Have you ever had a thought of poking something into your eye? What about a sudden urge to kick a baby? Or an image of acting on an unwanted sexual impulse? How about distracting blasphemous thoughts during prayer? Or wondering what it would be like to harm someone you love and aren't even upset at?

It turns out that nearly everyone has intrusive thoughts, and for the most part the intrusive thoughts that people without OCD have aren't very different in terms of content from the intrusive thoughts that people with OCD have. They can be weird, violent, or sexual. They can be things that we prefer not to think about.

Check out what comedian Tom Papa has to say about how common violent intrusive thoughts are:
https://www.youtube.com/watch?v=vUloDaSFzGM

There's even a subreddit (http://www.reddit.com/r/intrusivethoughts) where people record intrusive thoughts!

If everyone has these kinds of thoughts, why do some people have so much trouble coping with them, get so anxious about them, and experience them so frequently?

The answer has to do with how you relate to those thoughts. If you react without concern or with dispassionate curiosity (e.g, "Hey that's a funny thing to think - I hope I remember to pick up milk when I get off the bus..."), the thought is unlikely to cause distress or recur. In fact, you may not even remember it later, just like you didn't remember many of the other thoughts you had and things you saw for a passing moment. Why? Because they didn't matter.

However, if you attribute meaning to the thoughts (e.g., "Oh my gosh, why would I have a thought like that? Does it mean I want to do it? Does it mean I will do it? Does it mean I am a bad person for thinking it?"), you are likely to get anxious. And if you get anxious about a thought, you are likely to try not to think that thought. And if you try not to think a thought - any thought - you are likely to keep thinking that thought. And if you are anxious about a thought, especially if it recurs, you may engage in avoidance or behaviors to try to feel less anxious in the short run. But in the long run, those behaviors maintain the fear, cause the thoughts to come back, reinforce the beliefs that the thoughts mean bad things, and interfere with your life. So, attributing meaning to intrusive thoughts leads down a path to anxiety and then unhelpful ways of coping with anxiety (e.g., trying not to think about it, avoidance, compulsions, reassurance-seeking), and counterproductively keeps those thoughts around, creating a vicious cycle.

If you want to be less bothered by your thoughts, treat them like white noise - just some random neural firings that are sometimes quiet and sometimes loud but probably not worth paying much attention to. And allow yourself to think whatever you think.

As they say, if you want to think about something less, think about it more.

Have you ever met someone who was so happy with their appearance that if presented with a magic wand to fix any one flaw they would say, “No thanks, there’s nothing about my appearance I’d like to change”? Nor have I.

Now think for a moment about how you look at yourself in the mirror. If you are like many people, your eyes are immediately drawn to examine the aspects of your appearance with which you are least satisfied. You check to see whether your [fill-in-the-blank] is particularly bad today. You adjust or smooth or cover-up or whatever you do with that feature. Then you move to the next feature, and one piece at a time, examine your appearance, with a particular focus on the flaws and on fixing or hiding them. The result is that you spend a disproportionate amount of time looking at the parts of your appearance you don’t like, and tend to see yourself as a composite of parts, rather than a whole.

You imagine other people see you that way, too.

In contrast, when you look at others, you don’t notice details as much as you see their overall appearance.

You can try this out by staring closely at a friend’s face – you may find several marks that you never noticed before. In fact, try staring for 10 seconds at a mark on someone else and you may discover that you notice it several more times during the rest of the conversation. That’s because when you scrutinize something it seems more prominent in your mind.

But if you spend most of your mirror time scrutinizing your own perceived blemishes, you are left with a skewed perception of how you look, seeing a disjointed grouping of flawed parts.

Check out this clever campaign by Dove called “Real Beauty Sketches.” In interviews, the participants thought they were just trying to describe themselves in careful detail. So, do we see our appearance differently from how others see us?

Scrupulosity is a type of OCD in which obsessions relate to moral or religious fears. Sometimes symptoms of scrupulosity seem uniquely religious, such as blasphemous obsessions or refusal to take communion for fear of dropping the wafer. Other times, they may resemble non-scrupulous OCD symptoms, such as fears of contamination and excessive washing rituals, but the feared consequence is religious (e.g., ritual contamination and purity). In cases of secular moral scrupulosity, an individual may obsess about the moral implications of behaviors unrelated to specific culture-bound religious practice, such as being a bad person by not recycling a sheet of paper.

Although the particular symptoms of scrupulous OCD may seem quite different from those in other forms of OCD, the fundamental processes that maintain the disorder are quite similar. As with all types of OCD, obsessions cause distress (usually anxiety) and compulsions (a.k.a. rituals) are efforts to reduce distress by neutralizing or counteracting the obsessions, potential consequences, or anxiety. A careful analysis of symptoms of scrupulosity will help identify the precise nature of the moral or religious obsessions and compulsions, and particularly how they feed each other.

Individuals with scrupulosity sometimes believe that they are “pure obsessionals,” meaning that they have obsessions without compulsions. It is important to realize that compulsions can be entirely mental, and there is increasing recognition among researchers and clinicians of the ubiquitous presence of at least covert rituals. For example, an individual with intrusive blasphemous thoughts may ritualize by mentally erasing the thoughts (e.g., perhaps even picturing erasing a whiteboard), replacing them with good thoughts (e.g., thinking “God is good.”), or engaging in mental prayers in response to the obsession.

Exposure and response prevention (ERP), selective serotonin reuptake inhibitors, and clomipramine – separately or in combination – are first-line treatments for OCD, and would be appropriate for scrupulosity, as well. A foundation of a cognitive-behavioral approach to scrupulosity would likely be ERP, perhaps with the inclusion of cognitive therapy techniques to examine unhelpful or dysfunctional thinking patterns.

Individuals with scrupulous OCD about religion often express concern about working with a therapist who does not share their religious beliefs on matters that are entangled with religion. It is important to emphasize that religion is not the cause of OCD, even scrupulosity. Rather, for individuals with OCD, obsessions tend to latch onto domains of personal or cultural importance. Moreover, the goal of treatment is not to sin or violate religion any more than the goal of treatment for someone who has contamination fears is to contract HIV. Instead, the goal of treatment is to disentangle religion from OCD and to eliminate the latter. In fact, most people with scrupulosity report that their symptoms interfere with their religious experience and their relationship with God. Although treatment may involve taking permissible risks of sin that other co-religionists take (again similar to someone with contamination fears who learns to take risks that people without OCD accept), the goal is ultimately to have a more fulfilling and unadulterated religious life, in which religion is not co-opted by OCD.

Following are additional readings about cognitive-behavioral treatment of scrupulosity:

Ciarrocchi, J. W. (1995). The doubting disease: Help for scrupulosity and religious compulsions. Mahwah, NJ US: Paulist Press.

Deacon, B., & Nelson, E. A. (2008). On the nature and treatment of scrupulosity. Pragmatic Case Studies in Psychotherapy, 4, 39-53.

Huppert, J. D., & Siev, J. (2010). Treating scrupulosity in religious individuals using cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17, 382-392.

Purdon, C., & Clark, D. A. (2005). Overcoming obsessive thoughts: How to gain control of your OCD. Oakland, CA US: New Harbinger Publications.

Originally written by Dr. Jed Siev for www.mghocd.org. ©2010 Massachusetts General Hospital OCD and Related Disorders Program | Reprint only with permission