Intrusive Thoughts, Anxiety & OCD - Therapist Jenna Overbaugh

So we're talking about intrusive ideas, images, impulses, feelings, urges. These thoughts that kind of come in out of nowhere that can feel very intrusive and a lot of times they're very ego-dystonic which means they're inconsistent with your values. So a lot of times these thoughts can be things that are really scary. You feel the urge to get rid of the thought somehow or to feel better about the thought somehow.

What drew me to that work initially was as a kid I struggled significantly with what I know now to be intrusive thoughts. I was generally a very anxious kid. I had a lot of intrusive thoughts myself. One really consistent pattern that stands out to me as I look back in hindsight was I used to feel the need to do everything in threes.

So I really loved the band Hanson as a kid and if you know who they are then we're on the same page, we would be good friends. But if you don't know who they are, they were a very popular 90s boyband and I loved them and I felt like as a kid it was my singular sole responsibility to keep them alive and by doing that I did everything in threes.

So I had to tie my shoes three times, I had to walk in and out of doors three times, and I felt like if I didn't do everything three times, then one of the Hanson brothers would die, and it would be my fault. So, in hindsight, you can see that that was very obsessive-compulsive. It was linked to magical thinking, these weird intrusive thoughts that came in out of nowhere, and I felt the need to get rid of it or feel better about that.

And so, I also struggled with social anxiety as a kid. I struggled to raise my hand and participate, afraid of what other people would think of me, but I also knew from a very early age, without being able to tell that it was exposure and response prevention or pushing myself outside of my comfort zone, I knew that the only thing that was worse than being anxious about these things was letting that entity win, letting that fear voice win.

And so, as scary as it felt to say raise my hand and participate in class because I was afraid that people would judge me, it was even worse of an experience for me to just sit there and shrink and, be even more afraid the next time. And so, I knew from a very early age that it was just better to rip the band-aid off.

It was better to just do it and get it over with. I became very competitive with my anxiety and with this intrusive thought voice. And so, not having context for that, I just did it, and I realized that it was helpful, and it made me braver, and it made me more courageous and more confident, and I didn't feel like my world was shrinking.

Of course, I eventually went on to learn that that was basically exposure and response prevention, and that's what really got me into this work initially.

Your story of raising your hand in class because it scared you is so interesting because it's the exact opposite of what most people who feel this way do, which is to try and stay as invisible as possible. What do you attribute your ability to fight through the pain in that way? And if I don't feel like I have that type of courage, what should I do?

This is a really great question because I want to be clear, it's also what I wanted to do in that moment, right? I wasn't, 100% gung-ho when I have to raise my hand and I feel great about it and this is going to be amazing and no qualms, right? I too felt scared and that's what this work is all about.

It's about feeling scared and doing it anyway. And so, I love that you use the word courage because courage you can have, courage you can build and you build courage by taking small steps outside of your comfort zone, building evidence that you can handle these things. And so, if raising your hand in class is something that is too far outside of your comfort zone right now and it's like a 10 out of 10 anxiety for you, what would be some other things that would be maybe a three or four on the zero to 10 scale?

How can we start to get you to challenge yourself a little bit more in ways that are challenging but manageable. That's the sweet spot. And so, you build courage, you develop courage over time by doing these small things and you start to collect evidence through these behavioral changes that you're making that you can do difficult things. And hey, I raised my hand and the world didn't end and even if someone did make fun of me, I can handle it.

That's what this work is all about. You challenge yourself, you push yourself outside of your comfort zone because you want to learn a couple of different things. One, you need to learn that your feared outcome isn't as likely as you thought. Two, that your feared outcome isn't as catastrophic as you thought and three, even if something bad does happen that you can handle it.

Those are all really important things for you to learn. Learning those things not by intellectualizing your way there, not by talking your way there, but by actually giving your brain the behavioral proof, the evidence of you moving and maneuvering differently in the world. That's how you give your brain proof of courage. That's how you become braver. I'm not really as interested in you feeling better, I'm more interested in you getting better at feeling.

Because unfortunately, if you're living a life that's worthwhile and of value, being triggered, having anxiety, having scary thoughts, it's kind of a tax of having a really meaningful, really fulfilling life. And so, if we're not teaching people to get better at feeling triggered and better at feeling anxious, better at feeling uncomfortable, then I think we're missing a really big part of it.

I often tell my clients, my students, if they have OCD, anxiety, or intrusive thoughts, that our work together boils down to three things. One, you've got to push yourself outside of your comfort zone. Two, I need you to reduce your safety behaviors, those compulsions, those rituals, those things that you're doing to try to feel better urgently and desperately. And I also need you to reduce your avoidance.

I don't think that that's sufficient for the work that people have to do, but I do believe that it's necessary. So, those three things, I often will tell people like you can get lost in all the bells and whistles of this treatment, you can get lost in the mindfulness of it. And, what's a coping skill versus what's just you, preferring to go out for a walk.

It can get really confusing at times. And it's also really important to come back to those three really important tenets, which is one, push yourself outside of your comfort zone, two, reduce your safety behaviors, reduce your compulsions, and three, reduce avoidance. I don't think anybody in the world couldn't benefit from that type of work.

I wish more people understood that OCD does not just come in the manifestations that we see as TV ready or media ready. OCD and anxiety don't just come in the form of relentless hand washing and fear of germs or needing things to be absolutely perfect and symmetrical. It can come in so many other forms and fashions. In fact, I always say, you can be obsessive and compulsive about anything.

OCD is limited only to your imagination. So, there are a lot of other less commonly talked about manifestations of OCD including relationship OCD, somatic OCD, sensory motor OCD, existential OCD, religious OCD, moral OCD, harm intrusive thoughts, sexual intrusive thoughts. There's really no limit to it. I think it's also really important for people to realize that just because you don't look like you have compulsions, just because you're not washing your hands relentlessly or checking your stove 20 times, it doesn't mean that you're not still struggling.

You can still have compulsions and you can still meet criteria for OCD even if you're doing no physical compulsions at all. A lot of times mental compulsions are a really big issue for people. Mental compulsions could be things like analyzing your thoughts, trying to logic your way out of these thoughts. You could spend a lot of time ruminating. Even simply paying attention to a certain thought can be obsessive and compulsive, can create this level of engagement where you're having that thought more often.

And so, really important that you're working with someone who understands mental compulsions and can see not just the tip of the iceberg when it comes to OCD, but can see and appreciate the whole potential big picture.

There seems to be a lot of overlap between OCD and anxiety. How do you know when you have one rather than the other? And is there something that anxiety sufferers can take away from what you teach about OCD?

When it comes to how do you tell whether you have anxiety versus OCD, I have my opinion, but let's go with what the official diagnostic criteria says. What the official diagnostic criteria says in the DSM-5, when it comes to anxiety, which is going to be more generalized anxiety disorder, we're looking at things that are more down-to-earth concerns. So, things that are more plausible, things that could happen, things that aren't so outlandish, let's say.

So, these are going to be things like people being really anxious about their health or the future, the state of the world, death, bills, finances, stuff like that. Whereas with OCD, it's typically thought of as being more outlandish, more creative, if you will. So, typically we're thinking of anxiety being, more down-to-earth, more practical fears, and OCD is a little bit more outlandish.

I don't necessarily see it that way anymore. I've worked with so many people who do meet criteria for OCD, but we would agree that they have pretty practical fears. COVID, for instance, was a really great moment in that regard where we kind of sat back as clinicians and providers like, these individuals are clearly washing their hands they're clearly obsessive and compulsive, but there is a pandemic happening right now.

Like, it's not that outlandish. It's not that creative. Before COVID, it probably would have been outlandish and out there, but it's not anymore. And so, we're also looking at other manifestations of OCD such as, relationship OCD. Being obsessive and compulsive about your relationship with a romantic partner, for instance. That might be more practical. And so, I don't think that it's useful to get stuck in, do I have this diagnosis or do I have this diagnosis?

If someone comes to me and they're struggling and they're more anxious than the facts warrant, my job is to help them only be as anxious as the facts warrant.

This work is often paradoxical in that it's kind of like quicksand. The more that you try to get away from anxiety, the more anxious and the more stuck in it you feel. Like quicksand, we actually have to just allow ourselves to be anxious. We actually have to stop trying so urgently to claw our way out of it, and it's only then that we feel the anxiety start to settle a little bit, but it feels very paradoxical.

What does surrender actually look like in that moment of high anxiety?

I actually have a visual that comes to my mind anytime that we talk about the word surrender, and it's very much like this. Where your chest is open and your eyes are open and your head is up and you're kind of open, right? Your arms are out and you're just open. When I think of anxiety, when I think of intrusive thoughts and compulsions, I think like this.

Like we're so closed grip and we're white knuckling and we're bracing ourselves. And so it would be different for everybody, but what surrender is instead is it's more openness. It's willingness. The willingness to feel discomfort is huge. They've actually done so much research to show that willingness to feel discomfort is predictive of treatment success. Willingness to feel discomfort is predictive of people getting better and staying better when it comes to OCD and anxiety.

It's not necessarily about how severe they are, it's not about their socioeconomic status as much, it's not about any of those things. It's about their willingness to tolerate some level of discomfort. Can you make space for discomfort in the short term so that you can have those long-term gains of being able to raise your hand, of being able to go and be present with your kids, of being able to drive on the highway, or whatever it is that you're struggling with?

So, if I'm having an anxiety attack or intrusive thoughts, what do I actually do when everything in me is telling me to fight or flight?

I always tell my clients and my students, your brain is always watching. Your brain is always collecting evidence as to what's important and what's dangerous. And so, if you give something a lot of attention, your brain is going to get the message that it's important. And if you avoid it somehow, you're going to give your brain the message that it's dangerous. What does your brain do when you give your brain the message that something is important and dangerous?

You think about it a lot and you're very scared, you're very incapacitated by it, okay? And so, we have to understand that, okay, we can feel that urge. You can feel that urge to fight. You can feel that urge to flee. And there's a moment in between the feeling and the reaction where we have choice. And it gets tricky, it takes practice, it takes repetition, it takes skill, it takes education, which is why talks like this are so important.

We need to feel that feeling and in that moment before we react, before we fight, before we do the ritual, before we avoid, before we run away, we have a choice. And we can, as hard as it would be, we can challenge ourselves for our long-term gain.

When it comes to OCD, there are five core fears. You can look them up. Dr. Elna Yadin has done a lot of great work when it comes to core fears in OCD, but really big ones are fear of making some irreversible mistake that you'll never be able to recover from, fear of being uncomfortable forever, fear of being alone forever, fear of being a bad person, and fear of dying.

So, really those are the five, and I think a lot of people, if they were to trace their superficial fears back to those things, I think they could resonate with that. I think most people are afraid or at least don't love the concept of being alone forever or of dying or of being uncomfortable, of making an irreversible mistake.

These are all objectively not pleasant things, but that's where other really great skills come in, like acceptance, like, tolerating discomfort, like not ritualizing over things that we can't possibly address. We do need to understand that at the core of this is an intolerance of uncertainty and an intolerance of doubt, an aversion to discomfort. And I truly do believe that unless we work on those three things, unless we work on you getting better at tolerating discomfort, unless you get better at tolerating uncertainty, and unless you get better at tolerating doubt, your OCD is probably going to play what we call Whac-A-Mole.

It's going to go all over the place because you might superficially feel better about your contamination OCD, you might feel better about that, do some exposures about that, and be fine about that. But, if you don't actually work on your core intolerance of uncertainty, and you don't get better at accepting uncertainty in general, what we see happen often is that we just have another subtype of OCD comes up.

You're not really worried about contamination OCD anymore. That's old news, but now you're really worried about hit-and-run OCD, or now you're really worried about these harm intrusive thoughts that you're having. If you work on becoming more tolerant of uncertainty, and just the natural human experience of uncertainty in general, as uncomfortable as it is, if we get better at tolerating that and making peace with that, those more superficial fears don't really have as much of a grip to sink their teeth into.

Absolutely, overthinking can be a compulsion. Back to what I had mentioned earlier about how mental compulsions can be so prevalent in OCD. One really big mental compulsion that a lot of people listening will probably resonate with is rumination. So, rumination has been defined as a couple of different things. A lot of people would say that it's just any mental engagement with a thought, just more generically and more generally.

I tend to think of rumination like you're trying to figure something out. you can also engage in other kind of overthinking patterns, like trying to mentally review an old conversation. You can try to pre-plan something really obsessively and really repetitively. You can try to logic your way out of a thought. Like I said, even paying attention to a thought can be compulsive in some form or fashion.

One really great visual that I use for people is you can't really help a bird landing on your head, but you are responsible for whether that bird can build a nest, right? And so, a bird landing on your head would be the thought popping up. You can't really help that. That has nothing to do with you. It's quite frankly none of your business.

But, there are often lots of things that we do, i.e. mental compulsions like rumination, paying attention to these thoughts and engaging with them in so many sneaky ways that we can kind of allow that thought to stay and we even encourage it to stay. We engage with that so it gets stronger and stronger. And yes, I agree, telling yourself to just stop thinking about it is not enough.

In fact, that might even have a rebound effect of you thinking about it more. Stop thinking about a white elephant. Don't think about a white elephant. No matter what you do, don't think about a white elephant. You're going to experience the rebound effect where you actually think about that thing more. What I'm encouraging is not to stop having the thoughts, but we do need to understand, back to my previous point of you have this urge, in between an urge and a reaction, there's a choice.

You can have the urge and it takes time, it takes practice to kind of get mastery over it, but you can have the urge. You can witness when that thought pops up and you can really challenge yourself and you can get really good at not answering that question.

I heard you give an example of an intrusive thought of throwing your baby down the stairs. What are some other types of thoughts you've encountered that people might recognize in themselves even if they've never identified as having OCD?

When we ask people who don't have OCD what their most common intrusive thoughts are, when we ask people who do have OCD what their most common intrusive thoughts are, and we get a list of the most common intrusive thoughts from the non-OCD group and the OCD group, and then we look at those two lists and we give those lists to professionals, those professionals are not able to reliably determine this is the OCD list and this is the non-OCD list.

That means that individuals, whether they have OCD or not, they experience the same thoughts. Now, yes, people who have OCD obviously experience them with more difficulty, more frequency, more distress is associated with them when they're doing these compulsions, but I think it's really important for people to know that the thoughts that you might be having and that you're really distressed by, that you think make you a monster or that make you a really bad person, a lot of other people are having the same thoughts.

The thought of not wanting to, but oh my gosh, I just had that thought of throwing my baby down the stairs. What does that mean about me? They're having the same thought of that person driving really slow in traffic and just, punching the [censored] out of their face, right? Like that we all have those intrusive thoughts and we have those thoughts all the time.

It's just part of human nature. And so, I think it's really important for people to understand that if you're reading more about OCD, if you're finding yourself really resonating with more of these experiences, it might feel like a lot. It can feel like a really bittersweet experience to see yourself so much in this diagnosis. And it can also feel really kind of scary because you don't know where to start.

What you need to know is that there are so many great resources out there. It's so great that we have since COVID, there have been so many more people coming online to talk about it. And so, it is so treatable. OCD is one of the most treatable, most addressable conditions. Research shows it takes on average someone from 10 to 17 years from when they first started struggling with OCD to when they actually got the right treatment, exposure and response prevention, so on and so forth.

And that just is wild to me because it's not that we don't have the treatments that work. It's not that they're not available. It's not that it doesn't work. It's that there's limited knowledge about OCD. It's that we're not talking about all the different ways that it can manifest. It's that people are getting misdiagnosed with just anxiety and they're slipping through the cracks in that way.

So, getting more education about it if you're super new to this is where I would start. The International OCD Foundation has great resources. I try to talk about my stuff as much as possible from the lens of someone who's been there, also from the lens of someone who's been treating it since 2008. but there are lots of really great pieces of information out there online.

Just make sure that you're working with someone who is an actual licensed professional counselor or a licensed social worker who has actual expertise in this field. It can get really tempting with all the different misinformation that's out there to just listen to someone who has lived experience or just listen to a coach. And unfortunately, I don't think that just lived experience is enough here.

I think the lived experience is great, if anything it's necessary, but it's not sufficient. You do need to work with somebody who has treated individuals who have had OCD and anxiety.

If you could go back in time and revisit yourself in a moment where you needed it most, what would you want to tell yourself?

I would want to tell myself that yes, you have these scary thoughts. Yes, you have this fear voice that feels really relentless and just won't shut up some days, but it's more about the breadth and the depth of your brain versus just you having these weird quirky scary thoughts. As you grow up, you will come to learn that you have creativity and you have this wild, wonderful imagination.

And that sometimes, yes, that wild, wonderful imagination comes out in the form of scary thoughts. And it's also going to come out in the form of awesome metaphors that you'll use to help your community. It's also going to come out in the form of you being able to write a Substack and write a book. And you're going to be that person who puts on the best birthday parties for your friends because you have a great memory and you're so creative and you're so thoughtful.

And so, I know as a kid, little Jenna, if I'm speaking to her, it's really easy to focus on and want to get rid of these scary thoughts that you're having. It's not necessarily just about getting rid of those scary thoughts. You have a big depth of brain that you're working with. You have a lot of creative thoughts that a lot of other people don't necessarily have access to.

Some of those are scary, but some of those are going to be really wonderful and help you have a large, rich, beautiful life.