Intrusive thoughts are treatable. Yes, they’re terrifying. And it’s awful to think about doing things you find reprehensible – even heinous. But the tortuous thoughts can become less frequent and intense, if not eliminated. Let’s chat about treatment for intrusive thoughts…
Our buddy’s expression has gone from stunned horror in part one to hopeful listening. He’s been having intrusive thoughts for about a month and just learned they’re treatable. He’s cautiously ready to talk about them and accept help.
Quick review: an intrusive thought (IT) is an invasive – often shockingly and graphically disturbing – involuntary thought, image, and/or unpleasant idea. In many cases, an IT may become an obsession: a continual thought, concept, picture, or urge which is experienced as invasive and not proper, and results in significant fear, distress, or discomfort.
I know ITs well. There was a time when some of mine chilled me to the bone. But, no more.
Come on, let’s see what we can see…
How are intrusive thoughts treated?
As with any malady we talk about here on Chipur, treatment for ITs is determined by the impact of the thoughts on one’s routine – life. For many, self-treatment, using selected strategies and techniques, works just fine. For others, therapy, even meds, is the way to go.
Let’s get right to it, as we take a look at some guiding facts and tips anyone can use to manage their ITs…
Learn all you can about ITs and come to understand the context within which yours occur. Perhaps it’s OCD, PTSD, generalized anxiety, or severe stress. Maybe something else. Just always remember that our brains can be smashingly good at creating “junk thoughts.”
When it comes to ITs, having a specific thought is not a predictor of future action. A thought is not an impulse, and impulse control isn’t the issue here.
Do everything you can not to engage with the IT or attempt to push it out of your mind. In fact, open your mind and let the IT in.
Forget about the supposed literal meaning of an IT. The more you mull it over, the more intense it’ll become. Trying to apply reason and exercising control will only make matters worse.
Don’t waste your time trying to convince yourself you won’t act on the thoughts. And don’t change any of your behaviors in an effort to avoid action. Think about the last time you had an IT. You didn’t act.
Identify the triggers of your ITs. And instead of avoiding them, spend time with them. Learn there’s no danger.
Monitor and manage your levels of anxiety, stress, and fatigue. They always make ITs worse.
Consider that an IT may be your mind’s way of getting your attention so you’ll slow down and emotionally tune-in.
Once you’ve slowed down, tuned-in, and come to believe you can handle your emotional experiences, the ITs may lighten-up. After all, they’ve accomplished their mission, so what reason do they have to exist?
Given an IT may, in fact, be sending you an important message, when the thought occurs, ask yourself questions like these: “What am I really trying to control, avoid, or fill?” “What is the thought trying to protect me from?”
Be it with a spouse, partner, friend, therapist, spiritual leader, or someone else you may trust, talk about your ITs. You need to divulge your secret.
There are many more facts and tips out and about; however, these will get you off to a great start with managing your ITs. But there isn’t going to be relief if you don’t start working them – now.
What therapies and meds are used for intrusive thoughts?
“It isn’t easy talking about my intrusive thoughts, but it feels right – and good.”
Perhaps your ITs are causing routine – life – interruption. It happens, and when it does it’s time for professional assistance.
Often used to treat ITs is cognitive behavioral therapy (CBT). Simply, CBT helps with understanding the impact of thoughts, especially negative ones, on behavior. Yes, they’re interrelated.
And then there’s exposure and response prevention therapy (ERP), which is a form of CBT. Many consider ERP the treatment of choice for ITs. Simply, ERP is the practice of staying in an anxiety-provoking or feared situation (in this case, the IT – which may be an obsession) until the distress or anxiety diminishes. That’s what helps with side-stepping a compulsive reaction, such as avoidance.
For instance, someone may be having an IT about physically harming a child. Perhaps the IT has become an obsession. It makes sense that the individual would do all s/he can to avoid children.
But engaging in activities – compulsive reactions – to supposedly prevent the feared outcome of the IT only serves to strengthen it. See, it’s all about negative reinforcement: the mind learning that the only way to avoid a thought or feeling is to engage in a reactive (compulsive) thought and/or behavior. And that’s what we want to get around.
So relief ultimately comes by opening the door to the IT, having learned how to stay away from the compulsive reaction side of the fence.
Now, ERP will likely not totally eliminate ITs. But millions of people endure undesirable thoughts and consider them nothing more than an annoyance. And that’s where we want to go: to a point of management, eliminating routine – life – interference.
There are medications available to treat ITs. Commonly prescribed are the selective serotonin reuptake inhibitors (SSRIs): paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), escitalopram (Lexapro), and citalopram (Celexa). Also prescribed is the tricyclic antidepressant, clomipramine (Anafranil). An atypical antipsychotic, such as aripiprazole (Abilify) or quetiapine (Seroquel), may be used as an augmenting agent. A benzodiazepine, such as clonazepam (Klonopin), may also be prescribed to get one over the hump.
Keep in mind, the above medications are used for ITs caused by their most common generator, OCD or similar circumstances. We know ITs can present as a manifestation of other emotional/mental disorders. In such cases, other medications may be prescribed.
So goes the series
Well, that’s going to do it for our two-part intrusive thoughts series. If you found it relevant, I hope you found it helpful.
Believe me, I know how terrifying and shame-inducing intrusive thoughts can be. But I also know that through learning and the use of well-considered strategies and techniques, they can lessen in frequency and intensity, if not go away entirely.
Take heart, okay? The torture of intrusive thoughts can be no more.
Intrusive thoughts are terrifying. How awful to think about doing things you find reprehensible – even heinous. “How can I be thinking these things?” But the torturous thoughts continue. The best way I know to calm down and find relief is to learn. So let’s do just that…
Our friend above has been having intrusive thoughts for about a month now. He has no idea what’s going on, and he sure as heck isn’t going to share what he’s thinking. Understandably, he’s stunned – and horrified.
I’ve written and posted articles about intrusive thoughts several times here on Chipur. The pieces continue to be popular; however, two of them are eight years old and the other is ten. So it’s time for an update.
Let’s jump right in by taking a look at a common violent intrusive thought. I’m warning you in advance, you may find this hard to absorb…
Dad’s making dinner, while the rest of the family is in the den watching TV. The entrée is in the oven, so Dad decides to work on the salad. After washing the lettuce it’s time to slice some tomatoes. Dad grabs a knife and the terror begins. He thinks about walking into the den with the knife and stabbing all of them.
Now, if you found that hard to read, imagine how the individual experiencing such an intrusive thought feels. And it isn’t just a one-time thing.
When it comes to intrusive thoughts, there’s just so much to cover, so we’re going to handle our biz in two parts. This piece will review what intrusive thoughts are, and their causes. And we’ll discuss how intrusive thoughts are treated in part two.
By the way, I used to have intrusive thoughts that Hollywood would’ve paid big bucks for.
What is an intrusive thought?
So, what’s an intrusive thought (IT)? Well, it’s an invasive involuntary thought, image, and/or unpleasant idea. Often, an IT becomes an obsession: a continual thought, concept, picture, or urge which is experienced as invasive and not proper, and results in significant fear, distress, or discomfort.
“I’m a sweet person. These thoughts can’t be who I am.”
ITs most often occur as a symptom of obsessive-compulsive disorder (OCD). However, they may present as a manifestation of many emotional/mental disorders, including anxiety disorders, posttraumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), bipolarity, major depressive disorder, and eating disorders.
But an individual may just happen to experience the occasional IT. And there’s no diagnosis involved.
If you experience ITs, don’t think you’re alone. It’s been suggested that if people in the United States with ITs gathered, they’d form the country’s fourth largest city – behind New York, Los Angeles, and Chicago.
ITs are often classified into categories. I like these four, with common presentations…
Sexual
Fear of being sexually attracted to infants
Fear of being sexually attracted to family members
Fear regarding sexual orientation
Relationship
Obsessively analyzing the strength of feelings for a partner and finding fault
Constantly seeking reassurance from a partner
Doubts regarding fidelity
Religious
God not providing forgiveness for perceived sins and sending one to hell
Having negative thoughts in a religious building
Continually repeating certain prayers
Fear of having lost touch with God or one’s beliefs
Constantly analyzing one’s faith
Violent
Harming loved ones or children
Killing others
Using knives or other items to harm others, which may result in locking away sharp objects
Poisoning loved ones’, which may result in cooking avoidance
Of course, the biggest dynamic at play in all of this is the fear of acting upon an IT. And on come fear, guilt, anxiety, shame, avoidance, depression, and despair.
Thing is, though, there isn’t going to be any action.
What causes intrusive thoughts?
Now that we have a handle on what ITs are, let’s discuss what may cause them. I’ll begin by sharing this comforting perspective from counselor Sheryl Paul, MA. It’s from an article on her website, Conscious Transitions: The Architecture of Anxiety and Intrusive Thoughts…
The irony about people who are prone to intrusive thoughts such as these is that they’re among the most gentle, loving, sensitive, kind, creative, and thoughtful people you’ll ever meet. The thought is so far from reality that it’s almost laughable, except that it’s not funny at all because my clients believe the lie which, of course, creates a massive amount of anxiety.
Or maybe it’s not ironic at all. Perhaps it’s precisely because of this high level of sensitivity and empathy that their mind has gravitated toward an alarming thought as a way to try to avoid the intensity of feeling with which they respond to life. Highly sensitive people were once highly sensitive children, which means their nervous systems were wired at birth to respond to the sights, sounds, and experiences of life at amplified levels. And because most highly sensitive children were raised by parents who had no idea how to teach their kids to value and feel their difficult feelings in a manageable way, they learned early in life to try to control the external world as a way to attempt to manage their inner one.
Certainly, this doesn’t apply to all who experience ITs; however, it’s incredibly relevant to many of us.
Now, the absolute causes of ITs? It’s all theoretical, so who really knows. Sure, they can be manifestations of OCD and other emotional/mental situations, but that really isn’t the bottom-line we may hope to get to.
So, let’s just say we’re at least talking about learned behavior. And you know the drill: that, along with genetics, biology, and reactions to environment and stressors make ITs roll.
Oh, but there is this interesting angle. Some scientists have wondered if ITs are misinterpreted warning signals. For instance, a mother who experiences the sudden urge to drop her newborn baby. It could be her brain’s way of warning her to hold on tightly so she, indeed, doesn’t drop the little one.
So in a peculiar way, ITs may be our mind protecting us from the very thing we fear.
Now for part two
Well, that’s going to do it for part one of our intrusive thought series. No doubt ITs are mega-terrifying; however, coming to understand what they are, and that we’re not alone in them, is the first step toward relief.
Be sure to read part two – our discussion of how to treat intrusive thoughts.
You know in your heart you love him. But every day – all day – you wonder if he’s really the “Right One.” It’s torture. Here’s what you need to know about relationship OCD, before you make a huge mistake…
‘Is he the Right One? Do I love him enough? Is he the love of my life or am I making the biggest mistake of my life?’
A loving committed relationship is something to hold onto.
Yet many unnecessarily bite the dust because of something known as relationship obsessive compulsive disorder (ROCD).
Our ROCD guides
Given the stakes, we’re going to learn about ROCD with the guidance of clinical psychologists Dr. Guy Doron and Dr. Danny Derby.
The docs are world-renowned ROCD researchers, and we’ll tap into a summary of a portion of their work as resource material. It appears on the International OCD Foundation website.
Case example
Okay, let’s get started by taking a look at one of the three ROCD case examples provided by Doron and Derby…
At the age of 30, after many dating experiences, Evelyn found someone that she thought was great. He was smart, good-looking, had a good job, and they felt great together. After a year of dating he started pressing her to commit.
Since then, she can’t stop thinking, ‘Is he the Right One? Do I love him enough? Is he the love of my life or am I making the biggest mistake of my life?’ She checks whether she thinks about him enough at work, whether she feels relaxed when she is with him, and whether she has critical thoughts about him. When she is unhappy or tense, she always thinks ‘Maybe it is because I am not happy with him? Maybe he is not the ONE.’
Evelyn is highly distressed and her obsessions impair her work and ability to function in social situations.
What is relationship OCD?
Evelyn presents with ROCD, obsessive compulsive symptoms that target intimate relationships.
Sure, it’s common for people to have some doubts about the suitability of their partner or the relationship at some point during a romantic connection.
“I dunno’, is this the right relationship for me?”
However, for individuals with ROCD, these common relationship doubts and concerns become increasingly time-consuming and distressing.
And for the record, ROCD symptoms may occur outside of an ongoing romantic relationship (e.g., obsessing about the past) and may cause people to avoid entering relationships altogether.
ROCD symptoms have been linked with significant personal difficulties, such as mood, anxiety, and other OCD symptoms. Couple difficulties, such as relationship and sexual dissatisfaction, have also been reported.
Compulsive behaviors
In addition to obsessive preoccupations and doubts, ROCD is associated with a variety of compulsive behaviors generated in an effort to reduce feelings of uncertainty, anxiety, and distress – or to reduce the frequency of distressing thoughts.
Common compulsive behaviors include…
Monitoring and checking one’s feelings (“Do I feel love?”), behaviors (“Am I looking at others?”), and thoughts (“Do I have doubts?”)
Comparing one’s relationship with those of others’, such as friends, colleagues, or even characters in romantic films or TV sitcoms
Trying to recall good – secure – experiences with one’s partner
Consulting friends, family, therapists, fortune tellers, psychics, and others about the relationship
Avoiding situations and activities that may trigger unwanted thoughts and doubts about relationships
Are you seeing how tormenting and destructive ROCD can be? Is it happening to you?
Types of relationship OCD
ROCD includes two common presentations…
Relationship-centered: The individual often feels overwhelmed by doubts and worries focused on their feelings towards their partner, their partner’s feelings towards them, and the “rightness” of the relationship experience. They may repeatedly find themselves thinking “Is this the right relationship for me?”, “This is not real love!”, “Do I feel ‘right’?”, and “Does my partner really love me?”
Partner-focused: The individual may focus on their partner’s physical features, (“Her nose is too big.”), social qualities (“He is not social enough.” “She does not have what it takes to succeed in life.”), or personality attributes, such as morality, intelligence, or emotional stability (“She is not intelligent enough.” “He is not emotionally stable.”).
Relationship-centered and partner-focused symptoms may occur at the same time.
Treatment for relationship OCD
Treatment of ROCD is similar to cognitive behavioral treatments for any presentation of OCD. But it’s vitally important for those with ROCD to first recognize that their symptoms are getting in the way of their ability to fully experience their relationships.
In addition to assessment and information gathering, treatment includes symptom tracking. And it’s crucial that the therapist and client come to an understanding of the beliefs and views of self and others that may be impacted by the individual’s ROCD symptoms.
Therapies
A variety of cognitive behavioral therapies (CBT) – e.g., cognitive restructuring, exposure and response prevention (ERP) – are used to explore and challenge the ROCD client’s beliefs and views, and to reduce compulsive behaviors.
Experiential techniques, such as imagination-based exposures, may also be used.
Treatment gains are reviewed, effective strategies are summarized, and relapse prevention plans are made for possible setbacks down the road.
Meds
If meds are indicated, the first choice is typically one of the selective serotonin reuptake inhibitor antidepressants (SSRIs). Keep in mind, higher doses are often used for OCD vs. depression.
No regrets
In their work, Dr. Doron and Dr. Derby have found that individuals enduring any form of OCD typically feel a great sense of relief when they read or hear about someone going through what they’re experiencing.
So raising awareness and understanding is a priority.
I hope our discussion has been helpful. Heck, maybe a wonderful relationship will be saved. Perhaps one will be “permitted” to happen.
Relationships: how can something that feels so good bring such torture? Now you know.
I couldn’t include everything in this article. So be sure to read Dr. Doron’s and Dr. Derby’s piece on the International OCD Foundation website.
And if you’re up for reading more Chipur mood and anxiety info and inspiration articles, hit the titles.
Slick detective work is essential when it comes to understanding the neurobiology of OCD. But the hopeful part comes with how that work translates into relief. I mean, scientists can talk a good game, but who can’t? What say we get down to cases…
The docs then introduce the question: Can imaging be used to direct or predict treatment response? Well, just like using a brain scan to diagnose an individual case of OCD, which we discussed in Part 1…
We started this two-part series with a same-titled piece last week, featuring the work of Dr. Jon Grant and Dr. Samuel Chamberlain. Their Psychiatric Times article, Exploring the Neurobiology of OCD: Clinical Implications, is full of recent research information, as well as news on treatment developments.
Part 1 of our series handled the former. Now it’s time to address the latter.
Advances in Understanding the Neurobiology of OCD: Treatment Impact
As they did when discussing advances in understanding the neurobiology of obsessive-compulsive disorder (OCD), Grant and Chamberlain cleverly open their discussion of the impact on treatments with a vignette…
Joseph is 28 and has a 10-year history of severe OCD. Of particular significance are contamination obsessions and washing compulsions, extensive procrastination, and repetitive list-making/doodling. Joseph is incapacitated by his illness and has difficulty leaving the house to work or socialize. Joseph has been treated with assorted selective serotonin reuptake inhibitors (SSRIs), on occasion augmented by a low-dose antipsychotic and n-acetylcysteine. He’s also participated in extensive cognitive behavioral therapy (CBT) using exposure and response prevention.
Joseph’s Neurosurgery
After an ethics board review and approval, and making sure he understood risks and benefits, Joseph underwent a neurosurgical procedure to implant electrodes targeting his brain’s nucleus accumbens.
Some six months following this deep brain stimulation (DBS), and continuation of meds and CBT, Joseph reported a significant improvement in symptoms. He was even able to leave his home for work and social activities. With ongoing treatment, Joseph’s relief continued three years post-surgery.
Neuroimaging
According to Dr. Grant and Dr. Chamberlain, progression in neuroimaging has brought advances in the understanding of the neurobiology of OCD.
Still, how does that translate into the expansion of treatment approaches?
If you endure OCD, I’m thinking you know that current first-line, evidence-based treatments include SSRIs and/or CBT featuring exposure response prevention.
Grant and Chamberlain cite a recent systematic review and meta-analysis that indicates this approach shows superiority over placebo for the treatment of adult OCD. Fact is, these treatments have been used for over 30 years and haven’t been altered by advancing neurobiological research.
Neuroimaging has presented insights into brain mechanisms by which treatments may improve OCD. Study data show that structural and functional brain changes associated with OCD symptoms normalize to a degree with efficacious meds and psychotherapy treatment.
The docs then introduce the question: Can imaging be used to direct or predict treatment response?
Well, just like using a brain scan to diagnose an individual case of OCD, which we discussed in Part 1, there’s no existing evidence that treatment can be usefully predicted.
But the docs say that algorithms for treatment response can be built, including the ability to predict response to psychotherapy. Thing is, the approaches have yet to be generalized or show usefulness at the individual patient level in clinical practice. Sounds like there’s hope for the future, though.
More on Neurosurgical Techniques
As in Joseph’s deep brain stimulation or gamma ventral capsulotomy, neurosurgical techniques are at times used in the toughest treatment-resistant OCD cases. Well, results vary, to include no help at all.
That reality has led to researchers addressing the improvement of neurosurgical interventions based upon a more detailed understanding of the neurobiology of OCD.
For instance, a recent study used a clinical assessment and symptomatic provocation during functional MRI to enhance electrode placement for DBS in a sample of patients.
Let’s Wrap It Up
That three-pound mass of tissue and fluid encased in our skulls: I can’t think of anything more mysterious in the entire universe. And, of course, if you’re doing all you can to live with OCD – any emotional/mental disorder – mystery is the last thing you need.
Yes, I find work like Dr. Grant’s and Dr. Chamberlain’s slick and hopeful. And the cool thing is, they’re doing the investigative reporting on the creative and brilliant research work that marches onward.
You can’t fix something if you don’t know how it works. Cars, clogged drains, a bad back, emotional/mental health disorders: it’s just a fact of life. OCD is a complicated illness that deserves a fix. And though its workings are complicated, there’s a lot of slick and hopeful detective work going-on. Like this…
She asked if her scan can be used to help confirm that she has OCD. See, Claire read online about research that can accurately diagnose OCD using brain scans.
We have a lot to do, so we need to dig right in. But real quick, two important things…
First, if you have obsessive-compulsive disorder (OCD), you know why detective work pertaining to its neurobiology is vitally important. Secondly, our Sherlocks are Dr. Jon Grant and Dr. Samuel Chamberlain. Their work was presented in their article Exploring the Neurobiology of OCD: Clinical Implications, which appeared in Psychiatric Times.
Okay, in the moment executive decision: now that I think about it, we’re going to have to discuss Grant and Chamberlain’s work in two parts. There’s just too much significant info to cut corners. So let’s handle Part 1 now and we’ll do Part 2 in a handful of days.
Good?
In setting the table for their work, the docs underscore this foundational truth: OCD is the model disorder of compulsivity (a tendency toward repetitive habitual actions that the patient needs to perform, regardless of life-disrupting consequences). For the record, other compulsivity disorders include trichotillomania, hoarding, body dysmorphic, skin-picking, and Tourette’s disorders.
OCD: Brain Circuitry
As they discuss brain circuitry in OCD, Grant and Chamberlain cleverly open with a vignette…
Claire is a 21-year-old student whose five-year history of moderately severe OCD is headlined by taboo sexual thoughts with the repeated need to confess.
Claire signed-up for a research study exploring the neurobiology of OCD, a structural brain scan being provided. She asked if her scan can be used to help confirm that she has OCD. See, Claire read online about research that can accurately diagnose OCD using brain scans. She even asked for a picture of her brain so she can see the changes that happen with OCD.
We’ll get to the docs’ response in just a bit.
In the meantime, Grant and Chamberlain acknowledge that cortical (the 2-4 mm outer layer of brain tissue, excluding the cerebellum) and sub-cortical structural and functional abnormalities are implicated in OCD.
Though the thought that the orbitofrontal circuit (orbitofrontal cortex and basal ganglia, particularly the caudate nucleus), are at the core of OCD, recent research says a variety of frontal lobe and basal ganglia loop circuits are in on the action.
Specifically, we’re talking about grey matter volume increases and decreases, reductions in cortical thickness, and reductions in something called fractional anisotropy – a measure of fiber density, diameter of axons, and myelination in white matter.
Bottom-line: a whole lot of shakin’ goin’ on all over the place.
OCD Brain Circuitry: Recent Findings
It’s interesting that recent findings from case-control studies pertaining to functional connectivity show that OCD patients and their clinically asymptomatic first-degree relatives (parent, sibling, child) experienced reduced functional connectivity during a motor inhibition task (an executive function that allows us to inhibit impulses and behaviors in response to stimuli).
Yes, I said asymptomatic. As in no symptoms.
There are other studies that show connectivity issues in OCD patients and asymptomatic first-degree relatives. This is mightily significant because it may show vulnerability markers for OCD.
The Docs Respond to Claire’s Questions
Okay, back to the vignette and Grant and Chamberlain’s response to Claire’s questions…
Will OCD show on a brain scan? Although brain changes have been reported when comparing groups of people with OCD to those without it, these are average differences and are very subtle. They can’t be seen on a brain scan.
Can OCD be diagnosed using a brain scan? No. There is no appropriately validated algorithm that can be used to do it. Now, there have been studies that built predictive models that can classify scans, but that’s about it.
That’ll Do It
So that takes care of biz for Part 1. We’ll continue with Dr. Grant’s and Dr. Chamberlain’s work in Part 2 as they consider the impact on treatment of advances in understanding the neurobiology of OCD.
Reality says detective work doesn’t bring immediate relief. But can you see how vitally important it is for fixes in the future? And does it give you hope that hard work continues?
Chipur uses cookies so we can provide you with the best user experience possible. Cookie information is stored in your browser and performs functions such as recognizing you when you return to our website and helping us understand which sections of the site you find most interesting and useful.
Strictly Necessary cookies should be enabled at all times so that we can save your preferences for cookie settings.
If you disable this cookie, we will not be able to save your preferences. This means that every time you visit this website you will need to enable or disable cookies again.
3rd Party Cookies
Chipur uses Google Analytics to collect anonymous information such as the number of visitors to the site and the most popular pages. Keeping this cookie enabled helps us improve our website.
Please enable Strictly Necessary Cookies first so that we can save your preferences!
According to Dr. Grant and Dr. Chamberlain, progression in neuroimaging has brought advances in the understanding of the neurobiology of OCD.
As they discuss brain circuitry in OCD, Grant and Chamberlain cleverly open with a vignette…
