Is the intrusive thought or image ego-dystonic?

In adults with OCD, intrusive sexual thoughts are ego-dystonic, i.e. they are entirely repugnant. They are totally at odds with the values of the individual and there is no aspect of them that is attractive or sexually stimulating (but see the section on sexual arousal below). Thus, someone with OCD with intrusive thoughts about having sex with children is likely to be extremely caring towards children. They are likely to: (a) already be a parent and/or working with children (or would very much like to be so involved in the future); and (b) evaluate themselves as ‘bad’ for having such thoughts.

Ego-dystonicity in young people, however, can be especially difficult to assess, as they are often still in the process of sexual development and maturation. They may therefore feel very confused as to whether a sexual thought is wanted or unwanted, permitted or deviant. It is not uncommon for young people to have sexual obsessions involving children, parents, siblings, animals or objects, which may be very confusing and distressing. In children with OCD, especially the younger ones, there may be more difficulty in eliciting ego-dystonicity (Reference GellerGeller 2006). The young child may lack the cognitive maturity to identify thoughts as unwanted, may think it is ‘weird’ to say so, or may feel that if they admit to wishing they did not have symptoms, they may be asked to stop ritualising, which they fear would be difficult and anxiety-provoking. So it is important to note that the absence of ego-dystonicity or insight does not exclude the diagnosis of OCD, especially in a child or adolescent. By contrast, a paedophile is likely to regard sexual thoughts as ego-syntonic: to be more ambivalent about having such thoughts and to find them attractive at least some of the time or to be cautious about revealing their true feelings.

Is the current behaviour consistent with the intrusive thoughts and images?

People with OCD neither act on their intrusive sexual thoughts nor fantasise or masturbate about them. They may, however, experience the unwanted intrusions when they masturbate to an adult fantasy or have sex, and become confused as to whether the thoughts are ego-dystonic or whether they wanted to have them. Very rarely, people with OCD might appear to act once on their obsessional urge but in a way that is not significantly harmful. Thus, a man with OCD said he once accessed child pornography to check whether he was aroused by it but typically reacted with repugnance. A woman with OCD described how she once touched her baby daughter's genitalia to check whether she would insert her finger. Men with OCD may very rarely masturbate to an adult fantasy before going into situations where they may be in contact with a child with the goal of reducing the likelihood of sexual arousal while there. Sexual offenders are more likely to use sadomasochistic or paedophilic pornography regularly for pleasure.

Does the person try to avoid situations or activities that trigger the intrusive sexual thoughts and images?

People with sexual obsessions that involve children typically avoid being alone or near young people. Avoidance behaviour may be quite subtle, particularly in children and adolescents, where parents or other authority figures may prevent gross avoidance. For example, the teenager with a sexual obsession about younger children may attend school, but avoid looking at younger children and wait to catch a later bus after the younger children have gone home. A paedophile is more likely to consciously seek out places where children play or find opportunities to be alone with them.

Does the person attempt to suppress, neutralise or distract themselves from intrusive sexual thoughts?

Individuals with OCD are more likely to try to avoid, neutralise or suppress repugnant thoughts. They may sometimes examine them in detail to check whether they truly find them repulsive. A potential paedophile may sometimes try to suppress or avoid intrusive thoughts but is more likely to engage with them.

How frequent are the intrusive thoughts and images?

People with OCD are likely to experience frequent intrusive thoughts that may dominate their mental life as they constantly monitor their thoughts for signs of danger and then try to suppress them. A person at risk of paedophilia is likely to have intrusive thoughts that are less frequent and which are more likely to be cued by specific triggers such as childcare activities. Some sexual offenders experience intrusive thoughts only when they are intoxicated. When the thoughts are frequent then a paedophile is more likely to be elaborating them in detailed fantasies.

What is the dominant emotion?

People with OCD seek help because they are extremely anxious and distressed by thoughts, images or urges. They will feel guilty simply because they have the thoughts even though they do not experience any pleasure from them. A potential paedophile or violent offender is less likely to be distressed by such thoughts or the distress is understood by the motivation to avoid being caught. They are more likely to experience pleasure from the thoughts, although some may also feel guilty or remorseful early in their ‘career’ if they have acted on the thoughts in any way.

Does the person experience sexual arousal with intrusive thoughts?

Self-reported sexual arousal is an unreliable indicator of sexual interest. Someone with OCD may be especially sensitive and may consequently overreport arousal (Reference Warwick and SalkovskisWarwick 1990). They may monitor and check the state of arousal in their genitalia. However, selective attention and feedback on the degree of arousal may increase both blood flow and level of arousal. In addition, the experience of anxiety may be confused with sexual arousal. As far we are aware, phallometric evidence of response to sexual stimuli has not been conducted in OCD, nor should it. However, it has been shown that anxiety increases phallometric indices in normal men. Many clinicians believe the opposite to be true, leading them to doubt whether or not a patient with an obsession has an anxiety disorder when they report physical signs of arousal; some male patients show clear signs of physical arousal in obsessional situations – this is not an indication of sexual interest, but of anxiety (Reference Warwick and SalkovskisWarwick 1990).

Is there comorbidity?

Comorbidity with Axis I or II disorders may be present in both OCD and sexual offenders. However, the issue becomes complex when a person with OCD (in one domain such as contamination) is, for example, sexually immature and might have paedophilic sexual fantasies (a different domain). Thus, an understanding of the psychopathology is crucial as in such an individual the sexual thoughts are not ego-dystonic.

Does the person easily disclose material?

People with OCD are usually extremely ashamed of their intrusive thoughts and often do not reveal the details (equally, a paedophile may not reveal the details of their thoughts because of their fear of being caught). An interview with someone with OCD therefore needs to be sensitively handled. If an individual is unable to disclose the details of their intrusions, then the interviewer might offer a multiple choice answer (e.g. ‘I myself have had and talked to a lot of patients with intrusive thoughts or images that concern, for example, rape, homosexuality, sex with children, sex with a parent or an animal, or some thought or image that I find personally unacceptable. Do you experience any intrusive thoughts like these?’).

Another problem in OCD is the overdisclosure of an irrelevant past sexual history and a search for past peccadilloes (e.g. reporting that as an adolescent they once looked through a window with a pair of binoculars to view a woman undressing) in an effort to find evidence that they may be a sexual offender. Individuals may also be excessively concerned about their own exploratory sexual behaviour with peers during childhood or adolescence. They may report events where they think they may have become aroused inappropriately. Overreporting may be a way of reassurance-seeking or neutralising anxiety.

Occasionally, children and adolescents with comorbid behavioural disorders disclose their obsessions in quite an aggressive and intrusive way to provoke distress in others.

A paedophile is less likely to reveal information but more likely to have a history of exploitation or abuse of others, or of sexual offences.

What is the motivation to seek help?

People with OCD are motivated to seek help because they regard their intrusive thoughts or images as repugnant and they are fearful of acting on them. They are extremely worried about the implications of their urges towards children and about acting in such a way.

A paedophile is more likely to be worried by the consequences of being caught. However, sometimes people with OCD are concerned that they may be incorrectly accused (e.g. because they left DNA in the vicinity of a crime, and that others will think they are a bad person and the complete opposite of what they are).

What is the nature of the referral?

People with OCD are likely to have sought referral because they are very worried about their thoughts. Occasionally they will be referred for specialist evaluation because they have revealed the content to others who have also interpreted the thoughts as a sign of risk. A person at risk of paedophilia is less likely to seek help voluntarily and is more likely to be referred by an external agency.

Are other symptoms of OCD present?

Many people with OCD who experience intrusive thoughts and images of a personally repugnant sexual content will also have obsessions and compulsive behaviours in other domains (e.g. washing, checking, order). Other obsessive–compulsive symptoms are probably less likely to occur in sexual offenders.

Is there a history of sexual abuse, or of accidental or deliberate exposure to sexually explicit material?

There are obvious risks to missing a history of sexual abuse in a distressed child, but equally there are risks to incorrectly assuming that a child or adolescent with intrusive sexual thoughts has been abused, when in fact they have OCD alone. Thus, some children with OCD have compulsions that involve their genitals, such as excessive washing, repeated touching or checking behaviours. In most cases, however, these thoughts and behaviours are part of the disorder, not signs of sexual abuse, and excessive questioning or investigations for child sexual abuse can do significant harm.

Although sexual abuse must always be considered in a child with sexual preoccupations and/or behaviours, the authors of one case series they felt confident in excluding sexual abuse (Reference Healy, Fitzpatrick and FitzgeraldHealy 1991). None of the children had disclosed abuse, nor did they show affective change when discussing this possibility or seem burdened by a ‘secret’. In addition, family relationships were good, unlike those commonly seen with intrafamilial abuse, and symptoms improved quickly when the children received appropriate treatment for obsessions.

In another case series, however, the authors report onset of OCD in two young children after sexual abuse or sex-play, and suggest that these experiences had become incorporated into obsessional content (Reference Freeman and LeonardFreeman 2000). Both children rapidly disclosed these events, so appropriate interventions were incorporated into the management plan.

Thus, it is appropriate that a clinician assessing a child with sexual obsessions considers the issue of child sexual abuse while remaining aware that excessive questioning may be harmful.

Postnatal OCD

Images of stabbing are common; intrusive thoughts such as putting the baby in a saucepan or microwave can also occur. Mothers often experience intrusions about acting on urges to suffocate or stab their baby. Such thoughts are quite prevalent in mothers and there are several well-described case studies (e.g. Reference Sichel, Choen and DimmockSichel 1993; Reference Maina, Albert and BogettoMaina 1999). The differential diagnosis is with puerperal psychosisFootnote ^† (especially in the absence of a history of OCD). However, OCD is extremely unlikely to first occur in the context of a depressive psychosis. Conducting an incorrect or lengthy risk assessment or placing an adult with the mother at all times can be harmful as it can have the unwanted effect of increasing her doubts, reducing her confidence and leading to greater distress, avoidance and compulsive behaviours. In the absence of other psychotic features, such thoughts can be understood as an escalation of less unusual thoughts about causing harm. In such cases, reports of thoughts or images of violent content can cause well-meaning mental health professionals inappropriately to anticipate a risk of infanticide or harm to a child.

Secondary-risk violence

People with OCD are occasionally violent not because of obsessions about violence but because of extreme distress when someone either inadvertently or deliberately tries to prevent or terminate the compulsion or ‘breaks the rules’. The secondary risk is that individuals can become violent or intimidating towards family members or health professionals (e.g. if someone ‘contaminates’ a clean object or says a word that is avoided, a person with OCD can feel extremely threatened). This is particularly likely to occur in children or adolescents because there is commonly a very high level of family involvement in rituals, which can lead to a great deal of frustration and anger in the home (Reference Storch, Geffken and MerloStorch 2007).

Another group vulnerable to angry or violent outbursts are people with OCD in the context of an autism-spectrum disorder, especially when there are very rigid routines. Such individuals commonly have a poor understanding of their own and others' mental states (Reference Baron-Cohen and GliddenBaron-Cohen 2001); they may therefore have difficulty in empathising with the effect of their compulsions on others, may be unable to explain what they are experiencing, or may be unable to deal with the situation by expressing affect appropriately. In such cases, the individual is not acting on their obsession; rather they are acting in response to the distress, frustration and anger when they are thwarted in acting on their compulsion or avoidance in their usual way. Substance misuse can increase this impulsivity.

Case study: When seeking help makes things worse

Individuals with OCD may undergo unnecessary, lengthy and damaging risk assessments, which make their disorder worse. The case study is an illustrative case history. A person with OCD hates uncertainty and the initial assessment is not an appropriate time to introduce patients to tolerating doubt (although it may be important to do so later in therapy when there is a good therapeutic alliance). Box 3 shows how patients have described assessments by health professionals.

Primary risk

The obsessional thoughts of someone with OCD may concern self-harm or suicide. In this respect they are no different from intrusive thoughts of violence to others and similarly present an apparent primary risk. For example, a person fears that they may put their fingers in an electric socket or jump from a great height or take their own life (when they do not want to). In fact, most people with OCD would not want to die by suicide because of the harm that they would cause to others through doing so. In cases where OCD has been clearly established, and the thoughts about the fear of self-harm or suicide (e.g. acting impulsively) are ego-dystonic, then the case should be managed as for any other intrusion about violence.

Secondary risk

The assessment of the secondary suicide risk of self-harm becomes more complicated if, over time, the individual becomes more depressed and hopeless or has a comorbid personality disorder that is associated with impulsive behaviour. People with OCD are at greater risk of suicide than the general population. In the survey by Reference Torres, Prince and BebbingtonTorres et al (2006), at least a quarter of people with OCD had attempted suicide at some time in their life. In such situations, it is usually helpful to establish the main problem as well as the motivation for ending life. Motivation arises from increased feelings of hopelessness about progress in overcoming the disorder or accessing therapy, or the individual's belief that they pose a real danger to others. They may then desire to escape from their intrusive thoughts and make plans to end their life.

In a small number of instances, patients may take their own life as a compulsive act. For example, a person who is terrified that they will harm their loved ones may take their own life in order to protect them; we are aware of several sad cases of this happening. Others may have comorbid borderline personality disorder and be self-harming as a way of regulating their mood and reducing their level of anxiety (e.g. a person with borderline personality disorder may self-harm as a way of reducing feelings of contamination).

Depression

Depression is the most common comorbid condition.

It is often secondary to OCD, in which case:

1. • the patient describes their OCD as their biggest problem;

2. • the symptoms of depression developed after the onset of the OCD;

3. • the person predicts that the symptoms of depression would improve if the OCD were effectively treated.

Very occasionally patients have a comorbid bipolar disorder or recurrent depression in which obsessions and compulsions are symptoms of depression. Here the onset of depression and symptoms of OCD are simultaneous, and if the depression is effectively treated then the OCD improves.

The most important message to give to people with OCD who are suicidal is that the disorder is treatable. Behavioural activation is probably the most helpful psychological approach in OCD with comorbid depression. This is because if the depression is severe, it may be more effective than standard cognitive therapy (Dimidjan 2006; Reference VealeVeale 2008). It also targets cognitive processes such as depressive rumination and avoids the risk of patients trying to challenge the content of their obsessions, which is unhelpful. Sometimes it may take time to access a specialist service in CBT for OCD or to find the right approach. For pharmacotherapy of depression comorbid with OCD, potent or selective serotonin reuptake inhibitors are more effective than noradrenergic reuptake inhibitors (Reference Hoehn-Saric, Ninan and BlackHoehn-Saric 2000). If two or more selective serotonin reuptake inhibitors (SSRIs) are ineffective, then augmenting the SSRI with a noradrenergic reuptake inhibitor may be helpful (Reference Mancini, van Ameringen and FarvoldenMancini 2002).

Schizophrenia and psychosis

Obsessive–compulsive disorder can also be comorbid with schizophrenia. Some clinicians subsume a diagnosis of OCD within a hierarchical model. It is then assumed that if the psychosis is treated then the obsessive–compulsive symptoms will also improve. However, when psychotic symptoms are controlled then the symptoms of OCD often become more prominent and should be treated in their own right.

In young people, there may be a greater risk that OCD is wrongly diagnosed as a psychotic illness, especially if they present with unusual obsessions, which are mistaken for delusions. Sometimes the distress caused by bizarre and frightening obsessions leads to fear-driven behaviours, which are interpreted as behavioural manifestations of psychosis, such as shouting out loud in an attempt to cancel out thoughts. In one series of young people presenting with unusual obsessions about magically acquiring unwanted characteristics from others (termed ‘transformation obsessions’), the majority had previously received an incorrect diagnosis of psychosis and had often been prescribed unnecessary antipsychotic medication (Reference Volz and HeymanVolz 2007). Sometimes severe avoidance behaviour and self-neglect in a person with OCD appears similar to negative symptoms of schizophrenia and the diagnosis of OCD is overlooked.

There are extremely rare cases of comorbid command hallucination in OCD (usually in the context of trauma and an emotionally unstable personality disorder), which can potentially lead to violence. Such hallucinations (which are usually ego-syntonic) can be confused as being related to the obsession but are in fact distinct processes. The assessment should focus on the emotional stability and propensity to shift into a psychotic state and the contexts in which it occurs.

Antisocial personality disorder

In extremely rare cases, OCD exists with comorbid antisocial personality disorder and a history of crime and violence, in which some of the intrusive urges are ego-dystonic in some domains (e.g. contamination) but not in others (e.g. violent impulses). Alternatively, some of the intrusions may be ego-syntonic (e.g. people who the person believes ‘deserve’ to be harmed) and ego-dystonic at other times (e.g. causing harm to loved ones by not being careful enough).

Action if risk is identified

If family members are at risk, then a decision will need to be made about admitting the individual with OCD to hospital or finding alternative accommodation. The ideal goal is to help family members to be emotionally supportive without accommodating or excessively controlling the person with OCD. At times families may decide to compromise as they reduce their involvement. Changes may take time to implement if members of the family have been enmeshed in the rituals for a long time. Equally, the person with OCD will need to accept that they cannot expect others to comply with their demands or to live with such behaviour. If they feel threatened, family members should be asked to call the police or to seek protection through the courts. Ideally, family members work with sufferers to support them in the process of change, rather than supporting continued obsessions and compulsions.

Involving child protection services

A key issue in assessment is the discrepancy between the degree of harm that the person with OCD believes they are causing to their child and that which the child, another family member or the professional believes is being caused. Ultimately it may be appropriate to notify Social Services, especially when the person lacks insight into the degree of harm being caused to the child and is refusing to engage in treatment. Ensuring proper care of the children can be a helpful motivator, but not when couched in terms of a threat. The prospect of involving care agencies or the act itself may inhibit the patient from engaging properly with treatment. If the treating clinician can see no hope of sufficiently speedy change (i.e. within the timescale likely to avert serious harm to the children), referral to social services needs to be discussed. If possible, referral should be made by someone not directly involved in the treatment in order to minimise negative effects on the therapeutic alliance. It is to be hoped that treatment will continue in parallel with proceedings related to child protection.

Siblings

Finally, especially with children and adolescents with OCD, it is important to consider the risk to siblings. There are circumstances where siblings sharing a room with a child with OCD may became very distressed, for example, by the child who is up all night ritualising, preventing them sleeping, and so affecting school performance and other aspects of functioning. Aggression can be especially marked between a child suffering from OCD and their siblings. Sometimes a brother or sister becomes incorporated into obsessions, the child with OCD believing they are ‘contaminated’ by them, and avoiding all contact with them or even with anything they have touched. Sometimes, siblings without OCD learn quickly to identify the triggers for their affected sibling's fears and purposely taunt them by forcing exposure to a feared stimulus such as an object believed to be dirty. Although encouraging the whole family to help with exposure tasks as part of therapy can be helpful, this needs to be done with the patient's explicit permission and built into a graded exposure programme rather than being imposed. Purposeful or even unintentional teasing by a sibling can cause aggressive outbursts from the child with OCD.

Access to and engagement in treatment

Domiciliary visits may be needed for individuals with poor insight or those who have become housebound. They might be encouraged to engage with a cognitive–behavioural model of OCD, offered medication and helped to follow their important directions in life despite their disorder. The family may also need help in working as a team to set progressive boundaries around their involvement. People who cannot be treated as out-patients or on domiciliary visits may find admission to a specialist residential unit with frequent CBT more helpful.

Involuntary admission on an acute ward should be avoided if at all possible. Cognitive–behavioural therapy without the patient's active involvement is almost certain to fail, so involuntary admission is only used when any secondary risks reach serious proportions or there is a need to break a cycle of involvement by a relative. The Mental Health Act can theoretically be used for a trial of medication because of a serious risk to the patient or a need to remove the patient from their family or home environment. When patients are admitted to an acute ward, little is usually gained by staff trying to control compulsions, although boundaries may be needed for the practical running of a ward (e.g. the number of paper rolls or plastic gloves used or length of time taken in a communal shower).

Cognitive–behavioural therapy has to be done on a voluntary basis but if a patient with OCD has to be detained under the Mental Health Act, then it would be good practice for an experienced therapist to try to start the process of engagement and a formulation of the factors that are maintaining the problem. If the process is successful then CBT can be continued on a voluntary or out-patient basis. Sometimes transfer to a specialist unit in OCD and finding alternative accommodation may assist in breaking a cycle which became established in the family environment.

When living at home is no longer an option

If a young person is unlikely to be able to manage on their own and the parents can no longer cope, then they should be advised on how to request that their child be rehoused or otherwise accommodated. Seeking rehousing may motivate someone with OCD to change if they feel unable to cope without family support. The NICE (2005) guidelines also recognise that some people with chronic OCD and who have never developed an adequate level of functioning may need supportive accommodation in addition to therapy.