What to Read
There are dozens of categories of different obsessions and compulsions that make up the disorder known as OCD, and while these cover a wide range of differing themes, they all share many characteristics in common. These would include intrusive unpleasant thoughts, unceasing doubt, guilt fears of being insane, and crushing anxiety. While all forms of OCD can be painful, paralyzing, repulsive, and debilitating one of the nastier and more startling is the type known as morbid obsessions. This is particularly true of those obsessions in this category that are violent in nature and include thoughts of killing or injuring others or oneself, or of acting sexually in ways that are against society’s norms. I include thoughts of acting out sexually in this category as they really represent a form of violence and have little to do with sex.
Violent thoughts may involve both mental images and impulses to act. These can include those in which people see themselves hitting, stabbing, strangling, mutilating, or otherwise injuring their children family members, stranger’s pets, or even themselves. They may envision themselves using sharp or pointed objects such as knives, forks, scissors, pencils, pens, broken bottles, letter openers, ice picks, power tools, poison, their bare hand’s, or even their cars. The urges they experience may involve pushing or throwing themselves or others into the paths of trains or cars, out of windows, or off balconies, buildings, or other high places. Some report thoughts of hitting pedestrians, ramming their cars into bridge abutments on the highway, or steering into the path of oncoming traffic. Others fear snapping or going berserk in public and harming people. One patient of mine would have thoughts of opening one of the exit doors aboard an airliner. In reaction, sufferers tend to fear being alone with anyone smaller and weaker they feel they could easily overpower, such as children and elderly people. They often avoid going to such places as train platforms, pedestrian-filled street corners or being in crowded public places. Mothers may experience repeated thoughts of acting violently towards their infants or small children. Sexual thoughts in this category usually involve raping or sexually abusing children or other adults. Fears of acting out other sexually inappropriate behaviors may also occur.
It is important for sufferers to understand that the thoughts are just thoughts and do not cause anxiety, but rather the anxiety is caused by the views sufferers take of the thoughts. They need to overcome the idea that, “If I think it, it must be real.” It should be noted that people who suffer from these thoughts have no history of violence, nor do they ever act out on their ideas or urges. Although OCD can project extreme and bizarre thoughts into people’s minds, it is not the thoughts or the anxiety as much as people’s solutions to having the thoughts that represents the real heart of the problem. It is the compulsive acts that people perform to relieve their anxiety that cause the paralysis that they experience. Compulsions are seductive in that they offer the illusion of immediate relief from anxiety, even if it only lasts a brief time. Compulsions, paradoxically, start out as solutions but eventually become the problem itself. They may grow from taking only a few minutes per day, to taking up hours at a time. Instinct tells people with OCD to avoid or run away from the things they fear and they erroneously believe that this is possible. Unfortunately, the opposite proves to be true, and the avoidance only worsens the problem and increases the fear. A person’s whole life may become oriented around never coming into contact with the things that make them anxious. In actuality you cannot run from what you fear. It must be faced. People with OCD do not remain in the presence of what they fear long enough to learn the truth of things, which is that nothing would happen, even if they did no compulsions. Regardless of the type of obsessions, treatment for OCD is all about getting sufferers to accept that their solutions do not work, and will never work, and that they have to finally face their obsessive thoughts while resisting their urges to do compulsions. Anything short of this will not be powerful enough to get the job done.
These principles are put into action in a treatment known as Exposure and Response Prevention (ERP). This is a systematic way of confronting the violent (or any other) thoughts in a step-by-step manner. The actual exposure itself is very straightforward. Sufferers can be exposed to violent thoughts in a number of ways. These may involve assignments carried out under a therapist’s direction in an office or on one’s own at home. What all these methods have in common is that they don’t reassure. Instead, they are designed to provoke anxiety by essentially saying that the thoughts are true, that the feared consequences will really happen, and that nothing can be done to prevent them. Ideally exposure should be done whenever and wherever the thoughts occur. Those who suffer from violent obsessions have various types of scripts they write for themselves, and it is important to understand these scripts in order to be able to use them in designing homework assignments. A typical script for violent thinkers runs something like, “I must be having these thoughts because I’m really psycho and want to do these things. Maybe I’ll lose control and really do them. If I do act on my thoughts they’ll lock me up forever. That will be horrible for my family and me; they will suffer because of what I did and I will suffer knowing what I did to them and to my victim. I won’t be able to live with the guilt. I’ll either die in prison or kill myself.” Scripts such as these are worked into a series of graduated assignments.
Finally, I would like to share some rules that my patients find helpful in dealing with violent thoughts and other forms of OCD:
- Expect the unexpected — you can have an obsessive thought any time or any place.
- Never seek reassurance. Instead tell yourself the worst will happen or has happened.
- Always agree with all obsessive thoughts — never analyze or argue with them.
- If you slip and do a compulsion you can always mess it up and cancel it out.
- Remember that dealing with your symptoms is your responsibility alone. Don’t involve others.
- When you have a choice, always go toward the anxiety never away from it.
What to Watch
Please watch the videos below relating Intrusive Violent Thoughts OCD.
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What to Do
Create your own exposure hierarchy. Follow the link below to access instructions.
What to Measure