(p. 7) Understanding Sexual Obsessions
About Obsessive-Compulsive Disorder
When most people think of obsessive-compulsive disorder (OCD), they picture someone with a germ phobia, a person meticulously straightening a crooked picture frame, or someone arranging a collection of shoes by color in a painfully well-organized closet. We tend to laugh at these images in the media, but as clinicians we know that OCD is much more than a quirky character trait. In fact, OCD can be quite serious, and most people with the disorder aren’t laughing about it. OCD is highly disabling, and nearly two thirds of those with the disorder suffer in nearly every major life domain, including family life, social life, work or school, and intimate relationships (Ruscio, Stein, Chiu, & Kessler 2010; Wetterneck, Knott, Kinnear, & Storch, 2017). People with OCD experience almost four times the unemployment rate of the general population due to the disabling nature of symptoms (Koran, Thienemann, & Davenport, 1996). In fact, OCD is considered one of the leading causes of disability worldwide, with a global impact comparable to that of schizophrenia (Ayuso-Mateos, 2006; Zohar, Fostick, Black, & Lopez-Ibor, 2007).
Almost all people with OCD have other diagnosable mental disorders as well, with 40% suffering from major depressive disorder, 76% suffering from an anxiety disorder or posttraumatic stress disorder (PTSD), 56% suffering from an impulse control disorder, and 39% suffering from a substance use disorder (Ruscio et al., 2010). These additional diagnoses can complicate treatment if not also managed. The average age of onset is 19.5 years and childhood onset is common, particularly in males (Fogel, 2003; Ruscio et al., 2010), but even among those who develop OCD in adulthood, most can remember having some symptoms as children.
OCD is defined by the presence of obsessions and compulsions. According to the fifth edition of the Diagnostic and Statistical Manual of (p. 8) Mental Disorder (DSM-5; American Psychiatric Association [APA], 2013), obsessions are
recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress; the individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action. (p. 237)
Compulsions are defined as
repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly; the behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. (p. 237)
Additionally, symptoms “are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment” in an important area of functioning (p. 237).
For a diagnosis of OCD, symptoms must not be “attributable to the physiological effects of a substance or another medical condition” and are “not better explained by the symptoms of another mental disorder” (APA, 2013, p. 237). However, it is worth noting that some cases of OCD, particularly in children, are due to an autoimmune response typically trigged by a strep throat infection (pediatric acute-onset neuropsychiatric syndrome, aka PANS [Swedo, Leckman, & Rose, 2012] or pediatric autoimmune neuropsychiatric disorders associated with Streptococcal infections, aka PANDAS [Murphy, Storch, Lewin, Edge, & Goodman, 2012]).
The specific diagnostic criteria for OCD have changed in relatively minor ways from the fourth, revised edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV-TR) to DSM-5. The word impulse, which was previously used in the description of obsessions, has been replaced with urge. The word inappropriate, used to describe obsessional thoughts, has been replaced with the word unwanted (Abramowitz & Jacoby, 2014). The requirement that patients recognize their obsessions and (p. 9) compulsions as senseless and excessive has been removed. The insight specifier in DSM-5 now includes three options, which are “good or fair insight,” “poor insight,” and “absent insight/delusional beliefs.” This was done to improve differential diagnosis as people with OCD have a range of insight into the senselessness of their symptoms (Foa et al., 1995). Thus, people with OCD may completely lack insight without being psychotic.
The most notable change is that OCD is no longer classified as an anxiety disorder. It is now included in a new category called “Obsessive-Compulsive and Related Disorders.” This change was made primarily to group together disorders characterized by obsessive thoughts and/or repetitive behaviors, as there is increasing evidence that these disorders are somehow related (APA, 2013). However, this regrouping is not uncontroversial (Abramowitz & Jacoby, 2014), as several obsessive-compulsive–related disorders may be a better fit in other categories (such as impulse control disorders), and some disorders most similar to OCD were left out this new section entirely (i.e., illness/health anxiety).
Although people with and without OCD experience unwanted sexual thoughts (Smith, Wetterneck, & Harpster, 2011), people with OCD seem to get hung up on a subset of these unwanted thoughts and place too much importance on them (Rachman, 1997). These unwanted thoughts then become obsessions, which demand an action to produce relief. Any actions performed to alleviate an obsession are considered rituals or compulsions, although avoidance is also a common response. Thinking about the symptoms behaviorally, compulsions provide negative reinforcement by bringing about temporary relief through the performance of compulsions (Franklin & Foa, 2011; Mower, 1939, 1960). While compulsions may initially relieve anxiety caused by obsessions, they actually reinforce the behavior so that the likelihood of doing more compulsive behavior in response to obsessions increases. Continued use of compulsions to reduce OCD-related anxiety creates a reinforced behavioral response that becomes increasingly more entrenched and difficult to resist, leading to greater impairment. Thus, obsessions and compulsions are functionally related.
Like its predecessor, the DSM-5 permits a diagnosis if either obsessions and compulsions are present, but there is some scientific disagreement as to whether it is possible to have obsessions without compulsions (sometimes termed “pure obsessional” or “pure-o”; Williams, Crozier, & Powers, 2011). Research and clinical observations indicate that virtually all patients with OCD have both obsessions and compulsions (e.g., Leonard & Riemann, (p. 10) 2012), although compulsions without clear obsessions are sometimes seen in children and those who have a need for things to be “just right.”
The Many Faces of OCD
OCD comes in many varieties; therefore, each person’s symptom presentation may be different, and these presentations can change over time. Nonetheless, decades of research seem to point to four specific symptom dimensions that describe most OCD sufferers. These include (a) contamination obsessions with washing/cleaning compulsions, (b) symmetry obsessions with ordering compulsions, (c) doubting obsessions with repeated checking compulsions, and (d) unacceptable/taboo thoughts with mental/covert compulsions and reassurance-seeking (Williams, Mugno et al., 2013). People with OCD may have worries in one or all of these areas, although in our clinical experience most people have one major area of concern with smaller worries in one or two other areas. Because of the wide range of symptom presentations, OCD is misdiagnosed both in doctors’ offices and among mental health professionals (Glazier, Calixte, Rothschild, & Pinto, 2013; Sussman, 2003); thus, a good understanding of the OCD presentations is vitally important for all clinicians to ensure a correct diagnosis. Here we briefly describe each major symptom dimension.
Contamination Fears and Cleaning Rituals
Although one of the most widely studied presentations (Ball, Baer, & Otto, 1996) and the one most often associated with OCD in the popular press, fear of contamination may account for only a quarter of obsessional fears among those with OCD in the general population (Ruscio et al., 2010). Nonetheless, such concerns are prominent in OCD sufferers worldwide (Williams & Steever, 2015). Fear of contamination typically involves excessive concern about the threat of illness or disease, difficulty tolerating the sensation of being physically unclean, or even a feeling of being mentally polluted in some way (Rachman, 2004). Feared contaminants are not limited to dirt and germs but may include such things as blood, household chemicals, and sticky substances or residues, as well as people who appear unclean or unkempt and various insects or animals. People may worry that (p. 11) if they become contaminated it will cause them harm in some way, or they will spread the contamination, leading to being responsible for harm to others, or a combination of the two.
To minimize exposure to contamination, individuals with this type of OCD may go to great lengths to avoid places and situations that might expose them to feared contaminants (e.g., public restrooms, crowded malls, etc.) and/or may involve themselves in a myriad of protective rituals. Such rituals may include disinfecting and sterilizing, throwing away “contaminated” objects, frequently changing clothes, and designating “clean” areas within the home that are off limits to others. If contaminants cannot be avoided, however, individuals often resort to excessive hand washing, showering, or housecleaning in an attempt to decontaminate themselves and their belongings. Among those with this form of OCD, contact with a feared contaminant often results in feelings of fear or disgust and, in some cases, may cause feelings of responsibility for spreading dreaded contamination to others, such as children or pets (Williams, Mugno et al., 2013).
Doubting and Compulsive Checking Rituals
The OCD symptom dimension we refer to as “doubt about harm/checking” has also been called “fear of harm” or “overresponsibility for harm.” Individuals whose main obsessions fall into this category typically experience fears related to unintentionally harming themselves or somebody else due to carelessness or negligence. For example, two of the more common harming fears include the fear of hitting a pedestrian while driving and the fear of forgetting to turn off the stove before leaving the kitchen, thereby leading to the accidental death of a loved one in a house fire. Accompanying this fear of harm and heightened sense of responsibility are often extreme feelings of doubt, dread, or uncertainty. Repeated checking behaviors are used to neutralize these feelings by attempting to prevent the perceived dangerous consequence; thus, individuals engaging in these behaviors are often called “checkers” (although most people with OCD do some form of checking behaviors). In addition to checking, individuals with fears of harming often report other rituals that may have a “magical” quality, such as repeating “safety” words, phrases, or prayers; counting; or saying or withholding certain words or phrases.
(p. 12) People with this form of OCD tend to doubt their own recollections of past actions, and there has been some research into the idea that people who doubt and repeatedly check may have some actual memory deficits. Some studies have found that OCD patients who compulsively check are both less confident in their memories and have poorer performance on certain types of memory tasks (e.g., Woods, Vevea, Chambless, & Bayen, 2002). It is not completely clear if this is an actual neuropsychological deficit or simply a result of high anxiety. However, research suggests that in those with OCD repeated checking results in natural reductions in memory confidence, which is then worsened by an increased perception of responsibility for potential harm (Boschen & Vuksanovic, 2007).
Finally, research also suggests a relationship between the checking subtype of OCD and the experience of traumatic life events. For example, researchers found a significant, positive relationship between the experience of trauma and the magnitude of doubt about harm/checking symptoms and the symmetry/ordering symptom dimension, even after controlling for age, age of OCD onset, and mental health conditions (Cromer, Schmidt, & Murphy, 2007). It is not uncommon for people to have symptoms of OCD and PTSD intertwined. For example, someone who experienced a sexual assault might repeatedly check door locks for safety. In contrast, there was no association found linking the experience of traumatic life events to either the contamination/cleaning symptom dimension or hoarding.
Symmetry Obsessions and Ordering Rituals
Perfectionism is a common symptom of OCD patients whereby they are preoccupied with order, symmetry, and exactness. To reduce anxiety, these individuals tend to engage in compulsive behaviors that include repetitive arranging, organizing, or lining up of objects until certain subjective conditions are met. For example, they may experience intense discomfort if the objects on their desk are not symmetrically aligned or a certain distance apart from one another. It has been proposed that a common theme in the symmetry and ordering category is a feeling of “incompleteness,” which has also been associated with compulsive slowness (Summerfeldt, 2004). People with this type of OCD may also engage in tapping and touching behaviors or fear not saying just the right thing. These behaviors are sometimes accompanied by magical thinking—that is, the belief that a thought (p. 13) can cause an event to occur or not occur (e.g., “If I don’t align the silverware just right, my husband might have a car accident and die on his way home from work”), although there is also a large group of individuals who do not report unusual beliefs of this sort (Calamari et al., 2006; Taylor et al., 2006).
Compared to those with other OCD symptom dimensions, people with symmetry and ordering symptoms are much more likely to also experience dissociative symptoms (Grabe et al., 1999). Those with symmetry compulsions are also more likely to have comorbid tic disorders, be male, and have an earlier age of onset (Hasler et al., 2005; Leckman et al., 1995; Mataix-Cols et al., 1999). It is natural for most people to feel more comfortable and less anxious in an orderly environment. Thus, it may be that the compulsion to arrange things is based in an adaptive desire for orderliness; however, this need for order is taken to an extreme in patients with this particular form of OCD. It should also be noted that while people with OCD appear to be at higher risk for obsessive-compulsive personality disorder than those in the general population (with rates of 23% to 32% in OCD samples versus 1% to 3% in community samples; Albert, Maina, Forner, & Bogetto, 2004; Garyfallos et al., 2010; Samuels et al., 2002), there is some evidence that those with symmetry obsessions and ordering compulsions have the highest risk (Eisen et al., 2006).
Another finding that seems to be unique to the symmetry/ordering symptom dimension concerns suicide. One large study of clients being followed after having received cognitive-behavioral therapy (CBT) treatment found that those with symmetry/ordering symptoms were more likely to attempt or complete suicide in the six years after treatment than individuals with other symptom presentations. These patients were also more likely to have favorably responded to treatment initially only to have relapsed at a later point (Alonso et al., 2010). Other studies have found that ordering symptoms have the most consistent association with anger, including expression of anger toward others, holding in or suppressing anger, and difficulty controlling angry feelings (Tellawi et al., 2016; Whiteside & Abramowitz, 2005). It may be that anger is what drives the relationship between ordering symptoms and a higher risk of suicide. Alternatively, as noted previously, the experience of traumatic life events may also drive this relationship, given the connection between symmetry/ordering symptoms and trauma (Cromer, Schmidt, & Murphy, 2007). Taking all this into account, it is recommended that clinicians treating patients with symmetry and ordering assess for past trauma, monitor and address feelings of anger (p. 14) during treatment, and closely watch for suicidal ideation (Williams, Mugno et al., 2013).
Unacceptable/Taboo Thoughts and Mental Rituals
The unacceptable/taboo thoughts symptom dimension includes unwanted obsessions that are often of a religious, violent, or sexual nature. Traditionally, people in this group were referred to as “pure obsessionals” due to their lack of observable compulsive behaviors (i.e., Baer, 1994). It is now apparent, however, that these individuals do engage in ritualizing behaviors, but these rituals tend to be primarily mental in nature (e.g., praying, mental counting, etc.) or otherwise mostly covert (e.g., reassurance-seeking; Williams et al., 2011). This symptom dimension includes individuals whose obsessions often manifest as intrusive, unwanted thoughts, urges, or mental images of committing acts that severely violate their personal morals or values. Examples include thoughts of sexually molesting children, blasphemous thoughts about religious figures, and the experience of sudden urges or impulses to act out violently. People with excessive health concerns are also often represented in this category (Williams, Farris et al., 2014). Although violence is often a prominent theme in this particular category, those who have these thoughts usually have no history of violence, nor do they act on their obsessions; however, because such individuals think their OCD thoughts are dangerous and overly important (Obsessive Compulsive Cognitions Working Group, 2003), they put a lot of mental effort into trying to suppress the thoughts. Paradoxically, attempts at thought suppression have the unwanted effect of actually increasing anxiety and perpetuating symptoms. That is, purposefully trying not to think of a specific thing often has the opposite effect of making the thought more likely to return (Wegner, Schneider, Carter, & White, 1987).
Other ways people with this form of OCD usually try to control these thoughts include mental ritualization (e.g., arguing with oneself over the morality of one’s character), neutralizing (e.g., mentally “canceling out” bad thoughts by replacing them with good thoughts or engaging in excessive prayer or confession), performing some form of mental checking (e.g., reviewing one’s behaviors), and/or seeking reassurance from others. Avoiding known triggers is also especially common in this group. For (p. 15) example, sufferers may make excuses to avoid childcare responsibilities or religious ceremonies. Some research suggests that those with unacceptable thoughts may suffer with more severe obsessions than those with other forms of OCD (Alonso et al., 2001). For example, in one of our own studies, we found that patients with obsessions about their sexual orientation were much more distressed than those with different OCD worries, and they reported more interference in their lives as a result of their symptoms (Williams & Farris, 2011).
One of our clients wrote the following:
I am a 37-year-old woman who has had OCD about being gay since I was 11 years old. I have gotten CBT before, but the treatment only made me worse. I am currently on medication too. I’ve only ever dated men and only want to be straight. I have been doing well with the OCD until last November when I had a dream where I asked a dream figure “Am I a lesbian?” and he said “Yes, you’ve been in denial—but you’ve just been too scared to admit it!” This dream has terrified me so much that I attempted suicide a month ago. I am so scared that this is definitive proof that my subconscious is saying I’m gay and that it must be true. I realize that sexual content dreams are symbolic and don’t mean what they appear; however, my dream was not symbolic with sexual content, but it straight out said I was a lesbian in denial. I am terribly concerned that this might not be OCD.
Sexual symptoms in OCD are the focus of this treatment manual, and most clients’ with sexual OCD (S-OCD) will have primary symptoms that fall into the unacceptable/taboo thoughts category. However, sexual symptoms may be tied to other categories as well (e.g., contamination/cleaning dimension), and most clients will have some OCD symptoms in at least one other area. It will be important to understand and address all OCD symptoms in treatment to prevent symptoms from jumping to another area once the S-OCD is under control.
About Sexual OCD
Although many OCD patients report sexual obsessions as their primary symptom, sexually themed OCD remains understudied and (p. 16) misunderstood. Sexual obsessions may include fears about engaging in undesirable sexual acts, having unwanted sexual mental images, experiencing a change in sexual orientation, having sexual contact with a child, sexual thoughts about religious figures or incongruent with religious/moral values, sexual aggression, and becoming pregnant or impregnating others through unlikely means.
In one study of sexual symptoms in treatment-seeking OCD patients, out of a sample of 296 adults, researchers found current or past sexual obsessions among a quarter of patients (Grant et al., 2006). Patients with sexual obsessions were, on average, 38 years of age and included males and females fairly equally, which was not much different from those without sexual symptoms. Over 80% had an additional mental health diagnosis, and one in five were disabled due to their OCD symptoms. Both patients with and without sexual symptoms had a moderate level OCD severity; however, those with sexual symptoms had a slightly higher severity level. There were no differences between groups in amount of insight into OCD symptoms, indicating that those with S-OCD were just as aware of the senselessness of their symptoms as those with other forms of the disorder. In other words, sexual obsessions in OCD seem to be rather common, with more recent studies uncovering S-OCD in greater numbers than previously believed. Additionally, such symptoms appear to be uniquely distressing.
In one example of S-OCD, a 38-year-old woman came to one of the authors’ outpatient clinics for help for upsetting thoughts about something that had happened a year ago. We’ll call her Linda. She was born and raised in Indiana, and her husband was an East Asian immigrant. They were both devout Catholics and lived in an upscale neighborhood. She was a homemaker and homeschooled their five children, while he worked in advertising. One night while he was working late, she was in bed reading while her youngest child, aged three, had fallen asleep on the other end of the bed. Feeling a bit lonely missing her husband, she decided to masturbate before falling asleep herself. She had not thought much about that event for several months until one day she was reading a religious text that said that masturbation was a sin and a perversion. This made her reflect on this experience, and she immediately felt remorseful about it. She wondered if it meant she had perverted tendencies and if this was doubly so since her small child was in the bed with her. She reminded herself that her daughter was asleep and could not have known what was happening or been affected by it, but the nagging doubt would not go away. She decided never to masturbate again (p. 17) and spent much time praying about the incident and asking for God’s forgiveness. She shared her fears with her husband who quickly dismissed her concerns and urged her to stop worrying. As time passed, the worries continued to grow, and she started to wonder if perhaps she had been sexually aroused by her child, which she surmised would make her a pervert. She then began to wonder if she had, in fact, done something illegal and should turn herself into the police. She imagined that she would be taken to jail and then face scorn and rejection from her family, church, and even God. These thoughts pushed her into a depressive spiral, and some days she was so sad that she could hardly speak to her husband or children at all.
Given the effects of these type of thoughts on the sufferer, it should be no surprise that rates of clinical depression are significantly higher among clients with sexual obsessions compared to other concerns in OCD (Dell’Osso et al., 2012; Grant et al., 2006). In fact, a preliminary analysis we conducted with data from a group of OCD patients in a residential facility showed a similar pattern of higher suicidal ideation (Osegueda, Wetterneck, Williams, Hart, & Bjorgvinsson, 2013), although there were no significant differences in OCD severity. Those with sexual obsessions scored significantly higher—almost twice as high on a measure of suicidality compared to those without sexual obsessions. We think this is due to the stigmatizing nature of such thoughts, leading to greater distress and despair and more depression.
S-OCD affects people of all ages and can even strike children. It used to be believed that S-OCD was rare in children, but it is more likely that S-OCD has been missed in children because sexual symptoms were being misdiagnosed as other problems. At an OCD treatment center in London, a quarter of their child patients were found to be experiencing unwanted sexual obsessions (de la Cruz et al., 2013). These children also suffered from more depression than the other children with OCD and were as young as eight years old.
In the case of Linda, one of her other daughters later began to show signs of S-OCD. This was triggered by having been accidentally exposed to a sexually provocative advertisement on the Internet, which had slipped past the stringent parental control safeguards that had been installed on her iPad. Linda was very upset when she learned about what happened. She blamed herself, became hypervigilant of her daughter’s computer use and even wondered at times if her daughter could become a danger to the other children in the home. The good news is that such children have not been found (p. 18) to pose any risk to others (de la Cruz et al., 2013). Additionally, the results of the London study showed that treatment was equally effective for children with and without S-OCD.
When children present with S-OCD, it is common for adults to suspect that symptoms are an indication of sexual abuse. There are examples in the literature of S-OCD being linked to abuse in some cases but not others. Therefore, it is appropriate to consider sexual abuse when assessing S-OCD in a child, while keeping in mind that excessive questioning may be unnecessary or even harmful (de la Cruz et al., 2013). In the case of Linda’s daughter, part of the intervention included resisting the urge to keep discussing what had happened, as Linda’s repeated questioning of her daughter only served to perpetuate obsessional anxiety in both mother and daughter.
Sexual Obsessions across Ethnicity, Race, and Culture
S-OCD in Ethnic and Racial Minorities
Ethnoracial minorities in the United States tend to be wary of traditional Western mental healthcare, due in part to cultural mistrust, concerns about discrimination, and concerns that their groups’ culture and values will not be appreciated. Widespread negative stereotypes contribute to a sense of stigma and shame among many people in minority groups. Among African Americans, for example, negative stereotypes include being lazy, poor, unintelligent, and, notably, sexually predatory or deviant (Williams, Gooden, & Davis, 2012). In one OCD study that we conducted, we found that at least 17% of African Americans experienced sexual obsessions either currently or in the past (Williams, Elstein et al., 2012), but African Americans with OCD may be hesitant to disclose sexual obsessions for fear of confirming stereotypes about being sexually deviant.
Safer, Bullock, and Safer (2016) reported on the interesting case of a 20-year-old African American college student with OCD and a sexual identity characterized by same-sex attraction. He presented for an evaluation for sexual reassignment surgery due to severe, anxiety-producing doubts about his gender identity. His worries started abruptly after the use of marijuana, at which point he began to question whether or not he was happy being a male. Specifically, he suffered from paralyzing obsessions of being (p. 19) transgender that caused him terrible distress, and as a result he engaged in mental and behavioral compulsions such as “testing” his reactions to certain thoughts or images and reassurance-seeking. He also experienced problems in school, depression, and fleeting suicidal thoughts. It may be interesting to consider possible reasons for why he experienced this previously undocumented form of OCD at that particular time. OCD symptoms often focus on what is most important to those afflicted, and sexual identity tends to be particularly salient to adolescents and young adults due to their developmental stage. Considering the greater awareness of transgender issues due to greater trans representation in the media (e.g., former Olympic athletic now known as Caitlyn Jenner), it is to be expected that we would see more questioning and worry about gender dysphoria among young people prone to OCD. In addition, the role of cultural issues in this case must also be considered. There is greater stigma of LGBTQ identity within the African American community, and transgender African Americans are disproportionately likely to experience discrimination and violence from hate crimes than their transgender White counterparts. This patient was already coping with the difficulties of his intersectionality—having an LGBTQ identity as a Black man—and becoming transgender would have been another massive stigmatizing hurdle to navigate. These social realities may have contributed to heightened anxiety and more obsessional worries in this particular patient (Williams & Ching, 2016).
Thus, treating ethnoracial minorities with S-OCD may involve more challenges and require a special patience and sensitivity. It is important for clinicians to take time to learn about the culture and values of their minority clients. Ignoring cultural values or differences using a colorblind approach may make minority clients more reluctant to open up about their concerns (Terwilliger et al., 2013). Making treatment a more collaborative process with minority clients may improve the process by giving the client more control over their recovery and establish more trust between the therapist and client (Williams, Sawyer, Ellsworth, Singh, & Tellawi, 2017). Furthermore, cultures differ in their attitudes about acceptable sexual behaviors. It will be important to understand and show respect for these practices and beliefs, even if they differ from mainstream Western practices and beliefs.
Treating OCD in ethnoracial minorities will usually require a considerable amount of rapport building, assessment, acknowledgement of cultural values, and psychoeducation. Traditional Western psychotherapy may not (p. 20) foster these ideologies, so it is essential for clinicians to be sensitive to a minority client’s value system and potential negative cultural attitudes toward experiencing a mental disorder and mental healthcare overall. In a recent study of treatment outcomes at a major OCD residential/intensive treatment center, we found that ethnoracial minority patients were requiring longer stays, despite entering treatment with the same OCD severity as their White counterparts (Williams, Sawyer et al., 2015). It was thought that increased awareness of culturally appropriate approaches might improve future outcomes with patients from these groups. However, therapists should also remember that ethnoracial minorities are not a single homogeneous group; therefore, generalizing culturally relevant principles may not encompass the value systems of all minorities.
In Western cultures, it is widely believed that OCD is a mental condition caused by biological factors (Coles & Coleman, 2010), with washing, symmetry, and checking related dimensions more quickly recognized as OCD than sexual symptoms. Nonetheless, sexual symptoms in OCD have been reported around the world, including in India, Korea, South Africa, and Mexico (Williams & Steever, 2015). That being said, sometimes these sexual symptoms look very different than what we usually see in the United States.
In India, the culture-bound disorder termed puppy pregnancy is described as fear of being pregnant with a canine embryo (Chowdhury, Mukherjee, Ghosh, & Chowdhury, 2003). This condition is ironically more common among men than women and may emerge after having been bitten by a dog. Puppy pregnancy has been primarily reported in rural parts of West Bengal, India, and is thought to often be a variant of OCD. Puppy pregnancy includes a fear of internal contamination (from the puppy fetus), disability (impotence due to damage to internal sexual organs), and even death. For example, one case report involved a 27-year-old milkman who after having seen a dog licking milk cans was then bitten by the dog when trying to move it away. The subject became fearful of dogs, worried that he was being chased by a dog, and would check all milk cans, worried they had been licked by a dog. Gradually his obsessions about dogs increased, and he developed a severe doubt that all his household articles were contaminated (p. 21) by contact with a dog. He also experienced obsessive thoughts involving fear of dog bites and avoidance of places where dogs had been seen. He eventually became housebound and feared that he might die after painful delivery of puppies through his penis.
Another culture-bound disorder found mainly in Southeast Asian cultures is koro. This disorder is described as the phenomenon where sexual organs (penis in males and nipples/breasts in women) retract back into the body, disappearing and potentially causing death (APA, 2013). Although this condition has been noted as occurring within females, the majority of cases observed have been in males (Davis, Steever, Terwilliger, & Williams, 2012). Similar to obsessions seen often in OCD, koro can cause a lot of anxiety and disability in those suffering. Additionally, common reactions to symptoms that seem analogous to compulsions are tugging and pulling on genitals to stop the retraction process (Davis et al., 2012). More research is needed on the cause(s) of initial symptom manifestation, but in two cases studies the authors noted each koro sufferer began to experience symptoms after being warned about an outbreak via social networking (i.e., a phone call and local news reports). Each koro sufferer was checked by a physician for physical abnormalities, but none were found (Roy et al., 2011). Isolated cases have also been reported in the West, which indicates that koro may not be simply a culture bound syndrome but an OCD-related phenomenon with more universal constructs (Davis et al., 2012).
It has been suggested that sexual orientation obsessions in OCD (SO-OCD) are a Western cultural variation of OCD, as there have been no reports in the literature of this type of OCD outside the United States. This may be due to the societal tension around non-heterosexual orientations in the United States. In some Eastern cultures, homosexuality and transsexuality are embraced socially as a common form of lifestyle/expression. In some cultures, there is evidence of sexual practices between people of the same sex (which would be considered by Westerners as “homosexual”) being seen as acceptable and separate from one’s sexuality. That being said, we have been in touch with clients from around the world suffering from SO-OCD. This includes clients from cultures where same-sex behavior is frowned upon (i.e., India, Saudi Arabia, Philippines) and countries that tend to be very accepting of different orientations (i.e., Canada, England, Sweden). This leads us to believe that this form of OCD is universal and not simply a byproduct of cultural attitudes.
(p. 22) Types of Sexual Obsessions
Pedophile obsessions (P-OCD) are perhaps the most troubling form of OCD, and this incarnation of the disorder can have specific or general obsessional targets. Some pedophilia obsessions involve specific family members or loved ones, while others may be about any random child, regardless of whether there is a pre-existing relationship. P-OCD can develop after a person has a baby (i.e., postpartum OCD) where they begin to fear it is inappropriate to touch a child’s genitals while wiping, cleaning, or changing a diaper (Larsen et al., 2006). A parent may be concerned that they could become aroused by any of these acts, stimulate their baby, or even be aroused by stimulating their baby. As we will discuss in a later chapter, one woman we worked with felt as though her baby’s penis moved too often or urinated while being wiped during a diaper change and feared she was a pedophile for continuing to stimulate him in this manner. Others fear that they must be doing something wrong during bathing, dressing, or changing a baby, and when someone else finds out, they will be accused of sexually harming the child.
As noted, P-OCD concerns are not limited to one’s own children. A stray thought of being inappropriate around children during a routine “fun” activity (e.g., tickling or wrestling) or even when having a warm thought toward a child (e.g., “Oh, he’s such a cute little boy” or “She looks so grown up in that dress”) can balloon into much larger fears and unhelpful rituals or avoidance. Clients may wonder, “Did I enjoy being physically close to that child or become aroused at all? Did I accidentally touch them too close or directly on an inappropriate part of their body? Did I accidentally allow them to touch me somewhere? Maybe it wasn’t an accident and I wanted to touch them or have them touch me? What is wrong with me?” Another line of obsessions may begin with the question, “Why did I have that thought about how they look? Was I seeing the child as an adult or someone that could be attractive? Would someone think I was a pervert for saying he was cute or commenting on her dress? I need to watch what I say or perhaps people will begin to question if I am a deviant of some sort.”
The original obsessions themselves are met not only by more obsessional thinking but also behavioral changes or checking. The person may begin to have less physical contact with the child or any children and make (p. 23) excuses why they cannot wrestle, pick them up, hug them, or even give them a “high-five.” They may avoid children altogether, making excuses to get out of their own childcare responsibilities or see other children or not allow themselves to be alone with a child. They might stop commenting on a child’s appearance or refuse to look at a child below the neck so as to avoid sexualizing them. Others might engage or watch children from a safe distance, even occasionally to check their own reaction to make sure there is no arousal to seeing a child. Eventually they may try to avoid children altogether, despite not feeling aroused after numerous attempts to check because they could not bear if “the next time will be the time I am aroused.”
We want to be clear that when a client has thoughts about children, their own or others, those with OCD are the least likely to do anything inappropriate. As a clinician, your primary question is to determine whether any of these thoughts are ever “wanted” or wanted to produce arousal. Those with OCD will deny wanting these thoughts (as they are ego-dystonic), and some will simultaneously cry or show great distress as they doubt why, then, they are having them. Having unwanted sexual thoughts about a much younger person is more common than most would know, as indicated by a traditional college-aged sample from Canada (endorsed by just over 50% for men and 25% for women; Renaud & Byers, 1999). Thus, asking these questions by normalizing the experience and finding out if the thoughts are wanted is crucial.
Sexual Orientation Obsessions
SO-OCDs were originally thought to be when a heterosexual person has an obsession about having a different sexual orientation (i.e., same-sex attraction or perhaps bisexual), and this was called homosexual OCD (H-OCD) in the first articles on this topic (Williams, 2008). This term evolved out of the OCD online self-help community in the early days of the Internet. We now know that people with sexual orientation concerns are not only present in those who are heterosexual but also that people who are gay or lesbian may have obsessions that they are straight/heterosexual, and so we revised the term to be inclusive and now call this presentation SO-OCD. Given the stigma that sexual minorities face in society, we do believe these obsessions are more likely to develop when stigma is greater, so those who are heterosexual are more likely to fear being LGBTQ than vice versa. This (p. 24) observation is mainly anecdotal at this point but is in line with our clinical observations.
There is research on the prevalence of SO-OCD overall from the large DSM-IV Field Trial (n = 409), which found 8% reported current SO-OCD and 11.9% with lifetime symptoms (Williams & Farris, 2011). More data, reported by Pinto et al. (2008) based on the OCD Collaborative Genetics Study reported approximately 10% of the sample (n = 485) acknowledged past or present obsessions related to same sex thoughts.
Similar to P-OCD, SO-OCD can develop in a variety of ways, with a number of accompanying compulsions. A heterosexual individual may initially have a thought when noticing a member of the same sex and finding that person attractive (e.g., a guy seeing a movie ad thinks, “That Brad Pitt is a sexy dude”) and then questions the meaning of the thought. Other examples include a heterosexual male being complimented on his apparel by another male and then wondering if the person felt attracted to him and perhaps that is because him appears, acts, or actually is LGBTQ. Likewise, a very pro-LGBTQ–affirming lesbian may start to worry about being straight when noticing an attractive male and wonder if her orientation is changing.
As mentioned earlier, we believe these obsessions become much more challenging during periods where one has less experience and knowledge about sexuality, while also experiencing more physical reactions (or hearing about others experiencing reactions while they have yet to experience them); adolescence is a time where these concerns are heightened and where peers may be especially stigmatizing about differences, or when one feels as though these differences will be interpreted as negative.
One adolescent male client who came to our outpatient practice told us the following story:
My mom was always talking about how cute Ryan Gosling was and told me I was just as cute as him. I told her that I did not think he was cute, but really had no idea who he was. My mom showed me a picture of him and said, “C’mon, you have to admit he’s a hunk.” He looked like a player, so I told my mom, “Ok, yes he’s a hunk alright.” We both laughed about it, but then I started considering that he was, you know, attractive, and then, did that mean, I was like, gay or bi- or something? It’s so hard to even talk about this. I like to want girls and only girls, but the fact that I agreed must mean I could go the other way. I don’t even want to watch any movies anymore because of it.
(p. 25) These obsessions could develop in other ways, including misinterpreting a bodily reaction. An episode of the television show Seinfeld illustrated such an example that we have heard referenced by a few clients. In the show, George, a fairly worrisome guy, is getting a massage and finds out what he thought would be a female masseuse is actually a male. During the massage, the masseuse applies slight pressure to George’s lower back, and he immediately is distressed. Already heightened by the uncomfortableness of having a male touch him, he later tells his friends that he thinks “it [his penis] moved” and he worries that he might be gay. Although this example is from a sitcom, misinterpretations that are more easily explained by subtle movements, shifts in pressure around the genitals, or even a natural physiological arousal response to being touched may be the thought that begins SO-OCD. Conversely, absence of an arousal response (the failure to develop an erection or experience vaginal lubrication) when engaging in a physical, intimate behavior (e.g., kissing, hugging, caressing, or even groping or direct touching) with someone of the other sex that one is attracted to may also be interpreted as “Maybe I am really not straight.”
These obsessions then lead to compulsions, which may present as the person checking for sexual arousal when around others or mental reminders about being heterosexual. Symptoms may also include avoidance, such as not watching television shows in which there is an LGBTQ character or keeping physical distance from others of the same sex (i.e., Williams et al., 2011). The individual may watch pornography with same-sex themes to determine whether it produces sexual arousal and compare that reaction to heterosexual pornography. Another compulsion is to increase sexual intercourse with an other-sex partner to demonstrate that the person’s sexual preference has not changed.
We should note that SO-OCD is not caused by homophobia/heterosexism; the individual may or may not have negative feelings toward LGBTQ individuals (Williams, 2008). This is also different from internalized homophobia/heterosexism (IH), which occurs when an LGBTQ person has negative feelings about himself or herself due to sexual orientation or identity (Szymanski, Kashubeck-West, & Meyer, 2008), although LGBTQ people with OCD can also suffer from IH. Because it can be difficult for clinicians who do not have experience with OCD to distinguish between “sexual identity confusion” and SO-OCD, SO-OCD may be misdiagnosed (Glazier et al., 2013).
(p. 26) As you can see, there can be issues with identifying SO-OCD; however, we believe that through careful interviewing (e.g., establishing whether the thought is ego-syntonic or ego-dystonic and examining the function of the compulsions) and even some evidence-based measures (which we will share later in this book; see Chapter 3), clinicians will have more confidence in correctly identifying OCD concerns. We cannot overstate the importance of correct, thorough case conceptualization to allow clients to receive appropriate treatment and to reduce misdiagnosis, stigmatization, and other outcomes that prolong suffering and a less valued life.
Religious Sexual Obsessions (Scrupulosity)
Many types of obsessions fall under the category of religious sexual obsessions, either due to content or the client’s beliefs about morality. An example of a content related religious obsession could have to do with having sexual images or thoughts about a religious figure. We have had clients report being distressed by images of acting sexually inappropriate with a religious role model in their life (i.e., anywhere from hugging or kissing to more sexual touching or intercourse with a pastor or church elder) or implausible sexual relationships with a religious figure, such as Jesus Christ. While these overt examples of religious sexual obsessions are distressing for some obvious reasons, the idea of scrupulosity is a complicating factor and is involved with other, more regular sexual thoughts and judgments about behaviors.
If one is scrupulous, it means they have identified scruples, which are moral or ethical standards and have to do with what one believes is right and wrong. It is important to note that people do not have to be religious or even knowledgeable about religion in any way to have scruples. In addition, not all OCD obsessions that involve scrupulosity are religious or sexually oriented. For example, clients may present with obsessions related to scruples about following rules correctly or conservation of resources and the environment. They may become distressed by thoughts that they have used too much water, which endangers our fresh-water resources, thrown away items in appropriate containers (i.e., not recycled items that are recyclable) making them responsible for pollution or inefficiency, or a number of other concerns.
Scrupulosity about sexual thoughts or behaviors does not have to be religiously influenced either. In the previous examples of those with P-OCD, (p. 27) knowing sexual activity with children is illegal maps onto the concept of scruples. For many with OCD, adding religious scruples to a sexual obsession adds additional consequences to illegal activities or creates immorality and consequences where it does not have to exist. Consider people with P-OCD, they may fear going to prison as a result of the ego-dystonic thoughts and now add the consequence of being judged by themselves and others and religious communities and a higher power, who may send the sinner to eternal hell after death.
Scrupulosity may also lead to obsessions about behaviors that may or may not be against one’s religion. From most Christian perspectives, it is against God’s law to “covet thy neighbor’s wife” or enjoy “sins of the flesh.” For those with OCD, an innocuous thought about a married person may lead to doubt about whether that reflects inappropriate interest in them. Other feelings or behaviors, such as having a physiological sign of sexual arousal, a thought of sex, or masturbating while thinking about the married person could be considered a sign of sinful thoughts or activities. When paired with the concept that one’s higher power is everywhere and knows all, it leads to great distress and compulsive behaviors to alleviate associated anxiety and disgust (e.g., attending more religious services, frequent confessions, praying, etc.) and ultimately leaves less time for other meaningful life activities.
Religious obsessions present a unique challenge for the clinician as the evidence-based techniques will require actions that clients may feel challenge religious doctrine, even though many times the procedures are about areas open to interpretation. Clients often express early on that we are asking them to do things that feel wrong or are additional “sins.” The idea is to create exposures that are anxiety-provoking but not sinful based on the accepted tenets of the client’s religion. We will get as close to the line as possible without crossing it. We recommend communication with a religious/spiritual leader (more on this in Chapter 2) to assist and ease concerns for both the clinician and client.
Sexual Assault Obsessions
One of the most upsetting types of obsessions concern worries that a person may cause harm to others impulsively. Common OCD examples include the fear that the person will punch a friend when they are not angry but (p. 28) just because they can. People with aggressive obsessions may be concerned that they might push an elderly person into subway tracks or stab a loved one while using a kitchen knife. The focal point of these worries is usually loved ones but can be strangers or pets. Sometimes the person is not worried about harming others but worries about harming himself or herself, which is not to be confused with suicidal ideation, as people with these types of fears will do anything to avoid causing the harm they worry about.
Therefore, it should be no surprise that these sort of aggressive thoughts can involve sexual behaviors as well. People can have S-OCD focused on fears of seducing other people, sexual harassment, touching others inappropriately, or even violent rape. Here we recount the true story of a patient who struggled with sexual assault fears during his college years and later.
Although I had always struggled with sexual fears and obsessions, through careful avoidance of potential “problem areas,” I had been able to resist temptation. In high school I never dated, even turning down an offer to go to the prom for fear that I would rape the girl I was with. Sex was dirty. I vowed that I would either never marry, or I would marry my first girlfriend. This decision was fueled by the fear that I would lose control with a woman. I had no explanation for this as I had never been a violent person.
In college, I avoided women my entire freshman year. I was afraid of being around the women at my dorm, and I had decided that I definitely would not date any of them because the situation was just too dangerous. If I dated it was inevitable that I would end up in a situation where it would be too easy to lose control. My worst fear was that I would lose my virginity in a sexual escapade. If that was gone, it would surely be a quick downhill slide from there. I knew only too well what it was like to lose control—I had struggled for many years with an eating disorder that almost killed me.
My sophomore year I met someone I really enjoyed spending time with. I felt torn by the situation because she lived in my dorm. Part of me wanted to spend every moment with her but another part was terrified. I abruptly broke off the relationship, but somehow within a few weeks we were in bed together. Although we slept together for close to a year, I never lost my virginity. This should have proven to me that I indeed possessed a considerable amount of self-control. However, my feelings were just the opposite. I felt tremendous shame for being so close when we weren’t married. (p. 29)
Even after I was married I continued to struggle with unfounded fears that I would cheat on my wife. As far as I was concerned, marriage was a lifetime commitment between two people that I had no desire to break. I blamed my weaknesses in this area on a variety of different factors: the fact that I had never dated in high school with no opportunity to sow any “wild oats”; my parents, for not communicating the facts of life to me at any point; sexual abuse perpetrated against me as a child by a close relative; an overly permissive society that allowed naked women to be brazenly displayed across the pages of a magazine available at any convenience store; but most of all myself. I blamed myself for having such a warped mind. I was convinced it was deadly character defect that would someday be my undoing.
I started a pattern of avoidance to keep my sexual obsessions at bay. I tried to never spend any time alone with another woman. I would even exhale when I passed a woman on the street so that I would not smell any perfume she might be wearing. I was convinced that any such stimulus could push me over the edge. When I walked down the street my eyes followed a tortuous path so that I would not look at a woman, even for an instant. If I looked at her, I was afraid I would begin to lust uncontrollably. There were times when I genuinely thought I was losing my mind, and I would call my therapist in a panic. He would talk me through it and I would feel okay for a while, but it was always only temporary.
When conceptualizing sexual assault obsessions, it is important to recognize that people with this sort of S-OCD find their thoughts immoral and do not wish to act them out. They are different from fantasies, as the obsessions are unpleasant and provoke guilt, rather than being enjoyable. As a result, the thoughts cause distress, which may be connected to unwanted emotions, such as lust, disgust, anger, and frequently guilt. This distress is directly related to the frequency of the sexual obsessions and may lead to depression, difficulties concentrating, anxiety, and avoidance of others.
We once heard an interesting story about a German woman we’ll call Gretchen, who got pregnant with a candle. She was a single woman with no current boyfriend, who lived with a female roommate in Berlin. When (p. 30) she felt so inclined, she would masturbate with a special candle in their apartment that she had determined was particularly well-suited to the task. Her roommate knew about the candle, and it had become a shared joke between the two of them. One day after her roommate had come home from a particularly unsatisfying sexual encounter with her boyfriend, she decided to finish the job with Gretchen’s special candle, then she put it back in its holder on the mantle. When Gretchen came home later that evening, she used the candle for its usual purpose, and the residual semen on the candle, left there second-hand from the roommate’s boyfriend managed to impregnate her. Gretchen was astonished to learn she was pregnant, and after the baby was born, she applied for public assistance. A paternity test confirmed the supposed route of impregnation, and her roommate’s boyfriend was forced to pay child support. Could such a scenario actually lead to pregnancy? Or, was the candle a convenient excuse to hide an affair with a friend’s boyfriend?
Getting pregnant from a candle seems far-fetched if not impossible. We may never know what actually happened, but for the person with impregnating obsessions in OCD, stories like this fuel terrifying worries of pregnancy occurring without even having sex. Women with this type of OCD may worry about getting pregnant from a toilet seat or in a swimming pool. Men with this form of OCD may fear impregnating others through sperm transferred by various means such as a handshake. The following is a typical account of a woman with frightening obsessions about pregnancy resulting from unlikely circumstances.
I have been in a great relationship with a great guy for a while. But since we started having sex I totally freak myself out that I may become pregnant. I know there is no reason to be worried because I’m on “the pill,” I insist we use a condom, and he pulls out every time. I ruin the experience for him afterwards because I am freaking out, and I didn’t even enjoy the sex because of all the anxiety. And even now we hardly get intimate because of my fear that somehow I will get pregnant through just touching.
When we’re not having sex, I make myself sick with worry because it’s all I think about. I start to feel pregnant with most of the symptoms, though in saner moments I know it’s really all in my head. Last month I took at least 10 pregnancy tests, and all were negative. Then I went to see my gynecologist and got another pregnancy test, which was also negative. And even after I got my period I still think I’m pregnant. I read a story on (p. 31) the Internet about a woman who kept having periods even though she was pregnant, and I worry that will happen to me too. I’ll be the one in a million woman that gets pregnant but won’t know it until the baby pops out.
I keep pressing my abdomen to see if I can figure out if my uterus is enlarging, and sometimes I actually feel like my tummy is getting bigger. The weird thing is that I lost four pounds, and you’re supposed to gain weight when you’re pregnant. Anyway, that doesn’t stop me from freaking out. I’m crying all the time and thinking what I’m going to do if one day I wake up and my tummy is big as a watermelon. I keep searching the Internet for more and more information and waste so much time on it, sometimes hours at a time. I end up having panic attacks, worrying how I would hide it, what if it gets too late for an abortion, and then what would happen to me.
This example presents the obsessive-compulsive cycle in action. The obsessions are the ongoing, agonizing fears of pregnancy, and the compulsions are the repeated pregnancy tests and searching for answers on the Internet.
Are People with Sexual Obsessions Dangerous?
People with OCD are not dangerous. To clarify, they are not dangerous because they have OCD. In fact, they are less likely, in our opinion, as well as any OCD expert you ask, to engage in actions that they fear. Keep in mind, to have the disorder, the thoughts have to be unwanted—the thoughts are not in line with what a person values nor how they would like to be. But fear and doubt can be so overwhelming that, when combined with clinicians who have less experience with certain OCD presentations (or specialties in other areas that may also seem to explain the symptoms), there can be real concern. Your client is telling you they fear being sexually aggressive toward others, molesting a child (or in the case of aggressive violent obsessions, acting on those thoughts), or being “hypersexually aroused” and a danger. That’s hard to hear and you want to do a great job ruling out the worst possible scenarios. It takes time to habituate to our own fears about doing therapy when the topics appear to be life-threatening, illegal, or include situations in which we are mandatory reporters. It gets easier over time, but if you have doubts early on in this book about your ability to diagnose or (p. 32) work with these presentations, we want you to know that is normal! All of our students and trainees express these concerns. And you will be able to help your client and get through it yourself as a clinician. You don’t have to be 100% certain, and, ironically, this feels very much like what our clients have already been going through and will experience during treatment.
Back to the idea of danger. Understand that the function of all of client behavior is to keep the obsession from being a reality. Most avoid situations where harm or sexual behavior is even accidentally possible (e.g., the client with P-OCD avoids interacting with children, even their own; the person who fears touching a woman inappropriately does everything possible to maintain more space between them and females). Even situations where the client engages in something that could be a sign that the obsession is true (e.g., a client watches pornographic video that does not actually align with his or her orientation to check for signs of arousal) is done in the service of relieving anxiety and/or to disconfirm the belief. If the belief is not disconfirmed (e.g., a client has a physiological arousal response to the aforementioned video) it is met with fear, shame, or disgust and not acted upon in a manner that makes it a reality. There are no moments where a person with OCD is advertently testing to see if they will have a sexual reaction to something, experiences the sexual reaction (e.g., develops an erection or vaginal lubrication to the video), and then embraces the idea that they are a different sexual orientation, a pedophile, or a rapist and subsequently leads his or her life according to this belief. Our clients instead remain anxious, shameful, and disgusted; they increase self-loathing, restrict even more activities, and become depressed. They do not turn into what they fear.
What Is the Prognosis for People with Sexual Obsessions?
There are a lot of data indicating that those with OCD can get better with evidence-based treatment. However, there have been little data on treatment specifically for sexual obsessions as most studies using cognitive-behavioral interventions involving exposure and ritual (response) prevention (Ex/RP) have patient samples predominantly consisting of those with washing/cleaning and checking compulsions (Ball, Baer, & Otto, 1995; Williams, Mugno et al., 2013). There are less available findings for areas of unacceptable thoughts overall and few looking at only sexual and religious thoughts.
(p. 33) So far, a few case studies have been published on the successful treatment of SO-OCD (Williams, Slimowicz, et al., 2014) and fears related to P-OCD (O’Neil, Cather, Fishel, & Kafka, 2005; Reid et al., 2016). In addition, some studies have tried to compare those with sexual (Mataix-Cols et al., 2002; Starcevic & Brakoulias, 2008) or unacceptable thoughts in general in outpatient (e.g., Williams, Faris, et al., 2014) or residential treatment (Chase, Wetterneck, Bartsch, Leonard, & Riemann, 2015) to those with other primary obsessions. As previously mentioned, the studies that compared small numbers of those with sexual obsessions to those with other obsessions had a poorer prognosis. Nonetheless, those with S-OCD still were shown to make large and significant improvements. And the latter studies involving the unacceptable thoughts as a large group showed no differences in outcomes compared to those with other primary obsessions.
While more research is required before conclusions can be drawn, more successful outcomes are likely when treatment is tailored specifically to the symptom dimension—which is exactly our reason for writing this book! Sexual obsessions and other unacceptable thoughts may have features that are distinct from other symptom dimensions, including a more intense, repulsive, and morally reprehensible ego-dystonic nature; greater overall obsessional severity and distress; and greater time spent on obsessions, more covert mental compulsions and reassurance seeking than overt compulsions (Williams et al., 2011), and increased social stigma and shame (Cathey & Wetterneck, 2013; Grant et al., 2006). So, you made a wise choice to seek out the specialized knowledge and approach detailed in this book.
Psychotherapies for OCD
OCD used to be considered extremely difficult, if not impossible, to treat. Psychoanalytic thought, based on Freud’s theories of unconscious drives and wishes, produced many theories and interesting case studies that described sexual obsessions in a number of patients. However, his treatment of these obsessional states could not be reliably replicated. Nonetheless, due to lack of alternatives, Freudian approaches continued to be advanced as the treatment of choice for OCD, despite limited benefit (Williams, Powers, & Foa, 2012). This class of treatment includes psychoanalysis, (p. 34) psychodynamic therapy, and “insight-oriented therapy.” Sometimes people call it “talk therapy.” Sadly, people with OCD often ended up housebound or institutionalized.
It is now widely recognized that, for OCD, psychodynamic approaches have little evidence to justify their use. Concerning these therapies, the most current expert guidelines most tellingly note that “there is doubt as to whether it has a place in mental health services for OCD” at all (National Institute for Health and Clinical Excellence, 2006, p. 104). Nonetheless, such approaches for OCD continue to be widespread, despite their lack of efficacy. The good news is that today there are several effective treatments for OCD, including CBT, medication options, and their combination. Of the CBT approaches, Ex/RP (or ERP) has the most empirical support (Williams, Powers et al., 2012), although clinicians may use Ex/RP in combination with other therapies, such as cognitive therapy (CT), acceptance and commitment therapy (ACT), mindfulness, and functional analytic psychotherapy (FAP), which have shown some utility, particularly among those with unacceptable/taboo thoughts (Wetterneck, Williams, Tellawi, & Bruce, 2016).
There are other therapeutic techniques that may also help. Motivational interviewing may be useful to increase motivation at the onset of treatment to reduce ambivalence; motivational interviewing has been shown to improve treatment initiation and adherence when used before or with other treatments (Simpson & Zuckoff, 2011). Exercise has also been shown beneficial for mood and anxiety disorders, with studies suggesting some benefits in OCD (Rector, Richter, Lerman, & Regev, 2015). We believe these strategies should not be used instead of the evidence-based approaches but as additional ways to increase success in treatment. Finally, stress management CBT, consisting of relaxation and deep-breathing exercises, positive imagery, and problem-solving skills, has not been shown to be effective for OCD.
Alternative Treatments for OCD
We do not yet know whether other complementary and alternative therapies are useful for OCD. One study suggested that OCD patients can benefit from mindfulness meditation, and a Chinese study suggested that three weeks of electro-acupuncture was helpful, but these trials were small and (p. 35) not randomized; thus, more research is needed (Sarris, Camfield, & Berk, 2012). After some brief initial excitement, the over-the-counter supplement St. John’s Wort was shown to be ineffective. Some people have also used 5-hydroxytryptophan (5-HTP) to combat symptoms.
Marijuana has not been demonstrated to be helpful in OCD, and, in fact, OCD symptoms have been linked to cannabis use in both case reports and epidemiological studies (Williams & Ching, 2016). Cannabis is known to predispose youth to motivational, affective, and psychotic disorders; there is strong evidence of the psychopathogenic effects of cannabis on the developing brain, and studies indicate that early cannabis use is associated with major depressive disorder and substance use disorders (Chadwick, Miller, & Hurd, 2013; Moore et al., 2007). Thus we strongly discourage its use by people with OCD, especially during adolescence and early adulthood. For several clients we have assessed, marijuana was actually the catalyst that triggered OCD symptoms, sometimes after just a single use. Furthermore, marijuana can impair verbal learning, which can interfere with the CBT treatment process (Bhattacharyya et al., 2009). However, there have been isolated reports of some people improving with cannabis use; thus, further study of the relationship between cannabis and OCD is needed. It could be that some components of marijuana are helpful and some harmful, and it could be that hazardous effects only occur in young people.
Medications for OCD
Although Ex/RP has been shown to be the most effective approach so far, it is rarely the first treatment received by those with the disorder. Many people simply do not have access to CBT for OCD because of a lack of therapists who use empirically supported treatments, particularly in rural areas (Taylor et al., 2003). Additionally, most clinicians do not receive training in Ex/RP or empirically supported treatments in general (Barlow, Levitt, & Bufka, 1999), resulting in a lack of therapists who can effectively treat OCD. As a result, would-be patients may have difficulty locating qualified providers in their communities. In fact, over half of those with OCD admit to uncertainty about where to go for help or who to see (Williams, Domanico et al., 2012). Less than a third with OCD obtain OCD-specific treatment, but just over half are seen by a general medical practitioner (Ruscio et al., 2010). Thus, the first-line treatment for OCD is typically a (p. 36) medication option, specifically selective serotonin reuptake inhibitors (SSRIs), due to their widespread availability and manageable side effects (Koran & Simpson, 2013). However, in most cases these medications only result in a modest decrease in OCD symptoms, leaving most people unsatisfied with the result.
When this happens, prescribers may augment the SSRI with other medications. Commonly prescribed medications for augmenting include benzodiazepines (e.g., muscle relaxants such as Clonazepam), mood stabilizers (e.g. lithium), and neuroleptics (e.g., Risperdal, Zyprexa, Seroquel). However, the efficacy of these add-on regimens is questionable, and, in some cases, they are unsafe. But we will discuss OCD medication issues more in depth in the next chapter.
Options for Treatment Refractory OCD
Although CBT for OCD can be extremely effective, this is probably a good place to mention that not everyone with OCD will be helped by even the best CBT therapy. Often clients are anxious about diving into CBT because they fear that nothing will help them and they don’t want to be disappointed. We always encourage them by saying how effective the treatment is and also note that there are other approaches we can try if they happen to be in the minority that does not benefit from CBT. The sad truth is that all of us who work with OCD have had our share of treatment failures that were not due to lack of effort or expertise. When treatment-as-usual is not working, consider increasing the intensity of Ex/RP (e.g., intensive/daily outpatient care) or increasing the level of care, (e.g., a residential OCD program). If these are not effective, it is important for clients to know that additional options are available, although they are more invasive than therapy or medication.
Psychosurgery is an option for treatment-refractory OCD that essentially involves destruction of a small part of the brain. Psychosurgery can be controversial due to the now-discredited prefrontal lobotomy procedure and other surgical procedures that took place from the mid-1930s to the 1950s. These procedures were overzealously performed on people with issues such as schizophrenia, same-sex attraction, depression, autism, criminality, etc. A prefrontal lobotomy is a surgical procedure in which the frontal lobes of the brain are irreversibly severed. This procedure was abandoned in part because of common and severe side effects such as death, personality change, (p. 37) intellectual impairment, loss of emotional responsiveness, and paralysis. António Egas Moniz, who invented prefrontal lobotomies, sadly received a Nobel Prize—making it a good case study for anyone who believes that medicine has all the answers. In 1949, Moniz was shot by one of his own patients and was subsequently bound to a wheelchair. He continued his work until 1955, when he died just as lobotomies were falling into disrepute.
Modern medicine and psychiatry are different than in years past, with safeguards in place to prevent such travesties. Psychosurgery is much safer today than in previous years and much more judiciously performed. One must also take into account the reason it is even considered: for extreme, treatment refractory disorders. People with treatment refractory OCD often have some of the most debilitating symptoms, leading to a very poor quality of life.
The neuroanatomy of OCD is becoming increasingly better understood, although there is always much more to learn. Through imaging studies, doctors can see brain activity, lending evidence as to which parts of the brain are affected in patients with OCD. The evidence seems to point to the limbic system and its connection with the basal ganglia. The most commonly used psychosurgical treatments for OCD in the United States involve the use of radio-frequency waves (called a gamma knife) to destroy a small amount of brain tissue, which disrupts the specific circuit in the brain that has been implicated in OCD. This area is the corticostriatal circuit, and it is comprised of the orbitofrontal cortex, the caudate nucleus, the pallidum, the thalamus, and the anterior cingulate cortex. Surgical techniques for this purpose include anterior cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy.
These are generally safe procedures that do not usually affect a patient’s memory or intellect. The various methods all appear to be equally effective, with cingulotomies believed to be the safest. Long-term outcomes of these procedures appear to be about 70% effective in alleviating symptoms of treatment-refractory OCD (Martinez-Alvarez, 2015). Side effects include confusion, cognitive impairment, urinary incontinence, fever, nausea/vomiting, hallucinations, and depression, lasting between two and six months. Improvements appear gradually over the course of the two years after surgery.
Remember, psychosurgery is brain surgery. Because of the many ethical, legal, and social implications of psychosurgery, a relatively small number of these procedures are done at just a handful of medical centers around the (p. 38) world. It should not be considered unless the patient has failed several lengthy attempts at medication at the full dosage with augmentation and many months of focused and intensive CBT. Although psychosurgery should be a last resort, it should be considered as an option if nothing else is working.
Other brain-based techniques that do not involve the destruction of brain tissue involve neuromodulation, which means altering nerve activity through the delivery of electrical stimulation or chemicals to specific sites of the body. It directly treats the nervous system itself to rebalance the activity of neural circuits and manage symptoms. One neuromodulation technique for OCD is deep brain stimulation (DBS). DBS involves surgery whereby electrodes are implanted into the brain to target multiple neural circuits to reduce symptoms in patients with refractory OCD. The electrodes stimulate the brain by way of an implanted pulse generator (IPG), which is calibrated for best effects. To date, over 100 patients have undergone DBS implantation surgery for OCD. However, outcomes need to be cautiously interpreted due to the relatively small numbers of people using the technique (Sharma, Saleh, Deogaonkar, & Rezai, 2015). However, unlike psychosurgery, the effects are reversible and the electrodes can be removed.
Another less invasive technique is transcranial magnetic stimulation (TMS), although it is still considered experimental. TMS involves placing a magnetic coil near an individual’s head to deliver small electrical currents directly through the skull into the brain, stimulating brain cells to relieve OCD symptoms. Research has demonstrated TMS can be effective in treating depression, and researchers are in the process of expanding this treatment to OCD.
OCD is a chronic, debilitating, and often perplexing disorder, with many symptom presentations, including those with sexual themes. These worries are the opposite of what clients want and are in no way predictive of future sexual behaviors. Ex/RP is the most well-supported approach to the treatment of all kinds of OCD, including S-OCD, although other psychotherapeutic approaches may be helpful as well. Not everyone will be successful in using CBT, and so it is important that clients understand there are other options for them, including medication and even more invasive approaches, such as brain surgery.