Most people have occasional violent or sexual ideas that flash through their minds, but they tend to have little trouble dismissing them. For people with OCD, however, these thoughts or images may trigger panic and great distress. While changing her son’s diaper, for example, a new mother might suddenly realize that there is nothing to prevent her from molesting him. She might immediately recoil, with panicked fears racing through her brain: “Could I really do that? Why would I think that? Am I a pedophile? Would I harm my child?” Naturally, she would seek to qualm her terror by reassuring herself: “No! I’d never do such a thing! I could never harm my child!” At first, the distress might abate, but kernels of doubt would remain: she could struggle with questions about why she thought about this act in the first place, or she could find herself unable to know for certain that she would be able to resist this kind of impulse. Such doubts would generate more attempts at reassurance, perhaps including lengthy research into the lives and thoughts of pedophiles. Any relief these efforts might bring would be temporary, however; the mother with this kind of obsession would, over time, experience increasing distress caused by her inability to eliminate all possibility of harm. Terrified, she might start avoiding her child and spend increasing amounts of time on rituals to assure her son’s safety.
Intrusive thoughts, images, or impulses about harming others (loved ones or strangers), either sexually or violently, are common obsessions. To individuals experiencing them, the harmful behavior may seem completely foreign and antithetical to their values. Despite this rational understanding, the person’s feelings about these obsessions make them nearly impossible to ignore. For many with OCD, it is the remote — but ever-present — possibility that they might commit such an act that gives rise to hours spent ruminating and reassurance seeking. People with this type of OCD tend to feel always on the verge of conclusively determining that they could not commit the acts they abhor, but this feeling simply draws them into increasingly frantic compulsions. These can include seeking reassurance from others, repetitive checking and reviewing of past events, and making extensive lists of their moral and amoral behaviors. The person can also find him/herself avoiding increasing numbers of people, places, and activities to avoid triggering the distressing thoughts or images, or to ensure that s/he will commit no harm. These strategies can provide brief respite, but inevitably the person finds him or herself in an ever expanding, all consuming battle with a beast that grows more fierce with every round of fighting.
Case Study:
During an argument with her husband, Meryl had an intrusive image of stabbing him with a kitchen knife. She had a momentary spike of anxiety and started thinking: “Why did I have that image? Could I actually do this to him?” “Is this repressed anger, or am I going crazy?” She was able to reassure herself of the absurdity of the fear… after all, she’d never physically harmed anyone or anything her whole life. She reminded herself of how much she loved her husband. But she couldn’t quite shake the memory of the image, and the more she tried to forget about it, or exorcise the obsession from her mind, the more the image came back. She became increasingly panicky and upset that such horrible images were occupying her thoughts, after all, “What kind of person thinks such horrible things!” She began avoiding the kitchen when her husband was near and wouldn’t pick up a knife anywhere near him. She started worrying that she might harm him during the night when she was deep in sleep, so she slept as far away from him as possible. She started avoiding watching movies with violence, and then even news programs (the stories seemed to all be about harm and crime), as they triggered the “bad” thoughts and panic. Meryl found herself spending more and more time on the Internet researching information about “killers” and violent people to reassure herself that she wasn’t like them. More and more of her life was consumed by avoiding situations that might trigger the obsessions or where she might have the possibility of harming someone. She dared not tell her husband about the thoughts when he asked what was wrong; and their relationship started suffering as she was avoiding being alone with him or doing the activities with him that they used to share and enjoy. The fear started to spread, and Meryl starting worrying about harming close friends and co-workers. She feared she was losing her mind or becoming “psychotic.”
Treatment:
As with other forms of OCD, a person’s efforts to eliminate or neutralize harm obsessions ultimately strengthen the brain’s sense that the images are, in fact, dangerous. This process generates stronger impulses for the person to avoid or escape the “danger” that the obsessions present. In an ever worsening and self-perpetuating cycle, the person’s compulsions generate more frequent and stronger obsessions, to the extent that they cause significant distress and impairment.
The goal of exposure and response prevention (ERP) is to gradually and repeatedly show a person’s fear system that the intrusive thoughts and/or images do not need to generate anxiety. When a person deliberately engages with the feared thoughts/images and associated uncertainties without engaging in neutralizing behaviors (i.e., the compulsions or rituals), the brain learns that obsessions are not dangerous. As the person’s fear system becomes used to these kinds of thoughts, the brain spends less energy looking for them. As a result, a person’s anxiety and distress decrease greatly: not only does s/he feel less fear when s/he has an obsession, but the frequency of the images and thoughts decreases over time.