Understanding the Core Fear is foundational to effective treatment of OCD, and can unlock even the most baffling cases.
Dr. Elna Yadin introduced the idea that each person with OCD has a ‘Core Fear,’ and that their avoidance and compulsions are aimed at preventing it. This idea is very powerful, because OCD symptoms can seem very random and nonsensical, but when you see them as strategies aimed at preventing the Core Fear, they suddenly make a lot of sense.
According to Dr. Yadin, the most common Core Fears are ruining (causing irreversible damage), suffering, being bad in some way, being completely alone, and death.*
Though I fully agree with Dr. Yadin’s idea that each person with OCD has a Core Fear, I have a somewhat different perspective on what that means.
Based on my experience, I believe that the Core Fear is always a form of emotional suffering, and that even if a person endorses a concrete event as their worst fear, what they are really afraid of is some specific form of emotional suffering associated with that event. More specifically, they are afraid of doing something that would lead to being in that state of emotional suffering permanently.
The specific type of emotional suffering that an individual most fears can be highly individual, and cannot always be captured in one word. It is typically a form of emotional suffering that they have experienced themselves or witnessed someone else experiencing. Some common examples are:**
- Feeling judged, ashamed, or rejected
- Feeling disconnected, untethered, alone, or abandoned
- Feeling hopeless, helpless, or trapped
- Feeling contaminated, uneasy, or ‘off’
- Feeling inferior, not good enough, worthless, or like a disappointment
- Feeling how I felt when X happened, when I was abused, etc.
- Feeling vulnerable (e.g., to shame, rejection, or harm)***
When the person perceives something as a potential path to experiencing this form of emotional suffering permanently, they attempt to prevent this from happening, via either avoidance or compulsion. When for some reason they begin to experience this form of emotional suffering, they frantically try to escape it through the same means.
To summarize what’s been said thus far about the Core Fear:
- Each person has only one.
- It is a specific form of emotional suffering.
- The person is afraid of experiencing this state of emotional suffering permanently.
- A person is triggered by anything that causes them to feel that form of emotional suffering in the present, or represents a potential avenue to experiencing that state of emotional suffering permanently, in the future.
- All forms of avoidance and compulsion are attempts to protect the person from experiencing this form of emotional suffering permanently.
Why is it so important to identify the Core Fear?
In my experience, I have found that identifying the Core Fear, and figuring out how all forms of avoidance and compulsion are aimed at preventing it, makes ERP more precise, more effective, and faster. It is one factor that significantly reduced the number of sessions I need to treat someone with OCD.
I believe that the main reason it’s so important to identify the Core Fear is that OCD treatment is about choosing to take risks, and you can’t choose to take a risk if you don’t know what the risk is that you’re taking.
Here are several other reasons it is so important to identify the Core Fear:
- It helps the therapist and patient to develop a simple and accurate case formulation.
- It enhances the patient’s sense of agency by showing them that their symptoms are actually strategies that they are using to protect themselves, and that they could choose to let go.
- By identifying the goal of the avoidance and compulsions as avoiding emotional suffering, it allows the patient to assess that their strategies are backfiring by causing emotional suffering.
- Mapping out the causal connection between the trigger and the Core Fear underscores the unrealistic nature of the sequence of events that would have to go perfectly and irreversibly wrong in order to arrive at the Core Fear (not to mention that even then, the state of emotional suffering wouldn’t be permanent).
- Identifying the outcome that is expected to occur without compulsion/avoidance provides the opportunity to see that this outcome didn’t happen. (As discussed above, one important example of this is seeing that if you don’t do a compulsion or ruminate, a distressing feeling will pass on its own.)
- As stated above, identifying the Core Fear facilitates precise exposure exercises. For example, let’s say someone is a compulsive wiper. Is the Core Fear feeling ashamed forever? Feeling contaminated forever? Being distracted, making a terrible mistake, and feeling regretful forever? Each might indicate a different approach to the exposure.
- It allows you to catch subtle manifestations of avoidance and compulsion that might not have been identified as symptoms but are important to address as part of treatment (and also provide opportunities for exposure).
- For all of the above reasons, it helps cultivate the willingness to let go of avoidance and compulsion and to participate in ERP.
So how do you identify the Core Fear?
Below are the steps I use to identify the Core Fear with my patients.
I am excited to share this worksheet with you. It will take you step-by-step through the questions that will help you to identify the Core Fear.
- Monitor: Trigger → Feared Outcome → Behavior (Avoidance or Compulsion)****
- Review the monitoring and for each Feared Outcome, identify the worst possible personal consequence, and how the person would feel if that happened.
- Identify the feelings that all of these have in common.
- Ask the patient if they can connect that feeling to one or more painful early experiences. In addition to providing a sense of coherency to the patient’s experiences, this can also help to clarify the nature of the feeling.
- Go back to any symptoms that don’t seem to be connected to the hypothetical Core Fear and see if the patient can figure out how they might indeed be connected, or adjust the hypothetical Core Fear to fit them in.
- If you have the right Core Fear, everything will fit.
- The Core Fear should ring true to the patient.
- Consider asking the patient to monitor their symptoms again with the hypothetical Core Fear in mind, and to either confirm that the hypothesis fits, or bring in examples of symptoms that don’t seem to fit.
- Adjust or refine the hypothesized Core Fear as needed.
- Start ERP work based on your hypothesized Core Fear, but remain open to revising it in light of new information.
In my experience, identifying the Core Fear has been a key factor in making ERP more precise, and consequently faster and more effective. I hope the above will help patients and therapists to gain a better understanding of OCD, and that this will lead to better treatment outcomes.
*Dr. Yadin’s description of the Core Fear can be found here.
**A previous version of this article identified guilt and regret as examples of the Core Fear. I removed them from the list because I have moved towards the conclusion that these feelings are emotional consequences of rumination, rather than the Core Fear. In other words, these feelings are symptoms, rather than the underlying emotional threat.
***I am not using the word vulnerability in the same way Brené Brown does. I am using it more literally to denote feeling afraid of being caught off guard by another specific painful emotional experience. I often use the metaphor of lying in bed knowing the front door is unlocked. When the Core Fear is vulnerability to some other painful feeling (e.g., vulnerability to rejection), the person is more concerned with avoiding the feeling of vulnerability than with avoiding the other painful feeling itself. This may manifest in seemingly self-defeating, counter-phobic compulsions that involve running towards the painful feeling, or doing things to bring it on or get it over with. These make perfect sense once you realize that the Core Fear is the feeling of vulnerability.
****This also applies when the compulsion is rumination. You would want to know what the rumination is aimed at figuring out, what the person is afraid would happen if they didn’t figure that out immediately, and how that could lead to the Core Fear.