Obsessive-compulsive disorder (OCD) is a debilitating condition in which individuals frequently experience intrusive thoughts, images, or urges (obsessions), to which they feel compelled to respond with a variety of behaviors or mental acts (compulsions) to alleviate the distress caused by the obsessions. OCD is a heterogenic disorder, in which obsessive concerns can revolve around various themes, including contamination, fear of harming oneself and others, symmetry, sex, morality, and religion (Miguel et al., 2005).

Throughout the past decade, increasing clinical and research focus has been given to a specific manifestation of OCD called relationship OCD (ROCD). People with ROCD experience an ongoing barrage of doubts about the suitability of their relationship or partner and engage in time-consuming and energy-draining compulsive attempts to resolve these doubts (Doron & Derby, 2017).

Although OCD fears revolve around a wide range of themes, such fears typically reflect the presence of an underlying core fear. When dealing with OCD and ROCD, it is crucial to identify and confront the core fear that underlies an individual's obsessions and compulsions.

 

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What Core Fears Are

People’s reported fears are typically aligned with yet differ from their underlying core fear (Borkovec et al., 1998). Individuals struggling with OCD are mostly aware of their surface fears and the triggers that evoke them, but not of the core fear that underlies all (or most) OCD-related surface fears.

For example, some people with OCD fear being contaminated by objects that have been touched by others (their surface fear) and often avoid touching such objects or compulsively wash themselves if they come into contact with them. When exploring the source of their avoidance and compulsions, they may mention feeling anxious, disgusted, bad, or unclean if they do not wash themselves.

However, these unpleasant feelings often reflect a deeper and more fundamental fear, such as fear of contracting a detrimental disease like AIDS. Yet even this may not be the deepest level of their fears, as the meaning of having AIDS can vary from person to person. While some people’s core fear may be prolonged suffering and death, others may primarily fear social rejection due to their illness. Some may be terrified of infecting their loved ones, while others may worry about being unable to work and be productive (Huppert & Zlotnick, 2012).

As seen in this example, similar surface fears (and subsequent compulsions) can result from different underlying core fears in different people. Oftentimes, people avoid delving into their fears at a deeper level and remain fixated on their surface fears, because contemplating their core fears can trigger significant anxiety (Zlotnick & Huppert, 2022). However, one’s core fear represents a perceived underlying threat that makes one’s surface fears appear dangerous. Hence, the ultimate goal of compulsions and avoidance is to prevent the core fear from materializing.

Common core fears in individuals with OCD include fear of being responsible for causing harm; being a bad or immoral person; irreversibly ruining one’s life; dying; going insane; going to hell; being abandoned and rejected by family, friends, or society; and being trapped in everlasting emotional suffering (Gillihan et al., 2012; Greenberg, 2020).

Core Fears in ROCD

Individuals with ROCD are highly occupied with various issues concerning the suitability of their relationship and/or their partner (e.g., “Is this relationship suitable enough?”; “My partner may not be smart enough”). Such surface fears can be triggered by a variety of external and internal triggers and are typically accompanied by distress, shame, and urges to engage in compulsions.

Digging deeper into these surface fears, individuals with ROCD hold more fundamental fears. These include the fear of being stuck in an unsuitable relationship, missing out on the perfect relationship, regretting one’s relationship choices (whatever these may be), and being endlessly trapped in obsessive loops.

However, for many people with ROCD, a deeper core fear underlies the fears mentioned above. In many cases, it taps into a profound fear of being trapped and alone in a never-ending cycle of suffering. This core fear can manifest either as endless regret for prematurely ending a relationship with their “one true love,” or as remaining in the “wrong” relationship and enduring endless suffering, caught in the grip of obsessive thoughts.

Hence, when individuals with ROCD compulsively engage in perpetual deliberations regarding the suitability of their relationship, monitor their feelings toward their partner, or compare their partner to potential alternatives, they often believe that they are trying to determine the suitability of their relationship (i.e., address their surface fear). However, they are primarily engaged in futile, compulsive efforts to prevent their core fear of being trapped in endless suffering from materializing.

Working With Core Fears

Recognizing one’s core fear is an important step in the treatment of OCD and ROCD. Many clients wonder about the origin of their fears, obsessions, and compulsions and why they manifest in the form that they do. Helping clients recognize their core fear assists them (and their therapists) in better understanding themselves and the deeper motivation underlying their various compulsions. Through this process, clients also learn that their use of compulsions, often intended to avoid emotional suffering, actually backfires, exacerbates their emotional distress, and leaves them stranded inside their heads, grappling with their thoughts and feelings.

Working with core fears also influences the effectiveness of the treatment of ROCD. In a previous post, I discussed exposure and response prevention (ERP) as a fundamental step in the treatment of ROCD. In ERP, clients deliberately expose themselves to their fears, allow themselves to experience the distressing feelings that arise, and refrain from engaging in compulsions to alleviate those feelings.

Recognizing one’s core fear significantly enhances ERP by incorporating exposures to the core fear itself—for example, through imagining the manifestation of the core fear or writing a script about the core fear coming true.

For instance, a client obsessed over their partner’s appearance may practice ERP by actively viewing unflattering pictures of their partner while refraining from engaging in compulsions, thereby facing their surface fears. However, writing a script about living a life filled with endless suffering and regret over choosing the wrong partner may serve as an exposure to their core fear.

Thus, combining exposure to one’s core fear deepens ERP and makes it more precise for the client. If ERP only addresses surface fears, new compulsions may emerge to replace the ones previously challenged through ERP. However, as clients become more adept in tolerating the distress resulting from exposure to their core fear while refraining from compulsions, their reduced distress generalizes to other triggers and surface fears, bolstering their ability to reduce reliance on compulsions.

Through deepening the investigation of one’s fears, OCD specialists help clients peel away the layers of their surface fears, as well as recognize and challenge the profound fear that underlies their compulsions. Although the examples provided above give a general indication of common core fears, it is essential for each person to recognize and articulate their core fear in their own words.