Are my intrusive thoughts a sign of complex PTSD (C-PTSD) or OCD?

Intrusive thoughts are unwanted and repetitive thoughts, images, or urges that involuntarily enter a person’s mind. They often appear abruptly and can be, at the very least, confusing. At worst, they can create overwhelming distress, anxiety, and fear.

These random thoughts can take various forms and themes. They can be focused on fears of harm or danger, disturbing sexual or violent images, thoughts of contamination or illness, or even blasphemous or morally unacceptable ideas. It’s worth mentioning that almost everybody has intrusive thoughts from time to time, and most have no trouble dismissing them for what they are—a random glitch that comes with having a brain.

For others, however, these unwelcome thoughts can “stick” and cause significant distress. If these thoughts are in conflict with a person’s values and beliefs, they can also lead to intense feelings of guilt or shame. 

These sticky, intrusive thoughts are a central feature of obsessive-compulsive disorder (OCD). People with OCD find it impossible to dismiss these thoughts, fixate on their perceived significance, feel great distress as a result, and engage in compulsions in an attempt to feel better. Compulsions are repetitive or ritualistic actions, which can be physical and mental, that temporarily reduce the distress that stems from intrusive thoughts, images, or feelings, which are known as obsessions.

Experiencing intrusive mental content is also common among people who have experienced trauma and have developed significant psychiatric symptoms in the post-trauma period. An example of this is post-traumatic stress disorder (PTSD), a condition that often co-occurs with OCD. Some individuals may experience a related condition that is often referred to as complex PTSD (C-PTSD). In this article, we’ll learn what C-PTSD is and the types of intrusive thoughts associated with the condition. We’ll also touch on how OCD and C-PTSD overlap and how people can reduce their impact and reclaim control over their lives.

Understanding complex PTSD (C-PTSD)

Being involved in a car crash, being sexually assaulted, witnessing a terrorist attack, or losing someone close to you are among the many possible causes of PTSD—a condition that around 8% of women and 4% of men will experience at some point in their lives. PTSD symptoms include flashbacks, nightmares, hypervigilance, emotional distress, and avoidance of triggers associated with the traumatic event.

“As the name suggests, complex PTSD is a more complex version of PTSD,” says Aaron Hensley MSW, LCSW, a therapist with NOCD. “Unlike witnessing a murder or being caught in a natural disaster, someone with C-PTSD will have experienced multiple and prolonged traumas like childhood abuse, domestic violence, or ongoing interpersonal trauma. The term C-PTSD encompasses this broader range of symptoms and experiences and emphasizes the complexities and challenges of treatment and recovery.” 

Interestingly, C-PTSD is not a distinct diagnosis in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—the standard classification system used by mental health professionals to diagnose mental disorders. This is mainly due to ongoing debates and discussions about its conceptualization and diagnostic criteria.

But while C-PTSD is not officially recognized in the DSM-5, it has gained recognition and support among many mental health professionals and researchers. They argue that C-PTSD captures the unique symptomatology and challenges faced by people who have experienced complex trauma. 

C-PTSD encompasses the core symptoms of PTSD mentioned above, but includes additional symptoms arising from ongoing and repeated trauma. These additional symptoms may include difficulties with emotional regulation, self-perception and identity changes, interpersonal relationship disturbances, a pervasive sense of hopelessness or despair, and a compromised sense of safety. Experiencing intrusive mental content is a common symptom of both PTSD and C-PTSD. 

Differentiating intrusive thoughts in C-PTSD and OCD

Intrusive thoughts associated with C-PTSD commonly revolve around traumatic experiences, replaying distressing memories, images, or sensations. These thoughts can be intrusive, vivid, and overwhelming, frequently intruding into various aspects of daily life. 

OCD, on the other hand, involves a distinct pattern of intrusive thoughts known as obsessions. These thoughts may or may not have any relation to past experiences or trauma whatsoever, and can encompass a wide range of themes, such as contamination, sexuality, symmetry, or harm. Unlike C-PTSD-related thoughts, OCD-related intrusive thoughts tend to be irrational—and people are often quite aware of this. Despite understanding that their thoughts and fears aren’t logical, people with OCD engage in compulsions in response to their thoughts, aiming to alleviate the anxiety and distress caused by their obsessions.

“While intrusive thoughts are different in each of these conditions, they both trigger the ‘fight or flight’ response,” says Hensley, referring to our reaction to perceived threats. “With PTSD, that can be an echo of a real life or death situation. With OCD, it’s more often centered around an irrational fear, and one that might not have any real-life precedent.” 

While C-PTSD and OCD are different conditions, it is essential to note that people can experience both simultaneously. In fact, while OCD occurs in about 1-2%% of the general population, studies show that a large portion of people diagnosed with PTSD—around 30%— meet the diagnostic criteria for OCD within a year of their PTSD diagnosis. In such cases, intrusive mental content from C-PTSD and OCD may coexist and interact, further complicating one’s psychological well-being. 

Examples of intrusive thoughts associated with C-PTSD

1. Flashbacks: People with C-PTSD may experience intrusive thoughts in the form of vivid and distressing flashbacks, where they relive past traumatic events. These intrusive experiences can be triggered by various stimuli, such as sights, sounds, or smells associated with a traumatic experience.
2. Intrusive memories: Recurrent and unwanted memories of traumatic events can intrude upon people’s thoughts with C-PTSD. These memories can be distressing, intrusive, and difficult to control, often causing emotional distress.
3. Negative self-perception: C-PTSD can lead to intrusive thoughts that revolve around a negative self-perception and self-blame. People may constantly criticize themselves, replaying thoughts such as “I am worthless,” or “I am unlovable.”
4. Hyperarousal and hypervigilance: People may experience persistent worries, intrusive images, or thoughts of imminent danger. These thoughts can make it challenging to relax, leading to constant anxiety and fear.

Examples of intrusive thoughts associated with OCD

There’s no limit to the themes—or “subtypes”—that OCD can focus on, and it’s common for the theme of a person’s obsessions to change over time. That said, here are some common types of intrusive thoughts that may become obsessions for people with OCD: 

1. Contamination obsessions: Folks with OCD may experience intrusive thoughts about contamination or germs. They may have persistent and distressing thoughts about being contaminated by dirt, germs, or chemicals, leading to excessive cleaning rituals.
2. “Taboo” thoughts: OCD can involve intrusive thoughts considered taboo or morally unacceptable. These thoughts may involve aggressive or violent impulses, sexual obsessions, or religious or blasphemous ideas that go against a person’s values.
3. Symmetry and orderliness: People may experience distressing thoughts or a strong urge to arrange objects in a specific way or maintain a sense of balance. Deviating from these patterns can cause significant anxiety.
4. Intrusive thoughts of harm: Some people with OCD may experience intrusive thoughts about causing harm to themselves or others, even though they have no intention of acting on these thoughts. 

Understanding the distinction between C-PTSD and OCD-related intrusive thoughts is crucial for accurate diagnosis and effective treatment planning. While both conditions can involve intrusive thoughts, the origins, themes, and patterns of these thoughts differ significantly. 

Recognizing these differences helps clinicians tailor therapeutic interventions to address the specific needs of people with C-PTSD, OCD, or both simultaneously. By targeting the underlying mechanisms and triggers of intrusive thoughts in each condition, mental health professionals can provide more targeted support and enhance the overall well-being of those experiencing these distressing symptoms.

Exposure and response prevention therapy (ERP) for OCD 

Effective for around two thirds of people with OCD, exposure and response prevention therapy (ERP) is considered the gold standard treatment. Its goal is to disrupt the cycle of anxiety and compulsive behaviors by deliberately exposing people to situations or triggers that provoke their obsessions, while guiding them to resist engaging in their typical compulsive responses. 

Throughout an exposure exercise, people are encouraged to refrain from performing compulsive behaviors or rituals and instead sit with the discomfort they feel, allowing them to learn that their anxiety naturally fades over time without compulsions, which only serve to make OCD worse over time. 

Prolonged exposure therapy for C-PTSD

Treatment for C-PTSD most often includes some version of the most effective treatment options for PTSD, including Prolonged Exposure (PE) therapy, which boasts response rates ranging from 65 to 80%.

Like ERP in OCD treatment, PE aims to disrupt the cycle of anxiety and avoidance behaviors by systematically exposing individuals to trauma-related situations so that they can learn new responses to their triggers. Throughout an exposure, people are encouraged to confront and remain in these distressing situations without resorting to safety-seeking behaviors or avoidance strategies. In time, they can retrain their brains to feel less threatened by triggering situations. 

Getting help

If you or someone you know is struggling with intrusive thoughts, I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment with the NOCD Care Team to learn more about how a licensed therapist can help. 

While all NOCD therapists specialize in OCD and receive ERP-specific training, many also specialize in treating PTSD with PE and have experience treating people with both. Trauma and OCD are commonly related to each other, and many people have found freedom from both OCD and PTSD with the proper treatment plan.