OCD, ERP, & doubt sensitivity: Shattering the illusion of certainty

OCD and Doubt

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 behaviors. Likewise, uncertainty about whether a stove has been turned off (and worry about potentially dire consequences) can underlie checking rituals.

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).

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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