Harm OCD: What it is and how to treat it
Everything you need to know about harm OCD, including harm OCD stories, causes, treatment, and how to live with harm OCD
Kids and teens often avoid sharing their harm OCD urges, leading them to feel hopeless and isolated.
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Introduction
“I don’t actually want to hurt myself! – but it’s like someone is messing with my brain and telling me to.”
People with harm OCD—a type of OCD that centers around fears of hurting oneself or others—often suffer in silence as they avoid sharing their anxiety with others due to the alarm their family and friends may experience when they hear these types of thoughts. The quote above is adapted from a young boy I worked with after he shared his fears of hurting himself with his teacher.
Is it important for us to take comments like this seriously? Absolutely! But, as we’ll explore in this guide, there’s a big difference between true impulses to hurt oneself or someone else versus harm OCD urges.
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What is harm OCD?
Harm OCD is defined by obsessions and compulsions related to a person’s fear that they will harm themselves or someone else.
What “harm” means can range widely for kids and teens. For example, a teen who worries about self-harm may worry about something minor, like that she’ll cut her finger while cooking, or something extreme, like she’s going to throw herself out of a moving car into traffic.
The same range exists for worries about harming others. A child might worry about saying something that hurts his sister’s feelings, doing something to accidentally cause his sister physical harm (e.g., tripping her when walking by), or purposefully hurting her (e.g., stabbing her with scissors).
Kids and teens might worry about hurting strangers, about people who are close to them like their parents or best friends, or their pets. A lot of people with harm OCD impulses are especially afraid of harming people who are more vulnerable, like babies or their elderly loved ones.
You can imagine how scary it is to have these thoughts! Often, the compulsions for this type of OCD involve avoidance. For example, the child who is afraid of hurting his sister might leave the room every time his sister walks in, or the teen afraid of hurting herself may refuse to ride in a car. Others may stick really close by the person they’re afraid of hurting, asking over and over if they’ve said or done anything that offended them.
Family and friends of someone with this type of OCD might get anxious when they hear about these obsessions. This makes a lot of sense, but it can also make youth with harm OCD feel like they have to keep their fears to themselves and deal with things on their own. What’s more, it can make these kids and teens believe that their harm OCD impulses really are dangerous.
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Harm OCD examples
(Note: As with all clinical examples, I use fictional names and compile information from multiple clients to protect client confidentiality.)
Let’s dive into some examples based on kids and teens I’ve worked with in my own practice to get a better picture of what harm OCD looks like.
Trey is a 10-year-old male who is afraid of harming himself and his 21-year-old brother. Trey avoids touching anything sharp—scissors, knives, pencils, etc.—because he worries that he will pick it up and stab himself or his brother. He avoids heights, including his grandparents’ balcony and multi-story parking garages, because he is worried that he’s going to jump. He can’t open his family’s medicine cabinet because he worries that he is going to overdose on medications. He cannot say or write the words “death” or “kill” without getting really upset. He frequently asks his brother if he has hurt his feelings or hurt him physically in some way, and he has difficulty separating from him (e.g., follows him around the house, sleeps in his room, calls him when he’s been out of the house for a while).
When I asked Trey whether he wished he was dead, Trey answered, “No way! I don’t want to die—I would miss my family and my pets so much!” I asked about what it felt like when he thought about hurting his brother, and he said that it made him sick to his stomach to think about his brother hurt, especially if Trey had something to do with it.
Confident that I was seeing harm OCD impulses rather than true thoughts of killing himself or his brother (more on the importance of thorough assessment later), I knew we were ready to start Trey’s process of overcoming harm OCD.
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What causes harm OCD?
“Why do I have random violent thoughts?” is a question I hear from many clients. Did parents allow their children too much time playing violent videogames or watching inappropriate television? Is it due to abuse or trauma that a child has experienced, or something violent that they’ve seen or heard about?
While stressful life events can be a risk factor in developing many mental health conditions, including OCD, research tells us that OCD is not caused by parenting approaches or things that happen to us but rather by a mix of our genes, biology, and life experiences. Many children exposed to violent media or who experienced trauma growing up don’t go on to develop harm OCD, and there are many people with harm OCD who have no experience with violence.
Most people are surprised to learn that having random violent thoughts is actually pretty common. In fact, 85% of adults without OCD report having troublesome violent thoughts about hurting themselves or a loved one pop up from time to time. For example, a woman might have a fleeting thought of swerving into oncoming traffic during her commute home from work. A new uncle may have an image of throwing his newborn niece against the wall the first time he holds her.
Some believe these thoughts may be something our brain has evolved to do over time to keep us and our loved ones safe. That is, our imagining scary situations that could happen could lead us to take action to avoid them (e.g., pay attention to the road while driving, hold a newborn baby with care). After all, there’s a reason a lot of harm OCD impulses relate to babies and other vulnerable people.
However, while people without OCD are able to dismiss these thoughts as an odd, temporary blip of the brain, the minds of individuals with harm OCD work differently, getting stuck on these thoughts and incorrectly determining that they signal true danger. The good news is that we can help the brain get unstuck and recognize these random violent thoughts for what they really are.
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Harm OCD treatment
(Note: The therapeutic techniques described in this section are for educational purposes only and do not constitute advice or therapeutic recommendations. Don’t try these techniques on your own, but please contact me or another qualified provider if you’re interested in learning about how OCD treatment could help you or your child.)
Does harm OCD ever go away? As you can tell from above, harm thoughts often happen from time to time for many people—with or without OCD—but fortunately, we have treatments that help make those thoughts a whole lot less frightening. Namely, there’s exposure and response prevention (ERP) and other complementary treatments (e.g., Cognitive Behavioral Therapy, mindfulness).
I’ve written about ERP before, but here’s a refresher on ERP: ERP is a treatment used for all types of OCD (e.g, harm OCD, scrupulosity OCD) to help the brain learn that the thing we were worried about isn’t actually that likely to happen after all. We learn this by purposefully exposing ourselves to the thing we’re afraid of, step by step, starting with a less difficult action (e.g., saying the word “death” out loud) and working our way to harder ones (e.g., telling a loved one, “I want to hurt you”).
At the same time, we make sure to engage in response prevention, or making sure that we don’t do any compulsions after the exposure. Compulsions, or rituals, are actions that temporarily relieve our anxiety in that moment, but we know they don’t really work long-term and even make things worse. For example, when we are engaging in response prevention, we’d make sure not to say “I’m sorry” or “I don’t really mean that” after saying the threatening comment to a loved one, and we’d stay in the same room with someone that we usually avoid because we’re afraid we’re going to hurt them.
Over time, we learn that the outcome that we were most worried about isn’t all that likely to happen or be as bad as we think it will be, and not just because of a ritual we did but rather because our fears were overestimations or misrepresentations of our reality.
Here are a few exposures that I did with Trey:
Say the words “death” and “stab” out loud, followed by statements like “I might hurt my brother.”
Carry bottles from his family’s medicine cabinet in his pockets.
Stand next to a closed 10th-story window and look down to the street below.
Insult his brother (e.g., “I don’t like your shoes!”).
It certainly wasn’t easy, but Trey learned over time that his thoughts about hurting himself or his brother were just thoughts after all.
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Frequently Asked Questions
Can harm OCD be dangerous? Can OCD thoughts of killing turn into the real thing?
I mentioned earlier how important it is to do a careful assessment at the start of treatment, including past history of self-harm or harm to others and a structured clinical interview. But that’s just a part of the process.
When I’m working with a client with harm OCD, my assessment is a continuous process of checking in throughout treatment to make sure I truly understand his or her fears and urges. My clients and I use things like rating scales and questionnaires to help us keep track of their mood and worries, so that if they do develop genuine risk of harming themselves or others, we’re ready to adjust our treatment to meet their needs for safety.
That being said, it’s a misconception that people who struggle with harm OCD are dangerous, and it can lead to stigma and isolation as people feel uncomfortable to share their fears with others. Too many harm OCD stories involve months or years of kids and teens feeling alone in their fears until they meet someone who understands this very common type of OCD.
What about harm OCD ERP? Can that be dangerous?
It should go without saying that self-harm OCD treatment should never involve activities that would put a child in serious danger of ending her life (e.g., telling her to stand on the edge of a very tall building). Nor should treatment for a teen who fears harming others involve exposures that would truly hurt someone else (e.g., telling him to drop his baby sister on the floor).
However, ERP for harm OCD does involve doing activities that feel above and beyond what we’d normally do. We don’t typically encourage children to carry around sharp objects, and we don’t typically want to hear a teen tell his sister, “I’m going to stab you!”
This is because of what’s called “overcorrection.” For someone with harm OCD to get to a middle ground, they need to overcorrect with seemingly risky behavior or (mildly) harmful actions. This way, they will return to a balance of being able to accurately assess safety and act accordingly, while also not being paralyzed in fear and avoidance.
Isn’t it wrong to encourage a child to perform harm OCD exposures?
During harm OCD treatment, we don’t try to convince a child or teen that they’re really dangerous. Rather, we encourage them to dwell in a place of uncertainty. A lot of people with OCD, including harm OCD, take action to try to be certain that a scary outcome won’t happen (e.g., leaving the room when a loved one enters to ensure that you won’t hurt them). When someone learns to handle uncertainty, they feel less anxiety over time because they know that, even if something is unknown, that doesn’t mean it’s something dangerous.
As an example, Trey often asked for my reassurance during treatment. He would say things like, “I’ll do the exposure—but it’s not something that could actually hurt someone, right? There’s no way I’d actually jump out this window, right?” Providing a reassuring answer (e.g., “No way, Trey—I’d never do something in treatment that would actually hurt you or anyone else!”) not only fails to make him feel less anxious in the long term, but it actually works against treatment because it doesn’t let Trey learn for himself he’s really safe. In other words, the reassurance serves as the response that “undoes” the exposure, the response we’re looking to prevent!
Rather than providing reassurance in those moments, I would prevent the response but encourage Trey instead (e.g., “I know this is really hard, and I see how hard you’re working!”). In learning to let go of his need for momentary certainty, Trey could collect evidence that refuted his anxious thoughts. Over time, he became more confident and assured in his ability to determine what was safe and what wasn’t, allowing him to live more freely and to have closer relationships with his loved ones.
Conclusion
While random violent thoughts are actually pretty common, harm OCD can be very alarming for kids, teens, and their families. It can lead them to feel isolated, stigmatized, and hopeless about their ability to be close with others. Fortunately, we know how to treat harm OCD effectively, and we can help these youth develop a more balanced understanding of safety and self-awareness. If you or your child is living with harm OCD, let’s break the stigma and see how treatment can help your family.