Healthy Doubt Versus Unhealthy Doubt

crossing NYC street

This post first appeared on my blog in August 2013….

I’ve previously written about how I used to scrutinize my son Dan, trying to decipher which of his behaviors were OCD related. I finally realized my intense involvement in his life was doing us both more harm than good, and I was able to let go and just trust my son.

What I wasn’t aware of at the time is that sometimes those who deal with obsessive-compulsive disorder aren’t sure themselves if their thoughts and behaviors are related to their disorder. Because those with OCD often have good insight in regard to their illness, I just assumed they knew when what they were thinking or how they were acting was OCD based. However, from reading blogs and connecting with people, I realize this isn’t always the case.

So how do we know if certain feelings and/or actions are related to OCD?

In his book When in Doubt, Make Belief, author Jeff Bell discusses healthy (intellect-based) doubt vs. unhealthy (fear-based) doubt. I highly recommend reading this book, if you haven’t already. While theoretically it might be easy to distinguish between the two, Jeff, by using an example of a man deciding whether or not to cross a busy New York street, shows us how complicated it can be. As he says, “…the same fear-based doubt that can distort our thinking is also quite adept at masquerading as intellect-based doubt.” (When in Doubt, Make Belief, page 9).

In his book, as well as in this interview, Jeff talks about the five questions he asks himself to help determine the source of his doubt:

  1. Does this doubt evoke far more anxiety than either curiosity or prudent caution?
  2. Does this doubt pose a series of increasingly distressing “what if” questions?
  3. Does this doubt rely on logic-defying and/or black-and-white assumptions?
  4. Does this doubt prompt a strong urge to act — or avoid acting — in a fashion others might perceive as excessive, in order to reduce the anxiety it creates?
  5. Would you be embarrassed or frightened to explain your “what if” questions to a police officer or work supervisor?

If you answer “yes” to these questions, there’s a strong chance you are dealing with unhealthy doubt.

As the saying goes, knowledge is power, and the more people with OCD understand their disorder, the better position they will be in to fight it. A competent therapist can also help those with OCD distinguish between healthy and unhealthy doubt, giving them a clearer picture of how OCD operates.

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The Nonsense of OCD

by stuart miles

A version of this post first appeared in August 2013, and might be triggering for some people…..

As we know, it is the need for certainty that fuels the fires of OCD. Compulsions are performed to reduce anxiety by making sure everything is okay. For people with OCD to recover, they must refrain from doing these compulsions and learn to live with doubt. Indeed, every one of us has to live with uncertainty if we want to be mentally healthy. But it’s not easy. Over and over we hear from those with OCD and others who admit it’s just too difficult to do.

But is it really? If you think about it, we live with uncertainty all the time. When we wake up in the morning, how do we know we will even make it out of bed? Or to the bathroom? Unless all our loved ones are standing right in front of us, how do we truly know they are okay? Even if we can see them, how do we know how healthy they actually are? You get the idea. Aside from what you absolutely know to be true in this moment, everything else is uncertain.

So we all live with uncertainty every single day, and in most cases, don’t even think about it. Even those with OCD only deal with particular issues in regards to uncertainty. Often OCD latches on to what’s most important to an individual: staying healthy, not hurting others, maintaining relationships, and the list goes on. So while people with OCD struggle with obsessions, compulsions, and certainty in these targeted areas, they often easily live with uncertainty in many other ways. Many of us complain it’s just too hard to live with uncertainty, yet we actually do it all of the time.

OCD is such a strange illness. While I accepted a long time ago that the disorder makes no sense, I’m continually amazed at how absurd it really is. Some people with OCD who have germ and/or contamination issues might spend hours in the shower but have no trouble sifting through garbage. I’m sure everyone who lives with obsessive-compulsive disorder has their own examples. And while those with the disorder acknowledge and realize none of this makes any sense, it doesn’t matter. That’s just how OCD works.

To me, another odd aspect of the disorder is that a seemingly random obsession such as the fear of hitting someone while driving, or a compulsion such as needing to pick up twigs and branches and rocks so that nobody will get hurt by them, are actually quite common. I’ve heard from many people with OCD who always assumed they were the only ones who suffered from a particular obsession or performed a specific compulsion, only to find out that others do the exact same thing. Why? Why, for example, isn’t the fear of  a car exploding because it hasn’t been properly maintained a common obsession, but fear of not turning off the stove is? Where’s the rhyme or reason?

As far as I know, there isn’t any. I hate that this illogical illness has so much power and destroys so many lives. I wish everyone with OCD would realize how much smarter they are than this nonsensical disorder so they can find the courage to fight it head on. Now that’s one thing that would make sense.

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Is That an Exposure….or a Ritual?

by master isolated images


For the next few weeks I will be sharing some of my older posts. This guest post by Seth J. Gillihan, PhD, first appeared on my blog in September 2013….

In exposure and response prevention (ERP) for OCD, the OCD sufferer deliberately confronts situations and thoughts that provoke distress (the exposure part), and resists the urge to do compulsive behaviors (the response prevention). This combination eventually makes the situations and thoughts less upsetting and makes it easier to stop doing compulsions.

Most of the time it’s pretty easy to tell the difference between exposure and rituals. In the short-term, good exposures raise a person’s level of distress, whereas rituals lower distress. For example, consider a person with contamination-related OCD. This individual is likely to feel worried and anxious about touching a dirty sink, and probably would feel a drop in anxiety if she were to give in to the urge to wash her hands after touching the sink. In this case the behaviors that we would call “exposure” (touching the sink) and “ritual” (washing her hands) clearly are different.

However, it’s not uncommon for a person in ERP to get confused about whether something is an exposure or a ritual, and for good reason: Sometimes exactly the same behavior can serve as an exposure or a ritual.

Take the example of a person whose obsession is that his bank account will be compromised and he’ll lose all his money. A major trigger for his anxiety is looking at his bank account statements, where he often sees withdrawals that he does not immediately recognize. For this person, looking at his bank statements will be an item on his exposure hierarchy.

Now imagine that the person is working with his therapist on this exposure. At first the man reports strong anxiety during the exposure, and after a few minutes tells his therapist that the bank statement no longer bothers him. It might be easy to conclude that the exposure was successful and that the man quickly learned to tolerate the distress and uncertainty of viewing his bank statement. However, he reports that after he read each item carefully he recognized each transaction, and felt reassured that he needn’t worry. The problem, of course, is that the exposure turned into a checking exercise, with OCD masquerading as treatment.

As always with OCD, we have to ask what the function of the behavior is. Does it raise distress, enhance the sense of uncertainty, and encourage tolerance of negative emotions? If it does, it’s probably an effective exposure. Or does it try to provide a sense of certainty and a short cut to relief? If so it’s a ritual. Other examples include:

  • Looking at one’s clothes or body for suspicious spots that could be blood (exposure) vs. carefully inspecting these spots to make sure they’re not blood (ritual)
  • Watching where one is walking to see ambiguous items that could be biohazards (exposure) vs. staring at an item on the ground to see if it really was a biohazard (ritual)
  • Viewing erotic images to trigger uncertainty about one’s sexuality (exposure) vs. viewing the images to make sure one doesn’t get “inappropriately” turned on (ritual)
  • Feeling one’s car bumper for irregularities that might indicate having hit a pedestrian (exposure) vs. trying to confirm that the bumper has no signs of impact (ritual)

In all of these cases the behavior is easy to label once we consider its purpose. Careful attention to the nature of the exposures can ensure that valuable treatment time is not wasted and that recovery is achieved as quickly as possible.

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Let’s Talk about ERP Therapy

by stuart miles

A version of this post first appeared on my blog in July 2013……

If you’ve followed my blog for a while, you know I’m a big proponent of exposure and response prevention (ERP) therapy for the treatment of obsessive-compulsive disorder. I don’t delve into the details often, as I’m not a therapist or an expert on ERP. However, I do think it’s important for anyone whose life has been touched by OCD to have a good basic understanding of this therapy.

The premise behind ERP Therapy is straightforward: face your fears repeatedly, and eventually they will cease to frighten you. Sounds easy (well, at least to those of us without OCD). But as we know, nothing related to obsessive-compulsive disorder is simple, and in fact, ERP Therapy can get quite complicated. Just as an example, I’d suggest taking a look at this great guest post written by Dr. Seth Gillihan, on mental rituals, OCD, and ERP. His discussion and the ensuing comments demonstrate how important it is to work with an experienced therapist who really understands the complexities of OCD and ERP.

Like OCD, ERP Therapy is often misrepresented by the media and misunderstood by the general public. Reality shows where patients are asked to do things such as licking toilet seats do more harm than good. Someone with OCD who is already apprehensive about beginning treatment will surely stay away after seeing this portrayal.

So we need accurate, quality information. While this article, written by Tom Corboy, MFT of the OCD Center of Los Angeles, focuses on ERP Therapy for the treatment of Harm OCD, it can easily be applied to the treatment of other types of OCD as well. I love the analogy he uses in the last sentences when explaining ERP Therapy:

The primary behavioral therapy tool used when dealing with Harm OCD is called Exposure and Response Prevention (ERP).   While cognitive therapy challenges the content of our intrusive thoughts, and mindfulness addresses our perspective towards those thoughts, ERP directly confronts the behaviors done in response to those thoughts.  While mindfulness and cognitive therapy set the table, ERP is the main course.  This is where the real work gets done.

I recommend reading the whole article, but also want to share Mr. Corboy’s clarification of some basic ground rules of ERP Therapy:

  1. We won’t ask you to do anything we wouldn’t do ourselves.
  2. We won’t ask you to do anything illegal, immoral, or dangerous.
  3. We will never force you do anything.

Just as we need to spread the word as to what OCD really is and is not, we also need to provide accurate information about exposure and response prevention therapy. I believe those who have already successfully undergone ERP Therapy for OCD are an invaluable resource. Was it different from what you expected? Were there any big surprises? How helpful was it to you? What were some of your best/worst experiences? Demystifying ERP Therapy might be all that is needed to inspire some people with OCD to commit to it. And as so many of us know, that can be the beginning of a new life – one free from the confines of OCD.

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OCD and Honesty

by kittisak

This post first appeared on my blog in July 2013…

As a child, my son Dan never lied to me. Okay, I guess I can’t be 100% sure about that, but he was usually an upfront, truthful boy. Teachers and relatives would comment on his honesty as well, saying things like, “If we want to know what really happened, we ask Dan.”

Enter OCD. Now he’s telling us he didn’t realize there were fingerprints all over the walls, or he was too tired to go here or there, or he just wasn’t hungry. All lies (which worked) to cover up his obsessive-compulsive disorder. Even after he was diagnosed and I’d ask how he was doing, the answer was always “fine,” despite the fact that he was obviously so not fine. He lied about his feelings and about taking his meds. My hunch is he lied to the first few doctors he saw, or at the very least, wasn’t completely honest with them regarding his symptoms.

OCD can turn those with the disorder into liars. Whether it’s the fear of being found out, the fear of what others will think, or a host of other reasons, those with OCD often do whatever they can to cover their tracks. They become sneaky, courtesy of  OCD.

What I find ironic is that many of these same people deal with honesty issues as part of their disorder. For example, some with OCD are so afraid of lying they might have to review their entire day in their minds to make sure everything they said was true. Others might even confess to “bad things” they never did, but how do they know for sure they didn’t do them, so the right thing to do is to own up to the wrongdoing. Concerns that revolve around hyper-responsibility often involve being honest and doing the right thing to keep loved ones, or maybe even the whole world, safe. And of course, scrupulosity is all about upstanding moral behavior, which involves telling the truth.

So once again we see the disconnect between what those with OCD strive for and what OCD delivers. People with OCD who value truth and honesty become deceitful. This is just one example of how those with OCD struggle to be certain all is well, but then this insidious disorder goes ahead and makes sure the opposite happens – lives are destroyed.

It is true that OCD can steal what is most important to us all, but only if we let it. Please don’t let it. If you have obsessive-compulsive disorder, you can fight back with ERP Therapy and regain control of your life. Honestly.


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OCD and Making Important Decisions


A version of this post first appeared on my blog in 2013…….

Is it just me, or does life sometimes seem like a series of decisions? Should I do this, go there, buy that? Many of our daily decisions are made with little to no thought, and are unlikely to have a major impact on our lives. Then there are the major decisions, which deserve more attention and involve more deliberation. We have to weigh the pros and cons, the benefits and the risks, and then make a choice. Or maybe it all just becomes so overwhelming that we put the decision off until later or, in some cases, forever.

Two of the most important decisions I’ve made over the past decade are starting this blog and writing my book. I truly agonized over both of them. Who am I to write about obsessive-compulsive disorder? I don’t even have the disorder! What could I contribute that would possibly be of any value? I’m no expert. All I have are my own thoughts and experiences to share. People will laugh, or even worse, criticize me. They’ll get angry. Of course, I could go on and on. I had no shortage of reasons why I shouldn’t write about my family’s experiences with OCD.

But even with all my  misgivings, I took the plunge. I had to. I owed it to myself and my son to try to find some meaning in his suffering from severe OCD. The results have gone way beyond my wildest dreams and in retrospect, my concerns about my “credentials” almost seem ludicrous. Being an expert is not what it’s about. My main goal, from the very beginning, has been to share our story so that others will find hope, and to spread the word that OCD, no matter how severe, is treatable.

Which brings me to the purpose of this post. I’ve written before about OCD and decision making, about how doubt is the cornerstone of OCD and how those with the disorder often struggle with making choices. But there is one decision, in my opinion, that all those with OCD need to make, and that is to get proper treatment. Maybe you’ve been mulling it over, considering it from all angles, and procrastinating. Maybe you feel you aren’t motivated enough, or it’s too scary. There’s so much to consider.

But really, there’s not. I have never heard anyone regret undergoing proper therapy for OCD, which includes exposure and response prevention (ERP) therapy. Indeed, most people wish they had done it sooner. Yes, decisions can be hard, but sometimes the most difficult ones bring us the greatest rewards. So if you haven’t already, please take the plunge. It might just be the most important decision of your life.

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Can Artificial Intelligence Predict Success with OCD Treatment?


In some interesting research on obsessive-compulsive disorder, researchers at the University of California Los Angeles have developed an artificial intelligence system that predicts whether patients with OCD will benefit from Cognitive Behavior Therapy (CBT). The February 2018 study, published in the Proceedings of the National Academy of Sciences, used a functional MRI machine, or fMRI, to scan the brains of 42 people with OCD before and after four weeks of intensive, daily cognitive behavioral therapy. Researchers specifically analyzed how different areas of the brain activate in sync with each other — a property called functional connectivity — during a period of rest.

The researchers then fed the participants’ fMRI data and symptom scores into a computer and used machine learning (that’s where the artificial intelligence comes in) to predict which people would respond well to treatment. The machine-learning program demonstrated 70 percent accuracy. It also correctly predicted  participants’ final scores on a symptoms assessment within a small margin of error, regardless of how they responded to the treatment.

Dr. Jamie Feusner, a clinical neuroscientist and the study’s senior author, said:

“This method opens a window into OCD patients’ brains to help us see how responsive they will be to treatment. The algorithm performed far better than our own predictions based on their symptoms and other clinical information.”

Dr. Feusner goes on to say that if the study’s results are replicated, treatment for OCD could someday start with a brain scan.

While I find this study fascinating, it also makes me a little uncomfortable. I will be the first to admit I have a limited understanding of neuroscience and artificial intelligence, but I shudder to think that CBT (specifically exposure and response prevention therapy which is the evidence-based treatment for OCD) would not even be offered to someone with OCD based on a preliminary scan of their brain. I see obsessive-compulsive disorder as so complicated. Could it really be that easy to predict who will or will not benefit from Cognitive Behavioral Therapy?

There are already many known reasons why exposure and response prevention (ERP) therapy doesn’t work for some people. You have to be totally committed to it, and there are various aspects of OCD and this therapy that can make that commitment difficult. The degree of family support and understanding of OCD as well as comorbid diagnoses are just two more examples of why exposure and response prevention therapy might not initially be successful. In addition, there are therapists out there who think they understand ERP therapy, only to make common mistakes during treatment that jeopardize their patients’ success. Conversely, there are people out there who are exceptionally motivated (my son was one of them) and are determined to beat OCD no matter what obstacles they might face. As I’ve said, OCD is complicated, so it is not surprising that treating it is often a complex undertaking best left to experts in obsessive-compulsive disorder.

To me, it’s a bit of a paradox – the fact that an impersonal machine (artificial intelligence) might lead to more personalized treatment. I know this is the wave of the future, and of course I can imagine the possible benefits and discoveries that are likely to arise from cutting edge research involving the brain. I just hope that we don’t get so caught up in data and test results that we neglect to pay attention to the whole person and their individual circumstances.


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