Beyond risk management: reconsidering P-OCD in inpatient mental health care

Obsessive-compulsive disorder (OCD) is characterised by recurrent intrusive thoughts, images or impulses (obsessions) and repetitive behaviours or mental acts (compulsions) (American Psychiatric Association, 2013). One of the key features distinguishing obsessions from non-OCD worries is their ego-dystonic nature: they feel contrary to the individual's values and self-concept, often generating intense anxiety and shame (Audet et al., 2016). In its most severe form, OCD can lead to significant self-neglect, self-harm, and even suicide attempts (Brakoulias et al., 2026). OCD may also present as a co-morbid condition in individuals with psychotic disorders, which can further complicate assessment and treatment (Palermo et al., 2020). Despite this, OCD symptoms are not typically expected or routinely recognised on inpatient psychiatric units, meaning presentations may go unnoticed or misunderstood, with negative consequences for patient care (Brakoulias et al., 2026). When these presentations are overlooked, clinicians are left managing distress and risk without a clear formulation, which intensifies a broader tension within inpatient settings: balancing patient-centred care with the demands of a highly risk-averse system (Markham, 2019).One example that illustrates how easily OCD can be misinterpreted on inpatient units is Pedophilia-Themed OCD (P-OCD) -a presentation involving intrusive, ego-dystonic thoughts about harming children. These thoughts are profoundly distressing, and individuals often respond with compulsions such as mental reviewing, checking for signs of arousal, reassurance seeking, or avoiding children altogether (Bruce et al., 2018).Superficially, these behaviours can resemble those seen in Pedophilic Disorder, which involves ego-syntonic sexual interest in prepubescent children (Bonagura et al., 2022). The crucial distinction is function: in P-OCD, the person is trying to reduce anxiety and disconfirm feared harm; in Pedophilic Disorder, avoidance may occur to prevent acting on sexual urges. The outward behaviours can look similar, but the internal drivers are fundamentally different. This nuance is easy to miss in busy inpatient environments, where staff must make rapid safeguarding decisions with limited information.Inpatient care is organised around identifying and managing immediate, externally observable risks such as self-harm, violence, or safeguarding concerns. Because of this focus, OCD presentations-especially those involving intrusive thoughts about harm-can be easily misinterpreted as indicators of actual risk by staff who are trained to detect genuine safeguarding issues. Due to carrying a lot of safeguarding responsibility, staff members may feel anxious about missing potential risks and facing professional repercussions, and therefore misinterpret the OCD symptoms as egosyntonic. For example, if a patient with P-OCD starts compulsively confessing his intrusive thoughts to staff members, they might feel like they have to alert the safeguarding team and introduce special measures on the ward to decrease the risk of harm. That in turn can increase the patient's guilt and embarrassment about their symptoms which are one of main drivers of OCD (Laving et al., 2022). In extreme scenarios, these risk-averse practices might lead to social services involvement and children being taken away from their parents (Gupta & Kiran, 2019). These inpatient practices as well as lack of knowledge of OCD means that the more honest and help-seeking the patient is, the more likely they are to be misunderstood, restricted, or even escalated within safeguarding pathways. In this sense, inpatient environments can inadvertently punish the very openness that effective OCD treatment requires. Wheaton et al. (2016) found that self-concealment correlates with more severe OCD symptoms which might be because those individuals are less likely to seek support, and therefore do not receive appropriate help.While it is essential to hold the psychological formulation in mind during risk assessment, it is equally important to acknowledge that genuine risk to others can occasionally be missed. At admission, staff often have limited information and must make rapid decisions, frequently opting for the alternative associated with the lower burden of potential harm. In this context, misdiagnosing Pedophilic Disorder as P-OCD could have serious consequences -both in terms of actual harm to children and the legal and professional ramifications for staff who inadvertently overlook risk.Acknowledging these pressures does not diminish the need for improvement; rather, it clarifies where change must occur. If inpatient teams are to distinguish genuine risk from ego-dystonic distress, the system must equip them with clearer guidance and more psychologically informed frameworks. To improve the safety and quality of care for patients with OCD on inpatient units, several practical changes are urgently needed. These changes would require shifts in ward culture, where fear-based responses to intrusive thoughts are replaced with curiosity and focusing on function rather than only content of the behaviour.One of the most important recommendations that come to mind is obviously is staff training, and encouraging staff members to think about the function rather than content of thoughts. What often leads to misinterpreting intrusive thoughts as ego-syntonic is the focus on the content of disclosure rather than on their function. Instead of only focusing on what the individual said, it is important to consider why they said it. Furthermore, the difference between ego-dystonic vs. ego-syntonic thoughts and recognising the role of inflated sense of responsibility and shame in OCD should be emphasised (Salkovskis, 1999).However, even the most comprehensive staff training might not be able to solve the problem of risk-averse culture if the staff members do not feel safe and confident in responding compassionately to patients. That is why we need clear written guidance that would help staff distinguish intrusive thoughts from intent during risk assessments and outline exactly how OCD should be managed on the unit. Staff also need to know whom to approach for consultation, and this is where the role of psychology on wards is crucial. Well-established psychology teams can offer rapid formulation support, modelling curiosity, and validating staff perspectives while also advocating for the patients.Taken together, these issues highlight a broader challenge in how inpatient services understand and respond to distress, not only one related to OCD. Inpatient staff often work under intense pressure, with high acuity caseloads, limited information, and substantial safeguarding responsibilities which makes them less inclined to take positive risks. This, in turn, might lead to patients' distrust and concealment of their emotions and thoughts in fear of being deemed "risky." This, in turn, can lead to worsening symptoms and frequent re-admissions. If inpatient care is to be truly therapeutic, it has to become a place where showing distress is not penalised. Issues that come up in context of P-OCD presentations reveal how fundamental psychological input is on wards. Our role as psychologists is not only to support the, frequently burnt out, staff members, but also to facilitate conversations about free emotional expressions, taking positive risks, and thus bridging the gap between formulation-led care and risk management.