Types of Obsessions
Expert Help for Obsessive-Compulsive Disorder
Louisville OCD Clinic
Monnica Williams, Ph.D.
Offering expert treatment for all types of OCD, including sexual obsesions. Our OCD treatment program is typically 20 sessions. We offer twice-weekly sessions and intensive programs. Intensive program can be in person or combined with Skype. State of the art medication management is also an option. Low cost options. [More.]
Sexual Thoughts in OCD
Sexuality Concerns in Obsessive-Compulsive Disorder (OCD)
Many people with obsessive-compulsive disorder (OCD) have sexual obsessions, or unwanted sexual thoughts. This may include sexual orientation fears, which is sometimes referred to as sexual orientation OCD (SO-OCD) or HOCD. Theses are not the same as fantasies or being homophobic.
Sexual thoughts in OCD may include the following:
- the obsessive fear of being or becoming LGBTQ
- intrusive, unwanted mental images of upsetting sexual behaviors
- the fear that one may become a pedophile
- the fear of becoming sexually aggressive
If you have unwanted sexual thoughts, please contact us to participate in a study so that we can learn more about this issue.
The Worst Kind of OCD
Although people with OCD may obsess over any number of concerns, one of the most upsetting types of OCD involves worries about causing sexual harm to a child, sometimes called pedophile OCD or POCD. Although this type of OCD typically receives little attention from the media, the Power to Change recently aired the story of a man whose POCD was so severe he contemplated suicide before he was treated by Dr. Monnica Williams. Hear his story online and learn about OCD treatments from Dr. L. Kevin Chapman. Read his story or watch it now.
OCD Therapy Going Nowhere?
Although any medical doctor can take your blood pressure, only a few can do heart surgery. Likewise, any therapist can help someone who is feeling a bit blue, but only a few can effectively treat OCD. OCD treatment is a type of therapy that requires a specialized protocol called Exposure and Ritual Prevention (ERP or EX/RP). Learn about the Top Mistakes Made by OCD Therapists.
Top Seven Myths About OCD
One stereotype is that people with OCD are neat and tidy to a fault. Actually, nothing could be further from the truth. Although many people with OCD wash because they are concerned about dirt and germs, being tidy is actually not a typical symptom of the disorder. Almost two-thirds of people with OCD are also hoarders... Learn more about the Top Myths about OCD.
Take The OCD Self Test
The OCI-R is a short, reliable, scientific test of common obsessive-compulsive symptoms. This measure was developed by OCD experts. Take our OCD Self Test.
Therapy for Obsessive-Compulsive Disorder
What to Expect
Starting therapy for OCD can be frightening. Knowing ahead of time what to expect can help put your mind at ease and make the treatment feel less daunting. Below are described the major components of cognitive behavior therapy (CBT) specifically for OCD.
Psychotherapy for OCD
Exposure and ritual prevention (EX/RP) is an effective type of CBT treatment for OCD. The word "Response" in EX/RP is often replaced by "Ritual" as the word "Response" is too broad — not all responses are compulsions. Though behaviorally-based, EX/RP includes both behavioral and cognitive techniques. A more cognitive approach, called simply "cognitive therapy (CT)," is advocated by some and may be useful for patients who are not responding well to behavioral strategies. However, EX/RP and CT both typically include behavioral and cognitive elements. EX/RP has been used in a variety of formats, including individual and group treatment, family based treatment, computer based treatment, self-help techniques, and intensive programs. This article will describe the important components of EX/RP and CT for OCD.
In Vivo Exposure.
Exposure is the cornerstone of EX/RP treatment. In vivo exposure has been shown to reduce obsessions and related distress. This technique involves repeated and prolonged confrontation with situations that cause anxiety. Exposure sessions may last anywhere from 30 minutes to two hours. The immediate goal is for the patient to remain in the situation long enough to experience some reduction in anxiety and to realize that the feared "disastrous" consequences do not occur. With repeated exposures, the peak of the distress as well as the overall distress decreases over sessions. Thus, the patient habituates to upsetting stimuli in two ways, within the session and between sessions.
Typically, exposure is gradual and the patient begins by facing objects and situations that result in only moderate levels of anxiety. Constructed in collaboration with the patient, the list of distress-evoking stimuli are placed in a hierarchical manner, beginning with the least distressing stimuli and gradually proceeding to more distressing ones. A rating scale of 0-100 (often called a SUDS scale for Subjective Units of Distress/Discomfort Scale) is used to rate the expected amount of distress associated with each item. After an item from the hierarchy is confronted in session with a therapist, the patient then practices self-exposure to the same item as daily homework. Once mastered, the patient faces the next progressively more distressing object or situation. The patient learns (1) that the feared consequence will not occur, (2) to better tolerate anxiety, and (3) that anxiety diminishes over time even without performing the rituals. As the patient progresses up the hierarchy, each next items become a bit easier.
In some cases it is not possible to construct an in vivo exposure to a patient's fear, and in these instances an exposure can be done in the imagination. Situations especially appropriate for an imaginal exposure are those in which the patient fears he may change in a fundamental way (i.e. shifting in sexual orientation or becoming a serial killer), cause a distal catastrophe (i.e. starting a chain of events that results in harm coming to unknown people), or that the outcome of failing to do a ritual is far in the future (i.e. going to hell or dying from cancer).
To conduct an imaginal exposure, the therapist and patient develop a detailed scene together based on the patient's worst fear. The story will describe a catastrophe befalling the patient and/or loved ones as a direct result of the patient's failure to perform rituals. The therapist might first recount the story aloud and then have the patient do the same, ideally in the present tense to make the events seem more real. SUDS levels are taken at various points throughout the narrative (i.e., every 5 minutes) to assure that the story is evoking enough anxiety to be productive. The exposure is typically recorded to facilitate repeated listening as homework.
Imaginal exposure is effective when it evokes the same distress in a person as the actual obsession. A person with OCD typically fights the obsession because they believe that if they entertain the ideas, the feared outcome will be more likely to occur. However, fighting the obsession only strengthens it. By repeating the distressing ideas in the form of a narrative, the person with OCD habituates to the fears and also learns that dwelling on the thoughts does not make them happen. The person gains a new perspective on the fear and is able to attend to it more objectively.
The ritual or response prevention component involves instructions for the patient not to engage in compulsions or rituals of any sort. This is important because patients perceive that the rituals prevent the occurrence of a feared outcome. Only by stopping the rituals do patients learn that rituals do not protect them from their obsessional concerns. In the vast majority of cases, rituals have a functional relationship with the obsessional thought (i.e. "washing will prevent me from becoming ill," or "if I don't wash I will be distressed forever and will fall apart" ); many times this functional relationship is logical (e.g. "checking will prevent me from making mistakes"), but sometimes it has a magical flavor (i.e. "If I tie my shoes 4 times the right way, my pet will be hit by a car.") Sometimes patients cannot articulate any negative outcome that is prevented by performing the rituals. Rather, the performance of the ritual "just feels right;" in this case the function of the ritual is to reduce anxiety or discomfort, and the disastrous consequence is psychological, such as falling apart.
The implementation of ritual prevention involves a detailed analysis of all compulsions or rituals performed by the patient. Typically, patients are asked to keep daily logs of all rituals performed. The therapist uses these logs initially to identify the rituals that need to be stopped, and, as treatment progresses, it is used to identify areas of difficulty that need more therapeutic attention.
OCD patients feel anxious or distress when engaging with their obsessional thoughts or images, because they interpret them as warnings of events that are dangerous and likely to occur. CT is designed to help patients identify these automatic unrealistic thoughts and change the interpretations of the thoughts, resulting in decreased obsessions and distressing compulsions.
In the first stage of CT, patients are taught to identify their worries as obsessions and their rituals as compulsions. The patient keeps a daily diary of obsessions, called a thought record. In the thought record, patients write down their obsessions and the interpretations associated with the obsessions. Important details to record may include what the patient was doing when the obsession began, the content of the obsession, the meaning attributed to the obsession, and what the patient did in response to the obsession (usually a compulsion).
The therapist reviews the thought records with the patient with an emphasis on how the obsession was interpreted. Using reasoning and Socratic questioning, the therapist helps the patient challenge their unrealistic beliefs. This helps the patient to identify the cognitive distortion, typically a faulty assessment of danger, an exaggerated sense of responsibility, or fears that thinking something negative will make it come true (called "thought-action fusion").
Once patients are able to identify their obsessions and compulsions as symptoms of OCD, the therapist initiates a few behavioral experiments to disprove errors in thinking about cause and effect. For example, if a patient believes that smoking three cigarettes will prevent her family from being harmed in an auto accident, the therapist may instruct the patient to smoke only two cigarettes and then wait to see if family members are actually harmed that day in an auto accident. The therapist may then use the results of this experiment as material for discussion about other types of magical thinking. Over time, patients learn to identify and re-evaluate beliefs about the potential consequences of engaging in or refraining from compulsive behaviors and subsequently begin to eliminate compulsions.
Source: Williams, M., Powers, M., & Foa, E. (2012). Obsessive-Compulsive Disorder, Chapter 13. In P. Sturmey & M. Hersen (Eds.), Handbook of Evidence-Based Practice in Clinical Psychology, Vol. 2 (pp. 313-335). Hoboken, NJ: John Wiley & Sons, Ltd. ISBN-10: 0470335440.
Updated: June 27, 2016>