Psychiatry · Year 2 · from Psychiatry
Case 3: Obsessive-Compulsive Disorder - Harm Obsessions
Patient Presentation
Demographics: 35-year-old male
Chief Complaint: "I have terrible thoughts about hurting my daughter. Please help me."
History of Present Illness: A 35-year-old father of a 2-year-old girl presents in significant distress. For the past 8 months, he has been experiencing intrusive thoughts about harming his daughter - images of stabbing her, throwing her down stairs, or suffocating her. He is horrified by these thoughts and emphasizes, "I would never hurt her. I love her more than anything." The thoughts occur dozens of times daily, especially when he is alone with his daughter. To prevent acting on these thoughts, he has hidden all knives in the house, refuses to be alone with his daughter, avoids going near stairs when holding her, and repeatedly seeks reassurance from his wife that he is not dangerous. He mentally reviews his actions constantly to confirm he has not harmed her. He has begun avoiding his daughter, which causes him profound grief. He has seen multiple providers who reassured him he is not dangerous, but the relief lasts only minutes. He has no history of violence, no desire to harm anyone, and no psychotic symptoms. He tearfully states, "I feel like a monster."
Mental Status Examination:
- Appearance: Visibly distressed, tearful
- Behavior: Anxious, seeking reassurance
- Mood: "Terrified"
- Affect: Anxious, distressed, tearful
- Thought content: Ego-dystonic intrusive thoughts of harm; no intent or desire to act; no psychosis; passive SI due to shame
- Insight: Good - recognizes thoughts are irrational and ego-dystonic
Workup:
- Y-BOCS: Score 28 (severe)
- PHQ-9: Score 16 (moderate depression)
- Detailed risk assessment: No actual intent to harm, no psychotic symptoms, thoughts are ego-dystonic and distressing (consistent with OCD, not concerning for violence)
Diagnosis: Obsessive-Compulsive Disorder, harm obsession subtype (forbidden thoughts), with good insight
Treatment:
- Extensive psychoeducation that harm obsessions in OCD are not predictive of violence - the distress and ego-dystonic nature distinguish OCD from actual harmful intent
- Explained that reassurance-seeking and avoidance maintain the cycle
- Started sertraline 50 mg daily, titrated to 200 mg
- Referral for specialized OCD treatment with ERP:
- Imaginal exposure to feared harm scenarios (writing scripts, visualizing)
- In vivo exposure: gradually spending time alone with daughter, near knives
- Response prevention: eliminated reassurance-seeking, stopped checking behaviors
- Family therapy to address impact on marriage and help wife stop providing reassurance
- At 12 weeks: Y-BOCS improved to 18, thoughts still present but less distressing
- Able to be alone with daughter, knives returned to kitchen
- At 6 months: Near-complete resolution, Y-BOCS 11
Clinical Pearl: Harm obsessions (violent, sexual, or blasphemous intrusive thoughts) are among the most distressing OCD presentations because patients fear they are dangerous. These thoughts are ego-dystonic (inconsistent with values), cause marked distress, and are NOT associated with violence risk - the very fact that the thoughts are distressing and unwanted distinguishes OCD from actual harmful intent. Education about this distinction is therapeutic. Avoidance and reassurance-seeking are maintaining behaviors that must be addressed in ERP.
Clinical Image
Image Description: Neuroimaging showing hyperactivity in the orbitofrontal cortex-striatum-thalamus circuit in OCD. This cortico-striato-thalamo-cortical (CSTC) loop shows increased activation in patients with OCD compared to healthy controls, particularly in the orbitofrontal cortex and caudate nucleus.
Attribution: Brain imaging demonstrating the neural basis of OCD. CSTC circuit hyperactivity is a consistent finding across neuroimaging studies. Educational use.
Image Source: Wikimedia Commons - Search for "OCD brain imaging" or "cortico-striatal circuit"