When addressing obsessive-compulsive disorder (OCD), one key concept often discussed by experts is core fears. But what exactly are these core fears, and why are they so crucial in the treatment process? Let’s explore how understanding and addressing core fears is an essential initial step in OCD treatment.

Dr. Elna Yadin, a psychologist at the University of Pennsylvania School of Medicine, pioneered the concept that each person with OCD has one or more core fears and that compulsions and avoidance behaviors are intended to prevent the outcome of these fears.

This concept is extremely important in OCD treatment. On the surface, OCD symptoms can seem random, but when we view compulsions as attempts to prevent a core fear, we shift from playing whack-a-mole with symptoms to gaining a broader, bird’s-eye perspective of OCD.

According to Dr. Michael Greenberg, the most common core fears include causing irreversible damage, suffering (emotionally or physically), being bad in some way, being alone, and death.

These core fears are unique to each individual and play a significant role in driving the compulsions and anxiety seen in OCD.

Why Core Fears Are Crucial in Building an Exposure Hierarchy

In OCD treatment, it’s vital to understand and address the core fears fueling compulsive behaviors. Exposure therapy involves gradually facing feared situations to reduce anxiety over time, and the most effective exposures target the root causes of anxiety, not just surface-level triggers.

Exposures should be tailored to an individual’s core fears to ensure they address the real issue. If we don’t adequately understand the core fear in the early stages of treatment, we can’t create high-quality exposures—an essential part of effective OCD treatment.

Why Focusing Only on Surface-Level Symptoms Doesn’t Work

When treatment focuses only on immediate triggers or surface-level symptoms without digging into deeper fears, it often falls short. People might feel like exposures “don’t work” for them.

Consider an example where someone experiences panic when their heart rate increases during exercise, leading them to engage in compulsions like checking their Apple Watch, body-scanning, and Googling symptoms.

On the surface, we might assume this panic is related to the fear of a catastrophic medical event. However, we must dig deeper to understand the many unique ways this situation could manifest.

Example: Anxiety Triggered by Exercise

Imagine someone who panics when their heart rate spikes during exercise. For one person, the core fear could be related to fainting or losing control of their body. They might worry that physical sensations will escalate into something dangerous and possibly lead to death.

For another person, the same bodily sensation might trigger anxiety, but their core fear could be social embarrassment—fear of not keeping up with teammates during sports, leading to feelings of isolation or rejection. (Both examples are true of clients I have worked with over the years!)

Focusing only on the physical symptoms that trigger panic misses the real issue. The core fear—whether it’s losing control or fearing judgment from others—needs to be understood before effective treatment can take place.

Tailoring Exposure Therapy to Core Fears

Understanding a person’s core fear is critical when building a personalized exposure hierarchy. This ensures that exposures directly address what’s driving the anxiety.

For example, if someone fears fainting, interoceptive exposures—such as breathing through a straw to simulate difficulty breathing—can help them gradually tolerate the sensations that trigger panic. Over time, they learn that these sensations aren’t dangerous and can be managed without compulsive behaviors.

For someone whose anxiety is rooted in social fears, such as embarrassment in front of others, the exposure hierarchy might focus on social situations. This could start with mild exposures, such as exercising in front of a few people, and progress to more challenging situations, like participating in team sports. The goal is to address the core fear of social judgment rather than just focusing on the body’s physical response. The hierarchy might also extend to other social situations involving fear of judgment that have nothing to do with exercise.

This demonstrates how OCD can extend far beyond the symptoms a client initially focuses on and how it can show up in multiple areas of life. Doing this core fear work early in treatment allows for more precise exposures, making treatment more efficient and impactful, so clients experience results sooner.

Core Fear Work: A Cornerstone of OCD Treatment

Core fear work is essential for establishing a strong foundation in OCD treatment. It helps us understand that OCD is less about the specific content of obsessive thoughts and more about an overwhelming need for certainty and control—shaped by one’s unique values and life experiences. The content can be considered the “surface” issue that draws someone into treatment.

What truly drives OCD is the inability to tolerate uncertainty. Compulsions are attempts to reduce the anxiety caused by doubt, but they don’t address the underlying need for certainty. When treatment focuses solely on content, we risk ignoring the core fear and failing to resolve the disorder.

Moving Beyond Content: Strengthening Tolerance for Uncertainty

The key to effective OCD treatment lies in helping individuals manage the uncertainty that fuels their compulsions. Instead of staying focused on the content—whether it’s contamination, health, or relationships—the focus should shift to building the capacity to tolerate doubt and discomfort. This is where real progress happens.

In conclusion, understanding and addressing core fears is a fundamental part of effective OCD treatment. By identifying these fears and incorporating them into the exposure process, we can tailor treatment to each person’s unique experience, ensuring lasting results.

The goal is not just to manage the content of OCD but to help individuals tolerate the uncertainty beneath the surface, ultimately empowering them to navigate life’s challenges with greater confidence and less anxiety.

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Barb Shepard is a Licensed Mental Health Counselor, OCD and Anxiety Specialist, and Sober Curious advocate in Syracuse, New York. Any content on my website or blog is a not substitute for therapy and is for educational purposes only. I cannot provide tailored therapeutic advice unless you are a therapy client. Reading this blog or listening to audio content does not constitute a therapeutic relationship. If you are seeking therapy, visit psychologytoday.com. If you are in crisis, dial 911 or visit your local emergency room.