What are intrusive thoughts?
Intrusive thoughts are unwanted, unpleasant, and often distressing thoughts, urges, or images. These thoughts can seem to come out of the blue, or may present as a result of some external trigger.
Intrusive thoughts are one important part of obsessive-compulsive disorder (OCD)—all people with OCD generally have distressing intrusive experiences, but most people who experience intrusive thoughts do not have OCD.
Why do my intrusive thoughts often come at night?
Some people experience intrusive thoughts at night, wondering what they can do when these thoughts impact their ability to sleep. They feel like when they get into bed their mind starts racing with worrying or random thoughts that grab their attention as they try to relax.
Some people feel the need to replay their day in their head, making sure everything was done and their so-called list was checked off. Others may worry about conversations they had and things they may have said. Did I offend someone in the office? Did I say something wrong and now I can’t even remember?
These thoughts seem to occur more often at night, but that’s not the only time they can happen—in fact, everyone has intrusive thoughts, and they can occur anytime. For one person they may tend to come at night, for another while they are driving, and for another while watching TV. If you notice that your intrusive thoughts often occur at night, it’s probably due to the simple fact that during the day your attention is focused on the different things you’re engaged in, so random intrusive events become more noticeable when you try to relax.
Does it mean something if my intrusive thoughts always come at night?
When a person experiences intrusive thoughts, it may feel like they have to have some meaning. Why else would we have them?
As hard as it may be to believe, there is no significance to the content of intrusive thoughts or the times they occur, but rather how a person responds to those intrusions. Nearly everyone experiences intrusive thoughts, and most people are able to brush them off as insignificant, proceeding with their day despite intrusive mental events.
The only thing that makes intrusive thoughts seem significant to them is the way we respond to them. When we feel unable to let go of intrusive thoughts, or they create a strong urge to engage with them, these responses can actually have a major impact. Are nighttime intrusive thoughts affecting your quality of life? Are you losing sleep because you’re so focused on “figuring out” your intrusive thoughts?
Instead of trying to figure out what it means that intrusive thoughts are happening at night, it’s more important to think about what comes after the intrusive thought, image, or urge—these responses are where intrusive thoughts hold their power.
Could nighttime intrusive thoughts be a sign of OCD?
It would be odd for intrusive thoughts in OCD to come only at night, but it is not uncommon for people with OCD to report that it is more difficult to deal with their intrusive thoughts at night, or that intrusive thoughts grab more of their attention when they are trying to go to bed.
OCD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) primarily by the presence of two groups of symptoms: obsessions and compulsions.
Obsessions are defined as “recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.” Some examples of obsessions may be:
- Sexually explicit thoughts or images/disturbing or taboo content
- Thoughts of harming someone else or oneself
- Fear that something may be contaminated
- Doubts about one’s memories
- Moral scrupulosity/fear of making a moral mistake
Compulsions are “repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.” Compulsions are done in an attempt to relieve the anxiety that comes from obsessions or to prevent a feared outcome. Here are some examples:
- Repetitive hand washing to rid oneself of contamination after touching anything that hasn’t been sanitized.
- Repeating words in one’s head in order to drive out an unwanted thought or feel reassured about one’s doubts.
- Repetitively revisiting places or objects to ensure that nothing is wrong.
- Hiding all the knives in a house, so there is no opportunity to hurt a loved one.
- Excessive praying until one feels a “perfect” sense of satisfaction or ease.
In OCD, these behaviors cause a significant amount of distress and will cause impairment or disturbance in one’s day-to-day functioning.
How can I sleep when nighttime thoughts bring anxiety?
In order to take the power away from intrusive thoughts, it’s important to change the way you respond to them. For people with OCD, the gold standard treatment is exposure and response prevention (ERP) therapy, which involves directly confronting the anxiety, distress, and fear that results from intrusive thoughts, while resisting the urge to engage in compulsions like rumination, checking, and reassurance-seeking for quick relief. By eliminating these responses to intrusive thoughts, you can retrain your brain to recognize intrusive thoughts for what they actually are: not threats or signs, but minor disturbances without any greater significance. ERP has been shown to be highly effective in treating OCD, but the principles of response prevention can be useful for anyone who is bothered by intrusive thoughts, whether or not they have been diagnosed with OCD.
For example, if David struggles with intrusive thoughts at night that he may have said something inappropriate during the day at work and spends hours mentally reviewing his conversations, his therapist may help him design exposure exercises to target this specific fear. A small hierarchy of exposures for David may look something like this:
- Exposure: Before bed make a list of all the bad things you could have said to coworkers and then read it over and over.
- Response prevention: Do not ask spouse if you might have said these things.
- Exposure: Lay in bed and say the things on the list to yourself.
- Response prevention: Do not repeat “I’m sorry” after stating these things.
- Exposure: Think about the list of bad statements while at work
- Response prevention: Do not ask people at work if you said anything inappropriate.
David will practice these exposures and allow himself to feel anxious without engaging in his compulsions of reviewing, reassuring himself, or even seeking reassurance. Over time David will begin to habituate to the anxiety he feels when intrusive thoughts occur at night, gain tolerance for the uncertainty he feels, and his anxiety will reduce over time.
How should I respond when I get intrusive thoughts at night?
Intrusive thoughts may tend to come at night because your attention is elsewhere during the day or because your stamina to handle them decreases as they get tired. The next time you experience an intrusive thought at night, you can try to implement some ERP techniques.
Write your thought down so you can look at it the next day. Practice having that thought during the day. Play with the thought a bit. Say a non-engagement response to yourself: “This may or may not happen,” or “Maybe it happened, maybe it didn’t. So what?”
Most importantly, if nighttime intrusive thoughts are causing a lot of distress or taking up lots of time, you should reach out to a qualified, specialty-trained mental health professional for help. A trained ERP specialist can evaluate you to see if you may be dealing with OCD or another condition. There is hope and support in treatment, and these thoughts don’t have to hold power over your sleep forever.