seek appropriate OCD treatment and support.
In recent years, Transcranial Magnetic Stimulation (TMS) has emerged as a promising treatment option for individuals with treatment-resistant OCD. TMS therapy uses targeted magnetic pulses to stimulate specific areas of the brain involved in obsessive thoughts, compulsive behaviours, and anxiety. Research suggests that TMS for OCD may help reduce symptom severity, improve daily functioning, and enhance overall quality of life. As a non-invasive treatment that does not require anaesthesia or medication changes, TMS is becoming an increasingly recognised option within modern mental health care. TMS may also benefit individuals experiencing co-occurring conditions such as depression and anxiety, which are commonly associated with OCD.
At Smart TMS, we provide evidence-based TMS treatment for OCD for individuals who have not achieved sufficient symptom relief through conventional treatments alone. TMS works by targeting brain networks involved in obsessive-compulsive symptoms, helping to reduce the intensity and frequency of obsessions and compulsions.
Our experienced clinical team offers comprehensive assessments to determine whether TMS therapy may be suitable for your individual needs. With clinics located across the UK and Ireland, Smart TMS is committed to improving access to innovative, non-invasive mental health treatments delivered within established clinical governance frameworks.
If you are looking for OCD treatment, OCD therapy, or would like to learn more about TMS for OCD, treatment-resistant depression, or anxiety disorders, our team is here to help. Contact Smart TMS today to discuss your symptoms, learn more about TMS treatment for OCD, and find out whether this evidence-based, non-invasive therapy could form part of your path towards recovery.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Doron, G., Derby, D. S., & Szepsenwol, O. (2014). Relationship obsessive compulsive disorder (ROCD): A conceptual framework. Journal of Obsessive-Compulsive and Related Disorders, 3(2), 169–180. https://doi.org/10.1016/j.jocrd.2013.12.005
Greenberg, D., & Huppert, J. D. (2010). Scrupulosity: A unique subtype of obsessive-compulsive disorder. Current Psychiatry Reports, 12(4), 282–289. https://doi.org/10.1007/s11920-010-0127-5
Katz, T. C., Bui, T. H., Worhach, J., Bogut, G., & Tomczak, K. K. (2022). Tourettic OCD: Current understanding and treatment challenges of a unique endophenotype. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.929526
McCarty, R. J., Guzick, A. G., Swan, L. K., & McNamara, J. P. H. (2017). Stigma and recognition of different types of symptoms in OCD. Journal of Obsessive-Compulsive and Related Disorders, 12, 64–70. https://doi.org/10.1016/j.jocrd.2016.12.006
Rosmarin, D. H., Pirutinsky, S., & Siev, J. (2010). Recognition of Scrupulosity and Non-Religious OCD by Orthodox and Non-Orthodox Jews. Journal of Social and Clinical Psychology, 29(8), 930–944. https://doi.org/10.1521/jscp.2010.29.8.930
Siev, J., Baer, L., & Minichiello, W. E. (2011). Obsessive-compulsive disorder with predominantly scrupulous symptoms: Clinical and religious characteristics. Journal of Clinical Psychology, 67(12), 1188–1196. https://doi.org/10.1002/jclp.20843