Pedophilia-Themed Obsessive–Compulsive Disorder: Assessment, Differential Diagnosis, and Treatment with Exposure and Response Prevention

  • Simone Leavell Bruce
  • Terence H. W. Ching
  • Monnica T. Williams
Original Paper

Abstract

Fears of sexually harming children are fairly common among clients suffering from obsessive–compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and sexually violating, children. Expressing these concerns may provoke misjudgments from uninformed mental health professionals that a client is presenting instead with pedophilic disorder. This misdiagnosis and subsequent improper interventions can then contribute to increased fear, anxiety, and in many cases, depression, in affected clients. Therefore, it is imperative that mental health professionals first possess a good understanding of this common manifestation of OCD. As such, in this article, we described obsessions and compulsions typical of P-OCD, in order to inform the reader of the distinctive differences between P-OCD and pedophilic disorder. Information about how to assess for P-OCD symptoms is then provided, followed by suggestions on how to tailor aspects of exposure and response prevention to treat this specific form of OCD.

Keywords

Obsessive–compulsive disorder Pedophilia Exposure and response prevention DSM-5 

Notes

Acknowledgements

The authors would like to thank Jessica Combs, Psy.D., and Judy Mier-Chairez, B. S., for their assistance with earlier drafts of this article, and Chandler Smith for help with data entry.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., … Hale, L. R. (2010). Assessment of obsessive–compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive–Compulsive Scale. Psychological Assessment, 22, 180–198.CrossRefPubMedGoogle Scholar
  2. Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure therapy for anxiety: Principles and practice. New York: Guilford Press.Google Scholar
  3. Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive–compulsive disorder. Journal of Consulting and Clinical Psychology, 71, 1049–1057.CrossRefPubMedGoogle Scholar
  4. Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive–compulsive disorder. Lancet, 374, 491–499.CrossRefPubMedGoogle Scholar
  5. Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2005). The effectiveness of treatment for pediatric obsessive–compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55–63.CrossRefGoogle Scholar
  6. Alonso, P., Menchón, J. M., Pifarré, J., Mataix-Cols, D., Torrres, L., Salgado, P., & Vallejo, J. (2001). Long-term follow-up and predictors of clinical outcome in obsessive–compulsive clients treated with serotonin reuptake inhibitors and behavioral therapy. Journal of Clinical Psychiatry, 62, 535–540.CrossRefPubMedGoogle Scholar
  7. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  8. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press.CrossRefGoogle Scholar
  9. Baer, L. (1994). Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. Journal of Clinical Psychiatry, 55, 18–23.PubMedGoogle Scholar
  10. Ball, S. G., Baer, L., & Otto, M. W. (1996). Symptom subtypes of obsessive–compulsive disorder in behavioral treatment studies: A quantitative review. Behaviour Research and Therapy, 34, 47–51.CrossRefPubMedGoogle Scholar
  11. Barlow, D. H. (Ed.). (2014). Clinical handbook of psychological disorders: A step-by-step treatment manual. New York: Guilford Press.Google Scholar
  12. Brown, T. A., & Barlow, D. H. (2014). Anxiety and related disorders interview schedule for DSM-5 (ADIS-5)—Adult and lifetime version: Clinician manual. New York: Oxford University Press.Google Scholar
  13. Calvocoressi, L., Lewis, B., Harris, M., Trufan, S. J., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive–compulsive disorder. American Journal of Psychiatry, 152, 441–443.CrossRefPubMedGoogle Scholar
  14. Cathey, A. J., & Wetterneck, C. T. (2013). Stigma and disclosure of intrusive thoughts about sexual themes. Journal of Obsessive-Compulsive and Related Disorders, 2, 439–443.CrossRefGoogle Scholar
  15. Clark, D. (2007). Cognitive-behavioral therapy for OCD. New York: Guilford Press.Google Scholar
  16. Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.CrossRefPubMedPubMedCentralGoogle Scholar
  17. First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015a). Structured clinical interview for DSM-5—Clinician version (SCID-5-CV). Arlington, VA: American Psychiatric Association.Google Scholar
  18. First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015b). Structured clinical interview for DSM-5—Research version (SCID-5-RV). Arlington, VA: American Psychiatric Association.Google Scholar
  19. Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive–Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14, 485–496.CrossRefPubMedGoogle Scholar
  20. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.CrossRefPubMedGoogle Scholar
  21. Foa, E., & Kozak, M. (1997). Mastery of obsessive compulsive disorder: A cognitive behavioral approach. New York: Oxford University Press.Google Scholar
  22. Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., & Latimer, P. R. (1984). Deliberate exposure and blocking of obsessive–compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450–472.CrossRefGoogle Scholar
  23. Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive–compulsive disorder: Therapist guide (2nd ed.). New York: Oxford University Press.CrossRefGoogle Scholar
  24. Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau, N., Rheaume, J., Letarte, H., & Bujold, A. (1997). Cognitive-behavioral treatment of obsessive thoughts: A controlled study. Journal of Consulting and Clinical Psychology, 65, 405–413. doi:10.1037/0022-006X.65.3.405.CrossRefPubMedGoogle Scholar
  25. Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1, 251–257.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Glazier, K., Calixte, R., Rothschild, R., & Pinto, A. (2013). High rates of OCD symptom misidentification by mental health professionals. Annals of Clinical Psychiatry, 25, 201–209.PubMedGoogle Scholar
  27. Glazier, K., Swing, M., & McGinn, L. (2015). Half of obsessive–compulsive disorder cases misdiagnosed: Vignette-based survey of primary care physicians. Journal of Clinical Psychiatry, 76, e761–e767.CrossRefPubMedGoogle Scholar
  28. Gordon, W. M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17, 343–354.CrossRefGoogle Scholar
  29. Grant, J. E., Pinto, A., Gunnip, M., Mancebo, M. C., Eisen, J. L., & Rasmussen, S. A. (2006). Sexual obsessions and clinical correlates in adults with obsessive–compulsive disorder. Comprehensive Psychiatry, 47, 325–329.CrossRefPubMedGoogle Scholar
  30. Hout, M. A., & Kindt, M. (2004). Obsessive–compulsive disorder and the paradoxical effects of perseverative behavior on experienced uncertainty. Journal of Behavior Therapy and Experimental Psychiatry, 35, 165–181.CrossRefPubMedGoogle Scholar
  31. Huppert, J. D., & Roth, D. A. (2003). Treating obsessive–compulsive disorder with exposure and response prevention. The Behavior Analyst Today, 4, 66–70.CrossRefGoogle Scholar
  32. Huppert, J. D., Walther, M. R., Hajcak, G., Yadin, E., Foa, E. B., Simpson, H. B., & Liebowitz, M. R. (2007). The OCI-R: Validation of the subscales in a clinical sample. Journal of Anxiety Disorders, 21, 394–406.CrossRefPubMedGoogle Scholar
  33. Jacoby, R. J., Leonard, R. C., Riemann, B. C., & Abramowitz, J. S. (2016). Self-punishment as a maladaptive thought control strategy mediates the relationship between beliefs about thoughts and repugnant obsessions. Cognitive Therapy and Research, 40, 179–187.CrossRefGoogle Scholar
  34. Kessler, R. C., Berglund, P., & Demler, O. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593–602.CrossRefPubMedGoogle Scholar
  35. Lang, R. A., & Frenzel, R. R. (1988). How sex offenders lure children. Annals of Sex Research, 1, 303–317.CrossRefGoogle Scholar
  36. Leckman, J. F., Grice, D. E., Boardman, J., Zhang, H., Vitale, A., Bondi, C., … Pauls, D. L. (1997). Symptoms of obsessive–compulsive disorder. American Journal of Psychiatry, 154, 911–917.CrossRefPubMedGoogle Scholar
  37. McPhail, I. V., Hermann, C. A., Fernane, S., Fernandez, Y. M., Nunes, K. L., & Cantor, J. M. (2017). Validity in phallometric testing for sexual interests in children: A meta-analytic review. Assessment. doi:10.1177/1073191117706139.PubMedGoogle Scholar
  38. Meier, S. M., Mattheisen, M., Mors, O., Schendel, D. E., Mortensen, P. B., & Plessen, K. J. (2016). Mortality among persons with obsessive–compulsive disorder in Denmark. JAMA Psychiatry, 73, 268–274. doi:10.1001/jamapsychiatry.2015.3105.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Moulding, R., Aardema, F., & O’Connor, K. P. (2014). Repugnant obsessions: A review of the phenomenology, theoretical models, and treatment of sexual and aggressive obsessional themes in OCD. Journal of Obsessive-Compulsive and Related Disorders, 3, 161–168.CrossRefGoogle Scholar
  40. Newth, S., & Rachman, S. (2001). The concealment of obsessions. Behaviour Research and Therapy, 39, 457–464.CrossRefPubMedGoogle Scholar
  41. Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version. Behaviour Research and Therapy, 41, 863–878.Google Scholar
  42. O’Neil, S. E., Cather, C., Fishel, A. K., & Kafka, M. (2005). “Not knowing if I was a pedophile…”—Diagnostic questions and treatment strategies in a case of OCD. Harvard Review of Psychiatry, 13, 186–196.CrossRefPubMedGoogle Scholar
  43. Piacentini, J., Bergman, R. L., Chang, S., Langley, A., Peris, T., Wood, J. J., & McCracken, J. (2011). Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive–compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 1149–1161.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Pinto, A., Eisen, J. L., Mancebo, M. C., Greenberg, B. D., Stout, R. L., & Rasmussen, S. A. (2007). Taboo thoughts and doubt/checking: A refinement of the factor structure for obsessive–compulsive disorder symptoms. Psychiatry Research, 151, 255–258.CrossRefPubMedPubMedCentralGoogle Scholar
  45. Pinto, A., Greenberg, B. D., Grados, M. A., Bienvenu, O. J., Samuels, J. F., Murphy, D. L., … Nestadt, G. (2008). Further development of YBOCS dimensions in the OCD collaborative genetics study: Symptoms vs. categories. Psychiatry Research, 160, 83–93.CrossRefPubMedPubMedCentralGoogle Scholar
  46. Purdon, C. (2004). Cognitive-behavioral treatment of repugnant obsessions. Journal of Clinical Psychology/In Session, 60, 1169–1180.CrossRefPubMedGoogle Scholar
  47. Purdon, C., & Clark, D. (2005). Overcoming obsessive thoughts: How to gain control of your OCD. Oakland, CA: New Harbinger Publications.Google Scholar
  48. Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802.CrossRefPubMedGoogle Scholar
  49. Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research and Therapy, 36, 385–401.CrossRefPubMedGoogle Scholar
  50. Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233–248.CrossRefPubMedGoogle Scholar
  51. Radomsky, A. S., & Alcolado, G. M. (2010). Don’t even think about checking: Mental checking causes memory distrust. Journal of Behavior Therapy and Experimental Psychiatry, 41, 345–351.CrossRefPubMedGoogle Scholar
  52. Radomsky, A. S., Gilchrist, P. T., & Dussault, D. (2006). Repeated checking really does cause memory distrust. Behaviour Research and Therapy, 44, 305–316.CrossRefPubMedGoogle Scholar
  53. Rosa-Alcázar, A. I., Sánchez-Meca, J., Gómez-Conesa, A., & Marín-Martínez, F. (2008). Psychological treatment of obsessive–compulsive disorder: A meta-analysis. Clinical Psychology Review, 28, 1310–1325.CrossRefPubMedGoogle Scholar
  54. Salkovskis, P. M. (1985). Obsessional–compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571–583.CrossRefPubMedGoogle Scholar
  55. Salkovskis, P. M. (1999). Understanding and treating obsessive–compulsive disorder. Behaviour Research and Therapy, 37, S29–S52.CrossRefPubMedGoogle Scholar
  56. Schwartz, J. (1996). Brain lock: Free yourself from obsessive compulsive behavior. New York: Harper-Collins.Google Scholar
  57. Shafran, R., Thordarson, D. S., & Rachman, S. (1996). Thought-action fusion in obsessive compulsive disorder. Journal of Anxiety Disorders, 10, 379–391.CrossRefGoogle Scholar
  58. Sheehan, D. V., Lecrubier, Y., Sheehan, L. H., Amorim, P., Janavas, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.PubMedGoogle Scholar
  59. Sibrava, N. J., Boisseau, C. L., Mancebo, M. C., Eisen, J. L., & Rasmussen, S. A. (2011). Prevalence and clinical characteristics of mental rituals in a longitudinal clinical sample of obsessive–compulsive disorder. Depression and Anxiety, 28, 892–898.CrossRefPubMedPubMedCentralGoogle Scholar
  60. Starcevic, V., Berle, D., Brakoulias, V., Sammut, P., Moses, K., Milicevic, D., & Hannan, A. (2011). Functions of compulsions in obsessive–compulsive disorder. Australian and New Zealand Journal of Psychiatry, 45, 449–457.CrossRefPubMedGoogle Scholar
  61. Storch, E. A., Rasmussen, S. A., Price, L. H., Larson, M. J., Murphy, T. K., & Goodman, W. K. (2010). Development and psychometric evaluation of the Yale–Brown Obsessive–Compulsive Scale—Second edition. Psychological Assessment, 22, 223–232.CrossRefPubMedGoogle Scholar
  62. Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. (2010). An initial investigation into the processes of change in ACT, CT, and ERP for OCD. International Journal of Behavioral Consultation and Therapy, 6, 67–81.CrossRefGoogle Scholar
  63. Viar, M. A., Bilsky, S. A., Armstrong, T., & Olatunji, B. O. (2011). Obsessive beliefs and dimensions of obsessive–compulsive disorder: An examination of specific associations. Cognitive Therapy and Research, 35, 108–117.CrossRefGoogle Scholar
  64. Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5–13.CrossRefPubMedGoogle Scholar
  65. Wetterneck, C. T., Siev, J., Adams, T. G., Slimowicz, J. C., & Smith, A. H. (2015). Assessing sexually intrusive thoughts: Parsing unacceptable thoughts on the Dimensional Obsessive–Compulsive Scale. Behavior Therapy, 46, 544–556.CrossRefPubMedPubMedCentralGoogle Scholar
  66. Wetterneck, C. T., Smith, A., Hart, J. M., & Burgess, A. (2011). Distress from sexually intrusive thoughts: Do religiosity, emotions, and thought appraisal matter? Journal of Cognitive Psychotherapy, 25, 189–202.CrossRefGoogle Scholar
  67. Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C., & Hale, L. R. (2010). The relationship between obsessive beliefs and symptom dimensions in obsessive–compulsive disorder. Behaviour Research and Therapy, 48, 949–954.CrossRefPubMedGoogle Scholar
  68. Whittal, M. L., Woody, S. R., McLean, P. D., Rachman, S. J., & Robichaud, M. (2010). Treatment of obsessions: A randomized controlled trial. Behaviour Research and Therapy, 48, 295–303.CrossRefPubMedGoogle Scholar
  69. Williams, M. T., & Farris, S. G. (2011). Sexual orientation obsessions in obsessive–compulsive disorder: Prevalence and correlates. Psychiatry Research, 187, 156–159.CrossRefPubMedGoogle Scholar
  70. Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014a). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive–compulsive disorder. Journal of Anxiety Disorders, 28, 553–558.CrossRefPubMedPubMedCentralGoogle Scholar
  71. Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., … Foa, E. B. (2011). Myth of the pure obsessional type in obsessive–compulsive disorder. Depression and Anxiety, 28, 495–500.CrossRefPubMedPubMedCentralGoogle Scholar
  72. Williams, M. T., Mugno, B., Franklin, M., & Faber, S. (2013). Symptom dimensions in obsessive–compulsive disorder: Phenomenology and treatment outcomes with exposure and ritual prevention. Psychopathology, 46, 365–376.CrossRefPubMedPubMedCentralGoogle Scholar
  73. Williams, M., Powers, M., & Foa, E. (2012). Psychological treatment for obsessive compulsive disorder. In P. Sturmey & M. Hersen (Eds.), Handbook of evidence-based practice in clinical psychology (Vol. 2, pp. 313–335). Hoboken, NJ: Wiley.Google Scholar
  74. Williams, M. T., Slimowicz, J., Tellawi, G., & Wetterneck, C. (2014b). Sexual orientation symptoms in obsessive compulsive disorder: Assessment and treatment with cognitive behavioral therapy. Directions in Psychiatry, 34, 37–50.Google Scholar
  75. Williams, M. T., Tellawi, G., Davis, D. M., & Slimowicz, J. (2015). Assessment and treatment of sexual orientation obsessions in obsessive–compulsive disorder. Australian Clinical Psychologist, 1, 12–18.Google Scholar
  76. Wolpe, J. (1969). The practice of behavior therapy. Oxford: Pergamon Press.Google Scholar
  77. World Health Organization. (2010). International statistical classification of diseases and related health problems (10th rev.). Geneva: Author.Google Scholar

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Authors and Affiliations

  1. 1.Department of PsychologySpalding UniversityLouisvilleUSA
  2. 2.Department of Psychological SciencesUniversity of ConnecticutStorrsUSA
  3. 3.Louisville OCD ClinicLouisvilleUSA

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