An intrusive thought is an unwanted, sudden thought, picture, or idea that is not wanted and can cause worry or sadness. These thoughts are hard to control or stop. When these thoughts happen along with obsessive-compulsive disorder (OCD), Tourette syndrome (TS), depression, autism, body dysmorphic disorder (BDD), or sometimes attention deficit hyperactivity disorder (ADHD), they can become very upsetting, cause anxiety, or last a long time. Intrusive thoughts may also be linked to memories from OCD, post-traumatic stress disorder (PTSD), other anxiety problems, eating disorders, or psychosis. These thoughts, feelings, or images often involve things that are not suitable for the situation and usually have themes about aggression or sex.

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Many people have thoughts that are negative and uncomfortable, similar to what people with more intrusive thoughts experience, but most can easily ignore them. For most people, these thoughts are only a short and minor annoyance. Psychologist Stanley Rachman asked healthy college students to complete a questionnaire and found that almost all of them said they had these thoughts sometimes, including thoughts about sexual violence, punishment, unusual sexual acts, painful sexual activities, inappropriate or offensive images, thoughts of harming elderly people or those close to them, violence toward animals or children, and sudden outbursts of anger or abuse. These thoughts are common among all humans and have "almost certainly always been a part of the human condition."

When intrusive thoughts occur with obsessive-compulsive disorder (OCD), patients have more difficulty ignoring the unpleasant thoughts and may pay too much attention to them, making the thoughts more frequent and troubling. Trying to stop intrusive thoughts often makes them more intense and last longer. These thoughts may become obsessions that are very troubling, constant, and severe, and they may involve topics such as violence, sex, or blasphemy. Unlike the normal intrusive thoughts experienced by many people, intrusive thoughts linked to OCD can be very worrying, hard to stop, and continue for a long time.

How people respond to intrusive thoughts can affect whether these thoughts become severe, turn into obsessions, or need treatment. Intrusive thoughts can happen with or without compulsions. Doing the compulsion reduces the anxiety, but each time the compulsion is done, it makes the urge to do it again stronger, which can make the intrusive thoughts worse. According to Lee Baer, trying to stop intrusive thoughts only makes them stronger, and realizing that bad thoughts do not mean a person is truly evil is an important step in dealing with them. There is evidence that accepting intrusive thoughts instead of trying to stop them can help. In one study, people who were told to stop their intrusive thoughts felt more distressed after doing so, while those who were told to accept the thoughts felt less uncomfortable. These results may be related to the thinking processes involved in OCD. However, accepting intrusive thoughts can be more difficult for people with OCD.

It is unlikely that most people with intrusive thoughts will ever act on them. People who are very upset, guilty, anxious, or ashamed about their thoughts are very different from those who actually act on them. People who are not troubled by their thoughts, do not find them unpleasant, or have actually acted on them may need to have more serious conditions such as psychosis or possible criminal behavior ruled out. According to Lee Baer, a person should be concerned that intrusive thoughts are dangerous if the person does not feel upset by the thoughts or finds them enjoyable, has ever acted on violent or sexual thoughts or urges, hears voices or sees things others do not see, or feels uncontrollable and strong anger.

Intrusive thoughts may involve violent or harmful thoughts about hurting others or themselves. These thoughts can be linked to obsessive-compulsive disorder. These thoughts may include harming a child, jumping from a bridge, mountain, or tall building, wanting to jump in front of a train or car, or wanting to push someone else in front of a train or car. Rachman's survey of healthy college students found that almost all of them had intrusive thoughts from time to time, including:

• causing harm to elderly people
• imagining or wishing harm to someone close to oneself
• impulses to violently attack, hit, harm, or kill a person, child, or animal
• impulses to shout at or abuse someone, or attack and punish someone, or say something rude, inappropriate, or violent to someone.

These thoughts are part of the human experience and do not ruin the life of the person experiencing them. Treatment is available when the thoughts are linked to OCD and become long-lasting, severe, or very troubling.

One example of an aggressive intrusive thought is the high place phenomenon, which is the sudden urge to jump from a high place. A 2011 study looked at how common this was among US college students and found that even among those with no history of thinking about suicide, over 50% had felt the urge to jump or imagined jumping from a high place at least once. A 2020 study in Germany found similar results. This phenomenon is more common in people with high levels of anxiety sensitivity and may be caused by the brain misinterpreting a natural safety signal.

Sexual obsessions involve intrusive thoughts or images of kissing, touching, fondling, oral sex, anal sex, intercourse, or rape with strangers, acquaintances, parents, children, family members, friends, coworkers, animals, or religious figures. These thoughts can involve heterosexual or homosexual content with people of any age.

Common sexual themes for intrusive thoughts in men include:

• having sex in a public place
• having people come into contact with oneself while naked
• engaging in a sexual act with someone who is not acceptable because they are in a position of authority.

Common sexual themes for intrusive thoughts in women include:

• having sex in a public place
• engaging in a sexual act with someone who is not acceptable because they are in a position of authority.
• being sexually victimized.

Like other unwanted intrusive thoughts or images, most people have some inappropriate sexual thoughts at times, but people with OCD may give these thoughts too much importance, causing anxiety and distress. The uncertainty that comes with OCD makes people worry about whether they might act on these thoughts, leading to self-criticism or self-hatred.

One of the more common sexual intrusive thoughts happens when a person with OCD doubts their sexual identity. Like most sexual obsessions, people may feel shame and live alone, finding it hard to talk about their fears, doubts, and concerns about their sexual identity.

A person experiencing sexual intrusive thoughts may feel shame, embarrassment, guilt, distress, fear of acting on the thought or impulse, and doubt about whether they have already acted on it. Depression may result from the self-hatred that can happen, depending on how much OCD interferes with daily life or causes distress. Their concern over these thoughts may lead them to check their bodies to see if the thoughts cause feelings of arousal. However, focusing on parts of the body can cause feelings in those areas, which may lower confidence and increase fear of acting on the urges. Part of treating sexual intrusive thoughts involves therapy to help people accept the thoughts and stop trying to check their bodies for reassurance. This arousal in the body is due to natural physical responses in the brain, which react to the fact that a sexual thought is happening, not necessarily to the content of the thought. Research shows that the connection between mental and physical arousal is 0.66 in men and 0.26 in women. This means that a physical reaction does not necessarily mean the person wants what they are thinking about. However, thinking processes try to explain this reaction, and OCD makes people assign false meaning and importance to it.

Age factors

Adults under the age of 40 are often most affected by intrusive thoughts. People in this age group typically have less experience managing these thoughts and the stress and negative feelings they cause. Younger adults also face life challenges specific to their age, which can make dealing with intrusive thoughts more difficult. However, both younger and middle-aged adults try to reduce the frequency of these thoughts when they occur.

Middle-aged adults (40–60 years old) have the highest rates of OCD, making them more likely to experience anxiety and negative emotions linked to intrusive thoughts. This group faces unique challenges, as they must manage stress from both earlier and later stages of life. Middle-aged adults may be more likely to have intrusive thoughts because they have more life experiences to consider. Despite this, they are generally better at managing these thoughts than younger adults, even though it takes them longer to process them. Older adults often view intrusive thoughts as a mistake in thinking rather than a moral failure, unlike younger adults. They struggle more with suppressing these thoughts, which can lead to higher stress levels when dealing with them.

Intrusive thoughts happen at similar rates throughout life, but older adults are usually less negatively affected than younger adults. This is because older adults have more experience learning how to ignore or reduce strong negative reactions to stress.

Associated conditions

Intrusive thoughts are often linked to OCD or OCPD but can also appear in other conditions like post-traumatic stress disorder, clinical depression, postpartum depression, generalized anxiety disorder, and anxiety. Most people with severe intrusive thoughts have at least one of these conditions. A 2005 study showed that aggressive, sexual, or religious obsessions are commonly found alongside anxiety disorders or depression.

The main difference between OCD and PTSD is that people with PTSD have intrusive thoughts about real traumatic events they experienced, while those with OCD have thoughts about imagined disasters. People with PTSD must distinguish between violent, sexual, or blasphemous thoughts and memories of trauma. If treatment for intrusive thoughts does not work, doctors may suspect past abuse. Research suggests that people who focus on positive outcomes after trauma may feel less depressed and have better self-well-being. However, they might also have more intrusive or avoidant thoughts.

A study on women with PTSD found that intrusive thoughts lasted longer when they used avoidance strategies to cope. These findings support that not all coping methods reduce intrusive thoughts.

People with depression may feel intrusive thoughts more strongly and see them as proof they are worthless or sinful. Suicidal thoughts, which are common in depression, are different from intrusive thoughts because they can be dangerous.

Non-depressed individuals show more activity in a brain region called the dorsolateral prefrontal cortex when trying to suppress intrusive thoughts. This area helps with thinking, memory, and planning. People at risk of or with depression show less activity in this region. When intrusive thoughts return, non-depressed people also show more activity in the anterior cingulate cortex, which helps with detecting errors, motivation, and managing emotions.

About 60% of depressed individuals report physical, visual, or auditory sensations along with intrusive thoughts. These sensations are linked to more severe depression and a need for stronger treatment.

Unwanted thoughts about harming babies are common in postpartum depression. A 1999 study of 65 women with postpartum depression found that the most frequent aggressive thought was harming their newborns. A study of 85 new parents showed that 89% had intrusive images, such as the baby suffocating, being harmed, or kidnapped.

Some women may develop OCD symptoms during pregnancy or the postpartum period. Postpartum OCD often occurs in women who already have OCD, even if it is mild or undiagnosed. Postpartum depression and OCD often occur together. Though doctors may focus on depression, a study found that 57% of new mothers with postpartum depression also had obsessive thoughts.

A study by Wisner found that common obsessions in mothers with postpartum depression include imagining the baby lying dead in a casket, being eaten by sharks, or drowning. Baer estimated that up to 200,000 new mothers with postpartum depression each year may have these thoughts. Many avoid sharing them due to fear of being judged, which can worsen their depression.

Intrusive fears of harming children can last beyond the postpartum period. A study of 100 depressed women found that 41% had obsessive fears of harming their child, and some avoided caring for them. Among non-depressed mothers, 7% had similar thoughts, which adds about 280,000 non-depressed mothers in the U.S. with intrusive thoughts about harming their children.

Treatment

Treatment for intrusive thoughts is similar to treatment for obsessive-compulsive disorder (OCD). A type of therapy called exposure and response prevention (ERP), also known as habituation or desensitization, is often used to help people manage intrusive thoughts. For mild cases, cognitive behavioral therapy (CBT) may also be helpful. CBT teaches patients how to recognize and manage unwanted thoughts.

Exposure therapy is the most common treatment for intrusive thoughts. According to Deborah Osgood-Hynes, Psy.D., Director of Psychological Services and Training at the MGH/McLean OCD Institute, "To reduce fear, you must face it. This is true for all types of anxiety and fear, not just OCD." When people experience uncomfortable thoughts, feelings, or urges, they often try to avoid them by doing something to make the feelings go away. Over time, this behavior becomes stronger because the brain learns that doing a ritual or compulsion helps avoid the bad feelings. When OCD becomes severe, these behaviors can interfere with daily life and increase the frequency and intensity of intrusive thoughts.

Exposure therapy (or ERP) involves staying in a situation that causes fear or anxiety until the discomfort decreases. The goal is to reduce the fear reaction and learn not to react to unwanted thoughts. This method is the most effective way to lower the frequency and severity of intrusive thoughts. The goal is to stay in the situation that causes the most fear for one to two hours without leaving or doing anything to distract or comfort oneself. Exposure therapy does not eliminate intrusive thoughts—everyone has unwanted thoughts—but it can help reduce their impact on daily life.

Cognitive behavioral therapy (CBT) is a newer treatment than exposure therapy and is used for people who cannot or do not want to try exposure therapy. CBT has been shown to help reduce intrusive thoughts. It is important to work with a therapist to understand the patient’s specific obsessions and compulsions. One technique used in CBT is mindfulness, which involves paying attention to thoughts, accepting them without judgment, and learning to see thoughts as separate from oneself.

For severe cases where intrusive thoughts do not improve with CBT or exposure therapy, antidepressants or antipsychotic medications may be prescribed. If the cause of intrusive thoughts is OCD, depression, or post-traumatic stress disorder (PTSD), a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) is most commonly used. Intrusive thoughts can also occur in people with Tourette syndrome (TS) who have OCD; these thoughts often respond to SSRIs as well.

Antidepressants that have been shown to help treat OCD include fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and clomipramine (Anafranil). While SSRIs are effective for OCD, there is less research on their effectiveness for intrusive thoughts. Studies of patients with sexual obsessions showed the most improvement with SSRIs. A study of patients with religious or blasphemous obsessions found that most improved with fluoxetine or clomipramine. Women with postpartum depression may need lower doses of SSRIs and may benefit from adding CBT or ERP to their treatment.

If SSRIs or other antidepressants do not help, doctors may prescribe certain types of medications called neuroleptics, such as risperidone (Risperdal), ziprasidone (Geodon), haloperidol (Haldol), and pimozidone (Orap).

Some studies suggest that inositol, a substance found in the body, may help reduce obsessive thoughts when taken in therapeutic doses.

Epidemiology

A 2007 study showed that 78% of people with obsessive-compulsive disorder (OCD) in a medical group had unwanted images in their minds. Many people who experience these unwanted thoughts do not think they have OCD because they may not have common signs like washing their hands repeatedly. However, studies that look at how common things are suggest that unwanted thoughts are the most frequent type of OCD worldwide. If all people in the United States who have these unwanted thoughts gathered together, they would form the fourth-largest city in the U.S., after New York City, Los Angeles, and Chicago.

OCD affects at least 2% of people in every culture studied. Most of these people have obsessive thoughts, or bad ideas, but not other behaviors. This leads to an estimate that more than 2 million people in the United States alone were affected by OCD as of 2000. One writer said that 1 in 50 adults has OCD, and about 10–20% of these people have obsessive thoughts about sexual topics. A recent study found that 25% of 293 people who were mainly diagnosed with OCD had a history of obsessive thoughts about sexual topics.