Threat Assessment in OCD

This is an excellent article.
Examples of obsessions:

Examples of normal intrusive thoughts include the image of touching the genitalia of a child, worry (in the absence of any evidence) as to whether one had caused an accident on the way home, urges or impulses to attack a loved one with a kitchen knife, or thoughts and images of jumping onto a railway track in front of an oncoming train.

That is a pretty good list, and the author points out that 80% of the population report having these thoughts also.

The risk is that the patient will act on an obsession (e.g. suicide or sexual acts with a child) or impulsively act out an obsessional fear. At its simplest, this need never be a concern: there are no recorded cases of a person with OCD carrying out their obsession. By definition, such intrusions are unacceptable and ego-dystonic, and the person is no more likely to act on their intrusions than a person with height phobia is to jump off a tall building. The obsession represents a type of fear or worry that the patient does not want to happen; like all fears or worries, it concerns ideas that the patient wishes to avert at all costs.

That seems to be correct, however, when the illness gets severe, the person can become convinced that they actually want to carry out these acts. I have spoken to quite a few people with OCD who told me that the illness made them feel like they wanted to have gay sex or have sex with children or assault and murder people. This is probably correct though in that people with OCD do not act on their obsessions. I have not met one person who acted on an obsession of causing harm to themselves or others, or how did anything sexual to a child in response to an obsession.
However, there are cases of people with gay OCD who get so convinced that they are gay that they go out and have sex with someone of the same sex. Usually this is a complete disaster and I would not advise it.
There are also cases of people with Relationship OCD who have left their partners or spouses. Generally, this does not solve the ROCD dilemma.

Where compulsions are concerned, urges that are themselves obsessions need to be distinguished from urges arising as responses to obsessions. Once this is done, the risks are relatively obvious. Thus, if someone has an obsessional fear of cutting themselves, you can be very certain that they will not harm themselves.
However, if the idea of harming others is the obsession, they might respond by cutting themselves rather than harming someone they love. Secondary risks are often subtle. For example, a parent who is constantly preoccupied with their obsessions may become less responsive and emotionally available to their children.

This is interesting. I have dealt with a few OCD’ers who cut themselves. All were women.
The next part goes into differentiating Sexual OCD from the type of thinking that goes on in a sex offender.

OCD or potential sexual offender?
Various factors differentiate the intrusive sexual thoughts of people with OCD from those of sexual offenders

  • Ego-dystonicity of the thoughts
  • Failure to act on or masturbate to the thoughts
  • Avoidance of trigger situations
  • Efforts to suppress the thoughts
  • Very frequent or constant occurrence of the thoughts
  • Dominant anxiety, distress and guilt about the thoughts
  • Overdisclosure of irrelevant past sexual history
  • Wanting help and seeking referral to mental health services
  • Presence of additional obsessive–compulsive symptoms

That is a pretty good list.
Assuming that in a sex offender, we are dealing with some sort of a paraphilia, I had one OCD’er who had obsessive thoughts of slitting his father’s throat. He was terrified that he was going to act on these thoughts and that he got some sort of sexual arousal out of them. His therapist told him that this was OCD, and that paraphilias are “about desire, not fear,” and “no resistance.” This is about right. I would expect to see little to no resistance in a paraphilia. OCD is a problem of fear and paraphilia is a problem of desire.
You are also looking at something that is occurring all or almost all of the time. If it is, it is likely you are dealing with an obsession. With paraphilias, they are much less likely to be going all the time, and when they are frequent, the person is likely to be fantasizing.
The anxiety, distress and guilt over the thoughts is often profound. I have had quite a few OCD’ers tell me that they were crying for hours on end, either could not sleep or were lying in bed all day or had even lost weight due to not eating. It is quite common for them to say that they are suicidal; however, OCD’ers usually do not attempt or commit suicide. I have only had OCD’er who attempted suicide and she tried twice.
Presence of another disorder like Borderline Personality Disorder is likely to greatly increase the risk of suicidality. In such cases, the suicidality is likely due to the BPD and not the OCD. It is curious that OCD’ers are so commonly suicidal but they rarely attempt or carry it out. The OCD’er is a shy, almost meek person whose dominant emotion is fear or even terror. Quite simply, they are too scared of dying to kill themselves, so the fear associated with suicide prevents them from carrying out the act. In contrast, a violent of sexual offender is likely to see the thoughts as fun or enjoyable, though sometimes they feel guilty for enjoying them so much.
Wanting help is a great one. When someone comes to me on the brink of suicide due to their “horrible pedo thoughts that popped up out of the blue,” I am quite certain that this person is not a pedophile. I have only have one pedophile come to me in all the time I have worked with OCD’ers, and he went away pretty quickly. In contrast, sex offenders or pedophiles will rarely show up for help. One man who was interested in working with pedophiles as a career was told that unless he was working in a prison setting, he would never see one in clinical practice.
Resistance is the hallmark of OCD. George Winokur, a famous psychiatrist, said, “Look at how hard the person fights the thoughts. That is a clue to whether you are dealing with OCD or with something else.”
Another interesting thing you will see is checking. So the person with pedophile thoughts will constantly conjure up pedo thoughts and then examine their reaction to them to see if they are properly horrified. A person with gay thoughts tests himself to see whether or not he finds gay sex repulsive. A person with violent thoughts frequently conjures up violent thoughts or scenarios to check to see if they are actually repulsed by them or if they are repulsed by them enough. Sometimes the thought or image must be repeated over and over until the person finally feels that they have obtained the “right” level of disgust. You will see much less resistance in paraphilias; in fact, typically, there is none.
Failure to masturbate to the thoughts is not a great checkpoint, as I have had quite a few folks who were masturbating to pedo thoughts as a way of checking to see if they were turned on by this sort of thing. In the paraphilias, the person masturbates, often compulsively, to the imagery of the paraphilia, pedophilic, sadomasochistic or other fantasies or pornography. They get great pleasure out of this, and they generally do not want to stop.
Ego-dystonic is excellent. Paraphilias are much more likely to be ego-syntonic. Although this one is a bit tricky, and the OCD will often argue with the person and tell them that they actually like the thoughts when they do not. This leads to a lot of confusion over whether they enjoy the thoughts or not.

They will avoid trigger situations.
Harm OCD’ers will avoid other people or avoid weapons, heights or pill bottles if they worry about self-harm. Pedophile OCD’ers will avoid children like the plague. Gay OCD’ers will avoid anything to do with gay people. Sometimes they avoid their own sex or even the opposite sex. In contrast, many pedophiles will actively seek out places where children are present.
Overdisclosure of irrelevant past. Many times, those with pedophile worries will reveal all sorts of incidents in their childhood past that they feel prove that they are pedophiles. Usually this is just harmless child sex play of the sort that all children engage in. A Harm OCD’er will reveal incidents in his past in which he was violent in order to prove that he is a murderer. Usually this sort of thing is sort of a back-checking and doubting sort of thing in which the mind is trying to come up with reasons why the obsession is true. In contrast, a sex offender will often hide their past due to fears of being caught.
Presence of other OCD symptoms. This is an excellent clue that you are dealing with OCD, and I use it often when I am trying to figure out if I am dealing with OCD or something else. With a sex offender, usually you will not find any OCD.

Factors suggesting OCD in thoughts of violence

  1. Ego-dystonicity
  2. Absence of past behavior consistent with the thought
  3. Presence of avoidance behavior (e.g. avoidance of knives or sharp implements)
  4. Frequent thoughts
  5. High degree of distress
  6. Strong motivation to seek help

The ego-dystonic nature of violent thoughts is often profound, and the resistance provoked by them is often extreme. In contrast, real violent thoughts are typically ego-syntonic and are quite pleasant to the person.
Absence of past violent behavior. The Harm OCD’er is typically a very nice, kind, sweet and gentle person – the last sort of person you would think would do such a thing. They typically have little violence in their past, certainly little violent crime or unprovoked attacks on innocents.
Presence of avoidance behavior. The Harm OCD’er is often afraid of knives, weapons, etc. and tries to put them away or hide them. In contrast, a violent person may be quite comfortable with weapons.
Frequent thoughts. When the violent thoughts are going all the time like a broken record, you may be dealing with OCD. Violent people do not necessarily think violent thoughts all the time. Instead they only think them some of the time.
High degree of distress. Harm thoughts provoke severe anxiety. Some people hospitalize themselves to avoid hurting other people. I talked to one woman who had been in a hospital for four years with Harm OCD. In contrast, violent people tend to like their violent thoughts and they think them anytime they want to with great pleasure.
An OCD’er with Harm OCD told me that they went to a forum for psychopaths and asked them about the harm thoughts that he was experiencing and whether they experienced the same thoughts. The sociopaths were mystified that the man felt the thoughts were abhorrent. One of them said, “Actually, one of the few things I like to think about is hurting people and killing people.” The rest of the sociopaths all endorsed that statement. Dangerous people like to think violent thoughts; they get kicks out of it.
Strong motivation to seek help. The OCD’er is panicked over is violent thoughts and desperately wants to be rid of them. By contrast, a truly violent person likes to feel violent and doesn’t want to feel any other way. I have not yet had a truly violent person come to me wanting help with violent thoughts so they don’t carry them out.
I had one homicidal person, but they very much wanted to feel that way, and there was nothing I could do to talk them out of it. The whole problem with this sort of thing is that the people who are actually going to carry out violent and sexual offenses, the people who are really going to do these things – well, they never show up. Instead the only ones clinicians see are the people who are never going to act on any of this stuff.
Resistance. I would add this one to the list. Violent thoughts often provoke furious resistance in an attempt to keep them out of the head. In contrast, someone who is actually going to carry out an unprovoked act of violence against an innocent person spends little if any time resisting thoughts. One Harm OCD’er was afraid he was a serial killer, but he had never committed any violent acts along those lines.
He asked his therapist, “What about a person who actually does these things? Do they ever try to stop the thoughts?”
“No.”
“Not even once.”
“No, not even once, of course not.”
So resistance or the lack of it really is a good marker for OCD versus something else.
Therapists often make OCD worse in various ways. Here are some of the ways that they can make it worse.

Examples of patients’ comments regarding their assessments
‘He gave me a differential diagnosis which made me panic as it increased my doubts about whether I did have OCD.’
‘She said that, to be on the safe side, it would be better if I avoided working with children until I had received treatment.’
‘He said SSRI’s might reduce my sexual urges so I assumed he must think there was a problem.’
‘She said I was unlikely to act out any urges but she was still obliged to notify Social Services.’
‘He implied I might have an unconscious wish to stab my baby.’
‘He said it was extremely rare for such thoughts to mean that someone was dangerous, but if I was still worried, I could go for a specialist assessment at the sexual offenders unit.’
‘She said it was very rare for this type of violent thought to lead people to act on it, but “as you obviously have a problem dealing with anger, then therapy would be a good idea”.’

There is no point in saying any of these things, and I try very hard not to make OCD’ers worse when I deal with them.

References

Veale, David; Freeston, Mark; Krebs, Georgina; Heyman, Isobel and Salkovskis, Paul. 2009. Risk Assessment and Management in Obsessive–compulsive Disorder. Advances in Psychiatric Treatment 15: 332-343
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10 thoughts on “Threat Assessment in OCD”

    1. OCD Please elaborate.
      Yes it is true in a few cases.
      I worked with one man who was incredibly confusing to figure out. It finally turned out that he was a nonexclusive pedophile, but he had also had some horrible OCD going on about it too, basically because he simply could not accept that he was wired up as a biological pedophile. Was a tragic case really.
      Every now and then you get someone where you aren’t sure if it’s Gay OCD or a Sexual Orientation Problem. I worked with a 15 yr old boy who had what almost looked like Gay OCD but it turned out he really was just basically gay but he couldn’t accept it. My job was to enforce the idea that he had to accept his orientation as fixed and unchangeable and try to live a happy life as a gay male.
      You always have to rule out pedophilia when you deal with POCD, but most POCD cases are just that.
      And you need to rule out a sexual orientation issue with Gay OCD, but almost all Gay OCD is just that.
      Some cases get horribly confusing because it really does look like OCD, but they get so convinced it is real. I have worked with people where I had to argue with them that they were not lesbians or pedophiles. One guy kept shouting into the phone at me, “I’m a pedophile!” I kept laughing and said, “No you’re not!”
      OCD stuff is not always very straightforward.

  1. “I worked with one man who was incredibly confusing to figure out. It finally turned out that he was a nonexclusive pedophile, but he had also had some horrible OCD going on about it too, basically because he simply could not accept that he was wired up as a biological pedophile. Was a tragic case really.”
    Was it the same person you were referring to in the article? The one who went away pretty quickly?

    1. No, that is somebody else.
      The other fellow was wondering whether he had pedophilia or POCD, and he was 99.99% sure that he had pedophilia. I reviewed his case and told him that indeed he did have pedophilia, that it was incurable, and that the only way for him to be happy was to accept it and be ok with it.
      There is no shame in being a biological pedophile!

      1. Hi Robert. I am currently 20 years old and have been suffering from what I have been told is ocd for about three and a half years now. I’ve had anxiety since I was 13, and just got diagnosed with ocd about a year ago. My ocd primarily focuses on the fear that I am going to kill myself. Sometimes it even goes as far as to say, well what if I actually want to do this. The amount of anxiety I feel from this is so intense. It began as a fear that I was going to lose control and hurt myself with a knife, but has moved onto this. I was reading online and it said that a person with this type of harm ocd could develop actual suicidal thoughts. Of course this sent my anxiety into an absolute uproar. It went on to state that because these conflicting thoughts could be confusing, it was likely for someone to act on it. I cried to my mom all day after reading this and made her make an appointment with my psychiatrist for tomorrow. I feel like there is just constant doubt. What approach should I take to help myself feel better?? thank you soooo so much for your article.

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