For many people struggling with OCD, the fear that they do not actually have OCD and are merely “in denial” becomes one of their most intractable obsessions. Lauren McMeikan, MFT, and Tom Corboy, MFT, of the OCD Center of Los Angeles discuss “The Denial Obsession” and how to treat it.
Obsessive Compulsive Disorder (OCD) has often been called “the doubting disease”. OCD certainly lives up to this moniker, especially for those struggling with variants of the disorder that are often informally described as “Pure Obsessional OCD” or “Pure O”. OCD plays on an individual’s greatest fears, leading sufferers to question fundamental aspects of themselves and their character. While those without OCD effortlessly dismiss most of the unexpected thoughts that pop into their consciousness, those with OCD get trapped in a seemingly endless loop of obsessions and compulsions. Some of OCD’s more common refrains include:
• “What if I’m a murderer?”
• “What if I’m secretly gay?”
• “What if I am secretly straight?”
• “What if I don’t really love my partner?”
• “What if I am a pedophile?”
• “What if I have committed a terrible sin?”
• “What if, at my core, I am a bad person with bad intentions?”
• “What if reality, as I experience it, isn’t reality at all?”
You might notice something that ties all of these phrases together – the struggle to answer the question “what if …?” This phrase strikes terror into the hearts of those grappling with OCD. These two short words introduce enough doubt and anxiety into the minds of sufferers that they feel compelled to repeatedly perform compulsive behaviors in a seemingly endless attempt to reduce or eliminate their distress.
OCD and The Denial Obsession
When most people think of the compulsions experienced by those with OCD, they think of the stereotypical hand washing or door checking seen in Hollywood films like The Aviator or As Good As It Gets. And most people with OCD do in fact have some overt compulsions such as these. However, for many with OCD, especially those struggling with any of the Pure O variants, their response to their obsessions is more likely to be in the form of internal “mental compulsions” that are less readily recognized as OCD symptoms. For these individuals OCD is, quite literally, all in their heads.
There are numerous ways in which people with OCD do mental compulsions in an effort to reduce their anxiety, including:
- Mental Checking – Purposely calling up a “bad” thought to see if it still causes distress.
- Mental Review – Compulsively ruminating on a past event in order to prove to yourself that you didn’t do something “bad”.
- Thought Neutralization – Focusing on a “good” thought or image in an effort to undo or prevent a “bad” thought or event.
- Mental Reassurance Seeking – A type of thought neutralization in which one compulsively repeats reassuring or calming statements.
As a result of these and other mental compulsions being less obvious to the outside world, many of those struggling with these types of internal rituals are more prone to discount their diagnosis of OCD, and to battle what could be described as the ultimate obsession:
“What if I don’t have OCD at all, and I’m just in denial?”
Given that OCD is characterized by near-constant doubt, it is not at all surprising that those with the disorder frequently question the authenticity of their diagnosis. In fact, it is not uncommon for those struggling with OCD to at times obsess about the possibility that they are nothing short of a fraud, with an internal monologue that goes something like this:
“I am an imposter. I don’t really need or deserve treatment. My so-called symptoms are just an excuse that allows me to deny my true character.”
This issue is further complicated by the fact that many mental health treatment providers are so uninformed about OCD that they too think OCD only exists if an individual exhibits the more overt symptoms such as hand washing and door checking.
But compulsions are compulsions, whether they are obvious to the outside world, or quietly and endlessly festering away in the mind of the sufferer. Simply put, those struggling with OCD do compulsive behaviors, including mental compulsions, because the condition makes the empty promise that such compulsions will relieve the nagging doubt that accompanies their obsessive thoughts. However, the compulsions provide only temporarily relief of the doubt. After fighting off their obsessions with any number of compulsions, the sufferer often briefly believes that they do in fact have OCD. Then the insidious uncertainty begins to creep in anew, often in just seconds, and the cycle thus starts again. The internal questioning continues indefinitely, with the false hope of a definitive answer always seeming just slightly out of reach.
So What is Denial Anyway?
Many people think that denial involves being so profoundly disturbed by an idea that one’s mind somehow will not allow that idea into consciousness. In actuality, denial involves active knowledge of something, coupled with a desire to reject said knowledge.
The person who has been diagnosed with cancer and who is “in denial” knows that they have cancer, and is simply attempting to ignore it because acceptance of their mortality may seem too difficult to tolerate. Likewise, if an individual is “in denial” about their spouse’s alcoholism, they are not completely oblivious to the problem, but rather are purposefully choosing to ignore every indication that something is awry for fear of the impact on their marriage and family. And someone who is attracted to the same sex and “in denial” knows about their attraction, but refuses to acknowledge or accept their sexual orientation, likely because social and cultural mores may make open acceptance of their urges seem unbearable.
Denial and the “Meaning” of Thoughts
Many people are under the misguided belief that all thoughts have important underlying meanings. Those who struggle with the thought, “What if I am in denial and don’t really have OCD at all?” might believe that this thought represents some underlying truth trying to break through from their unconscious. But the truth is that the vast majority of our thoughts are not intrinsically important. The human brain generates an endless stream of thoughts, including some that are deeply bizarre and unnerving. Does it mean anything that I just considered sticking a banana up my nose? Some would have you believe that this represents some inner urge, or has some secret meaning that needs to be ferreted out. We would posit that this thought, like so many of its brethren, is merely an odd byproduct of being a human being with a functioning brain.
Some people with OCD worry that accepting their diagnosis is somehow a “cop out”. This is particularly noteworthy as, in order for this to be true, an individual would have to mimic an extensive set of OCD symptoms of which they were previously unaware. Similarly, many people with OCD fret, “What if ‘deep down’ I know that this is my reality and I’m refusing to accept it?” We wonder where this “deep down” place is located, and would argue that it does not exist. One either knows something or does not.
The Denial Obsession in Various OCD Sub-Types
Most people with OCD occasionally (or frequently) fear that accepting their diagnosis would be a form of denial. The specific denial obsession varies depending upon the individual’s sub-type of OCD. For example:
In HOCD, also known as Sexual Orientation OCD, or Gay OCD, individuals question the validity of their expressed sexual preference. Those struggling with this sub-type of OCD often fear that they are in deep denial about their true orientation. For those who are straight, they incessantly question if they might actually be gay. Conversely, those who are gay question if they are in actuality straight. When people with HOCD experience the denial obsession, the thoughts often sound something like, “What if I’m using OCD as an excuse so that I do not have to deal with the difficulties of coming out?” or “What if I’m acting like I have OCD because I am in such deep denial of the truth about my sexual orientation?”
Relationship OCD (ROCD) generally targets the legitimacy of an individual’s romantic relationship, frequently employing the question of whether or not one’s partner is “the one”. Many with ROCD wonder, “What if I don’t have OCD, and I actually don’t love my partner?”
Those with Harm OCD obsess that they may harm others or themselves. They often question, “What if I wrongly accept this OCD diagnosis, and then suddenly lose control and kill someone?” Harm OCD obsessions often focus on violent thoughts or images, and the anxiety is often secondary to the overwhelming fear that the presence of such thoughts indicates a sub-conscious desire to purposely engage in violent behaviors. People who doubt that they have Harm OCD might ask questions like, “What if, deep down, I actually want to act on my thoughts, and I’m just manipulating my therapist into thinking that I have OCD so that I can go on a killing spree?”
Hit and Run OCD is a variant of Harm OCD in which the sufferer obsesses that they have accidentally or purposely run someone over with their car. When doubting their OCD diagnosis, they may think, “What if I actually did run someone over and they are lying in the street dying, with no one to help them because I am not accepting the fact that I ran them over?”
Perinatal / Postpartum OCD (PPOCD) is experienced by expectant and new mothers, and generally manifests as a variant of Harm OCD in which the sufferer obsesses about purposely or accidentally hurting their newborn child. Women with PPOCD are susceptible to denial obsessions such as, “What if I foolishly accept the idea that I have OCD, let my guard down, and then injure or kill my baby?”
Religious Scrupulosity focuses on a person’s faith and their alleged failings in adhering to their religion’s standards. Someone who struggles with Religious Scrupulosity is likely to question whether they actually have OCD, and might struggle with questions like, “What if I’m really not practicing my faith correctly, and I spend eternity in hell because I accepted this false diagnosis of OCD?”
Similar to Religious Scrupulosity, Moral Scrupulosity leads individuals to question whether or not they are “good” people living life in accordance with their morals, ethics and values. Those struggling with the denial obsession in Moral Scrupulosity are likely to worry, “What if I’m saying that I have OCD as a cop-out so that I don’t have to do the hard work of being morally upright?” or “What if I’m being dramatic – what if I’m faking OCD for attention because I’m an innately bad person?”
Relapse OCD is essentially a sub-type of Moral Scrupulosity that targets those in recovery from substance use disorders. These individuals fear that they may relapse, and go to great lengths to avoid any contact with mind-altering substances. A person with Relapse OCD might wonder, “What if my concerns are legitimate and accepting the idea that I have OCD leads me to let down my guard and relapse?” Those with Relapse OCD might also question the validity of their diagnosis of OCD as it relates to a specific past event – for example “What if my concerns that I did relapse are valid and aren’t OCD at all?”
Blackout OCD usually surfaces in one of two ways. Some have obsessive thoughts that they may have committed an offensive act during a substance-induced black out. Others question the nature of their activities during periods of time in which they cannot account for the exact moment-to-moment specifics of their behaviors. These individuals are apt to question their diagnosis by wondering, “What if I really did act inappropriately during that time, and I’m using OCD as an excuse so that I can get away with my bad behavior?”
Those with Pedophile OCD (POCD) experience unwanted thoughts about committing inappropriate sexual acts with children. Those who have POCD might be consumed with thoughts such as, “What if I’m actually a pedophile pretending to have this disorder so that I have the opportunity to surreptitiously prey on children?”
Someone with Hyper-responsibility OCD might be concerned that reducing supposedly “disordered” behaviors will result in a tragedy. For example, “What if I don’t pick up that trash along the side of the road because I’ve decided this is OCD, and a driver drives over the trash, gets a flat tire, loses control of their car, gets in an accident, and kills an entire family, all because I foolishly bought into the idea that I have OCD?”
Superstitious OCD is not dissimilar from Hyper-responsibility OCD. In this variation, individuals experience magical thinking, which leads them to follow arbitrary rules and/or perform unnecessary rituals with the purpose of averting completely unrelated negative events. Those with this form of OCD might think, “What if my superstition is actually realistic, and by not performing my rituals, I cause terrible harm to myself or to those I love?”
With Mental Health OCD, the sufferer worries that they are on the verge of decompensating into a grave mental disorder. Some fear they are developing Schizophrenia (sometimes call Schiz OCD), while others may be overly concerned with the idea that they have Bipolar Disorder. Those with Mental Health OCD often fear that their diagnosis is inaccurate, wondering, “What if my therapist missed something and my symptoms truly represent another, more debilitating disorder, not OCD?”
For those with Existential OCD, obsessions focus on the nature of reality. Someone with this form of OCD might wonder, “What if my focus on this issue isn’t OCD, but is instead a legitimate inquiry into the nature of reality and the universe that I truly need to resolve?”
This list is by no means exhaustive. It is also worth noting that, while the denial obsession is most common in these Pure O variants of OCD, it can also be present for those with more stereotypical manifestations of the disorder such as compulsive checking and washing. If your particular type of OCD is not mentioned here, it is only because the manifestations of OCD are as vast and varied as the individuals who have the disorder. Virtually all incarnations of OCD include some variation of the fundamental question surrounding the authenticity of the diagnosis – “What if I am in denial?” But this fear of being in denial is merely another manifestation of the incessant doubt that defines the disorder, and one that exemplifies OCD’s tendency to target an individual’s most terrifying fears.
Denial and the Backdoor Spike
One of the most pernicious manifestations of the denial obsession occurs with what is known as a “backdoor spike”. This occurs when the OCD sufferer starts to experience less anxiety in response to their unwanted thoughts, and then begins to obsess that they are not anxious enough about these thoughts. When this occurs, the person with OCD often sees this as further evidence that they have been in denial all along. “After all”, goes their reasoning, “if I am not upset about these horrible unwanted thoughts, they must be valid indicators of my true character and intent.” We have treated many people over the years who have found the backdoor spike to be the most difficult challenge they face in the course of treatment. Of course, the truth is that the backdoor spike is just one more way in which OCD injects doubt into the mind of the sufferer.
Treatment of The Denial Obsession
Research has repeatedly and consistently found that Cognitive-Behavioral Therapy (CBT) is the most effective treatment for OCD. CBT focuses on both the individual’s distorted obsessive thoughts (i.e. their cognitions) and the compulsive behaviors they employ in an effort to reduce or eliminate these thoughts.
When viewed from a cognitive therapy perspective, the goal of treatment for the denial obsession is to recognize that many distorted thoughts are present in all variants of OCD, and that the non-acceptance of an OCD diagnosis is the real “denial”. Using a technique called “Cognitive Restructuring”, individuals learn to challenge the content of their obsessions. For example, the obsession, ”What if I don’t really have OCD, and I am in denial that I am a murderer?” highlights a cognitive distortion called “selective abstraction” in which an individual over-attends to one negative detail instead of seeing the whole picture. In this example, those with OCD over-attend to this one unwanted thought, while ignoring four facts that frame the bigger picture:
First, that thoughts are just thoughts, and are not the same as actions. Second, that they have had millions of thoughts in their life, and this is just one of them. Third, that they have had this particular unwanted thought many times, and have never acted on it. And fourth, that they have lived many years, and have never even come close to killing anybody. By methodically and systematically questioning their anxiety-provoking thoughts, OCD sufferers can begin to see their obsessions for what they are – irrational and unrealistic thoughts that have been twisted into lies that they unfortunately have come to believe.
Mindfulness training is a valuable compliment to the cognitive component of treatment for both obsessions and compulsions. From a mindfulness perspective, treatment is focused on accepting of the presence of whatever thoughts pop into one’s mind, including thoughts of doubt and denial. The ultimate goal of mindfulness for someone with OCD is to develop the capacity to sit with the discomfort and uncertainty that their mind presents to them, making no effort to eliminate their unwanted thoughts or the anxiety they produce. A mindful response to the denial obsession in OCD might go something like this:
“Maybe it’s OCD, and maybe it isn’t. Oh well, I guess I’ll have to live with the uncertainty.”
The most important part of CBT for OCD is the behavioral component, which focuses on Exposure and Response Prevention (ERP). This is a technique in which the individual with OCD is purposely and repeatedly exposed to situations and things that trigger their anxiety. The primary goal of ERP is to tolerate exposure to one’s obsessions without responding with compulsions (hence, the name Exposure and Response Prevention). By repeatedly facing their fears without responding with compulsive behaviors, OCD sufferers “habituate” and become “desensitized” to the triggers that provoke their anxiety. In other words, they become bored by what previously caused extreme distress.
When tackling the denial obsession with ERP, the sufferer may be asked to do, or not do, certain behaviors, such as:
- Purposely go to places that trigger the fear of being in denial. For example, if you are struggling with whether you have HOCD or are in denial, purposely and repeatedly go to a gay bar.
- Don’t avoid things you would normally do just because you are obsessing about being in denial. For example, if you are struggling with whether you have ROCD or are simply in denial about not loving your partner, continue to spend time with them despite your fears.
- Don’t ask for reassurance from friends or family about OCD symptoms. For example, don’t ask people whether they think you have Harm OCD or are really a murderer.
- Don’t do online research about the nature of your thoughts, feelings, or urges. Compulsive research never provides long-term certainty about OCD.
- If you struggle with Religious Scrupulosity, don’t compulsively read religious texts in an attempt to find scriptural evidence to prove or disprove that you are a sinner.
- Post the word “denial” on numerous post-it notes throughout your home so that, over time and through repeated exposure, the word itself no longer evokes the same fear response.
- Read articles about denial until words like “denial” and “subconscious” no longer hold the same triggering potential.
- Resist the urge to analyze thoughts, feelings, or events in an effort to determine with certainty that you are not in denial.
ERP also often includes what is called Imaginal Exposure in which the sufferer, with the assistance of their therapist, writes fictional short stories outlining their worst fears. When addressing the denial obsession, this might include writing a short story about your anxiety-provoking thoughts turning out to be true, and the realization that you have been in deep denial. A variant of this is to email your therapist on a daily basis about how you do not have OCD and are actually in denial.
As with all variants of OCD, the goal for those struggling with the denial obsession is to expose themselves to the unwanted thought repeatedly, without doing compulsions, until they habituate to it. Through this process, they learn first-hand that, when they do not respond to the obsessions by performing compulsions, the anxiety sparked by the idea of being in denial greatly diminishes over time.
For those with the fear that their OCD diagnosis is a charade – that they are OCD imposters – the ultimate fear can be summed up as follows:
“What if I’m in denial, and this isn’t OCD, and I never recover from whatever this actually is?”
If you have OCD and are struggling with this question, we would ask one alternative question in return:
“For someone who doesn’t have OCD, and is merely in denial about their “true self”, aren’t you spending an awful lot of time compulsively seeking out the alleged truth?”
After all, people without OCD spend no time whatsoever trying to determine whether or not their thoughts are evidence of OCD.
• Lauren McMeikan, MFT, and Tom Corboy, MFT, are psychotherapists at the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions. In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.