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

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.

Serious negative consequences associated with exposure and response prevention for obsessive‐compulsive disorder: A survey of therapist attitudes and experiences

“…Some therapists reported reservations at the prospect of involving weapons (especially firearms) in exposure, with concerns raised regarding safety, the ethics of bringing weapons into treatment environments, and practicalities around access. Therapists also reported specific concerns regarding exposures for pedophilic obsessions (Bruce et al, 2018) and exposures with sexual content involving young clients (Fernández de la Cruz et al, 2013). Willingness‐to‐treat ratings were high overall, though willingness was lower for weapons‐related exposures, and for sexual exposures in youth.…”

“…The starkest example of this involved an ERP provider being reported to their licensing board following a student training in which they taught the application of ERP techniques for sexual and violent intrusive thoughts (Table 3, case 9). This is an evidence‐supported technique for OCD (Bruce et al, 2018; Molding et al, 2014; Williams et al, 2011), yet the case remained unresolved for over 1 year and the therapist incurred significant legal costs in their defense. Other responses included negative reactions to ERP training from a nonexpert audience.…”

“…Some SNC represented secondary risks of OCD (Veale et al, 2009), that is, actual negative outcomes that happened as an unintended consequence of OCD. There are many resources available for therapists to minimize secondary risks of harm‐related exposures (Bruce et al, 2018; Lewis et al, 2019; Molding et al, 2014; Veale et al, 2009). Care should also be taken when treating minors (Storch & Lewin, 2016), especially to ensure that planned exposures are developmentally appropriate, and to that parents understand the rationale for specific exposure tasks and have a chance to voice any concerns before tasks being attempted.…”

“…Providing that the diagnosis of OCD has been properly made, the expert clinical consensus is that there is no evidence of primary risks because of OCD, that is, clients do not act on intrusive thoughts of harming themselves or others (Veale, Freeston, Krebs, Heyman, & Salkovskis, 2009). Unfortunately, the risk of serious harm associated with OCD can be misunderstood and unnecessary safeguarding procedures can reinforce OCD symptoms (Lewis, Stokes, Heyman, Turner, & Krebs, 2019), and potentially lead to unnecessary legal interventions or child separations (Bruce, Ching, & Williams, 2018; Challacombe & Wroe, 2013; Preskey, 2020). Concerns about the safety of ERP may be magnified when clients present with harm‐related or taboo symptoms such as sexual or aggressive obsessions (Bruce et al, 2018; Molding, Aardema, & O'Connor, 2014).…”

“…Unfortunately, the risk of serious harm associated with OCD can be misunderstood and unnecessary safeguarding procedures can reinforce OCD symptoms (Lewis, Stokes, Heyman, Turner, & Krebs, 2019), and potentially lead to unnecessary legal interventions or child separations (Bruce, Ching, & Williams, 2018; Challacombe & Wroe, 2013; Preskey, 2020). Concerns about the safety of ERP may be magnified when clients present with harm‐related or taboo symptoms such as sexual or aggressive obsessions (Bruce et al, 2018; Molding, Aardema, & O'Connor, 2014). Although these are common symptoms (Ruscio, Stein, Chiu, & Kessler, 2010) therapists may perceive them as challenging to treat or have ethical or legal concerns about treatment (e.g., involving children in exposures for pedophilia‐OCD symptoms or handling weapons for those with violence‐related symptoms).…”