Harm OCD S1 C6: Harm OCD – An introduction

Harm OCD is one of the fairly common presentations of OCD and is highly disturbing. According to estimates approximately 45% to 50% of adults (Milliner-Oar et al., 2016) and 30% to 70% of children and adolescents suffering from OCD experience harm obsessions (Milliner-Oar et al., 2016). Further, sufferers who experience harm obsessions have greater obsessional symptom severity than other those with other types of OCD (Abramowitz et al., 2003).

In Harm OCD, the sufferer may get violent thoughts towards someone and instead of being able to dismiss it, he may begin to believe it to be his true desire and believe that he indeed wants to harm someone (Moulding et al., 2014).

• Thoughts could be about harming to hurt or even harming to kill.
• Thoughts could be about harming by accident or harming deliberately.
• Thoughts could be about specific people, random people, kids, or even self.
• Thoughts could be about harm coming to self or others through other events or other people.

Thoughts of causing harm, violent images, violent impulses, violent feelings, or even violent dreams at odd times may be common and distressing occurrences. One of the chief fears associated with Harm OCD is, what if I actually cause harm some day? Or, what if I am a psychopath? Compulsions may be overt (such as checking, reassurance-seeking) or covert (such as neutralizing, praying) in order to get rid of unwanted thoughts (Abramowitz et al., 2003).

A variation of harm OCD is Hit and Run OCD. In this type, the sufferer may have a fear of running someone over with his vehicle. This may make him hypervigilant while driving and even the smallest bump on the road may make trigger the obsession that he may have hit someone. He may get off the vehicle repeatedly to check, and sometimes, may retrace his path to go back and check to make sure that he hasn’t hit anyone (Milliner-Oar et al., 2016). Eventually, he may stop driving altogether. An additional manifestation of this is that the person may have a fear of even touching anyone, lest they be hurt. This may result in the person not wanting to even leave his house for fear of harming someone.

Sometimes when the fear is about dying or causing death, it is not referred to as Harm OCD but Death OCD (Kauffman, 2021). In this presentation, you may feel that you may bump into someone and push them in front of an oncoming train or into traffic. You may thus choose to walk far away from the edge of the railway platform or away from people. The fear in this case is not of causing deliberate harm but accidental harm. And the fear is not about hurting but about causing death. Another subtype closely tied to Harm OCD is Suicide OCD. You may not want to commit suicide but may persistently battle with the doubt that you may want to and may fear that you may lose control and do it (Vaughn, 2020). Doubts of suicide may make you avoid heights, sharp objects, chemicals, and anything else that you may think you would willingly use to die.

Table 1.6.1 provides an understanding of the types of harm thoughts a person with Harm OCD may have. Importantly enough, not only do people switch from one presentation to another in OCD, but even within Harm OCD, you may switch to different obsessions. You may start off with a few specific obsessions and, sometime later you may have completely different obsessions.  Sometimes, your anxiety may be on account of not being able to go back to your original obsessions. ‘Why can’t I go back to what it was earlier?’ you may end up remonstrating. So, your Harm OCD may keep switching from one obsession to another and may sometimes multiple obsessions too. Discuss with your family about the fears of Harm OCD you experience and note them down in Worksheet 1.5.

Note: It is very essential that a distinction be made between thoughts and urges brought about by OCD and the thoughts of violent and sexual offenders or thoughts of people who are actively suicidal or want to engage in self-harm. All thoughts as illustrated above should necessarily be ego-dystonic – that is, they should not reflect the real feelings of the sufferer; they should feel unnatural and unreal to the sufferer.

If the sufferer feels that any of the thoughts are real, it may not be Harm OCD. For example, if the sufferer feels the urge to harm himself and thinks of it as an escape from reality, that is not Harm OCD, because self-harm in this case is a coping mechanism and not a fear. In such cases, the sufferer may be suffering from non-suicidal self-injury (NSSI) urges.

Another possibility of harm thoughts not being Harm OCD is where the sufferer really believes that someone may be out to harm him. If the sufferer is not able to accept the irrationality of the thought, the person may be suffering from persecutory delusions, a form of paranoia. These delusions can be seen in disorders like schizophrenia, schizoaffective disorder, PTSD and others. Thus, unless the sufferer strongly considers the thoughts to be irrational and unpleasant, an alternate diagnosis may be needed through a professional.

Table 1.6.1: Type of harm thoughts in Harm OCD

		Harm to Me		Harm to Others
Responsibility	Mode	Harm to Hurt	Harm to Kill	Harm to Hurt	Harm to Kill
Where I cause harm	Accidental	What if I accidentally poke myself in the eye with this pencil?	What if I accidentally poison myself and die?	What if I accidentally injure someone in the eye with my finger?	What if I push someone under a bus and kill them?
	Deliberate	I am getting the urge to cut myself with this box cutter	I feel I want to jump off the 15th floor and commit suicide	I am getting the urge to scratch my partner’s face with my nails	I feel the urge to stab my pets and kill them
Where others cause harm	Accidental	What if someone accidentally stabs me with a screwdriver?	What if my food is poisoned by mistake?	What if my dad gets into an accident and breaks a leg?	What if my dad gets into an accident and dies?
	Deliberate	What if my friends are planning to hurt me?	What if my friends are planning to kill me?	What if my manager wants to harm my girlfriend?	What if my best friend wants to kill my cat?

For a correct understanding, the following factors should be considered (adapted from Veale, Freeston, Krebs, Heyman, & Salkovskis, 2009):

(1) Are your thoughts ego dystonic?

(2) Do you avoid situations that trigger the thoughts?

(3) Do you attempt to suppress or neutralize the thoughts?

(4) What is the dominant emotion you experience when you have the thoughts (e.g., anxiety, distress

or guilt vs. pleasure)?

(5) Do you have other symptoms of OCD?

(6) What other mental disorders do you have?

(7) What is your motivation for seeking help? and

(8) Do you have a history of harming yourself or others?

               If there is still any doubt remaining about whether it is Harm OCD or not, a professional assessment is important.