Intrusive Thoughts in OCD

Why they happen, why they stick

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Most people who live with persistent intrusive thoughts arrive in therapy after years of private distress. The thoughts come without warning. They can be violent, sexual, blasphemous, or morally transgressive. What makes them unbearable is not usually the content, disturbing as it often is. It is the conviction that the thought reveals something real and shameful about the person having it.

Four decades of research into obsessive compulsive disorder suggest that this conviction, rather than the thoughts themselves, is the right target for treatment. Understanding how intrusive thoughts become stuck is the first step toward loosening their grip. This article sets out what the research tells us, drawing on the cognitive, behavioural, and self-focused models that guide contemporary evidence-based treatment.

Intrusive thoughts are a universal experience

In a foundational study published by Stanley Rachman and Padmal de Silva (1978), around 80 percent of people with no clinical difficulty reported experiencing unwanted thoughts that were similar in content to the obsessions described by people with OCD. The finding has been replicated many times since, across different countries and cultures (Purdon and Clark, 1994; Moulding and colleagues, 2014; Pascual-Vera and colleagues, 2019). The presence of a disturbing thought is not, in itself, a sign that anything is wrong. It is a sign of being a person with a working mind.

The human mind generates a large amount of associative material every day. Some of it is useful, most of it passes without notice, and a portion is odd, dark, or out of step with what the person values. This is true for people with no mental health difficulties at all. What differs in OCD is not the presence of the thoughts. It is what happens next.

It is not the thought. It is the meaning.

The cognitive model of obsessions, developed by Paul Salkovskis (1985, 1989) and extended by Stanley Rachman (1997, 1998), proposes that intrusive thoughts become clinically distressing when they are interpreted in particular ways. The thought itself is not the problem. The interpretation of the thought is.

Common interpretations that give intrusive thoughts their power include the belief that thinking something is close to wanting it, the belief that thinking something is morally equivalent to doing it, the belief that failing to prevent a feared outcome makes one responsible for it, and the belief that the thought reveals something hidden and true about the self. These interpretations are sometimes called thought-action fusion and inflated responsibility (Shafran and colleagues, 1996; Salkovskis and colleagues, 1999). They are not accurate accounts of how the mind works. Having a thought does not cause an event to happen, does not mean the person wants the content of the thought, and does not reveal hidden intentions.

Once an intrusive thought is interpreted this way, a predictable sequence follows.

The thought feels more important and more threatening. Attention is drawn to it, so it appears more often. Mental or physical actions are then performed to resolve the perceived threat. These actions are called neutralising, and they include mental reviewing, counting, checking, silent prayers, replacement thoughts, and reassurance seeking. Neutralising provides short-term relief, which reinforces the response, and it teaches the mind that the thought was genuinely dangerous, which strengthens the pattern.

Why the thoughts feel so personal

One of the most useful contributions to understanding OCD in recent years comes from the work of Frederick Aardema and his colleagues (Aardema and O'Connor, 2007; Aardema and colleagues, 2013). They proposed that intrusive thoughts carry their particular sting because they appear to the person as evidence of a feared version of themselves.

The feared self is a possible self that the person would find intolerable. It is a version of them they experience as incompatible with their values, their relationships, or their moral identity. For different people, the feared self takes different forms. A person who sees themselves as caring and protective may fear being cruel. A person whose identity is built around honesty may fear being deceitful. A person who values gentleness may fear being violent.

When an intrusive thought arrives that matches the feared version of the self, it feels diagnostic. It feels like a glimpse of a truth the person has been hiding. The research suggests the opposite is closer to accurate. People are most disturbed by intrusive thoughts that run against their values, not in line with them. The content of the most feared intrusions often reveals what matters most to a person, rather than what is hidden inside them.

A systematic review by Jaeger and colleagues (2021) examined 62 studies on self-related constructs in OCD and found that general self-esteem did not reliably differentiate people with OCD from people without. What differed was specific, content-laden self-doubt concentrated on a narrow band of feared qualities. Many people with intrusive thoughts function well in most areas of their lives and hold serious doubt only in the place where the intrusive thoughts have landed.

Why pushing thoughts away makes them louder

A series of experiments by Daniel Wegner and colleagues (1987) asked participants not to think about a white bear. Those instructed to suppress the thought reported more white bear thoughts than those who were free to think about anything. Wegner (1994) proposed that mental control creates an ironic problem. In order to avoid a thought, the mind has to keep checking whether the thought is present. That checking process keeps the thought accessible.

For people with OCD, this matters for two reasons. First, effort directed at keeping a thought out tends to bring it back. Second, when suppression fails, as it eventually does, the return of the thought is often interpreted as confirmation that the thought is dangerous or uncontrollable. This adds a second layer of distress about the original distress, a pattern that Adrian Wells (2009) has called metacognitive distress.

None of this means the person has been trying the wrong way and should try harder. It means that suppression is not a strategy that can work in the long term, for anyone. Research on thought suppression in clinical populations consistently shows that it contributes to the persistence and intensification of unwanted thoughts (Purdon, 1999; Abramowitz and colleagues, 2003).

What tends to help is allowing the thought to be present without acting on it, without arguing with it, and without attempting to cancel it out. This is the core principle behind exposure and response prevention, one of the most researched treatments for OCD (Foa and colleagues, 2012). It is also the principle behind acceptance and commitment therapy, which frames the therapeutic task as changing the relationship with thoughts rather than changing their content (Hayes and colleagues, 2012).

What therapy for intrusive thoughts or OCD can offer

The research base points toward several approaches that can help when intrusive thoughts have become a persistent source of distress. Exposure and response prevention gradually reduces the cycle of appraisal, neutralising, and avoidance. Inference-based therapy, developed by Kieron O'Connor and Frederick Aardema (O'Connor and Aardema, 2012), directly addresses the obsessional doubt about the self that sits beneath the feared-self pattern. Metacognitive therapy (Wells, 2009) targets beliefs about thoughts, including beliefs about their uncontrollability and significance. Acceptance and commitment therapy shifts the work from controlling thoughts to living in line with values while intrusive content continues to arise. Compassion-focused therapy (Gilbert, 2010) addresses the shame and self-criticism that often accompany intrusive thoughts with morally-laden content.

No single approach suits everyone. Formulation matters, and the evidence supports tailoring treatment to the mechanisms most active in a particular presentation. At Behavioural Edge Psychology, adult assessment and therapy for OCD and intrusive-thought difficulties draws on these evidence-based approaches, with specific attention to late-diagnosed adults, women and non-binary clients whose presentations have often been missed or misread, and neurodivergent adults whose intrusive thinking may intersect with autism or ADHD.

A final thought

Intrusive thoughts are not evidence about a person's character. The meaning attached to an intrusive thought, rather than the thought itself, is what drives distress. The thoughts that cause the most pain are typically the ones that run hardest against what the person values. Suppression strengthens the pattern. A more workable relationship with one's own mind can be built, and the research supports that this takes time rather than effort of will.

A research-informed client handout on intrusive thoughts is available on the resources page of the Behavioural Edge Psychology website. Individuals seeking clinical input for OCD or intrusive-thought difficulties are welcome to contact the practice directly.

References

• Aardema, F., and O'Connor, K. (2007). The menace within: Obsessions and the self. Journal of Cognitive Psychotherapy, 21(3), 182 to 197.

• Aardema, F., Moulding, R., Radomsky, A., Doron, G., Allamby, J., and Souki, E. (2013). Fear of self and obsessionality. Journal of Obsessive-Compulsive and Related Disorders, 2(3), 306 to 315.

• Abramowitz, J., Whiteside, S., Kalsy, S., and Tolin, D. (2003). Thought control strategies in obsessive-compulsive disorder. Behaviour Research and Therapy, 41(5), 529 to 540.

• Foa, E., Yadin, E., and Lichner, T. (2012). Exposure and response prevention for obsessive-compulsive disorder (2nd ed.). Oxford University Press.

• Gilbert, P. (2010). Compassion focused therapy. Routledge.

• Hayes, S., Strosahl, K., and Wilson, K. (2012). Acceptance and commitment therapy (2nd ed.). Guilford Press.

• Jaeger, T., Moulding, R., Yang, Y., David, J., Knight, T., and Norberg, M. (2021). A systematic review of obsessive-compulsive disorder and self. Journal of Obsessive-Compulsive and Related Disorders, 31, 100665.

• Moulding, R., Coles, M., Abramowitz, J., and colleagues (2014). They scare because we care: The relationship between obsessive intrusive thoughts and appraisals across 15 cities. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 280 to 291.

• O'Connor, K., and Aardema, F. (2012). Clinician's handbook for obsessive-compulsive disorder: Inference-based therapy. Wiley-Blackwell.

• Pascual-Vera, B., Roncero, M., and Belloch, A. (2019). The cross-cultural universality of mental intrusions. Journal of Obsessive-Compulsive and Related Disorders, 21, 5 to 12.

• Purdon, C. (1999). Thought suppression and psychopathology. Behaviour Research and Therapy, 37(11), 1029 to 1054.

• Purdon, C., and Clark, D. (1994). Obsessive intrusive thoughts in nonclinical subjects. Behaviour Research and Therapy, 32(8), 713 to 720.

• Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793 to 802.

• Rachman, S., and de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233 to 248.

• Salkovskis, P. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571 to 583.

• Salkovskis, P., Clark, D., Hackmann, A., Wells, A., and Gelder, M. (1999). An experimental investigation of the role of safety-seeking behaviours. Behaviour Research and Therapy, 37(6), 559 to 574.

• Shafran, R., Thordarson, D., and Rachman, S. (1996). Thought-action fusion in obsessive compulsive disorder. Journal of Anxiety Disorders, 10(5), 379 to 391.

• Wegner, D. (1994). Ironic processes of mental control. Psychological Review, 101(1), 34 to 52.

• Wegner, D., Schneider, D., Carter, S., and White, T. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53(1), 5 to 13.

• Wells, A. (2009). Metacognitive therapy for anxiety and depression. Guilford Press.