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OCD with Harm Obsessions — MRCPsych Paper B MCQ

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ModerateAnxiety & Stress-Related DisordersOCD with Harm ObsessionsMRCPsych Paper B

A 35-year-old man presents with a 6-month history of recurrent, unwanted images of harming his infant son. He finds the images abhorrent, has no wish, intention or plan to act on them, and repeatedly checks that his son is safe. He also avoids being alone with him. There are no hallucinations, delusions or features of intoxication, and his wife describes him as an attentive father. According to NICE guidance, what is the most appropriate assessment approach?

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Correct answer: C — Conduct an OCD-focused clinical and risk assessment, seeking specialist OCD advice if uncertain

Explanation lettering: C = shown as A · D = shown as B · B = shown as C · E = shown as D · A = shown as E

The correct answer is B. The unwanted, ego-dystonic images, marked distress, checking and avoidance form an obsession–compulsion pattern typical of OCD. NICE CG31 states that aggressive intrusive thoughts are common in OCD and are often misinterpreted as indicating risk. They should nevertheless be assessed properly, including actual intent, self-harm and suicide risk, the effects of compulsions, comorbidity and relevant psychosocial factors; specialist OCD advice is appropriate if uncertainty remains. The content alone does not mandate an immediate safeguarding referral (A), although genuine safeguarding indicators would require action. Preserved insight and absence of psychotic symptoms argue against psychosis (C). Intrusive thoughts can occur in the general population, but clinically significant distress and compulsions require assessment, excluding D. No enduring personality pattern supports E.

Reference: National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31), recommendations 1.4.1.2–1.4.1.3. 2005; last reviewed 2024. https://www.nice.org.uk/guidance/cg31/chapter/Recommendations