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Queer Themes in OCD
There are a number of ways in which OCD and LGBTQIA+, polyamorous, and kink communities intersect
While OCD has as many manifestations as there are colors in the rainbow, some OCD themes may present more frequently in the LGBTQIA+ community as well as the polyamorous, kink, and other non-traditional relationship communities. The purpose of this article is to identify some interesting trends and unique OCD themes I have noticed in working with these populations.
In my experience, folks in these communities have a greatly increased chance of their OCD latching on to themes involving sexual orientation, gender, and/or relationships. This may be because folks in these communities have an increased awareness of the role that sexuality, gender, and relationships play in their lives, as they may have had to fight for, accept, process, and wrestle with these concepts more than others. Therefore, when the broken alarm system that is OCD creates an urge to scan one’s life for potential problems, folks in these populations may be more predisposed to obsess around these themes.
A little precursor before we jump into some examples: it is completely healthy and even expected for a given individual to struggle at some point in their lives with many of these concepts. When I talk about OCD however, I am describing a situation where an individual finds it so difficult to tolerate fears that they may be concluding something incorrectly that they spend an excessive amount of time and energy trying to achieve certainty, which significantly impacts their daily functioning. This search can include observable actions such as googling, asking friends, or testing if one’s genitals respond to different images, as well as covert compulsions such as mentally reviewing information and engaging in an endless internal debate. If an individual has OCD, the therapeutic goal is to build an ability to identify their best guess and tolerate the uncertainty that it is wrong. For more about the nuances of treatment, check out this and this article.
The following are some themes that folks with OCD that I worked with or know have obsessed over:
Relationship OCD (ROCD):
Many queer folks face rejection and descrimination from others, including their biological family. Therefore, the people they choose to bring into their lives can carry an extra special importance to them. Sometimes, this can lead to folks feeling extra pressure to choose the right person to be in a relationship with or especially fear losing the person they’ve chosen.
Some folks in queer communities may compulsively respond to this pressure through avoiding intimacy. For example, one trend amongst gay and bi men seems to be an increased likelihood of engaging in flippant sexual encounters either to avoid the risk of intimacy or to compulsively check elements about their sexual orientation.
Queer folks with ROCD may obsessively ask:
How do I know if I’ve found the one?
How do I know if my partner will leave me?
Is our relationship passionate enough?
Am I sexually attracted to my partner enough?
How do I know if I’m gay enough, masculine enough, feminine enough, or queer enough for my partner?
How do I know if my partner is gay enough, masculine enough, feminine enough, or queer enough for me?
Sexual Orientation OCD
At first, sexuality and gender themed OCDs colloquially fell under a category (not created by psychologists, but by those within the OCD community) called Homosexual OCD (HOCD). Nowadays we understand sexuality to be far more complex than a gay-straight binary and likewise understand that OCD themes can be more nuanced as well. The umbrella these themes fall under is now usually referred to as Sexual Orientation OCD (SO-OCD). Folks struggling with SO-OCD may obsessively ask:
I identify as straight but what if I’m wrong? How do I know if I’m really straight?
I identify as gay but what if I’m wrong. How do I know if I’m really gay?
I identify as bisexual/pansexual but mostly pursue X gender. What if I’m wrong in determining the “ratio” of my bisexuality/ pansexuality? What if I’m not actually bisexual or pansexual? How do I know if I’m bisexual or pansexual?
I identify as (any sexual orientation) but what if I’m wrong. How do I know what to identify as? Which labels describe me best?
Gender OCD (GOCD)
This theme has had somewhat of a rising trend the last few years as more folks learn that one’s gender identity is a choice, which can evoke distress that one’s choice could be “wrong”. While GOCD can come up in someone who has no innate desire to transition or alter their gender but fears that they could be wrong, it can also come up in those who genuinely want to transition and fear that they may make the wrong choice. Folks struggling with GOCD may obsessively ask:
I identify as cis-gender, but what if I’m wrong?
I identify as transgender, but what if I’m wrong? How do I *know* if I’m trans?
Should I take hormones? Should I get surgery?
How do I know how much transitioning I want to do? When should I stop transitioning?
How do I know what to identify as? What pronouns should I use?
Pedophilia OCD (POCD)
One harmful and baseless stereotype about queer folks, especially gay men, is that they are malevolent pedophiles. Growing up with these stereotypes can lead to internalized homophobia, which in turn can inspire OCD to manifest around the theme of pedophilia. Folks with POCD may ask:
How do I know if I’m a pedophile?
What are signs that I’m a pedophile?
What if I get arrested under suspicion that I’m a pedophile because of XYZ?
Polyamory, Kink, and other Non-traditional Relationship Styles
Folks with OCD who identify as polyamorous or engage in other non-traditional relationship styles sometimes struggle with the freedom of choice and lack of imposed structure inherent in these relationship styles. They may obsessively ask:
How open or closed should my relationship be?
Do I really want to be poly? What if it’s just avoidance of intimacy?
How do I know what labels to use for my partners?
What if I’m making the wrong choice? Will polyamory ruin my relationship?
For kink-centric relationships:
Am I giving too much power to my partner?
What if I’m too kinky or not kinky enough for my partner?
What if asking to include my kink more in the relationship will ruin it?
Of course the above are all just a sampling of the many ways that OCD can manifest. If you don’t see yourself reflected above but are still struggling with obsessions and compulsions, know that OCD is as unique and diverse as humanity itself. That said, it is my hopes that pointing out these trends can help some readers feel less alone in their struggles. As I always say, OCD is very treatable. If you’ve been struggling, don’t wait any longer to seek help!
What can Therapy Change?
How can therapy help me with my OCD?
When folks come to therapy it is often with the hopes that their clinician can “get rid of” their Obsessive Compulsive Disorder (OCD) and help them achieve certainty about their obsessive topic. For better or for worse, therapy cannot so radically change the automatic processes of a person’s mind, nor can certainty be provided around any topic*. However, this does not mean that someone with OCD must accept all the distress that they are experiencing, unbridled and unmitigated. Therapy can be expected to reduce overall distress, but it’s important to understand what types of distress therapy targets.
To understand what types of distress therapy seeks to reduce, we must first have a language for describing distress in different ways. In OCD treatment, we often draw from the Bhuddist distinctions of “pain” and “suffering”.
Pain can be described as the inevitable, unavoidable challenges of life. These can include bigger life events such as losing a job, going through a breakup, or suffering an injury, as well as smaller everyday experiences such as experiencing stress from deadlines or experiencing unwanted intrusive thoughts.
Suffering on the other hand is what we add to the pain due to our maladaptive relationships to those unavoidable experiences. Examples include avoiding, ruminating, drinking, numbing through media, beating ourselves up, obsessing, and compulsing.
Pain generally makes up a small minority of the overall distress in any given person’s life. Instead, it is our engagement with suffering that really degrades the quality of our lives. In therapy we learn how to accept the slim minority of distress (intrusive thoughts and emotions) in order to dramatically reduce that which is causing the majority of our distress (obsessing and compulsing). As a result, our overall level of distress dramatically reduces and the quality of our lives improve significantly.
There is another pragmatic way to look at the types of distress we experience and how they can be affected by effective therapy. We can measure our intrusive thoughts through four categories: duration, frequency, content, and intensity. Therapy can be expected to affect each of these variables in different ways.
Duration: By engaging in skillful response prevention, one can have a direct effect on the duration of each experience with an intrusive thought. The logic here is simple: by resisting the urge to respond to the question or thought our brains produce, we speed up the time it takes for the experience to pass on its own.
Intensity: This in turn decreases the likelihood of experiencing intense distress. Rarely do we experience out of the blue a ten out of ten level of distress from OCD. Intense distress most often comes from our obsessing and compulsing and trying to escape the distress. By acting unskillfully, we add fuel to the fire and end up feeling more uncertain and more concerned. By engaging in response prevention, we can starve that fire, preventing it from reaching certain intensities far more often.
Content: Interestingly, our work can often have an effect on the content of OCD, but not in the way you might think. When we engage in response prevention, we send our brains a signal that we’re not going to explore the topic that it has deemed a potential emergency. As a result, the brain may search for other “emergencies” to explain why it’s experiencing distress. In fact I often see theme switching as a positive (but not necessary) sign that one is being skillful with their OCD. Essentially it doesn’t matter at all if one’s theme switches or not, but understanding that it might can help one not become surprised or dismayed when it happens but instead see it as a result of their skillfulness.
Frequency: In my experience in working with clients, a moderate level of adherence to Exposure and Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT) protocols can quickly have effects on the duration and intensity of intrusive thoughts, but the frequency of experiencing intrusive thoughts are more stubborn. What this means is that an individual may still experience intrusive thoughts a number of times each day, but they have the skills and ability to usually let those experiences last just a moment and remain at a low intensity. However, that is not to say that the frequency of intrusive thoughts can’t be affected at all by our work. It is my belief and personal experience that achieving a stellar level of response prevention, through self exploration and understanding the nuanced, subtle ways that we may still be compulsing, can reduce the frequency of intrusive thoughts.
Knowing what change can be expected to take place through effective therapy help us invest our energy in changing what we can, accepting what is more change-resistant, and having the wisdom to identify the difference between the two. When we can skillfully balance change and acceptance, our overall level of distress plummets. It is the key to treatment success.
*In sessions, to display this point I’ll raise my right hand and discuss how there can be no certainty that this in fact is my right hand. Maybe it’s a prosthetic, maybe the client is dreaming and I don’t exist, maybe their sense of right and left is inaccurate and they’ve never realized.
What Can Our “Gut” Tell Us?
How to trust our gut when it comes to OCD.
In my early career, I often spoke ill of the phrase “gut feeling.” I would tell patients that having OCD challenged one’s ability to make decisions based on feelings because OCD creates powerful misleading emotional signals. Because much of the suffering from OCD comes from ascribing too much relevance to emotions such as a sense of dread or intense anxiety, I advised my patients to only make decisions based on their rational, logical side of their mind.
I was (sort of) wrong.
As an OCD specialist who has OCD, I am often informed not just by research in the field, but also by my personal experiences with OCD. The lesson I learned in regard to the role emotions play in decision making came from a challenge with relationship themed OCD that I experienced. In this relationship I experienced intense and frequent anxious and intrusive thoughts and feelings about whether or not it was the right relationship for me. I worked tirelessly to ascribe irrelevance to all of the signals I was experiencing because I had determined that staying in the relationship was logical and aligned with my values. However, I didn’t realize how disconnected my rational assessment was from the very real and legitimate emotions I was feeling. I had fallen into a state of mechanical logic. There were parts of the relationship that I could “feel” were not right, but I denied the validity of those feelings with lines such as “it’s against my values to judge this quality of my partner” or “rationally I understand a relationship takes work, so I need to pay this toll to be connected to someone in this way.”
My heart was sending me signals that this was not the right relationship to me, but I couldn’t tell that these were legitimate signals because at the same time, I truly was experiencing intense OCD. My relationship was a topic I could not stop thinking about, the consequences felt pressing and catastrophic, and I experienced intense anxiety for hours each day.
The most useful relationship with one’s “gut”, I finally learned through the guidance of wise clinicians, is more of a “both-and.” While it is incredibly important for anyone with OCD to learn and frequently use the skill of ascribing irrelevance to certain emotional signals, it is also integral that they be able to identify their more “authentic” or “true to self” feelings and understand what these feelings are trying to convey.
It is important to note that this should not be interpreted as me advising that every emotion should be directly listened to and dealt with, nor that they mean that acting on them is necessary. Some emotions may just be asking of us to be heard, others advise us that there is an issue that needs communication or problem solving (rather than the life or death extreme solutions OCD more often suggests).
In therapy, I still suggest that the first step is for a client to practice using response prevention ubiquitously. Prior to therapy, someone with untreated OCD has likely swung way too far in the direction of ascribing relevance to every thought and feeling. It is also easier to first focus just on learning the skill of response prevention before adding in the complex layer of when and where to apply it. However, once a client has mastered response prevention skills sufficiently, it is an important part of our work to introduce the concept of a “gut feeling” in a healthy and useful way. The client, in good therapy, learns how to distinguish what their OCD is trying to communicate versus what their true thoughts and feelings are on a given matter. In this way, the client learns how to more fully trust themselves and is able to draw from the whole spectrum of information their mind, heart, and body is seeking to convey.
OCD and Autism
Contributed by our staff, McKenzie Gelvin, M.S.
OCD and Autism Spectrum: Understanding the Overlap
Obsessive-Compulsive Disorder (OCD) and Autism Spectrum Disorder (ASD) are distinct conditions, but they can and often do occur together. When this happens, OCD can present in ways that are sometimes misunderstood or overlooked. Understanding the overlap is important because while autism may influence how OCD looks, OCD remains treatable.
Why OCD and Autism Can Look Similar
One of the main reasons OCD and autism are confused is because both can involve repetitive behaviors. However, the function of these behaviors is different. In OCD, compulsions are performed to reduce distress caused by intrusive thoughts. These thoughts are unwanted, often feel threatening, and create a strong urge to do something to feel better or gain certainty.
Examples include:
Checking to prevent harm
Mentally reviewing past events
Seeking reassurance
Avoiding situations that trigger fear
In autism, repetitive behaviors are typically related to:
Comfort and predictability
Sensory regulation
Routines or preferences
Focused interests
These behaviors are usually not performed to neutralize intrusive thoughts or prevent feared outcomes. This distinction—fear-driven vs. preference-driven behavior—is key.
When OCD and Autism Occur Together
When both conditions are present, the picture can become more complex. Some common patterns include:
Compulsions blending with routines: A behavior may look like a routine but is actually driven by anxiety or fear.
Increased rigidity: Both OCD and autism can involve difficulty with change, which may amplify each other.
Difficulty identifying obsessions: Some individuals may have trouble recognizing or describing intrusive thoughts, making OCD less obvious.
Overlapping behaviors: Repetitive actions may serve both a regulatory (autism) and anxiety-reducing (OCD) function.
Because of this, OCD is sometimes mistaken for “just part of autism,” which can delay appropriate treatment.
Why This Distinction Matters
Treating OCD requires a different approach than addressing autistic traits. If compulsive behaviors are misunderstood as routines or preferences, we might end up allowing for these compulsive behaviors, which would in turn fuel and sustain OCD.
Can OCD Still Be Treated?
Yes. OCD is treatable even when autism is present. The most effective treatment is Exposure and Response Prevention (ERP).
ERP works by helping individuals:
Gradually face feared thoughts or situations
Resist engaging in compulsions
Learn that anxiety can decrease on its own
Build tolerance for uncertainty
For individuals with autism, ERP may be adapted by:
Using more concrete and structured explanations.
Examples:
“Your OCD gives you a thought that says something bad might happen, and then it tells you that you have to do something to make yourself feel safe. We're going to practice having a scary thought without doing the thing OCD tells you to do. At first, you might feel uncomfortable, but we're going to practice staying with that feeling until you learn, ‘I can handle this feeling without compulsing.’”
“Your brain is asking you to get an answer so you can feel 100% sure. We're going to practice not asking for the answer and letting your brain be unsure.”
Incorporating visual supports: A visual aid with simple pictures or even words can be useful, for example showing a mapped out flowchart such as:
"Intrusive thought → anxiety → compulsion → temporary relief → OCD returns"
Pacing exposures more gradually (working with a client to help them slowly adjust to each new challenge)
Considering sensory sensitivities (targeting exposures to OCD content, but respecting some sensory needs if appropriate)
However, the core process of treatment remains the same.
The Most Important Thing to Remember
OCD is not defined by the content of the thoughts—it is defined by the cycle.
Even when autism is present:
Intrusive thoughts can still be addressed
Compulsions can still be reduced
Meaningful improvement is possible
Autism may influence how OCD presents, but it does not change the fact that OCD responds to the same evidence-based treatment.
Common Mental Compulsions
Contributed by staff member Cayley Gersh, M.A.
Compulsions (repetitive attempts to alleviate the distress or anxiety that often comes with uncertainty) can take many different forms. Some of the most easily recognizable forms are physical behaviors, such as cleaning, hand washing, rearranging, or checking appliances. However, other times compulsions are sneakier mental actions that an observer wouldn't be able to see. While mental compulsions can be particularly difficult to notice, identifying them is an integral first step; once identified, they can be resisted or spoiled. It is critical not to give into compulsions as they perpetuate the cycle of OCD. Only by resisting compulsions can you give your brain the opportunity to learn an alternative response pattern to the obsession or intrusive experience and thereby gain sustained relief from your OCD symptoms.
Below, we have identified frequent mental compulsions that folks engage in during exposures or in response to intrusive thoughts. Becoming familiar with these sneaky compulsions is essential in many cases to make treatment gains!
Problem solving
Planning for outcomes that haven't happened yet to assure yourself that you can handle it.
Obsession: What if I have a panic attack during the wedding?
Compulsion: Mentally planning every possible way to escape, calm down, or leave if it happens.
Suppressing
Trying to think of other thoughts or divert attention elsewhere in an attempt to suppress or avoid intrusive thoughts or the distress associated with them. Note: this is different from response prevention/mindfulness in an important way: suppression is the perspective that we want to focus on something so hard we don’t experience intrusive thoughts- response prevention is allowing our mind to say whatever it wants to, while at the same time placing attention on the present moment.
Obsession: What if you shout something offensive out loud?
Compulsion: Quick! Think about your to-do list to avoid this thought.
Searching/checking for evidence
Searching for a way to answer the unanswerable question: the "what if" that your OCD and anxiety have presented to you. There are various avenues this can take; one can check…
In the past, checking past behavior as evidence of the certainty of future behavior
Obsession: What if I cheat on my partner?
Compulsion: I have never cheated before.
Through logic: if this is true, then that is true
Obsession: What if I am a bad person?
Compulsion: Bad people don't worry about being bad, therefore I must not be a bad person.
Through feelings or sensations: if I feel this, it means that
Obsession: What if I hurt my mom?
Compulsion: If I feel upset by that thought, it means I won't.
Through mental review: let's replay past events in an attempt to determine what happened, what something meant, or whether certainty can be achieved
Obsession: What if I said something offensive?
Compulsion: Replaying the conversation repeatedly to determine exactly what was said.
Reassurance
Trying to push out intrusive thoughts by reassuring yourself that it will be ok, they won't happen, or they aren't true. Similar to how we may seek reassurance from those around us, we may internally reassure ourselves.
Obsession: What if I accidentally hit someone with my car and didn't notice?
Compulsion: No, you would definitely know if you hit someone.
Obsession: What if I don't really love my partner?
Compulsion: Of course you love them. You've been happy together for years.
Depressive compulsion
Accepting the worst-case scenario as true instead of acknowledging the uncertainty. Choosing the worst outcome brings about sadness, but it also provides a false sense of certainty, which is sometimes preferred over the anxiety and distress associated with uncertainty.
Obsession: What if ERP doesn't work for me?
Compulsion: It won't, you will be struggling with this forever.
Obsession: What if I made the wrong decision?
Compulsion: I definitely did, and I've probably ruined everything.
Mental compulsions are not dangerous or wrong; they are understandable attempts to reduce anxiety and gain certainty. However, when they become repetitive, they can keep OCD and anxiety going. The goal of ERP is not to stop intrusive thoughts from occurring, but rather to practice noticing mental compulsions and choosing not to engage with them. Over time, this helps individuals build tolerance for uncertainty and learn that anxiety can decrease on its own far more effectively without compulsions. By resisting the urge to compulse, we end up experiencing significantly less anxiety and can live happier, healthier lives.
When OCD Exposures Go Off Course: A Therapist Guide
It can be one of a new OCD therapist's biggest fears: you're conducting an exposure with a client and it suddenly starts to veer off course. Although you collaboratively mapped out the initial content, something shifted during the exposure. The client's mind jumped to a bigger or different fear, one they weren't prepared to face, and since this is one of your first exposures together, they feel overwhelmed and unready for what their mind is throwing at them.
The Dilemma: Pushing Forward vs. Abandoning the Exposure
As the clinician, you feel stuck between a rock and a hard place. To press on might mean pushing the client to sit with something they're clearly communicating they're not ready for. While there are times to challenge that resistance, this might not be one of them. On the other hand, abandoning the exposure could be equally problematic. After all, the goal of exposure is to teach the client that they can tolerate distress. If they start the exposure, encounter unexpected intensity, and then flee, it can reinforce the belief that distress is intolerable or unsafe.
Fret not, o burgeoning OCD expert! There is a way to gently land this plane.
Managing Exposure Intensity: The Solution
In moments like this, your job is to moderate the intensity of the experience while still creating a meaningful learning experience. One effective approach is to shift the focus away from specific intrusive thoughts and toward the physical sensations of distress. This technique, borrowed from Acceptance and Commitment Therapy (ACT), is called an expansion exercise.
How to Use the Expansion Exercise Technique
Here's how it works:
Guide the client to focus on the physical experience of distress. Ask them to describe in detail where they feel it in their body.
Prompt them to observe its different qualities. What shape does it take? What is its texture, color, or temperature?
Then, help them explore the boundaries of the discomfort. Often, acute distress occupies only a small portion of the body, frequently the chest or stomach.
Once they can identify its location and size, invite them to breathe around the discomfort—not to get rid of it, but to make room for it. Encourage them to soften any muscles they've been tensing around the discomfort, allowing space for the feeling to simply exist.
Benefits of the ACT technique in OCD Therapy
By gently turning toward the physical discomfort without amplifying or resisting it, the client still learns the main two lessons of an exposure:
how to skillfully sit with distress and
that in doing so, distress is easier to manage than they might have predicted.
This can have a calming or even relieving effect, similar to what we often see with well-structured exposures. Once you've successfully landed the plane, you can step out of the exposure and have a conversation about what new fears arose and how to gradually build toward addressing them in future sessions.
What is an Intrusive Thought?
Contributed by our staff, Gianna Puccio, MA
Have you ever had a thought that felt very out of alignment with who you are at your core? A thought that felt disturbing, unwanted, and disruptive? If this experience resonates with you, you have had an intrusive thought! Intrusive thoughts are not pathological - everyone, regardless of an OCD or anxiety diagnosis, experiences intrusive thoughts. By definition, an intrusive thought is an involuntary thought, image, or urge that is unwanted.
Why do intrusive thoughts feel so triggering?: Intrusive thoughts explained through an OCD lens
Sometimes intrusive thoughts can feel extremely distressing because of how they conflict with your values, morals, and sense of self. When thoughts clash with our values and we disagree with the premise of the content, we call the thoughts egodystonic. The main difference between how intrusive thoughts affect individuals with and without OCD is the level of distress they cause the person due to the relevance or irrelevance placed on them. For example, an individual without OCD may experience an intrusive thought and think, “Whoa, that was a weird thought”, and move on with their day, thinking little to nothing of it. On the contrary, an individual with OCD may experience an intrusive thought and then begin to obsess over why their brain created this thought, analyze what it means, and try to find some certainty about this. This obsessive process typically leads to feelings of distress, such as anxiety, fear, and shame. In an attempt to find relief from the discomfort that these emotions may induce, individuals with OCD will then engage in compulsions- behaviors or mental acts aimed at reducing distress and discomfort. The temporary relief that engaging in a compulsion provides is what perpetuates this cycle and increases the likelihood of engaging in compulsions again in the future. In summary, intrusive thoughts are not what cause the cycle of obsessions and compulsions; rather, it is an individual’s relationship to their intrusive thoughts and the emotions and urges that accompany them.
How can I relate to my intrusive thoughts differently?: An ACT perspective
It can feel extremely empowering once you learn that YOU get to choose whether or not to ascribe relevance or irrelevance to thoughts, emotions, and urges. From an ACT perspective, in order to relate to your intrusive thoughts differently, you can practice separating yourself from your thoughts, or de-fusing from them. De-fusing from thoughts means separating thoughts from your identity, and simply viewing it for what it is: a thought! If you think of thoughts as a string of words, or a mental event, you can take away their value and the power they have over you. Thoughts are not facts, thoughts are not commands, and thoughts do not need to be taken at face value and guide your mood and behavior. You can notice a thought without buying into it or doing anything about it. Simply put, relating to your thoughts differently just means viewing them as thoughts, and nothing more. I know this might sound simple, and that's because it is. Although it’s simple, it doesn’t mean it's easy.
Try this cognitive defusion exercise: Instead of thinking “I am anxious”, reframe your relationship to this thought by changing the language to “I am noticing the thought that I feel anxious in this moment.” Notice how one version might seem like a fact about you, while the other seems like an observation of a thought that passed through your mind. By changing the language, you can relate to your thoughts differently, reminding yourself that you are the one noticing the thought, not the thought itself.
If you resonate with this post, it does not automatically mean you have OCD! However, if you notice yourself spending significant time and energy obsessing over intrusive thoughts, and engaging in compulsive behaviors or avoidance to find relief, then you are in the right place. Reach out to an OCD specialist today!