Core fears are the ultimate or underlying catastrophic consequences that are feared to occur by patients diagnosed with obsessive-compulsive disorder if they do not perform their rituals. They motivate avoidance, safety behaviors, compulsions, and other prevention strategies. In CBT, they are often used as foci for imaginal exposure or help to identify hot cognitions. Initial reports about a patient’s fears are often remote from their underlying core fears. Generally, the core fears are determined via the “downward arrow” 16 technique in which a patient is recursively asked what they are afraid will happen if they don’t engage in any avoidance or safety behaviors. Clinical experience suggests that undercovering core fears is oftentimes a difficult, iterative process. The current study presents a structured method for identifying core fears, and describes their phenomenology.

Method

In an analog OCD sample (n=52); we developed and administered a semi-structured interview determining each participant’s core fears. Interviews were analyzed to improve the process used to identify core fears. In addition, phenomenology of the content of core fears was examined.

Results

We describe a new, semi-structured interview for identifying core fears, including methods to circumvent avoidance and increase patients’ access to underlying fears and guidelines for determining that the core fear has been identified (e.g., stopping rules for the downward arrow technique). We discuss patterns identified in the core fears, and raise questions regarding the conceptualization of core fears in disgust, not-just-right experiences and other phenomena.

Significance

Core fears serve to personalize exposure therapy in OCD; improving their theory and clinical application should improve treatment outcome.