The patient had been previously treated with pharmacotherapy, resulting in inadequate Intrusive sexual thoughts ocd reduction and unwanted side effects. OCD symptoms included anxiety about the possibility of becoming gay, mental reassurance, and avoidance of other men, which resulted in depressive symptoms and marital distress.
The effect of treatment was evaluated using standardized rating instruments and self-monitoring by the patient. Improvement also occurred in mood, quality of life, and social adjustment. Issues concerning the assessment and treatment of homosexuality-themed obsessions in OCD are highlighted and discussed. Obsessive-compulsive disorder OCD is estimated to occur in 1. It is a disorder marked by significant distress and interference in daily activities. The hallmark features of this disorder include both obsessions and compulsions.
Obsessions are intrusive thoughts, impulses, or images that cause distress and increased anxiety. Compulsions are behaviors performed to decrease anxiety or distress associated with obsessions and may be either mental or physical.
Many studies have been conducted to describe subtypes of OCD across different symptom clusters, and there has been some agreement between researchers as to which symptoms tend to cluster together. Similar Intrusive sexual thoughts ocd other types of obsessions, sexual obsessions can take many different forms. For example, this type of obsession could include fears of molesting a child, fears associated with sexual orientation, fears of engaging in inappropriate sexual activity, or intrusive sexual images.
As with all obsessions, sexual obsessions must be considered intrusive and unwanted and should not include sexual thoughts or images that the patient finds pleasurable. Some examples of compulsions that might accompany sexual obsessions include checking arousal levels to determine attraction, maintaining sufficient physical distance from others to ensure that inappropriate touching does not occur, or mental reassurance that one is not sexually deviant.
The limited research into this topic has shown that approximately Current and lifetime prevalence of sexual obsessions among this group, regardless of whether they are considered a primary symptom, Given these rates, it appears that such obsessional content is common in OCD. One particular form of sexual obsessions that has received even less attention in the literature is sexual-orientation fears, which may include a fear of experiencing an unwanted change in sexual orientation, fear that others may perceive that one is homosexual, or fear that one has latent homosexual desires.
Lifetime rates for homosexual obsessions have been reported at 9. To date, the only published work on homosexual obsessions has been a qualitative book chapter Williams, This dearth of literature may be reflective of the often misunderstood nature of homosexual obsessions and sexual obsessions more generally. Sexual obsessions are often mis-diagnosed or missed completely by clinicians who are unfamiliar or inexperienced with this form of OCD Gordon, From a cognitive behavioral perspective, obsessions are maintained through use of rituals that serve to decrease the anxiety or distress the individual feels as a result of the intrusive obsession.
Because the ritual immediately reduces the distress, the individual fails to learn that the obsession does not represent a real threat. Without such awareness, the individual comes to Intrusive sexual thoughts ocd that the ritual is the only means by which to decrease the anxiety felt following an obsession while reinforcing the danger that the obsession represents.
In the case of a patient with sexual-orientation obsessions, the process remains the same. The patient is asked to expose himself to the feared that is, he might be homosexual, and to also refrain from any rituals he uses following such an obsession, that is checking arousal levels, self reassurance, and so on.
Throughout the course of treatment, patients are asked to engage in increasingly more challenging exposure tasks while continuing to refrain from the use of rituals and avoidance to decrease anxiety and distress. The patient was fully consented as to the content of this manuscript. To maintain confidentiality, all demographic information was altered.
He is married with two children and identifies his religious affiliation as Catholic. Many of these fears involved the concern about what might happen if he were gay, including having to leave his wife and children, concern about being ostracized by his family and friends, and fear of enjoying a sexual relationship with another man.
Simon also described significant concern related to the fear that he had been gay all along and did not know it, thus perhaps had been lying to himself about his true sexuality. Simon reported feeling significant distress when these thoughts occurred and stated that these thoughts occupied several hours per day.
Initially, Simon had some difficulty identifying the compulsions that resulted following his obsessions. He indicated that he Intrusive sexual thoughts ocd physical distance from other men. If another man walked into a room, particularly in his office at work, he would place his hands behind his head in an effort to avoid touching them. He also sought reassurance from his father and mental health professionals about his sexuality. In addition to these compulsions, Simon reported that he was engaging in a great deal of avoidance behaviors in an attempt to minimize number of obsessions he was having as Intrusive sexual thoughts ocd as the distress he felt around other men.
Most notably, his relationship with his wife was suffering. This included a decrease in sexual activities, due to the fear that he would have obsessions during sex, and poor communication. In addition, he reported avoiding social interactions due to the discomfort of being around other men, which extended to activities with his family outside the home.
He stated that decrease in libido coincided with initiation of a selective serotonin reuptake inhibitor antidepressant SSRI. Simon also Intrusive sexual thoughts ocd periods of crying between sessions and significant depressive rumination. He reported at intake that he experienced some social anxiety specifically related to public speaking.
Simon stated that he started having worries about being gay at age He also reported that he had experienced some obsessions related to the fear of harming himself or others in the past, but this was not a current concern for him. In college, Simon saw a psychologist periodically for supportive therapy. He continued to see this particular clinician for 10 years but was never diagnosed with OCD. After that initial therapist, he was seen by several other clinicians for brief periods of time.
Four years prior to coming to treatment at this time, he was examined for 1 year by a psychologist who treated him using exposure techniques for OCD. Simon described this treatment was somewhat helpful but with very difficult homework, which ultimately resulted in his leaving the treatment before its completion. In addition, Simon had tried an SSRI at Intrusive sexual thoughts ocd time with minimal symptom reduction and significant side effects.
Simon described growing up in a large family of four children with one brother and two sisters. Simon described a similarly distant relationship with his mother whom he portrayed as very anxious.
He did indicate that he had a close relationship with his father and stated that they spoke nearly every day. Simon was asked to describe situations in which he experienced intrusive thoughts about being gay. He described having these distressing thoughts when he saw what he considered to be a masculine looking man or images in magazines or on television representing masculinity.
He also reported that seeing two men talking to each other could trigger thoughts about possibly being gay. In addition, Simon described sexual side effects related to his SSRI and reported that the loss of sexual interest in his wife would also trigger "Intrusive sexual thoughts ocd" concerns about being gay.
To monitor his progress throughout treatment, Simon was given several assessment measures on a monthly basis. These assessments included both self-report questionnaires and clinician-administered Intrusive sexual thoughts ocd assessments.
The HAM-D Hamilton, is a clinician-administered interview designed to assess current symptoms of depression. This scale is designed to measure the level of insight the patient has into the obsessional beliefs they are experiencing. The BABS has been found to have excellent interrater reliability and test—retest reliability as well as a high level of internal validity.
It consists of a total score as well as several subscales. This measure has been found to have good reliability and validity. This measure has been found to be both reliable and valid while reflecting changes following treatment Kocsis et al. Fifty-four items measure functioning across multiple domains including social interactions and work functioning.
Simon interpreted these thoughts as significantly distressing and Intrusive sexual thoughts ocd efforts to avoid thinking similar thoughts in the Intrusive sexual thoughts ocd. In addition, he avoided being in confined areas with other men.
When forced to be in such situations, he would create physical distance between himself and the other man. These avoidance strategies served to decrease the anxiety Simon was experiencing in the short term.
By removing himself from stimuli that prompted the intrusive thoughts, he was able to decrease the frequency of the thoughts. However, despite his attempts at avoidance, he was unable to completely avoid intrusive thoughts, and their continued presence caused him increased distress over time. Increased social isolation and job stress contributed to both his symptoms of depression and his continued belief that intrusive thoughts were highly problematic. Avoidance of the thoughts also served to reinforce the idea that the thoughts were indeed threatening by proving that if he avoided the feared stimuli i.
Because his strategy of avoidance worked temporarily reducing anxiety, Simon saw avoidance as a necessary strategy.
Thus, in the future when an intrusive thought about being gay occurred, Simon avoided other men or created physical distance when total avoidance was not possible. In this way, Simon continued the cycle of intrusive thought, avoidance, and temporary relief from anxiety. At his initial baseline evaluation, Simon had a score of 24 on the YBOCS, which is above the clinical cutoff for study inclusion. At that point, Simon was
Intrusive sexual thoughts ocd 60 mg of citalopram as an and 0.
Because Simon had only partially responded to this regimen, this was augmented with risperidone to enhance the effect of the SSRI, titrated up to 2. He was able to consistently take these medications as prescribed on a daily basis.
He initially showed some improvement following the addition of risperidone but had significant side effects, including musculoskeletal rigidity, weight gain, and decreased libido. He was maintained on 80 mg of citalopram and 0. His YBOCS score at Intrusive sexual thoughts ocd 12 was a 9, which is in the borderline range and is indicative of his improvements while on the risperidone.
During these initial sessions, the therapist instructed Simon in completing self-monitoring forms to track his rituals throughout the day. Between Sessions 1 and 2, the patient only completed 2 days of monitoring.
Importance of daily monitoring was addressed again during the second session to help the patient understand that the monitoring is vital in the treatment planning process.