"Split," the most recent thriller from M. Night Shyamalan, was the top-grossing movie during its first weekend of release. It tells the story of a man with Dissociative Identity Disorder (DID, formerly "Multiple Personality Disorder") who kidnaps and terrorizes three teenage girls.
Judging from the trailer, "Split" seems sure to creep out most viewers. For some individuals with obsessive-compulsive disorder (OCD), the movie might trigger a very different reaction—a gripping fear that they themselves might commit some horrific act. An individual might think, for example, "DID is a mental disorder, and so is OCD, so maybe I'm capable of doing really bad things to other people." These frightening thoughts are the obsession in OCD.
Common obsessions in this kind of OCD include:
All of us want to prevent bad things from happening if we can, so the person with OCD will do a compulsion to try to make sure nobody gets hurt. For example, imagine that a person is holding a knife and has the sudden thought, "I could stab my family member right now," even though he has no desire to. A person with OCD might put down the knife and say a brief prayer to make sure he doesn't act on the thought.
Compulsions often provide at least temporary relief from the worry and anxiety. They’ll generally involve trying to prevent the thoughts, trying to prevent the feared actions, and trying to make sure I’m not a bad person. However, the net effect of compulsions is a strengthening of the OCD and a greater fear of the upsetting thoughts.
One of the most common compulsions is reassurance, either from oneself or others. The person might tell herself, “You would never do that. You’re not a violent person." Or they might ask their spouse whenever they have a compulsion, “You don’t think I would actually do anything like that, do you?”
Sometimes a person with this type of "Harm OCD" will seek out an OCD expert not only for treatment but as a form of “checking with an authority.” If the expert confirms that it's OCD, the individual will feel relieved. Unfortunately the relief from reassurance doesn’t tend to last long, and only leads to needing more reassurance.
Other rituals can include compulsive praying and checking repeatedly for evidence that the person isn't dangerous—which often backfires if they find similarities between themselves and a person who committed some gruesome act. Avoidance is also a very common response to Harm obsessions: avoiding the news in case there’s a triggering story, movies and TV shows with violence, knives and other sharp objects, the grocery store and other places with lots of people, and anything else that leads to the obsessions. Although avoidance might provide some temporary relief, it plays the same role as compulsions in keeping the person in the clutches of OCD.
This cycle of obsessions and compulsions happens countless times in OCD, filling the person's days with fear and dread. The fallout can be devastating. A man might never marry out of fear that he could end up hurting his kids. A college student may never eat with her friends in the dining hall because she doesn't want to stab one of them with her silverware. The only person actually harmed is the individual with Harm OCD.
There is also an incredible emotional toll from living every day worried—even convinced—that the person is a terrible human being. Depression frequently follows as a result of these self-condemning beliefs and the social isolation, and in some cases even suicide.
A lot of what's isolating about this form of OCD is that it's so hard to talk about. How do you tell someone who doesn't understand OCD that "I'm bothered by thoughts of stabbing people, all the time," or that "I'm worried I'm going to hurt a child"? Even the mental health community historically has misunderstood this condition. Obsessions about harm used to be called "Aggressive" obsessions based on the old-fashioned belief that having this condition means the person "deep down" really wants to do the things she's afraid of.
In reality, a person with Harm OCD is probably less likely than the average person to hurt anybody. Thus it's important to distinguish between this form of OCD and a truly high risk for causing harm. A person who is actually dangerous may have a history of assault and will feel a desire to hurt others. The person may try not to give in to these urges to avoid getting in trouble, but not because they're horrified by the thought of acting on them.
People with Harm OCD, on the other hand, typically say that hurting someone is the last thing they want. Even thinking about it is very upsetting, and to actually do something heinous would be unimaginable. And yet the thoughts come back, over and over.
I know that trying to distinguish between these two categories will only feed into the doubt that plagues those with Harm OCD. After all, how can I be completely sure that these thoughts aren't a reflection of my desires? And what if I suddenly exchange my old identity for a new, sociopathic one? Or what if I've been faking it all along, pretending to be "normal," acting like it's OCD, and have succeeded at fooling everyone, myself included?
When it comes down to it, we can't be completely sure of anything, and the effort to be 100% certain that I'm not an evil person actually plays into OCD's hands.
The person with Harm OCD may well wonder, “But if I don’t want to act on these thoughts, why am I thinking about them all the time? What kind of person does that?” The answer is: someone who doesn’t want to do anything wrong.
Importantly, thoughts like "What if I pushed this person down the stairs?" are not unique to OCD; most people (including me) have them, whether or not they have OCD. Our minds are great at imagining bad things that haven’t happened so we can prevent them. If we see a knife near the edge of the counter, our minds can easily imagine its getting knocked off and hurting someone. Having this image come to mind helps us prevent it by moving the knife away from the edge.
So the difference in Harm OCD isn’t the thoughts themselves but rather the reaction to these thoughts. For most people, having the sudden thought, "I could shove this person in front of the oncoming train" might seem a little weird, and then the mind will move on to something else—no big deal.
In contrast, a person with OCD will be horrified by the thought and may worry there’s something dreadfully wrong with him. To make sure he's not a bad person and won't act on the thoughts, he’ll try to never have a violent thought.
Unfortunately trying not to have violent thoughts only causes them to multiply. We can't keep something out of our minds without thinking about it, so the occasional thought of harm will morph into daily, hourly, even constant thoughts.
What’s worse, constantly thinking about terrible things can make them feel less upsetting simply from the repetition. A person with Harm OCD then might be horrified that he’s no longer sufficiently repulsed by the thoughts, mistakenly believing he's getting closer to acting on them.
Thankfully exposure and response prevention, or ERP, is a highly effective treatment for Harm OCD. (For a description of ERP see Seven Ways Therapists Can Mess Up the Best OCD Treatment.) ERP is essentially about doing the opposite of what OCD demands. Exposure will involve doing things that trigger obsessions, like holding a knife near another person, being around kids, or watching the news.
Treatment begins with the easier items on the list and continues through gradually more difficult ones. Through repetition the exercises become less difficult. Exposure is always coupled with prevention of the compulsions—exposure without ritual prevention won’t be helpful. The person will need to stop seeking reassurance, saying ritualized prayers, checking to see if they might be prone to violence, and so forth. Resisting compulsions gets easier with practice.
Stepping out of the fight against OCD-related thoughts strips them of their power. With the right treatment, the obsessions will decrease, and in some individuals may go away completely. People also generally feel more confident that they won’t act on their thoughts, and can shrug them off more easily.
However, the point of ERP is not to know for sure that the obsessive thoughts aren’t a concern, or even to get rid of them. Perhaps the most important part of the treatment is becoming more comfortable living with some degree of uncertainty. After all, we can’t be 100% certain that any given person won’t act violently, myself included. We can learn to better tolerate that uncertainty.
Like anything worthwhile, the work of ERP can be challenging—as well as rewarding as it leads to freedom from OCD.