Intrusive Thoughts in Clinical Disorders: Theory, Research, and Treatment


Advancing our understanding of the cognitive underpinnings of psychopathology, this is the first volume to focus on the role of unwanted intrusive thoughts, images, and impulses in a variety of psychological disorders. Leading experts explore the nature and causes of cognitive intrusions, examining how they become so persistent--and distressing--for certain individuals. Compelling findings are presented on the contribution of these phenomena to the etiology and maintenance of such diverse problems as ...
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Advancing our understanding of the cognitive underpinnings of psychopathology, this is the first volume to focus on the role of unwanted intrusive thoughts, images, and impulses in a variety of psychological disorders. Leading experts explore the nature and causes of cognitive intrusions, examining how they become so persistent--and distressing--for certain individuals. Compelling findings are presented on the contribution of these phenomena to the etiology and maintenance of such diverse problems as obsessive-compulsive disorder, posttraumatic stress disorder, depression, generalized anxiety disorder, insomnia, and sexual offense. Highlighting important questions for future research, each chapter also discusses practical implications for assessment and treatment. Clearly organized and tightly edited, this book will inform the work of researchers, students, and clinicians alike.
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Editorial Reviews

From the Publisher

"Too many young clinicians are planning treatment without formulating causation of an individual patient's symptoms. This book counteracts that tendency (to make a DSM-IV diagnosis and jump to a manualized approach). It takes one very important symptom--intrusive thoughts--and examines it in several disorders and from many perspectives. The book will be very helpful in teaching therapists how to think about what causes each of the several presented complaints."--Mardi J. Horowitz, MD, Langley Porter Psychiatric Institute, University of California, San Francisco

"This book highlights the ubiquity of unwanted mental activity, a facet of cognition that is orthogonal to the pervasive categorization of thoughts as positive or negative. It is a 'must read' for researchers, clinicians, and students eager to understand why mental control and suppression are bound to fail in dealing with these intrusions, and how--while it may seem counterintuitive--approaches that encourage patients to develop a curious, detached awareness of these thoughts have proven helpful across a host of clinical problems."--Zindel V. Segal, PhD, Department of Psychiatry, University of Toronto, Canada

"This volume provides a highly valuable survey of the research on intrusive thoughts in several clinical states, including depression, anxiety disorders, psychosis, and sexual disorders. It will be useful to clinicians, to instructors in graduate and upper-level undergraduate courses in clinical psychology, and to researchers in social, personality, and cognitive psychology."--Susan Nolen-Hoeksema, PhD, Department of Psychology, Yale University

Psychiatric Services

"A comprehensive summary of cognitive theory on intrusive thoughts, with information that will be useful to researcher and clinician alike. It is compelling in its ability to stimulate the reader to think about how the thoughts that underlie disorders are shaped and controlled. Researchers will appreciate the descriptions of research tools and methods. Clinicians will benefit from the ample attention paid to the clinical applications of current theory."--Psychiatric Services
Cognitive Behavioral Therapy Book Reviews

"Cognitive therapy begins with a conceptualization of the individual and this book offers a valuable insight into the role of intrusive thoughts in a range of disorders. These are important concepts to include in our case conceptualizations."--Cognitive Behavioral Therapy Book Reviews
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Product Details

  • ISBN-13: 9781593850838
  • Publisher: Guilford Publications, Inc.
  • Publication date: 10/13/2004
  • Edition description: New Edition
  • Pages: 255
  • Product dimensions: 6.30 (w) x 9.00 (h) x 1.00 (d)

Meet the Author

David A. Clark, PhD, is a Professor in the Department of Psychology at the University of New Brunswick, Canada. He received his PhD from the Institute of Psychiatry, University of London, England. Dr. Clark has published numerous articles on cognitive theory and therapy of depression and obsessive-compulsive disorders, and is the author of Cognitive-Behavioral Therapy for OCD and the coauthor (with Aaron T. Beck and Brad A. Alford) of Scientific Foundations of Cognitive Theory and Therapy of Depression. Drs. Clark and Beck recently developed the Clark-Beck Obsessive-Compulsive Inventory to assess self-reported severity of obsessive and compulsive symptoms. Dr. Clark has received a number of research grants to study the cognitive basis of emotional disorders, the most recent being a Canadian federal grant to investigate intentional control of unwanted intrusive thoughts. He is a Founding Fellow of the Academy of Cognitive Therapy and an Associate Editor of Cognitive Therapy and Research.

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Read an Excerpt

Intrusive Thoughts in Clinical Disorders

Theory, Research, and Treatment

The Guilford Press

Copyright © 2005 The Guilford Press
All right reserved.

ISBN: 1-59385-083-2

Chapter One


Implications for Clinical Disorders

David A. Clark Shelley Rhyno

The flow of human thought does not always follow a purposeful, task-oriented, reasoned, or intended path. Instead the natural world of human thought is frequently punctuated with unwanted cognitive activity that interferes with our ability to engage in productive thought and performance (Sarason, Pierce, & Sarason, 1996). Worry, distractions, attentional biases, memory lapses, mindwandering, daydreaming, self-focus, ruminations, and obsessive thought are examples of mental processes that create cognitive interference (Klinger, 1996). These unwanted mental intrusions can interfere in task performance as well as intellectual pursuits and social behavior, and they play a significant role in a number of psychopathological conditions (Sarason et al., 1996).

This volume focuses on a particular type of cognitive interference that is clearly present in a number of psychological disorders. Our subject matter is the unwanted intrusive thoughts, images, or impulses that are primarily self-oriented and emotionally charged and interrupt the flow of thought. They frequently grab attention and may impel one towardsome response that is intended to regulate or control the mental intrusion and its associated distress. Thus the occurrence of unwanted intrusive thoughts, their functional role in maladaptive behavioral and emotional states, and deliberate attempts at regulating these thoughts are important topics addressed by the chapter contributors.

In this chapter we examine the nature of clinically relevant unwanted intrusive thoughts, images and impulses in nonclinical samples. After three decades of empirical research, it is abundantly clear that nonclinical individuals experience unwanted mental intrusions that are similar in form and content to the cognitive intrusions that are so problematic in clinical states (for reviews, see Clark, 2004; Papageorgiou & Wells, 2004; Pope & Singer, 1978; Rachman & Hodgson, 1980; Sarason et al., 1996; Wegner & Pennebaker, 1993). The occurrence of clinically relevant cognitive intrusions in nonclinical individuals is clearly illustrated in the following example of an obsession-relevant intrusive impulse recently experienced by one of us (DAC).

It is customary for me to begin the day with an early morning run with a group of fellow runners. Our run takes place in the early morning hours before sunrise and the route involves crossing a couple of bridges over a river that divides our city. On this particular dark, cold late-autumn Canadian morning, I crossed a very busy, two-lane highway bridge with a narrow sidewalk and low guardrails. Suddenly and unexpectedly I felt an intense urge to leap over the bridge railing and imagined myself plunging head first into the frigid water far below. The impulse was so intense that my knees actually felt weak. I mentioned the experience to my co-runner, a sergeant in the Canadian army, who expressed complete bewilderment about my internal mental state.

Upon reflection I was able to identify a number of characteristics of this unwanted intrusive impulse that are typical of this type of cognitive interference. First, the impulse was unwanted and entirely discordant with my current flow of thought and mood. Prior to stepping onto the bridge, I was having a particularly good run and an enjoyable conversation. Second, the impulse was externally cued by the unusually low guardrail and narrow sidewalk. As soon as I left the bridge, the impulse left and did not return despite later running across a second bridge but with a much higher guardrail. Finally, the more I attended to the intrusive impulse, the more intense the sensation. By thinking intently on whether I really could "lose control" and act on the impulse, I was able to intensify the experience but only as long as I was physically on the bridge.

If unwanted intrusive thoughts, images, and impulses are a universal experience, why do some people become so distressed by these cognitive intrusions? How common are unwanted intrusive thoughts in nonclinical persons? What are the similarities and differences between the unwanted mental intrusions in clinical disorders and the same unwelcomed intrusions found in nonclinical samples? How do sudden and unwanted intrusive thoughts differ from other types of cognitive interference such as worry, ruminations, and negative automatic thoughts? What are the origin and function of unwanted cognitive intrusions in the nonclinical state? These are a few of the questions addressed in this chapter. We begin by offering a definition of the phenomena of interest: unwanted intrusive thoughts, images, and impulses.



The human mind is a rich tapestry of constantly shifting thoughts, images, feelings, sensations, and impulses. Based on his thought-sampling studies with university students, Klinger (1978, 1996) determined that the median duration for specific thought content was 5 seconds, which means that individuals may experience approximately 4,000 distinct thoughts in a 16-hour day. It is reasonable to expect that some proportion of these thoughts will be unwanted mental intrusions that disrupt current on-task performance and attention. We are reminded of the complexity of the human psyche by the number of different types of cognitive events that psychologists have identified as part of the flow of thought, that is, what William James (1890/1950) referred to as the continuous, but ever-changing personal consciousness, or "stream of thought, of consciousness or of subjective life" (p. 239). As a result of this cognitive diversity, it is important to clearly define one's subject matter. This is also necessitated by the fact that the unwanted intrusive thoughts involved in clinical disorders cannot be restricted to any particular theme, or content. As evident in subsequent chapters, clinically relevant intrusive thoughts can encompass any topic, theme or content that is pertinent to the individual or situation at hand. Our definitions of unwanted intrusive thoughts, then, must specify the process characteristics, dimensions, or properties that enable clear identification of this cognitive phenomena and its differentiation from other types of clinical cognition (Clark & Purdon, 1995; Klinger, 1978; Parkinson & Rachman, 1981a).

For the purposes of this chapter, we define unwanted clinically relevant intrusive thoughts, images or impulses as

any distinct, identifiable cognitive event that is unwanted, unintended, and recurrent. It interrupts the flow of thought, interferes in task performance, is associated with negative affect, and is difficult to control.

This definition is consistent with conceptualizations offered by other researchers interested in this phenomenon. Rachman (1981), for example, defined unwanted intrusive thoughts "as repetitive thoughts, images or impulses that are unacceptable and/or unwanted ... are accompanied by subjective discomfort" (p. 89). According to Rachman, the necessary and sufficient conditions for a thought to be considered intrusive are that it interrupts an ongoing activity, is attributed to an internal origin, and is difficult to control.

The cognitive phenomena we labeled clinically relevant unwanted intrusive thoughts would also be consistent with Klinger's (1978, 1978-1979, 1996) description of a type of thought that is respondent (i.e., spontaneous, unintended thoughts that occur in response to a cue), undirected, and frequently stimulus independent. These thoughts interrupt ongoing activity and may, on occasion, involve content that the individual considers quite usual or strange. Singer (1998) noted that respondent processes include daydreams, fantasies, and nighttime dreams.

Horowitz (1975), in his research on cognitive and affective responses to traumatic stress, defined intrusive thoughts as "any thought that implies nonvolitional entry into awareness, requires suppressive effort or is hard to dispel, occurs perseveratively, or is experienced as something to be avoided" (p. 1458). Although these definitions are fairly precise, some researchers have assumed a broader definition of the phenomena, defining intrusive thoughts as any conscious thought that is internally generated and that distracts (interferes) from on-task activity (Yee & Vaughan, 1996).

Table 1.1 lists the key properties of unwanted intrusive thoughts that are based on our previous definition of the phenomena. The unwanted mental intrusions that are the focus of this inquiry are subjectively experienced as distinct or separate, identifiable thoughts, images, or impulses that quite suddenly enter conscious awareness. Thus our subject matter concerns conscious thought that is amenable to self-report. Unwanted intrusive thoughts, then, are not chains of mentation or more general patterns of sustained thought but rather discrete "cognitive bytes." Because any thought, image, or impulse could be experienced as a mental intrusion, it is important to consider both the properties or process characteristics of the thought as well as its content when identifying unwanted intrusive thoughts for particular clinical disorders (Clark & Purdon, 1995).

Beck's content-specificity hypothesis (Beck, 1967, 1987; Clark & Beck, 1999), which states that psychological disorders are characterized by a distinct cognitive content, might be helpful in distinguishing the type of unwanted intrusive thought content associated with different emotional states. The unwanted intrusions evident in depressive states would primarily involve thoughts of personal loss or failure, the mental intrusions relevant in anxiety would deal with threat and vulnerability, and the unwanted cognitions related to anger would involve themes of personal injustice and unfairness. As discussed later, researchers have been particularly interested in the role of unwanted intrusive thoughts in obsessive-compulsive disorder (OCD), where the theme involves egodystonic concerns (i.e., content that is inconsistent or contrary to a person's sense of self or identity). When investigating unwanted intrusive thoughts, then, it is important to take into consideration whether one is dealing with, for example, depressive, anxious, obsessive, intrusive cognitions.

The person experiencing an unwanted intrusive thought readily acknowledges that the phenomenon is his or her own thought; that is, it has an internal origin. Although this internal attribution would be applicable to all nonpsychotic intrusive thinking, Morrison (Chapter 7, this volume) makes a convincing argument that in psychotic states unwanted intrusive thoughts occur in which the person attributes his or her thoughts to an external source. Whether attributed to an internal or external source, we agree with Rachman (1981) that a critical feature of these mental intrusions is that the individual perceives them as unwanted or unacceptable in order to distinguish this phenomenon from a host of welcomed cognitive intrusions such as inspiration, pleasant daydreams, or fantasy.

One of the most important characteristics of unwanted intrusive thoughts is that they interfere in ongoing task performance (Sarason et al., 1996). Because of this interference, task-irrelevant intrusions have been most often studied within the context of test anxiety and, more recently athletic performance and social interaction (Pierce, Henderson, Yost, & Loffredo, 1996). Not only will unwanted intrusive thoughts interfere in current behavioral performance, but we can expect the intrusions to break into the flow of thought, thereby diverting attention away from some existing cognitive activity. One of the problems with unwanted intrusive thoughts is their capacity to interrupt concentration and impede cognitive and behavioral performance. As noted in Table 1.1, unwanted mentation is not easily ignored when it breaks into conscious awareness. Yee and Vaughan (1996) emphasized that cognitive interference must be understood in terms of impairment in the functioning of attention with interference indicated by the degree to which individuals are distracted from task performance by the imposition of a stimulus. In this sense, unwanted intrusive thoughts, images, and impulses would be an internal stimulus that is highly distracting because it captures attentional resources. Experimental research on control of unwanted intrusive thoughts indicates that individuals have a particularly hard time disattending to these mental intrusions (Edwards & Dickerson, 1987a; Sutherland, Newman, & Rachman, 1982).

Clinically relevant unwanted intrusive thoughts, images, and impulses are unintended or nonvolitional, are associated with negative affect, and are difficult to control. The nonvolitional, undirected or "spontaneous" (i.e., respondent orientation according to Klinger, 1996) quality of unwanted intrusive thoughts is the key property of this cognitive phenomenon. Klinger (1996) noted that intrusive thoughts occur without intended purpose, and Rachman (1981) speaks of the "wilful independence" of intrusive cognitions. Moreover, the unwanted intrusive thoughts relevant to clinical states also possess emotion-arousing properties. These are not benign or fairly neutral spontaneous mentation but, rather, cognition with an "emotional bite." Based on the content-specificity hypothesis, we expect that the type of emotional response associated with the intrusion will depend on its thought content. Given these characteristics, it is not surprising that unwanted intrusive thoughts are more difficult to suppress or ignore. As a result, they often reoccur despite the person's attempt to exert increased mental control.


As documented throughout this volume, unwanted intrusive thoughts play an important role in the psychopathology of clinical disorders (see also Sarason et al., 1996). There is increasing evidence that effective treatment of anxiety, depression, insomnia, and other conditions will require clinicians to target relevant distressing intrusive cognitions and the patient's reaction to these thoughts.


Excerpted from Intrusive Thoughts in Clinical Disorders Copyright © 2005 by The Guilford Press . Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

1. Unwanted Intrusive Thoughts in Nonclinical Individuals: Implications for Clinical Disorders, David A. Clark and Shelley Rhyno
2. Intrusive Thoughts in Posttraumatic Stress Disorder, Sherry A. Falsetti, Jeannine Monnier,
and Heidi S. Resnick
3. Seeking Solace but Finding Despair: The Persistence of Intrusive Thoughts in Depression, Richard M. Wenzlaff
4. Unwanted Intrusive Thoughts in Insomnia, Allison G. Harvey
5. Worry, Intrusive Thoughts, and Generalized Anxiety Disorder: The Metacognitive Theory and Treatment, Adrian Wells
6. Thinking Is Believing: Ego-Dystonic Intrusive Thoughts in Obsessive-Compulsive Disorder,
David A. Clark and Kieron O'Connor
7. Psychosis and the Phenomenon of Unwanted Intrusive Thoughts, Anthony P. Morrison
8. Unwanted Thoughts and Fantasies Experienced by Sexual Offenders: Their Nature, Persistence, and Treatment, W. L. Marshall and Calvin Langton
9. Unwanted Intrusive Thoughts: Present Status and Future Directions, Christine Purdon
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