The Misunderstood and Hidden Tyranny of Harm OCD

Written by: Dr. Nicholas Demas

When people hear the term “OCD,” a stereotypical image often arises, of someone going out of their way to avoid germs and repeatedly washing their hands, or perhaps hyper-focused on checking and symmetry. This is likely due to popular television and movie portrayals of individuals who experience the contamination and checking subtypes of Obsessive Compulsive Disorder (OCD). While these presentations account for a large majority of OCD sufferers, it’s not the whole story. There is a significant percentage of individuals who display no observable compulsive behaviors.

Previously referred to as “Pure Obsessionals” or “Pure O” OCD, this is a misnomer, as these individuals spend just as much time and energy attempting to relieve their distress and fight their intrusive thoughts, albeit with mental rituals. They experience unwanted, intrusive, and repetitive thoughts (obsessions), and then engage in ritualistic thinking (compulsions) to ward off feelings of anxiety, disgust, guilt, and shame. They perform a type of mental handwashing, seeking reassurance by reviewing the thoughts again and again to prove them wrong, engaging in magical thinking, such as repeating numbers, prayers, or mantras—anything and everything to get rid of the intrusive thoughts.

Approximately 24.2% of individuals with OCD experience intrusive thoughts of harming themselves or others [1]. “Harm OCD” is particularly insidious, precisely because it doesn’t look like what most people associate with OCD. Where is the hand washing? Where is the checking? These harming images flood in, out of nowhere, depicting graphic violence and unwanted sexual acts. Often these thoughts involve family members and loved ones, which makes it all the more terrifying and confusing. Since it doesn’t look like stereotypical OCD, most people don’t recognize is as such. If someone’s never heard of Harm OCD, how on earth do they make sense of these thoughts?

Tragically, most folks conclude that the thoughts must mean something, and convince themselves that they’re “going crazy” and will “turn into a monster” unless they can stop the thoughts. Common misinterpretations and fears include:

• There has to be a reason I’m having these thoughts–I must want to do this on some level
• If I can’t control or eliminate these thoughts, I will actually do these things one day
• What if I’m just a secret psychopath in training?
• There’s just no way my mind could come up with this stuff out of nowhere—it’s too detailed and nonstop—it must be some evil part of me trying to get out
• Prisons are filled with killers and sex offenders, who’s to say I’m not going to become one of them? Why else would I be having these thoughts if I didn’t really want to do these things???

So here’s the paradox about Harm OCD, and the most important takeaway: If you actually wanted to do these things, the thoughts wouldn’t bother you!

If these thoughts aligned with your values, they wouldn’t produce such massive fear and shame. You wouldn’t be spending all your waking hours trying to fight the thoughts and prove to yourself that you’re not a monster. It’s precisely because these thoughts are against people’s intentions and values, that they cause distress in the first place. The suffering is a result of the shame and fear of the perceived meaning of the thoughts, and perceived potential of “losing control” and becoming someone who will not just do these things, but will want to do these things and enjoy doing them.

Of course, if it were true that the thoughts actually meant these things about us, wouldn’t you or I or anybody do everything they could to prevent these terrible things from happening? And so it goes for folks with Harm OCD, who go to great lengths to avoid people or situations they believe could increase risk of harming others, such as:

• Avoiding being in the presence of knives or sharp objects, especially around family members
• Avoiding driving (What if I run someone over, either by accident or I realize I want to do it)
• Avoiding edges of subway platforms, standing at the center with hands in pockets (What if I get the uncontrollable urge to push someone onto the tracks?)
• Avoiding violent or sexual content on tv or movies (e.g. Law & Order SVU)
• Avoiding being alone with younger family members

One of the most debilitating forms of Harm OCD is Pedophilia OCD (POCD), and yes, it’s just as awful as it sounds. In this case, the intrusive, unwanted, and distressing thoughts and images are of sex and violence toward children. Again, if you’ve never heard of Harm OCD or POCD, what conclusions would you come to? What could be worse than having thoughts like that over and over? If you believe that having these thoughts mean that you will engage in these acts one day, what could be more shame-producing? Especially with the recent amplification in the news and popular culture of the word “pedophile,” what are you to think about yourself and your future?

This is where Harm OCD actually becomes dangerous, but not in the way the intrusive thoughts like to suggest. Harm OCD, and especially POCD, can lead to hopelessness and suicidality. With POCD, the perceived stakes of “turning into a monster” are raised with the (erroneous) belief that one might harm children. The presence, frequency, and salience of the thoughts create continued doubt and fear and shame. The fear and shame prevents seeking help or talking about it. No matter how hard one tries to ritualize or avoid, the thoughts keep coming. Remember, the thoughts wouldn’t be distressing if they aligned with one’s desires and values, so the math goes like this: “There’s no way I’m ever going to let myself harm a child, so I may as well take myself out, before I become the monster who wants to do these things.”

Even though many with anxiety, depression, and OCD may be hesitant talking about their challenges, and delay seeking help, they know the help is there, and they’re encouraged to talk about what they’re going through. However, before someone learns that Harm OCD and POCD is a real, well-understood, and treatable condition, they suffer in silence, avoiding most people and places. They’re terrified about what the thoughts might mean about them, and how others would judge them. They don’t talk about it—with anyone. They don’t seek help, and can live a life paralyzed by fear and shame. If you’ve experienced intrusive thoughts of harming yourself or others, please take a moment to refer to the online resources listed below. Step one is to learn more and lift some of the confusion, and hopefully start on your way to lifting a lot of the shame.

***Spoiler Alert***
If you have OCD, your mind will not fully believe what you just read in this article, nor fully believe the information provided in the links below. The stakes seem too high, and the doubt is too strong. That’s okay, it’s part of the process. Please keep reading anyway, and please know that every patient I’ve ever worked with has shared some version of the following: “Ok. It makes sense. I see that Harm/POCD is a real thing. But what if I’m the exception? Maybe everyone else that has these thoughts has OCD, but what if I really want to do these things?”

When you experience thoughts like these, just ask yourself one question: What’s the likelihood that the author of this article is a mind reader, versus the likelihood that these thoughts arose as a predictable part of a well-known pattern of doubt and fear associated with OCD?

The doubt, unfortunately, is not going to go away, but you know the answer.