1. Intolerance of Uncertainty in Patients with OCD
I am a clinical social worker who specializes in the cognitive behavioral treatment of OCD, mostly with adolescents and young adults.
Sara Tischler, LMSW – Michigan Medicine, Ann Arbor, MI
July 7th, 2017

2. 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

3. 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

4. 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,

5. 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
Intrusive ”what if” thoughts
Excessive reassurance-seeking: asking others about a decision in order to ensure the best choice
Double-checking: rereading s before sending them in order to ensure that there are no spelling mistakes, calling a loved one repeatedly to ensure that they are alright
Refusing to delegate: doing all the housework alone to make sure that it is done correctly (just rights)
Excessive information-seeking: looking up excessive information online about products prior to making a final purchase
Avoidance of uncertain or novel situations: avoiding bathrooms outside of the home, unsure of cleanliness
Procrastination: putting off the completion of work tasks when unsure of the correct way to complete them (just right), waiting until the last minute before completing work that is due in order to minimize the time remaining to consider uncertain aspects of the task
Impulsive decision making: making a quick decision about a purchase in order to avoid thinking about the uncertain aspects of the decision
Partial commitment: avoiding definitively committing to a social event given the uncertainty that another event might come up at that time or that something bad might happen, keeping friends at a distance to avoid the uncertainty that the friendship might not work out
You can see how some of these are related to OCD
Robichaud, M,, 2013,

6. 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

7. 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.)”

8. 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 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”)
Learning something that competes with what you’ve already learned, thereby decreasing reactivity

9. 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.

10. 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,
Freeston, M.H., Rheaume, J., Letarte, H., Dugas, M.J., & Ladouceur, R. (1994). Why do people worry? Personality and Individual Differences, 17,
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
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,
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,