If you live with Obsessive-Compulsive Disorder (OCD), you're likely familiar with the torment of 'what if' thoughts. These thoughts are not just fleeting worries; they are persistent and often feel impossible to escape. Many individuals with OCD find themselves caught in a mental loop, where a troubling thought keeps circling in their mind until it feels like there's no room for anything else. This is a common experience for those with OCD, where intrusive 'what if' thoughts can wreak havoc on their peace of mind and sense of control.
These thoughts might appear out of nowhere and are often taboo, strange, bizarre, or downright disturbing. While everyone experiences intrusive thoughts from time to time, for those with OCD, these thoughts create such intense uncertainty and dread that ignoring them feels impossible. This compulsion to resolve these thoughts is driven by a desperate need to regain a sense of control and safety.
If you are reading this as a therapist, you've likely heard it countless times: "How do I get rid of these thoughts?" "What will make the thoughts go away?" Your clients ask these questions with a sense of urgency, hoping for a quick fix to a problem that feels unbearable. They want the thoughts to stop, to vanish completely, to have a mind that is clear and calm.
But here's the challenge: Trying to stop these intrusive thoughts is a false promise. There is no magic button to make them disappear. The idea that we can "get rid" of thoughts, especially those that are intrusive and distressing, is a common misconception. The reality is, everyone has unwanted thoughts, but it's the response to these thoughts - rather than their mere presence - that makes the difference between fleeting discomfort and prolonged suffering.
Instead of focusing on getting rid of these thoughts, effective management lies in changing how we respond to them. This article will explore what makes these thoughts so sticky, how to identify if they are part of OCD, and what strategies and treatments can help you and your clients navigate them more effectively.
Understanding Intrusive Thoughts in OCD
Many people struggling with OCD believe that this disorder is purely a 'thinking problem.' It’s common to hear clients ask how they can stop their 'what if' thoughts. However, OCD is also very much a 'feeling problem.' These thoughts are not just cognitive; they are accompanied by intense feelings of anxiety, doubt, and fear.
It’s understandable to think that if the thoughts went away, you could find joy and happiness again. But there are two crucial points to consider:
We cannot stop any thought, including intrusive ones. Attempting to do so is futile and often makes the thoughts even more persistent.
If a thought occurred without any accompanying negative emotion, you might brush it off as just 'a bit weird' and carry on with your day.
The greatest deception of OCD is its ability to convince you that these thoughts need resolution. Any feelings of doubt naturally compel us to explore, consider, and seek clarity. This is because doubt arises when we face the unknown (uncertainty), and our brains don’t handle this well.
‘What if’ thoughts are sneaky whispers of doubt that can grow louder and more insistent. They exploit our desire for certainty and often pose unanswerable questions. If we knew the answer with 100% certainty, we wouldn’t need to consider all possible outcomes. But life is inherently uncertain, full of potential outcomes, both good and bad.
In OCD, these 'what if' thoughts always lean towards the negative, creating a sense of risk and perceived danger. What distinguishes these intrusive thoughts in OCD is the significant distress they cause. People with OCD often assign excessive importance to these thoughts, interpreting them as signs of genuine threats or potential harm. The more they try to suppress or control these thoughts, the more persistent and intense they become, perpetuating a cycle of obsessions and compulsions.
It’s important to remember that having intrusive thoughts alone does not indicate OCD. Intrusive thoughts are a common human experience, and many people without OCD occasionally have fleeting intrusive thoughts. However, in OCD, these thoughts become pervasive, intrusive, and result in significant distress and disruption in daily life.
OCD ‘What If’ Thoughts vs. Non-OCD ‘What If’ Thoughts
If everyone experiences ‘what if’ thoughts, how can we determine if they’re a ‘normal’ thought or an OCD-related thought?
OCD "what if" thoughts are characterised by their repetitive, distressing, and often irrational nature. They lead to excessive uncertainty and anxiety, which cannot be left unexplored. In contrast, non-OCD "what if" thoughts are fleeting and do not cause significant distress or interfere with daily functioning.
OCD-related thoughts feel relentless and persistent, leaving the sufferer feeling like a prisoner of their mind.
Examples of ‘What If’ Thoughts in OCD Subtypes
Here are some specific examples of 'what if' thoughts commonly associated with different subtypes of OCD:
Contamination OCD:
- "What if I touch a contaminated surface and get seriously ill?"
- "What if I accidentally ingest something toxic and harm myself?"
- "What if I am carrying germs and infect others?"
Checking OCD:
- "What if I left the stove on and my house catches fire?"
- "What if I didn’t lock the door properly and someone breaks in?"
- "What if I didn’t turn off an electrical appliance, and it causes harm?"
Harm OCD:
- "What if I impulsively harm my loved ones or strangers?"
- "What if I lose control and commit a violent act?"
- "What if I am responsible for causing harm to others without realising it?"
Sexual Orientation OCD (SO-OCD):
- "What if I’m actually gay, even though I’ve always identified as straight?" (or vice versa).
- "What if my lack of attraction to a specific gender means I’m not who I thought I was?"
- "What if my thoughts or doubts about my sexual orientation define my true identity?"
Relationship OCD (ROCD):
- "What if I’m with the wrong partner and I’m missing out on true love?"
- "What if my doubts about my feelings mean I don’t really love my partner?"
- "What if I’m not attracted to my partner anymore, and it’s a sign of a failing relationship?"
The context of the thought depends on the individual’s theme and OCD presentation, and they can vary greatly from one subtype to another. One thing is for certain—they are emotionally exhausting and can significantly limit one’s experience of life.
How to Know if It’s an OCD ‘What If’ Thought or a ‘Normal’ Thought
It’s important to note here that a thought is just a thought. Intrusive thoughts occur both within and outside of OCD, and it’s incredibly common to have ‘what if’ thoughts. Our brains are always going to wonder what MIGHT happen one way or another.
Here are a few factors to consider to distinguish whether or not you may be caught in the OCD cycle:
Frequency: OCD thoughts typically occur frequently and persistently. They can feel like a broken record that’s impossible to turn off. Non-OCD thoughts, on the other hand, are generally more fleeting and do not cause such significant distress or preoccupation.
Uncertainty and Anxiety: OCD thoughts lead to intense distress, anxiety, and discomfort. They provoke a sense of urgency or fear that we feel compelled to solve. Non-OCD thoughts, although they may sometimes be worrisome, typically do not evoke the same level of distress.
Impact on Daily Life: If your thoughts significantly interfere with your daily functioning, relationships, or overall well-being, it may indicate OCD. For instance, if you find yourself spending excessive amounts of time and energy engaging in rituals or avoiding certain situations due to your thoughts, it could suggest OCD.
Persistence and Resistance: OCD thoughts tend to be persistent and resistant to rational arguments or reassurance. Even when you recognise that the thoughts are irrational, you may still find it challenging to simply let them be. Normal thoughts, on the other hand, are more easily dismissed or reasoned with.
Compulsive Behaviours: If you feel compelled to engage in physical or mental compulsions that offer temporary relief from the discomfort of those obsessions, this may be a sign that you’re stuck in an OCD loop.
It’s important to understand that only a qualified mental health professional can provide a definitive diagnosis. If you have concerns about your thoughts and their impact on your well-being, it’s advisable to consult with a qualified mental health professional experienced in assessing and treating OCD. They can help evaluate your symptoms, provide an accurate diagnosis, and guide you towards appropriate treatment options.
Can You Stop Intrusive ‘What If’ Thoughts?
It is common for those with OCD to want to know how they can stop these ‘what if’ intrusive thoughts, but this is not the goal of effective OCD recovery. The goal is to be able to identify those thoughts, accept them, allow them, and then continue with your day as you would if they never occurred.
Intrusive thoughts cannot be stopped, but we can change our relationship with them so they no longer dictate how we live our lives.
Why Do ‘What If’ Intrusive Thoughts Become Sticky?
“What if” intrusive thoughts can become “sticky” or persistent for several reasons:
Anxiety Sensitisation: When you experience anxiety in response to a particular thought or situation, your brain can become sensitised to it. This means that the more you try to avoid or suppress the thought, the more it becomes ingrained in your mind, leading to its persistence.
Attention Bias: The brain has a natural tendency to pay more attention to potential threats or negative information. In the case of OCD, “what if” thoughts are often perceived as threats, causing your brain to fixate on them and make them appear more significant as a problem that needs to be solved.
Safety Behaviours and Reassurance-Seeking: Engaging in safety behaviours or seeking reassurance in response to intrusive thoughts can inadvertently strengthen their hold. These behaviours provide temporary relief from anxiety, which reinforces the belief that the thoughts are indeed dangerous, leading to a continuation of the obsession-compulsion cycle.
Emotional Significance: The emotional weight attached to intrusive thoughts can make them stickier. They often provoke intense fear, guilt, or discomfort, leading your brain to perceive them as significant and requiring attention.
Perseveration: OCD is characterised by repetitive thinking patterns. The more you ruminate on a “what if” thought, analyse it, or try to find a solution, the more it becomes stuck in your mind. This perseveration contributes to the stickiness of the thoughts.
Strategies for Unsticking Sticky ‘What If’ Thoughts
While it can be challenging, it is possible to manage and reduce the impact of “what if” intrusive thoughts associated with OCD.
Here are some strategies that may help:
Recognise and Accept: Acknowledge that these thoughts are a symptom of OCD and not a reflection of your true self or intentions. Acceptance can help decrease distress and reduce the urge to engage in compulsive behaviours.
Mindfulness and Meditation: Practise mindfulness techniques to observe your thoughts without judgement. Cultivating mindfulness can help create distance between yourself and the intrusive thoughts, reducing their impact on your emotions and behaviour.
Exposure and Response Prevention (ERP): Work with a mental health professional trained in ERP, a form of cognitive-behavioural therapy specific to OCD. ERP involves gradually exposing yourself to your intrusive thoughts, feelings, sensations, and urges without engaging in compulsive behaviours. Over time, this can help reduce the power and frequency of intrusive thoughts.
Self-Care and Stress Reduction: Engage in activities that promote relaxation and well-being. This can include regular exercise, getting enough sleep, practising stress-management techniques, and engaging in hobbies or activities that bring you joy.
Remember, overcoming intrusive thoughts takes time and persistence.
It’s important to be patient and compassionate with yourself and seek professional help if needed. With appropriate treatment and strategies, you can learn to cope with and reduce the impact of “what if” intrusive thoughts.
Best Treatment for Intrusive Thoughts in OCD
The best treatment for intrusive thoughts, particularly when associated with OCD, involves a combination of evidence-based approaches:
Cognitive-Behavioural Therapy (CBT): CBT, especially a form of it called Exposure and Response Prevention (ERP), is considered the gold standard treatment for OCD. ERP involves gradually exposing oneself to the thoughts, situations, or triggers that provoke intrusive thoughts while resisting the urge to engage in compulsive behaviours or rituals. Over time, this helps reduce the anxiety and distress associated with the thoughts and weakens their grip.
Acceptance and Commitment Therapy (ACT): ACT focuses on accepting the presence of intrusive thoughts without trying to eliminate them. It aims to help individuals clarify their values and commit to taking actions that align with those values rather than being controlled by their thoughts. ACT can help manage the distress caused by intrusive thoughts and reduce their impact on daily life.
Mindfulness: Mindfulness-based approaches, such as Mindfulness-Based Stress Reduction (MBSR) or Mindfulness-Based Cognitive Therapy (MBCT), can help individuals develop skills to observe their thoughts without judgement and cultivate a more accepting and non-reactive stance towards them. Mindfulness techniques can be beneficial in reducing the distress and emotional impact of intrusive thoughts.
Medication: In some cases, medication, such as selective serotonin reuptake inhibitors (SSRIs), may be prescribed to help manage the symptoms of OCD, including intrusive thoughts. Medication can work in conjunction with therapy to reduce the severity of the thoughts and associated anxiety. Medication should ONLY be prescribed by a qualified mental health professional following an effective diagnosis.
It’s important to consult with a mental health professional, ideally one with experience in treating OCD, to determine the most suitable treatment approach for your specific needs.
They can conduct a thorough evaluation and create an individualised treatment plan tailored to your circumstances.
Note to Practitioners
For practitioners, being able to explain why intrusive thoughts feel so real and why they persist is invaluable in the therapeutic space. When clients understand that these thoughts are a common symptom of OCD and not a reflection of their character or desires, it can provide significant relief and reduce the shame and guilt often associated with these experiences. Educating clients on the nature of OCD and guiding them through evidence-based strategies like ERP can empower them to regain control over their thoughts and improve their quality of life. Always approach these conversations with empathy and patience, reinforcing that their thoughts do not define them and that recovery is possible.
