1. How can you know if something is an intrusive thought, or monkey brain, and what is a genuine desire to do something bad? Where do the intrusive thoughts even stem from? 

Drs. Debra Kissen and Paul Greene hosted a live webinar on December 5 (now available free on-demand) focused on Intrusive thoughts: how to recognize intrusive thoughts, how they differ from other anxiety symptoms, and tools and techniques to move past them. There were many questions asked throughout and after the webinar/ Drs. Kissen and Greene agreed to answer 10 of the most frequently asked questions in this blog post.

If you're anxious about whether something is a genuine desire or "just" an intrusive thought, chances are it's an intrusive thought. Having said that, the most important thing you can do is to notice that your desire to get this question answered is part of the anxiety. As such try applying the four-step technique we covered in the webinar. As for what the thoughts stem from, the best answer we can offer to that is that they are related to a fear of having those thoughts. Consider reviewing Dr. Kissen's webinar comments on thought suppression as well as her slide on tip #2.

1. How can you know if something is an intrusive thought, or monkey brain, and what is a genuine desire to do something bad? Where do the intrusive thoughts even stem from? 

2. Can excessive attention to the content of the intrusive thought lead to more obsessive examination of it? Does trying to ignore the thought make it more persistent? I also am extremely hard on my myself which makes obtrusive thoughts do difficult to ignore sometimes. 

Yes, trying to suppress or ignore the thought is likely to make it come up more often. Being excessively hard on yourself also creates the conditions for intrusive thoughts to be a problem; therapy can help with that. If you can practice being more self-compassionate, it wouldn't be surprising for intrusive thoughts to improve.

3. Are repeated intrusive thoughts tied to or indicative of depression or trauma? 

No. They are not signs of depression or trauma. However, you can certainly have two or even all three of those problems at the same time.

4. What about intrusive thoughts that involve bad things happening to people who you love so much? 

These thoughts are largely similar to the ones discussed in the webinar; the only difference is that they can be less personal to you. For example, the thought of your loved one being hit by a bus has nothing to do with you but it can feel horrifying nonetheless. Learning to tolerate that thought without reflexively trying to get rid of it is helpful. Exposure and response prevention therapy can help with this. Also helpful is to remember/review what we discussed in the webinar about thought/action fusion.

5. Often, I get positive intrusive thoughts about my future when I am feeling elated. Can these thoughts be tied to bipolar disorder? 

Typically these type of thoughts are not related to bipolar disorder. A more common phenomenon is for the thoughts to occur at very happy moments because that's when we least want them to happen! Remember, the more you don't want the ITs to happen, the more vulnerable you become to having them. For this reason, it is not uncommon for ITs to happen during moments like wedding ceremonies, christenings, funerals, sex, and other times when the ITs would be even more unwelcome than usual. Whether through exposure and response prevention or through your own efforts, if you're able to improve your ability to tolerate the thoughts, you'll find they start to come up less often. Good luck!

6. What if you have thoughts that confirm that you want to do a bad thing but horrify you?

By definition, you are going to be horrified by your intrusive thoughts. Intrusive thoughts highlight your worst fear about yourself coming true. Regarding an intrusive thought “confirming” that you want to do a bad thing this is impossible. There is no way for a thought to confirm a desire. I could have the thought "I love chocolate ice cream" but I actually detest chocolate ice cream and only like vanilla. Thoughts are not equivalent to desires. But trying to think your way into what you truly desire is a set up think your way into a ball of confusion. The very act of trying to figure out what you desire will lead to doubt and a lack of clarity. We can never know with 100% certainly what we “truly” want and that is why this topic is such a popular stomping ground for OCD.

7. I feel deep shame for these thoughts which leads to sadness and hopelessness and that I am not a good person. I have yet to talk to any friends and family due to the shame and the fear that they may look at me differently. Any advice?

The first bit of advice is to congratulate yourself for posing this question. You are now one step closer to being free from the prison of shame you have placed yourself in. Anxiety and intrusive thoughts run rampant in the shadow of shame and self-judgment. What I can tell you clinically, is that many times I have engaged in the exposure exercise of having a client share an intrusive thought with a loved one. Such as a wife sharing the intrusive thought to her husband “What if I lose control in the middle of the night and stab you". And as terrified as she was to share this thought she was met with the reaction, by her husband, of him cracking up. The absurdity and the obvious dichotomy between an intrusive thought and how a person lives their life are so clear and obvious once the thought it shared out loud.

8.  How do you build tolerance to the uncertainty of intrusive thoughts?

The way to build tolerance of the uncertainty associated with intrusive thoughts is through Exposure Response Prevention (ERP) based exercises. By practicing exposing yourself to a scary thought and not engaging in any compulsions your brain will learn it can tolerate these thoughts and the uncertainty that comes with them.

9.  What mindfulness tactics might help with coping with intrusive thoughts? 

I, Dr. Kissen, developed a mindfulness exercise to assist with intrusive thoughts. Which can be found here or at www.thinkmindfully.com. The key concept behind this exercise is practicing making contact with intrusive thoughts from a nonjudgmental, acceptance-based stance. Then practicing gently redirecting back to the current moment instead of getting stuck reacting to or fighting with the intrusive thought.
 
10. Do you think it will get to the point where thoughts are gone over time? 

If you get to the point where thoughts are gone over time you will be in big trouble :).  We humans need our thoughts to guide us towards effective problem-solving and survival. No one can live a life free of intrusive thoughts but through Exposure Response Prevention (ERP) based treatment and exercises, you can arrive at a place where you have a decreased emotional reaction to your intrusive thoughts. And you come to see them as brain spam instead of critical messaging.

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