We live in a society where we do not like to be uncomfortable, and we have difficulty tolerating distress. Anxiety is a word that has a lot of negative connotations, and because of this, we go into problem solving mode and try to quickly find solutions. For some people, the danger signal gets attached to everyday neutral things that are generally innocuous, such as people, social situations, doorknobs, dogs, physical sensations or emotions. The actions we take when anxiety is present are called safety behaviors, or within the context of OCD, compulsions. These actions are meant to decrease our distress, which they do, but only temporarily. Some common safety behaviors are avoidance, reassurance seeking, researching, substance use, washing, counting, etc. Since these behaviors actually work in lowering anxiety, they continue to be used in a repetitious manner, causing the individual to get trapped in this cycle and preventing them from learning that the fear was unfounded or tolerable. Ironically, these safety behaviors and compulsions actually maintain the fear in the long run and simultaneously prevent growth and learning, which can severely limit an individual’s life. The thought, situation, emotion, or body sensation that creates the anxiety might be different within each presentation of OCD, but the cycle that maintains it is exactly the same. Please see our previous blog entry – Understanding the Cycle of Anxiety – for further information.

What is Harm OCD?

Harm OCD is defined as obsessions (intrusive thoughts and images) and compulsions regarding hurting oneself and/or others around them. Individuals with Harm OCD struggle with what these thoughts mean about them and their character. They live in fear of acting upon these thoughts and/or wanting to act upon them. Due to their fear of hurting others, individuals can avoid or create distance within their relationships as a perceived safety measure, which can create an additional barrier and negative impact on their life.

Common Obsessions with Harm OCD

Obsessions may include any thought or mental image that the individual experiences related to harming themselves or others. These obsessions include:

• Fear of impulsively harming others or fear of having done so in the past
• Fear of committing or having committed a violent act or fear of having done so in the past
• Fear of harming themselves
• Fear of having a harmful identity
• Fear of giving in to a violent urge or emotion or fear of having done so in the past
• Fear of accidentally harming someone or fear of having done so in the past
• Fear of committing suicide

These thoughts can arise as a command or a “do it” thought or an impulse and create an overwhelming responsibility to prove to themselves, and to those around them, that they will not act on the thought. These thoughts can create a high level of anxiety for the individual and make them feel a need to abide by rules and rituals which then become compulsions. Please see our previous blog entry – Intrusive Thoughts – for further information.

 Common Compulsions with Harm OCD

Compulsions are defined as any intentional thought or behavior done in an effort to neutralize or reduce the distress caused by an individual’s anxiety, whether caused by thoughts, images or emotions. These can include:

• Avoidance of triggering people, objects (knives, chemicals, medication), locations (windows, balconies, isolated areas, ledges), media (movies, news) or negative emotional states
• Reassurance seeking by asking others if they think harm would occur
• Providing self-reassurance (“I would never do that. I don’t want to hurt anyone. I love him/her”)
• Researching online people who have committed violent acts or police reports to make sure they were not on there or to try to find information that shows that they are unlike people who have committed violent crimes
• Checking to see if harm was done to themselves and others
• Questioning their own motives
• Mental rituals of reviewing intentions and situations in their life that prove otherwise
• Neutralizing bad thoughts with good ones
• Compulsive and excessive prayer to prevent harm from occurring
• Rationalizations of why the individual would not harm themselves or someone else
• Emotional checking to confirm that what they were feeling in different situations was the “right” thing
• Visually replaying situations to make sure no harm was done
• Retracing their steps (driving around the block several times to make sure that they did not hit anyone with their car)
• Excessive praying to prevent behaviors
• Superstitious rituals

Individuals can feel very ashamed about these thoughts and behaviors and consequently, will typically feel the need to hide them from others. As a result, individuals with this subtype of OCD may be suffering in silence and the prevalence rates are likely higher than the research shows. Individuals might have shared these thoughts with someone in the past and that listener did not know how to respond, or he/she responded poorly. Such a response which only would have reinforced and confirmed the fear that the individual has of these thoughts or what these thoughts mean about them. Some individuals may have expressed these thoughts to a clinician in the past who assumed that these thoughts were active suicidal ideation, instead of intrusive OCD thoughts, resulting in the individual getting hospitalized for safety concerns. Such reactions can prevent individuals from sharing these thoughts again and getting the treatment that they need. It is crucial to work with an experienced anxiety and OCD mental health professional who understands the various subtypes of OCD and who can appropriately diagnose and distinguish OCD from other presenting concerns.

Treatment of Harm OCD

The most evidence-based treatments for Harm OCD are Cognitive Behavior Therapy (CBT), Exposure and Response Prevention (ERP), and Acceptance and Commitment Therapy (ACT). Within CBT, individuals are able to recognize and differentiate their thoughts from their OCD’s thoughts (externalization of anxiety), acknowledge that many people have the same type of intrusive thoughts, and recognize that because of their OCD their thoughts get stuck. Individuals can learn to observe what they are thinking and recognize cognitive distortions that are present, especially catastrophizing, emotional reasoning, and predicting the future.

Through ERP, individuals can engage in exposures by being around previously avoided situations, people, objects and locations. An anxiety hierarchy is created with the individual identifying their triggers and fears and their clinician providing input. Through imaginal exposures, individuals are able to write stories about their fears coming true (hurting themselves or others) and how they would respond. Another exposure may be to watch news reports that detail violent crimes. ERP helps individuals learn to tolerate the uncertainty, discomfort, and doubt that their OCD creates by confronting their fears and what they are avoiding. Through the ERP process, and with refraining from their compulsions, individuals are able to build self-confidence, break the cycle, and retrain their brain. They will learn that thoughts, mental images, and impulses do not necessarily lead to corresponding outward behaviors. Avoidance behaviors are also targeted to reintegrate the person back into situations, activities, and environments that they previously exerted a lot of effort to evade. Please see our previous blog entry — What is Exposure and Response Prevention ERP – for more information about this treatment.

Within ACT, individuals are introduced to the concepts of mindfulness and acceptance, helping them to be present with their emotions and thoughts without trying to change them or engage in compulsions. Thought diffusion is also utilized to deal with these intrusive thoughts and feelings of shame. Throughout treatment, individuals are better able to differentiate their thoughts and values from their OCD and are able to allow their thoughts to come and go nonjudgmentally. Self-compassion is also a critical component of the treatment process for this subtype of OCD. Outside of therapy, individuals with Harm OCD can also benefit from medication.

Need help or support?

If you or a loved one are struggling with OCD or any other mental health need, know that you are not alone. If you are a parent/caregiver and are seeking additional information about these diagnoses or how you can best support your child, our office provides parent training with the SPACE program. Please see our November 2021 Newsletter for more information on SPACE. For these or any other mental health concerns, please contact the OCD and Anxiety Center at (630) 522-3124 or email info@theocdandanxietycenter.com.

We have offices located in Oak Brook and Orland Park and offer telehealth services available in Illinois, Indiana, and Iowa. At the OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, etc.). We will work closely with you to create an individualized treatment plan and discuss the frequency of visits, having the ability to meet with you once a week or more if needed. We look forward to hearing from you!

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Jacqueline Jones is a licensed clinical social worker at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in treating all forms of OCD and anxiety in children, teens, and adults.  She provides Exposure and Response Prevention Therapy and is comfortable working in and outside the office, wherever anxiety happens.