When most people hear "OCD," they picture someone washing their hands until they bleed or checking the stove door five times before leaving the house. These are real presentations of Obsessive-Compulsive Disorder — but they represent only a fraction of how OCD actually shows up in people's lives. Millions of people are living with OCD right now without knowing it, often because their symptoms don't look anything like what they've seen on TV. Many have been told they have anxiety, depression, or even a personality disorder. Some have been in therapy for years without getting better, because the real problem was never identified.
This post is for anyone who has a sense that something is "off" in their mind — a relentless mental loop they can't escape, a fear that feels shameful and strange, or a pattern of behavior they can't explain. You deserve accurate information.
What OCD Actually Is
OCD is driven by two interlocking mechanisms: obsessions and compulsions.
Obsessions are intrusive, unwanted thoughts, images, or urges that cause significant distress. They feel "sticky" — they show up uninvited, and the harder you try to push them away, the louder they get. Compulsions are the behaviors or mental acts a person performs to reduce that distress, even temporarily. The relief never lasts, so the cycle repeats.
What most people don't realize is that compulsions are often invisible. They don't have to be physical rituals. Mental compulsions — silently reassuring yourself, mentally reviewing past events, trying to "neutralize" a thought — are just as common and just as disabling as anything you can see from the outside.
Why OCD Goes Undiagnosed
Several factors make OCD easy to miss — both for clinicians and for the people experiencing it.
It masquerades as other conditions. The anxiety OCD produces can look identical to generalized anxiety disorder. The low mood and hopelessness that come from living with relentless intrusive thoughts can look like major depression. The avoidance behaviors OCD creates can resemble social anxiety or even agoraphobia. When a treatment team focuses on the surface symptoms without recognizing the OCD underneath, therapy may help somewhat but rarely leads to lasting change.
Standard anxiety treatments can make it worse. This is a critical point. Many well-meaning therapists treat OCD-driven anxiety with approaches designed for generalized anxiety — relaxation techniques, reassurance, helping clients avoid triggers. For OCD, this is like pouring gasoline on a fire. OCD feeds on reassurance and avoidance. Without specific treatment (primarily Exposure and Response Prevention, or ERP), symptoms tend to worsen over time.
People are ashamed to disclose the real content of their thoughts. This brings us to what clinicians often call "taboo OCD" — and it's where the most underdiagnosis happens.
Taboo OCD: The Type People Are Afraid to Name
There is a category of OCD subtypes defined by the fact that the obsessional content is deeply disturbing to the person experiencing it. These thoughts are ego-dystonic — meaning they feel completely at odds with who the person is and what they value. That is precisely what makes them so distressing, and precisely what makes them so easy to misidentify.
Here are some of the most common taboo subtypes:
Harm OCD involves intrusive thoughts about harming others — often the people the person loves most. A new parent might be tormented by unwanted images of hurting their baby. A devoted partner might have sudden intrusive thoughts about violence toward their spouse. The person experiencing these thoughts is horrified by them. They are not a sign of intent; they are a hallmark of OCD in someone with a strong conscience.
Pedophilia OCD (POCD) causes intrusive fears that the person may be attracted to children. This subtype is particularly undertreated because sufferers are terrified to tell anyone — therapists included. They spend enormous energy mentally reviewing their feelings, seeking reassurance, and avoiding situations involving children. The distress is profound, the shame is paralyzing, and tragically, POCD is sometimes misidentified as something it is categorically not.
Sexual Orientation OCD (SO-OCD) involves obsessive doubt about one's sexual orientation — not as an authentic process of self-discovery, but as a relentless, anxiety-driven loop that brings no resolution. Sufferers may compulsively "check" their reactions to people, seek constant reassurance, or ruminate for hours. This is distinct from genuine questioning and should not be conflated with it.
Religious or Scrupulosity OCD centers on fears of sin, blasphemy, or moral contamination. A person might obsess over whether they had a "bad thought" during prayer, confess the same sin dozens of times seeking certainty of forgiveness, or avoid religious practice entirely for fear of doing it wrong. This subtype is frequently mistaken for a crisis of faith or an anxiety disorder with religious content.
Relationship OCD (ROCD) involves obsessive doubt about romantic relationships — whether you truly love your partner, whether they are "the right one," whether you're somehow deceiving them or yourself. It can be misidentified as ambivalence, commitment issues, or even a personality disorder.
What all of these subtypes share: the person is not their thoughts. The thoughts are intrusions, not reflections of character or desire.
How Taboo OCD Gets Misdiagnosed
When someone with harm OCD or POCD finally works up the courage to tell a provider about their thoughts, a few things can go wrong. A clinician unfamiliar with OCD may focus on the content of the thoughts rather than the structure of the cycle. They may recommend further assessment for safety risk rather than recognizing the OCD pattern. In some cases, the person is labeled with something like "intrusive thoughts" or a personality disorder and given a treatment that does nothing to address the underlying mechanism.
More often, the person never discloses the thoughts at all. They present with "anxiety" or "depression" and receive treatment for those surface symptoms while the OCD continues unchecked. They may spend years in supportive therapy that feels meaningful but doesn't move the needle, because the core OCD cycle was never targeted.
What Effective Treatment Looks Like
The gold-standard treatment for OCD is Exposure and Response Prevention (ERP), a specific form of cognitive-behavioral therapy. In ERP, clients gradually face the situations and thoughts that trigger obsessions — while deliberately refraining from compulsions. Over time, the brain learns that the feared outcomes don't occur and that the anxiety is tolerable and temporary.
For taboo OCD specifically, this means a therapist who is comfortable sitting with the disturbing content without reacting to it as a danger signal, and who understands that engaging with the thought's content (trying to disprove it, reassure the client it isn't true) is itself a form of accommodation that strengthens the cycle.
Inference-Based CBT (I-CBT) is a newer evidence-based approach that is also showing strong results, particularly for subtypes where the obsessional content feels like genuine self-doubt rather than an obvious intrusion.
Medication, particularly SSRIs at therapeutic doses, is also a well-supported treatment and is often used in combination with ERP.
What to Do If This Resonates
If you read any of this and felt a shock of recognition, that reaction matters. OCD is highly treatable — but only when it's accurately identified.
Look for a therapist who specializes in OCD and is specifically trained in ERP. The International OCD Foundation (iocdf.org) maintains a therapist directory. When you contact a potential therapist, it is completely appropriate to ask whether they have experience with OCD, with ERP, and with taboo subtypes specifically.
You are not defined by your intrusive thoughts. The fact that they horrify you says more about your values than it does about any supposed threat within you. Help exists, and you don't have to keep white-knuckling through this alone.
If you're a therapist reading this and want to discuss OCD-informed care, feel free to reach out. Consultation and training in this area can be genuinely life-changing for clients who have been stuck and we can offer 1 free consultation and refer you to some great organizations for low-cost training.