What Drives the Intolerance of the Uncertainty Rule in OCD

By Kim Rockwell-Evans, PhD, author of Breaking the Rules of OCD

We all live with uncertainty in our lives. Much of it we resolve automatically, such as with the assumption that loved ones we spoke to recently are safe, or that we’ll have an uneventful experience running errands. Do we really know for sure? Can we really know what will happen from one moment to the next? The answer is no, we really can’t know for sure, but we generally assume that we are safe enough when there are no signs of danger. Unless, of course, we have OCD—in which case we might find it incredibly difficult to tolerate uncertainty related to the obsessions that maintain our OCD cycle. Intolerance of uncertainty is associated with OCD and anxiety disorders. Three types of uncertainty-related beliefs are described as important in OCD: (1) beliefs that it is necessary to be certain, (2) beliefs that you are unable to cope with unpredictable change, and (3) beliefs that you can’t tolerate ambiguous situations—meaning the potential outcome is unclear (Taylor 2002). When you believe that your experiences associated with uncertainty are unmanageable, you respond to your obsessions with compulsive behavior as you try desperately to know for sure. How does the normal experience of uncertainty, doubt, ambiguity, and unpredictability that everyone lives with become OCD? Intolerance of uncertainty is often associated with a pattern of overestimating threats. When you have OCD, your brain is extremely sensitive to perceived threats. When you are afraid of uncertainty, your threat system is easily activated “to be on the safe side.” As with any threat, your focus becomes narrowed to assess the situation. As your focus narrows, you are processing limited information, so you start jumping to conclusions based on thoughts you associate with the threat. Once you think what if, a threatening story begins to emerge. This can create physiological distress—a relentless drive, in your mind, to solve the what-if story by “figuring it out” with additional information—which further reinforces your belief that “not knowing” may be dangerous. You might also start to avoid ambiguous situations. This provides temporary relief from anxiety, as you have an illusion of certainty. But it doesn’t take long for your mind to generate another what-if question. The more you engage in ways to “be sure,” the more uncertain you become, and the narrower and more constricted your life becomes. The more you seek relief from your fear of uncertainty, the less confident you will be in your ability to assess your situation. Research has shown that repeated engagement in checking compulsions leads to Develop Your “Don’t Know” Mind 71 memory distrust (Radomsky et al. 2014). More doubts about the accuracy of your memory just further validate that you can’t trust yourself. Intolerance of uncertainty is also linked to indecisiveness. It may seem like you can never gather enough information to make a good decision. There are often many equally good decisions to choose from and no one “best” choice. And although you can eliminate what would be undesirable choices, you can’t know for sure which decision would be best. You can never know whether your decision has provided you with the best, second best, okay, mediocre, or worst outcome. When making decisions, you may experience analysis paralysis. You also lose out on opportunities to learn through experience that you can handle the things that happen to you, even when your choice in a given situation isn’t the “best” one.

How This Rule Affects Your Life You must be absolutely certain is a rule that affects almost every theme of OCD.

Here are a few examples of the fears that can arise and the compulsions that can result:

• Fear of writing a curse word in an email, and checking repeatedly for inappropriate words to “be sure” • Fear of purposely trying to sexually arouse someone after a party and mentally reviewing the event to “be sure”

• Fear of hitting someone while driving, circling around to check, and later watching the news

• Concern about being contaminated by a poisonous substance that causes a medical illness, then getting lost in excessive googling to gain information • Asking loved ones for reassurance that you closed the garage door before you drove away, even though you already checked several times

• Wanting to make the “right” decision or risk being unhappy, and seeking reassurance from others

• Questioning whether you married the right person for you

• Questioning your sexual orientation and doing online searches for information to “figure it out”

• Wanting to know for sure whether you will go to heaven Now that we have explored how your attempts to be absolutely certain keep you in your OCD maintenance cycle, you can begin identifying your own personal experience of following this rule. Signs include:

• Feeling fears around uncertainty, doubt, and the unknown

• Trying to eliminate doubt through certainty-seeking behaviors— like checking, gathering information, seeking reassurance—and covert mental compulsions, like reviewing events to alleviate your doubts about them These, of course, only lead to more thoughts of doubt.

You likely become less confident, which in turn can drive more compulsions. Ultimately, your avoidance of ambiguous situations, decision making, or situations with unknown outcomes contribute to your being stuck in the OCD maintenance cycle.

Exercise: The Certainty Rule Reflect on how you follow the rule You must be absolutely certain by identifying specific thoughts, compulsions, and avoidant behavior that you engage in. How does following this rule affect your quality of life and your carrying out behaviors that matter to you?

Now that you know the signs that you follow the rule You must be absolutely certain, we’ll address how you can break it.

Kim Rockwell-Evans, PhD, is a licensed professional counselor and licensed marriage and family therapist with more than thirty-five years of experience treating children, adolescents, and adults with OCD and anxiety disorders.