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What Are Intrusive Thoughts with Dr. Avital Falk

A psychologist helps us understand the difference between a worry and an intrusive thought and when it may be time to seek treatment.

What Are Intrusive Thoughts with Dr. Avital Falk

A psychologist helps us understand the difference between a worry and an intrusive thought and when it may be time to seek treatment.

This week, our host Faith Salie talks with Dr. Avital Falk, program director of the Intensive Treatment Program for OCD and Anxiety in collaboration with the Center for Youth Mental Health, to help better understand intrusive thoughts. She explained what makes these thoughts so sticky, how people can manage them, and the relationship between intrusive thoughts and obsessive compulsive disorder.

Episode Transcript

Welcome to Health Matters – your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Faith Salie.

What’s the difference between a worry and an intrusive thought? While both are thoughts that come into our head and are hard to shake, they are actually very different from one another. 

This week, I spoke with Dr. Avital Falk, a clinical psychologist at NewYork-Presbyterian and Weill Cornell Medicine to help better understand intrusive thoughts. She explained what makes these thoughts so sticky, how people can manage them, and the relationship between intrusive thoughts and obsessive compulsive disorder. 

Faith: ​Dr. Avital Falk, it’s so nice to have you on Health Matters.

Dr. Falk: It’s nice to be here. Thank you.

Faith: Can you break down for us what an intrusive thought is?

Dr. Falk: So intrusive thoughts – that’s a term that gets thrown around a lot. And when I think about intrusive thoughts, I’m thinking about it generally in the context of OCD.  And it’s a thought that pops into your head that you don’t want. That’s why it’s an intruder. It’s intruding upon you. And it’s not just that you don’t want it, but that it’s something that you actively disagree with.

It’s something that we call ego dystonic, meaning it doesn’t agree with what you really desire. And so, for example, I’m sitting with you today and I might have a thought pop into my head. What if I just punched you?

Faith: Mm-hmm.

Dr. Falk: And I can tell you right now, I absolutely do not want to punch you.  

Faith: Thank you.

Dr. Falk: And so, that, that’s, you know, an example very just clear cut where something is popping into my mind that disagrees with what my desires or thoughts or wishes are.

And in fact, it can be very distressing. So now, a lot of people have just random thoughts that pop in, and most of us can just dismiss them really quickly and say, oh, that was a weird thought. Moving on. But somebody who has OCD, their thoughts may become stickier and the person gives those thoughts more credit.

So instead of being able to just dismiss it and say, that was a weird thought. Their mind starts saying, hang on. Why did you have that thought? Does it mean that deep down you’re violent because who else would have a thought about punching somebody in the middle of a conversation and…

Dr. Falk: there’s a really strong desire to get rid of the thought because, you know, when we think about it with OCD, we’re thinking about what’s the obsession? What’s the compulsion? And so here the obsession is what if my thought means something about me? What if it means something about who I am?

Maybe even though. That doesn’t sound like something I want to do. Why else would I be having that thought? And then the compulsion is often something to try to get rid of the thought or neutralize the thought. So you know, saying, don’t think about that. Don’t think about that, don’t think about that. Or something like, You know, maybe I should stay away from people something to try to combat that fear and that thought that’s going on.

Faith: It’s a layer of not only experiencing an unwelcome and negative thought, but then, on top of that, feeling a burden to manage it and control it and some kind of self-critical introspection about it all at the same time.

Dr. Falk: Yeah. And it may not even be self-critical, but it’s fearful. So it’s, it’s what if that means something about me and therefore I don’t want to experience that. So, I have to figure out something to really neutralize that, or at least, at the very least get rid of the thought.

But what we know is that the more you try not to think about something, unfortunately, the more you think about it. So if I’m sitting here saying, don’t punch Faith, don’t punch Faith, don’t punch Faith, all of a sudden that’s all I’m thinking about. And that’s what often happens. And then the thoughts just come in more and more and more. Almost as a result of those attempts of getting rid of them.

Faith: How do we understand how an intrusive thought differs from a worry or a rumination?

Dr. Falk: It’s a great question, I think typically worries and fears, they kind of make sense to you. Now, they may be excessive, which is where we get to the point where we’re thinking about an anxiety disorder, where they’re excessive and messing up your life in some way.

However, they do make sense. So for example, if I have a fear of heights, that makes sense to me, right? I don’t want to fall that fear that the, the idea of falling is scary. So it makes sense that I’m thinking about it and fearing it and worrying about that. Now versus the example I gave you before about having a thought about punching you, that just doesn’t really add up with who I am, what I’m thinking, what I’m doing. So I think that’s just an example. Both of those are thoughts. I don’t want to have, I don’t want to be thinking about heights. If I’m afraid of heights. I also don’t want to be thinking about punching you.

However, one of them really makes sense with who I am, and that’s a fear of mine and that’s something I really don’t want to happen. And the other one almost feels kind of strange and almost the opposite of what I want to be. I really don’t want to be a violent person, so why am I having an image of being a violent person?

Faith: You’ve mentioned both the intersection of intrusive thoughts and OCD obsessive compulsive disorder, and you also touched a little bit on generalized anxiety disorder. So do you want to start with the connection between intrusive thoughts and OCD?

Dr. Falk: When we think about OCD, we’re often trying to identify what is the obsession and what is the compulsion. And what we understand is that somebody has an obsession, which is a thought, image or urge that comes in over and over and over and can be extremely distressing. And then they either do something or think something or avoid something. To try to get some relief from that obsession. And that part is the compulsion. 

Now with intrusive thoughts. The obsession is what if my thought means something about me?

So it’s not just the thought itself, it’s. What you’re concerned about in terms of, now that I’ve had this thought, what does it mean? And the compulsion can be any number of things that are intended to get you some relief from that concern. As I was saying earlier, many, many people try to get rid of the thoughts because the thoughts them, they’re concerned. Having a thought means something about me, so I’d rather get rid of it, and so they may do all sorts of things within their mind to try to get rid of the thought or distract themselves from the thought. 

Faith: But to be clear, we can all experience intrusive thoughts that don’t point to having OCD.

Dr. Falk: Absolutely.

Faith: Well, let’s talk about a treatment plan for OCD. What does that look like?

Dr. Falk: So the treatment for OCD typically involves what we call exposure and response prevention. Exposure, meaning facing the things that’s challenging for you, and response prevention is preventing some sort of compulsion or response. And now when we do that, we have to think about, well, what is the obsession?

What is the fear that we need to be facing? With intrusive thoughts, like I said, the obsession is usually about what if this thought means something about me?

We want to face that. And so I think this is where things get a little bit confusing sometimes for people where they think, wait, if my obsession is a thought about punching somebody, you’re going to tell me to punch somebody as my exposure practice? And the answer is, of course, absolutely not. But if we understand that the obsession is not punching somebody itself, the obsession is, does the fact that I’m having this thought about punching somebody mean something about what’s going to happen or about me, then we can say, oh, so the fear is actually about thinking thoughts and being able to tolerate having a thought and hopefully eventually recognizing that it doesn’t dictate anything about who you are or what you will do.

And so the exposure exercise that we may do might be to actually think about that thought on purpose. So I might actually have somebody think about punching somebody or even have their fist balled up and ready to go. And the idea is that a thought is just a thought. Nothing more, nothing less, and doesn’t change our desires or what we’re going to do.

It doesn’t have that power. And so the more that we learn to face the thought without running away from it or neutralizing it in some way or doing that compulsion, the more the person learns to tolerate that thought and gets better and better and better at understanding that that thought doesn’t change who they are and actually the less afraid of it they are, guess what? The less they try to get rid of it, and then when they are trying to get rid of it less, hopefully these thoughts actually start decreasing in frequency.

Faith: Can you help us understand when it might be a good time to reach out to someone for support or help? 

Dr. Falk: We think about all of these things as reaching that disorder status when they’re debilitating to daily functioning and life. And so that can be defined in a number of ways. What does impairment look like? What does it look like when these things are impairing to you? And it could be that it’s taking up a significant portion of your time.

It’s taking you hours and hours and hours to do certain compulsions. Or it could be that it’s causing you really significant distress. The worries or the compulsions, depending on what you’re experiencing or that obsessions themselves are just extremely upsetting. And are causing really impairing distress levels.

Or it could be that your symptoms are standing in the way of you being able to go to school or to work or impacting your friendships. So it’s really about when you’re finding that your experience with your thoughts, with your behaviors, whatever it may be, is really interfering with your ability to live your life fully and what you want to be doing. That’s a time where it makes sense to seek out help and understand what’s going on for you and whether there are things that can be really helpful.

Faith: Are there exercises or, or practices you would recommend to someone to who wants to disrupt intrusive thought patterns? Are there, are there things we can do, in our own homes, in our own minds that combat or, or curb them?

Dr. Falk: Yeah, I think there is an element of sit with the thought, and recognize that a thought is just a thought. And sometimes I’ll have somebody do a very silly example just to get them started that may feel unrelated to the actual intrusive thoughts that they’re having. So I might ask a child, what is a  food that you absolutely hate, and they’ll tell me, Brussels sprouts.

Okay, so right now I want you to think on purpose how much you love Brussels sprouts. I want you to say, I love Brussels sprouts. I want you to close your eyes and just imagine this gorgeous plate of brussel sprouts. This is all I want you to think about for the next 24 hours and at the end of the 24 hours, let’s have your parents offer you some Brussels sprouts for dinner and see, if just having that thought, closing your eyes and imagining it, thinking about it, has actually changed your own desires. And so that’s, that’s just a simple way of thinking about this exercise. And then of course, we can step up to thinking about and practicing sitting with the thoughts that the person is truly struggling with.

Faith: Dr. Falk, I’m now craving brussels sprouts.

Dr. Falk: I personally love brussels sprouts, so.

Faith: Dr. Falk, thank you so much for shedding light on all of this for us.

Dr. Falk: My pleasure. It’s been great to be here. Thank you.

Our many thanks to Dr. Falk

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