Intrusive thoughts; examples, diagnosis and how to stop them

What are intrusive thoughts?

Intrusive thoughts are disturbing ideas or images that enter your consciousness without warning or invitation. The thoughts can occur as part of mental health conditions but not necessarily. The main characteristics are noted below and shall be expanded throughout this guide.

Key points

Everyone gets intrusive thoughts, but whether they become clinical depends on how you interpret them.
There are different types, including aggressive, sexual, harm related and ideas about religion.
Intrusive thoughts are not actions. Many people react to the thoughts as if they have already carried out the act or can do so. Just because you have the thought does not mean you will act on it.
You can get over them; they are not a life sentence. Talking therapy such as CBT and ERP help you understand and change your thought patterns, reduce the anxiety they create and help you experience the thought without resorting to compulsions.

Are they normal?

Having intrusive thoughts is perfectly normal. Almost everyone gets them; 94% of the population, according to Professor Radomsky 2 , experience uninvited thoughts. Both men and women get them. However, women’s intrusive thoughts may be more related to relationships or causing harm, and men’s tend to be more aggressive or sexual. (2.1)

I think a better question is, why do some become problematic?

Intrusive thoughts in simple terms.

In my video above, I liken intrusive thoughts to unwelcome guests that arrive unexpectedly at your house. You don’t invite them in; they walk in. They are loud, argumentative, and not a good fit for the other people in your home. They demand and take all your attention. What you do next affects how long they stay.

You can try to throw them out, bringing them more attention.
Reason with them, which ends up getting louder,
Or ignore them, give your attention to the other people in your home, which calms you down, and they eventually leave.

I hope you can see from my metaphor that these unwelcome thoughts can get more substantial depending on how you engage with them and eventually leave if ignored.

If you suspect you have intrusive thoughts or have been recently diagnosed, this guide will help you understand what is happening and will educate you, particularly it is intended to help you.

Know the difference between normal thoughts and intrusive thoughts that could become problematic regarding your mental health and
When and how to seek professional help.

Interpretation

Suppose you have thought, what if I jump in front of the train while waiting on the platform, you have an intrusive thought. One of my random thoughts was poking myself in my eye with the toothbrush while brushing my teeth.

Although momentarily alarming, these thoughts are a passing nuisance for most people. However, depending on how you appraise the thought, they may negatively influence your life.

It is not the thought that counts; it’s the appraisal. If, for example, you had thought of pushing someone onto train tracks, and although unpleasant and out of character, you ignored it, you will be fine. However, if you personalised the thought and wondered why you had it, what it meant about you, and whether you were capable of causing harm to another person, you are adding meat to the bones of the thought.

How you interpret the thought plays a role in whether it hangs around. Seeing it as a random thought means you feel the shock once; when you have it. Personalising it and the following analysis is like a double shock; the first hurt is the thought, and the second hurt comes from the thoughts in your head regarding the first thought! Thinking about thinking or its proper name – metacognition.

Metacognition, it’s the thought that counts.

Metacognition is simply our ability to think about thinking, and it has a significant role in developing intrusive thoughts.

For example, consider two people who think of pushing someone onto a train track.

Person 1 has a healthy thinking style and is aware that it is a random thought and dismisses it.

Person 2 has more dysfunctional metacognition and starts to think about the thought negatively, causing more distress. What’s wrong with me that I want to push someone on the track? This style of thinking and the upset it causes the person only strengthens the thought.

What’s the difference between normal thoughts and intrusive thoughts?

Normal thoughts	Intrusive
tend to be related to what you are currently doing, or future plans or recalling the past.	does not have relevance to what you are doing.
do not normally cause much distress	extremely distressing and cause other strong emotions such as shame or disgust
usually in line with your mood, for example, in you are happy, random stream of consciousness thoughts may be happy or neutral	not in line with mood, you could be happy and have intrusive thought that causes intense distress

If intrusive thoughts are normal, how will I know when they are a mental health condition? If

you can dismiss the thought and it does not interfere with your daily life, you do not have a problem.
The thought keeps repeating and causes distress; this is more obsessional.

Furthermore, if you start doing things to ease the discomfort, such as checking or seeking reassurance, these actions that you feel compelled to do, are the start of compulsions. Not being able to ignore the thought and behavioural changes are signs that they may be affecting your mental health.

It is helpful to read this article on what thoughts are.

Structured self-help course for Intrusive Thoughts from the privacy of your home

Dr Ryan: Psychologist and Founder of MoodSmith

Find out more

What mental health conditions have intrusive thoughts?

People with OCD

People with OCD experience intrusive thinking when they are thinking, for example. Did I lock the door? Have I done something terrible in the past?

Postpartum depression

You may experience postpartum OCD with anxiety-related thoughts that make you think you could harm your baby, which causes intense distress.

Post-traumatic stress disorder

The mental flashbacks associated with post-traumatic stress are one of the significant symptoms of PTSD.

The remainder of this article shall discuss the thoughts that occur as part of obsessive-compulsive disorder.

Types of intrusive thoughts

Most people know that OCD consists of obsessions and compulsions, but the content of the obsessions varies. According to Abramowitz et al. (2010 3), the thoughts fall under several categories.

Contamination
symmetry/ incompleteness
responsibility for harm, and
Intrusive taboo thoughts.

The public perception of OCD and most research covers contamination, symmetry, and responsibility for harm, with less understanding or awareness of intrusive thoughts. This lack of attention may be due to a shame or stigma surrounding more taboo content (Glazier et al., 2015).4 According to Cathey & Wetterneck, (2013) 5, the public finds more taboo thoughts socially unacceptable. This stigma may render the person with intrusive thoughts less likely to seek treatment or disclose their suffering.

Examples of intrusive thoughts

Sexualised thoughts

These can include thoughts or mental images of violent sexual acts, sex with inappropriate people or things, questioning your sexual identity or any sexual idea that cause you distress.

These types of thoughts can be distressing, as arousal is involved. Even though you have not carried out the act, the idea of it may cause you to feel aroused.

Arousal does not mean that it is true; it is a normal physiological response.

Unwanted thoughts regarding children

These thoughts or mental images are distressing, as you may have unwanted thoughts that could harm a child somehow. This can include unwanted thoughts that you could cause harm to your child.

These thoughts can occur in postpartum depression and are part of mental illness instead of reflecting on you as a person.

Read more on Postpartum OCD and also POCD.

Aggressive thoughts

These may involve causing harm to yourself or others. Again, these thoughts are distressing as they may include the fear that you may hurt someone, even though you have probably never hurt someone.

It can comprise an impulse to be aggressive to someone or cause physical harm. This does not mean you will carry this out; instead, see it as one symptom of OCD.

Religious

These include inappropriate sexual thoughts regarding religious people or figures. Swearing during prayer or worship. Strong urges to misbehave during services.

Most people that I work with find it difficult to see these as harmless thoughts. They are more than likely to see them sign that something must be wrong with them to have such ideas.

Or even believe the thoughts–“Why would I be having them if I haven’t done……..?” They are just thoughts.

Sexual identity

Many people have unwanted thoughts that make them question their sexual orientation. This is not the same as someone who knows they are attracted to the same sex. Suppose you have intrusive thoughts regarding your sexual orientation. In that case, you still are heterosexual, but you may suffer from doubts because of your beliefs. It is known as Homosexual OCD, and I have a detailed post on HOCD here.

Family

These can include thoughts relating to;

Kissing members of your own family.
Sexualised thoughts regarding family members.
Intrusive images of family members, for example, naked.
“What if I am attracted to my sister, my brother?” etc.

Death

This can include worrying about death, which your heart could give up. It can also include distressing images of death, either you own or someone you care about.

Needing certainty

Worrying about your kids and family when they are not with you is normal. Still, you might worry and experience intrusive thoughts and images concerning their safety. These can include.

Thinking that they have had an accident when you have no real reason to believe this.

Thinking that they could come to harm or hurt themselves.

These types of thoughts may make you seek reassurance regarding their safety. You might tell people you care about sending a message or calling you when they reach their destination or message when they are leaving to come home.

Do I Need To See A Doctor?

Meeting with your doctor or a licensed mental health professional is advisable to get a correct diagnosis. Getting a diagnosis and understanding why the thoughts occur can be the basis of a treatment plan.

How Are They Diagnosed?

Suppose you meet with a mental health professional. In that case, they will undertake a complete assessment of your presenting problem to provide you with a diagnosis. This diagnosis is to formulate a plan of treatment.

The psychologist or physiatrist will ask you a series of questions to determine, for example, if your unwanted thoughts occur because of a specific mental health condition, such as OCD.

There are two main manuals that a clinician may refer to for diagnostic criteria:

International Classification of Diseases; ICD1.1 6
Diagnostic and Statistical Manual of Mental Disorders; DSM2. 7
In my career, I would have referred to the DSM, and according to DSM, obsessions are

Recurrent and persistent thoughts, urge, or images experienced during the disturbance as intrusive and inappropriate and cause marked anxiety and distress.
The person attempts to suppress or ignore such thoughts, impulses, or images or neutralise them with other thoughts or actions.
If, for example, your diagnosis is that your intrusive thoughts are occurring because of having Obsessive-Compulsive Disorder, your clinician can then devise treatment based on the diagnosis of OCD.

Will they ever go away?

To answer this, it is worth talking about intrusive thoughts and obsessions. The goal is not to eliminate unwelcome thoughts, as this is impossible. Everyone gets intrusive thoughts, but as noted by Rachman, (1997), 8 people with OCD place too much importance on these types of thoughts, and the distress then experienced compels the person to perform compulsions to ease their pain.

What is causing you pain is not the thoughts per se but how much power the idea has over you. Do you believe it? Do you feel personally responsible for having thoughts like this? Do they interrupt your day or result in you spending time performing mental analysis or avoiding certain aspects of your life as you are afraid of being triggered?

So, to answer, do they ever go away, in terms of OCD, obsessions and compulsions, with proper treatment? Yes, they can. Will you ever get an intrusive thought again? Yes, you will, just as I will, but it does not have to become an obsession.

Can you stop intrusive thoughts?

In a word, no, but there are things you can do to overcome them. It’s only semantics; technically, you cannot stop intrusive thoughts, but you cannot prevent any type of thought from occurring. You might have heard of the pink elephant experiment. If not, try this.

Do not think of pink elephants; that’s all you have to do. Do not think about their trunk, whether it is a blush pink, baby pink or bright pink, do not think of their big pink ears. Stop reading this for a second and start your test for about 15 seconds and do not think of pink elephants.

I’m guessing your first thought was of a pink elephant. That’s normal. No matter how hard you tried not to think of pink elephants, the thought or image would still come. That’s just how your mind works. It’s near impossible to stop a thought from coming, but the key is, just like the pink elephant, for the thought not to bother you, for it to be neutral. Thinking about pink elephants is neutral and you will forget about it quickly and will not subject it to the screening and analysis that you reserve for your intrusive thoughts, which paradoxically only serves the strengthen the thought.

The question should be, not how do I stop them, but what do I need to do to overcome them?

How to overcome intrusive thoughts

Before explaining more formal therapy options, I shall start by discussing things you can try by yourself to help with your thoughts.

It follows a stepped-care approach to treatment, starting with the least intensive intervention, such as self-help, before moving to counselling with a licensed mental health professional.

Structured self-help course for Intrusive Thoughts from the privacy of your home

Dr Ryan: Psychologist and Founder of MoodSmith

Find out more

Psycho-educational

Do not give time to the thought; label and move on

If you analyse your thoughts, wondering why you have them or what it says about you as a person, there are models of therapy that will help you stop doing this.

Why do you need to stop doing this?

Thoughts need energy to survive. Acceptance and Commitment Therapy works well by teaching you to label the thought and move on.

You can do this right now, although it takes practice. Next time you have an intrusive thought, label it just as a thought and move your attention away rather than dedicate time to it. Try it now.

Decide on your label. You can use a label such as.

there’s an intrusive thought
It’s just a thought

For example, if you were thinking that you are going to shout out something really bad during your Church service, rather than trying to stop the thought or analyse it, tell yourself;

I am having an intrusive thought

Do not try to stop the thought

Don’t push the thought away; this does not work. The more you tell yourself to stop thinking about something, the more likely you will think about it. Try this for yourself. Don’t think about your favourite food for one minute. This might be desserts, pie, steak, whatever it is, do not think about it.

Did you notice an increase in saliva? If you did, not only did you think about the thought, but you changed your physiology, as your body is now preparing for food!

Keep labelling; and move on.

Accept your thoughts

If you are suffering, you cannot accept intrusive thoughts as ‘just a thought.’ You react to them as accurate or worried that you might act on the thoughts and cause harm to yourself or someone else. You have developed several ways to cope with your thoughts, including avoiding things or avoiding your thoughts.

Learning to accept your thoughts helps to stop the thought-action fusion. This is where you believe that thinking about something makes it more likely to happen.

Once you have been taught to accept them, the thoughts shall no longer mean anything to you with practice. They keep popping into your mind because you shine a spotlight on them, trying to figure out what they mean, trying to avoid them, and adopting various tactics to ensure you do no harm. Your brain has decided, ‘this is something we need to pay serious attention to.’ Learning to label them and move on helps to stop this.

Stop doing things differently.

You might have changed the way you exist in the world to prevent yourself from causing some harm (concerning your thoughts.) For example, if you

have intrusive thoughts regarding knives, you might have moved the blades in your kitchen, or
experienceunwanted thoughts regarding children, you might avoid children’s parties, be extra careful with how you look at a child or be uncomfortable bathing and dressing children. or
have unwanted thoughts regarding your sexuality, you may avoid people, places or things that trigger your thoughts.

It would be best if you learned to stop doing this, as even though the strategies you have developed help you in the short term, they are not effective long term, as they only keep this cycle going.

Cognitive Behavioural Therapy, besides mindfulness-based approaches, combined with relaxation training, will help you achieve this.

Know the difference between thoughts and reality

There is a stark contrast between I will stand up and shout something obscene in Church right now, and I am worried I might say something blasphemous.

The first thought contains action, something you will do now, whereas the second is the worry, and doubt. Reality-based action thought. I am going to punch that person. Doubt I am worried I might hurt someone.

Understanding doubt and reality is crucial in overcoming unwanted intrusive thoughts. Once you can see the difference, it becomes easier to accept that you need to work with doubt instead of the content of the thought.

Worrying that you might do something or have done something in the past and cannot remember it is not the same as actually doing it.

People with intrusive thoughts go out of their way, carrying out elaborate compulsions to ensure they never act on the thought.

For example

People with obsessive thoughts or Pure O may not know they carry out compulsions. The following examples will highlight some of the compulsions you may do and need to work on to end intrusive thoughts.

People with HOCD may check themselves to ensure their sexual preference has not changed. This checking is carried out to ease the distress caused by internal thought and is a compulsion.

Someone with Harm OCD may remove objects they fear might hurt someone. This compulsive act is carried out to prevent a feared consequence.

Trust your senses

I shall start with a more classic OCD example to explain how to start trusting your judgment.

A person with OCD may lock their front door, repeatedly pull the handle, unlock and relock and stare at the door for a long time before feeling able to walk away.

The doubt that characterizes OCD makes locking up very difficult for the person; they cannot trust their actions and sight.

In non-OCD tasks, they rely on their senses; for example, if a person has just put a plate in the cupboard and walked away and I ask where the plate is, they will answer in the closet as they can trust their actions and their sight that they saw the plate in the cupboard.

If I ask two people about their romantic preference, one may state; that they are, for example, heterosexual, and if I inquire how they know, they can trust their judgment to answer the question.

However, if the person has Sexual orientation themed OCD, they will not be able to trust their decision as they are plagued with doubt caused by OCD.

People with HOCD may no longer trust their judgement and check to see if they are attracted to members of the same sex or opposite sex and if they are lesbian or gay.

If you have been heterosexual or in a same-sex relationship, your sexual identity should be a given; it is a fact based on reality.

The doubt caused by intrusive thoughts conflicts with reality.

Do not overuse your senses.

In the example above, where the person repeatedly locks the door and stares at it, to overcome the obsessive thought that the door might not be locked, they have to relearn to trust their senses, and they do that by using the following.

Lock the door and look at the action of turning the key, and walk away. It can be challenging to begin with, as doubt will create high anxiety levels.

Resist walking back to check the door, as this will reinforce the pattern that checking makes you feel more relaxed and reassured.

Therapy for intrusive thoughts

Psychoeducation. Arm yourself with information
If you are ready to start therapy, I appreciate that this may be daunting, as you may feel deep shame and fear regarding discussing your thoughts. For that reason, I have included articles on MoodSmith to make the process as transparent as possible.

Start by reading this introductory series.

Treatments that help

Cognitive behavioural therapy CBT
CBT is well-researched and remains one of the most influential models of therapy as noted by Healthline is used to manage intrusive thoughts

Why Are The Thoughts About Bad Things?

I think the best way for me to answer this is to do it in two parts;

what things are important to you, and
how much attention you pay to the thought.
obsessions latch on to the things that are important to you. For example, I adore animals; if the idea popped into my head that I could harm an animal, this would certainly grab my attention, as it would shake my values to their core.

I could have several uninvited thoughts in my head, but most will go unnoticed. Those that go against my core values will stick out from the rest.

If you get an idea that goes against your core values, you will probably feel something like fear, disgust or alarm. These strong negative emotions make the idea appear more robust than it is.

So to answer the first part of why the thoughts are about bad things, it is essential to note that it differs from person to person. It is what you consider bad, what would attack your core values.

Once a thought strikes your core values, if you leave it alone, it will wither and die, but if you pay attention to it, think about it, analyse it, and give it special attention amongst all the other thoughts, it will become stronger.

Urges

The urges are the same as the thoughts; they are both a symptom in that they fall under the umbrella of obsessions. An urge is an obsession.

Typical urges experienced in OCD and Intrusive Thoughts

Touch someone inappropriately
Want to kiss someone? This can include kissing someone that would seem inappropriate, such as members of your own family, members of the same sex (if you are heterosexual)
to hurt someone that you care about
To confess to something that you haven’t done.
The urges you get depend on what you hold dear, what you value most. Intrusive Thoughts, including the urges you get, tend to go after your value base – the things you would never do.
Urges can also include the desire to carry out a compulsion, e.g., if you think that you could hurt someone else, you might be urged to remove all implements that could cause harm.

Or, if you falsely believe that you are a terrible person and have done something bad, you might have the urge to confess.

Are the urges different from the thoughts?

No, both the urges and the thoughts are, in fact, obsessions.

Recap

Any random thought can become intrusive if it disturbs you or you change how you react based on the content of the thought. A good understanding of what is happening puts you in control and ready to take steps to overcome intrusive thought.

Should you wish to continue reading my articles, you can find more on the subject here.

Intrusive thoughts, what are they, and can you stop them?