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A comprehensive guide to Counting OCD

Counting OCD (sometimes also referred to as arithmomania) is a form of OCD that involves intrusive thoughts and compulsive rituals that revolve around counting various actions or objects.

Some of the data from the psychological literature shows that about 21% of OCD patients have counting-related compulsions, which makes Counting OCD one of the most common forms of the disorder.

This guide is meant to provide you with general information about Counting OCD – how it can be treated in an evidence-based manner, what the usual causes are, how the symptoms can be identified and more.

How many people have Counting OCD?

We know that 2-3% of the general population suffers from some kind of OCD; and since roughly 1 in 5 of OCD patients seem to have symptoms of Counting OCD, we can assume that approximately ~0.4-0.6% of all people have Counting OCD.

However, a lot of people have less serious (subclinical) versions of OCD that aren’t severe enough for an actual OCD diagnosis, so the real percentage of people who have experienced counting-related obsessions/compulsions is likely even higher.

What causes Counting OCD?

One of the main cognitive mechanisms behind Counting OCD is something called thought-action fusion (TAF), which is essentially a mechanism of faulty thinking where one imagines a false connection or correspondence between one’s thoughts and reality.

In other words, a sufferer of Counting OCD might think their counting-related rituals are somehow going to affect external reality works, when that simply cannot occur due to the lack of even a potential causal connection.

In very general terms, we know that obsessive-compulsive behavior is explained by both genetic and environmental factors, with the latter being slightly more influential on the development of OCD symptoms.

Examples of Counting OCD

  • Counting steps as one walks up or down the stairs
  • Counting objects (e.g. floor tiles)
  • Counting words or syllables when speaking (or when reading something)
  • Counting up to (or down from) a particular number
  • Doing specific actions in a certain numbered order
  • Touching things a specific amount of times (e.g. light switches)
  • Checking that a number on a clock is divisible by some other number (e.g. 5 or 8)
  • Counting prime numbers, or doing certain actions only in primes

How can Counting OCD be treated?

One of the most efficacious types of treatment, which is often considered the best treatment for treating OCD, is something called CBT (cognitive behavioral therapy). CBT is an evidence-based form of treatment that helps patients change their thinking patterns and behaviors that contribute to their OCD symptoms. This specific type of therapy is known to have no adverse effects at all and has a 70% response rate in patients with OCD.

Another type of treatment that’s often utilized for various forms of OCD, is something called ERP (exposure and response prevention; sometimes called exposure and ritual prevention). For patients who receive this form of therapy, patients have around a 50-60% reduction in symptoms on the Y-BOC (Yale-Brown Obsessive Compulsive) scale. ERP is designed to help patients gradually confront their feared objects/situations until the fear dissipates.

A specific type of CBT called ACT (Acceptance and Commitment Therapy) has also shown significant results – with a clinical response rate of 46-56%, ACT is one more viable option for treatment. One of the principles of ACT is that trying to get rid of pain can make it worse and entangle you even more intensely.

What could also work is something called rTMS (repetitive transcranial magnetic stimulation), which seems to be efficacious for about 35% of OCD patients; the mechanism behind it lies in the introduction of a magnetic pulse into specific areas of the brain to stimulate activity.

What are the options if you have treatment-resistant Counting OCD?

When the common, first-line treatments don’t seem to work, one must look towards other potential options. Unfortunately, we know that about 25 to 30% of people with OCD don’t respond to first-line treatments. Treatment-resistant OCD is defined by a lack of improvement in symptoms after treatment with CBT and at least two SSRI-category antidepressants (or one SSRI and clomipramine, which is a tricyclic antidepressant).

For example, there are different types of medications (or combinations of medications) that have shown potential for treatment-resistant OCD patients:

  • The combination of an SSRI with aripiprazole or risperidone (drugs in the antipsychotic class) – in one study from 2011, symptoms decreased by 35% or more on the Y-BOC (Yale-Brown Obsessive Compulsive) scale for 8 patients (50%) with aripiprazole and 13 patients (72.2%) with risperidone.
  • The combination of clomipramine with another SSRI (such as fluvoxamine) – a recent study from 2021 demonstrated that this is an effective and well-tolerated mix. The combination allows for the patient to have a lower dose of clomipramine than normally used in clomipramine monotherapy (using only clomipramine on its own).
  • Intravenous clomipramine – when this medication doesn’t work in tablet form, it is also an option to have the clomipramine injected intravenously for a particular number of sessions; it has been shown to be more effective than oral clomipramine.

A few less common treatments would be:

  • Ketamine – there is some evidence that treatment with ketamine (and esketamine) can lead to a decrease in OCD symptoms; it is thought to work by decreasing NMDA (N-methyl-D-aspartate) activity in the brain, which is a type of receptor that regulates memory and learning capabilities.
  • Electroconvulsive therapy (ECT) – this form of treatment can seem a bit scary, since it involves being put under general anesthesia, but it’s relatively safe; about 60.4% of OCD patients seem to have a positive effect from it, although the evidence is still limited.
  • Deep brain stimulation (DBS) – an intervention of this sort is truly a last-resort option, as it involves an actual surgical procedure where electrodes are implanted into specific areas of the brain, which are then connected to a device called a pulse generator that helps to control symptoms. When applied, DBS has shown efficacy in treatment-resistant OCD patients.

Is Counting OCD ego-dystonic or ego-syntonic, and what does that mean?

Counting OCD can either be ego-dystonic or ego-syntonic; an ego-dystonic form of OCD means that the sufferer is consciously aware that their obsessions and compulsions are irrational and intrusive rather than a genuine part of themselves; An ego-syntonic form of OCD, however, means the sufferer feels like their compulsions are in harmony with who they are, and that the disorder is a genuine part of themselves.

Ego-dystonic Counting OCD means the sufferer feels compelled to keep counting certain objects or numbers while feeling like it’s not really “who they are” and that the impulse itself is foreign, whereas ego-syntonic Counting OCD means they might see their counting-related obsessions and compulsions as perhaps simply a set of unique characteristics about themselves.

According to Professor Emeritus W. John Livesley’s “Handbook of Personality Disorders”, ego-dystonic disorders are therefore simpler to treat, because the sufferer usually has a real desire to get rid of the dysphoric experience, whereas an ego-syntonic sufferer might not. In essence, someone with the former type of OCD is much more likely to feel like their disorder causes them suffering and intense distress than the latter.

How to help a family member or friend who suffers from Counting OCD

If you think that a friend or family member may be suffering from Counting OCD, the best thing you can do is talk to them about it and try to get them to see a mental health professional as soon as possible.

It’s very important to not encourage the compulsive behaviors of someone with Counting OCD, because the sufferer giving into these compulsions does nothing more than amplify and intensify their symptoms.

Talk to other people about Counting OCD

Make sure to check out our community forum where we even have a specific category for Counting OCD; here you can connect with other Counting OCD sufferers and share personal experiences, talk about treatments, and more!

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