In episode 290, I received a question from a listener who has OCD and struggles with intrusive thoughts particularly related to the worry of harm coming to their family and friends. In this post, I discuss the topics of OCD and intrusive thoughts and offer my thoughts on what you can do to help combat unhelpful ruminations such as this.
I’ve been listening to your podcast for a while, and I think you give great advice with accompanying ways to cope. I have OCD, specifically rumination and intrusive thoughts. My biggest fear is harm of my friends and family. I perform compulsions to ensure nothing bad happens to them, and if it does then I carry extreme blame and guilt. Recently I’ve been having this strange feeling that in any moment my “true” self will emerge and hurt the ones I love. I feel almost powerless to that fear even if that side of me doesn’t exist. I started therapy a few months ago but only have appointments maybe twice a month. I started taking medication 2 months ago as well. I just wanted to hear your thoughts on this and if there’s any way to separate my fears from reality.
I hope you have a great day!
Thank you for writing this in. First off, I want to say that you are not crazy and you are not alone in this. Fears of harming others are extremely common in individuals with OCD. But I understand. It’s scaaaarrrry. So, I totally understand why you would want to figure out a way to reduce these thoughts.
To start, let’s talk about how thoughts in OCD work vs another disorder like schizophrenia. In schizophrenia or other forms of psychosis, you have what are called delusional thoughts. These are thoughts that are not congruent with reality, but you believe them. For instance, you might have a delusion that your food is being poisoned or you might have the delusion that you are involved in an important organization like the FBI. Delusional thoughts are interesting because they are consistent with your view of yourself. This is your reality, which is why it’s so hard to cope with delusions without the help of medication.
Now, this is a little different from the obsessive thoughts that come along with OCD. In OCD, the thoughts are not consistent with you as a person. They are intrusive in nature. They crash into your mind and are unwelcome. In this way, a lot of people with intrusive thoughts from OCD are freaked out and scared by their thoughts because they feel like they are going crazy, whereas someone who is delusional may fully stand behind their thought patterns regardless of how separated from reality they are.
The reason I’m trying to be clear about this distinction is that you need to remember that these obsessive thoughts are unwelcome intrusions. They do NOT mean that you have a desire to harm your family buried deep down in there. The reason you are so concerned about them and that they freak you out enough to get treatment is that they are inconsistent with who you are. These thoughts are unwelcome. They are not a sign or a hidden desire.
Initial actions to consider
It seems like you have a lot of awareness about your patterns already, which is great and I’m proud of you for getting some treatment. With the amount of concern that you have, it strikes me that twice-monthly therapy may be a little sparse. There are obviously questions of access to treatment, insurance, etc. to consider here. But if it’s possible for you to get weekly therapy, that would likely be even better. I would also ask whether you are seeing someone who is trained in treating OCD. It’s a tricky issue and a lot of therapists aren’t going to be super well-equipped to help you deal with this unless they actually specialize in treating OCD.
You described a really common loop in OCD, where you have an obsessive thought (in your case, that your loved ones might be harmed) and then your brain tries to seek reassurance or reduce the stress and tension caused by this thought through engaging in some sort of compulsive behavior. These compulsions are sometimes thematically linked to the obsession in some way, but not always. One that would be linked would be repetitively checking the air pressure in the car tires to alleviate the fear of someone’s tire blowing out on the freeway and killing them. One that would not be linked would be counting or repetitively saying a phrase to yourself.
Anxiety, exposure, and response prevention
While it’s not categorized as an anxiety disorder currently, anxiety does play a huge role in OCD. If you think about it, you are essentially using compulsions to reduce the anxiety caused by your obsessive thoughts. It’s essentially a form of avoidance. Rather than sitting with the discomfort that the thought causes, you allow the anxiety of it to cause you to try irrational actions to reduce it. Just like with other forms of anxiety, this gives it credit and actually reinforces the anxiety. Your brain essentially notices the effort that you are putting into avoiding the thoughts and concludes that they must be scary and dangerous in some way. It’s like a self-reinforcing process. So, for OCD, one of the most common focuses in treatment is called exposure and response prevention (ERP). It’s really pretty straightforward and just what it sounds like. The exposure part is allowing yourself to have exposure to the obsessive thought without forcing it away or avoiding it in some way. Again, we are trying to not give the thought so much credit and control over our behavior. The response prevention part is where you attempt to not engage with the compulsive behaviors that typically provide you temporary relief from the anxiety caused by the obsessions. The idea is that you better learn to tolerate the discomfort rather than amplifying it by running from it or using your compulsions to give you relief from them. The thoughts themselves are not dangerous. They are just thoughts. Nothing more. You don’t need to give them any more credit than that.
This is a pattern that you might see in several areas in your life. It may be that you not only have the more overt compulsive behaviors, but also more subtle forms of checking and seeking reassurance. For instance, in your case, you might spend a lot of mental energy and time reviewing past events, your own history, and trying to find evidence to convince yourself that you are not evil and murderous. Or you might ask other people for reassurance that they are not afraid of you etc. These can be forms of avoidance. Rather than recognizing the intrusive thought and letting it pass, you feel a sometimes desperate need to make it go away through your efforts. It doesn’t have to go away. There is no correlation between how big and scary your intrusive thoughts are and their likelihood of coming true.
Medication, Therapy and ERP
Medication isn’t always necessarily the most effective at reducing the intrusive thoughts in OCD, although you may see a benefit there. One of the ways that it can definitely be useful though is helping you to better endure the anxiety that comes along with the exposure and response prevention method. You are inviting anxiety and trying to build a tolerance to it. Meds can help to reduce the discomfort that happens when you do that.
Hopefully, your therapist is working with you on some of this stuff. Through therapy, you can develop some ideas for doing what’s called in-vivo exposure. Basically, replicating aspects of what scares you intentionally in order to help you neutralize the fear and build a tolerance to the tension that comes when you don’t allow yourself to engage in compulsive behaviors. This is going to be different from person to person. If you are afraid that you might take a knife and stab someone that lives with you, you might spend some time gaining exposure to sharp knives and proving to your body that you aren’t any more likely to kill them just because you sometimes have visions of doing so. This is especially relevant if your thoughts and fears have led to specific forms of avoidance. Knives, being alone with loved ones, driving in the car, etc. There are a lot of potential areas where you may have adjusted your life to accommodate your OCD. We want to try to reverse those things.
You can also use imagined exposure, which could take a number of forms from writing stories or drawing images of the feared scenes in your head, or watching triggering videos online. The thing is, the point of these exercises is to not run away from them. To not seek reassurance from them. You simply want to build your tolerance for them and prove to yourself that they are just thoughts and images. They have no correlation to your actual behavior. Talk with your therapist about these strategies. You can absolutely do ERP on your own, but I don’t know your situation as well as they do. If there is a history of violence or self-harm where certain forms of exposure would actually be unwise, then obviously we don’t want to put you in harm’s way. One big mistake that people make when going through the ERP process is simply finding another subtle way to reassure themselves or check. For instance, if you are exposing yourself to a movie that is triggering, but the whole way through you are constantly checking in about whether you want to kill someone or not, you aren’t really preventing the response. You are giving into it by checking and seeking reassurance over and over.
A couple of other quick things here. One is mindfulness. If you have learned a bit about mindfulness already, hopefully you can see where it might be helpful. Mindfulness is a strategy that helps you to sit with your thoughts more successfully without fully giving over to them. You work toward being less judgmental of your thoughts and categorizing them as good/bad or safe/unsafe. Practicing mindfulness (like actually practicing, frequently) will help you to be less derailed by your thoughts and will allow you to recognize them as being totally separate from your behaviors.
Lastly, make sure you are taking care of yourself in general. A lot of times, when we get so focused on a particular aspect of our mental health, we can do so at the detriment of taking care of ourselves overall. Simple stuff. Make sure you are sleeping and eating well. Get some sunshine and some exercise if you can. Practice your regular coping skills and also make sure that you are doing things OTHER than just therapy, coping, learning, etc. Go bowling. Go see a movie. Do other stuff with your life too.
Great question and I hope this helps you understand the process a bit more!
You can listen to this on Episode 290 of the podcast!
Thank you for the great question!
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