Intrusive thoughts and OCD: Understanding mental compulsions and the need for certainty
OCD is often associated with visible rituals such as checking, cleaning or washing. But many compulsions happen entirely in the mind. Intrusive thoughts, mental compulsions and the search for certainty can all become part of the cycle that keeps OCD going.
Most people experience intrusive thoughts from time to time. A disturbing image, an unwanted impulse, a strange doubt or a thought that seems completely out of character can suddenly appear in our mind.
For most people, these thoughts usually come and go without feeling particularly important. For people with OCD, however, an intrusive thought can become the beginning of a long process of questioning, analysing, checking and trying to find certainty.
This is one reason OCD can be difficult to recognise. The compulsions are not always visible. Sometimes, the entire ritual takes place inside your head.
When intrusive thoughts become a problem
Having an intrusive thought does not mean that you want it to happen, that it says something important about you, or that it reflects your values.
In fact, people with OCD are often deeply disturbed by the thoughts they experience. The more frightening, unacceptable or meaningful a thought feels, the more difficult it can be to simply let it be.
You might find yourself thinking:
What if this thought means something about me?
What if I secretly want this?
What if I made a terrible mistake and don't remember it?
What if I hurt someone without realising it?
What if I am not really in love with my partner?
What if I am actually a bad person?
The particular content of the thought can vary enormously. OCD can involve fears about harming others, contamination, relationships, health, sexuality, morality, religion, responsibility, mistakes or losing control, among many other themes.
What these different forms of OCD often have in common is not the specific content of the obsession, but the person's relationship with uncertainty.
The search for certainty
OCD often creates a feeling that something needs to be figured out. You may feel that you cannot move on until you know for certain that you did not make a mistake, that you are a good person, that you really love your partner, that you are not dangerous, or that something bad will not happen.
The problem is that some questions simply cannot be answered with complete certainty. Instead of accepting this uncertainty, you may start trying to resolve it. You might analyse the thought from every possible angle. You might replay a conversation in your mind. You might check how you feel. You might compare your reactions with other people's. You might search online, ask someone for reassurance, or repeatedly test yourself.
For a moment, this can feel helpful. You may experience a brief sense of relief or control.
But the doubt often returns. And when it does, the mind may conclude that you need to think about it even more. This is one of the ways the OCD cycle can become self-reinforcing.
When the compulsion happens in your head
Compulsions are often associated with visible behaviours: washing your hands, checking the door, arranging objects or repeating actions.
But compulsions can also be entirely mental.
Mental compulsions may include:
analysing what a thought means
mentally reviewing memories or conversations
checking how you feel
comparing different possibilities
trying to prove that a feared outcome is impossible
mentally rehearsing situations
looking for the “right” feeling
testing yourself to see how you react
repeatedly reassuring yourself
mentally replacing or neutralising an unwanted thought
These behaviours can be difficult to recognise as compulsions because they can look like ordinary thinking.
There is an important difference, however, between thinking something through once and feeling that you have to keep thinking until you reach a particular feeling or level of certainty. The latter can become part of the OCD cycle.
Reassurance can become part of OCD
Reassurance seeking is another common example. You might ask your partner, a friend, a therapist or a doctor whether something is okay. You might search the internet for the same question repeatedly. You might read forum posts looking for someone who has experienced exactly what you are experiencing.
There is nothing inherently wrong with asking for reassurance. Sometimes reassurance is appropriate and useful. The difficulty arises when reassurance becomes a way of trying to eliminate uncertainty. Because we simply can’t.
You get an answer, feel better for a while, and then the doubt returns. You ask again and again because the previous answer no longer feels sufficiently reassuring. You may be searching for a feeling of complete certainty which is impossible to reach and the more you search, the more uncertain you end up feeling.
Why trying not to think about something can make it worse
Another common feature of OCD is the struggle with unwanted thoughts themselves. You may try to push a thought away, suppress it, replace it with a “good” thought, or monitor your mind to make sure it does not appear again.
Unfortunately, monitoring whether you are having a particular thought can make the thought more likely to appear and will also make you even more aware of it when it does. The more important it becomes that this thought must not occur, the more threatening its presence can feel, and our nervous systems tend to focus intensely on perceived threats, even when those threats are simply thoughts.
This can create a paradox: the more you try to control your thoughts, the more attention you give them which only sustains them.
Treatment for OCD therefore is not about learning how to eliminate intrusive thoughts. Instead, the goal is to change how you respond to them.
How is OCD treated?
Cognitive behavioural therapy (CBT), particularly exposure and response prevention (ERP), is one of the main evidence-based treatments for OCD.
ERP involves gradually approaching situations, thoughts or feelings that trigger OCD while reducing the compulsive responses that normally follow.
For someone with primarily mental compulsions, this may look different from the stereotypical picture of ERP. The work may involve learning to notice the urge to analyse, check or seek reassurance without automatically responding to it.
The aim is not to convince yourself that nothing bad will ever happen. It is to develop a different relationship with uncertainty.
Instead of: “I need to know for sure” the therapeutic direction may gradually become: “I don't know for certain, and I don't need to solve this right now.”
This can be challenging work. It usually becomes much more manageable though when you understand how the OCD cycle works — and why responding to intrusive thoughts with compulsions tends to keep that cycle going.
OCD does not have to look a certain way
OCD is often portrayed as excessive handwashing, cleaning or checking. While these can certainly be symptoms of OCD, the disorder can take many different forms.
Some people experience predominantly mental compulsions. Others experience intrusive thoughts that seem completely inconsistent with who they are. Some spend hours researching, analysing or seeking reassurance without realising that these behaviours may be maintaining their anxiety.
You do not have to have visible rituals for your experience to be real. And you do not have to be completely certain that you have OCD before seeking professional help.
If you recognise yourself in these patterns, an assessment with a psychologist can help clarify what is happening and whether OCD is an appropriate way of understanding your difficulties.
If you are looking for an English-speaking therapist in Copenhagen, I offer therapy for anxiety, OCD, stress and other mental health challenges.