I remember the first time I met the mother of a young adolescent who presented with self-harm obsessions. She was scared about these thoughts because a psychiatrist, who was a friend of hers, previously told her, “If I really did not know you and XXX, I would call the police because I am not certain about the truthfulness and dangerousness of these thoughts.” This is an example of a situation that can happen to us as mental health professionals and to our patients with (self) harm OCD. Some people with OCD, in fact, can experience aggressive and death related obsessions. Unfortunately, they may be subject to inappropriate risk assessments, with negative consequences for them. In fact, an incorrect, useless, and long risk assessment only can increase the fear, the sense of guilt, and the embarrassment related to the intrusive thoughts. Consequently, patients could experience increased distress, mistrust of health professionals, and familial/legal problems.
So, what can a mental health professional do when presented with a patient who may be experiencing thoughts of self-harm? What are some guidelines to distinguish between a real self-harm risk from self-harm OCD? Here are some general rules to follow when assessment and diagnosis seem difficult.
In general, if the therapist is not an expert about the risks related to intrusive, aggressive, and death-related thoughts in OCD patients, he/she should consult an expert colleague in this field for a specific assessment before reporting the case to the authorities. This foresight may prevent unpleasant situations for the therapist, but overall for the patients.
Another recommendation is the evaluation of comorbidity with depression and the presence of previous self-harm or suicide attempts. The presence of depression and/or previous self-harm or suicide attempts are two high-risk factors for current and/or future self-harm behaviors, regardless of a presence (or not) of a diagnosis of OCD.
The therapist must remember that the intrusive thoughts are considered unacceptable and disturbing by the OCD patients. These obsessions are “ego-dystonic” meaning that the thoughts occur against the volition of the patients and are inconsistent with the patients’ value system. Many times, we hear patients with self-harm OCD say, “I would never be the person who can harm him/herself.” Therefore, a difference between a person who has self-harm OCD and a person who really wants to harm themselves is not the content of the thoughts; however, the appraisals that patients with self-harm OCD attach to the occurrence and/or the content of the thoughts.
Moreover, another characteristic that a therapist has to consider is that people with self-harm OCD generally avoid situations or activities where there is a risk for themselves, such as being on a rooftop of a tall building or crossing a railroad. In the same way, they try to mentally avoid, suppressing or neutralizing, the intrusive thoughts. People who have real self-harm intentions do not necessarily try to avoid these situations or thoughts.
Another difference is related to the frequency of the thoughts that patients with self-harm OCD reported. Since the patients view the thoughts as disturbing, they constantly monitor their mind for signs of their presence. This mental behavior creates a vicious cycle because the patients, involuntary, focus their attention on the intrusive thoughts which increases the frequency that these thoughts enter their minds. People with self-harm intentions do not constantly monitor the frequency of their thoughts.
The therapist also should consider emotions. People with self-harm OCD are extremely anxious and distressed by the thoughts, images, and/or urges. Furthermore, they may feel embarrassed and guilty about having these intrusive thoughts. Finally, there are greater chances that patients with self-harm OCD are more motivated to seek help to reduce the anxiety associated with their thoughts, than a person without distress surrounding these thoughts.
Please consider these guidelines when assessing patients for self-harm, as misdiagnosis may increase distress and decrease motivation in patients.
1 Veale, D., Freeston, M., Krebs, G., Heyman, I., & Salkovskis, P. (2009). Risk assessment and management in obsessive–compulsive disorder. Advances in psychiatric treatment, 15(5), 332-343.