Alone together: the role of existential concerns in symptoms of relationship obsessive-compulsive disorder

ABSTRACT

Objective

Emerging research has identified the relevance of existential concerns in various subtypes and dimensions of obsessive-compulsive disorder (OCD). However, at present, no studies have examined these concerns in relation to relationship OCD (ROCD).

Method

The current study examined the association between ROCD symptoms and all five existential concerns (i.e., isolation, identity, meaninglessness, guilt, and death). Data was obtained from a sample of undergraduate university students in Sydney, Australia (N = 353), M_age = 20.95 years. Participants completed a number of scales including measures of ROCD symptoms, attitudes to relationships, and existential concerns.

Results

The results revealed significant positive correlations between all five existential concerns and ROCD symptoms. In particular, the correlations found for Isolation and Identity concerns were significantly larger than those found for Meaninglessness, Guilt, and Death. Notably, the relationships between ROCD symptoms and all five existential concerns remained significant after controlling for quality of current relationship, catastrophic beliefs about relationships, and neuroticism.

Conclusions

The current findings highlight the need to consider existential issues in conceptualising ROCD. Clinical implications are discussed.

KEY POINTS

What is already known about this topic:

1. The “big five” existential concerns (i.e. meaninglessness, death anxiety, identity, isolation, guilt) have been linked to various mental illnesses.

2. Specific existential concerns, such as death anxiety, have been linked to several domains of OCD symptoms.

3. No study has explored these existential concerns in the context of relationship OCD symptoms.

What this topic adds:

1. All five existential concerns are associated with symptoms of relationship OCD.

2. In particular, isolation and identity concerns emerged as most relevant to this presentation.

3. Existential concerns should be considered in the conceptualisation and treatment of ROCD.

KEYWORDS:

• Relationship obsessive-compulsive disorder
• existential concerns
• death anxiety
• isolation
• identity

Relationship obsessive compulsive disorder (ROCD) is a symptom dimension of OCD focusing on close relationships. Whilst the focus of relationship obsessions can involve various types of relationships (e.g., parental, religious figures), obsessions surrounding one’s romantic partner are particularly common (Doron et al., 2014; Levy et al., 2020; Ratzoni et al., 2021). ROCD involves preoccupation with the quality and suitability of one’s romantic partner (i.e., partner-focused symptoms) and/or the nature and “rightness” of the relationship itself (e.g., relationship-centred symptoms). Both manifestations of ROCD are characterised by intrusive thoughts (e.g., “Is this how love should feel?”, “Is she right for me?”) and images (e.g., of a future life with the partner), which are experienced as egodystonic and unwanted (Doron et al., 2014). In addition, ROCD symptoms may include compulsive behaviours such as hypervigilance to one’s feelings about the partner, comparisons between one’s partner and others, and reassurance seeking (Doron et al., 2016). These obsessions and compulsions typically result in significant distress and dysfunction, and are associated with poorer relationship satisfaction and self-esteem (Doron et al., 2012a, 2012b).

The “Big Five” existential concerns

ROCD has garnered increasing attention in the literature, with a surge of recent efforts to identify predictors and mechanisms of this condition. For example, studies have implicated maladaptive beliefs (Doron et al., 2016; Melli et al., 2018), self-related vulnerabilities (e.g., Doron & Szepsenwol, 2015) and personality traits (e.g., Tinella et al., 2023) as predictors of ROCD. One area that has been underexplored in relation to ROCD, is that of existential psychology. The five “givens” of existence (i.e., isolation, meaning, identity, guilt, and death; Koole et al., 2006; Yalom, 1980) have been increasingly linked to psychopathology (e.g., Iverach et al., 2014). For example, links have been demonstrated between existential concerns and depression, anxiety, and stress (Berman et al., 2006; Constantino et al., 2019; Menzies, Sharpe, et al., 2022), as well as symptoms of addiction (Menzies et al., 2019) and personality disorders (Menzies et al., 2024).

The five existential concerns, and their potential relevance to ROCD, are outlined below.

Existential guilt refers to the awareness that an infinite number of choices exist in life (i.e., existential freedom), and the resulting fear of making the wrong decision (Yalom, 1980). Theoretically, existential freedom and guilt may play a key role in ROCD. ROCD is characterised by a fear of choosing the “wrong” partner, and often involves catastrophic beliefs about the consequences of being in a relationship which is imperfect, or the consequences of breaking up (Doron et al., 2016). Further, the excessive comparisons between one’s current partner and other potential partners, and catastrophic beliefs about staying in the “wrong” relationship, can ostensibly be linked to existential guilt, overlapping heavily with items measuring this latter construct (e.g., “I worry about not living the life that I could live”; van Bruggen et al., 2017).

Consistent with this proposed link, Doron and Derby (2017) argue that a fear of future regret (e.g., “I won’t be able to cope with the thought that I have made a wrong decision”; p. 551) is key to the distress experienced in ROCD. Relatedly, one study demonstrated that the fear of guilt predicted symptoms in both relationship-centred and partner-focused ROCD (Tinella et al., 2023). However, this study only examined the fear of guilt (i.e., the tendency to try and avoid feeling guilt, or punish oneself for feeling guilty), rather than existential guilt (e.g., the fear of making poor life choices). In one study, existential guilt was found to significantly predict overall OCD severity and sexual obsessions, above and beyond neuroticism (Chawla et al., 2022).

Identity refers to the human struggle to discover who one really is. Identity concerns have been demonstrated to have a key role in OCD: One systematic review revealed that maladaptive beliefs about oneself (e.g., beliefs that one is morally deficient) play a significant role in OCD (Jaeger et al., 2021). Further, identity concerns have been shown to be positively associated with overall OCD severity and severity of sexual obsessions, but not aggressive obsessions (Chawla et al., 2022). This discrepancy between sexual and aggressive obsessions highlights the unique relationship between identity concerns and OCD presentations involving one’s feelings about other people, rather than physical harm.

Whilst no studies in ROCD have explicitly measured broad identity concerns, scores on a measure of the “feared self” (i.e., the tendency to believe one’s character contains covert negative traits), have been shown to be a unique predictor of ROCD symptoms (Fernandez et al., 2021). Further, the life domains on which people base their identity appears to play a key role in ROCD. For example, people whose self-esteem is highly contingent on their current relationship (Doron et al., 2013), or those who view their partner’s flaws as reflecting negatively on themselves, are more likely to be vulnerable to ROCD (Doron et al., 2014).

Existential isolation refers to the innate human desire for connection, in the face of the “unbridgeable gap” between our own subjective experiences and that of others. Arguably, people who are more troubled by existential isolation may be more prone to ROCD. That is, a person who typically feels anxious about the gap between oneself and others may be more sensitive to experiences of feeling misunderstood by, or disconnected from, romantic partners. Among OCD patients, isolation was significantly correlated with OCD symptom severity, although this relationship was no longer significant after controlling for neuroticism (Chawla et al., 2022).

In the context of ROCD, Doron et al. (2013) have demonstrated evidence for a double relationship-vulnerability; specifically, attachment anxiety and a tendency to base one’s self-worth on intimate relationships (as discussed above) may jointly increase a person’s vulnerability to ROCD. That is, a high need for closeness with one’s romantic partner, and anxiety in the absence of this closeness, appears to be a risk factor for ROCD. Arguably, attachment insecurity is related to existential isolation, and indeed these links have been demonstrated (Helm et al., 2020). However, existential isolation has not been explicitly measured in relation to ROCD symptoms.

Meaninglessness refers to the human desire for purpose in life, in the face of a world which offers no inherent meaning or structure (Yalom, 1980). It is possible that doubts about the meaning of life may exacerbate doubts about one’s relationship, particularly if one views their relationship is an impediment to them creating purpose in life. For example, if an individual feels their life has no real meaning, they may be more hypervigilant to aspects of their relationship which further threaten their ability to create this meaning (e.g., a partner’s values or aspirations which differ from their own).

Consistent with this, in the general population, meaning in life has been positively associated with marital satisfaction (Chasson et al., 2021; Stavrova & Luhmann, 2016). Among people with OCD, meaninglessness (like identity and guilt) has been shown to significantly predict overall disorder severity, and severity of sexual obsessions (but not aggressive obsessions), above and beyond neuroticism (Chawla et al., 2022)

Death anxiety is increasingly attracting attention as a transdiagnostic construct in mental illness (Iverach et al., 2014). Whilst death anxiety may not appear directly related to ROCD, its important role in OCD has been consistently demonstrated. Death anxiety has been repeatedly shown to predict overall OCD severity (Menzies & Dar-Nimrod, 2017; Menzies et al., 2019). Further, it is associated with all six symptom domains of OCD, including those which do not share explicit themes of physical harm (e.g., hoarding, “just rightness”; Menzies et al., 2020). Further, of all five existential concerns, only death anxiety predicted aggressive obsessions after controlling for neuroticism. However, death anxiety did not remain a significant predictor of sexual obsessions, suggesting that its role in presentations related to attraction and relationships may potentially be limited (Chawla et al., 2022). Thus, whilst a body of evidence links death anxiety to most OCD presentations, its potential relevance to ROCD is unclear, warranting exploration.

The current study

Currently, no studies have explicitly examined the relationship between existential concerns and symptoms of ROCD. The current study aimed to address this gap in a community sample. It was hypothesised that existential concerns would predict ROCD symptoms. In particular, given theoretical arguments and previous findings (e.g., Chawla et al., 2022), it was expected that isolation, identity, and guilt would demonstrate the strongest relationships with ROCD symptoms.

Method

Participants

An a priori power analysis using G*Power indicated that 207 participants would be needed to provide 90% power to detect a small-to-medium effect (r = .20). This calculation was based on previous effect sizes found in studies with similar designs and hypotheses (e.g., Menzies et al., 2020). However, given the use of a non-clinical community sample in the current study, and the absence of any existing effect sizes regarding ROCD specifically, we expected that the relationships found may be smaller than those previously reported for other OCD types using clinical samples (e.g., Menzies et al., 2020). As a result, we did not introduce a sample-size cap.

Participants were recruited from a sample of undergraduate psychology students at an Australian university, across two semesters. Participants took part in the study in exchange for course credit. The study was advertised as exploring personality traits, mental health, and attitudes to relationships. The inclusion criteria were: 1) Being over the age of 18 years, and 2) Having been in at least one romantic relationship for three months or longer. There were no exclusion criteria. Institutional ethics approval was obtained from the Human Research Ethics Committee of the University of Sydney, Australia (protocol number 2023/001).

Measures

Existential Concerns Questionnaire (ECQ; van Bruggen et al., 2017)

A 22-item measure which assess five existential concerns: Isolation (three items; e.g., “I have the anxious feeling that there is a gap between me and other people”; α = .75), Identity (four items; e.g., “I am afraid that I will never know myself at the deepest level”; α = .76), Guilt (four items; e.g., “It frightens me when I realise how many choices life offers”; α = .76), Meaninglessness (four items; e.g., “The question of whether life has meaning makes me anxious”; α = .78), and Death (seven items; e.g., “It frightens me that at some point in time I will be dead”; α = .87). Response options range from 1 (“Never”) to 5 (“Always”). In the current study, the internal consistency for the overall scale was excellent (α = .94).

The Relationship Obsessive-Compulsive Inventory (ROCI; Doron et al., 2012b)

A 12-item measure which assesses ROCD symptoms across three subscales: Feelings towards one’s partner (e.g., “I continuously reassess whether I really love my partner”), appraisal of the “rightness” of the relationship (e.g., “I check and recheck whether my relationship feels right”) and perception of partner’s feelings (e.g., “I continuously doubt my partner’s love for me”). Items are rated from 0 (“Not at all”) to 4 (“Very much”). The total ROCI score, which demonstrated excellent internal consistency (α = .90), was used as the measure of ROCD symptoms.

The following three measures were included as control variables, given their demonstrated role in ROCD or OCD more broadly:

Relationship Catastrophization Scale (ReCats; Doron et al., 2016)

A 20-item measure which assesses catastrophic beliefs about relationships. The ReCats consists of three subscales, pertaining to overestimation of the negative consequences of 1) separation, (e.g., “As far as I am concerned, there is nothing harder than dealing with a break-up”), 2) being in the wrong relationship (e.g., “I believe that being in the wrong relationship almost always leads to a wasted life”), and 3) being alone (e.g., “The thought of going through life without a partner scares me to death”). Each item is rated from 1 (“Disagree very much”) to 7 (“Agree very much”). In the current sample, the internal consistency was excellent (α = .82).

Relationship Quality (RQ; Chonody et al., 2016)

A 9-item measure which assesses satisfaction with one’s relationship (e.g., “I think of my partner as my soul mate”). Each item is rated from 1 (“Strongly disagree”) to 5 (“Strongly agree”), with a higher score indicating greater perceived relationship quality. The RQ was only administered to participants who reported being in a current relationship. In the current study, the internal consistency was excellent (α = .80).

Big Five Aspects Scales – Neuroticism subscale (BFAS; DeYoung et al., 2007)

A 20-item subscale of the BFAS, which measures neuroticism (e.g., “Get upset easily”). Items are rated from 1 (“Strongly disagree”) to 5 (“Strongly agree”). This measure was included to control for neuroticism as a potential confound, consistent with previous research (Chawla et al., 2022). In the current study, the internal consistency was excellent (α = .88).

In addition, a series of demographic questions were administered, including questions pertaining to gender, age, relationship status, sexuality, and mental health history.

Results

Sample characteristics

In total, 394 participants consented to take part; of these 390 completed the survey (99% completion rate). In total, 34 participants (8.8%) failed a single-item attention check, and were excluded from analyses.

Demographics

In this final sample, 77.6% identified as female, 20.7% as male, and 1.7% as gender non-conforming or non-binary. The mean age of the sample was 20.95 years (SD = 5.38). Regarding ethnicity, the sample was largely Asian (49.1%) and White (41.7%), with 0.9% identifying as Middle Eastern, 0.8% identifying as Aboriginal or Torres Strait Islander, and 0.3% identifying as African.

Relationships and sexuality

Regarding their relationship status, 52.7% were currently in a relationship, 41.9% were single, 3.1% were married, 2.0% were in a de facto relationship, 0.3% were divorced, and 0.6% were widowed. The mean number of total romantic relationships was 2.57 (SD = 2.11) The sample predominantly consisted of participants identifying as heterosexual (73.4%), with 18.1% identifying as bisexual, 3.1% as gay or lesbian, 2.3% as pansexual, 2.0% as queer, and 1.1% as “other”.

Mental health characteristics

Across the sample, 116 participants (32.9%) reported a current mental health condition; of the 237 participants who reported no current mental health condition, 53 (22.4%) reported having had a previous condition. Thus, a total of 169 participants (47.9%) indicated a mental health condition in their history. The majority of the sample (57.5%) had previously sought psychological treatment. On the ROCI, the mean total score was 14.31 (SD = 9.94); 21 participants (5.9%) scored above the mean of 30.73 previously reported in ROCD samples (Melli et al., 2018).

Primary analyses

First, across both the overall sample, and the subsample of those currently in a relationship, all five existential concerns were significantly and positively correlated with ROCI scores (see Table 1). Examining this further in the overall sample, a small correlation was found between Death and ROCI scores. In contrast, moderate correlations were observed for all other existential concerns, and the Total ECQ. Additional analyses (i.e., Fisher r-to-z transformations) were conducted to determine whether there were significant differences in the size of these correlations in the overall sample. This revealed that the correlation found for Identity and ROCI scores was significantly larger than those found for Guilt (p = .019), Meaninglessness (p = .007), and Death (p = .001). Similarly, the correlation found between Isolation and ROCI scores was significantly larger than that found for Death (p = .002) and Meaninglessness (p = .05). No other differences between the correlation sizes reached significance.

Table 1. Pearson correlations between variables for the overall sample (N = 353; above the diagonal) and the subsample of those currently in a relationship (n = 203; below the diagonal).

	Total ECQ	Meaninglessness	Guilt	Isolation	Identity	Death	ROCI	ReCats	BFAS	Age
Total ECQ		.83**	.81**	.84**	.85**	.87**	.49**	.43**	.55**	−.22**
Meaninglessness	.84**		.61**	.59**	.69**	.63**	.40**	.37**	.42**	−.14**
Guilt	.82**	.65**		.65**	.66**	.59**	.41**	.31**	.45**	−.20**
Isolation	.86**	.61**	.69**		.75**	.64**	.47**	.38**	.54**	−.22**
Identity	.84**	.70**	.67**	.74**		.58**	.49**	.41**	.52**	−.19**
Death	.87**	.63**	.61**	.68**	.57**		.35**	.35**	.43**	−.19**
ROCI	.52**	.45**	.43**	.52**	.49**	.37**		.28**	.49**	−.20**
ReCats	.43**	.34**	.34**	.42**	.40**	.34**	.26**		.22**	−.15**
BFAS	.57**	.49**	.48**	.52**	.54**	.43**	.51**	.27**		−.27**
Age	−.21**	−.13	−.18*	−.21**	−.19**	−.19**	−.21**	−.17*	−.33**
RQ	−.18**	−.21**	−.17*	−.17*	−.21**	−.08	−.48**	.13	−.23**	−.03

Correlations above the diagonal (i.e., quadrant on top right) represent the complete sample (N = 353). Correlations below the diagonal (i.e., bottom left quadrant) represent the subsample currently in a relationship (n = 203). BFAS = Big Five Aspects Scale – Neuroticism subscale; ECQ = Existential Concerns Questionnaire; ReCats = Relationship Catastrophization Scale; ROCI = Relationship Obsessive Compulsive Inventory; RQ = Relationship Quality (administered only to those currently in a relationship).

*p < .05, **p < .01.

Next, six hierarchical regressions were conducted with ROCI entered as the dependent variable. BFAS, RQ, and ReCats were entered in the first step, and each existential concern was entered in the second step. Given that RQ was only completed by those currently in a relationship, the regression analyses was solely conducted on this subset of 203 participants. These analyses revealed that all five existential concerns remained significantly associated with ROCI scores above and beyond neuroticism, relationship quality, and relationship catastrophisation (see Table 2). To examine whether this finding was unique to participants in a current relationship, the analyses were repeated with the inclusion of single participants. In these regressions, the RQ was omitted given this was only completed by participants in a relationship. Across these six subsequent regressions, the pattern of significance described above remained unchanged. That is, across the overall sample, each existential concern remained a significant predictor of ROCI scores after controlling for neuroticism and relationship catastrophisation.

Table 2. Results of six hierarchical regressions for ROCI symptoms amongst participants in a relationship (n = 203).

	Model 1					Model 2
	B	SE B	β	p	R^2	B	SE B	β	p	R^2	F for ΔR^2
(1) Relationship Quality	−.90	.12	−.43	<.001	.45	−.84	.11	−.40	<.001	.48	13.48
ReCats	.13	.03	.22	<.001		.08	.03	.14	.019
Neuroticism	.26	.04	.36	<.001		.18	.05	.25	<.001
Total ECQ						.13	.04	.25	<.000
(2) Relationship Quality						−.85	.12	−.40	<.001	.47	7.49
ReCats						.10	.03	.17	.003
Neuroticism						.21	.04	.29	<.001
Meaninglessness						.43	.16	.17	.007
(3) Relationship Quality						−.87	.12	−.41	<.001	.46	6.61
ReCats						.10	.03	.18	.002
Neuroticism						.21	.04	.29	<.001
Guilt						.48	.19	.16	.011
(4) Relationship Quality						−.83	.11	−.40	<.001	.49	17.81
ReCats						.08	.03	.13	.028
Neuroticism						.18	.04	.25	<.001
Isolation						.81	.19	.27	<.001
(5) Relationship Quality						−.84	.12	−.40	<.001	.47	9.10
ReCats						.09	.03	.16	.009
Neuroticism						.20	.05	.27	<.001
Identity						.49	.16	.20	.003
(6) Relationship Quality						−.89	.12	−.42	<.001	.46	5.37
ReCats						.11	.03	.18	.002
Neuroticism						.22	.04	.31	<.001
Death						.20	.09	.14	.021

ECQ = Existential Concerns Questionnaire; ReCats = Relationship Catastrophization Scale; ROCI = Relationship Obsessive Compulsive Inventory.

Discussion

The current study examined the relationship between the five existential concerns and ROCD symptoms. All five existential issues were significantly associated with ROCD symptoms. Consistent with predictions, Isolation and Identity were most strongly associated with ROCD symptoms, relative to other concerns. However, Guilt demonstrated a somewhat weaker association with symptoms than expected; the size of this relationship did not differ significantly from that found for Meaninglessness or Death. Notably, the relationships between ROCD symptoms and all five existential concerns remained significant after controlling for the quality of one’s current relationship, catastrophic beliefs about relationships, and neuroticism. This highlights the striking robustness of the current findings.

In particular, the current study demonstrates the potentially unique role of existential isolation in ROCD, relative to other OCD dimensions. In the study by Chawla et al. (2022), Isolation emerged as the only existential concern which did not significantly predict OCD severity above and beyond neuroticism. By contrast, the present findings identified Isolation as one of two largest predictors of ROCD symptoms. These findings suggest that feeling there is a gap between oneself and others, or that others will never be able to understand one’s experiences, may increase doubts about whether one is truly “in love”. Conversely, it is also possible that ROCD symptoms may increase existential isolation. For example, maladaptive behaviours which characterise ROCD (e.g., checking and monitoring one’s internal states, interrogating one’s partner, or avoiding investing time and effort in one’s relationship; Doron et al., 2014), may increase the feeling of an unbridgeable distance between the self and others. Consistent with this latter explanation, Doron and Derby (2017) propose behavioural strategies such as increasing experiences and activities with one’s partner, which may arguably build connection and alleviate feelings of existential isolation.

The current findings also emphasise the role of identity concerns in ROCD, echoing previous findings suggesting maladaptive beliefs about the self and broad identity concerns play a role in OCD (Chawla et al., 2022; Jaeger et al., 2021). It appears that higher levels of uncertainty about one’s identity are associated with greater doubts about one’s partner, and excessive attempts to check the “rightness” of the relationship. This may be because perceived flaws in a relationship are seen as reflecting unfavourably on oneself, among individuals who struggle with questions of identity. Such a finding adds further weight to the notion that relationship-contingent self-worth is particularly central to ROCD (Doron et al., 2013). This is also consistent with some treatment approaches proposed for ROCD, which involve bolstering one’s sense of self (e.g., by engaging in valued activities that are important to the individual, or challenging beliefs about the importance of relationships to self-worth; Doron & Derby, 2017).

Existential guilt also emerged as a significant predictor of ROCD symptoms, albeit less so than isolation and identity. That is, anxiety about the number of choices life offers, and worries about the consequences of one’s choices, were associated with greater ROCD symptoms. The relevance of existential guilt is apparent in the worries often reported by patients with ROCD, such as whether they are in the “right” relationship or have found “The One”, given the vast number of potential partners that exist (Doron & Derby, 2017). The current findings highlight the need to consider existential guilt in treatment approaches for ROCD. Several existing treatment components for ROCD can be conceptualised as targeting this construct, including: 1) in vivo exposure therapy targeting deliberately making wrong choices in daily life (e.g., buying the “wrong” pair of shoes), and 2) imaginal exposure to feared future scenarios involving suboptimal choices (e.g., writing and repeatedly reading catastrophic scripts about being trapped in a relationship with the “wrong” partner; Doron & Derby, 2017).

The finding that meaninglessness similarly predicted ROCD symptoms is consistent with previous research demonstrating its role in OCD, particularly in sexual obsessions (Chawla et al., 2022). Meaning has thus far received little attention in research on ROCD. In light of the current findings, it is possible that excessive doubts about the rightness of one’s relationship lead people to question their sense of meaning in life. The reverse may also be true; fearing that one’s life lacks any meaning may place additional pressure on choosing a life partner who may provide life with purpose. At present, treatment approaches to ROCD appear to have largely ignored the role of meaning in life. Based on the current results, interventions which attempt to bolster meaning may warrant further attention in the context of ROCD.

Lastly, the finding that death anxiety was significantly associated with ROCD symptoms even after controlling for neuroticism is somewhat surprising. While death anxiety has been strongly linked to certain OCD subtypes, such as contamination (Menzies & Dar-Nimrod, 2017) and checking (Menzies et al., 2020), two subtypes which directly involve attempts to prevent death (i.e., through preventing illness, fire, or electrocution), its role in other subtypes appears smaller. Specifically, Chawla et al. (2022) demonstrated that sexual obsessions were no longer significantly associated with death anxiety after Bonferroni correction. In light of this, the current finding is somewhat unexpected. Why might death anxiety predict ROCD symptoms? On the one hand, secure attachments and close relationships have been repeatedly shown to buffer fears of death (Mikulincer, 2018). It is therefore possible that doubts about one’s relationship leave an individual vulnerable to anxiety about their mortality. On the other hand, the fact that this relationship remained significant after controlling for the quality of one’s relationship, suggests that death anxiety is continuing to explain unique variance in ROCD even after controlling for this known buffer. Further research is needed to elucidate how death anxiety influences ROCD symptoms, or vice versa.

Strengths and limitations

The current study has several strengths. First, it represents the only attempt to explore the relationship between existential issues and ROCD symptoms. Second, the use of a large and sufficiently powered sample is a further strength of the study. Third, the attempt to control for potential confounds (e.g., neuroticism), as well as more general relationship-related variables (e.g., relationship quality), may increase confidence in the robust nature of these relationships.

However, the limitations of the study should be noted. First, the cross-sectional nature of the study precludes conclusions regarding causality. Whilst it is possible that existential concerns lead to symptoms of ROCD, it is equally possible that experiencing ROCD symptoms heightens a person’s sensitivity to existential issues, as discussed above. For example, there is evidence that the relationship between meaning in life and intimate relationship satisfaction is bidirectional (Stavrova & Luhmann, 2016); the same may apply to other existential issues and ROCD symptoms. Experimental research is needed to further explore the direction of causality in the demonstrated relationships.

Second, the use of a student sample is a limitation of the current study. It remains unclear whether these findings would replicate in a sample of individuals diagnosed with OCD. Despite this, the mental health characteristics reported by the sample suggest they may be considered a clinically-relevant group. That is, the majority of the sample had previously sought psychological treatment, and nearly half reported having had some form of mental health condition in their lifetime. Such findings are not inconsistent with previous research demonstrating poorer mental health among Australian university students compared to the general population (Larcombe et al., 2016; Stallman, 2010), a problem which has worsened since the COVID-19 pandemic (Dodd et al., 2021). However, the current study did not explicitly assess how many students had OCD, and did not include a more general measure of OCD symptoms. Thus, it is unclear how many of these participants had a history of current or previous OCD. In any case, future studies should seek to examine whether the current findings replicate in a sample of people with a formal diagnosis of OCD.

Treatment implications

In sum, existential concerns appear highly relevant to ROCD. In particular, experiences of existential isolation and questions about one’s identity appear most strongly associated with this symptom domain. Treatment approaches may benefit from explicitly considering these concerns in the conceptualisation and management of ROCD. Notably, recent findings suggest that existential concerns remain largely unchanged following standard treatments, indicating that they may require more targeted intervention (Menzies et al., 2024). Fortunately, treatments which directly target existential concerns such as meaninglessness (Sun et al., 2022) and death anxiety (Menzies et al., 2018; Menzies, Julien, et al., 2022) have been shown to be effective in alleviating these concerns. However, it remains unclear whether these treatments produce more generalised improvements in broader mental health symptoms, outside of the existential concern they were designed to target (e.g., Menzies & Menzies, 2023).

In light of the current findings, existentially-oriented treatments may potentially be beneficial to patients with ROCD. Therapeutic approaches which specifically integrate existential isolation and identity concerns alongside standard treatment (e.g., CBT; see further Menzies et al., 2022, 2024) may be particularly promising for ROCD, given the current findings. However, this remains speculative, and further research is needed to examine whether such treatments may be beneficial for this population.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data is available from the author by request.