Repugnant obsessions: A review of the phenomenology, theoretical models, and treatment of sexual and aggressive obsessional themes in OCD

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Highlights

  • Repugnant obsessions – unwanted sexual/aggressive thoughts – are a common OCD theme.

  • Clinically distinct, linked to covert actions, self-testing, and ego-dystonicity.

  • Negative self-beliefs have been proposed as particularly important.

  • Specialized cognitive techniques required, with emerging evidence of success.

Abstract

Obsessive–compulsive disorder (OCD) is a highly disabling psychiatric disorder, characterized by the occurrence of intrusive, unwanted thoughts (obsessions), which lead to the performance of repetitive compulsions and/or rituals in order to reduce distress and prevent feared outcomes from occurring. In particular, one grouping of obsessive themes that has been highlighted in the clinical literature involves the predominance of thoughts that are highly repugnant to the individual; specifically, unwanted sexual or aggressive thoughts. Compared to other OCD themes, these thoughts may have distinct clinical characteristics, such as being linked to different forms of compulsions including covert rituals and thought-suppression, being linked to greater distress, and being rated as being more ego-dystonic. Theoretically, different mechanisms have been proposed that may underlie these obsessions, for example the meaning that the thought has for the individual has been highlighted, and the theme of obsessions has also been linked with negative self-related beliefs. Finally, such repugnant thoughts may also require specialized techniques in cognitive behavioral therapy. This review outlines such clinical, theoretical and treatment-related aspects of this theme of OCD, and thereby highlights the impact of content on form in this disorder.

Introduction

“This all started about two years ago, with obsessions about being gay … I can't do anything without freaking out that it is a sign… I am in the medical profession. If I have to do a belly exam, and a girl is skinny (and of course I'm jealous), I get visuals that I don't want. If a couple comes in and the husband is ugly, but the wife is pretty and thin, I think, “Oh my God, I would rather be with the wife than the husband….” Then I try to picture myself years down the road … and I can't see who I am with—a man or a woman … And at times I feel so full of sadness and depression, that I forget how much I love (or think I love) … my boyfriend.” (Williams, 2008, p. 198–199).

Obsessive–compulsive disorder is a highly disabling psychiatric illness, characterized by obsessional thoughts, images or impulses, and covert or overt acts performed in order to ward off the resulting anxiety or the potentially negative event related to the obsession (American Psychiatric Association [APA], 2013). Classically, the literature has tended to focus on those individuals experiencing OCD with predominant overt compulsions—notably checking symptoms (“checkers”) and those with predominant cleaning or washing symptoms (“washers”; e.g., Lewis, 1936). However, a number of individuals with OCD have thoughts that are personally repugnant, particularly concerning aggressive or sexual themes, which may or may not be associated with overt compulsive acts. For example, the patient quoted above is consumed by obsessions that she may be homosexual, despite her attraction to men, and compulsions such as trying to “test” herself as to which gender she wishes to be with. This article discusses these repugnant obsessions—and the impact of content on the form of the disorder. It will discuss the clinical characteristics of such symptoms, theoretical models, and implications for therapy. Note that while religious obsessions are often linked to this symptom dimension (but not always; cf. Siev, Rasmussen, Silverman, & Wilhelm, 2013), they will be dealt with specifically elsewhere within this special issue (Abramowitz, 2013).

Section snippets

Evidence for the differentiation of repugnant obsessions

OCD is heterogeneous—as exemplified by the first comment from a recent postgraduate student after viewing multiple videos of people experiencing OCD, “they are all so different”. However, equally there are characteristic symptom themes, so that the beginning therapist's “initial impression is soon replaced by the realization that the obsessions and compulsions are remarkably limited in number and stereotypic” (Rasmussen & Eisen, 2002, p. 1602). While attempts at “subtyping” OCD having generally

Phenomenology of repugnant obsessions

One of the most recent characterizations of a symptom dimension revolving around repugnant obsessions was by Lee and Kwon (2003). These author focused solely on obsessive thoughts (with or without compulsions), and proposed that they can be classified into two subtypes (autogenous and reactive obsessions) based on their content and form. Generally consistent with the studies reviewed above, autogenous obsessions were stated to include sexual, aggressive, and immoral thoughts or urges that are

Self-construct in cognitive-models of OCD

In his influential cognitive model, Rachman, 1997, Rachman, 1998 proposed that obsessions without compulsions are caused by the individual catastrophically misinterpreting their mental phenomena. Such misinterpretations follow from the individual's belief that their thoughts reveal unwanted, hitherto hidden aspects of themselves, and lead to their attempting to neutralise the thought through thought-suppression or covert compulsions. The “content of the obsession is of critical concern” in this

Exposure and cognitive behaviour therapy

It has long been noted that repugnant obsessions may be less amenable to treatment through exposure-based strategies; in particular, they are accompanied by fewer overt behaviors making behaviorally-oriented treatment more difficult (Lee & Kwon, 2003), and it may also be more difficult to engage individuals in treatment given the potential threat of such obsessions to the individual's self-view. As noted earlier, the presence of pure obsessions has been considered a negative prognostic sign for

Conclusion

In sum, repugnant obsessions – comprising aggressive and sexual intrusions – are an important aspect of the phenomenology of OCD. Generally, factor analytic studies suggest that such themes hang apart from other OCD-symptom dimensions, with some overlap with religious obsessions, and sometimes with checking behaviors. Such themes also seem fairly prominent in studied samples (despite the likelihood of under-reporting of such themes), and are associated with clinical features such as a greater

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      Citation Excerpt :

      Repugnant obsessions may involve content such as intentional/accidental harm to others (e.g., thoughts of stabbing a family member), religion (e.g., thoughts of engaging in sinful acts), pedophilia (e.g., thoughts or images of engaging in sexual acts with a child), or sexuality (e.g., doubts about one's sexual orientation). Repugnant obsessions are prevalent in the OCD population with estimates of 20–30% of individuals with OCD reporting such obsessions as their primary concern (Moulding et al., 2014). Additionally, 50–60% of individuals with OCD will report experiencing repugnant obsessions at some point in their lifetime (Pinto et al., 2008).

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