By: Jeremy Shuman
OCD is often thought of as an anxiety disorder. But in reality, anxiety is only part of the picture. Mental health professionals actually place OCD within a category called “Obsessive-Compulsive and Related Disorders”—separate from anxiety disorders since 2013. For many people, more than anxiety, OCD is strongly shaped by the emotions of shame, disgust, and a type of distress called a “not-just-right experience.” These emotions and the distress around them can lead to anxiety, but they are fundamentally different experiences from the type of anxiety stereotypically associated with OCD. Sensitivity to shame, disgust, and things being “not just right” may also serve as risk factors for OCD, and are helpful variables to understand when creating an OCD recovery gameplan.
Shame sensitivity
Shame sensitivity is the tendency to react strongly to the possibility that something is bad, defective, immoral, embarrassing, or unacceptable. It can go along with beliefs about hyper-responsibility and feelings of intense empathy. People with a high degree of shame sensitivity can have a harder time than others allowing self-compassion, and visceral emotional reactions can overwhelm and get in the way of the higher-order thinking needed for cognitive interventions.
In OCD, intrusive thoughts that produce shame can feel like evidence about identity. This is especially common in forms of OCD involving morality, sexuality, relationships, harm, or taboo thoughts. Strong sensitivity to shame combined with intrusive taboo thoughts can lead to a fundamental misunderstanding of one’s character. Just as someone with body dysmorphia can perceive a distorted picture of their appearance when looking in a mirror, so too can someone with shame-fueled “character dysmorphia” perceive a distorted version of themselves.
It can be helpful as part of a treatment plan for OCD to address shame directly by incorporating self-compassion, values identification, emotion regulation, distress tolerance, and mindfulness in tandem with ERP. Ameliorating masochistic and ego-dystonic beliefs can sometimes occur quickly with ERP, and yet other times beliefs reflect more ego-syntonic moral absolutism intertwined with intense empathy and in those cases expect to shift much more glacially.
Disgust sensitivity
Disgust is another powerful emotion that can become involved in OCD. Physical disgust evolved partly to help us avoid contamination, disease, bodily waste, spoiled food, and other potential sources of harm. But we can also feel forms of disgust that are more socially based, and that evolutionarily served to help us to avoid social rejection.
Not everyone experiences disgust in the same way. One person’s habits will revolt another person, and both people’s behaviors can fall within normal limits for a culture. Many parents will have had the experience of one parent having a stronger reaction to the diapering process than the other based on an aversive feeling of disgust. One person’s values can be austere and another’s self indulgent as well. Two people who are both deep moral thinkers can come to opposite conclusions about ethics within the same culture as well.
In OCD, an obsession can trigger the disgust response, and proneness to experiences of disgust can then impact how OCD shows up behaviorally. Rules about food preparation and hygiene could be very different depending on what is considered gross, and OCD can capitalize on this inherent variability by making rules that become increasingly restrictive and ego-dystonic over time. At the same time, this means that there is no normative way to make rules about disgust related cleaning that will apply to all individuals.
Further, disgust is not limited to germs. People can also experience moral disgust: a feeling of being revolted by an action, thought, person, memory, or even by oneself. In this way, shame sensitivity and disgust sensitivity can overlap.
ERP can help to change people’s appraisal of what is disgusting and what is not, but disgust sensitivity is not likely to fully change. While invisible, imagined, “what if” particles may fade into inconspicuousness with repeated exposure, actual smells, textures, and visuals can still create strong aversive emotions in folks sensitive to disgust. ERP may need to shift its goalposts in these cases toward resolving ego-dystonic disgust and using judicious safety behaviors to re-engage with behaviors avoided due to ego-syntonic disgust.
“Not-just-right experiences”
Not-just-right experiences, or NJREs, are feelings that something is incomplete, uneven, off, or simply wrong. They do not always involve fear that something bad will happen. A person may know intellectually that nothing is wrong and still feel intense pressure to keep adjusting, repeating, rereading, or reviewing until things feel right.
NJREs overlap with perfectionism, but they are often more sensory and less belief-driven. Someone may know that something is good enough and still feel unable to leave it alone because the internal sense of completion has not arrived.
ERP for NJREs often involves deliberately stopping before things feel finished or correct. The goal is not to make the feeling disappear, but to become more able to function while something still feels off. Over time, the experience can become less authoritative: something can feel wrong without actually needing to be corrected. Folks with a propensity for distress when they don’t have all the details, or who particularly value pedantic perfectionism, may benefit from additionally practicing their tolerance of being suboptimal or disorderly as part of their plan.
Surfing the experience of emotions
At its best, ERP creates learning that can supplant obsessional reasoning and drive distress far into the background. Even when that happens, distress related to an underlying sensitivity can still remain if that sensitivity was not itself part of an obsession. A person may no longer believe that a surface is dangerously contaminated but still be grossed out by eating off of it. Someone may stop treating an intrusive thought as evidence that they are dangerous while still feeling awful every time they experience the thought. Someone may stop ritualizing around incompleteness while still holding a persnickety pattern of arranging their belongings.
In those cases, it can be immensely helpful to directly practice skills for managing emotions by surfing whatever emotional wave one needs to survive to avoid getting pulled into the compulsive loop. The emotion rises, crests, and eventually changes, but it does not need to be solved before life continues. The task is to stop treating every wave of shame, disgust, or wrongness as evidence that something requires correction. In this way one can both stay out of the patterns of thinking that lead to obsession as well as address ego-syntonic avoidance that was never part of OCD.
Begin identifying what emotional state you are actually trying to escape. Am I treating the potential for future shame as such an awful concept that I am justifying actions that have been ruining my life in the present? Have I let my dislike of feeling disgusted dominate my choices so much that I have convinced myself there is nothing outside my safe space that I could possibly enjoy anymore? Am I losing the forest for the trees again because I am having a hard time breaking away from something I can’t seem to finish? Am I working on a problem with a realistic solution, or am I just desperate to change the way I feel?
Exposure and response prevention may then involve deliberately allowing these states to remain unresolved. That could mean leaving something slightly imperfect, allowing an embarrassing possibility to remain unanswered, touching something that feels disgusting without excessive cleaning, resisting confession, making a decision without complete certainty, allowing oneself grace for behaviors that were outside of one’s values, or stopping a task before it produces the satisfying feeling of “just right.”
The goal is not to become careless, unhygienic, immoral, or indifferent to quality. The goal is to learn that those feelings can fade into the background when your focus is on something you care about even more. Over time, OCD recovery often involves becoming less governed by the demand that your internal experience must feel acceptable, clean, or correct before you are allowed to move forward. OCD is more than anxiety, and understanding any shame, disgust, and “not-just-right” sensitivities in a full case formulation can help people build treatment around the experiences actually driving their compulsions.