Doubt is a core component of OCD and must be addressed explicitly in treatment.
Many individuals with OCD hunger for certainty. It’s a craving that often can’t be easily sated. Early conceptions of OCD from the 19th century acknowledged this issue directly, in that OCD was often termed the “doubting disease.” It is this need for certainty, the need to eliminate doubt, that leads many people with OCD to perform repetitive behaviors, which are known as rituals. For example, it is doubt about whether one’s hands are sufficiently clean that leads one to engage in repetitive hand-washing rituals. Likewise, uncertainty about whether a stove has been turned off (and worry about potentially dire consequences) can underlie checking rituals. Many different types of rituals involve reassurance-seeking behaviors.
For people with OCD who have intrusive bad thoughts (e.g., What if I secretly want to hurt a family member? What if I don’t believe in God enough and go to hell?), an inability to tolerate doubt can be devastating. This can leave a person stuck in a moral quagmire that feels hopeless. The person not only has symptoms of OCD but also is experiencing an existential crisis about their own nature. It is for this reason that many people with OCD feel confused, guilty, and alone.
Unfortunately, rituals never provide a long-term solution. Although they can sometimes be helpful for reducing doubt in the moment, this relief is only temporary. Doubt will inevitably rebound, rituals will become less effective at reducing anxiety over time, and symptoms will grow.
The truth is that certainty is always a mirage. We can never have complete certainty. We can never erase all traces of doubt. We don’t live in a world where that is possible.
But that’s okay. We can learn to live with doubt.
Coexistence is possible, and it’s probably happening right now. You just haven’t realized it.
When we drive to the grocery store, are we guaranteed that we will arrive? Of course not. And yet many of us undertake that risk without even thinking about it. Chances are, if you really think about it, you can identify many examples in which you set aside your doubt and take risks.
If you’re a person with OCD, you can learn to strengthen your tolerance of uncertainty through exposure and response prevention (ERP). This strategy works where others have failed (i.e., trying to control your thoughts).
How does ERP work?
ERP emerged from research on fear learning in OCD. One theory suggests that ERP works by helping the brain recalibrate its super-sensitivity toward doubt and uncertainty. Through repetition, ERP results in a more functional set point. Interestingly, the neural basis of this change can be observed using neuroimaging techniques, like fMRI. The idea is that through ERP, hyperactivity of the anterior cingulate (a brain area thought to be related to perceptions of “wrongness” and “a lack of cognitive closure”) can be downregulated. In this way, ERP provides a way to adjust the throttle of your brain.
Whether you’re currently engaging in ERP or not, start to take a look at the role that doubt and uncertainty play in your own symptoms. This knowledge, combined with a liberal dose of ERP guided by an experienced clinician, can help you learn to live more happily in a world that is uncertain.
There are no guarantees that we’ll complete every car trip. There is no promise that when we say goodbye to loved ones that we’ll be reunited on this earth. But that’s okay.
Luckily, we don’t need those guarantees. We can learn to be happy even in the face of the unknown.
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Fear, Doubt, Uncertainty, ERP, & the Monster Under the Bed
OCD symptoms: the obvious (and the not so obvious)
Scrupulosity
Dr. Seay,
I have been diagnosed with OCD many times and my particular obsession is worrying about if I am gay or not. I understand that one of OCD’s crucial symptoms is unrelenting doubt, and I wanted to know if it was common for people with my type of obsession to doubt their past opposite sex attractions. As of now my obsession is attacking this aspect of my life, I have plenty of old diaries suggesting that I was in fact attracted to the opposite sex but my OCD makes me doubt the validity of those past feelings. I am constantly questioning “did I really like that boy, or have I been lying to myself?” I just wanted to know with your experience of treating OCD was this a common doubt that your patients go through?
Hi Gabi,
Sadly, the doubt that you’re experiencing in relation to your symptoms is very common. This is why OCD is often referred to as “the doubting disease.” Many people with these types of fears also question, “What if this isn’t OCD? What if I really am gay?” These questions are ultimately unanswerable.
This is because there is no test or reassurance you can obtain that will erase the doubt. That is why treatment should not focus on “proving” whether or not you are straight or gay, but rather on learning to better tolerate the unknowable. Unfortunately, the more you analyze your thoughts and body to try to “figure out the truth”, the more likely you are to reinforce your symptoms. The best strategy for reducing your symptoms is exposure-based. Exposures in this context are built around purposefully seeking out situations you avoid and then resisting mental and physical rituals. Developing a good exposure hierarchy can be confusing, so find a good OCD therapist to guide you.
FYI, I hope to blog about this at some point, but I’m not sure when that will be. In the meantime, my posts on thought control, thought suppression, and Pure-O OCD may have some elements that are relevant to you.
I really enjoyed reading this article and I do recognize myself in many situations listed here. I have my doubts under control in some way, but there is one big problem that I have been doubting about for about a year now and I just can’t stop it.
Well, it’s about my relationship. As I have recently found out, people with OCD may have problems in their relationships because of their constant doubting. Well, here’s my story short: I have met a guy, we both liked each other, and soon fell in love. However, there have been many obstacles and challenges considering our relationship and we couldn’t be a couple for a long time. The biggest ones would be the fact that he had a girlfriend by the time and that my mother dislikes him a lot and doesn’t want us to be together. All these problems made me suffer a lot and I was under a lot of stress. Well, he split with his girlfriend now, and theoretically we could be together now, but I am still always questioning myself whether we are really meant to. I mean, all these obstacles… I somehow think that these are signs that we aren’t meant to be. My constant doubts about it really affected our good relationship. We started argueing and I somehow try to push him away unconsciously. I got obsessed by the thought that something bad will happen if we stay together. We see each other not very often, and I still have cancelled many dates because right before leaving the house I got scared that something bad will happen if I meet him.
I understand that I’m overreacting, but I just can’t help it. I have been searching for answers in many forums, but no answer could please me. Maybe you could give me some advice?
Hi Lisa,
Some individuals have a type of “relationship OCD” or “ROCD” that causes them to have doubts about their relationships. These doubts often focus on topics such as pursuing the “right” relationship (“Is this the right relationship/person for me?”, “What if I would be happier in a different relationship?”), one’s own fidelity (“What if I secretly want to cheat on my partner?”), one’s partner’s fidelity (“What if my partner is secretly cheating on me?”), and one’s sexuality (“What if I’m secretly gay?”). Relationship OCD (ROCD) rituals are often based around reassurance-seeking behaviors.
***NOTE: Many of these doubts are quite normal and don’t necessarily reflect OCD.***
Magical thinking might not necessarily reflect ROCD. If you’re concerned about OCD, you should meet with a psychologist and have your symptoms assessed.
Hello there Mr. Seay, My name is George and I have OCD which seems to primary be of the purely obsessive type. It has tormented me most of my adult life. I started dating a wonderful women named Mary. WE have been dating for 8 months now and I have found myself really struggling emotionally in the context of our relationship. I find myself constantly hyper focus on her flaws or focused on our differences as individuals. nearly all day some days I will be struggling not to obsess over them. She has treated me so well and I have not aloud my hyper sensitivity toward her flaws to cause me to treat her poorly i have still treated her with respect. But I have found myself struggling to accept her with her flaws. I feel like OCD is playing a part in this and not only that but whenever I try to look at my feelings for her they evaporate. I know I love her but it seems like any attempt at introspection of my own emotions in regards to her causes the emotions I have for her to evaporate and turn into anxiety. I find myself very frequently in a state of doubt or fear in my relationship with her. But our relationship works well and we are fairly healthy as a couple. I know that I want to marry her but I feel constantly held back by a fear and obsession that I know is unreasonable. I want to move past my obsessive hyper focus but I feel powerless against it. Got any suggestions. Thank!
Hi George,
In these types of situations, it’s very important to work alongside a trained therapist who can guide you in the best way to proceed. In situations of relationship OCD (ROCD), treatment usually involves exposures that directly target doubt/perceived flaws.
Exposure will probably be only half of your solution, however. In addition to exposures, you also would likely benefit from some cognitive restructuring around the idea of the “happy ending”. Happy endings need not be 100% happy. They can also be 80% happy or 60% happy. While these outcomes might not be “perfect”, we don’t live in a perfect world. Your goal, then, is to learn to be happy despite imperfections.
FYI, I’ll blog about ROCD at some point in the future.
All the Best!