OCD, ERP, & doubt sensitivity: Shattering the illusion of certainty
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.
Questions? Comments? Sound off below.
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Dr. Steven Seay is a licensed psychologist in Florida & Missouri. He is the Director of the Center for Psychological & Behavioral Science and provides treatment & therapy throughout South Florida, including Palm Beach Gardens, Jupiter, West Palm Beach, Boca Raton, Boynton Beach, Fort Lauderdale, & Miami.
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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!
Hi Steven,
I’ve only just recently found your site and enjoy reading your articles. I’ve suffered from OCD since I was around 7 or 8 years old (I’m now in my thirties). Had some very successful ERP treatment when I was in my teens which left me pretty much OCD-symptom free for four years before a massive relapse which I’ve never fully recovered from. I’m on SSRI medication now and doing okay, trying to practice ERP as regularly as I can.
My question is one I’ve always been curious to ask – do people without OCD experience as much doubt as people with OCD? Or do us OCDers experience much stronger and more persistent doubt feelings than non-OCDers? Put another way, are OCD sufferers burdened with more doubt than non-sufferers, or is it just that people with OCD have normal levels of doubt but are just less able to tolerate it than non-sufferers?
I know the question is a bit circular and probably not very relevant in terms of treatment outcome, but just curious what the research says.
My troubles related to ‘doubt’ present a little differently to the usual descriptions I read. For me, say for example I’m really enjoying a hobby (take gaming as an example). I’ll have a spike/feeling that “if I don’t do this compulsion then I’m going to stop liking gaming and it won’t be pleasurable to me anymore.” or “I’ll always be burdened with obsessions and compulsions related to this activity and so I won’t ever be able to enjoy it like I naturally want to / feel I should”.
Argh…. OCD 🙁
Hi Matt,
Good question. My hunch is that people with OCD do experience more doubt and uncertainty than your average joe. Exactly why this occurs has been the subject of many research studies (i.e., Is it hardwired? Is it learned? Is it a combination of both?), but I don’t know that this has been answered satisfactorily.
Here’s what we do know: people with OCD have the same thoughts that everyone else does. Even in cases of Pure-O (harm obsessions, sexual obsessions, etc.), the thoughts themselves are not unique. We’ve all had blasphemous, aggressive, or taboo thoughts. The problem with OCD is that these thoughts tend to feel more important or more dangerous…which then results in the use of maladaptive problem-solving strategies (i.e., rituals) that ultimately exacerbate the problem.
In the end, rituals increase doubt and uncertainty…which leads to more rituals…which leads to more doubt and uncertainty…and the cycle continues.
RE: your symptoms, unfortunately that happens a lot. I don’t know that we have a specific name for that type of OCD. I tend to think of it as being related to emotional contamination in some ways. It’s also related to some aspects of perfectionism.
It can be a struggle, but keep working on it. You’ll get there.
Hi
I would like your opinoin if possible.
I relocated to a new state with my fiance because of a job transfer. Me and my fiance have been together for 4 years. And i never had a doubt about me and him. We have had an absolutly amazing relationship. Very early on in our realtionship we knew that we would be getting married. When we relocated for his job transfer, I started to worry that maybe i didnt love him and that we shouldnt be getting married shortly before we were getting ready to move. My reasoning that maybe i just fell out of love with him. This upset me terribly. The absoult thought of it made me think that maybe that “maybe i dont love him” must be true. Its been 6 months of hell for me because althought my physical anxiety has gotten better as ive adjusted to my new home and life, the constant cycle of “do i love him” should we get married” is stuck in my head like a bully whispering in my ear. As i type this my heart is racing. When i feel like i got to the point of saying yes i do love him and i want to get married, i think of soemthing else to ruin that thought. I did have one month of peace and i was fine and we were able to laugh at what i was doing to myself, then it came back and here i am again doubting.
I know that deep down i love him, and when i think of our wedding day it brings a smile to my face, i am normally a worrier and i do worry about things going wrong or being up infront of people, but this constant doubting threw me for a huge loop. I focus on the only question of “do i love him” my best guess is YES i do. i cant get my mind to stop. and because i did so much research and cant stop doing research because reaserach makes me feel better, i know its not helping.
how can i tell rocd thoughts between real thoughts? better question do u agree this is rocd? when dx somebody with rocd what signs and symptoms do you look for?
Diane,
Many of the symptoms you describe are consistent with ROCD, but it’s impossible to determine this outside of a therapeutic relationship. If you think you have OCD, you should consult with a local provider who can work with you and get the full history of your symptoms.
The premise of ROCD (much like other forms of “Pure-O”) is that you can’t know for sure. Efforts to know for sure and to get perfect clarity ultimately backfire…as these efforts end up forming the basis of rituals and other unhealthy reassurance-seeking behaviors. The goal of treatment is to learn to accept uncertainty, habituate to anxiety, and move forward despite not having perfect clarity about the situation. Just like other forms of OCD treatment, effective treatment is actually exposure-based rather than reassurance-based.
I’m in the process of writing a post on ROCD, but unfortunately it’s not going to be able to provide clarification about any specific individuals or situations. The general idea, though, is that ROCD typically involves pervasive doubt and uncertainty about relationships. Doubts can target:
Do I really love my partner?
Does my partner really love me?
Is this really the right relationship for me?
Is this really the right person for me?
These questions pop up in all relationships (they are not specific to ROCD), but individuals with ROCD experience paralyzing doubt about these issues and pursue answers in ways that ultimately are not helpful.
Hang in there!
Hello, I have been with my boyfriend for five years. We have been through a lot but I wouldnt trade him for the world. Hes very supportive and loves me unconditionally but everyday I ask am in love?. I know I do love him, but am I in love. I left him a few days ago and ive been fine since, but I think im only okay because we still talk everyday. I worry since im not panicing that I am not in love. Id ask everyone I know everyday there opinion and id get different responses from everyone.. this has been going on for a year but I get annnoyed easily and under pressures I want to leave cuz I get this trapped feeling. Idk what to do. Does this sound like rocd or do you think I fell out of love n just need to movd on. Please help
hi alex, i just read ur comment and i have to say, u almost definitely have ROCD.. because i have ROCD and that is the exact same way i felt about the guy i love. and i think you should see a psychiatrist.. even if its just to confirm you have it or not.
hey, I just wanted to ask, is there a condition in ROCD in which you start doubting your better half? i mean doubting whether he/she loves you or not..
Hey. Ive been diagnosed to have rocd. I loved my boyfriend alot, but left him a while back becuz of these crippling doubts. But now that i have been diagnosed, i am more unrestful. I dont know how to tell that guy that i didnt mean to leave him. Everything is so complicated. And though the doubts are gone, i can’t stop thinking about him non stop. I keep weeping, hoping something to happen to make him realize.. But i hurt him so bad.. That he doesn’t trust me anymore.. I wanna wait it out, see if he realizer but i just can’t stop being miserable and crying.
Dear Doc,
I have pure-O and almost negligible compulsions (very well controlled). But my obsessions are severe and highly distressing. You suggest ERP for Pure OCD; for 3 weeks I did self-administered ERP (imaginal) daily for 30 mins covering many area of my obsessions. And there was almost no improvement.
The problem is I’m unable to experience the associated anxiety during the ERP session. Outside ERP my anxiety scale for a given theme can be 80/100, but within ERP I’m unable to feel beyond 30/100, no matter how hard I try (reading out my spikes, watching photos of my spike, hear to myself say alound my spike). What can be done for making ERP effective?
My second question for you is that the nature of my pure O is highly changing and the themes themselves are infinite. How do you design ERP for say 50 spikes?
Thanks for your response
Dr. Seay,
I’ve had OCD my entire life. It seems to morph to what I currently have going on in my life. From thinking I’m going to hell at age 10 because I had recurrent bad thoughts about God, to thinking I was gay at 14. I dealt with these other obsessions by finally realizing that I’m not going to hell and I’m not gay. While thinking I was gay in highschool, I had a boyfriend. One day at lunch this guy said “you will probably find someone else in college” and BOOM, I start worrying for years if my boyfriend is the one or not. So my OCD was transferred from my intrusive thoughts about being gay to wondering if this guy was the right one or not. During this time I would have feelings of “love” maybe one day every two months. The rest was constant numbness from anxiety. I finally determined (after two years of constant anxiety) that he was not the right one. Now I am with a wonderful guy, but I seem to have triggers for my anxiety that he does. I feel a lot more with him then I did with the other. But I finally got on some anxiety medication. So now instead of a day every two months..it’s more like two weeks every month. But I still have that day where I can tell (like when you get cold in a room suddenly) that the feelings are muted. They normally come back. But now I worry about if they will or not. It’s a big cycle that goes on and on. I’m guessing I have some sort of ROCD? Because when my feelings are gone I obsess about thinking, “how do I feel now?” I wake up in the mornings thinking “how do I feel?” when normal people would feel tired? What are your thoughts?
This is my story.
I was 17 when it first showed up and I went a few months before I was diagnosed. I had no idea what was wrong with me, it never even occurred to me that I had a mental illness. For months my obsession of….(this is so hard to write, even writing it down is scary) getting possessed by the devil tormented me. It was there all the time. I developed insomnia because I kept waking up in the middle of the night with the obsession. I spoke to priests, who reassured me that it would never happen, but nothing made a difference. I was absolutely terrified all of the time. The only thing that helped a little was trying to counter the images in my head. In my head when it happened I was in a dark room all alone, so I slept with the light on, read the bible, prayed constantly and found it very difficult to sleep alone. I was in a really bad place- hadn’t got a good nights sleep in months, was constantly terrified, didn’t understand why those images would not go away, and felt incredibly alone. Eventually it got too much for me and I attempted suicide. It was a really horrible thing to put my family through but it did (kind of) get me the help I needed- I got sent to a psychiatrist who diagnosed me with Pure OCD. It was one of the greatest moments of my life finding out that I was not so alone, that I just had a common mental illness.
It’s came back again since then (I’m 25 now and the obsession has changed) Is this something that will come back repeatedly throughout my life or is there anything I can do to stop it once and for all?
MR seay
i am 13 and my thoughts are if im attracted to animals or not. so i have always loved animals as a kid normally. then i learned about zoophiles. i do not want to be a zoophile, but im afraid that deep down inside i do. i have tested myself by looking at animals to see if i get arousal and most of the time i do. i think this is because my OCD is making me do this. i have never felt this way before. even right before i start thinking about this subject i get arousal. im soooo scared and it has gotten to the point that my OCD is convincing me that i am a zoophile. now i cant even see anything bad about it. please im desperate and need help. i spend 90 percent of my time thinking about this. i just want to be a normal kid help!!!
Hello from Portugal!
I love my girlfriend very much. We are together since October 2013 (over a year ago). My relationship is quite perfect and so is she: she is supportive, makes me laugh, is kind, is beautifull, is smart – the “whole package”.
thing is, since last august i have been experiencing these awfull thoughts wether i love her or not, wether we will be together forever or not. i keep checking and rechecking all day without feeling “complete”. until august (when this all started) we never had a fight and i just had the best week of my life with her when i stayed alone with her for a full week in my house (since parents went on vacation).
my question is “how will i tell a psychyatrist this without him to tell me that I simply “don’t love her” when i do?
this is driving me crazy.
I am so sorry for my grammar mistakes. please do respond Steven. And thank you.
Hi,
I am a person who always seeks for certainty. I had many doubts on my partner of 8 years long relationship, but now happily married.
I always feel less motivated, unhappy with what I am doing and carving for something more in life and very less concentration.
Now, I am seriously suffering from a constant thought.
I have gone for an HIV test 6 months back for some reason. I have negative results. But I am worried that what if the needle used is not new and was used by some hiv patient and in turn I would have contracted HIV.
This is all because I have not seen the lab technician who have taken my blood sample taking new needle. so, my mind is always asking me to go for a test again.
But I am worried, if I have a test again and got negative results also, will my mind stop thinking and considers me that i am healthy.
I am normally a kind of person who generally thinks a lot for everything.
This is making me degrade my potential and I feel that i am not even 10% of what I am.
Does unwantingly feeling sexual towards your family members get treated with medicines or the therapies mentioned in the article? If it is therapy then I think I’ve done it myself, because I was really tensed about it when it happened initially but then I convinced myself that it is just a thought and the mind shows you what you don’t want to see. And I am not a disgusting pervert at all. Then I got involved in other things of my interest and focused on keeping myself busy. But still everyday when I see them I think ‘what if I think that again?’ and then there’s a little anxiety about it, but then again I make myself busy. But then suddenly I psychologically feel something towards my reproductive organ and then my mind takes me again to the same thoughts and I again convince myself that it is nothing. By the way I feel something in my reproductive organ because when I used to get the real visuals more often (initially) then I use to feel a certain energy on my sexual organ only. So now most of it is gone but sometimes I feel ‘what if I get those thoughts again’ and then the anxiety Is a little bad. But I’m trying to win over it and I’m also trying to explain to myself that it is just a game of the mind and not reality. And it actually helps. But still it’s not going away completely, is all I can say.
Doctor thanks a lot for this article! Can we please talk privately in detail about it. And also is this anxiety obsessive compulsive disorder or both and will it get treated with medicines or anyhow? Thanks a lot!
PLEASE REPLY! PLEASE!