Taboo OCD: Demystifying the OCD People are Scared to Talk About

Dr. Moses Appel (Edited by Matthew Shields)

Introduction

Talking about “taboo” OCD can feel uncomfortable—which is precisely why it’s so important. These thoughts are often ignored or hidden, sometimes to the person’s detriment. You may have noticed I’ve placed quotation marks around “taboo” because, as we’ll explore, no thought is truly off-limits. In this blog, we’ll take a closer look at common taboo-themed OCD subtypes and how we treat them.

Despite how disturbing they might seem, taboo OCD subtypes follow the exact same pattern as any other form of OCD. First, the person with a Taboo OCD subtype is subjected to a trigger, causing them distress. In response, they perform compulsions –behaviors or mental acts– that temporarily relieve the distress. Unfortunately, the relief they feel is short-lived, as compulsions cause them to feel even more distress the next time they’re triggered, thereby instigating escalating compulsions. It’s this exhausting cycle of fear and relief that makes proper treatment not just helpful—but necessary. For a further discussion on the OCD cycle, see my blog, “Inside the Loop: Understanding and Overcoming OCD.”

Here are some common subtypes of OCD, interspersed with some taboo OCD thoughts:

1)    Symmetry Obsessions with Ordering Compulsions

2)    Obsessions of Violence/Aggression

3)    Contamination Obsessions with Cleaning Compulsions

4)    OCD Relating to Sexual Taboos

5)    Hoarding

6)    Religious or Blasphemous Themed Obsessions

7)    OCD Suicidal Thoughts

8)    Harm Obsessions with Checking Compulsions

Wait, but isn’t this blog specifically about taboo OCD subtypes? Why mention the others? Why intersperse the taboo ones among them?

I laid it out this way to further enforce that there’s nothing inherently worse about taboo OCD as a subtype. I’ve seen that what makes Taboo OCD especially painful is the way it distorts self-perception: while someone with visible compulsions—like excessive cleaning—is easily seen as having a treatable condition, a person plagued by taboo intrusive thoughts may believe these thoughts make them monstrous or beyond redemption. These are just examples, but they highlight how the content of the obsession can lead to profound shame and isolation.

It's important to highlight that taboo OCD obsessions are often triggered in someone with OCD after they’ve been exposed to material relating to the taboo act in question. For example, if someone hears about a peer they knew who committed suicide, they may start contemplating whether they’re capable of ending their own life too.

Common Taboo OCD Presentations:

Now that we know that experiencing taboo OCD thoughts is no different from other, more popular types of OCD, we can go through some of the more common taboo OCD subtypes.

1) Harm OCD & Obsessions of Violence/Aggression: Imagine that every time you see your neighbor, you have a train of worrying thoughts like ‘What if I punch them? Why do I want to punch them? What kind of person thinks about punching their neighbor? Should I be locked up? It’s important to note that people who have violent thoughts like this don’t want to act on them; instead, they’re afraid they’re going to act on them. 

Fear of stabbing a loved one: One client of mine was haunted by the thought that they might stab their child—despite knowing in their bones they never would. Sometimes, this subtype presents where one’s anxiety relates to accidentally stabbing someone. For example, when chopping vegetables, they’re nervous they may trip and stab someone. In other cases, like with my client, the irrational fear revolves around intentionally stabbing someone else; in their specific case, they believed they needed to hide all the knives in their kitchen to prevent themselves from committing a crime they were never going to perform.

Pushing someone in the subway: This fear might feel very familiar for those living in a major metropolitan area. Again, with Taboo OCD, we're talking about the fear of pushing someone in front of the subway rather than the desire to do so. Like the previous example,  sometimes the thought revolves around accidentally pushing someone in front of a subway– for example, not putting on headphones while waiting for the train because, maybe, you’ll lose concentration and accidentally bump someone onto the tracks– while in other times, people might worry about intentionally pushing someone else in front of the train.

2) Suicidal thoughts: This is another example where someone is, from an OCD perspective, afraid they might act on the “what if” pertinent to their suicidal thoughts. I’ve had several patients like this, who have even taken a leave of absence from school or checked themselves into a hospital, because they were afraid that if they were left alone in a room, how could they certify they wouldn’t take their own life?

Suicidal thoughts are more complicated than some of the other examples here because sometimes, the person engages in genuine suicidal ideation, which we need to address as an independent mental health issue. We assess thoughts involving suicide extremely carefully, so it’s imperative that people with suicidal OCD work with a qualified OCD specialist to discern OCD suicidal thoughts from genuine suicidal thoughts and treat each appropriately. 

From an OCD perspective, someone with suicidal ideations may exacerbate their thoughts from something like ‘Life is meaningless, what is the point of my existence?’ to ‘Oh my God, these thoughts mean that I’m going to take my own life, so now I’m unsafe and need to protect myself.’  

3) Religious/Blasphemous thoughts: These thoughts counter the person’s core values. Common examples include thoughts like: ‘Maybe I hate God.’ or intrusive images of God that one finds inappropriate. To the religious people reading this blog, we know that this person doesn't actually believe what their brain worries over; OCD drives them to question if  they believe these thoughts.

4) Sexual Taboos: There are many ways people experience OCD as it relates to sexual thoughts and feelings. Some of the more common ones include:

a. Intrusive Images: This involves graphic, unwanted sexual images. Here, the person with OCD doesn’t want to be imagining the sexual content, yet they’re bombarded with it anyway. Like with many challenges in life, the more people try to push these thoughts away, the stronger they become. 

b. Incestuous Obsessions: This thought pattern looks something like this: ‘What if I want to engage in a perverse, sexual relationship with a family member?’ Again, and I can't stress this enough, people with this Taboo OCD iteration don't want to engage in these behaviors–they fear they might. Sometimes, people who have this fear might leave the room whenever a family member enters it, even though they don’t really want to engage in sexual contact with them.

c. Sexual Orientation Obsession: Someone who identifies as heterosexual might be deathly afraid over the possibility that they’re homosexual, or vice versa. The point isn't that the person genuinely feels attracted to the gender that might be taboo to them – but that they fear they might be sexually attracted to people they're not actually attracted to.

d. Pedophilic thoughts: If you've read some of my other articles, you might have seen me discuss this subtype before. I tend to talk about it for two reasons: A) It causes a ton of suffering for those who, unfortunately, experience it. B) If one understands how OCD relating to pedophilia is just an alternative presentation to all other types of OCD, it becomes undeniable that all OCD thoughts are irrational and meaningless.

• It goes without saying that pedophilia is, bar none, one of the worst crimes a person can commit; I have worked with so many individuals whose lives have been irreparably damaged by the abuse they’ve endured, so none of what I’m saying is to take this lightly. That’s why it’s so important to describe and explain pedophilic OCD thoughts. People who have them DO NOT want to engage in pedophilia. They never have. Instead, we need to view them as victims of an excruciating form of OCD. Sometimes, people who experience these thoughts might avoid playing with their kids even though they’re just as likely to sprout wings and fly to the Holy Land as they are to behave inappropriately.

5) Doing or Saying Something Socially Inappropriate:

a. Fear of saying something racist: ‘What if I accidentally blurt out a racist slur or an offensive comment, even though I don't believe those things at all? Sometimes just being around people of different backgrounds makes me panic, because I’m terrified I’ll say something unforgivable without meaning to.’

b. Fear of getting undressed in public: ‘What if I suddenly start taking my clothes off in front of everyone and I can’t stop myself? Even though I have no desire to do it, just the thought terrifies me—and I avoid crowded places just in case.’

c. Fear of opening an emergency exit on a plane: ‘When I fly, I can’t stop thinking: what if I suddenly lose control and yank open the emergency door mid-flight? I know it’s irrational—I don't even want to—but the fear is so strong that I avoid sitting near exit rows and sometimes I feel like I can barely board the plane at all.’ 

Taboo OCD: Rare or Misunderstood?

Now that we’ve discussed some of the more common Taboo OCD subtypes, the question is: Are the examples above rare, or are they common and just not discussed sufficiently?

In a 2007 study, Pinto et al. found that among 293 adults with a primary OCD diagnosis, when asking about the symptom categories of their obsessions, a whopping 45.4% of them (n=133) experienced aggressive OCD thoughts. Compare this with those who experienced contamination obsessions (n=169, or 57.7% of participants)– the presentation of OCD most widely understood by the public–and we can see that contamination obsessions were only 12.3% more prevalent than those of an aggressive nature! This highlights how surprisingly close the rates among the two are, despite contamination OCD being far more widely talked about in the zeitgeist than aggressive-oriented OCD thoughts.

To add to this point, in a study I performed, I asked people without OCD to read a short vignette about some of the different subtypes of OCD, and I found that a high majority of the participants easily identified Contamination OCD and Symmetry OCD. In contrast, in stories featuring sexual OCD or aggression OCD, close to 0% of people were able to identify the thought patterns in the story as OCD.

Even physicians, the first point of contact for many with OCD, misidentified Aggressive OCD at an 80% clip, Homosexuality OCD at 84.6 % of the time, and Pedophilia OCD at 70.8% (Glazier et al., 2015).

Worst of all, among American Psychological Association (APA) members, people who specialize in treating mental health, 77% were unable to identify Homosexuality OCD. Conversely, they only missed the diagnosis 15.8% of the time when presented with symptoms of Contamination OCD (Glazier et al., 2013).

Taboo OCD subtypes are clearly not understood enough relative to how prevalent

they are.

The good news is that educating people on these taboo OCD subtypes makes a real difference. Whereas 0% of people were initially unable to recognize Aggression OCD, 60% were able to identify the subtype after psychoeducation. Although people’s detection of sexual taboos increased several times over following education on the subject, at the end of the day, only a little over 20% were able to identify it. Possibly, this is because of the strength of this taboo in general society, but either way, it highlights the need for continuing education on the subject. 

While exposure to OCD subtypes helps with identification, it is also necessary for people to internalize how benign they actually are. People vastly overestimate the perceived dangerousness of taboo OCD subtypes compared to more widely understood forms of OCD. In my study, people perceived sexual and aggressive presentations of OCD as much as two or three times more dangerous than either Contamination or Symmetry OCD!

In reality, all subtypes are equally “dangerous” because when a person has sexual or aggressive type OCD, they’re not more likely to engage in such actions than people without such OCD, but somewhat possibly even less likely to engage in them. After all, they’re so cognizant and afraid of them. Nevertheless, as we see, the perception surrounding these people is that their OCD thoughts are more dangerous than those who experience OCD in more widely understood presentations, like Contamination and Symmetry OCD.

Based on all of this, therapists must create a safe space for people to talk about their thoughts and feelings so that patients can feel comfortable sharing how their OCD presents. Likewise, therapists need to ask the right types of questions about their patients’ OCD since, understandably, people are hesitant at first to talk about their taboo OCD thoughts and feelings. Seeing a specialist can help for every mental health condition, but I think it’s perhaps more necessary if someone struggles with taboo OCD.

How do we differentiate between taboo OCD and actual taboo desires?

1) History of actual behavior: Has the person with aggression OCD ever stabbed someone? Has the person with Pedophilia OCD ever engaged in pedophilic acts before? Has the person with suicidal thoughts ever attempted to take their life?  If someone has engaged in taboo acts, assume that their thoughts aren’t just a product of OCD but may be reflective of their actual desires.

2) Pleasure when placed in a triggering scenario: Do they receive any perverse pleasure when they see kids at the park? Does the person who thinks about stabbing his wife feel gratification at the thought? When people with Taboo OCD are triggered by their thoughts, they don’t feel pleasure at all. They feel anguish. 

As you can imagine, it can get a little more complicated when it comes to this since the person with OCD's thoughts may be genuine on some level. The person with Suicidal OCD might still have real suicidal ideation, and the person with aggressive OCD might have some level of authentic interest in harming others. A good rule of thumb is identifying it as OCD when the person experiences disproportionate fear about the possibility of wanting to commit the act vs. their desire to do so. Again, the best way to navigate this challenge is to meet with an OCD specialist.

Treatment:

There are three primary components when it comes to treating Taboo OCD subtypes:

1) Psychoeducation/Normalization: This involves getting more information about these subtypes (like by reading this blog), normalizing their existence as just another form of OCD, and recognizing how the OCD presentations of taboo topics are distinct from genuine desires to participate in them.  When we normalize taboo OCD thoughts—by informing individuals that intrusive thoughts are a common human experience and that having them doesn’t make them a freak or a bad person—we help dismantle the shame that fuels the disorder. That kind of validation can be incredibly powerful in helping someone begin to feel safe, understood, and capable of healing.

One note is that although we want to normalize their experience, we don’t want to provide reassurance. If every time they experience a taboo OCD thought, you reassure them that it’s ok, that itself can become a compulsion for them. Normalization should be a one-time conversation so they know they're not monsters, but it shouldn't occur so often as to engender an unhealthy compulsion.

2) Exposure and Response Prevention (E/RP): We'll discuss this further, but if you want a broader overview of E/RP as a therapeutic technique, see my blog, “Inside the Loop: Understanding and Overcoming OCD.” or watch its video counterpart here.

3) Acceptance of “healthy aggression:” Like normalization, people must understand that healthy aggression is a normal, sometimes healthy, part of being human. Healthy aggression allows us to stand up to bullies and fight for our values. We don't want a world where all aggression is outlawed; we want to channel our aggression to further our values rather than denigrate them. On that point, all people will feel angry from time to time when in frustrating situations. It’s perfectly reasonable to want to yell at the person in the car in front of you who keeps changing lanes without using their turn signal. Further, it’s perfectly normal for your brain to creatively generate various scenarios of you engaging in inappropriate behavior, and that does not necessarily mean that something is wrong.

Exposures:

We should always tailor our exposures to the specific anxieties we have, yet there are a few standard ones we at ADO Psychology Center tend to employ for taboo OCD subtypes. Before employing any of them, meet with an OCD specialist to confirm the diagnosis and tailor the appropriate exposures!

1) Violence and Aggression

• Have someone carry a knife with them in their backpack. Again, make sure to account for actual risk and legality, but under the guidance of an OCD specialist, this can be an invaluable exposure. Standing near other people by a train platform (not in a creepy way!) if the person has an irrational fear that they might push someone in front of the locomotive.

2)    Sexual Taboos

• For incestuous obsessions, purposely enter a room where family members are present. For pedophilia OCD, purposely sit on a park bench, play with your kids, nieces, or nephews, or volunteer to be the one who changes your baby’s diapers. For sexual orientation obsessions, go to an exercise class together with people of the gender you are afraid you might be attracted to.

3)    Suicidal OCD Thoughts:

• Reading articles relating to suicide can be a great exposure for those with suicidal OCD thoughts, especially if they make an effort to try to put themselves in the shoes of the subject of the article. Standing on a roof or near an open window can also be a great way to trigger the OCD fear. Like all of these, make sure to have this okayed by a mental health professional, preferably someone who specializes in OCD!

4)    Religious/Blasphemous:

• Consult with a religious leader who understands mental health issues. If you want to know more about Religious OCD, check out my blog, “Religious OCD Among Orthodox Jews.”

Summary:

• Taboo OCD themes are neither rarer, nor more dangerous than better-known subtypes.

• Treatment for taboo themes relies on the underlying mechanisms of Exposure and Response Prevention (E/RP), just like most other forms of OCD.

• For this subtype specifically, working with an OCD professional is critical for diagnosing and constructing particular exposures.

Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.