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by Debra Kissen, PhD, M.H.S.A. and Paul Greene, PhD

Death by suicide is a major public health problem that profoundly impacts families in a way few other things do. Every year, many people at risk of suicide seek and get help, potentially saving themselves and their loved ones untold grief. The good news is that death by suicide can often be prevented through early screening and obtaining effective treatment. We as a society are recognizing the critical need for these services. As awareness of this health condition increases, more and more lives will be saved.

But this article is actually about an entirely different condition called Harm OCD. Harm OCD can hone in on the fear that you will lose control and hurt another person or yourself.   

Harm OCD can involve intrusive thoughts about losing control and committing suicide.  Although this form of Harm OCD has yet to be given an official name, we see it frequently enough in our practices that we decided it has earned itself its very own name, so for the purposes of this article we will be calling this flavor of OCD “Self-Harm OCD.“

Common symptoms of “Self-Harm OCD”

Self-Harm OCD is often experienced as a vicious cycle. The first step in this cycle involves a disturbing, scary, intrusive thought or image (this is the “O” or “obsession” part of OCD) about suicide. This is often followed by an exhausting and lengthy process of attempting to figure out if you are actually suicidal (this is the “C” or “compulsion” part of OCD) by mentally reviewing questions such as:

•     “Do I want to harm myself?
•      “Did I just move towards the window (or the knife or any other potentially dangerous object) because I want to harm myself?   “What if I just lose it and hurt myself?”
•      “Is this what it feels like to be suicidal?”
•     “Is even thinking about this a sign that I am going crazy and could lose control and hurt myself?”

Certainty Seeking

At the heart of obsessive thoughts is the desperate need to know, with 100 percent certainty, that a feared outcome will not occur and that “everything is OK.” The neurological networks active in OCD are actually quite helpful in certain scenarios; humans would not have survived for very long without them.  For example, it is helpful when you leave the house and forget to close your garage door to have the thought, “Oh no, I forgot to close the garage. I better head back home to close it, or someone is going to steal my new bike.” Unfortunately, some people are overly reliant on the certainty that comes from that sort of checking. You may be experiencing symptoms of OCD if you spend significant time engaging in mental gymnastics or physical compulsions to become 100% certain that a devastating outcome will not occur.

How can someone with Self-Harm OCD prove to themselves, beyond any doubt, that they won’t harm themselves?  There are several often-used strategies. You can review the facts. You can remind yourself how many times you have actually tried to harm yourself.  You can assess if you have been making a specific plan of how to harm yourself. You can assess if you have been gathering deadly means to harm yourself.  But how can you PROVE to OCD that, with 100 percent certainty, that you won’t lose control and harm yourself? Ultimately none of us can have 100% certainty about what might or might not happen in the future.

The false promise of checking

And now we must give a brief apology. Perhaps you were lured into this article because you were hoping it would provide a handy way to help you differentiate between “true suicidal thinking” and obsessive / intrusive thoughts about suicide. Unfortunately that checklist not only does not exist but would be impossible to create. 

Desperate google searches to find information that calms your anxiety and proves to you that you are “OK” are often just a certainty-seeking compulsion. The problem with engaging in any compulsion as a means to calm your anxiety is that it only “feeds the beast” of OCD, and strengthens the thinking patterns that brought on the initial thought. Inadvertently such compulsions increase the likelihood that, after a short period of relief, the intrusive thoughts will come back with a vengeance, demanding even more certainty that you are ok.

ERP for OCD

Effective treatment for harm-related OCD entails assisting clients in fully experiencing their scary thoughts (exposure) over and over again until their brains grow bored with the thoughts. This process is similar to watching a scary movie until it loses its shock value and shifts from being frightening to absurd.  At the same time, treatment teaches strategies and to reduce or abandon behaviors meant to reduce anxiety (response prevention). This treatment approach is called exposure and response prevention (ERP) for OCD. ERP entails flipping the typical OCD experience on its head by practicing bringing on intrusive, anxiety provoking thoughts while disengaging from any compulsions (both physical and mental) that have been utilized to obtain short-term anxiety relief. 

Conclusion

The good news is that as you work on moving past “Self-Harm OCD,” you will learn how to not only tolerate but eventually play with uncertainty. In doing so you will be opening yourself up to all of the mysteries and wonders of life. And that is where all the fun begins.

For assistance in moving past harm-related OCD thoughts, contact a mental health professional trained in cognitive-behavioral therapy (CBT) or pharmacotherapies, or both. You can search for a therapist in your area on the ADAA website to help you with this challenging, but very important work.


About the Authors:

Dr. Debra Kissen is the CEO/Chief Exposure Officer at the Light on Anxiety CBT Treatment Center in Chicago. She specializes in CBT based treatment to children, adolescents and adults with a focus on anxiety and stress-related disorders, including OCD, PTSD, panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder, specific phobias, separation anxiety disorder, compulsive skin picking, trichotillomania and other Body Focused Repetitive Behaviors (BFRBs). Dr. Debra Kissen applies the principles of evidence-based treatments while at the same time treating the whole person, with deep respect for the human spirit and the challenges we all face on our journey through life.

Dr. Kissen is a Clinical Fellow at the Anxiety Depression Association of America (ADAA) and is a Co-Chair of ADAA's Public Education Committee.  

Dr. Paul Greene is the director of the Manhattan Center for Cognitive-Behavioral Therapy in New York City. He received his doctorate in clinical psychology from Boston University and completed postdoctoral training at Memorial Sloan-Kettering Cancer Center and the Mount Sinai School of Medicine. Dr. Greene served as an assistant professor at the Mount Sinai School of Medicine for six years. He is an expert in the treatment of anxiety and related disorders, and the application of mindfulness in cognitive-behavioral clinical interventions. Dr. Greene is  a member of ADAA's Public Education Committee.

Margaret farrell

October 20, 2019

Hello I'm living in England Thank you so much for bringing this to light,I feel sure this is how I suffer,but also the thoughts of self harm include being so very very frightened of what I may do,I go to bed early to try to get away from my thinking i have no idea of what I will do but it's like being frightened of thinking(if that makes sence) once again Big thank you regards margaret

Hi Margaret, I too suffer from the same thoughts. Its exhausting being terrified of your own thinking, I too go to bed early in an attempt to have a break from my thoughts. Its good to know we're not alone and certainly not going crazy. I hope you get the support and treatment you need and deserve towards recovery xx

Hi Margaret, Cat and Cindy. I suffer with this too and am comforted to know that I am not alone. I go to bed early too, to have some quiet in my head. Many days in the month I am waiting for bed time from early morning. Recently I have been having similar intrusive thoughts in my dreams but thankfully not frequently enough for me to fear sleep.

Thank you for this insight it is nice to confirm I am not the only one. If I knew about this I could have avoided years of self harm, followed by self medication and eventual alcoholism. I think I will call that therapist I have been meaning to talk to tonight as a result of this passage. It means the world to me that smart people like you both are looking out for people like me and want to help.

I don’t necessarily have suicidal thoughts; they’re more of a debate of probability. For instance (I’m in construction) while on a roof I imagine leaping off, not as a means to die, but “could I survive this” scenario in my head. I envision dismemberment while using power tools as a reminder to not get dismembered. I scare myself and cover my eyes watching horror movies but laugh walking through haunted houses.

Thank you very much I'm so pleased I found this Ive had OCD for years and years which I used to think was the stereotypical kind that people think of when they think of OCD but Ive found out recently it is more than that and this explains a lot about so many intrusive bizarre disturbing thoughts Ive had and still have and I have also found out about false memories and how ocd depression and anxiety are connected so it has explained a lot for me which has been a relief

I have been trapped in this cycle since I could talk. I am now 33 and still lost. The abuse that I suffered as a child and through to when I turned 23 when I finally left my so-called home has made it impossible to ever be normal. And then...of course I suffered a brain injury when I was 23, so I feel that my path is haunted by so much. I am fortunate to be married to someone who tries to be there for me. I try to make friendships with people, but I am so scared of them, whether that means hurting them or them hurting me. The anxiety of feeling like a burden on people makes me feel so terrified of messing it up. A dear friend gave up on me. He replaced the parental figures in my life. He was kind and he taught me a little about how to pull away from how suicidal I was. But now, due to a misunderstanding created by my fears ad anxieties, he sees me as someone who betrayed him. He used to tell me I Was a good person, as I try to be for anyone I meet, but I don't feel that I can ever be again. I keep looking to the internet because it doesn't have a face for me to disappoint. I keep looking for help through behavioral changes, but I always end up back here, swallowed up by the thoughts of suicide, just like this article states. Only I think it out not until my brain is bored of the thought. I actively shout against the thoughts of pure dispair. I try so hard to move forward despite the endless thoughts entering my mind. I don't tell people because I don't want to hurt them by knowing how close I have gotten to fulfilling the thoughts. But I made a promise to myself to never kill myself. To anyone out their in pain, please just make me a promise that you won't let the words circling in your head bring you there. I'll make you a promise that I won't let them end me either. These people seem to have the right idea. Tell the thoughts to go f*** themselves, to be crude and frank. Don't give in. And push it away to find some inkling of hope that the future will have its positive moments. That anything that you have done or that has been done to you will not prevent you from finding at least some peace and joy. Seek people...seek many people. It's going to take a village to pull you away from yourself if you have this version of OCD. Some experiences will bring it out again. Don't cave in. Go find someone else to be friends with. Don't be cruel. Don't be cowardly. Keep going.

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