Obsessive compulsive disorder - OCD treatment and therapy from NOCD

What are ego-dystonic thoughts? How experts use the term

By Elle Warren

Jan 18, 20248 min read minute read

Reviewed byApril Kilduff, MA, LCPC

Your brain is fascinatingly complicated—constantly digesting stimuli from the world around you and spitting out responses in the matter of nanoseconds.  (Did you know that research shows the average person has more than 60,000 thoughts each day? Wild, huh?) 

And if you’re like me, you might feel a sense of “enmeshment” with your thoughts—as if every one of them means something important about who you are, how you feel, and what you believe. 

In reality, because your brain does so much work and inputs so much stimuli, not all of your thoughts inherently mean anything at all. Until you assign meaning to them, those thoughts are just, well, thoughts. 

But what if they keep popping up—bringing you great distress? Here’s what to know, and how to find help, thanks to NOCD therapist and clinical trainer April Kilduff, LPCC, LCPC, LMHC.

What are ego-dystonic thoughts?

The term ego-dystonic is a fancy way of explaining thoughts that are out of sync with who you are and what you believe and value, Kilduff explains. 

They’re the opposite of ego-syntonic thoughts. For example, let’s say you’re in a loving partnership that you really value. You may see your partner doing the dishes and think, Wow, I really love and appreciate them. That’s an ego-systonic thought. In contrast, an ego-dystonic thought would be one like, My partner is so bad, and I don’t love them. “They’re always going to be out of character and not match up with who someone is,” Kilduff says. 

Many people have ego-dystonic thoughts, but immediately recognize them as untrue, and move on with their day. There is, however, a mental health condition where you may have recurring, repetitive thoughts that are almost always ego-dystonic—ones that you feel unable to move on from.

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What if you have ego-dystonic thoughts all the time?

Constant ego-dystonic thoughts can be a characteristic of obsessive-compulsive disorder (OCD). The condition is rife with misconceptions—including the idea that OCD means that you have a love or enjoyment of something like cleanliness or order. But it’s actually just the opposite. If you have OCD, you can feel trapped in a cycle of anxiety and fear.

The first half of the OCD equation—obsessions—consists of unwanted, intrusive thoughts, images, urges, sensations, or feelings that are almost always ego-dystonic. And you might be compelled to get to the bottom of your thoughts.

OCD can latch onto anything you value, but here are some common themes, or subtypes, of OCD:

  • Relationship. This is when your intrusive thoughts fixate on doubts about your relationship, such as whether you’re attracted enough to your partner, if you love your partner enough, or worrying what if we break up?
  • Contamination. Your intrusive thoughts center on fears surrounding being contaminated or dirty, and that you’ll contract or spread an illness, or just feel “gross” forever.
  • Harm OCD is a fear of becoming violent and hurting someone, either by accident or on purpose. Note: Sometimes this manifests as one worrying about being the victim of harm rather than the perpetrator.
  • Existential OCD centers on big, philosophical questions about life and death, such as the meaning of your existence, what happens when you die, or the realness of your existence. 
  • Pedophilia. This is a type of OCD where your intrusive thoughts fixate on the fear that you’re secretly attracted to children. This theme is a prime example of the ego-dystonic nature of intrusive thoughts. While this subject matter itself may be taboo, it doesn’t align with your values—and it’s important to see past and shame or stigma you may feel so you can address an uncomfortable theme like this.
  • Sexual orientation. You might fixate on knowing your “one, true” sexual orientation, worrying that you’ve been lying to yourself or your partner. This affects people of all sexual orientations.
  • Scrupulosity or religious OCD is intrusive thoughts about being good, moral, or  following your religion correctly—and going against ethical or religious codes that you.
  • Perfectionism. If you worry about not being enough, not doing enough, or not living up to an expectation that you have of yourself, despite it being an impossible standard, you may have Perfectionism OCD.

The ego-dystonic nature of these obsessions can bring high levels of distress, including anxiety, fear, panic, guilt, shame, and embarrassment. This is where the second half of the OCD equation comes in: compulsions. These occur when you engage in a physical or mental act with the hopes of relieving the distress caused by your obsessions. 

Compulsions can look like a million different things, but the root of them is the same. The person performing them wants to find certainty that their intrusive thoughts aren’t true, so they can stop feeling those uncomfortable feelings. Kilduff says compulsions are “anything that someone does in an effort to ‘figure it out’ and get rid of discomfort.”  

Here’s a few examples of physical compulsions:

  • Checking to make sure the stove is off, for example, or that the door is locked, or that there’s no dent in your car so you must not have hit something, or squeezing your hand to “check” that your body is real. 
  • Tapping or touching. With this compulsion, there is not necessarily a logical, factual connection between the intrusive thought and the action, but it still serves the purpose of relieving distress. For example, you may need to switch a light on and off or tap your elbow a certain number of times in order to feel OK.  
  • Redoing. Similarly to tapping and touching, this may not have a logical connection to the content of your intrusive thoughts. It could look like showering again because it didn’t feel “just right” the first time, or needing to ask your partner how their day was again because it felt “off” the first time or trying to do thing to perfection.
  • Reassurance-seeking from others, such as asking your partner, “We’re not going to break up, right?” or “Did I seem aggressive during that interaction with my friend?”
  • Washing or cleaning. This looks like excessive hand washing, showering, or disinfecting of surfaces.

Mental compulsions might include:

  • Rumination is extreme overthinking or overanalyzing, where you might turn something over and over in your mind, sometimes for hours a day. It often comes from feelings of needing to get to the bottom of something, or thinking your way out of intrusive thoughts and the feelings they bring.
  • Reassurance-seeking from yourself. For example, repeatedly thinking, Of course I love my partner or Of course I’m a good person. 
  • Checking. The internal presentation of “checking” happens when you scan your body or mind for specific feelings or sensations. For example, someone with Sexual Orientation OCD may see someone of a gender they’re worried they’re attracted to and “check” their body for signs of attraction.
  • Thought replacing. This is the act of constantly swapping a “bad” thought with a “good” one. For example, after thinking what if I want to push this person in front of the train?, you might immediately think They seem really nice. I hope we can be friends.
  • Mental reviewing. This looks like combing through prior experiences and situations to look for proof that intrusive thoughts are or aren’t true. For example, if you have harm OCD, you might look back and ask yourself, When I played tag with my friends as a kid, was I violent or aggressive? 
  • Distraction OCD happens when you try to keep your mind occupied to distract from intrusive thoughts. For example, maybe you spend hours scrolling social media, watching television, or reading books solely because these activities drown out your own thoughts.

Of course, the attempts of compulsions to soothe you are futile. They bring only short-term relief, usually wearing off relatively quickly before more doubt creeps in. This is because compulsions reinforce the OCD cycle. They continue to encourage your brain to see intrusive, ego-dystonic thoughts as serious threats rather than benign brain matter.

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How can I get help for ego-dystonic thoughts?

If ego-dystonic thoughts are overtaking your life, there’s an incredibly effective, evidence-based treatment for OCD called exposure and response-prevention (ERP) therapy

The ERP process begins with you and your therapist working together to gain a comprehensive understanding of your intrusive thoughts, what triggers them, and what compulsions you perform. From there, you will collaborate on developing a hierarchy of exposures that are tailored to your unique experience—meaning that you’ll start with low-level exposures that bring low-levels of anxiety, and work your way up to the ones that cause the most distress. That way, you’ll never have to do the scariest thing you can think of right off the bat. 

In the beginning of treatment, exposures will most often happen during or right before therapy sessions so your therapist can offer immediate guidance in resisting compulsions. 

As time goes on and you gain more skills, you get “exposure homework” that you do outside of sessions. This structured and strategic process may cause an initial uptick in anxiety, but this creates the opportunity for you to practice sitting with anxiety rather than doing something compulsive about it. Over time, this type of therapy actually retrains your brain to no longer trigger a red alert about a perceived threat. It becomes something that you can just be with. 

There are three different categories of exposures:

  • In vivo. These are real-life exposures to a fear. For example, if you have pedophilia OCD, you might go to a park where there’s a playground.
  • Imaginal. With this category, you simply use your imagination to expose yourself to your fears. You may think about doing the thing that triggers your OCD, or look at a picture or video of it, but you don’t do it in real life. Your therapist might ask you to write out a “worst case scenario” like, I’m not attracted enough to my partner, then…
  • Interoceptives are exercises to bring up the physiological experiences we have with anxiety and panic—such as your heart racing, or having a hard time breathing—and allowing your body to get used to those sensations without panicking. Interoceptives are more for specific situations in which the physical experience of anxiety is at the forefront and are not used as often as the two above.

Over time, you learn that anxiety, and the intrusive thoughts causing it, are not actually dangerous. You don’t need to sound your internal alarm in the presence of them. Yes, you’ll still experience intrusive, ego-dystonic thoughts sometimes, since they’re a natural part of being a human—but they’ll occur less frequently, and bring you low or no distress, as you give them less attention. 

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