Presentation on theme: "Homosexuality Anxiety:"— Presentation transcript:
1 Homosexuality Anxiety: Originally presented at the Quarterly Meeting, “Homosexuality Anxiety: A Misunderstood Symptom of OCD,” OC Foundation of New Jersey, Robert Woods Johnson Hospital, New Brunswick, NJ, : Sep 8, 2008A Misunderstood Form of OCDMonnica 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 PsychiatryPhone:Specializes in research and treatments for OCD & PTSD
3 Obsessive-Compulsive Disorder ObsessionsUnwanted, recurrent, disturbing thoughts that the person cannot suppress and which can cause overwhelming anxietyCompulsionsRepetitive, ritualized behaviors that the person feels driven to perform to alleviate the anxiety of the obsessionsPrevalence of OCDLifetime prevalence at 1.6% in the general population (Kessler, Berglund, & Demler, 2005)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):
4 OCD is Serious: Human Toll Severe DistressAnxietyDepressionSuicidal ideationDisabilitySocial ImpairmentFamily ProblemsAD Lopez, CCJL Murray, The global burden of disease, , Nature Medicine, 4, 1241-1243, 1998.
5 OCD Sub-TypesSub-types of OCD (Abramowitz, Franklin, Schwartz, & Furr, 2003)Aggression & Harming (by accident or on purpose)Contamination & WashingHoardingSymmetry & OrderingUnacceptable thoughts & Mental RitualsCommon unacceptable thoughtsReligious or blasphemousViolentSexual thoughtsAbramowitz, Franklin, Schwartz, Furr. (2003). Journal of Consulting and Clinical Psychology. Vol. 71, No. 6, 1049–1057
6 Sexual Obsessions25% experienced sexual obsessions currently or in the past (Grant et al, 2006)Actual prevalence rates may be higherCommon themes include unfaithfulness, incest, pedophilia, unusual behaviors, AIDS, profane thoughts combining religion and sex, and homosexuality (Gordon, 2002)Sexual obsessions seem to be equally prevalent in both male and female OCD patients. People with sexual obsessions are particularly likely to have co-occurring aggressive and religious obsessions, clinical depression, and higher rates of impulse control disorders (Grant et al, 2006).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:
7 Obsession vs. FantasySexual obsessions ≠ Sexual fantasiesNormal sexual fantasies are enjoyable and generally harmlessThey may consist of wishes or memories of past sexual experiencesSexual ideation in OCD is unpleasant and distressingThe individual with OCD does not want the thought to become realSexual obsessions in OCD rarely produce sexual arousalObsessions usually decrease sex driveThe obsessions result in guilt, shame, distress, anxiety
8 About Homosexuality Anxiety Homosexuality fears have been documented in people with schizophrenia, panic disorder, and other disordersFew studies have focused specifically on homosexual anxiety in OCDDSM 4 Field Trial identifies 12% with current or past concerns based on YBOCS (Williams & Farris, 2011)8% with present concerns4% with past concernsKeller 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),Foa & Kozak, DSM-IV Field Trial: Obsessive-Compulsive Disorder. Am J Psychiatry, 1995; 152:90-96.
9 What Is “H” OCD? Obsessions Compulsions The obsessive fear of being or becoming homosexualThe experience of intrusive, unwanted mental images of homosexual behaviorThe obsessive fear that others may believe one is homosexualCompulsionsUsually a form of checkingMore about this…Term “HOCD” (Homosexual Obsessive Compulsive Disorder) evolved out of the online communityStarted BrainPhysics.com 8 years ago
10 Examples of Homosexuality Anxiety Lesbian obsessionheterosexual female health worker finds obsessions are triggered by contact with attractive women patientsCompulsive checking20 year old male masturbates to images of men to measure his sexual valenceWorry about appearing gaya high-school student who worries that others of the same sex might find her attractive
11 Differential Diagnosis Mental health professionals may misdiagnose HOCDHOCD ≠ Internalized Homophobia (“ego-dystonic homophobia”)Few instruments address homosexuality anxiety (1 item on the YBOCS checklist)Most with HOCD have OCD symptoms in other areasDiagnosis may be hard if symptoms limited to homosexuality obsessionsGay people with HOCD may have heterosexual worries too (Goldberg, 1984)Goldberg RL. (1984). Heterosexual panic. American Journal of Psychoanalysis, 44(2): 209.
12 HOCD vs Real Sexuality Crisis (1) Sexual Identity Crisisfeels more sexually aroused by people of the opposite sexthoughts about engaging in same-sex relationships are unappealingfeels anxious about romantic relationships with people of the same sexfeels more sexually aroused by people of the same sexthoughts about engaging in same-sex relationships are arousingfeels excited about romantic relationships with people of the same sex
13 HOCD vs Real Sexuality Crisis (2) Sexual Identity Crisishave most enjoyed sexual experiences with a person of the opposite sexworry about same-sex thoughts mainly because don't want to give up opposite sexnot able to stop thinking about same-sex relationships, and the thoughts are a severe distractionhave most enjoyed sexual experiences with a person of the same sexworry about same-sex thoughts mainly because of what others might think or religious concernsoften thinks about same-sex relationships but able to stop
14 HOCD vs Real Sexuality Crisis (3) Sexual Identity Crisisfeel emotional intimacy with a partner of the opposite sexworry that people of the same sex might be attractedfantasize about physical relationships with opposite sex (including dreams)feel emotional intimacy with a partner of the same sexlike when people of the same sex are attractedfantasize about physical relationships with same sex (including dreams)
15 HOCD vs Real Sexuality Crisis (4) Sexual Identity Crisistries to learn more about sexual identity issues to reassure self that not gaytries to learn more about sexual identity issues to better understand self and others like self
16 Treating HOCD Misdirected Intervention Cognitive Understanding of HOCD Therapist told male patient to try being with a man, and that everybody is bisexualSymptoms became worse and patient became suicidal for 5 monthsCognitive Understanding of HOCDPatient receiving CBT came to realize he was dealing with OCD-induced thoughts and an underlying distorted belief system contributing to depressionPeople with sexual obsessions may need a longer and more aggressive course of treatment (Grant et al, 2006)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:
17 Dos and Don’ts for Therapists DO: Educate the patient about OCD and how obsessions are maintainedDON’T: Focus on the possible meaning of the obsessionsDO: Psychoeducation about sexual thoughts and sexual orientationDON’T: Suggest the patient is really gayDO: Exposures!
18 EX/RP for HOCD Exposure ideas No rituals before or after exposures! Devise a detailed story about the patient actually becoming gayVisit gay clubs and barsWear some clothing items of the opposite sexDisplay a Gay Pride buttonConfront 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
19 MedicationsSSRI medications will help alleviate obsessions, compulsions, and anxietyOne case report of a remission with Prozac of HOCDWill also cause sexual dysfunction in at least a third of patients, which may panic HOCD patientsMost OCD patients experience only a 30% reduction in symptomsPartial responders may benefit from augmentation with EX/RP or risperidone (Risperdal)Current augmentation study underway at Penn and NYCElmore JL. (2002). Fluoxetine-Associated Remission of Ego-Dystonic Male Homosexuality. Sexuality and Disability, 20(2):A Bystritsky, Current Pharmacological Treatments for Obsessive-Compulsive Disorder, Essent Psychopharmacol, 5:4, 2004.HB Simpson, EB Foa, MR Liebowitz, et al, A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am JPsychiatry in Advance, 1-10, March 2008.
20 Results of Augmentation Research Patients on an SSRI continue to improve when CBT (EX/RP) is addedSimpson HB, Foa EB, Liebowitz MR, et al. (2008). A Randomized Controlled Trial of CBT for Augmenting Pharmacotherapy in OCD, Am J Psychiatry in Advance, 1-10.QUESTIONS?
21 Summary Sexual obsessions are a common symptom of OCD Homosexuality anxiety is not to be confused with a sexual orientation crisisCognitive-Behavioral Therapy (EX/RP) and medication are considered the treatment of choiceResearch needed to define scope of problem and how to best tailor treatment to this populationResearch is underway to address these questions
22 ResourcesM. Williams: Homosexuality Anxiety: A Misunderstood Form of OCD. Leading-Edge Health Education Issues. L. V. Sebeki (eds.). Nova Publishers, 2008BrainPhysics OCD Mental Health ResourceNeuroticPlanet OCD Discussion ForumScholarly articles about HOCD:
23 ReferencesBystritsky 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. ppKessler 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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