Podcast Summary: "When OCD Makes You Fear You’ll Harm Yourself"

Get to Know OCD – Hosted by Dr. Patrick McGrath (NOCD)

Guest: Tracy Ibrahim ("Taboo Tracy"), Therapist & Chief Compliance Officer at NOCD
Date: November 2, 2025

Overview

This episode explores the misunderstood and often frightening topic of Suicidal OCD, a subtype of obsessive-compulsive disorder where individuals experience intrusive, unwanted thoughts about harming themselves. Host Dr. Patrick McGrath is joined by therapist and lived expert, Tracy Ibrahim, to distinguish the differences between genuine suicidality and OCD-related intrusive thoughts, shed light on their lived and clinical experiences, and provide guidance for individuals and clinicians navigating this territory.

Key Discussion Points & Insights

1. Defining a Crisis vs. Suicidal OCD

• True Crisis: Involves certainty, planning, intent, and actions toward self-harm or suicide (03:30–04:23).
  • Tracy: "When you start crossing the line into this feels right...I'm going toward this for sure...that's when you've hit a crisis." [03:30]
• Suicidal OCD: Characterized by distressing, ego-dystonic thoughts, urges, or images; not accompanied by a desire or plan to act.
  • Patrick: “But it feels so real… How do you help somebody who has OCD when they're feeling like this thing feels so real?” [05:28]
  • Tracy: “I've never figured any of it out and have spent, I'm sure, decades trying.” [08:53]

2. Lived Experience with Both Depression & OCD

• Tracy shares the difference between her past suicide attempt (a state of certainty and planning) versus her daily experience of Suicidal OCD ("What if" thoughts with no intent to act) (07:07–08:27).
  • Tracy: "Sure, I could collect pills today, and I don't want to take them, but OCD says...Yeah, but you do." [07:07]
  • Tracy (explaining OCD's doubt): “OCD might not even be as direct... What if you do want to today? That nugget of uncertainty...” [08:27]

3. Stigma, Misdiagnosis, and Clinical Harm

• Tracy discusses the repeated misdiagnoses and the harm inflicted by well-meaning but uninformed clinicians (19:07–21:52).
  • Tracy: "You put somebody who is ten years old in a hospital and said your intrusive thoughts are real and you're a harm to yourself. So we are going to treat you exactly like that. And that is doing clinical harm." [21:12]
• Importance of nuanced, clarifying questions in clinical intake to distinguish intrusive thoughts from actual intent:
  • “If they would have said, do you want to be dead right now? I would have said no.” [21:07]

4. Living with Intrusive Thoughts: Acceptance & Humor

• Ongoing presence of intrusive thoughts does not equate to risk.
• Use of humor and radical acceptance as coping mechanisms.
  • Tracy: "What I like to tell people is...living with OCD that's on full blast...That is not what we are talking about. When you have full blast untreated OCD...that's not as good as it gets." [13:27]
• Accepting uncertainty—embracing the notion that one cannot achieve absolute certainty about the future, harm, or safety (31:07–32:37).
  • Tracy: "You don't have to accept facts. But the fact is that most things are uncertain...We take leaps of faith all the time." [31:07]
  • Patrick: "OCD has convinced you that certainty is an option...and those are all some of the lies that I hear OCD tell people.” [30:00]

5. Treatment: ERP and Behavioral Activation

• Emphasis on Exposure and Response Prevention (ERP) as the gold-standard, evidence-based treatment for OCD, including taboo themes (43:30, 44:32).
  • Tracy: "Exposure response prevention has been the gold standard for decades for treating OCD." [44:32]
• For comorbid depression, behavioral activation is frequently integrated.
  • Tracy: "I build my ERP and my behavioral activation into my day to day life...if one of them is louder on a given day, I'll do more of that particular intervention." [25:50]

6. The “What If...” Nature of OCD

• OCD feeds on doubts and worst-case “What if...” scenarios, especially in areas deeply valued by the sufferer:
  • Patrick: “OCD is a what if condition. It is a what if disorder. It is those two words, ‘what if’, followed by whatever worst case scenario that person can drum up...” [27:30]
• Intrusive content is always personally meaningful, which is why one cannot “catch” another’s theme if it doesn’t resonate:
  • Tracy: “There's a couple themes I, on purpose, tried to catch...I can't get them because I don't care enough about them.” [39:36]

Notable Quotes & Memorable Moments

• On Evidence-Based Treatment & Acceptance

  • Tracy: “There is not a cure...when we radically accept that you are someone who has OCD...it's valid to go through a mourning period for the life you thought you'd have.” [13:27]
  • Patrick: “You can be laying on the ground looking under your car for a dead body for five hours and not see one, but still not feel like you've looked enough to get yourself convinced that you haven’t killed somebody... OCD gets you to doubt your own senses and sensory experiences...” [32:37]

• Illustrative Anecdotes & Humor

  • Tracy (on intrusive urges during breakfast): “I got this urge...you’re gonna go run out into the middle of the busy street and get hit by a car because you wanna die. I was like, okay, let me finish my breakfast and then I'll get my running shoes on...” [10:40]
  • Patrick (on his non-OCD intrusive thought): “Since age 13, I cannot see someone...on a bike or stroller...and assign point values to if I were to hit that, what points would I get?...And I don’t have OCD.” [16:13]
  • Tracy (on Cholesterol OCD): “I'm making the wrong meal choices...trying to kill myself with cholesterol...Maybe I'll take the steak. If I die, I had a great last meal. Put it on my tombstone if I have one!” [41:52–42:34]

• Clinical Harm Example

  • Tracy: “That was clinical harm because they didn’t ask enough clarifying questions to find out if maybe it was something else...they did clinical harm.” [21:07]

Advice for Individuals & Clinicians

For Individuals with Suicidal OCD:

• Intrusive “what if I harm myself?” thoughts are not an indication of true intent.
• Living with such thoughts, even ones that feel like “commands” or intense urges, is possible with ERP and acceptance strategies.
• Seek specialized OCD treatment; misdiagnosis can be harmful.

For Clinicians:

• Always ask clarifying questions about intent, planning, and desire during intake. Do not default to recommending hospitalization based solely on reported intrusive thoughts.
• Remember, harm comes from both underreacting to risk and overreacting to OCD symptoms.
  • Tracy: “There's another kind of doing harm that you hadn’t thought about...what if you asked, do you want to kill yourself right now in this moment? I would have said no.” [19:07–21:12]

Key Timestamps for Major Segments

• Defining Suicidal OCD vs. True Crisis: 03:30–05:28
• Personal stories of experimenting with ERP: 35:28–38:03
• Humor as a coping tool and real-life anecdotes: 10:40; 16:13; 41:52–42:34
• Advice to clinicians about clinical harm: 19:07–21:52
• On living (and thriving) with OCD: 13:27; 25:50; 31:07–32:37
• Certainty, uncertainty, and living with doubt: 27:30; 31:07; 32:37

Final Thoughts

The episode’s central message: Experiencing intrusive, distressing, or even ego-dystonic suicidal thoughts is common in OCD and does not mean you are a danger to yourself. Acceptance, humor, and exposure-based therapy—tailored by informed clinicians—are crucial for managing these symptoms and reclaiming life from OCD. Clinicians and sufferers alike should educate themselves, avoid snap judgments about risk, and pursue evidence-based strategies, above all else.

Find Tracy on Instagram: @TabooTracy
More info and help: nocd.com
Hosted by: Dr. Patrick McGrath

“Be good to yourselves, or at least much better than your OCD ever will be to you.” — Dr. Patrick McGrath [end of episode]