Harm OCD symptoms
 
People with harm OCD generally experience their obsessions and compulsions in two different ways. They either worry that they will harm themselves or someone else by accident, or that they will act on an involuntary impulse or urge to harm themselves or others. In the first scenario, someone may fear they would accidentally leave their stove on and burn the whole building down. They may be afraid to drive because they don’t want to potentially cause an accident. In the second scenario, someone may experience an involuntary impulse to harm another person and be terrified they would actually act on it. (“I just had an image of punching my spouse. It felt so real. I love her more than anything and I would never ever want to act on this. But how can I be certain I won’t?”)  Although it might sound surprising, it is relatively common to have a thought, impulse or urge to harm oneself or someone else, but these thoughts generally only last a few seconds at most. For example, someone might be going about their day and wonder, “What would happen if I put my hand on this burning-hot cooking pan?” When this happens, people will generally think, “That was a weird thought. Definitely a bad idea and not something I want to do,” and forget about it.
However, most people with harm OCD find thoughts like these are impossible to let go of. When someone with harm OCD catches themselves with a thought like this, their OCD latches on and assigns meaning to it. Suddenly, the person will think, “I just had a thought that I wanted to burn myself. That means I do. Otherwise, why did I just think that?” These thoughts can spiral until they feel unbearable. A person might start thinking, “I can’t believe I want to burn myself. Is there something wrong with me? This is terrible. Should I see a doctor?”

Examples of harm OCD 

• A person could be in the kitchen and preparing vegetables, and suddenly have an image that the knife in their hand could be used to stab their friend next to them. They might begin thinking, “Could I stab my friend? What if I act on this? Is there something wrong with me? Should I see a doctor?”
• A mother could be holding her baby and suddenly have an unwanted impulse to drop her. This would come as a complete shock, and she might start thinking, “Do I want to drop my baby? What if I actually did? There must be something wrong with me. Is my baby safe with me? What if I’m not meant to be a mother?”
• Someone may be excessively concerned with making sure they don’t take too much medication. They might think, “What if I accidentally took too much medication and harmed myself? What if I count the wrong number of pills by mistake?”
• Someone may be very angry and suddenly experience an urge to punch their spouse. This would scare them and feel terrifying. They might think, “What if I actually punched my spouse? I can’t bear the thought of it. Am I going crazy? Why did I just have this thought?”  

Examples of harm OCD compulsions

• Reassurance seeking: A person with harm OCD may seek reassurance from a friend, loved one or religious or community leader. They might ask, “Do you think I would actually harm another person or myself?” They may hope to receive the response, “Of course you wouldn’t. You’re the kindest person I know. You’d never hurt a soul.” This will relieve their anxiety temporarily, but it’s only a matter of time before the doubting thoughts return. “Does my friend really have all the information they need to determine with certainty that I won’t hurt anyone? After all, he doesn’t live in my head. What if he’s wrong about me?”
• Mental review: An individual may review past experiences over and over in order to reassure themselves they are not in danger of harming anyone. For example, they may think, “I have never harmed anyone in my life. I have nothing to worry about.” They may search their mind for past experiences when they were kind to the person they are afraid of hurting and continually replay these memories in their minds. They may think, “I have gone out of my way to help my friend 15 times in the last few months. I know he is someone I love and care about.” They may replay the moments when they’ve experienced an impulse to harm themselves in an attempt to rewrite this memory (“I didn’t have an urge to drop my baby. That’s not what happened. I actually just wanted to throw her up in the air and catch her, as a playful game.”).
• Mental rituals: Some people may engage in mental rituals to reassure themselves that they will not act on their thoughts, impulses or urges of harm. For example, they might count to seven or another lucky number every time a thought comes into their head as a way to reassure themselves they don’t act on their thoughts (“I just blinked three times, so now I can be sure I won’t hurt myself.”). A person might force themselves to think one positive thought for every intrusive negative thought they have, as a way to “cancel out” the bad thoughts.
• Avoidance: Someone may avoid certain scenarios or people where they think they will experience thoughts of harm. For example, they might avoid a specific coffee shop because they experienced a disturbing impulse to throw their coffee on the barista the last time they were there. They may avoid interacting with particular people for fear of experiencing unwanted thoughts, images or urges. They may remove sharp objects from their home or stop engaging in certain activities, like cooking, as a way to avoid the possibility of obsessive thoughts about harm.  

Harm OCD ERP therapy
 
The best course of treatment for harm OCD, like all types of OCD, is exposure and response prevention (ERP) therapy. ERP is considered the gold standard for OCD treatment and has been found effective for 80% of people with OCD. The majority of patients experience results within 12 to 20 sessions. As part of ERP therapy, you’ll track your obsessions and compulsions and make a list of possible ways to face your fears. You’ll work with your therapist to slowly put yourself into situations that bring on your obsessions and the accompanying anxiety or discomfort. Exposures will be mindfully created so that you’re gradually building toward your goal rather than moving too quickly and getting completely overwhelmed. The idea behind ERP therapy is that exposure to these thoughts and the discomfort is the most effective way to treat OCD. When you continually submit to the urge to do compulsions, it only strengthens your need to engage them. On the other hand, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to respond and will very likely experience a noticeable reduction in your anxiety as you provide yourself with opportunities to change your learning and practice living with uncertainty. ERP takes a targeted approach to address your obsessions and compulsions for suicidal OCD. An ERP-trained therapist will help by reviewing which thoughts or scenarios are causing you the most anxiety, avoidance, and compulsions and then work with you to come up with a specialized treatment plan to directly challenge them through gradual, controlled exposure to them.

Examples of ERP OCD exposures for Harm OCD
Rather than trying to make intrusive thoughts, images and urges about harming oneself or others go away with compulsive behavior, ERP therapy works to help a person become more comfortable with those thoughts. Or at least more willing to let the thoughts come into their awareness and exist. As a patient becomes more familiar with sitting with these unwanted thoughts without engaging in compulsions or avoidance, the thoughts will often lose the power they had. Here’s a specific example. Let’s say someone has continually experienced fears of accidentally hurting someone while driving. It’s never happened before, but the fear of the possibility has become so great that this person no longer feels safe driving. The goal of ERP therapy is to allow this patient to drive again with or without fear. During an ERP session, this patient might practice going for a drive with their therapist. At first, this might feel impossible. They might think, “I want to drive, but I just can’t. I’m too afraid.” The patient will work with their therapist to come up with a hierarchy of anxieties and related exposures and gradually work their way through them. For example, they may start with simply sitting in the car during a therapy session and allowing the uncomfortable thoughts and fears to come up. Instead of trying to reassure themselves, the patient may be asked to lean into uncertainty by repeating a statement like, “I may hurt someone and I may not. It’s impossible to know for sure.” Doing such an exposure contributes to learning and shows the patient that they can tolerate not knowing what will happen as well as the discomfort associated with the thoughts. After repeated exposure with response prevention, the patient may find they are able to drive their car for a short distance, and, eventually, they learn that their feared outcome won’t occur, that they can manage the outcome if it does occur, and that they can tolerate the anxiety or distress that arises when they have intrusive thoughts. In some cases, people find that their anxiety subsides to the point where they no longer experience intense fears of harming someone while on the road.