The paradoxes of doubting in obsessive–compulsive disorder

Once upon a time, obsessive–compulsive disorder (OCD) was conceptualised as consisting of ego-dystonic, anxiety-eliciting obsessions and anxiety-alleviating compulsions. This ‘classical’ model has been very influential and has served as the basis for the most effective psychological treatment of OCD to date – exposure and response prevention. However, the model proved to be too simplistic because it does not have explanatory power to accommodate all aspects of OCD, and the treatment approach based on it has only been partly successful.

Obsessions and compulsions: is the link exclusive?

According to the classical model, obsessions inevitably lead to compulsions and compulsions appear solely in response to obsessions. Clinical observations and research converge to suggest that this is not the case, although it is true that both obsessions and compulsions are present in the vast majority of people with OCD.

Frequent responses to obsessions include attempts at distraction or suppression and avoidance. These efforts at resisting obsessions are usually not sufficient, and compulsions often appear as another ‘line of defence’ against obsessions. However, compulsions do not replace distraction, suppression or avoidance, and all these are often seen together in various combinations.

Similarly, compulsions occur in response not only to obsessions but also to a range of other phenomena. These include a sense of incompleteness, ‘not just right’ feelings or perceptions, physical sensations and urges. A qualitative study by Van Schalkwyk et al. (2015) has demonstrated that compulsions also appear in response to anxiety unrelated to OCD. Compulsions may eventually become habits or be performed automatically, without clear triggers.

What is the nature of obsessions?

Although obsessions are usually defined as thoughts, images or urges, they are not only episodic and recurrent. Many individuals with OCD describe phenomena that are persistent and may permeate their personality or overall functioning: a pattern of thinking characterised by doubting, ideas about harm and/or specific preoccupations (e.g. with cleanliness or symmetry and order). The definition of obsessions should be broadened to encompass these phenomena.

Some obsessions, especially aggressive, sexual and religious ones, are ego-dystonic and over time remain ego-dystonic, that is, they are alien to the person and incongruent with their view of themselves. Many other obsessions, however, may be experienced as ego-dystonic initially but later become ego-syntonic, although they continue to be unpleasant and distressing. For example, a sense of the surrounding disarray that needs to be ‘fixed’ or even a ‘feeling’ of contamination is often not experienced as alien to the individual or incompatible with their perception of themselves.

Obsessions are associated with a sense of urgency of action that is not seen in conjunction with related phenomena such as worries and ruminations. In other words, something needs to be done with the obsessions, and they have to be resisted and cannot be left alone. This is usually due to a perception of threat associated with them, whether that threat is about contamination, being responsible for disastrous events, revealing to the world some shameful aspects of oneself or living in a chaotic environment where nothing feels right.

What are the effects of compulsions?

The reasons for performing compulsions vary (Starcevic et al., 2011). In many cases, compulsions decrease anxiety or distress, albeit this effect is short-lasting. A related function is prevention of future harm. Some compulsions satisfy a need to have things ‘just right’ or to achieve a sense of completion.

Van Schalkwyk et al. (in press) report a ‘spectrum of relief experiences’ after performing a compulsion. Not only is relief usually short-lived, but it may be followed by a sense of shame, failure or guilt. Some individuals report no relief at all, yet they cannot resist an urge to perform another compulsion. In such cases, compulsions continue to be performed although they are not reinforced; this pattern was considered similar to that seen in addictions (Denys, 2011). That is, the compulsion no longer serves its original purpose, but it does not stop possibly because of the fear that its cessation might result in intolerably high levels of anxiety or distress. This is analogous to the fear of sudden drug cessation causing severe withdrawal symptoms.

Towards a new model of OCD?

This brief overview of the variety of OCD manifestations calls either for the conceptualisation of its putative subtypes as distinct entities or for a model of OCD that might be able to explain such heterogeneity. The subtyping approach has not been particularly fruitful (e.g. Brakoulias, 2013), not least because individuals with OCD often present with various features both cross-sectionally and over time. The way forward would, therefore, be to postulate a new model.

The pathway to a new model might entail learning from the past. In 1875, a French psychiatrist Henri Legrand du Saulle published ‘La folie du doute avec délire du toucher’, an account of OCD with an emphasis on pathological doubting. Indeed, if one characteristic of OCD were to be deemed essential or overarching its diverse manifestations, it might be doubting.

Doubting is embedded in both obsessions and compulsions. People with OCD typically doubt their own obsessions, even as they take them seriously and cannot dismiss them. They are not sure, constantly question themselves and try to be rational. However, this intense mental activity is futile because doubting does not respond to reason. Individuals with OCD end up feeling stuck with thoughts such as ‘I may stab someone’ or ‘The house will burn down because of my negligence’, which both defy logic and require urgent attention. When action is then taken to get ‘unstuck’, it is accompanied by doubt about its effectiveness. Thus, even as people with OCD resist their obsessions through compulsions, they doubt that compulsions are going to work. And like a self-fulfilling prophecy, compulsions ultimately do not work. They may provide a temporary relief but only for doubting to subsequently return with full force.

Doubting and complete certainty appear to be related, with the latter being a potential ‘remedy’ for the former. In other words, complete certainty might abolish doubting. The paradox here is that people with OCD seem to believe that complete certainty exists (which fuels their compulsions), whereas this belief is one of the few things they do not doubt. If so, OCD may be construed as a persistent but doomed effort to prove that the impossible exists.

Clinical implications

If doubting is central to OCD, it needs to be addressed in treatment. Traditional psychological therapy approaches such as exposure and response prevention or cognitive restructuring may achieve partial results because refraining from avoidance or compulsions or convincing oneself that ‘silly thoughts’ should be ignored has no effect on the underlying tendency to doubt. For doubting to stop, people with OCD may need to learn how to ‘surrender to trust’ in the absence of complete certainty (De Haan et al., 2013). This may be the greatest challenge, as these people would seemingly be asked to give ‘everything’ (the power of doubting) in exchange for ‘nothing’ (loss of the idea of complete certainty). In fact, they would only be asked to exercise appropriate doubt and therefore give up the quest for what is unattainable (complete certainty) even before they fully realise that it is unattainable. Such a paradoxical proposition to manage doubt may be just adequate for all the paradoxes posed by OCD.