Severe harm-related obsessive-compulsive disorder with violent compulsions: a case report of psychopathology, risk conceptualisation and clinical management

Harm-related obsessions are a symptom subtype in obsessive-compulsive disorder (OCD). Due to the violent nature of these intrusive thoughts, they often result in high levels of distress for both patients and their families. This report presents a rare case of adult-onset severe harm-related OCD in a highly intelligent and previously high-functioning individual, characterised by intrusive, ego-dystonic self-harm-related thoughts and atypical compulsive behaviours that resulted in significant physical injury and profound functional decline. The patient’s obsessions centred on unwanted thoughts of harming himself (e.g. banging his head, stabbing himself, poking his eyes), accompanied by an intense fear of losing control. In response, he developed repetitive compulsive “testing” behaviours aimed at assessing and regaining control, which paradoxically escalated in severity and led to substantial self-injury, avoidance, and reliance on protective equipment. These behaviours were associated with marked shame, withdrawal, and a secondary depressive episode. This case illustrates an unusual and severe manifestation of harm-related OCD in which compulsions involved overt, injurious behaviours, highlighting the importance of careful psychopathological formulation to distinguish compulsive harm from impulsive or psychotic violence. The report contributes to a more nuanced understanding of risk, phenomenology, and maintaining mechanisms in severe harm-related OCD, with implications for assessment and management in complex presentations.