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.
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
Key Points
- The five existential concerns (death anxiety, meaninglessness, isolation, identity, and guilt) were significantly associated with overall OCD severity.
- Death anxiety was significantly associated with aggressive obsessions but not sexual obsessions in OCD.
- Identity concerns, meaninglessness, and guilt were uniquely associated with sexual obsessions in OCD.
- These findings suggest the relevance of existential concerns to specific OCD symptom presentations and have implications for incorporating existential issues into OCD treatment.
Rationale
Existential concerns have been argued to play a role in various mental health issues, including anxiety disorders and OCD (Iverach et al., 2014; Weems et al., 2004).
In particular, death anxiety has 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.
The current study aimed to address these gaps by examining the relationships between five existential concerns and aggressive and sexual obsessions in an OCD sample.
Existential theory posits that humans grapple with fundamental fears (Yalom, 1980):
- Death: The fear of one’s own mortality and the inevitability of death.
- Meaninglessness: The fear that life lacks purpose or significance.
- Isolation: The fear of being alone, disconnected, or separated from others.
- Identity: The fear of not knowing one’s true self or losing one’s sense of self.
- Guilt: The fear of making wrong choices or not living up to one’s potential.
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 a cross-sectional correlational 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
- Anxiety and Related Disorders Interview Schedule for DSM-5: Lifetime Version (ADIS-5L)
- Dimensional Obsessive-Compulsive Scale (DOCS) – aggressive and sexual obsessions subscales
- Existential Concerns Questionnaire (ECQ) – assesses death anxiety, meaninglessness, guilt, isolation, identity
- Vancouver Obsessive Compulsive Inventory (VOCI) – assesses overall OCD severity
- Big Five Aspects Scale (BFAS) – neuroticism subscale
Statistical Analysis
Pearson correlations examined associations between variables. Hierarchical regressions assessed whether significant relationships remained after controlling for neuroticism. Bonferroni corrections were applied.
Results
- The existential concerns were significantly correlated with overall OCD severity, even after controlling for neuroticism (except for isolation).
- As hypothesized, death anxiety was significantly associated with aggressive obsessions (r = .65) but not sexual obsessions (r = .28).
- Identity concerns, meaninglessness, and guilt were significantly associated with sexual obsessions (rs = .45, .45, .55, respectively). Contrary to hypotheses, identity and guilt did not significantly relate to aggressive obsessions.
Insight
This study highlights the relevance of existential issues to OCD presentations involving aggressive and sexual thoughts.
The findings suggest aggressive obsessions are dominated by fears of death, likely due to concerns about causing fatal harm.
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 use longitudinal designs to 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
- First study to examine relationships between the full range of existential concerns and OCD symptom dimensions
- Use of a clinical sample of treatment-seeking individuals diagnosed with OCD
- Analyses controlled for neuroticism as a potential confound
- Sufficient power based on a priori power analysis
- Utilized Bonferroni corrections to reduce Type I error
Limitations
- Cross-sectional design prevents causal conclusions
- Small sample size precluded between-group comparisons of those with different primary obsessions
- Findings may not generalize beyond the current sample demographics
- Modified DOCS subscales and existential concern measures require further validation
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 treatments may 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.
Keep Learning
- How might the treatment of OCD differ depending on one’s primary obsessional theme (e.g., aggressive versus sexual thoughts)? What are the pros and cons of symptom-specific approaches?
- To what extent do you think existential concerns cause OCD symptoms versus result from them? How would you design a study to test the direction of these relationships?
- Do you think everyone with OCD has underlying existential fears, or might these concerns only be relevant for a subset of sufferers? How could clinicians assess the relevance of existential issues for a particular client?
- Beyond OCD, what other mental health conditions might be impacted by existential concerns? How could researchers and clinicians draw upon existential philosophies and therapies to improve mental health treatment more broadly?
