Obsessional Doubt and Uncertainty: Are They Really Different?

Obsessional Doubt and Uncertainty: Are They Really Different?

Susan Wagner, PhD

Susan Wagner PhD

Dr. Susan Wagner is a licensed psychologist in New York. She completed a Ph.D. in both Clinical and Social Psychology at Columbia University. Her fellowship was at NY Presbyterian, Westchester Division where she then joined the faculty, working on the specialized in-patient unit for eating disorders, under the direction of Katherine Halmi, M.D. While there she treated in-patients individually and in groups, supervised therapy for all PhDs, MDs, and trainees, wrote manuals for group psychotherapy, and participated in team research and publications. After that she joined the voluntary faculty and continued with the above except for direct in-patient care.

After many years, Dr. Wagner’s interests shifted to obsessive compulsive disorder. She received training through the IOCDF, general BTTI and pediatric BTTI. She has had multiple trainings with senior OCD faculty, private consultations, and group supervisions.

Dr. Wagner has been treating children, adolescents, and adults with OCD and anxiety disorders for about 15 years. She specializes in these areas, using ERP, I-CBT, Mindfulness, and DBT tools.

Dr. Wagner facilitated a free GOAL support group, for 3 years. She is currently developing a manual for small group psychotherapy using I-CBT.
Dr. Wagner is passionate about working with people who struggle with OCD. She is thrilled about another empirically supported treatment for OCD now available in the US. Dr. Wagner recommends informing those seeking treatment about the different treatment options, explains them, and makes recommendations based on the individual’s history and present situation. She also believes that the final decision about treatment belongs to the person seeking treatment.
 

Boost Search Results
Off

Obsessional Doubt and Uncertainty: Are They Really Different?

Share
No
Obsessional Doubt and Uncertainty: Are They Really Different?

We have seen an explosion of interest, questions, concerns and stimulating debate since the arrival of Inference-Based Cognitive Behavioral Therapy for OCD (I-CBT) in the USA. One question stands out in high relief from others. Two factors may account for this. (1) It’s been raised by many in our OCD professional community and (2) this question is foundational to understanding the theory of I-CBT and treatment process. 

How do we distinguish between obsessional doubt and uncertainty in I-CBT? 

Uncertainty in I-CBT  

Uncertainty is a response to events which are going to happen or to situations in which there is insufficient information. Gathering the relevant facts resolves the uncertainty. * 

Occasionally there may be an instance when the full facts are unavailable. In those cases, it is necessary to accept that the pertinent facts are not accessible. (O’Connor and Aardema, 2012) 

Here is an example to help clarify: 

My dog has been shaking his head. Also scratching his right ear. There are times when he does this a bit and stops.  He’s been doing both more than usual, so I’m concerned. I think he might have an allergy or an ear infection. Hopefully nothing worse. 

I took him to the vet. The vet examined him, cleaned his ears, and took a sample to look under the microscope. She diagnosed him with a bacterial infection. She treated him with medication. 

Obsessional Doubt in I-CBT 

This occurs when realistic information is dismissed in favor of irrelevant information. In other words, realistic information is available and is perceived. However, once the doubting process gets under way, it is so compelling that perception of the present has lost importance. 

Typically, irrelevant information is based on possibilities. Possibilities usually begin with thoughts or statements such as, “What if”, “It could be”, “Maybe”, and involve,

1. ideas or images of what could happen at any moment, in the distant future, in the past, with friends/family/strangers/self, and so on. Obsessional doubt includes

2. faulty reasoning

3. justifying the doubt based on reasons that have no direct bearing on the situation at hand, no evidence in present and 4. trying to (unsuccessfully) resolve the doubt with more questions, justifications for the doubt, rituals, and compulsions. (O’Connor & Aardema, 2012) 

These processes are generated by the person. They do not “happen to” the person even though it can feel that way. 

The same example used above for uncertainty will now demonstrate obsessional doubt: 

My dog was shaking his head and scratching his right ear. I was worried so I took him to the vet. She examines him, looks in his ear and takes a sample to see it under the microscope. She says he has a bacterial ear infection. After cleaning his ear, she treats the ear with medication. 

She’s an excellent vet and I’m inclined to trust her. But what if she missed something important. One of my neighbors told me that her dog was diagnosed with terminal cancer. It’s common knowledge that even the best doctors can make mistakes.  

My dog seemed to have improved somewhat by the next day. I think I’ll get a second opinion just to make sure. I’d feel terrible if it turned out there was something else wrong with him and I didn’t get him the right care.  There’s a specialty animal hospital not too far from me. I’m calling now for an appointment. 

The brief questions and exercises that follow are intended to facilitate a better grasp of the concepts just discussed. 

Questions 

  • Review the example of uncertainty. Do you think that once pertinent information was acquired uncertainty was no longer present?  

  • Review the example of obsessional doubt. Try to identify the point at which there is acknowledgement of realistic information about the dog. When does obsessional doubt start? Can you identify the reasons given to justify the doubt? Are there any compulsions? What would you say is the “primary fear”? Do you see how doubt and its justifications override confidence in the relevant information about the dog? 

Exercise 

  • Write a brief story, real or fiction, about a situation when you were faced with a situational problem. You didn’t have the information you needed to solve the problem, but you did know where/how to get that information. Include something about where or from whom you got the information you needed and whether the problem was solved. 

  • Use the above story to turn it into one that veers off into obsessional doubt. Does obsessional doubt create more doubt? In the process there is probably inferential confusion. Do you see how the doubt and confusion make it extremely hard to get back to the real situation at the moment? 

*NB: Uncertainty in I-CBT should be distinguished from intolerance of uncertainty, which at its core is understood as a fear of the unknown. This is a transdiagnostic vulnerability that can be present in anxiety disorders, OCD, depressive disorders and eating disorders. (Einstein, 2014) 

For more information on I-CBT go to: www.icbt.online 

You will find a wide range of rich resources that include research publications, treatment articles, podcasts, videos on theory and practice, training, and more. 

If you would like to contact Susan Wagner, Ph.D. with questions or comments you can email her at: 

[email protected] 


References: 

Einstein, D.A. (2014) Extension of the Transdiagnostic Model to Focus on Intolerance of Uncertainty: A Review of the Literature and Implications for Treatment. Clinical Psychology Science and Practice, 25 September 

O’Connor, K, Aardema, F. Clinician’s Handbook Obsessive Compulsive Disorder. Wiley, 2012 


This post is presented in collaboration with ADAA's OCD and Related Disorders SIG. Learn more about the SIG

Susan Wagner, PhD

Susan Wagner PhD

Dr. Susan Wagner is a licensed psychologist in New York. She completed a Ph.D. in both Clinical and Social Psychology at Columbia University. Her fellowship was at NY Presbyterian, Westchester Division where she then joined the faculty, working on the specialized in-patient unit for eating disorders, under the direction of Katherine Halmi, M.D. While there she treated in-patients individually and in groups, supervised therapy for all PhDs, MDs, and trainees, wrote manuals for group psychotherapy, and participated in team research and publications. After that she joined the voluntary faculty and continued with the above except for direct in-patient care.

After many years, Dr. Wagner’s interests shifted to obsessive compulsive disorder. She received training through the IOCDF, general BTTI and pediatric BTTI. She has had multiple trainings with senior OCD faculty, private consultations, and group supervisions.

Dr. Wagner has been treating children, adolescents, and adults with OCD and anxiety disorders for about 15 years. She specializes in these areas, using ERP, I-CBT, Mindfulness, and DBT tools.

Dr. Wagner facilitated a free GOAL support group, for 3 years. She is currently developing a manual for small group psychotherapy using I-CBT.
Dr. Wagner is passionate about working with people who struggle with OCD. She is thrilled about another empirically supported treatment for OCD now available in the US. Dr. Wagner recommends informing those seeking treatment about the different treatment options, explains them, and makes recommendations based on the individual’s history and present situation. She also believes that the final decision about treatment belongs to the person seeking treatment.
 

Use of Website Blog Commenting

ADAA Blog Content and Blog Comments Policy

ADAA provides this Website blogs for the benefit of its members and the public. The content, view and opinions published in Blogs written by our personnel or contributors – or from links or posts on the Website from other sources - belong solely to their respective authors and do not necessarily reflect the views of ADAA, its members, management or employees. Any comments or opinions expressed are those of their respective contributors only. Please remember that the open and real-time nature of the comments posted to these venues makes it is impossible for ADAA to confirm the validity of any content posted, and though we reserve the right to review and edit or delete any such comment, we do not guarantee that we will monitor or review it. As such, we are not responsible for any messages posted or the consequences of following any advice offered within such posts. If you find any posts in these posts/comments to be offensive, inaccurate or objectionable, please contact us via email at [email protected] and reference the relevant content. If we determine that removal of a post or posts is necessary, we will make reasonable efforts to do so in a timely manner.

ADAA expressly disclaims responsibility for and liabilities resulting from, any information or communications from and between users of ADAA’s blog post commenting features. Users acknowledge and agree that they may be individually liable for anything they communicate using ADAA’s blogs, including but not limited to defamatory, discriminatory, false or unauthorized information. Users are cautioned that they are responsible for complying with the requirements of applicable copyright and trademark laws and regulations. By submitting a response, comment or content, you agree that such submission is non-confidential for all purposes. Any submission to this Website will be deemed and remain the property of ADAA.

The ADAA blogs are forums for individuals to share their opinions, experiences and thoughts related to mental illness. ADAA wants to ensure the integrity of this service and therefore, use of this service is limited to participants who agree to adhere to the following guidelines:

1. Refrain from transmitting any message, information, data, or text that is unlawful, threatening, abusive, harassing, defamatory, vulgar, obscene, that may be invasive of another 's privacy, hateful, or bashing communications - especially those aimed at gender, race, color, sexual orientation, national origin, religious views or disability.

Please note that there is a review process whereby all comments posted to blog posts and webinars are reviewed by ADAA staff to determine appropriateness before comments are posted. ADAA reserves the right to remove or edit a post containing offensive material as defined by ADAA.

ADAA reserves the right to remove or edit posts that contain explicit, obscene, offensive, or vulgar language. Similarly, posts that contain any graphic files will be removed immediately upon notice.

2. Refrain from posting or transmitting any unsolicited, promotional materials, "junk mail," "spam," "chain mail," "pyramid schemes" or any other form of solicitation. ADAA reserves the right to delete these posts immediately upon notice.

3. ADAA invites and encourages a healthy exchange of opinions. If you disagree with a participant 's post or opinion and wish to challenge it, do so with respect. The real objective of the ADAA blog post commenting function is to promote discussion and understanding, not to convince others that your opinion is "right." Name calling, insults, and personal attacks are not appropriate and will not be tolerated. ADAA will remove these posts immediately upon notice.

4. ADAA promotes privacy and encourages participants to keep personal information such as address and telephone number from being posted. Similarly, do not ask for personal information from other participants. Any comments that ask for telephone, address, e-mail, surveys and research studies will not be approved for posting.

5. Participants should be aware that the opinions, beliefs and statements on blog posts do not necessarily represent the opinions and beliefs of ADAA. Participants also agree that ADAA is not to be held liable for any loss or injury caused, in whole or in part, by sponsorship of blog post commenting. Participants also agree that ADAA reserves the right to report any suspicions of harm to self or others as evidenced by participant posts.