Why Relationship OCD Is Underrecognized

Source: pexels/cottonbro studio

A client arrives at the clinic to explore her relationship with her significant other and determine its suitability for her. Over several sessions, the client and the therapist examine the relationship, assess its pros and cons, analyze it from various perspectives, and investigate the extent to which the client’s needs are being fulfilled. At the conclusion of each session, the client expresses a sense of relief and feels that she is making progress toward reaching a decision.

However, with time, the therapist notices a troubling pattern in which the client returns to the same doubts and questions that had previously been addressed, effectively bringing them back to square one each session. Despite previous resolutions, the client persistently raises the same concerns and struggles to let go of the constant questioning about whether her relationship is suitable for her. While doing so, she mostly experiences her doubts and fears, rather than the relationship itself.

At this point, the therapist starts to wonder why, unlike others, this client does not seem to be growing in therapy, but rather becomes more and more entangled in her circulating deliberations.

The description outlined above may indicate the presence of Relationship Obsessive-Compulsive Disorder (ROCD). ROCD is a manifestation of obsessive-compulsive disorder (OCD) that is characterized by obsessive preoccupation with one's relationship. ROCD is not listed in the DSM-5 as a distinct diagnosis; rather, it describes a particular way that a diagnosis of OCD can manifest. Unfortunately, due to various reasons, OCD in general, and ROCD, in particular, are frequently misdiagnosed.

OCD: A Heterogenic, Underdiagnosed Condition

OCD is a heterogenic disorder in which obsessive concerns may revolve around themes including contamination, fear of harming oneself and others, symmetry, sex, morality, and religion. Individuals living with OCD frequently experience intrusive thoughts, images, or urges (obsessions), to which they feel compelled to respond with a variety of behaviors or mental acts (compulsions) to alleviate the distress caused by the obsessions.

Due to its elusive and diverse nature, OCD is often underdiagnosed. Various studies have demonstrated the high prevalence of OCD misdiagnosis by physicians and mental health providers, which may reach up to 50% (Glazier et al., 2013, 2015; Perez et al., 2022). These studies have also shown that while stereotypic OCD symptoms, such as symmetry and contamination, were less likely to be misdiagnosed, providers had substantially more difficulty recognizing less common manifestations, such as sexual, somatic, or religious symptoms.

The misdiagnosis of OCD plays a significant role in the delay of appropriate treatment, with the time between the disorder's onset and the start of proper treatment averaging between 10-17 years in the U.S. (Cullen et al., 2008; Perez et al., 2022; Pinto et al., 2006). Such delay in suitable treatment often results in years of struggle, shame, and functional impairment.

Underdiagnosis of Relationship OCD

The diagnosis of ROCD poses an additional challenge, as many clients and therapists are still unfamiliar with this phenomenon. Due to a lack of awareness of the diverse nature of OCD and its various manifestations, therapists may misinterpret ROCD symptoms as natural relationship concerns rather than recognizing them as signs of ROCD. In addition, the DSM-5 and traditional tools for the assessment of OCD (e.g., the YBOCS) do not account for relationship-related obsessions as a diagnostic criterion for OCD, further complicating the diagnosis.

Another factor contributing to the underdiagnosis of ROCD is the gray area in which obsessions and compulsions arise. Many (but not all) individuals coping with OCD symptoms know that their obsessions are somewhat illogical, but find it hard to resist the urge to engage in compulsions. In ROCD, the picture is often more complicated.

While some clients recognize that their thought patterns are the root of their issues rather than the relationship itself, others may struggle to differentiate between genuine relationship-related concerns and circular, obsessive thinking. In the course of therapy, relationship-related doubts and questions may emerge naturally in clients without ROCD, and they can bear a resemblance to those experienced by individuals with ROCD. Consequently, therapists may inadvertently overlook the presence of ROCD symptoms. Moreover, since romantic relationships are not immune to difficulties, separating productive relationship-related problem-solving from obsessive rumination can be a complex and perplexing task for clients and therapists alike.

OCD Essential Reads

The Potential of Psychedelic-Assisted Therapy for OCD

Helping Your Child Open Up About OCD Tendencies

An additional complication in diagnosing ROCD is the frequent use of covert internal compulsions. While some compulsions may be outwardly apparent, such as seeking reassurance from others about the 'rightness' of one's relationship, others may take the form of internal mental acts. These covert compulsions can include frequently monitoring one's emotions toward their partner or comparing their partner’s characteristics and flaws to those of others. (For more examples, click here.)

Although covert compulsions appear in other manifestations of OCD, they are especially prevalent among people coping with ROCD. The use of covert compulsions can make the diagnosis of ROCD more challenging as clients often perceive them as a natural thought process that is aimed at resolving their doubts and concerns rather than an excessive, circular behavior (e.g., “If I only deliberate long enough, I’ll achieve the desired resolution regarding my relationship”). Consequently, these covert compulsions may be more fleeting and less discernible than overt ones, both to clients and their therapists.

Improving the Diagnosis of ROCD

Diagnosis of ROCD is often challenging. When misdiagnosed, therapeutic interventions that endorse continuous deliberation may exacerbate the problem by perpetuating the client’s engagement in an ongoing ROCD cycle. Thus, it is vital to raise awareness of this condition among both clients and therapists to minimize the likelihood of misdiagnosis. Additional steps should include screening for ROCD in clients who experience other OCD symptoms, and in clients who are highly occupied with relationship problems.

Given that relationship-focused obsessions are common in clients with other OCD symptoms (Feusner et al., 2021), therapists should thoroughly inspect the presence of ROCD symptoms in clients with other types of OCD while paying close attention to the use of covert compulsions. Alongside clinical assessment, clinicians may use designated ROCD questionnaires, such as the Relationship Obsessive-Compulsive Inventory (ROCI; Doron et al., 2012a), and the Partner-Related Obsessive-Compulsive Symptoms Inventory (PROCSI; Doron et al., 2012b).¹

Therapists working with clients who experience relationship difficulties or avoid relationships altogether should be watchful for signs of ROCD. These indicators can include excessive, repetitive occupation with relationship-related doubts and concerns, often accompanied by distressing feelings and attempts at eliminating these feelings. Following DSM-5 criteria for the diagnosis of OCD, to receive a diagnosis of ROCD, the client’s occupation with relationship doubts and worries should be time-consuming (more than 1 hour per day), and/or cause significant distress or impairment in social, occupational, or other important areas of functioning.

ROCD is a highly debilitating condition that exacts a heavy toll on individuals and their relationships. Symptoms have been associated with depression, relationship-related distress, diminished relationship- and sexual satisfaction, and negative effects on one's partner (Doron et al., 2012a, 2012b, 2014; Derby et al., 2021; Littman et al., 2023). Early, precise diagnosis of ROCD may spare clients years of struggle by guiding them toward appropriate treatment with an OCD specialist.

To know more about Relationship OCD, click here.

To find a therapist, visit the Psychology Today Therapy Directory.