Intolerance of Uncertainty in
Patients with OCD
Sara Tischler, LMSW – Michigan Medicine, Ann Arbor, MI
July 7th, 2017
Intolerance of Uncertainty (IU)
• Defined as “the belief that uncertainty, newness, and change are intolerable
because they are potentially dangerous” (Steketee et al., 1997)
• Cognitive, emotional, and behavioral reactions to uncertainty that lead to
inaccurate assessments of increased threat level and reduced coping (Freeston et
al., 1994)
• People who have difficulty tolerating uncertainty may believe that they lack
sufficient problem-solving skills to manage threatening situations that could
evoke discomfort/distress (negative problem orientation)
• IU also leads to cognitive avoidance, causing patients to engage in unhelpful
strategies such as thought suppression, distraction, and thought replacement –
i.e. not exposure/ERP
Intolerance of Uncertainty (IU) Model
• Intolerance of Uncertainty Model (Dugas et al, 1995):
• Set of beliefs about uncertainty – stressful, upsetting, interferes with
functioning. Being uncertain about the future is perceived as unfair
• Worry will help to cope with negative events or prevent them from happening
• Worry then leads to negative problem orientation (lack of confidence in
problem-solving ability, perception of problems as threats) and cognitive
avoidance, which only maintains the worry
• Initially developed as an explanation for worries within the context of generalized
anxiety disorder (GAD) but there is evidence to suggest that IU is a central theme
in multiple anxiety- and OC-spectrum disorders
Positive Beliefs about Worry
• Worry is a positive personality trait
• Example: “Worrying about my loved ones shows that I am a caring person.”
• Worry aids in problem solving
• Example: “If I worry about my financial problems, I’m better able to find good solutions.”
• Worry is a motivating force
• Example: “Worrying about my health makes me more likely to exercise and eat right.”
• Worry protects against negative emotions
• Example: “If I worry about my mother dying of a serious disease, I’ll be more prepared
emotionally should it occur.”
• Worry in and of itself prevents negative outcomes
• Example: “If I worry about an upcoming exam, I’ll do well; If I don’t worry, I’ll fail.”
Robichaud, M,, 2013,
IU Safety-Seeking Behaviors
• “Approach” Strategies
• Excessive reassurance-seeking
• Double-checking
• Refusing to delegate tasks to others/doing everything oneself
• Excessive information-seeking
• “Avoidance” Strategies
• Avoidance of uncertain or novel situations
• Procrastination
• Impulsive decision making
• Partial commitment to people and situations
Robichaud, M,, 2013,
Intolerance of Uncertainty & OCD
• ”The Doubting Disease” – pathological doubt may be related to difficulty
tolerating uncertainty (Tolin et al., 2003)
• Doubt about whether you have washed your hands sufficiently, committed
sins, etc.
• Most clearly evident among patients with checking rituals
• Circling back to make sure you did not hit someone with your car
• Patients with OCD may find uncertainty distressing and engage in
compulsions/rituals to restore a sense of certainty, may view compulsions as their
only strategy for reducing distress
• Despite no differences in reported memory vividness, patients with OCD stated
that they desired more vivid memories than non-anxious controls (Constans et al.,
1995). This suggests an intolerance of uncertainty
Intolerance of Uncertainty & OCD
• Repeating rituals were also found to be associated with IU (Tolin et al., 2003).
• Patients with OCD often report urges to repeat certain actions (e.g., walking
down the stairs, opening a door) until they are performed “just right.”
• Inability to tolerate doubt/uncertainty leads them to repeat the action
• Positive beliefs about compulsions/rituals – “they are keeping me safe; they have
some deeper meaning (I am a pedophile, I am going to hell, etc.)”
Intolerance of Uncertainty in OCD
• Cognitive Behavioral Therapy for Intolerance of Uncertainty (CBT-IU)
• Psychoeducation about intolerance of uncertainty
• IU can provide a framework for understanding exposure rationale reassurance-seeking, checking, doubting are all driven by IU
• Exposure to uncertain situations with response prevention
• focus is not solely on habituating to anxiety, but on increasing tolerance to
uncertainty (inhibitory learning)
• Exposure ideas – fill out forms quickly, write email without checking it,
• Script exposures (“I may not have cleaned my hands thoroughly enough; there
are likely still germs on my hands; I can never know for sure and I will always
be uncertain”)
Intolerance of Uncertainty in OCD
• Important to discuss what the patient learned after each exposure/response
prevention exercise
• Feared outcome vs. actual outcome
• What happened? Were you able to cope with/tolerate it?
• Old fears do not necessarily go away, but through exposure the patient
assembles newer and more accurate layers of learning in the brain which can
be accessed in fear-evoking situations.
References
• Constans, J.I., Foa, E.B., Franklin, M.E., & Matthews, A. (1995). Memory for actual
and imagined events in OC checkers. Behaviour Research and Therapy, 33, 665671.
• Freeston, M.H., Rheaume, J., Letarte, H., Dugas, M.J., & Ladouceur, R. (1994). Why
do people worry? Personality and Individual Differences, 17, 791-802.
• Robichaud, Melisa. “Generalized Anxiety Disorder: Targeting Intolerance of
Uncertainty.” CBT for Anxiety Disorders: A Practitioner Book. Simos, Gregoris
(Ed); Hofmann, Stefan (Ed); Publisher: John Wiley & Sons; 2013, pp. 57-85.
• Steketee, G., Frost, R., Amir, N., Bouvard, M., Carmin, C., Clark, D., et al. (1997).
Cognitive assessment of obsessive-compulsive disorder. Behaviour Research and
Therapy, 35, 667-681
• Tolin, D.F., Abramowitz, J.S., Brigidi, B.D., & Foa, E.B. (2003). Intolerance of
uncertainty in obsessive-complsive disorder. Journal of Anxiety Disorders, 17, 233242.