Low self-esteem isn't a mental health disorder in its own right, but it's something that many people struggle with, and it can have an important relationship with obsessive-compulsive disorder (OCD). In my clinical practice, I often find that low self-esteem can influence how people interpret their intrusive thoughts, potentially making them feel even more threatening or convincing.
Interestingly, the relationship can also work in the other direction. Living with OCD can have a significant impact on how someone feels about themselves, sometimes contributing to longstanding feelings of shame, guilt or inadequacy.
How can low self-esteem influence OCD?
Low self-esteem involves having a generally negative view of ourselves. Someone might hold deeply rooted beliefs such as:
I'm not good enough.
I'm a bad person.
I'm worthless.
I'm fundamentally flawed.
There's something wrong with me.
These beliefs can influence how we interpret our experiences, including intrusive thoughts. For example, imagine someone who already has a negative opinion of themselves suddenly experiences an intrusive thought about harming somebody they love. Rather than recognising this as an unwanted mental event, they might wonder whether the thought reveals something terrible about who they really are.
What if I really am a bad person? What if there's something dangerous or evil inside me?
When intrusive thoughts seem consistent with our existing negative beliefs about ourselves, they can feel particularly frightening and difficult to dismiss. This doesn't mean that the thoughts are any more meaningful or valid. But they may feel more believable to the person experiencing them. And this can make the urge to analyse, challenge or neutralise those thoughts even stronger.
Can OCD cause low self-esteem?
Absolutely. And I think this is an equally important part of the relationship. Imagine repeatedly experiencing unwanted thoughts or images about hurting somebody, behaving immorally or doing something sexually inappropriate. Even when these thoughts are completely inconsistent with someone's values and intentions, their presence can be deeply distressing. Someone might begin questioning their character, feeling ashamed of their thoughts or believing that they're somehow fundamentally different from other people. Over time, this can have a significant impact on their self-esteem. This is something I particularly notice in people experiencing OCD relating to morality, harm, relationships or past events. For example, someone with real event OCD might repeatedly analyse something they did years ago, convincing themselves that it demonstrates they're a terrible person. Someone experiencing relationship OCD might interpret their intrusive doubts as evidence that they're dishonest, selfish or incapable of loving somebody properly. In these situations, OCD doesn't just create anxiety about a particular outcome. It can begin to undermine someone's entire sense of who they are.
Low self-esteem and rumination
I think low self-esteem can be particularly relevant when OCD involves extensive rumination. Someone who holds negative beliefs about themselves may feel a powerful need to prove that those beliefs aren't true. They might repeatedly review memories, analyse their intentions, compare themselves with other people or search for evidence that they're a good person. Unfortunately, these attempts to obtain reassurance can become mental compulsions. And the more someone ruminates about whether they're fundamentally bad or flawed, the more important the question can begin to feel. This can create a difficult cycle in which low self-esteem makes intrusive thoughts more threatening, while compulsive rumination reinforces the sense that there's something wrong with the person experiencing them.
What about people-pleasing and excessive responsibility?
Another interesting consideration is how low self-esteem can influence our everyday behaviour. People with low self-esteem may be particularly concerned about disappointing others, being criticised or being perceived negatively. As a result, they might develop patterns such as:
Excessive apologising, even when they haven't done anything wrong.
People-pleasing and putting other people's needs ahead of their own.
Taking responsibility for problems that aren't really their fault.
Finding it difficult to say no or establish boundaries.
Feeling a strong need to be seen as kind, responsible or morally good.
These behaviours aren't necessarily compulsions or symptoms of OCD. However, I sometimes think of them as OCD-adjacent behaviours, because the underlying beliefs can overlap with those that maintain certain obsessive-compulsive difficulties. For example, someone who already feels excessively responsible for other people's wellbeing might be particularly distressed by intrusive thoughts about causing harm. Someone who believes they must always be a good person might find morally troubling intrusive thoughts especially difficult to tolerate. And someone who fears upsetting or disappointing others might become trapped in cycles of excessive reassurance seeking, confession or apologising.
In this way, broader patterns of self-criticism and excessive responsibility can sometimes interact with OCD and make particular intrusive experiences feel more significant.
Can low self-esteem contribute to depression?
Low self-esteem is also associated with depression, which can sometimes complicate OCD treatment. Someone who feels persistently inadequate, guilty or worthless may become increasingly hopeless about themselves or their ability to change. And when depression is present alongside OCD, it can be more difficult to find the energy or motivation to engage in treatment. This doesn't mean that low self-esteem inevitably leads to depression, but it's another reason why understanding someone's broader psychological difficulties can be important.
Should low self-esteem be addressed during OCD treatment?
I think this depends on the individual. For some people, successfully treating OCD leads to considerable improvements in how they feel about themselves. As intrusive thoughts become less threatening and compulsions reduce, they may begin to recognise that their OCD never actually reflected their character or intentions.
For others, negative beliefs about themselves are more deeply rooted and may benefit from additional attention during therapy. This might involve exploring longstanding patterns of self-criticism, beliefs about personal responsibility or the tendency to prioritise other people's needs at the expense of their own.
Cognitive behavioural therapy (CBT) can be helpful for addressing these difficulties alongside exposure and response prevention (ERP) for OCD. However, there's an important distinction between working on underlying negative beliefs and repeatedly reassuring ourselves that an intrusive thought doesn't mean we're a bad person. The latter can easily become another compulsion. The aim is to develop a healthier relationship with ourselves while also learning that we don't need to resolve every intrusive doubt.
The bottom line
Low self-esteem doesn't necessarily cause OCD, and not everybody with OCD struggles with their self-esteem. However, the two can interact in important ways. Negative beliefs about ourselves can make intrusive thoughts feel more convincing and threatening. Meanwhile, living with distressing obsessions and compulsions can gradually undermine our confidence and sense of self-worth. Recognising these connections can be an important part of developing a more complete understanding of someone's difficulties. Overcoming OCD isn't just about changing how we respond to intrusive thoughts. It's also about recognising the broader beliefs and behaviours that can make those thoughts feel so profoundly threatening in the first place.