Harm OCD Versus Other Conditions: Differential Diagnosis

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. It’s just that I have personally never heard of a case.

In addition, as a 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 commit the act, but they stop before they are able to carry it out.

In one case, 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.

Generally, people read my articles and simply self-diagnose as OCD with whatever theme they have going. 100% of the people coming to me self-diagnosing as Harm OCD were in fact suffering from that very condition.

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 and also I know that the the OCD is simply not that bad yet.

As OCD gets worse and worse, resistance gets harder and harder. I have talked to a number of people 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  hears OCD sufferers say things like, “I hate this with every fiber of my being.” 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.

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 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 or loved ones or certainly people one is not angry 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.

And oddly enough, they are often remarkably passive and non-violent. This clashing of one’s morals 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, often the only people showing up inn therapy are the Harm OCD sufferers or in other words, the only 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 it and are not bothered by these thoughts, feelings, urges or plans, and they simply do not seek help. 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 just 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 person running around being a serial killer, there are probably 100 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 most to all sociopaths 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. 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. Sadism is extremely common in the gay community. 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 or an empty wallet at the casino or drug party, 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. 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.

This is not a case of OCD.

This is a sociopathic person who simply feels out of control.

In a case in the UK, 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.

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.

14 Comments

Filed under Anxiety Disorders, Borderline, Crime, Mental Illness, Mood Disorders, OCD, Personality Disorders, Psychology, Psychopathology, Psychotherapy, Serial Killers, Sex, Sociopathy

14 responses to “Harm OCD Versus Other Conditions: Differential Diagnosis

  1. Brengunn

    Robert, do you get people who have harm ocd that is specifically connected to a body part, like it’s not just a thought but almost a physical sensation? Say, a person wanting to hurt their hand, would get the picture in their mind but also a feeling like the thought is tethered to the hand. That both are connected, getting rid of the hand will get rid of the thoughts.

    At different points in my life I’ve had thoughts like this about different parts of my body. Is that common?

    Also, you talk about resistance to the thought. Would you say these thoughts are qualitatively different from other fantasies. e.g like you mention above, I’ve willingly indulged in violent fantasies, kidnap, torture, murder but these thoughts are happily indulged and are more about taking power back or winning the girl etc. than the violence. The harm thoughts are more like feeling pictures that pop into my head without warning and have no personal gain attached, only emotional pain.

    • It is extremely controversial, but apparently obsessions are not fantasies at all!

      I am not sure about your first paragraph. Apparently most folks have the obsessive thoughts that you describe in that paragraph. Surveys show that 80% of the population has obsessive thoughts at times. It’s only OCD if it’s taking over your life and screwing up your life.

      The fantasies you describe are simply fantasies. You enjoy them. I am starting to think that many folks have these kinds of fantasies, even including kidnapping, torture and murder. I have an article in mind called One Man Kills While 100 Men Dream. That is for every guy running around doing antisocial shit, there 1000 or so that like to think about it but have enough controls that they know they are never going to do it.

      I still like you a lot even though you have these fantasies. It’s quite alright if you wish to think that way.

      Do you have a firm mind though that these are only fantasies, and that you don’t think you would ever actually carry them out? That would be the thing that I would be looking for. If you know you would never do it, you can think of anything you like. There’s a difference between thoughts and behavior anyway, and these are only thoughts.

      Yes fantasies are very much different from obsessions.

      The harm thoughts are more like feeling pictures that pop into my head without warning and have no personal gain attached, only emotional pain.

      That’s an exact description of an obsessive thought!

      How often do you have these thoughts? Are they under control, or do you feel they are out of control and ruining your life? That’s what we look at.

      • Brengunn

        Are they under control, or do you feel they are out of control and ruining your life?

        Na, I more or less grew out of them. They still occasionally come back but are brief and manageable. I had a period of years spanning my late teens early twenties where I was suicidal and felt myself to be deviant. That I was wired up wrong. I still feel a bit haunted by them though, as it was so intense.

        The violent fantasies are just that, fantasies. Sort of Walter Mitty type imaginings except with violence. I’m an extremely non-violent person, I hate confrontation of any kind. These thoughts are merely to sooth my ego as at the end I end up the hero(moral vanity), or execute the perfect murder(intellectual vanity) or sleep with a beautiful woman(sexual vanity). They are a way to deal with a harsh reality. I chide myself for indulging in them, thinking ‘you’d never do something like that, so why even think it’. It’s some sort of emotional crutch.

        You know that’s one of the reasons why I found the East Area Rapist public meeting rape so terrifying. I can imagine myself filled with bombast standing up and saying ‘I’d never let my wife be raped’ never knowing that someone would test my resolve. Jesus, I don’t like to think about it.

    • Ado About Nothing

      I grew up with Harm OCD and was undiagnosed.

      I became an Eagle Scout, I graduated college, and now I am happily pursuing my chosen career as an educator.

      Undiagnosed, I always assumed that I was a terrible person as I was growing up. The fantasies have always been around and as I learned more horrible things from reading and the internet, they only became more gruesome and realistic.

      I eventually focused in on Abnormal Psych and really got into studying Psych in high school. Of course I self-diagnosed (everybody does it in Ab-Psych courses, it’s actually pretty funny), and I self- diagnosed as a Sociopath because I was a teenager and the thoughts were so common.

      I had no idea about Harm OCD at the time.

      I learned a lot of management techniques over time just to keep from becoming depressed by the constant violent images. I stopped fighting the images when I was in college and began to embellish on them as they came.

      Some times I try to “one up” the last image with my own terrible thought. It is sort of like telling my brain, “Oh, you think that’s awful, well how about this?!”

      I told my wife about my thoughts last year and this year we heard this on the radio (http://www.npr.org/2015/01/09/375928124/dark-thoughts) and we both turned to each other and were like, “That’s it! That’s what it is!”

      Thanks for more information on an interesting subject.

  2. Jack

    Robert… I suffer from a lot of the harm ocd symptoms you cover… I’ve never been a violent person I’m 19 turning 20 like the kid in one of the stories you mentioned. I don’t get to worked up about the thoughts anymore T first I was freaking out now it’s replaced with anger and it’s sort of like I go along with it n almost pretend to be how my thoughts make me out to be… But always come back n say no no that’s not right, what do you suggest is the best treatment? I’ve started meditating I just hope I haven’t developed some other personality as a result, I’m just sick of this shit it’s bullshit.

  3. Helen S

    I’m sorry, Robert, but I’ve just come across this article and I have to say, your comments about the BDSM community are damaging for these people. I am a fetishist of 8 years who enjoys various aspects of BDSM play. I have so much control and power in my day-to-day life that it helps to surrender it. However, I also have Harm OCD. Does my therapist know I engage in BDSM? No, I didn’t feel the need to tell her what I do in my private life, I don’t have any marks and I’m certainly not lacking brain cells,, either. It makes me feel safe, peaceful and rejuvenated. It is not dangerous or risky, because we ALWAYS exercise consent.
    In relation to the homicide and rape, things can and do go wrong sometimes. However, all individuals should exercise consent and caution and if you don’t feel safe, don’t go any further! Again, with the woman raped at knifepoint, there are individuals who do “fantasy rape” scenes and it may be the girl flighted during the scene and ran to the police. I am not saying that the homicide was an accident and I’m not saying the man is innocent, what I am saying is that just occasionally things do go wrong for participants of a BDSM scene and something may have slipped or the girl may have been scared and should of called an end to the scene. If, however, consent was not there, then it is without doubt a serious criminal conviction and as such the involvement of any sexual games plays no significance. Just as the same, there are people who own guns for hunting rabbits, are there more dangerous people who own guns than don’t? Probably not, because let’s be honest. Most of them exercise control. Same applies to us kinky folk. I’m just asking you to rethink the point you made about BDSM not being harmless, that’s all. You need to hear both sides of the coin before you can make this assumption:-)

    • BDSM is NOT harmless! I reiterate that. BDSM porn is not harmless either. Violent pornography has been proven to be harmful.

      Who am I harming by this type of talk?

      • Helen S

        Yes, granted, BDSM pornography is damaging because people learn from it in the same way kids learn wrestling from watching it on TV. I don’t like it, why? Because it promotes a harsh view of the BDSM community and not one I appreciate. If that’s your thing, fine, but we’re not all whips and chains.

        In response to your comment about harming people in the BDSM community, you harm those who practice consensual kink. That’s not to say it’s safe, but it’s consented to by both parties who know and acxept tbe risks where as victims of sexual predators do not consent. I’m not saying everyone is perfect and there are some bad eggs out there, but what I am saying is that you need to meet some of these people before you tar millions of people with one brush. You’ll realise a lot of us are normal, intelligent people and not so different at all.

        Going back to your original point, no, BDSM is not harmless. But then do you ever consider what might happen to you every time you step out of your front door? There are a lot of bad people out there, but not all of them hang out in sex clubs.

        • As someone who works in mental health, I do think this whole thing is unhealthy. There are sadists and masochists in this community. A sadist is someone who likes to hurt people. A heterosexual male sadist is a guy who likes to hurt women. That’s what kind of a person he is. A heterosexual female masochist is a woman who likes people to hurt her. And she often has devastatingly low self esteem, which the scene encourages.

          Neither of these strike me as healthy people.

  4. Ashton

    Helpful article! I’m diagnosed with pure o OCD for a year now and I am hackng some trouble with harm ocd. I feel almost numb, like the scary killing thoughts don’t bother me and every time I try telling my loved ones my worries about being numb I keep thinking “what if I am pretending to have ocd so they will feel bad for me so I can manipulate them.” (I wouldn’t actually manipulate them. I just feel like an actual killer (never killed anything!)

  5. Don

    Ashton,

    I feel the same way…

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