For Clinicians

Harm OCD Risk Assessment: A Clinician's Guide

Harm OCD risk assessment means separating primary risk, the feared act in the obsession, from secondary risk, the depression, avoidance and self-harm the disorder can drive, without your assessment becoming the patient’s next compulsion. Violent, sexual and self-harm intrusions are common presentations of OCD and are often misread as danger. An incorrect or unduly lengthy risk assessment can increase doubt, avoidance and compulsions (Veale et al, 2009).

A bad assessment can also erode trust in professionals, which is the last thing this patient needs. Here’s the short version, the one I’d want every assessor to have: 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).

Why does phenomenology come first in a harm OCD assessment?

You can’t assess risk in OCD accurately without 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 highly prevalent in the general population across countries and cultures (Pascual-Vera et al., 2019), and their content is largely indistinguishable from clinical obsessions (Rachman & de Silva, 1978). The difference lies not in the content but in the appraisals the person attaches to it. Hold onto that, because the most common error I see is treating disturbing content as evidence of risk. The content tells you what the person fears. On its own, it doesn’t tell you what they intend.

What is the difference between primary and secondary risk?

Primary risk is the feared act in the obsession itself. Secondary risk is the harm that compulsions, avoidance, depression and hopelessness cause along the way, and it is the one that tends to get missed.

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.

How do you distinguish harm OCD from genuine intent?

You distinguish harm OCD from genuine intent by the overall pattern, never by a single feature. 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. Sexual intrusions about children are covered for patients on our POCD page.

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 consultation with a clinician experienced in OCD are appropriate. Self-reported arousal is an unreliable indicator, as anxiety and self-monitoring can themselves increase physiological signs.

How should you assess self-harm and suicide risk in harm OCD?

Assess it in two parts: formulate clearly ego-dystonic self-harm obsessions as you would any other obsession, and assess secondary suicide risk separately with a standard suicide-risk assessment. 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.

Which covert compulsions should you ask about?

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. Much of the ritual in harm OCD is mental, which is why these presentations are often mislabelled as purely obsessional, or Pure O. In a large field trial, most patients had both mental and behavioural compulsions (Foa et al., 1995). These covert behaviours are the maintaining mechanism, and they are also what the person will try to draw the assessor into providing.

What assessment errors make harm OCD worse?

The errors that make harm OCD worse mostly turn the assessment into part of the ritual: assessing for too long, reassuring, chasing certainty, delivering confidentiality limits as a threat, and misreading obsessions as psychosis.

How do you help a patient disclose intrusive thoughts?

Explain the limits of confidentiality plainly at the start, and if the person still can't say the thought, offer the content as options. People with OCD are often deeply ashamed of their intrusive thoughts and will not volunteer the content, particularly when confidentiality limits were delivered as a warning rather than explained. 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? In my experience, gentle, non-judgmental inquiry elicits far more than a forensic line of questioning.

Which treatments should follow the assessment?

The two evidence-based treatments for OCD are cognitive behavioural therapy, specifically Exposure and Response Prevention, and SSRIs, both first-line in the American Psychiatric Association's practice guideline (Koran et al., 2007). Cognitive work targets the appraisals of responsibility, thought-action fusion, and the meaning and control of thoughts, rather than the truth of the obsession.

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.