Shariq Refai, MD, MBA
Board-certified psychiatrist and medical editor of Shrinkopedia
Professional scope
adult general psychiatry, anxiety and mood disorders, medication management, sports and performance psychiatry, physician mental health
About
Dr. Refai is a board-certified psychiatrist and the founder of shrinkMD, an independent multistate telepsychiatry practice providing adult outpatient psychiatric evaluation, medication management, and follow-up care. He is medical editor of Shrinkopedia and is the reviewer of record for every clinical entry on the site. He holds an MBA from Duke University and dual board certification with the American Board of Psychiatry and Neurology and the American Board of Sports and Performance Psychiatry.
Contributed perspectives
- Obsessive-compulsive disorder (Condition)
"What do people most commonly misunderstand about intrusive thoughts in OCD?" - Panic disorder (Condition)
"Why does avoiding the situations that trigger panic tend to make panic disorder worse?"
Elsewhere in The Shrink Network
Shariq Refai contributes across more than one site in The Shrink Network. Each site has its own editorial lane, and each contribution is verified against the same standard.
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Disclosures
Dr. Refai is the founder of shrinkMD and the medical editor of Shrinkopedia, both part of The Shrink Network. When his contributed perspectives appear on Shrinkopedia entries that reference shrinkMD, the network relationship is disclosed inline. No pharmaceutical, device, or referral relationships.
Verification
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What do people most commonly misunderstand about intrusive thoughts in OCD?
That the content of the thought means something about the person. Intrusive thoughts in OCD are ego-dystonic, which is a clinical term for “the person does not want them and does not identify with them.” They are the opposite of wishes. The specific themes people describe most often, harm thoughts about family members, taboo sexual or religious content, contamination fears, are the themes the person finds most distressing. That is not a coincidence. OCD selects the material that would horrify the person most and hands it back to them as a repeating intrusion.
Fifteen years of clinical practice tells me the shame around this content is the single biggest reason people wait years before seeking help. They assume that a thought this dark must reflect something dark about who they are, and that a clinician would react with alarm if they described it. Neither is true. Clinicians who work with OCD hear these exact thoughts every week. The horror the person feels about the thought is diagnostic evidence for OCD, not against it.
The practical implication for treatment is important. Exposure and response prevention works by helping the person face the trigger of the intrusion without performing the compulsion or the mental review that follows. That means the person has to be willing to let the thought sit uncomfortably without proving it wrong. Fighting the thought harder is what keeps it alive. Loosening the grip of the mental review, in careful, structured steps guided by a trained ERP therapist, is what lets it fade.
Why does avoiding the situations that trigger panic tend to make panic disorder worse?
Because the brain reads the avoidance as confirmation that the situation was dangerous. Every time a person leaves a grocery store, gets off a train, or skips a drive because a panic attack might happen, the nervous system files the successful escape as proof that the situation deserved fear. The next time the person considers that situation, the fear arrives faster and stronger.
This is the central mechanism of how panic disorder grows. The panic attacks themselves are not the problem long-term. Panic attacks peak and pass, and the body has a ceiling on how much fight-or-flight arousal it can sustain. The problem is what the person learns from having them. If the lesson is “I survived because I ran,” the fear expands. If the lesson is “the attack peaked, my body handled it, and the situation was not actually dangerous,” the fear starts to shrink.
Evidence-based treatment for panic disorder is built around this. Cognitive behavioral therapy for panic includes interoceptive exposure, where the person deliberately produces the physical sensations that trigger panic, and situational exposure, where they revisit the places they have been avoiding. Done in structured steps with a trained therapist, this is one of the most effective interventions in all of mental health treatment.
The hardest part for most patients is trusting that the counterintuitive move is the right one. The panic response is telling them, urgently, that leaving is the only safe option. Learning to stay, in careful graduated exposures, is what teaches the brain that the fear was the problem, not the situation.