What is Real-Event OCD?

Real-Event OCD is characterized by the presence of obsessions pertaining to concerns that stem from an event that has occurred in the past. The event may have occurred in the recent past (i.e. the past couple of months), or the remote past (i.e. years or even decades ago). Most often, individuals are concerned that they may have done something bad or caused something bad to happen. Consequently, the individuals question or doubt their own morality, which may lead them to regard themselves as a “bad” person. Experiencing feelings of guilt and/or shame is very common amongst people who have this subtype of OCD. Exposure to reminders of the event provokes a significant amount of distress and results in the individuals seeking ways (via compulsions) to attempt to gain more certainty about the event in question and/or to prove that they are not “bad” people by repenting for the negative outcome of the event. The compulsions enacted in such situations are extreme and typically time-consuming. The obsessions and compulsions present in OCD are excessive, cause a great deal of emotional upset, and have the potential to impair functioning in important life areas.

Common Obsessions in Real-Event OCD

Common obsessions include (but are not limited to):

• Worries that you caused others to feel badly or harmed them in some way
• Wondering what would have happened if you had not said and/or done _______
• Questioning if you are a bad person because of something you said and/or did in the past
• Believing that it is because of what you said and/or did that something bad happened
• Believing that you caused the suffering of a person you care about by what you said and/or did
• Believing that you caused the suffering of strangers by what you said and/or did
• Worrying that you are a bad, immoral, hypocritical, and/or deceitful person
• Worrying that you might have committed a crime
• Obsessing over the possibility of being caught for what you said and/or did
• Believing that you should be punished for what you said and/or did
• Having repeated thoughts about turning yourself in/confessing to your wrongdoing
• Having repeated thoughts that you made a big mistake and now your life will never be the same
• Intrusive thoughts, images, and/or memories about the event and/or what happened in the aftermath
• Believing that a negative circumstance is directly connected to something that you said and/or did in the past

Common Compulsions in Real-Event OCD

Common compulsions/rituals/safety behaviors include (but are not limited to):

• Engaging in repetitive mentally replaying of the event to try to increase your level of certainty about what happened
• Engaging in self-punishment by criticizing or berating yourself and/or preventing yourself from positive emotions or experiences by denying or withholding positive things from yourself
• Seeking reassurance from others who were present at the time of the event and/or those who know you well and can vouch for the quality of your character (e.g. asking others to tell you that you did not do anything wrong and/or that you are not a bad person)
• Apologizing at inappropriate times and/or or to an excessive degree
• Engaging in online researching to find out how such wrongdoings are punished and/or consulting attorneys or police officers about the consequences of the action
• Engaging in online research regarding how to obtain forgiveness and/or how to forgive yourself
• Repeated confessing previous negative things you said and/or did
• Repeatedly asking the wronged person(s) for forgiveness
• Mentally reviewing past interactions to determine how what you said and/or did impacted the other person
• Repeatedly thinking about what you would have done differently if you could go back in time and change what happened
• Attempting to rationalize what you said and/or did
• Observing the person that you believed you harmed (online and/or in person) in order to determine if what you said and/or did negatively impacted them
• Avoiding reminders (places, media, people, etc.) that are related to the event
• Engaging in excessive behaviors with the intention to become a better person
• Engaging in excessive good deeds in order to atone for your wrongdoing

Special Considerations for Real-Event OCD

• We all have said and done things that we are not proud of and that we wish we could take back. In hindsight, we wish we could have acted differently and we may feel guilty about our actions. This is a common experience. While many people can experience these reactions temporarily, or in a way that does not negatively impact them, people with Real-Event OCD experience extreme difficulty in moving on from such events. Real-Event OCD is distinguished from the more typical experiences of regret or guilt in its frequency, intensity, and the functional impairments it causes. Someone who has Real-Event OCD scrutinizes and ruminates over past events to an excessive degree over an elongated period of time in order to increase their certainty about what happened and/or to find proof that they are not a bad person. They are motivated by their anxiety, doubt, guilt, and/or shame to engage in excessive and unwarranted behaviors (compulsions) in attempts to avoid, change, or make up for the event. Unfortunately, none of these behaviors will enable them to achieve peace of mind
• As is common in other types of OCD, someone who has Real-Event OCD is likely to be plagued by a number of cognitive distortions. Cognitive distortions are ways in which the mind warps or distorts information. Cognitive distortions color information in ways are irrational and/or exaggerated and not representative of reality. Cognitive distortions that are predominantly present in Real-Event OCD obsessions include:
• Emotional reasoning – the person assumes that they way that they feel is evidence of something factual. In other words, “because I feel this way, _____ must be true. An example of emotional reasoning in Real-Event OCD is: “I feel guilty about what I said to my friend. My guilty feelings make me think that I have hurt my friend and damaged our friendship. This must be true, otherwise there would be no reason that I should feel so awful!” Associated with this cognitive distortion, there is also an associated distortion called Jumping to Conclusions
• Magnification (aka catastrophizing) – the person views the significance of the negative event in a way that is exaggerated and unwarranted. In other words, they view the negative event as having catastrophic outcomes that are irreparable. An example of magnification in Real-Event OCD is: “I made a horrible mistake and now my life will never be the same. There’s no way I can ever forgive myself.”
• Personalization – the person assumes responsibility and takes the blame for events that are beyond the scope of their management. An example of magnification in Real-Event OCD is: “I forgot to check the lock on the door so it’s all my fault that there was a break in.”
• All-or-nothing thinking – the person views things in a black or white fashion. This style of thought causes people to view things in extremes: something is either all good or all bad and there is no in-between. This distortion eliminates or discounts the gray zone and cancels out information that is contrary to the distorted belief. An example of all-or-nothing thinking in Real-Event OCD is: “Because of what I did, I am untrustworthy and immoral person.”
• In this subtype of OCD, individuals may become triggered by their decreased feelings of guilt and anxiety to content that they encounter during treatment and/or in their lives that reminds them of their obsessions. In other words, they may have anxiety about no longer feeling anxious or guilty when encountering previously triggering stimuli. They may believe that this reduction in distress is a sign that they are “okay” with and no longer remorseful about their wrongdoings, or that they have become a callous and vindictive person. Remember, this is the emotional reasoning cognitive distortion at work, and the experience or absence of anxiety or guilt is not necessarily credible proof that something is true or false.
• Components of treatment for Real-Event OCD involve the person doing work to create space for forgiving themselves. It is important to distinguish forgiveness from approval. Forgiving oneself is focused on letting go of the past by targeting rumination, mental replaying, and other compulsions that maintain OCD. Forgiveness also includes facilitating greater self-acceptance and self-compassion by allowing oneself to move forward without carrying the burdens of the past into the future.

Treatment of Real-Event OCD

The gold-standard treatment for Real-Event OCD is Exposure and Response Prevention (ERP). ERP is an evidence-based treatment, which means that there is a significant amount of research, empirical studies, and data that consistently demonstrate the efficacy of employing an ERP treatment protocol to successfully ameliorate the symptoms of OCD. In the context of Real-Event OCD, the goals of treatment are to both reduce distress associated with triggering stimuli and situations and to decrease functional impairments in daily living and significant areas of life. Through ERP, individuals engage in exposure to their fears in order to help them to learn to become less reactive to their triggers and to realize that things are not as all-or-nothing as their OCD leads them to believe. ERP facilitates opportunities to challenge worries and to increase the individual’s ability to tolerate the uncertainty, discomfort, and doubt that their OCD creates. Please see our previous blog entry — What is Exposure and Response Prevention (ERP) – for more information about this treatment.

Exposures can include anything that provokes anxiety and/or uncertainty related to the real event concerns. Examples of exposures that may be conducted in the context of ERP treatment for Real-Event OCD include:

• Writing out a narrative of the event as it actually happened
• Imagining all the ways that your words and/or actions negatively impacted the other person(s)
• Writing a worst-case-scenario story of how your words and/or actions have had a ripple effect of negative consequences for the other person(s)
• Writing an uncertainty story detailing how you will never know for sure how the other person(s) was impacted
• Creating a written confession of what you did and/or what you feared occurred as a result of what you said and/or did
• Writing a story of how your behavior will have negative consequences for yourself (e.g. I’ll never being able to stop obsessing about the event, I’ll get away with committing a crime, I will be rejected/cut off by others, my life will be ruined, etc.)
• Listening to music that reminds you of the event
• Watching movies that remind you of the event
• Visiting the location where the event took place
• Visiting the location where the event took place and reading the narrative or stories that you created while you are at the location

In addition to participating in exposure work with triggering stimuli, treatment must also include Response Prevention, which involves eliminating compulsions and deconstructing rituals. Examples of Response Prevention include:

• Refraining from seeking reassurance
• Refraining from researching (Googling, social media, etc.)
• Intentionally seeking out enjoyable things/positive experiences and refraining from withholding these things from yourself
• Refraining from making apologies
• Refraining from confessing the things you said and/or did in the past that are the focus of your OCD
• Allowing yourself to naturally encounter reminders (places, media, people, etc.) that have to do with the event and refraining from making attempts to avoid these reminders
• Refraining from and/or interrupting mental reviewing compulsions by redirecting your brain to a more neutral topic or mental exercise
• Refraining from engaging in any other compulsive ways to attempt to gain more certainty about the event and its ramifications

Engaging in ERP treatment helps individuals to learn new ways to respond to stressful situations (in the past, present, or future) and, after engaging in repetitious practice, they will likely experience a reduction in anxiety and/or learn that they are able to tolerate the stress and uncertainty while still engaging in enjoyable and meaningful activities.

Although ERP is the first-line treatment for Real-Event OCD, Acceptance and Commitment Therapy (ACT) can serve as a beneficial adjunct. Within ACT, individuals are introduced to the concepts of mindfulness and acceptance, which aid them in being present with their anxious thoughts without trying to change them or engage in compulsions. Interventions focusing on increasing acceptance of uncertainty and doubt are necessary to supplement ERP work in the treatment of Real-Event OCD. In the context of ACT, acceptance is making space for the thoughts and worries to be present without feeling the need to react or respond to them. Struggling against anxious or worrisome thoughts is likely to exacerbate anxious feelings and create more emotional suffering. Using ACT-based strategies, individuals are better able to differentiate their thoughts and values from their OCD and identify if the behaviors they are engaging in provide them joy and pleasure (which is the goal), or if they are behaving in response to anxiety and uncertainty stemming from their OCD. They are able to learn to be aware of their thoughts and fears, while not paying undue attention to and/or over-engaging with them. The goal is to learn to live life and participate in activities that are important, even if the thoughts are present. Thus, ACT is employed to increase psychological flexibility and reduce the cognitive rigidity seen in OCD. ACT aims to help people to defuse from their obsessive/intrusive thoughts and maintain a present-focused awareness. This awareness will enable them to engage in the activities taking place in the moment, rather than retreating into obsessive worries.

Interventions targeting the area of self-compassion may also be added to treatment for Real-Event OCD. Incorporating self-compassion interventions will help the individual develop skills that promote self-compassion and decrease self-criticism and recrimination. Acquiring greater levels of self-compassion can help to remedy the distress caused by the intense emotions of guilt and shame that often accompany Real-Event OCD. Interventions that are focused on facilitating self-compassion may include learning strategies to increase the person’s abilities to engage in self-care, to attend appropriately and compassionately to their own emotions and needs, and to direct kindness, understanding, and acceptance towards themselves. Outside of therapy, individuals with Real-Event OCD can also benefit from medication.

Need help or support?

If you or a loved one are struggling with OCD or any other mental health concerns, know that you are not alone. If you are a parent or a caregiver and are seeking additional information about these diagnoses and how you can best support your child, our office provides parent training with the SPACE program. Please see our November 2021 Newsletter for more information on SPACE.

To seek help for these or any other mental health concerns, please contact The OCD and Anxiety Center at (630) 522-3124 or info@theocdandanxietycenter.com. We have offices in Oak Brook and Orland Park, IL and Marietta, GA that specialize in helping individuals overcome anxiety disorder, Obsessive-Compulsive Disorder, and other co-occurring mental health conditions. We provide telehealth services that are available in Illinois, Indiana, and Iowa.

At The OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, etc.). We will work closely with you to create an individualized treatment plan and discuss the appropriate frequency of appointments (once a week or more, if needed). We look forward to working with you!

Dr. Ashley Butterfield is a licensed psychologist at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in Cognitive Behavioral Therapy and Exposure and Response Prevention Therapy for anxiety, OCD, and anxiety-related disorders. She is comfortable working with children and adults and is able to provide treatment both in the office and outside of the office, wherever anxiety happens.