For Clinicians

Harm OCD Risk Assessment: A Clinician's Guide

Intrusive thoughts of violence, sexual harm, and self-harm are common presentations of OCD, and they are frequently misread as indicating risk. The assessment itself can harm the patient: Veale and colleagues note that an incorrect or unduly lengthy risk assessment tends to increase doubt, avoidance, and compulsions, and can erode trust in professionals. This guide summarises how to assess risk in harm OCD accurately and safely, drawing on the risk framework of Veale et al (2009) and the cognitive model of Purdon (2004).

Start with the phenomenology

Accurate risk assessment in OCD depends on a working knowledge of the disorder. Obsessions are unwanted, intrusive thoughts, doubts, images, or impulses that are distressing and ego-dystonic. Compulsions are repetitive behaviours or mental acts performed to reduce that distress, and they may be overt (checking a door) or entirely covert (mentally reviewing an intention, silently reassuring oneself).

Unwanted intrusive thoughts, including violent ones, are near-universal in the general population, and their content is largely indistinguishable from clinical obsessions. The difference lies not in the content but in the appraisals the person attaches to it. Keeping this in mind prevents the most common error, which is treating disturbing content as evidence of risk.

Primary risk and secondary risk

A useful discriminating question is whether an urge is the obsession or arises as a response to it. An obsessional fear of cutting oneself carries low primary risk. But where the obsession is of harming others, a person may cut themselves to prevent that feared harm, which is a secondary risk that must be assessed.

Distinguishing OCD from genuine intent

The following factors, drawn from Veale et al (2009) and Purdon (2004), suggest that intrusive thoughts of violence or sexual harm reflect OCD rather than intent. No single factor is sufficient. The overall pattern is what matters.

By contrast, a person acting on paraphilic or antisocial impulses is more likely to find the thoughts ego-syntonic, to have a history of consistent behaviour, to approach rather than avoid opportunities, and to be concerned about the consequences to themselves rather than the victim. Where genuine doubt remains after a careful assessment, forensic assessment and specialist consultation are appropriate. Self-reported arousal is an unreliable indicator, as anxiety and self-monitoring can themselves increase physiological signs.

Self-harm and suicide risk

Obsessional thoughts of self-harm or suicide present the same apparent primary risk as thoughts of harming others, and where they are clearly ego-dystonic they can be formulated the same way. Secondary suicide risk, however, requires careful and independent assessment. People with OCD are at greater risk of suicide than the general population; in the survey by Torres et al (2006), at least a quarter had attempted suicide at some point.

Motivation typically arises from hopelessness about recovery or access to treatment, or from the belief that one is a genuine danger to others. In a small number of cases a person may take their own life as a compulsive act to protect others, and self-harm can itself become a compulsion used to neutralise an unacceptable thought. Comorbid depression and personality disorder complicate the picture. Assessing obsessional content does not remove the need for a standard suicide-risk assessment.

Recognising covert compulsions

Much of the ritual in harm OCD is mental, which is why these presentations are often mislabelled as purely obsessional. Ask specifically about mental checking of intentions, reviewing memories and movements for evidence, silent reassurance and self-argument, neutralising an image with a good thought or prayer, confession, and reassurance-seeking from others or online. These covert behaviours are the maintaining mechanism, and they are also what the person will try to draw the assessor into providing.

Common assessment errors

Eliciting disclosure

People with OCD are often deeply ashamed of their intrusive thoughts and will not volunteer the content, particularly after being warned about confidentiality limits. Where a person cannot disclose, a normalising, multiple-choice invitation is effective. For example: many people I work with have intrusive thoughts they find repugnant, about harming someone, about sex, or about a child, and they are usually the opposite of what the person wants. Is anything like that happening for you? Gentle, non-judgmental inquiry elicits far more than a forensic line of questioning, and it does not increase risk.

Treatment implications

The two evidence-based treatments for OCD are cognitive behavioural therapy, specifically Exposure and Response Prevention, and SSRIs. Cognitive work targets the appraisals of responsibility, thought-action fusion, and the meaning and control of thoughts, rather than the truth of the obsession. As Salkovskis put it, the problem to address is that the person is not dangerous, but is very worried about being dangerous.

References

• 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. DOI.
• Purdon C (2004). Cognitive-behavioral treatment of repugnant obsessions. Journal of Clinical Psychology, 60(11), 1169-1180.
• Rachman S, de Silva P (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233-248. PubMed.
• Torres AR, Prince MJ, Bebbington PE, et al (2006). Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking. American Journal of Psychiatry, 163(11), 1978-1985.