A woman is tormented by thoughts of stabbing her child.  A man is horrified by images of touching his daughter inappropriately. A teenager is plagued by impulses to shout out blasphemous thoughts in church.  When many people think of OCD, compulsive hand washing and repeated checking behavior come to mind. In reality, there are many different types of OCD themes and numerous ways in which the disorder wreaks havoc in a person’s life. One of the lesser known (but not uncommon) forms of OCD involves  repugnant obsessions. This refers to unwanted, intrusive thoughts, images, or impulses that are generally violent, blasphemous, or considered sexually deviant to the sufferer.  Examples of violent obsessions might be images of hanging oneself, thoughts of stabbing a loved one, or of pushing someone onto the subway tracks. A person suffering from blasphemous obsessions might experience satanic imagery while praying or have urges to curse God. Sexually repugnant obsessions often include thoughts about incest, child molestation, or homosexuality. It is not uncommon for individuals to suffer from a variety of repugnant obsessions involving violent, blasphemous, and/or sexual themes.

Repugnant obsessions often lead sufferers to be tormented by fears about their own nature (internal threats) rather than by dangers such as germs or catastrophic accidents (external threats). Freudian theories contend that these types of obsessions signify either real but consciously denied desires, or at least some type of unconsciously significant, repressed issue. Cognitive-behavioral theories maintain just the opposite—that these thoughts are entirely meaningless and signify absolutely nothing. Many studies have shown that virtually everyone has had intrusive thoughts, images, or impulses. CBT therapists believe that problems with intrusive thoughts develop and are maintained by cognitive (how we think) and behavioral (how we react) factors.

So why are some OCD sufferers tormented by these thoughts while most people hardly even notice them? The difference lies in both the meaning sufferers attribute to their intrusive thoughts and the escape and avoidance behaviors in which they engage. For example, imagine that you are on a balcony in a high-rise. As you look down, you think, “Gee, that’s a long way down. If I jumped I’d really go ‘splat.’ ” Most people would think this was a silly thought, perhaps even a bit humorous, pay it no mind, and go on with their day. However, someone with OCD might think, “Oh my gosh! Why did I think that? What does this mean? Do I want to jump? Maybe I should avoid tall buildings from now on to keep myself safe, just in case. I don’t feel like I want to jump, but maybe I do, deep down.” The person assumes the initial thought is meaningful (i.e. “There must be a reason I had that thought…!”) and then goes on to misinterpret, to a catastrophic degree, just what that meaning might be (i.e. “Maybe I secretly want to kill myself!”). This extreme misinterpretation of  the significance to the thought begins the cycle of doubt. Attributing meaning to the thought, along with other cognitive errors, (which are negative and unrealistic thinking patterns, and beliefs) lead sufferers to fear that they are immoral, dangerous, and/or deviant. Other types of cognitive errors that often contribute to the problem are “thought-action fusion (the belief that thinking something is the moral equivalent of doing it, or that having an urge means you will do it) overestimation of threat, excessive responsibility, beliefs about the importance of mental control, and intolerance of uncertainty.

A number of behavioral factors are important in the perpetuation and maintenance of the disorder. Avoidance (i.e. no longer going out on balconies) helps the person evade anticipated episodes of anxiety. Compulsive behaviors (checking, seeking reassurance, rationalizing, attempts to suppress the thought, neutralization strategies etc.) help the person escape when he/she does feel anxious. This escape and avoidance behavior also reinforces beliefs about the dangerousness of the thought, image, or impulse.

People are often ashamed and afraid to reveal these obsessions, as they fear that the thoughts, images, and impulses must reflect their hidden, inner desires and that they must truly be bad, dangerous, and/or deviant people. Sometimes sufferers fear they will be ostracized and/or turned into the authorities as a result of “confessing.” By the time sufferers muster up the courage to come in for treatment, they are usually feeling extremely desperate. The good news is that cognitive-behavioral treatment for repugnant obsessions is extremely effective. These types of obsessions are treated like any other OCD subtype-- with exposure and response prevention, in which clients are systematically exposed to their fears in a very gradual way. Clients also learn how to identify and correct the faulty cognitive beliefs from which the obsessions develop and grow. Through treatment, clients are able to free themselves from the agonizing cycle of doubt and self-loathing and reclaim their lives. If you or anyone you know suffers with these types of thoughts, please talk to a therapist about getting help. There is hope!

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Behavior Therapy Center of Greater Washington

11227 Lockwood Drive, Silver Spring, Maryland

phone: 301-593-4040  fax: 301-593-9148