The OCD Stories Podcast, Episode 512

Dr. Steven Phillipson and Sarah: Metaphysical OCD and Sarah’s Story

Original Air Date: November 16, 2025
Host: Stuart Ralph
Guests: Dr. Steven Phillipson (Clinical Psychologist) and Sarah (patient with lived experience)

Episode Overview

This episode explores the rarely discussed but profoundly impactful theme of Metaphysical OCD, with a particular focus on "metaphysical contamination." Dr. Steven Phillipson, an expert in OCD treatment, breaks down the nature of metaphysical OCD, its overlap with trauma and existential anxiety, and the frequent difficulties around diagnosis. Sarah shares her compelling personal account—from onset to therapy success—providing insight, hope, and practical takeaways for sufferers and clinicians alike. The episode also touches on involving loved ones in the recovery process and clarifies the distinction between OCD and psychosis.

Key Discussion Points and Insights

1. Defining Metaphysical OCD

[02:28–10:58]

• What is Metaphysical OCD?

  • Dr. Phillipson defines "metaphysical" as relating to abstract concepts beyond physical science, including existence, causality, and the nature of reality.
  • Explains that metaphysical OCD is among the most confusing subtypes, often being mistaken for psychosis due to its abstract nature.
  • Quote: “The themes of metaphysical OCD are so convoluted... many psychiatrists, many mental medical professionals have mistaken this subset of OCD for psychosis.” – Dr. Phillipson [04:05]

• Metaphysical Contamination:

  • Involves the idea that objects or concepts are imbued with a negative essence or energy from a past traumatic event.
  • Unlike traditional contamination OCD, the fear is not of physical illness but of “the existence of the essence of that history” attaching to people, objects, or even words.
  • Treatment often requires addressing trauma and OCD separately, sometimes concurrently.

[10:58–14:10]

• Distinction Between Metaphysical and Existential OCD:

  • Existential OCD involves philosophical anxieties (“what is the meaning of life?”), whereas metaphysical OCD couples abstract anxieties with an urgent sense of threat about one’s reality or culpability.
  • Quote: “There’s more of a threatening component [in metaphysical OCD]… that might have some type of deleterious effect on the future.” – Dr. Phillipson [11:11]

• Emotional Contamination vs. Metaphysical Contamination:

  • Differentiates emotional contamination (objects evoking unwanted emotion) from metaphysical, where the issue is a conceptual, almost “radioactive” association.

2. Broader Subtypes and Diagnostic Confusion

[17:24–22:34]

• Other Subsets of Metaphysical OCD:

  • Includes “magical thinking” (e.g., rituals to prevent harm due to intrusive thoughts), often involving loved ones’ safety.
  • Dr. Phillipson distinguishes OCD from psychosis: OCD sufferers have doubt and distress about these beliefs, while psychosis includes unshakeable conviction without ritualizing.
  • Quote: “It’s not a very difficult distinction… people with OCD are more frightened by this prospect, and that’s why they engage in rituals such as avoidance or undoing.” – Dr. Phillipson [20:42]

• Religious and Cultural Influences:

  • Religious communities may reinforce magical thinking (e.g., power of prayer), making differentiation between faith and OCD essential.
  • Pop culture influences like “The Secret” can worsen symptoms; concepts like "manifesting" can substantiate OCD doubts.

3. Sarah’s Story: From Onset to Recovery

Early Symptoms and Misdiagnosis

[25:14–36:08]

• Trigger Event: A major fire in her city, accompanied by Sarah’s intrusive thought that she might have influenced it indirectly, ignited her OCD.

• Symptom Progression: Started as rare intrusive thoughts, evolved into daily (and then multiple daily) occurrences each time she heard news of tragedies, triggering a cycle of anxiety and avoidance (e.g., avoiding news).

• Superstitious, Magical, and Cultural Conditioning: Childhood stories and cultural superstitions made these intrusive thoughts more believable.

• First Treatment and Misdiagnosis:

  • Diagnosed with “generalized anxiety with psychotic elements,” prescribed antipsychotic and anxiety medications.
  • Quote: “It was terrifying… my biggest fear was that I would go crazy and I have no control over my life.” – Sarah [32:36]
  • Medication sedated her but did not address the core OCD.

• Ineffective Past Therapies:

  • CBT for contamination OCD, talking therapy, EMDR, and neurofeedback did not address core issues or sufficiently reduce compulsions.

Effective Therapy With Dr. Phillipson

[38:37–57:14]

• Rapid Start and Precise Targeting:

  • Therapy started with identifying triggers (news of tragic events) and exposure tasks (watching news multiple times daily without ritualizing).
  • Utilized “index card therapy”—writing down the intrusive thought, distress level, compulsive behaviors, and emotional response, then periodically reviewing these cards until distress declined.

• Deliberate Exposure to Fears:

  • Progressed to purposely thinking negative thoughts and imagined tragedies, seeing that thoughts alone did not cause harm.
  • Memorable Example: “One of the things that Stephen encouraged me was to just think on purpose of some negative events... then after a few days there were multiple deaths involving horses...” – Sarah [43:58–45:42]
  • Both Sarah and Dr. Phillipson use humor and a degree of detachment (“my brain says...”) to distance self from OCD thoughts.

• Acceptance as Key Turning Point:

  • Moving from seeking reassurance/innocence to radical acceptance of potential (however impossible) guilt diffused anxiety.
  • Quote: “I just hope that one day I will be able to tell for sure that it’s not my fault. ...this should not be the goal... the goal should be that I’m able to accept that, okay, I might be guilty for tragic events. And in a paradoxical way, thinking like this... makes it harder to believe that I might be responsible.” – Sarah [48:13]
  • Dr. Phillipson emphasizes the paradoxical nature of OCD treatment: “By saying to your brain, ‘yep, maybe it was me,’... the brain just kind of disengages.” [52:44]

Recovery and Sustained Progress

• Sustained Recovery:

  • Sarah hadn’t been triggered in several weeks at the time of recording.
  • Ongoing task: Stay ready to face new intrusive thoughts (using a “blank index card” to symbolize readiness for future challenges).
  • Quote: “Let’s see, what or who did I kill today? ...Sometimes I do remind myself that, okay, I’m ready for the next killing.” – Sarah [54:00–54:52]

• Contamination OCD Progress:

  • Progress with contamination was swifter, largely because she anticipated it would be harder than it actually was.

4. Involving Loved Ones

[57:44–60:36]

• Role of Husband:
  • Initially, her husband was very cautious, but after participating in a therapy session, he began helping her confront triggers—often using playful banter (“so you killed those poor babies?”) to defang the OCD’s seriousness.
  • Humor and shared exposure exercises made the process less isolating and more effective.
  • Quote: “His job was to mention the bad news and to say that it’s my fault… being able to make fun of it… made it less serious.” – Sarah [58:17–60:27]

5. Reflections and Hope

[62:33–65:21]

• Sarah’s Advice:
  • Facing exposure tasks was less scary than anticipated; importance of the “right person supporting you” can’t be overstated.
  • Quote: “Just actually trying it made it, yeah, much less scary than I thought… it’s important to have the right person to guide you.” – Sarah [63:09]
• Dr. Phillipson’s Reassurance:
  • OCD is treatable and not necessarily a lifelong, untreatable condition; aggressive acceptance can lead to dormancy for years or decades.
  • Quote: “People with OCD are not born with a lifelong affliction, but a very treatable condition when, as Sarah said, in the right hands.” – Dr. Phillipson [64:18]

Notable Quotes & Memorable Moments with Timestamps

• Dr. Phillipson on Confusion in the Field [04:05]:

  “The themes of metaphysical OCD are so convoluted... many psychiatrists, many mental medical professionals have mistaken this subset of OCD for psychosis.”

• Distinguishing Metaphysical vs. Existential OCD [11:11]:

  “There’s more of a threatening component [in metaphysical OCD]… that might have some type of deleterious effect on the future.”

• Sarah on the Desperation for Certainty [48:13]:

  “I just hope that one day I will be able to tell for sure that it’s not my fault ... the goal should be that I’m able to accept that, okay, I might be guilty for tragic events.”

• Embracing Exposure and Humor [54:00]:

  “Let’s see, what or who did I kill today? ...Sometimes I do remind myself that, okay, I’m ready for the next killing.”

• Recovery is Possible [64:18]:

  “People with OCD are not born with a lifelong affliction, but a very treatable condition... when the patient, you know, engages with the treatment and the kind of aggressiveness that Sarah has taken on.” – Dr. Phillipson

Suggested Listening Timestamps

• 02:28–10:58: Definitions and key characteristics of metaphysical OCD
• 25:14–36:08: Sarah’s story: onset, initial suffering, misdiagnosis, and ineffective treatments
• 38:37–57:14: Effective ERP, index-card strategy, and breakthrough moments
• 57:44–60:36: Involving loved ones and using humor in recovery
• 62:33–65:21: Reflections, hope, and closing thoughts

Takeaways

• Metaphysical OCD can be deeply distressing and difficult to diagnose; it’s often mistaken for psychosis due to its abstract and convoluted nature.
• Effective treatment requires recognizing the OCD nature of the obsessions, separating them from trauma or psychosis, and using structured ERP, including written and cognitive exposures.
• Radical acceptance (e.g., “maybe it is my fault”) is counterintuitive but crucial in treatment success.
• Support from loved ones, when informed and involved, amplifies recovery.
• Hope is real: With specialized treatment and self-acceptance, even entrenched metaphysical OCD can go “dormant” for long periods—or life.