An investigation of doubt in obsessive–compulsive disorder

Abstract

Background

Clinicians have long considered doubt to be a fundamental characteristic of obsessive–compulsive disorder (OCD). However, the clinical relevance of doubt in OCD has not been addressed.

Methods

Participants included 1182 adults with OCD who had participated in family and genetic studies of OCD. We used a clinical measure of the severity of doubt, categorized as none, mild, moderate, severe, or extreme. We evaluated the relationship between doubt and OCD clinical features, Axis I disorders, personality and personality disorder dimensions, impairment, and treatment response.

Results

The severity of doubt was inversely related to the age at onset of OCD symptoms. Doubt was strongly related to the number of checking symptoms and, to a lesser extent, to the numbers of contamination/cleaning and hoarding symptoms. Doubt also was related to the lifetime prevalence of recurrent major depression and generalized anxiety disorder; to the numbers of avoidant, dependent, and obsessive–compulsive personality disorder traits; and to neuroticism and introversion. Moreover, doubt was strongly associated with global impairment and poor response to cognitive behavioral treatment (CBT), even adjusting for OCD severity and other correlates of doubt.

Conclusions

Doubt is associated with important clinical features of OCD, including impairment and cognitive–behavioral treatment response.

Introduction

Doubt has been described as a lack of subjective certainty about, and confidence in, one's perceptions and internal states [1]. Clinicians have long considered doubt to be an important characteristic of obsessive–compulsive disorder (OCD). For example, du Saulle described patients having “spontaneous and irresistible thoughts…with a “feeling of doubt” [2]. William James explained “the questioning mania” as a pathological excess of doubt [3]. Janet maintained that the symptoms in these patients are “designed to compensate for a lack of certainty” [4], [5]. In the modern era, doubt continues to be considered an important feature of OCD [6] and has variously been explained as the inability to “experience a sense of conviction” [7], to put closure on experience [8], or to generate the normal “feeling of knowing” [9].

Several studies have found that OCD is associated with lack of confidence in one's own memory, attention, and perception [10], [11], [12]. More recently, empirical studies have utilized cognitive paradigms to investigate doubt and indecision, under different levels of uncertainty, in individuals with and without OCD. For example, Sarig and colleagues [13] found positive correlations between obsessive–compulsive symptoms and performance on a color discrimination task, including amount of time required to complete the task, extent of search through the color continuum, and request for feedback. Stern and colleagues [14] found that OCD patients rated themselves as more uncertain than did controls, while accumulating evidence during a decision-making task, under conditions without objective uncertainty. Banca et al. [15] found that, compared to controls, OCD patients required more evidence to reach a decision on a random dot motion task, with longer response times and higher decision boundaries.

Although doubt was considered a potentially relevant domain in the early development of instruments to measure obsessive–compulsive beliefs [16], [17], more research attention has been devoted to other constructs in OCD. Indecision, i.e., difficulty in choosing a course of action given more than one option, occurs in many individuals with OCD and is especially prominent in compulsive hoarding [18], [19]. Perfectionism, a trait characterized by striving for flawlessness and having excessively high standards, is a frequent characteristic of OCD and obsessive–compulsive personality disorder [20]. Intolerance of uncertainty, which has been defined as the “belief that uncertainty, newness, and change are intolerable because they are potentially dangerous” [21], has been found to occur in OCD, several anxiety disorders, and major depression [22], [23]. Intolerance of uncertainty involves unwillingness to tolerate the possibility that negative events may occur in the future, no matter how low the probability [24]; in contrast, doubt involves lack of confidence or certainty in the information available to make a decision [1], [10], [11], [12], [25].

Important questions about the significance of doubt in OCD have not been previously addressed. The current study addresses several of these questions: First, is the severity of doubt related to OCD features, including age at onset, severity, and specific symptom dimensions? Second, is doubt associated with Axis I disorders (major depression and generalized anxiety disorder), personality disorder dimensions (avoidant, dependent, and obsessive–compulsive), or general personality dimensions in individuals with OCD? Third, is doubt related to global impairment and treatment response in OCD?