Harm-centered intrusive thoughts can be a sign of obsessive-compulsive disorder (OCD) that all-too-often flies under the radar. One mom shares her journey to a diagnosis—and a fear-free life.

By Laura Ojeda Melchor
November 10, 2020
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In her 2006 book, Down Came the Rain, actress Brooke Shields gave a voice to the intrusive, scary thoughts that many women have after giving birth. (She famously recounted seeing vivid images of her baby "flying through the air and hitting the wall in front of [her].")

Graphic, disturbing thoughts like this can be signs of perinatal mood and anxiety disorders (PMADs) such as postpartum depression, which Shields suffered from, or postpartum OCD. But they're not reserved for the postpartum period. The first time I had a terrifying thought about hurting someone I loved, I wasn't pregnant; I was 18 years old and a freshman in college.

I was walking to class at my university in California, palm fronds waving under a blue sky. Feeling excited about my upcoming visit to my home state of Montana for my sister's graduation from high school, out of nowhere, a horrific thought popped into my brain: What if, on that visit, I crept into my sister's room and stabbed her while she slept?

I stopped walking, trying to process the horror of the thought. I waited for it to go away, but it didn't. Instead, it infected every crevice of my mind. What if you do that? my brain whispered in a panic. I became terrified that I'd somehow hurt my sister.

I spent the rest of the day arguing with myself that I would never hurt her, that I loved her, that she was my best friend. But the more I tried to secure confidence that I'd never do such a thing, the more traumatic the thoughts became. My mind offered me grotesque images of my sister's blood gushing from her neck, of my parents weeping and staring at me in disbelief before calling the police, of me sitting in a high-security prison, my sister dead and my future obliterated. In my dorm room that night, I fell asleep crying out of anguish, grief, and complete loneliness. I knew I could never share these thoughts with anyone.

Before long, it wasn't just my sister I was afraid of hurting. Images of me hurting my boyfriend, my parents, and anyone that I loved tormented me every waking hour. News stories of people murdering their families became triggering and anxiety-inducing.

I made a pact that I'd kill myself before I hurt anyone else. The images of me stabbing myself with a knife became a comfort. At least if I was dead, everyone around me would be safe. For four more years, I suffered in silence.

What I didn't know was that there was a medical reason for my thoughts: aggressive obsessions sometimes referred to as "Harm OCD"—a symptom of obsessive-compulsive disorder (OCD) that all-too-often flies under the radar.

All About 'Harm OCD'

Despite the fact that I've suffered from emetophobia (a severe fear of vomiting), panic disorder, and generalized anxiety disorder since I was a child, I never considered that my intrusive, unwanted thoughts might belong to a mental illness, too. Yet, OCD—the mental health condition marked by repetitive, unwanted thoughts, sensations, or ideas that drive sufferers to carry out compulsions—is sometimes also marked by what's known as "aggressive obsessions" that center around fears of harming a loved one.

Of course, most people experience unwanted, disturbing thoughts at some point in life. You might take a knife out of the dishwasher, for example, and have an image of the knife stabbing your significant other. It's just that in a non-OCD brain, this thought isn't just dismissed as disturbing, but irrelevant and meaningless. For those with harm-centered intrusive thoughts, the brain malfunctions, explains Patricia Celan, M.D., a postgraduate psychiatry resident at Dalhousie University in Canada.

In people like myself, these harm-based thoughts have significance. They take on new meaning. This can lead to high levels of anxiety, compulsions, and rituals to diffuse the presumed dangerous thoughts, adds Sabrina Romanoff, Psy.D., a clinical psychologist at Lenox Hill Hospital in New York City.

Researchers used to consider OCD an anxiety-based disorder, but mounting research and experts like Dr. Celan note that OCD likely comes about as a result of inadequate neurotransmitters in the brain—something that weakens your brain cells' ability to communicate effectively. These faulty connections result in both OCD's different array of symptoms and intense anxiety.

So when a psychiatrist gave me an official diagnosis of OCD with harm-centered intrusive thoughts, I had an answer for the years of agony I'd been living with. But if you have these types of thoughts, getting a diagnosis of OCD isn't always easy.

People tend to assume that OCD is defined solely by its more hallmark symptoms of checking, cleaning, or performing rituals. But many OCD sufferers experience intrusive thoughts that are embarrassing, horrific, and shameful. Psychiatrists speculate that's part of the reason why the average time-to-treatment for any type of OCD is 11 years. It's hard to seek out help when you're afraid to talk about your thoughts.

OCD with harm-centered intrusive thoughts also has triggers, including stressful or traumatic events, depression, or becoming a parent. In fact, people who have these thoughts before having a child tend to experience a resurgence of symptoms once their baby is born. (In general, whether or not you have OCD, intrusive thoughts are also common among new parents with some 90 percent of moms and dads experiencing them.)

Personally, when I became pregnant, my thoughts—once under control thanks to therapy—came back in a sickening rush. I made my partner promise to give the baby a bath every day because I was terrified I would push my son's face under the water. And while I longed to feel safe at the thought of holding and cuddling him, I couldn't escape other thoughts: What if I dropped him on his head? What if I accidentally stabbed him?

When I was 9 months pregnant, I saw a psychiatrist who wound up prescribing me Zoloft. To this day, it keeps my thoughts from feeling real and scary. Sometimes I look back at the way I felt for so many years—like an up-and-coming criminal. I almost wonder how I could've ever felt so terrified of intrusive thoughts.

If left untreated, OCD has serious consequences, including avoiding being alone with your child, anxiety, and depression. And while harm-centered intrusive thoughts can feel debilitating, help is out there. Start with these four steps if you're suffering.

Help for 'Harm OCD'

Do some research

Reading about harm-centered intrusive thoughts can help you better understand why your mind does what it does and empower you to find ways to manage the condition. Most importantly, says Dr. Celan, is "understanding that Harm OCD is an illness and does not indicate that someone is a bad person is essential to recovery." Some websites and books offer mindfulness-based cognitive behavioral therapy (CBT) exercises that can help ease symptoms, too. A few great online resources to explore: the OCD Center of Los Angeles, The Center for Treatment of Anxiety and Mood Disorders, and the Manhattan Center for Cognitive Behavioral Therapy, suggests Shoshana Bennett, Ph.D., a clinical psychologist, and perinatal specialist. For new moms experiencing an increase in OCD symptoms, reading Postpartum Depression for Dummies and Beyond the Blues: Understanding and Treating Prenatal and Postpartum Depression & Anxiety can help.

Another recommended book for those suffering from Harm OCD is Overcoming Harm OCD: Mindfulness and CBT Tools for Coping with Unwanted Violent Thoughts, which offers up-to-date research, exercises, and advice for coping with Harm OCD from Jon Hershfield, M.F.T., the director of The OCD and Anxiety Center of Greater Baltimore.

Remind yourself that thoughts are thoughts

Harm OCD sufferers are no more likely to hurt loved ones than non-sufferers, says Kendra Kubala, Psy.D., a licensed psychologist in New York and Pennsylvania. Dr. Celan adds that the very reason the thoughts are highly distressing is that sufferers don't want to hurt anyone.

Knowing this, whenever an intrusive thought pops into your head, try repeating a mantra such as this one that has helped me: "Thoughts are thoughts, not threats. Feelings are feelings, not facts. Sensations are sensations, not mandates to act."

Also, as best you can, try not to stop or redirect thoughts. "Compulsive rituals to stop the thoughts may become part of the illness, such as repeatedly checking if someone has been harmed or hiding sharp objects," says Dr. Celan. Simply letting thoughts sit in your brain and see them for what they are—the meaningless babble of a complex organ—helps to not assign any level of importance to them, experts say.

Find a specialist

If you have harm-based thoughts, finding a knowledgeable mental health provider is critical. If your mental health professional isn't appropriately trained, they might mislabel you as suicidal—or even as a threat to others, notes Dr. Kubala.

For mothers, it's especially important to find a perinatal specialist, says Dr. Bennett. "Otherwise, the professional might mistake this disorder for postpartum psychosis—a completely different disorder—and the mom and her family might be unnecessarily traumatized," she says. With a professional who isn't properly trained in the condition you run the risk of having children unnecessarily taken away temporarily, for example, she says. "This is the worst possible outcome for the mother and for her family and it happens due to the ignorance of often well-meaning professionals who have not studied postpartum mental health."

If you're pregnant or a new mother, Postpartum Support International (PSI) has an online directory of therapists trained in perinatal mental health, including OCD. The International OCD Foundation also has an online resource directory that'll connect you with therapists in your area. Sometimes, therapists have free phone consultations. Take advantage of these, suggests Dr. Kubala.

Be open to medication

Serotonin is an essential neurochemical in your brain and research suggests it plays a role in how our brains process stress and anxiety. The latest research on OCD also indicates that those who suffer from OCD have a serotonin deficiency in certain regions of the brain. Several common antidepressants called selective serotonin reuptake inhibitors (SSRIs)—such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), among others—work well in reducing intrusive thoughts or images of OCD and any associated compulsions, says Dr. Celan. "The brain naturally produces serotonin, but for some people, it gets metabolized or cleared too quickly. SSRIs work to ensure that serotonin stays in the brain longer, reducing the symptoms of OCD."

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