Horrific Thoughts: A Common Form of OCD

By Marilee Feldman, LCPC, CADC

Most people have heard of obsessive-compulsive disorder (OCD). It’s become trendy to say, “I’m so OCD,” which is insulting to those who suffer from the agony of this surprisingly common disorder.

But how much do you really know about OCD? You’re likely familiar with the repeating and checking compulsions of Jack Nicholson’s character in As Good as It Gets or the contamination fears of Emma Pillsbury of Glee fame. While these are common forms of OCD, another category—perhaps causing the most agony of all—is that of intrusive horrific thoughts. It’s what is called “pure-O” OCD, in that there are no observable ritualistic behaviors such as checking or hand washing.

The most common horrific thought is that of impulsively harming someone. Sufferers may be afraid that they will stab or shoot someone, commit suicide, or molest a child. They may fear they are gay, racist, homophobic, or sociopathic; that they secretly wish someone would die; or that they are offending God. One particularly heartbreaking form is postpartum OCD, in which a mom fears she may harm her baby. OCD sufferers, while fixated on these thoughts, are actually horrified by them and in fact never act on them. These obsessions are usually about the people and values the person cares about the most, chosen by their hypervigilant brain to protect that person or value. We all actually have these thoughts and readily dismiss them, but if you have the highly neurobiologic condition of OCD, it’s not so easy.

In these cases, the obsession is the violent thought or image, but what’s the compulsion? Although it’s referred to as “pure-O” OCD, it’s not really obsessions alone, it’s just that the rituals are all mental rituals. If I’m concerned that I may harm my children, I may endlessly review in my head all of the reasons I would never do that. This is called mental reassurance, and it can go on for hours. But reassurance only lasts so long, and when the intrusive thought recurs, the cycle begins again. Other mental rituals include praying, substituting “good” words for scarier words, or mentally repeating certain words or phrases. While this happens, the person is terrified of what he might do and ashamed for having these thoughts. Because this form of OCD is not widely portrayed, he also feels isolated, afraid to tell others what is going on, and is less likely to seek help.

But the condition is highly treatable. Now in cases of OCD with observable compulsions, the treatment is to gradually expose people to the things they fear and then have them not engage in their typical “response” or compulsion. This is called exposure and response prevention (ERP) therapy. For example, a person with contamination OCD might be asked to touch a garbage can and not wash her hands.

How, then, do we treat “pure-O” if there is no ritual to block? One way is to “imaginally” expose the person to their fear. A person with fears of harming her child might close her eyes and be led through a narrative in which she actually does that, until her anxiety goes down. Another strategy might be to repeat their worst fear about themselves out loud or intentionally expose themselves to words, pictures, or videos that trigger the fear. While this may sound difficult—and it is—it is done gradually so that the therapy is tolerable.

What’s great about ERP treatment of OCD is that it works. If people do their exposures diligently and frequently, their symptoms will improve. In fact, ERP is probably the single most scientifically validated forms of therapy out there, for any mental health condition. There’s always hope for OCD.

The Most Essential To-Do before Saying “I Do”
The Little Pink Pill for Women: Worth Taking, or Not?