What is the fear of acting out?
The fear of acting out obsessions in people with obsessive-compulsive disorder (OCD) can be described as the fear of involuntarily performing unwanted behaviours, either against one’s will or in a state of uncontrollable frenzy.
Obsessions, which are intrusive thoughts, come in many forms and can be as numerous as the thoughts themselves. One way of categorising obsessions is to distinguish between reactive obsessions (externally triggered, focused on environmental factors) and autogenous obsessions (self-generated, focused on internal resistance to unwanted thoughts) (Lee et al., 2005).
Fear of acting out can be attributed to both types of obsessions: reactive (feeling obliged to prevent loss of control when confronted with triggering stimuli) and autogenous (believing that noticing thoughts of losing control means that something is wrong with oneself). The fear of acting out tends to manifest itself in the following types of obsessions:
- Aggression: Persistent thoughts of harming others or oneself.
- Sexuality: Unwanted thoughts about changing sexual orientation or engaging in unwanted sexual behaviour.
- Religion: Anxious thoughts about violating religious principles.
- Morality: Disturbing thoughts about engaging in morally objectionable actions.
All of these manifestations share a common underlying theme – fear of losing one’s identity. People with “Harm OCD” fear losing their sense of self and becoming violent individuals. Those with sexual obsessions fear losing their sexual identity, while those with religious or moral obsessions fear compromising their identity as pious or righteous individuals.
At the heart of this fear of identity loss is the understanding that a single choice of behaviour – whether intentional or uncontrollable – has the potential to tip the scales irrevocably towards darkness. If someone tormented by intrusive thoughts of violently attacking another person were to actually act on those thoughts, the entire construct of OCD would be reduced to a socially constructed belief that ultimately does not stand up to reality. Living so close to this line, where a single step can dismantle it all, constantly draws sufferers away from the historical evidence of their lives and towards the ever tantalising “what if…” scenarios.
Russian Roulette
In exploring the fear of acting out, two seemingly disparate concepts – Russian roulette and the kinesthetic sense – shed light on the inner experience of this pervasive fear associated with OCD.
Russian roulette, a form of torture, involves loading a single bullet into a revolver, spinning the cylinder, pointing it at one’s head and pulling the trigger, resulting in a one in six chance of death. This sadistic “game” is designed not only to kill, but also to inflict pain, illustrating the perpetrator’s indifference to the life or death of the player. For people with OCD, being in triggering situations produces a similar sensation to pulling the trigger when they allow intrusive thoughts of “snapping” or “losing control”.
Each intrusive thought feels like pulling the trigger, potentially bringing everything to an abrupt end. In the context of OCD, however, the end result is not just death, but the loss of a livable existence – an existence that is felt to be more unbearable than death itself. Examples include the fear of being discovered as a child molester or spouse killer.
The kinaesthetic sense
When people think of their senses, touch, taste, smell, sight and hearing usually come to mind. However, there is another sense – the kinesthetic sense, often referred to as the unspoken sixth sense. This sense allows people to be aware of the position of their body parts in relation to each other, even without visual or tactile information. Try putting your hand behind your back without touching it.
How can you tell where your hand is? Although it is difficult to articulate, your brain has an innate understanding of your hand’s position in space, independent of touch or sight. In rare cases where this sense is impaired, people may lose the ability to walk or make facial expressions (although visual compensation can help restore some functionality).
For most people, the fear of acting out is absent because they have a basic sense of knowing where their behavioural choices lie, so to speak. For example, as I write this, my daughter is having breakfast a few feet away from me. How do I know I won’t impulsively turn and hurt her? The answer is elusive because it seems unworthy of attention. Even contemplating the possibility now feels as nonsensical as contemplating turning into a piece of buttered toast.
But what if this sense were somehow dulled? It wouldn’t make me more prone to violence, but it would undermine my confidence in dismissing it as uninteresting. People who are plagued by the fear of acting out are not inherently more likely to act irrationally than others. However, they lack the reassurance provided by that ‘other sense’ that effortlessly resolves such concerns. How do I know I’m not going to lose control? I just know. But if I didn’t have this innate knowledge, there would be a compulsion to find out. This need to know is at the heart of OCD.
What is it that we are afraid of?
What exactly does it mean to “act out” and why do people have anxieties about this elusive concept? The lack of a clear definition can contribute to this fear. For example, if one of my children gets upset and throws a toy across the room, we might say that they are “acting out” their frustration.
Similarly, if a person indulges in the fantasy of being a skilled hunter, puts on hunting clothes and goes into the woods, we might say that they are ‘acting out’ a fantasy. Similarly, when a mass shooting occurs, the perpetrator is often described as ‘acting out’ a belief or emotion. However, these definitions fall short, especially when we consider that these actions are deliberate, premeditated and organised.
In the context of my clients with OCD, their fear of acting out takes on a different connotation. It seems to encompass one of two constructs:
Construct #1 – Reacting impulsively, uncontrollably and contradictorily to an unwanted thought, in accordance with the content of that thought. This involves spontaneously engaging in unwanted behaviour prompted by the presence of an unwanted thought.
Construct #2 – Experiencing the persistence of an unwanted thought over a period of time that the thinker considers excessive, leading to a sense of psychological defeat. This, in turn, impairs rational thought and can lead to a misguided decision to manifest the content of the thought through action – an action carried out due to the prolonged presence of the thought beyond what is deemed tolerable.
Examples of construct #1, which involves impulsive responses to intrusive thoughts, may manifest in the following feared events:
- An individual experiences an intrusive thought about pushing someone into oncoming traffic and, without control, physically carries out the action, resulting in the person’s death.
- A heterosexual person tormented by fears of homosexuality responds to a mental image of kissing a friend of the same sex by impulsively lunging forward and engaging in the action.
- A person with obsessive fears of being a paedophile will notice a physiological response while bathing their child and unconsciously begin to masturbate.
Someone with a fear of harming their son is confronted with an image of smothering the child with a pillow while he sleeps and, as if watching themselves in a film, suddenly grabs a pillow and acts out the thought. - A religious person struggling with scrupulosity experiences a blasphemous thought during prayer and spontaneously begins to worship the devil before realising the act.
Examples of construct #2, involving the prolonged presence of unwanted thoughts leading to psychological defeat and subsequent action, might include the following feared events:
- A person with paedophobic fears remains untreated for OCD for a long time, and the relentless presence of intrusive sexual images involving children plunges them into a deep depressive state. In this state, they conclude that they are a paedophile and behave inappropriately towards their children.
- A person with Harm OCD, overwhelmed by a constant barrage of intrusive violent thoughts, reaches a breaking point and experiences a psychotic break. Believing that only an act of violence will free them from these thoughts, they meticulously plan and carry out an act of violence.
- A person defeated by incessant unwanted “gay” thoughts will eventually become convinced of their homosexuality and begin to engage in same-sex sexual acts.
- A person with religious scruples, worn down by relentless intrusive thoughts about the devil, decides to defy his beliefs and engage in a series of sinful acts.
- A person burdened by moral scrupulosity succumbs to thoughts of dishonesty towards their spouse and, worn down over time, decides to have an affair.
The impact of anxiety in OCD
People with obsessive-compulsive disorder (OCD) often struggle with the fear of acting out, rather than with a documented history of such actions. These individuals, plagued by the fear of engaging in abhorrent behaviours, naturally seek reassurance that the two constructs, known as Construct 1 and Construct 2, will never materialise. Their desire for evidence of the impossibility of committing these acts extends beyond personal reassurance to the need for evidence that others with OCD have never engaged in such acts.
Seeking reassurance is a common compulsion in OCD, and trained therapists who specialise in treating the disorder understand the importance of withholding reassurance and fostering tolerance of uncertainty. However, even experienced OCD specialists can succumb to moments of empathy and unintentionally make statements such as “People with Harm OCD never commit acts of violence” or “Your distress over these intrusive thoughts would diminish if you really wanted them”. While these statements may seem innocuous due to their apparent obviousness, they raise several problematic issues:
- Verification of claims: Claiming that no OCD sufferer has ever acted out is challenging in the absence of data on non-committed crimes.
- The role of OCD in criminal behaviour: Although an analysis of criminals could potentially identify individuals with OCD, there is no existing data on the extent to which OCD influences criminal behaviour, if at all.
- Validation of intrusive thoughts: Relying on the idea that acting out is “impossible” inadvertently reinforces the belief that the intrusive thoughts themselves have intrinsic meaning. Effective treatment requires resisting obsessions without certainty of outcome.
- Possibility versus probability: Focusing on the impossibility of events addresses the issue of capability, while probability and attention to that probability remain critical concerns.
Safety behaviours and the fear of acting out
Driven by the fear of making inexplicable decisions in moments of vulnerability, people with OCD often resort to various safety behaviours to avoid succumbing to perceived weaknesses. They may adopt a hyper-vigilant approach to
- Ensuring adequate sleep and avoiding sleep deprivation.
- Being cautious about alcohol or other substances that might impair judgement.
- Viewing feelings of anger or sadness as harbingers of impending problematic behaviour.
- Seek constant distraction to prevent intrusive thoughts from gaining attention.
- Avoid solitude and situations that may trigger unwanted thoughts, especially around children or other vulnerable people.
- Exercise self-control in any situation that might raise doubts about their ability to resist compulsions.
Obsessions and the fear of acting out
Compulsions manifest themselves as physical or mental actions that are performed to achieve safety and to relieve discomfort caused by obsessive thoughts, such as the compulsion to wash hands. In the context of the fear of acting out, several common compulsions can be identified:
- Adopting avoidance and safety behaviours (as mentioned above).
- Seeking reassurance from others about the likelihood of intrusive thoughts materialising.
- Confessing the content of intrusive thoughts to reduce anxiety.
- Engaging in online or other forms of reassurance-seeking to distinguish between OCD and psychopathy.
- Mentally reviewing past intentions and feelings to assess the likelihood of acting on them.
- Examining hypothetical scenarios to test the potential realisation of intrusive thoughts.
- Repeating or chanting neutralising statements that contradict obsessive thoughts.
- Resorting to obsessive prayer.
Reviewing research on the fear of acting out
One study found that people with a fear of losing control are more likely to notice and experience distress from intrusive aggressive thoughts when confronted with imaginary situations that interfere with their goals. In essence, the frustration of thwarted goals can trigger the presence of aggressive thoughts. Conversely, those who do not fear loss of control tend to regard such thoughts as inconsequential. This study suggested that intrusive harmful thoughts are not purely random occurrences, but rather natural responses to frustrating circumstances, albeit exaggerated in those who harbour this fear (Riskind et al., 2007).
In addition, individuals with OCD generally show increased impulsivity, contrary to the previously held assumption that compulsivity and impulsivity remain distinct states that do not overlap (Benatti et al., 2014). In particular, impulsive behaviours commonly observed in OCD include alcohol consumption, hair pulling, skin picking and other body-focused repetitive actions.
In some cases, compulsive behaviours may even serve as a resistance mechanism against giving in to impulsive urges (Fontanelle et al., 2005). It is important to note, however, that this does not mean that people who are aware of unwanted impulses would act on them in the absence of rituals, as unwanted impulses are part of the human experience. Rather, it is the excessive fear of acting out that leads the OCD sufferer to seek comfort in rituals.
For example, consider a typical intrusive thought shared by people with and without OCD, such as “What if I swerve my car into oncoming traffic? Is this thought a real impulse that non-OCD people dismiss, while OCD people respond with obsessions? It is plausible that such impulses are normal and not arbitrary, unrelated to mental health. However, people with OCD perceive them as more threatening because of their heightened anxiety response. Therefore, the core problem is not the thoughts of acting out, but the anxiety associated with these thoughts.
Exposure with Response Prevention
The most successful treatment for obsessive-compulsive disorder (OCD) is cognitive behavioural therapy (CBT), specifically exposure with response prevention (ERP). ERP involves gradual exposure to feared situations while refraining from compulsive behaviours. There are two key elements to addressing the fear of acting out: eliminating safety behaviours and inviting opportunity.
Eliminating safety behaviours
In addition to the avoidance strategies described above, people with OCD often go to great lengths to make acting out highly challenging, as a safeguard against losing control. For example, people with harm obsessions may hide knives, hammers, belts or other objects associated with potential harm. Those with sexual obsessions may use online filters to block unwanted sexual images. These compulsive behaviours are designed to cause significant discomfort when attempting to perform an unwanted act in the face of an imagined loss of control.
It can be compared to a werewolf handcuffing himself to a tree before a full moon (a concept depicted in a film). Although it may seem somewhat comical when portrayed, people with OCD perceive these safety measures as necessary, albeit vague in detail but clear in intent. The problem, however, lies in the message the brain receives from these safety behaviours – the conclusion that the thinker must have been in danger to require such precautions.
Inviting chance and tempting fate
It is important to understand that “acting out” is the most terrifying scenario one can imagine, and it can take many forms. When people with OCD experience this fear, it manifests as vivid and distressing mental images that seem remarkably clear in the moment. The origins of such imagery can be traced back to a variety of sources, including television shows such as The Walking Dead (which predominantly depicts acts of violence), Homeland (which focuses on explosions and rooftop shootings), or The Affair (which depicts impulsive behaviour and deceit in relationships).
Thus, individuals who harbour a fear of acting out find concrete material in their minds that reinforces the narratives they construct. This is not to blame television or the news, but to highlight how even the slightest spark can ignite the reservoir of fuel present in the OCD mind. These visual representations and narratives surround us in our daily lives.
ERP as a treatment approach for the fear of acting out involves consciously confronting the fear by welcoming unwanted thoughts and emotions while refraining from engaging in reassurance or safety behaviours. Some examples of ERP techniques for the fear of acting out include
- Exposing oneself to triggering media while allowing intrusive thoughts and emotions to persist.
- Participating in social activities that may involve encountering triggers.
- Acknowledging thoughts associated with the potential for acting out.
- Voluntarily using triggering objects, such as volunteering to handle a knife while preparing dinner.
For these ERP strategies to be effective, it is imperative that the person undergoing exposure remains committed to resisting their compulsions. Without response prevention, exposure becomes merely a checking compulsion, where the focus shifts to determining whether the feared event will occur.
The purpose of ERP, however, is to retrain the brain to tolerate distressing thoughts, feelings and impulses without needing absolute certainty about the outcome. The aim is to activate the part of the brain that can provide confidence in the face of distressing mental experiences.
Nothing is sacred
Common understanding within behavioural therapy, and reality itself, recognises that we cannot directly control our thoughts or feelings. However, we do have the ability to influence our behaviour, and changes in behaviour can lead to shifts in the salience of certain thoughts and feelings.
Essentially, if we behave in a way that indicates a lack of concern about causing harm (for example, not responding to intrusive thoughts about harm in the presence of a child), over time we develop an aura of confidence that we pose no risk of acting out. Conversely, investing in avoidance, reassurance seeking and other safety behaviours tends to increase doubt and insecurity.
The idea that we can control our behaviour often gives people comfort. For example, if you are standing on the edge of the Grand Canyon, you might ask yourself: How can I be sure I won’t jump? The answer lies in the absence of thoughts or feelings that indicate an inclination to do so. It is the feeling of certainty that prevents such an action. But what if thoughts or feelings arise that suggest the possibility of jumping? In that case, we can still rely on our ability to choose not to act on those thoughts, because we have control over our behaviour.
However, people who fear losing control face an additional therapeutic challenge. They cannot find comfort in the widely held belief that we have complete control over all aspects of our behaviour. To consider this idea either becomes a compulsive reassurance or seems implausible, thereby perpetuating the existence of OCD. Such individuals need to go a step further and expose themselves to uncertainty about their own ability to control their behaviour.
The sacred illusion of control and the burden of OCD
The thought of losing control and having to deal with the consequences evokes an indescribable level of anxiety. One might question the decency of OCD itself, wondering if anything is sacred when it suggests the possibility of losing control and harming loved ones, self-harming, engaging in sexual misconduct, or violating personal religious or moral codes.
The truth, however, is that nothing is inherently sacred. Those who overcome OCD must follow its path, for the very notion of losing control implies the existence of control that can be lost – a concept the OCD mind eagerly seizes upon.
However, the reality is that there is no control to lose, as there is only the present moment in any given instance. Control is an illusion that comes from trying to predict the future. To claim “I know I will not act out” is to claim knowledge of events before they happen – an inherently harmful mindset for people with OCD.
It encourages the belief that morality depends entirely on what we might do in the future, rather than focusing on the choices we make in the present. It places an unbearable burden on reliance on rituals, as they become the only behaviours that evoke a sense of moral responsibility for the future.
I have never seen anyone snap, but I have seen people get better
In light of the discussion thus far, it is essential to acknowledge personal experience as a valuable perspective. From my own encounters, I have not witnessed individuals “acting out” their obsessions, using the definition provided.
Nor have I observed anyone abruptly losing control in an unpredictable manner (likely because my focus predominantly centers on treating individuals with OCD and anxiety, rather than those with psychosis or sociopathy). However, it is crucial not to dismiss the fear of acting out as mere OCD-related nonsense and brush off OCD sufferers with dismissive reassurances like “You won’t do that.”
This fear can plunge individuals into an isolated state, where they become apprehensive about taking any action at all. It can permeate their existence to such an extent that depression may appear as a respite from the overwhelming fear. Hence, we can go beyond treating the fear of acting out as something absurd. Instead, we can extend compassion to those who struggle with it and foster collaboration among sufferers, treatment providers, and family members to develop interventions that break through the formidable barrier of fear.
In addition to traditional cognitive behavioral therapy (CBT), which involves challenging distorted assumptions and gradually exposing individuals to feared situations (ERP), other approaches such as mindfulness can also be beneficial. Mindfulness allows individuals to adopt the role of an observer, exploring what it feels like to engage in mental Russian roulette or to confront the absence of an inherent sense of security. Through a comprehensive treatment approach, individuals can acquire the skills to conquer OCD, including the fear of acting out their most distressing intrusive thoughts. They can ultimately lead fulfilling lives marked by well-being and vitality.
Sources
- Benatti, B., B. Dell’Osso, C. Arici, E. Hollander, A.C. Altamura. 2014. “Characterizing impulsivity profile in patients with obsessive-compulsive disorder.” International Journal Of Psychiatry In Clinical Practice 18, no. 3: 156-160.
- Fontenelle, L.F., M.V. Mendlowicz, M. Versiani. 2005. “Impulse control disorders in patients with obsessive–compulsive disorder.” Psychiatry & Clinical Neurosciences 59, no. 1: 30-37.
- Han-Joo Lee, Seok-Man Kwon, Jun Soo Kwon, M.J. Telch. 2005. “Testing the autogenous–reactive model of obsessions.” Depression & Anxiety (1091-4269) 21, no. 3: 118-129.
- Riskind, J.H., C.R. Ayers, E. Wright. 2007. “Simulated Interpersonal Provocation and Fears of a Loss of Impulse Control as Determinants of Aggressive Mental Intrusions.” Journal Of Cognitive Psychotherapy 21, no. 4: 285-294.
