A very frequent complaint in OCD patients is thoughts of harm, either harming oneself or others. The general rule is that the person never acts on the thoughts, although this is somewhat controversial. Some say there have been a few cases of OCD sufferers acting on their harm obsessions. I have personally never heard of a case.
In addition, as a peer counselor, I have worked with countless OCD sufferers who have this particular theme over the past eight years as they come to me for help. I haven’t met one person yet who acted on the thoughts nor have I heard of anyone who has, and I have known people who have had this theme for more than 25 years.
However, sometimes sufferers start to act on a harm obsession, but they stop before they are able to carry it out.
For instance, a man had an obsession about turning his bicycle either in parked cars and pedestrians. Sometimes he would just start to act on the obsession and turn his bicycle towards the people or cars, but every time he did this, he simply crashed his bike. No one was hurt other than himself.
In another case, a man had an obsession about throwing his car into reverse while going at high speeds. One time while driving 60 mph, he threw his car into reverse. Whether he caused permanent damage to the transmission by doing this is not known. He could have hurt himself or possibly himself with this act, but mostly this was just an act of destruction towards a vehicle, which is an inanimate object.
The more severe the consequences of acting on the obsession, the less likely the person is to act on it.
Generally, people read my articles and simply self-diagnose as OCD with whatever theme they have going. 98% of the people coming to me self-diagnosing as Harm OCD were in fact suffering from that very condition. I have had two people, both adolescents, come to me who were suffering from other conditions. One was in the process of developing psychopathy and the other was suffering from schizophrenia and was possibly also developing Borderline Personality Disorder.
What to look for:
Resistance: I would look first and foremost for resistance. Look at how hard the person fights the thought. The harder the person fights the thought, the more likely it is to be an obsession. In fact, I would say that thoughts that are ferociously resisted are always or almost always obsessions.
Resistance to thoughts is not commonly seen in other conditions, if it is seen at all. Most persons without OCD simply do not ever try to stop or fight off their thoughts. If you ask them, they will say things like, “I only think things I want to think,” and “I don’t have unwanted thoughts.” So resistance to thoughts in people who do not have OCD is probably not common.
Although it is often said that resistance is a bad sign in OCD as it makes OCD worse, I don’t mind seeing resistance. The reason is that if a person is ferociously resisting and doing so successfully, then first of all, I am quite sure I have a case of OCD, so the diagnostic conundrum is over. In addition, I know that the the OCD is simply not that bad yet.
As OCD gets worse and worse, resistance gets harder and harder to accomplish. I have talked to a OCD sufferers who have gotten to the point where the thoughts have simply taken over the person’s mind and are going all the time. They can’t resist them anymore, if they ever could. Inability to resist thoughts or thoughts that have completely taken over is a sign of a more serious case.
Ego-dystonic: The person hates the thoughts, or at least it seems as if a large part of the person hates the thoughts. The new theory is that the entire self hates the thoughts and that no part of a person wants an obsession, but this is a bit controversial. Nevertheless, this is what I believe. One often hears OCD sufferers say things like, “I hate this with every fiber of my being” or something along those lines. That’s a good sign when they can think like that. As the condition worsens, the person gets more and more confused about whether they like the thoughts or not or want to get rid of them or not.
In an advanced case of Harm OCD, the person will feel evil and it will seem as if they like the thoughts and do not want to get rid of them. This can cause diagnostic confusion. Feeling evil, feeling like they like the thoughts and feeling like they don’t want them to go away are all aspects of advanced Harm OCD. The key here is ego-dystonicity. These feelings cause alarm and profound anxiety in the person, as they feel that they are turning evil against their will or that they are becoming something that is in opposition to their true self.
In other words, a person presenting with concern that they like the thoughts should not rule out OCD. We need to know instead how they feel about the fact that they seem to like the thoughts. If they feel terror, horror, anxiety, distress, confusion, suicidality, etc. about seeming to like the thoughts, then it is usually OCD. People with other conditions who enjoy harm thoughts typically are not distressed by the idea of enjoying them.
Ego-alien: The person is often confused as to why they are even thinking these thoughts. One hears such things as, “I have thought a million times, why the Hell would I even think of this stuff even one time, ever?…I love my mother/father/husband/wife, etc., so why am I thinking about killing them?” If you ask the Harm OCD sufferer if they feel angry, they will usually say that they don’t. The person is often frankly mystified why they are even having these feelings in the first place.
Another part of the ego-alien aspect is that the person feels that the thoughts are not even really their own. They know that the thoughts are just thoughts, and they know that the thoughts are coming only from themselves and not from an outside entity, but nevertheless the thoughts are so alien to the person’s identity that they often seem like they are not the person’s own thoughts.
The person’s inner voice can become split into a “sane voice” and an “OCD voice.” The OCD voice can sometimes sound like it is someone’s else’s voice other than the person’s own inner voice. Really it is just the person’s inner voice morphing into a new form. This experience is so alarming that the person often fears that they are going psychotic.
Thoughts versus voices: There is additional diagnostic confusion regarding whether the possible OCD thoughts are actual thoughts or if they are voices as in auditory hallucinations. The differential diagnosis here is OCD versus schizophrenia. In addition, some very confusing cases present as OCD and schizophrenia together in the same person. There may be additional confusion regarding whether these are just very loud thoughts that the person worries can be heard by others or if they are actual auditory hallucinations that the person really hears and assumes that others can hear.
In addition, some very aware schizophrenics actually hide symptoms after a while in order to keep out of the hospital and whatnot. They lack true insight into their disorder but after a while, they figure out that when they say certain things, people tend to haul them off to the hospital. This leads to lying about symptoms. An excellent clinician looking at the overall case and piecing together the person’s presentations of the thoughts vs. hallucinations conundrum can often figure out that these are actual hallucinations impressionistically.
Thoughts go against the person’s morals: This is the reason for all of the distress, resistance, anxiety, and alarm. The thought of hurting or killing random others, loved ones, or certainly people one is not angry towards at all with seems profoundly wrong on at least some level to the Harm OCD sufferer because typically deep down inside the person with this theme is, paradoxically enough, an extremely moral person.
In addition, oddly enough, they are often remarkably passive and nonviolent. This clashing of one’s morals and basic behavior is what engenders the strong resistance, discomfort, anxiety, worry, and alarm.
Differential diagnosis: There are apparently quite a few people with ego-syntonic fantasies of hurting and killing other people. Sometimes it is someone they hate, and sometimes it is anyone in general, women in general, or some particular ethnicity, race or religion in general. The major problem with thoughts of harming others is that the people who are never going to do it are often the main or only ones who show up clinically.
That is, almost all of the showing up in therapy are the Harm OCD sufferers, or in other words, most of the people who show up for therapy are the people who are never going to commit these acts.
The people who are really thinking seriously about hurting or killing other people or who like to think about such things and are not bothered by these thoughts, feelings, urges or plans typically do not seek help, although they do on occasion, especially if they are adolescents. This is a real problem: truly violent people generally simply do not show up clinically asking for help to try to stop acting on their violent urges. It would be nice if they did, but they simply do not.
These people are variable. Some go through life choosing to think these violent thoughts, and sometimes it is just a phase that they give up at some point. This is often seen in an adolescent male. In some cases of course, they act on the thoughts of harming others, and these are the people you read about in the papers.
But in many other cases, they never act on the thoughts and can go years, decades or a lifetime with frequent thoughts of harming others that are never acted on even once. For every one actual serial killer, there are probably 1,000 more who dream of such things, but due to various controls or fears, they are able to avoid acting on their fantasies. People have more control than we think. Nobody has to do anything.
Sociopathy: This is not OCD. Sociopathy develops in childhood and adolescence and is generally a long-standing problem. A non-sociopathic person simply cannot turn into a sociopath in adulthood de novo; it’s not possible. If you’re not a sociopath by age 18, you will never be one.
An informal survey of sociopaths on an Internet forum for sociopaths revealed that all sociopaths on the forum said that they enjoyed thinking about harming others. A typical comment was: “Thinking about hurting or killing people is one of the few things that I actually enjoy thinking about.”
So we see that most sociopaths take great pleasure in thinking about hurting or killing people. They think about it whenever they want to. If they want to think about it, they do, and if they don’t want to think about it, they don’t. The harm thoughts are ego-syntonic. They don’t feel bad about having these sorts of thoughts. Thinking about these things is simply their idea of a good time.
Unfortunately, most sociopaths never show up in a clinician’s office, although occasionally an adolescent in the process of developing psychopathy will present with some alarm over their harm thoughts. Differential diagnosis of developing psychopathy versus Harm OCD is crucial in such cases. Just thinking about something is fortunately not grounds for hospitalizing someone. Anyone can fantasize about being any kind of criminal that they want to be. As long at they don’t do anything, there’s nothing that the law or psychiatry can do.
Lack of guilt: You will sometimes run across people who have violent fantasies about people they hate. This is not OCD. They will often tell you that they are not going to act on the thoughts, but the fantasies sounds like a good idea since they hate the person so much. They do not feel guilty about these thoughts; instead they enjoy them. The thoughts are not resisted. A famous psychiatrist said, “A homicidal fantasy a day keeps the psychiatrist away.”
In more florid cases such as Borderline Personality Disorder or Bipolar Disorder, the person is making overt threats and seems to be capable of carrying them out. They generally don’t act on the threat, at least not homicidally, although they often commit minor acts of impersonal violence, damage property, and are generally menacing. Obviously in some cases they do commit acts of serious violence thought. But in my experience, the overwhelming majority of homicidal threats are simply empty threats.
Nevertheless, if presented clinically, this is cause for alarm, and in the US, under the Tarsakoff Rule, persons making homicidal threats can be hospitalized for making specific threats towards a specific person. In other words, in the US, if a person says, “I feel like killing people,” there is no grounds for commitment. There’s nothing to act on.
But in the US, if a person is making a specific threat towards a certain known individual that seems to be a credible threat, clinicians have to notify the person being threatened, and the person making the threats may be legally involuntarily hospitalized, although in many cases, they are not committed, or if they are, it is only for the 1-3 day minimum.
Note that it is very hard if not impossible to determine in a clinical setting exactly who is dangerous and who is not.
Potential serial killer stopped: A recent case history along these lines in a journal is instructive. A man had Bipolar Disorder. At some point in the disorder, he developed elaborate fantasies of being a serial killer. He had assembled a very fancy murder kit, including all the implements he might need. He also had a list of ~20 people he was going to kill. He had been following and observing them for some time and had taken precise notes on many aspects of their locations, travels, and behavior. He had notebooks with elaborate plans on how he planned to kill these people.
It’s not known how or why he revealed this in therapy, but he did. The threat was considered credible enough to be actionable. He was hospitalized for 1.5 years in an institution in which he underwent intensive therapy and was given medication. At the end of the period, his fantasies and desires to be a serial killer had been completely eliminated.
The team said this was a very unusual case of successful intervention. They noted that he was not a sociopath, and this was probably the only reason that he volunteered his plans in therapy and was able to renounce and be alleviated of his desires, and return to society as a healthy member. The man had some ambivalence about his plans, and this was due to his not being a sociopath.
This was not a case of OCD.
He enjoyed his elaborate plans, had been planning them for some time, had assembled kits and stalked potential victims and had elaborate, pleasurable, long-standing and ego-syntonic fantasies about homicide which were not resisted.
A person with Harm OCD will never assemble a murder kit, write down elaborate plans for how they are going to kill people, stalk potential victims or even carry weapons. The overwhelming emotion in Harm OCD is fear, and the tremendous fear will prevent them from doing any of those things.
Harm OCD sufferers often go to great lengths to keep from acting on their thoughts. Some “disarmed” themselves before they went to see another person. They would remove all “potential weapons” from their person so they could not use them to attack the person they were with. They would also “disarm their vehicle” when another person was getting into it. They would take all potential weapons and hide them under the seat of the car so they would not use them to attack the person.
Sexual sadism: Sexual sadism is a paraphilia that almost always develops in its strong form in childhood or adolescence. The person’s preferred means of arousal involves hurting, humiliating, degrading, insulting and abusing an other person. These are people who like to hurt other people. They get off on it sexually.
A very large number of serial killers are sexual sadists. They kill in order to get off sexually. Their masturbatory fantasies since childhood or adolescence have typically involved sadism, torture or even homicide.
It is very common for serial killers to have a history of kinky sex with their wives or lovers. The kinky sex usually involved bondage, discipline, sadism and masochism.
In addition, the severe sexual sadist may have an erotic arousal to images of women who are either dead or appear to be dead. These people, typically men, collect photos of dead bodies or women who appear to be dead.
Unfortunately, sexual sadism tends to escalate over time. There have been cases of serial killers or murderers who could only orgasm if they were pretending to strangle their wives.
A rather typical case might look like this:
A gay man with sexual sadism presents for therapy. His sadistic activities have been slowly escalating over time. The last time he had sex, he burned a man with cigarettes. He got so excited that he wanted to kill the man, and he had to restrain himself from doing that. He presented to therapy thinking he was out of control. He was afraid he would kill the next man he had sex with.
This is not OCD. Fantasies in paraphilias such as sexual sadism are typically very pleasurable. The thoughts, images, feelings, and urges are either seldom or never resisted. So what we look for her is an ego-syntonic syndrome with a lack of resistance. In addition, we are looking for strong sadistic sexual fantasies, typically dating from an early age, that are powerfully arousing. Such fantasies will be absent in Harm OCD.
The potentially confusing aspect of paraphilias and OCD is that while the paraphilia gives the person a great deal of sexual pleasure, and they often spend a lot of time masturbating to the paraphilic fantasies, it is rather common for them to feel strong guilt after they have an orgasm and the excitement fades. Alternately they can feel a lot of guilt about the paraphilia itself as in the case of exhibitionism, voyeurism or body part fetishes.
What is going on here is something like an addiction. Paraphilias look like addictions to drugs, alcohol, gambling or pornography. The paraphilic “addict” loves his paraphilic “high” and often feels out of control with wild pleasure almost like a roller coaster ride when they are caught up in the high of the addiction. They often describe themselves as feeling out of control in this phase.
When the drug run is over or the addict wakes up with a hangover, a crash or an empty wallet at the bar, drug party, or casino, there is a crash in which the addict feels terrible that they are so powerless over their addiction. They also feel guilty and pained that they are suffering the aftereffects of the addiction. Feelings of self-loathing are common in this phase.
However, in some very bad cases of Harm OCD, violent and sadistic thoughts about torture, murder, cannibalism etc. intrude quite often during masturbation or possibly sex. This is not sexual sadism; it is OCD. This is relatively common in Harm OCD, and the sufferers often describe it as being extremely unpleasant. The difference here is the intrusive nature of the thoughts which are generally not present in sexual sadism, where instead of being intrusive and resisted, the thoughts are pleasant and welcomed.
On occasion, a sociopath or potential serial killer will present to someone or other, more often law enforcement than a clinician with deep concerns about fantasies of murder, often sexual murder. They feel that the fantasies and urges are getting stronger and that they fear that they may act on them. Usually they present only once and then go away. Possibly years later, they may begin killing. In one case, one of the prime suspects for the possible Smiley Face Killer Gang presented to a police station about powerful urges to drown young men. He was afraid he was out of control, and he was going to act on them. The police could do nothing to retain him. It is not known if he ever acted on his fantasies.
This is not a case of OCD.
This is a sociopathic person who simply feels out of control.
In a recent case in the UK known as the Crossbow Killer, a serial killer gave a warning years before killing that he felt he was out of control and was afraid he was going to kill someone.
Once again, this is not OCD.
It’s another sociopath who fears they are losing control. This person will be having strong, long-standing ego-syntonic fantasies of homicide which are not resisted. They are pleasurable to the person, but they do not want to act on them, probably due to fear of going to prison. Over time, homicidal fantasies may become stronger so that the capacity to resist putting them into action becomes more difficult. This is what happens when these people fear they are losing control.
In short, a diagnosis of Harm OCD is relatively straightforward and should prevent few problems, although there are a few stumbling blocks in the cases of schizophrenia, developing psychopathy, and sexual sadism. Generally, ~98% of people presenting with concerns of having Harm OCD will actually have the condition. Although clinicians despise self-diagnosis as notoriously inaccurate and dangerous and urge everyone with profound symptoms to seek clinical help in determining what is wrong with them, I believe that people are a lot better at self-diagnosis than clinicians want to believe.
As I noted at the beginning of this piece, 98% of the people presenting to me with concerns about having Harm OCD actually had the disorder. An alternate diagnosis was quite rare. Nevertheless, rigorous differential diagnosis must be done in all cases to insure proper treatment and due to the severity of the differential diagnoses of psychopathy, schizophrenia and sexual sadism.
What we are looking at here is the difference between problems of fear and problems of desire. OCD is a problem of fear. These other problems are problems of desire.