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Homosexuality Anxiety: A Misunderstood Form of OCD Monnica Williams, Ph.D. OC Foundation of New Jersey, Robert Woods Johnson Hospital.

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Presentation on theme: "Homosexuality Anxiety: A Misunderstood Form of OCD Monnica Williams, Ph.D. OC Foundation of New Jersey, Robert Woods Johnson Hospital."— Presentation transcript:

1 Homosexuality Anxiety: A Misunderstood Form of OCD Monnica Williams, Ph.D. OC Foundation of New Jersey, Robert Woods Johnson Hospital

2 Introductions  Assistant Professor of Psychology in Psychiatry  Center for the Treatment and Study of Anxiety University of Pennsylvania, School of Medicine Department of Psychiatry  Phone:  Specializes in research and treatments for OCD & PTSD 2

3 Obsessive-Compulsive Disorder  Obsessions  Unwanted, recurrent, disturbing thoughts that the person cannot suppress and which can cause overwhelming anxiety  Compulsions  Repetitive, ritualized behaviors that the person feels driven to perform to alleviate the anxiety of the obsessions  Prevalence of OCD  Lifetime prevalence at 1.6% in the general population (Kessler, Berglund, & Demler, 2005) 3

4 OCD is Serious: Human Toll  Severe Distress  Anxiety  Depression  Suicidal ideation  Disability  Social Impairment  Family Problems 4

5 OCD Sub-Types  Sub-types of OCD (Abramowitz, Franklin, Schwartz, & Furr, 2003)  Aggression & Harming (by accident or on purpose)  Contamination & Washing  Hoarding  Symmetry & Ordering  Unacceptable thoughts & Mental Rituals  Common unacceptable thoughts  Religious or blasphemous  Violent  Sexual thoughts 5

6 Sexual Obsessions  25% experienced sexual obsessions currently or in the past (Grant et al, 2006)  Actual prevalence rates may be higher  Common themes include unfaithfulness, incest, pedophilia, unusual behaviors, AIDS, profane thoughts combining religion and sex, and homosexuality (Gordon, 2002) 6

7 Obsession vs. Fantasy  Sexual obsessions ≠ Sexual fantasies  Normal sexual fantasies are enjoyable and generally harmless  They may consist of wishes or memories of past sexual experiences  Sexual ideation in OCD is unpleasant and distressing  The individual with OCD does not want the thought to become real  Sexual obsessions in OCD rarely produce sexual arousal  Obsessions usually decrease sex drive  The obsessions result in guilt, shame, distress, anxiety 7

8 About Homosexuality Anxiety  Homosexuality fears have been documented in people with schizophrenia, panic disorder, and other disorders  Few studies have focused specifically on homosexual anxiety in OCD  DSM 4 Field Trial identifies 12% with current or past concerns based on YBOCS (Williams & Farris, 2011)  8% with present concerns  4% with past concerns 8

9 What Is “H” OCD?  Obsessions  The obsessive fear of being or becoming homosexual  The experience of intrusive, unwanted mental images of homosexual behavior  The obsessive fear that others may believe one is homosexual  Compulsions  Usually a form of checking  More about this…  Term “HOCD” (Homosexual Obsessive Compulsive Disorder) evolved out of the online community 9

10 Examples of Homosexuality Anxiety LLesbian obsession hheterosexual female health worker finds obsessions are triggered by contact with attractive women patients CCompulsive checking 220 year old male masturbates to images of men to measure his sexual valence WWorry about appearing gay aa high-school student who worries that others of the same sex might find her attractive 10

11 Differential Diagnosis  Mental health professionals may misdiagnose HOCD  HOCD ≠ Internalized Homophobia (“ego-dystonic homophobia”)  Few instruments address homosexuality anxiety (1 item on the YBOCS checklist)  Most with HOCD have OCD symptoms in other areas  Diagnosis may be hard if symptoms limited to homosexuality obsessions  Gay people with HOCD may have heterosexual worries too (Goldberg, 1984) 11

12 HOCD vs Real Sexuality Crisis (1) OCD 1. feels more sexually aroused by people of the opposite sex 2. thoughts about engaging in same-sex relationships are unappealing 3. feels anxious about romantic relationships with people of the same sex Sexual Identity Crisis 1. feels more sexually aroused by people of the same sex 2. thoughts about engaging in same-sex relationships are arousing 3. feels excited about romantic relationships with people of the same sex 12

13 HOCD vs Real Sexuality Crisis (2) OCD 4. have most enjoyed sexual experiences with a person of the opposite sex 5. worry about same-sex thoughts mainly because don't want to give up opposite sex 6. not able to stop thinking about same-sex relationships, and the thoughts are a severe distraction Sexual Identity Crisis 4. have most enjoyed sexual experiences with a person of the same sex 5. worry about same-sex thoughts mainly because of what others might think or religious concerns 6. often thinks about same-sex relationships but able to stop 13

14 HOCD vs Real Sexuality Crisis (3) OCD 7. feel emotional intimacy with a partner of the opposite sex 8. worry that people of the same sex might be attracted 9. fantasize about physical relationships with opposite sex (including dreams) Sexual Identity Crisis 7. feel emotional intimacy with a partner of the same sex 8. like when people of the same sex are attracted 9. fantasize about physical relationships with same sex (including dreams) 14

15 HOCD vs Real Sexuality Crisis (4) OCD 10. tries to learn more about sexual identity issues to reassure self that not gay Sexual Identity Crisis 10. tries to learn more about sexual identity issues to better understand self and others like self 15

16 Treating HOCD  Misdirected Intervention  Therapist told male patient to try being with a man, and that everybody is bisexual  Symptoms became worse and patient became suicidal for 5 months  Cognitive Understanding of HOCD  Patient receiving CBT came to realize he was dealing with OCD-induced thoughts and an underlying distorted belief system contributing to depression  People with sexual obsessions may need a longer and more aggressive course of treatment (Grant et al, 2006) 16

17 Dos and Don’ts for Therapists  DO: Educate the patient about OCD and how obsessions are maintained  DON’T: Focus on the possible meaning of the obsessions  DO: Psychoeducation about sexual thoughts and sexual orientation  DON’T: Suggest the patient is really gay  DO: Exposures! 17

18 EX/RP for HOCD  Exposure ideas  Devise a detailed story about the patient actually becoming gay  Visit gay clubs and bars  Wear some clothing items of the opposite sex  Display a Gay Pride button  Confront obsessions with thoughts like “I guess I might be gay”  No rituals before or after exposures!  Understanding the specifics of the patient’s fears essential to devising best exposures 18

19 Medications  SSRI medications will help alleviate obsessions, compulsions, and anxiety  One case report of a remission with Prozac of HOCD  Will also cause sexual dysfunction in at least a third of patients, which may panic HOCD patients  Most OCD patients experience only a 30% reduction in symptoms  Partial responders may benefit from augmentation with EX/RP or risperidone (Risperdal)  Current augmentation study underway at Penn and NYC 19

20 Results of Augmentation Research  Patients on an SSRI continue to improve when CBT (EX/RP) is added 20

21 Summary  Sexual obsessions are a common symptom of OCD  Homosexuality anxiety is not to be confused with a sexual orientation crisis  Cognitive-Behavioral Therapy (EX/RP) and medication are considered the treatment of choice  Research needed to define scope of problem and how to best tailor treatment to this population  Research is underway to address these questions 21

22 Resources  M. Williams: Homosexuality Anxiety: A Misunderstood Form of OCD. Leading-Edge Health Education Issues. L. V. Sebeki (eds.). Nova Publishers, 2008  BrainPhysics OCD Mental Health Resource  NeuroticPlanet OCD Discussion Forum  Scholarly articles about HOCD:

23 References  Bystritsky A. (2004). Current Pharmacological Treatments for Obsessive-Compulsive Disorder. Essential Psychopharmacology, 5:4.  Elmore JL. (2002). Fluoxetine-Associated Remission of Ego-Dystonic Male Homosexuality. Sexuality and Disability, 20(2):  Foa EB, Kozak MJ, Goodman WK, Hollander E, Jenike MA, & Rasmussen SA. (1995). DSM-IV field trial: Obsessive- compulsive disorder. American Journal of Psychiatry, 152(1):  Goldberg RL. (1984). Heterosexual panic. American Journal of Psychoanalysis, 44(2): 209.  Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, & Charney DS. (1989). The Yale-Brown Obsessive Compulsive Scale, I: development, use, and reliability. Arch Gen Psychiatry, 46:1006–1011.  Goodwin R, Koenen KC, Hellman F, Guardino M, & Struening E. (2002). Helpseeking and access to mental health treatment for obsessive-compulsive disorder. Acta Psychiatr Scand, 106: 143–149.  Gordon WM. (2002) Sexual obsessions and OCD. Sexual and Relationship Therapy, 17 (4).  Grant JE, Pintob A, Gunnipb M, Mancebob MC, Eisenb JL, & Rasmussen SA. (2006). Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 47:  Keller D & Foa EB. (1978). Phenothiazines combined with systematic desensitization in a psychotic patient with obsessions about homosexuality. Journal of Behavior Therapy and Experimental Psychiatry, 9(3),  Kempf EJ. (1920). The psychopathology of the acute homosexual panic. Acute pernicious dissociation neuroses. In: Psychopathology. Kempf EJ.; Mosby Co., St Louis, MO. pp  Kessler RC, 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(6):  Meyer IH. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5):  Rudden M, Busch FN, & Milrod B. (2003). Panic disorder and depression: A psychodynamic exploration of comorbidity. International Journal of Psychoanalysis, 84(4):

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