Harm OCD vs. Suicidal and Homicidal Ideation: Why the Difference Matters
⚠️ Trigger Warning: This post discusses intrusive thoughts, suicide, and self-harm.
Why This Distinction Matters
For people with OCD, especially Harm OCD, intrusive thoughts about self-harm or harming others can feel terrifying. But here’s the challenge: these thoughts can sometimes look very similar on the surface to suicidal or homicidal ideation (SI/HI).
Understanding the difference is crucial for:
Diagnosis – knowing what someone is really experiencing.
Safety – making sure risk is evaluated correctly.
Treatment planning – choosing the right approach.
Clarity – giving both clients and professionals a sense of direction and hope.
Harm OCD: Intrusive Thoughts Without Desire
Harm OCD is defined by intrusive, ego-dystonic thoughts—thoughts that go against the person’s values and desires.
Key features of Harm OCD:
Thoughts occur frequently and repetitively.
They are unwanted and distressing.
They bring intense guilt, shame, and fear.
They are often paired with compulsions like avoidance, checking, or reassurance-seeking.
The individual does not act on the thoughts.
Example: Someone with Harm OCD might think, “What if I lose control and stab my partner with this knife?” This thought horrifies them, so they hide the knives—an avoidance compulsion.
Suicidal or Homicidal Ideation: Desire or Intent
By contrast, true suicidal or homicidal ideation can look very different.
Key features of SI/HI:
Thoughts occur less often but feel more voluntary.
They are usually tied to negative emotions like despair, hopelessness, or anger.
They may bring a sense of comfort or relief rather than fear.
They may include wishing, fantasizing, or planning to cause harm.
In some cases, the individual acts on the desire or moves toward intent.
Example: Someone experiencing SI may think, “I can’t go on anymore. Ending my life feels like the only way out.” Unlike Harm OCD, the thought aligns with an actual wish or intent.
Where It Gets Complicated
It’s important to note that a person can experience both OCD and genuine suicidal thoughts at the same time. This overlap can make things confusing for clients and for providers, which is why careful assessment is essential.
Unfortunately, research shows that OCD is often misdiagnosed. One study found that 38.9% of mental health professionals misidentified OCD, especially when symptoms involved taboo themes like sexual orientation (77%), pedophilia (42.9%), aggression (31.5%), or religion (28.8%) (Glazier, Calixte, Rothschild, & Pinto, 2013). Another found that 50.5% of primary care physicians misdiagnosed OCD, with high rates of error around sexual orientation (84.6%), aggression (80%), compulsive speech (73.9%), and pedophilia (70.8%) (Glazier, Swing, & McGinn, 2015).
These numbers highlight why it’s so important to increase awareness, training, and accurate diagnosis.
Hope and Treatment
Whether someone is experiencing Harm OCD, suicidal ideation, or both, the good news is that there is help.
For Harm OCD: Exposure and Response Prevention (ERP) is one of the most effective treatments. ERP teaches people to face their intrusive thoughts and triggers without engaging in compulsions, gradually reducing anxiety and breaking the OCD cycle.
For Suicidal Ideation: Suicide-specific treatments may include safety planning, therapy for co-occurring conditions (like depression, PTSD, or substance use), and reducing access to lethal means.
Both require compassion, clarity, and the right clinical approach. With effective treatment, people can move from confusion and fear to understanding and hope.
✦ Next week’s post (the final in this series): We’ll explore treatment options more deeply, highlighting how Harm OCD and suicidal ideation are approached differently in therapy and why that distinction matters.
Sources:
International OCD Foundation (IOCDF.org)
Glazier, Calixte, Rothschild, & Pinto (2013)
Glazier, Swing, & McGinn (2015)
Springer & Tonlin (2020)
