Obsessive-Compulsive Disorder (OCD) impacts approximately 1 in 200 children and adolescents in the United States. While many people associate OCD with stereotypes like excessive hand washing, organization, or perfectionism, OCD does not look the same for every individual. Regardless of the specific presentation, identifying it early is important for ensuring the best possible outcomes. To understand the different presentations of this condition, it is helpful to first understand exactly what OCD is.

OCD is characterized by a cycle of two interconnected experiences:

• Obsessions: Unwanted recurrent thoughts, images, or urges that cause significant distress or anxiety. These are thoughts that are difficult to let go of, often leading to individuals feeling “stuck” on them.
• Compulsions: Repetitive behaviors or mental acts that are performed in an attempt to get rid of OCD thoughts or neutralize them.

Individuals with OCD may experience obsessions, compulsions, or both, and the specific content and presentation vary widely from person to person. Here are some of the subtypes of OCD:

Contamination OCD:

This subtype involves persistent fears about germs, illness, or contamination, often paired with intense anxiety about becoming sick or causing harm to others. These fears are not alleviated by reassurance and typically lead to ritualized behaviors and/or avoidance.
Examples of obsessions:

• Fears of contracting a serious illness despite minimal or no actual risk.
• Intrusive thoughts about spreading germs to others and causing harm.
• Recurrent thoughts that contact with bodily fluids, shared surfaces, or certain environments has caused contamination.
• Persistent doubts about whether something is truly clean.

Examples of compulsions:

• Repetitive or prolonged handwashing, showering, or bathing.
• Ritualized cleaning or disinfecting of surfaces, clothing, or personal items.
• Mental rituals like replaying interactions to check for contamination.

Harm OCD:

This subtype involves obsessive worry about causing harm to oneself or others, despite having no desire to do so. Common behaviors include frequent reassurance-seeking to confirm safety and avoiding objects that the individual fears could be used to cause harm.
Examples of obsessions:

• Intrusive thoughts or images of stabbing, hitting, or assaulting a loved one.
• Fear of losing control and harming others, such as pushing someone in front of a train or driving off the road.

Examples of compulsions:

• Hiding objects that could be used as a weapon.
• Replaying events in the mind to prove no harm was caused to others.
• Retracing steps to make sure no one was harmed or hit.

“Just Right” OCD:

This is characterized by intense discomfort with a feeling that something is “off,” uneven, or “not just right.” An individual may feel the need to do or re-do certain movements or actions until it feels “just right.”
Examples of obsessions:

• Recurrent thoughts that items are uneven, misaligned, or incorrectly arranged.
• Persistent doubts that something is not in the “exact right” place.
• Intrusive urges to make things feel complete, exact, or perfectly arranged.

Examples of compulsions:

• Rewriting or retyping things.
• Repeating actions like walking through a doorway or turning lights on and off.
• Counting or tapping.
• Moving items to even things out.

Pedophilia OCD:

This involves obsessive worry about whether one is sexually attracted to children. As with most OCD themes, these thoughts are ego-dystonic, meaning the thoughts are not aligned with the person’s values or desires, often leading to shame or guilt.
Examples of obsessions:

• Recurrent doubts such as, “What if I’m secretly attracted to kids?”
• Fear that a normal physical sensation means sexual interest.
• Persistent rumination about past interactions, like asking “What if I did something inappropriate when changing the baby’s diaper?” or “Did I touch them inappropriately without realizing it?”
• Intrusive images or thoughts involving children that feel alarming and unwanted.

Examples of compulsions:

• Excessive mental reviewing of past interactions with children to “make sure” nothing inappropriate occurred.
• Checking to see if feeling aroused.
• Comparing reactions to children versus adults to test attraction.
• Seeking reassurance from friends and family, asking things like “You know I would never do that, right?”

Relationship OCD:

This involves obsessive worry about whether one is in the right relationship or truly attracted to a partner. It includes doubts about the partner’s commitment to the relationship and frequent reassurance-seeking.
Examples of obsessions:

• Intrusive doubts such as “What if I don’t really love my partner?”
• Thoughts like “What if this isn’t the right relationship?”
• Worrying “What if I’m not truly attracted enough?”
• Persistent fears that “Maybe we’re not meant to be.”

Examples of compulsions:

• Persistent mental debate or analysis about the pros and cons of the relationship to “figure out” the truth.
• Compulsively comparing the relationship to those of friends or couples on social media.
• Repeatedly asking the partner for reassurance, such as “Do you really love me?”

Sexual Orientation OCD:

This involves intrusive doubt about one’s sexual orientation or fear that it may be different from what one believes it is. The core struggle is not genuine identity exploration, but a compulsive need for certainty that turns normal thoughts and feelings into sources of distress and doubt.
Examples of obsessions:

• Recurrent doubts such as “What if I’m not the orientation I think I am?”
• Persistent fear of being “in denial” about one’s true identity.
• Intrusive thoughts questioning past attractions or relationships, such as “What if that meant something?”
• Hyperawareness of thoughts or reactions around people of the same or different gender.

Examples of compulsions:

• Testing reactions to photos or videos to check attraction.
• Mentally reviewing past sexual experiences.
• Repeatedly checking for arousal or physical sensations.
• Seeking reassurance from others about what specific thoughts or reactions “mean”.

Scrupulosity OCD:

This presentation involves intrusive, distressing fears about committing moral or religious wrongdoing. Individuals may become preoccupied with whether one’s thoughts, intentions, or actions violate religious teachings or ethical standards. The core struggle is an overwhelming need for moral certainty and fear of being sinful, offensive to God, or deserving of punishment.
Examples of obsessions:

• Doubt in one’s religious beliefs, such as “What if I don’t believe?”
• Recurrent and intrusive doubts about committing a sin.
• Worry about the purity behind one’s actions.
• Worry that making a mistake will bring bad luck or bring bad luck to others.

Examples of compulsions:

• Seeking excessive reassurance from others that one is a “good person” or did the right thing.
• Mentally replaying conversations to check for offensive comments or lies.
• Excessive confession or prayer rituals.
• Compulsively researching religious doctrines or texts.

Existential OCD:

This presentation involves intrusive, distressing doubts about reality, existence, consciousness, or the meaning of life. Rather than engaging in philosophical curiosity, the individual feels stuck in repetitive questioning and an urgent need for certainty about unanswerable questions. The more these thoughts are analyzed, the more distressed and uncertain the individual feels.
Examples of obsessions:

• Intrusive doubts about reality, such as “What if none of this is real?”
• Fear of being in a dream, simulation, or alternate reality.
• Persistent questioning of existence, like “How do I know I exist?”

Examples of compulsions:

• Repeatedly “testing” reality, such as touching objects, checking mirrors, or performing actions to feel real.
• Seeking reassurance from others that things are real.
• Mentally debating or analyzing existential questions for hours.
• Compulsively consuming philosophical, scientific, or religious material in an attempt to find certainty.

Understanding the Whole Picture

Whether the fear is about relationships, morality, harm, or existence itself, the core cycle of obsessions and compulsions remains the same. Recognizing the diverse ways OCD manifests is one of the first steps toward getting the right help. If you recognize any of these patterns in your teen, know that these symptoms are treatable. Evidence-based care can help teens navigate these complex challenges and get back to living their fullest lives.