It’s hard to turn on the news without hearing about violent assaults, murders, and sexual abuse. We probably feel revulsion when we hear about these things, wondering how a person could do something so despicable. We might also fear for our loved ones’ safety, or our own.

For some individuals with obsessive-compulsive disorder (OCD), the fear can take on a very different quality. Rather than fearing that they or someone they love will be a victim, they are gripped with terror that they themselves might commit some horrific act.

Like any type of OCD, this form starts with a thought: What if I do something awful to another person? That thought is the obsession, which triggers anxiety since it would be terrible to do what the person fears. All of us want to avoid anxiety and prevent bad things from happening if possible, so the person will do something—the compulsion—to try to make sure s/he doesn’t hurt anyone. The person often feels temporary relief after a compulsion.

Let’s consider an example:

I’m standing in the kitchen chopping vegetables. My brother comes in the kitchen and asks me if I need any help. I’m about to ask him to wash the broccoli when an image suddenly comes to mind of him standing at the sink with his back to me and me holding the knife behind him. What if I stab him in the back? God forbid I think to myself as I shudder at the thought and try to put it out of my mind—Who thinks such things? I set the knife aside for a minute and say, “I’m good, but thanks for offering. Feel free to keep watching the game.” I wait until he’s out of the room before picking up the knife again.

This example has many of the common features of OCD. First, I’m triggered by a fear: What if…? I then do several things that are meant to prevent what I’m afraid of: I put down the knife, encourage my brother to stay out of the kitchen, try not to think about it, and say a short prayer. I’m also left feeling like I must be really messed up.

In OCD, these obsessions and compulsions happen over and over, taking up an incredible amount of mental space and filling my days with fear and dread. Let’s take a closer look at this form of OCD and how it can be treated effectively (yes, it can).

When Is It OCD?

It’s important to distinguish between OCD about hurting others (Fear of Harm OCD, or Harm OCD for short) and a truly high risk for causing harm. A person who is actually dangerous may have a history of assault and will feel a desire to hurt others. The person may try to resist those urges because of the likely consequences, but not because the idea of acting on the thoughts or urges is incredibly unsettling.

People with Harm OCD usually say hurting someone else is the last thing they would want to do. Even thinking about the possibility is upsetting. To actually commit such a heinous act would be the worst thing imaginable. And yet the thoughts come back, over and over.

But How Do You Know for Sure You’re Not a Terrible Person?

I’m fully aware that trying to distinguish between these two categories, important as it is, will almost certainly feed the doubt in those who have this form of OCD. After all, how do I know I don’t want to hurt someone? And what if I don’t want to right now but then have a sudden urge that I act on without thinking? Or what if I just “lose it” and snap? What if I’ve been pretending all along to be “normal”?

In fact, the quest to be 100% certain I won’t do what I’m afraid of is a big part of what makes it OCD. When it comes right down to it, it’s hard to be completely sure of anything. This uncertainty—or rather, the effort to eliminate uncertainty—is what fuels OCD. When we aim for certainty, OCD always holds the trump card. As we’ll discuss later on, beating OCD means refusing to play its game.

Myths About Harm OCD

As if having Harm OCD weren’t enough, there are unhelpful beliefs about it that compound the difficulty. The primary myth is that having this condition means that “deep down” the person really wants to do the thing s/he is afraid of. In fact, obsessions about harm used to be called “Aggressive” obsessions in the mental health community based on an old-fashioned understanding of the condition.

In a related way, the general public often misunderstands Harm OCD, too. Most of the time when someone says she’s afraid of hurting people, we take these concerns seriously, especially in the current environment where we’re told, “See Something, Say Something.” If we don’t probe a little deeper we’ll miss the crucial point that the person doesn’t want or plan to act on the fears.

I would trust an individual with Harm OCD to stand behind me on a train platform as a train arrives, to hold a knife near me, or to be around my kids. In reality, a person with Harm OCD is probably the last person who would hurt anyone.

Which raises the question, if I don’t want to do these things, why do I think about them all the time?

Why Do I Have These Thoughts?

Often in Harm OCD a person will ask, “But if I don’t want to do it, why am I thinking about it so often? What kind of person does that?” As we’ll see is, the answer is: someone who doesn’t want to do anything wrong.

Our brains are great at imagining things that haven’t happened. They do it in dreams as well as in our waking life. If we walk by a knife with its handle jutting off the edge of the counter, our minds automatically imagine a person walking by and knocking it off, possibly hurting someone. By imagining an accident, we can prevent it: We move the knife away from the edge. So our minds feed us images of bad outcomes to help us avoid them. It’s something our minds are good at and that helps us in countless ways.

It’s important to point out that thoughts like “What if I just decided to stab this person?” are not at all unique to OCD. I have them, others I talk to have them, and in fact the vast majority of people (whether or not they have OCD) will have these kinds of thoughts. The difference in OCD isn’t having thoughts of hurting others but the reaction to these thoughts.

If I have a sudden thought of, “What if I pushed this person in front of the oncoming Amtrak train?” I might think it’s a weird thought and then my mind will move on to something else. I won’t take it seriously.

In contrast, a person with OCD is likely to be horrified by the thought and to worry there’s something dreadfully wrong with him—and that he poses a serious threat to others. If he doesn’t want to be a bad person and doesn’t want to act on the thoughts, then he’ll probably try to make sure he never has a violent thought.

It’s exactly that effort to avoid having violent thoughts that causes them to multiply. As you probably know, it’s virtually impossible to keep something out of our minds without thinking about it—otherwise how will we know if we thought it? So whereas before a person with OCD might have gotten the thoughts a few times a week, by trying not to have them she will start thinking them many times a day, or multiple times an hour, or maybe even constantly.

What’s worse, constantly thinking about these fears can make them seem less upsetting simply from the repetition. Then a person with Harm OCD might be horrified that he’s not as horrified by the thoughts as he used to be, and may mistakenly believe that he’s warming up to the idea of acting on them.

Common Fears in Harm OCD

Obsessions about hurting others can take different forms. Stabbing someone with a knife is a common one, probably because knives are so readily available and the idea is so grisly. Others include:

  • Beating someone with a baseball bat
  • Stabbing someone with a pencil, skewer, scissors, or other sharp object
  • Sexually assaulting someone
  • Shoving someone off the sidewalk into oncoming traffic
  • Pushing someone in front of a train
  • Pushing someone down the stairs
  • Perhaps the most upsetting, being a child molester

Again, the individual with OCD does not want to do these terrible things and is not at a greater risk than the average person for doing them. Nevertheless they might worry that they’ll change in some fundamental way, becoming a cold, callous, sadistic human being, even a “monster.”

It’s important to mention that Harm OCD can also be directed toward oneself: What if I commit suicide? What if I impulsively jump from a bridge? I don’t focus on this topic here because it’s nuanced enough that it deserves being addressed separately.

Common Compulsions in Harm OCD

The compulsions (or “rituals”) in Harm OCD are intended to prevent what the person is afraid of. They’ll generally involve trying to prevent the thoughts, trying to prevent the feared actions, and trying to make sure I’m not a bad person.

One of the most common compulsions is reassurance, either from oneself or others. The person might tell herself, “You would never do that. You’re not a violent person,” or, “Thoughts are just thoughts, thoughts are just thoughts.” Or they might ask their spouse whenever they have a compulsion, “You don’t think I would actually do anything like that, do you?” or, “Having that thought doesn’t make me a bad person, right?”

Sometimes a person with Harm OCD might seek out a professional with expertise in OCD—not only for treatment but as a form of “checking with an authority.” Unfortunately the relief a person generally feels from reassurance doesn’t tend to last long, sometimes not even until the end of the session. Reassurance leads to needing more reassurance.

Others might ask God for forgiveness, perhaps with a set ritualized prayer: “God, I’m sorry to have these thoughts. Please know that I don’t mean them and would never act on them. Please take away these thoughts forever.”

It’s also common to check repeatedly for evidence that the person wouldn’t hurt anyone. For instance, when seeing a story about a gruesome murder, they might read everything they can about the perpetrator to see if they’re similar in any way. These checks can backfire, of course, because they might read about a “seemingly normal childhood” or “no previous history of violence” and realize with horror that they shared a similar background.

Avoidance is also a very common response to Harm obsessions: avoiding the news in case there’s a triggering story, movies and TV shows with violence, knives and other sharp objects, the grocery store and other places with lots of people, and anything else that leads to the obsessions. And while the avoidance might provide some temporary relief, it plays the same role as compulsions in keeping the person in the clutches of OCD.

Consequences of Harm OCD

The real harm, of course, happens to the individual who has Harm OCD, and the fallout can be devastating. An aunt might avoid being around her nieces and nephews for years out of fear that she’s a child molester—and may avoid having kids of her own for the same reason. A man might never go out with friends because he’s afraid of assaulting one of them. Students might not go to class where they worry they’ll attack the professor.

And of course the emotional toll can be severe. Imagine if you lived every day worried—maybe even convinced—that you were terribly dangerous or depraved. It’s common for OCD to lead to depression as a result of these self-condemning beliefs as well as the withdrawal from enjoyable activities and relationships. Tragically in some cases the person may even resort to suicide.

Treating Harm OCD

Thankfully there is highly effective treatment for Harm OCD in the form of exposure and response prevention, or ERP, a type of cognitive behavioral therapy. I’ve covered the basics of ERP elsewhere (see this post on my Psychology Today blog); here I’ll discuss some of the specific applications for Harm OCD.

In a nutshell, ERP is about doing the opposite of what OCD wants. The exposure part will involve doing the things that bring up obsessions. They might include:

  • Holding a knife with someone else nearby
  • Standing behind people on a train platform
  • Being around kids
  • Watching the news
  • Looking up stories about violent assaults

The therapist will work with the person to come up with a list of exposures for the person to start confronting. They’ll start with the easier ones and gradually work up to the more difficult ones. With practice a person will become more comfortable being around these triggers.

Crucially, the exposure will have to be coupled with prevention of the compulsions—exposure without ritual prevention won’t be helpful. So a person will need to stop seeking reassurance, saying ritualized prayers, checking to see if they might be capable of violence, and so forth. Over time it will get easier to do normal activities without compulsions.

With the right treatment, the obsessive voice will tend to quiet down; stepping out of the fight against the thoughts takes away their power. People also generally feel more confident that they won’t act on their thoughts.

However, the point of ERP is not to know for sure that the obsessive thoughts aren’t a concern, or even to get rid of them. Perhaps the most important part of the treatment is becoming more comfortable living with some degree of uncertainty. After all, we can’t be 100% certain that any given person won’t act violently, myself included. And we can learn to better tolerate that uncertainty.

As you might imagine, the work can be challenging—and at the same time worth the effort as it leads to freedom from OCD.

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