Existential concerns in OCD refer to deep-seated fears related to death, meaninglessness, isolation, identity, and guilt that may underlie obsessive-compulsive symptoms. Research suggests these concerns are associated with OCD severity and may be especially relevant to aggressive and sexual obsessions.
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Key Points
Rationale
Existential concerns have been argued to play a role in various mental health issues, including anxiety disorders andOCD(Iverach et al., 2014; Weems et al., 2004).
In particular,death anxietyhas been repeatedly associated with OCD (Menzies & Dar-Nimrod, 2017; Menzies et al., 2015). However, research has not examined how the full range of existential concerns may relate to specific OCD presentations, namely aggressive and sexual obsessions.
Furthermore, studies have largely examined existential concerns individually (e.g., Grouden & Jose, 2015), rather than assessing their combined effect.
These concerns have been argued to underlie various forms of psychopathology, including anxiety disorders and OCD (Iverach et al., 2014; Weems et al., 2004).
Specific to OCD, case studies and clinical observations have suggested that fears of death are central to aggressive obsessions, which often involve worries about causing fatal harm to oneself or others (Menzies et al., 2015). As such, the authors predicted that death anxiety would be uniquely related to aggressive obsessions.
In contrast, sexual obsessions often involve worries about acting on unacceptable urges that contradict one’s sense of self and morals (Gordon, 2002).
Therefore, the authors hypothesized that identity concerns and guilt would be associated with sexual obsessions.
They also predicted identity and guilt would relate to aggressive obsessions, given the ego-dystonic nature of harming thoughts.
Method
The study used across-sectionalcorrelational design. Participants completed self-report measures assessing OCD symptoms, the five existential concerns, and neuroticism.
Procedure
Treatment-seeking individuals with OCD first completed a diagnostic interview. Those who met inclusion criteria then completed self-report questionnaires measuring OCD symptoms, existential concerns, and neuroticism.
Sample
The sample consisted of 48 treatment-seeking adults (45.8% female) diagnosed with OCD. The mean age was 30.94 years (SD= 9.65).
Measures
Statistical Analysis
Pearson correlations examined associations between variables. Hierarchical regressions assessed whether significant relationships remained after controlling for neuroticism. Bonferroni corrections were applied.
Results
Insight
This study highlights the relevance of existential issues to OCD presentations involving aggressive and sexual thoughts.
In contrast, sexual obsessions appear to be less connected to mortality fears, and more related to threats to one’s identity, sense of meaning, and guilt about the possibility of acting on unacceptable urges.
While past research has linked death anxiety to OCD in general, this study reveals how death fears and other existential concerns map onto specific obsessional themes.
The lack of associations between some existential concerns and symptom types (e.g., identity/sexual obsessions) also provides useful information about the specificity of these relationships.
Future studies should uselongitudinal designsto establish the causal role of existential concerns in OCD symptoms. Research should also examine these associations in larger samples to enable between-group comparisons of those with different primary obsessions.
Strengths
Limitations
Clinical Implications
The findings suggest that existential concerns (ECs) should be considered in the treatment of OCD, particularly for presentations involving aggressive obsessions.
Standard OCD treatmentsmay not adequately address underlying existential fears, such as death anxiety, which could contribute to the “revolving door” phenomenon in mental health services. Individuals with high levels of death anxiety may experience multiple disorders before developing OCD, possibly due to unresolved existential concerns.
Targeting cognitive factors like thought-action fusion and inflated responsibility may reduce OCD symptoms, but failing to address death anxiety could lead to the development of other disorders in the future.
However, research has shown that death anxiety can be effectively treated using cognitive-behavioral therapy (CBT). An online self-guided CBT program has demonstrated clinically significant reductions in death anxiety among OCD patients, suggesting a potential cost-effective and accessible treatment option for those with aggressive obsessions, which could be delivered alongside standard exposure and response prevention (ERP) therapy (Menzies et al., 2022).
While addressing existential concerns may be beneficial for OCD treatment, it remains unclear whether it would lead to symptom improvement.
Moreover, death anxiety treatments may not be necessary for patients presenting solely with sexual obsessions.
Instead, targeting feelings of meaninglessness, identity concerns, and guilt may be more helpful for alleviating distress associated with sexual obsessions.
Existential psychotherapy, meaning-centered therapy, and cognitive-existential therapy are potential treatment approaches that could complement existing evidence-based treatments for OCD.
References
Primary reference
Chawla, S., Menzies, R. E., & Menzies, R. G. (2022). Existential concerns in OCD with aggressive and sexual obsessions.Journal of obsessive-compulsive and related disorders, 32, 100710.https://doi.org/10.1016/j.jocrd.2022.100710
Secondary reference
Iverach, L., Menzies, R. G., & Menzies, R. E. (2014). Death anxiety and its role in psychopathology: Reviewing the status of a transdiagnostic construct.Clinical Psychology Review, 34(7), 580-593.https://doi.org/10.1016/j.cpr.2014.09.002
Gordon, W. M. (2002). Sexual obsessions and OCD.Sexual and Relationship Therapy, 17(4), 343-354.https://doi.org/10.1080/1468199021000017191
Kissane, D. W., Bloch, S., Smith, G. C., Miach, P., Clarke, D. M., Ikin, J., Love, A., Ranieri, N., & McKenzie, D. (2003). Cognitive-existential group psychotherapy for women with primary breast cancer: a randomised controlled trial.Psycho-Oncology, 12(6), 532-546.https://doi.org/10.1002/pon.683
Menzies, R. E., & Dar-Nimrod, I. (2017). Death anxiety and its relationship with obsessive-compulsive disorder.Journal of Abnormal Psychology, 126(4), 367-377.https://doi.org/10.1037/abn0000263
Menzies, R. E., Sharpe, L., & Dar-Nimrod, I. (2018). The relationship between death anxiety and severity of mental illnesses.British Journal of Clinical Psychology, 58(3), 452-467.https://doi.org/10.1111/bjc.12229
Menzies, R. E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (2020). Are anxiety disorders a pathway to obsessive-compulsive disorder? Different trajectories of OCD and the role of death anxiety.Nordic Journal of Psychiatry, 74(7), 1-6.https://doi.org/10.1080/08039488.2020.1774057
Menzies, R. G., Menzies, R. E., & Iverach, L. (2015). The role of death fears in obsessive-compulsive disorder.Australian Clinical Psychologist, 1(1), 6-11.
Menzies, R. E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (2022). An online self-guided cognitive-behavioural program for death anxiety: a randomised controlled trial.Behaviour Research and Therapy, 154, 104111.https://doi.org/10.1016/j.brat.2022.104111
Weems, C. F., Costa, N. M., Dehon, C., & Berman, S. L. (2004). Paul Tillich’s theory of existential anxiety: A preliminary conceptual and empirical examination.Anxiety, Stress & Coping, 17(4), 383-399.https://doi.org/10.1080/10615800412331318616
Wong, P. T. (1997). Meaning-centered counseling: A cognitive-behavioral approach to logotherapy.International Forum for Logotherapy, 20(2), 85-94.
Yalom, I. D. (1980).Existential psychotherapy. Basic Books.
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Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
