Harm OCD
Harm OCD, is a subtype of OCD in which the individual experiences anxiety and distress in response to intrusive thoughts about having caused, or going to cause, harm to someone else. The condition can have severe consequences for the sufferer leading to difficulties in maintaining relationships and contact with other people.
People who experience harm OCD intrusions will avoid being in the company of others and take extreme and unnecessary steps to minimise any and all possible risk that they may harm someone else.
This article looks at the specific features of Harm OCD, what factors keep it going and at how Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) can be an effective treatment.
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Harm OCD – The main symptoms
There are many different subtypes of OCD with different “themes” which define how the disorder presents. Scrupulosity OCD, Pure O OCD and Orderliness OCD are all examples of types of OCD which, although different in terms of the content of intrusive thoughts and compulsive behaviours are all still maintained by the same anxiety based mechanisms.
In Harm OCD, the individual may have an intrusive thought about causing harm to someone – their child or partner for example. “Hit them in the face” or “Stab them with the knife” are both examples of the type of intrusion we’re talking about. For reasons that we’ll look into shortly, this intrusion is not just dismissed by the person. Instead, the distressing content leads to emotional distress – typically Anxiety.
We then see the individual, in an effort to stop the intrusive thought becoming something that is acted upon, use different strategies to stop the event from happening. These are what we call compulsions. Typical compulsions in Harm OCD include avoiding objects that may cause harm to others (e.g., knives, hammers, etc), avoiding people who the intrusive thoughts may relate to (children, family, parents), checking that we haven’t already harmed someone (e.g., revisiting part of a journey to make sure that we haven’t ran someone over) and seeking reassurance from others that we have not harm them.
There are many other compulsions that people may do in Harm OCD, but all of these have the aim of reducing the chance of causing harm to others. When the intrusive thoughts (obsessions) and Compulsions take up more and more of our time, and subsequently impact our lives more and more, then the problem can be overwhelming for the sufferer leading to problems in home, family and work life.
A Case example of Harm OCD
Tim was a 55 year old male who lived with his wife. He had two grown up children and 3 young grandchildren. He also had an elderly mother who lived on her own in supported accommodation.
One day when Tim was visiting his mother, just as he was hugging her to say goodbye, he had the thought, “punch her in the stomach.” The thought appeared to come from nowhere – he had not had a thought like this before and the idea of hurting his beloved mother made him feel sick inside. He felt his heart start pounding and he became hot, shaky and sweaty as he became increasingly anxious. Struggling with this unexpected experience, he shakily let go of his Mother, told her he would be back to see her soon and then made his exit, walking more quickly than usual.
In the car driving home, he started to think about the thought he had had about punching his mother. Why had he had that thought? Did he really want to hurt her? What if he secretly wanted to? He became nauseous at the thought and tried to push the thought out of his mind – this was difficult to do.
He thought that he shouldn’t have thoughts like this and he should be able to control them at least. He became wary of having a similar thought next time he visited his mother but he still made the effort of keeping the usual routine. Sure enough, he had the thought of punching his mother, but this time the thought was so overwhelming that he made an excuse that he wasn’t feeling well and that he needed to go home. He worried whether he could actually control the thought, and any urge that might follow.
He knew that he didn’t want to hurt his mother but he didn’t feel that he could trust himself because of these thoughts he was having. For the next week, he pretended he was sick so that he didn’t have to visit her. Instead, at home one night when he was cooking a meal for him and his wife and handling sharp knives, he had the thought, “cut her throat.” He threw the knife down and again made excuses so as not to be around the knives and his wife.
By this time, Tim was very distressed and found himself caught up in thinking about his intrusive thoughts for much of the time. In fact, he found himself engage in a sort of mental dialogue with himself, reassuring himself that he doesn’t want to hurt people but, as soon as he had convinced himself, another intrusion would pop up. This felt like a nightmare.
Over time, Tim found himself obsessing over his harm thoughts and what having them said about him as a person. He thought he must secretly be some kind of evil person who wants to hurt people. To avoid ever acting upon these thoughts he now avoided any hard or sharp objects that were available, he spent less time with his loved ones – this was especially difficult and he felt he was neglecting his mother and he loved spending time with his Grandchildren. He even stopped using his car in case he felt the urge to run over people. The harm OCD had really taken hold.
What keeps Harm OCD going?
As mentioned earlier, even though the actual content of the intrusions, obsessions and compulsive behaviours are different between types of OCD, the way in which they keep OCD going – the maintenance cycle – is generally the same.
First we have an intrusion. This intrusion can be anything, in fact we are all experiencing thousands upon thousands of thoughts every single day, but only some of these thoughts are significant enough to us to create a noticeable emotional response. This is because we appraise or think about certain thoughts in different ways to others. In OCD, we typically experience distress in relation to certain themes of thoughts which go against how we view ourselves. So, in Tim’s case above, he views himself as being a caring, supportive family man. But when he experiences the intrusive thought telling him to punch his mother, this thought is so against his character and view of himself that he experiences intense distress. We call intrusive thoughts that conflict with our view of ourselves in this way “ego dystonic.”
Further, there are other appraisals of the intrusive thought that Tim has that may also contribute to his distress. He may believe that thinking the thought is the same as actually wanting to harm his mother (thought-action fusion), or that thoughts such as this are more important that other thoughts and therefore need to be paid close attention to (over-importance of thoughts). These, and other, appraisals of the intrusive thoughts are what give rise to the anxiety and distress in OCD, rather than the thought itself.
The next stage in the OCD maintenance looks at the relationship between the anxiety or distress the individual feels and the use of compulsive behaviours to deal with it. The link between Tim feeling the need avoid all knives in response to his intrusive thought about cutting his wife’s throat is fairly straightforward. He hides the knives and there is less chance of him causing harm to someone. But the behaviour does more than this, and is important in understanding why the obsessions never go away.
Each time Tim engages in one of his compulsive behaviours, he experiences a short term relief from his anxiety. When a behaviour has the effect of removing something that we would rather not experience (i.e. anxiety), then the behaviour is more likely to be repeated. Therefore, the behaviour relieves the anxiety and then gets used more and more as a way of dealing with the anxiety cause by the intrusive thoughts. The problem with this is that Tim never gets to find out what would happen if he didn’t hide the knives. He may find out that, although he feels anxious, and worries about harming others, that he never acts upon these thoughts. So, the use of the compulsive behaviours contributes to keeping the problem going, feeding the obsessional thoughts about causing harm to others.
Cognitive Behavioural Therapy (CBT) for Harm OCD
The treatment with the best evidence for Harm OCD is Cognitive Behavioural Therapy with a particular emphasis upon an intervention called Exposure and Response prevention (ERP). ERP works by exposing the individual to something which would the OCD related distress and then having the nit use the OCD responses or making the have no effect. More recent developments in OCD treatment also look at the role that thinking errors at the level of the appraisal play and at how these may be changed. Behavioural experiments are a big part of this.
Exposure and Response prevention for Harm OCD
Exposure and response prevention (ERP) is the treatment intervention for OCD which has the strongest evidence for its effectiveness. It involves deliberately, in a graded way, exposing the OCD sufferer to triggers for their intrusions and their underlying themes – This is the exposure bit. The response prevention (also called ritual prevention) bit is where we inhibit the use of the compulsive behaviours.
When the individual is exposed to their feared scenario and prevented from using their rituals/responses a process called habituation takes place. This means that the anxiety associated with the exposure trigger reduced over time, without the client using any of their compulsive behaviours. When this is done repeatedly and with more and more OCD triggers, the individual starts to learn to tolerate their intrusions and understands that they are harmless without having to engage in any of their compulsive behaviours.
So, lets look at an example with Tim. Tim’s intrusive thoughts cause him distress because he interprets them as meaning that he wants to harm people and that he might act upon his thoughts. So, we want to create exposure and response prevention interventions around this theme. One example of an exposure and response prevention exercise with Harm OCD might be to get Tim to deliberately sit with a knife in the therapy room and allow any intrusive thoughts to come into his mind without using any of his responses (avoidance, trying not to think about it, counting, etc). The therapist would really provoke the anxiety by encouraging Tim to talk about his intrusive thoughts and how he is holding a dangerous weapon in his hands.
As we discussed earlier, the very reason that Tim becomes distressed when holding a knife is because he is appalled by the idea that he would or could harm someone. Remember, these intrusions are Ego dystonic. Therefore, we can expect that even though he has these thoughts, he is unlikely to act upon them. As we sit for an extended period of time, him holding the knife without engaging in any of his compulsions, the magic starts to happen.
Over time, through a process called Habituation, Tim’s distress starts to reduce. Typically this process will occur after between 45 minutes to 1 hour 30 minutes as Tim’s body gets used to the distress and develops a tolerance to it. We would then look to repeat this activity again and again, with Tim also doing this as a between session task. By repeatedly doing Exposure and Response prevention and taking steps to go further up the graded hierarchy of fears, Tim starts to relearn that he doesn’t need to use his compulsions to deal with his anxiety – over time, it will go by itself.
Theory A vs Theory B for Harm OCD
One of the key problems in OCD is the sufferer not always being able to see an alternative explanation for their OCD intrusions, and Harm OCD is no different. What we mean by this is that a lot of the distress that emerges in OCD is that the individual is concerned by the fact that the intrusion might be true. That is, if I have a Harm related intrusive thought, “I want to stab my child”, I may believe that this is something that part of me somewhere wants to do and that I need to work hard to stop this from happening. Theory A vs Theory B is an intervention which helps us with this.
Theory A vs Theory B is a technique used in CBT for OCD to enable an individual to look at an alternative explanation for their problem and gather evidence to see which of the two explanations might be true. It often presents one theory as being the clients interpretation of the problem – i.e., What the OCD says – and the other as being a more psychological interpretation.
So, in Harm OCD, we have the sufferer’s interpretation of their problem as Theory A. In Tim’s case, this might be phrased as, “My problem is that I want to hurt my mother.” Theory B is focused upon presenting an alternative psychological explanation of the problem, “My problem is that I worry that I want to hurt my mother.” See the subtle difference?
Theory A is basically what the OCD is “telling” us, whereas Theory B presents an alternative psychological theory.
What next? Once we have established the two different theories for our problem, we now have the task of seeing how much evidence we have for each theory. It’s useful to remember here that we are looking for evidence that supports a theory rather that one that definitively proves it. So, the evidence that Tim might have in this case for Theory A might be things like, “I have intrusive thoughts about hurting my mother; I avoid sharp objects when I’m around her.”
The evidence we have for Theory B might be things like, “I’m upset by the intrusive thoughts, so maybe I don’t want to hurt her – If I wanted to hurt her then I wouldn’t be so distressed.”
We follow this process of looking at how much evidence we have to support either Theory. Then, based upon how much evidence we have to support each theory, which one appears to be a more accurate theory to explain our problem? Spoiler: We typically find that there is much more evidence for our Theory B than there is for Theory A!
Now, we want to move the exercise into the domain of behaviour. We want to think about what it means for us if each of the Theories were true. So, if Theory A was true and Tim did in fact want to hurt his mother then the implications of this would be that he would have to not see his mother again, he would have to explain to people why this was and he would have to find someone else to take over her care. Clearly, none of this is what Tim wants – maybe Theory A isn’t such a good interpretation of his problem after all.
Now, if Theory B is true and the problem is that Tim worries about wanting to hurt his mother then he might choose to live his life in the following ways: He might need to be a bit kinder to himself when he has these thoughts and not engage in any of his compulsive behaviours. Similarly, he can continue visiting and caring for his mother and practice tolerating and noticing these thoughts when present, knowing that he won’t act upon them. Quite a difference from Theory A!
Behavioural experiments for Harm OCD.
We saw earlier how exposure and response prevention can be an effective intervention in allowing the individual with Harm OCD to find out both that their OCD distress anxiety will reduce over time and that the feared compulsions will not come true when they don’t use their behaviours. The proposed mechanism of change in Harm OCD, the process that actually leads to the change for the individual is called, Habituation.
Behavioural experiments, although sometimes also using habituation, have a mechanism of change which focuses more upon directly changing what we think about the intrusions themselves. This is in its nature a Cognitive intervention.
The first step in setting up our behavioural experiment is to think about the actual thought that we are going to test. There are of course lots of thoughts available to us in OCD, they are Obsessive after all, so we want to make sure that we target specific thoughts that have the most effect. There are a couple of considerations.
Firstly, we might want to test out the likelihood of us acting upon the thought (thought-action fusion), or the thought coming true (thought-event fusion). If we want to go down this route, then our Harm OCD Behavioural Experiment might involve us testing out the thought: “I’ll hurt someone if I hold this knife in their company.” We would then test this by doing exactly that – sitting with a knife in the company of the therapist, whilst tolerating and experiencing the intrusive thoughts. We would then at the end of the experiment discuss what exactly happened, and if it has changed the way in which the suffer now views their intrusions – “Do they really mean I’m going to act upon them?”
Further behavioural experiments around this theme can help us to re-evaluate whether these thoughts are really as harmful as we initially believe them to be.
We can also do experiments around our beliefs about the tolerability and control around thoughts such as these. There are many different ways of thinking about Harm OCD intrusions (their appraisals) which can all be subject to behavioural experiments and further allow the sufferer the opportunity to experience relief from their OCD symptoms.
