Sexual obsession compulsive disorder: 11 case studies

Obsessive-Compulsive Disorder (OCD) is a long-lasting disorder characterized by cyclic feelings and compulsive behaviors which lead to momentary relief. One of the recognized feature in obsessive-compulsive disorder is sexual obsessions. Compulsive sexual behavior has not yet received wide consideration from researchers and clinicians. Till date, there have been dearth of formal studies of sexual behavior in OCD. In spite of the scarcity of research, many patients with sexual obsession do present for the treatment andmental health professionals in any setting are likely to come across patients with this disorder. The present study aims to af irm that sexual obsessions are prevalent clinical features in OCD that arise sex based symptoms. For that purpose, the data was composed from 11 patients, in which the symptoms were existent for more than 1 year. The data was collected in the form of history taking Structured Clinical Interview, that has been a part of case studymethod. Itwas found that the patients display an obsession with the sexual acts and feel discomfort if unable to control their urges which later affect their personal and social functioning. So this paper will focus and summarize sexual behavior in OCD with the help of case studies.


INTRODUCTION
Obsessive-compulsive disorder (OCD) is a comparatively widespread state through six month occurrence rates of 1.5% to 2.1% (Karno et al., 1988;Meltzer et al., 1995). Mental health report estimated that OCD was among the top 20 causes of illnessrelated disability worldwide for people aged 15 to 44 years (World Health Report, 2001).
The report also suggested that OCD was the fourth most common mental illness after phobias, substance abuse, and major depression. OCD is associated with a wide range of functional impairments and has a signi icant impact on social and working life. There are several types of OCD that present in different ways.
According to Dell'Osso et al. (2012) common OCD obsessions include:(a) obsessions and checking (e.g., aggressive and unwanted sexual thoughts, including obsessions about homosexuality or incest, religious (offending God), somatic obsessions and checking compulsions); (b) symmetry and ordering (e.g., symmetry and exactness obsessions, repeating, counting, and arranging compulsions), perfectionism, including concerns about exactness, needing to remember things, and fear of losing thing's (c) contamination, including body luids, germs, and dirt and cleaning (e.g., contamination obsessions and cleaning/washing compulsions); and (d) hoarding.

Sexual obsessions
Sexual obsessions are usual clinical feature in obsessive compulsive disorder with prevalence of 13.3-24.9% (Grant et al., 2006). It has established slight consideration in research. Reasons for this can be awkwardness in conversing sexual content or because this type of obsession is sometimes deprived of giving the impression to deter the assessment of this particular problem. Sexual obsessions contain numerous forms of unwanted, unacceptable cognitive disturbances with ego dystonic sexual content that can range from feelings about family or children, concerns about sexual orientation, feelings of sex with animals or fears about appealing in sexually aggressive behavior. Prevalence of sexual obsessions in OCD range from 20 to 30% according to different studies (Rasmussen and Tsuang, 1986). They have also been found in children (Swedo, 1989), and some cases have been described to be associated with previous sexual molestation (Freeman and Leonard, 2000).Researches, although limited, examined clinical correlates of sexual obsessions and this type of obsessions were believed to be more common in male with obsessive-compulsive disorder (OCD) (Lensi et al., 1996) or in subjects with tic disorders (Zohar et al., 1997).They were also associated with poorer treatment response and with poorer insight (Alonso et al., 2001;Mataix-Cols et al., 2002) and with impaired sexual satisfaction (Freund and Steketee, 1989).
In the present study, obsession regarding sexual activities involve the symptoms like, 1. Frequency of performing masturbation more than 5 times a day 2. Watching porn ilms or involved in uploading videos or images of their private parts 3. Feeling of pain and severe weakness in their genital areas 4. Pleasure for masturbating in front of women or searching for a girl on social networking sites for making sexual relationship 5. Developing the thoughts of being naked at night and roam around the public places 6. Doubts or confusion of being sexually impaired, which caused stress and anxiety.
These symptoms can therefore affect the individual's daily life routine as they might get feelings of frustration, guilt, loneliness, sadness, loss of appetite, disturbance in sleep, and even they might get withdrawal from their social surrounding. The objective of this study is to explore the prevalence of sexual obsessions in a sample of individuals with obsessive-compulsive disorder (OCD).

Participants
A sample of male subject's age range from 21 years to 50 years was participated in the present study.
Exclusion of subjects was, if they had a history of psychiatric disorders based on DSM-IV (APA, 1994) criteria. Total 11 patients were incorporated in the present study those who were successively sent to clinical psychologists for the treatment of obsessivecompulsive disorder (OCD).

Instrument
Patient's evaluation was done on psychiatric condition using the Structured Clinical Interview for DSM-IV (First et al., 1997). Patients were evaluated on the subsequent standards, 1) Diagnosed mainly with symptoms of obsessivecompulsive disorder (OCD), de ined by the DSM-IV (APA, 1994).
(2) Occurrence of obsessions and compulsions (3) Had these (obsessive compulsive disorder) signs and symptoms for at least one year (4) Age ranging from 21 years to 50 years (5) Simultaneously not getting treatment for any psychological disease, no evidence of psychiatric disorders

Patient 1
Patient 1 was 27 years unmarried male, had reported the symptoms of the sexual obsession of 2-year duration. He reported that his parents were staying outside India, and he was staying with his grandparents in Punjab, India. He had developed the symptoms of excessive masturbating while talking to girls. He had some accounts and was spending money on buying the memberships on sex dating sites. He got this obsessive thought about talking to one speci ic kind of girl every morning when he woke up. He used to spend most of his time for inding similar girls over these types of sex dating sites to control his thought. He tried to stop himself, but nothing could help him. On the detailed assessment, he reported that his academics were being getting disturbed due to this habit, and he was not able to concentrate anywhere other than this. He had the feelings of sadness, loneliness, and guilt. He did not report the symptoms related to general obsessivecompulsive disorder (OCD) (cleanliness, germs, contaminants, etc.). He restricted himself into a room alone with a laptop. The frequency of masturbation was 8 to 9 times a day.

Patient 2
Patient 2 was 46 years married male having two children, was in government job. He reported obsessive-compulsive disorder (OCD) and a history of watching porn 2-3 hours every day since last two years. He had social withdrawal, loneliness, and irritation. He used to get frustrated easily while not getting access to the porn during the day and did not want to talk to his wife and children. Other reported symptoms were loss of appetite, disturbed sleep due to watching porn until 2:00-3:00 AM, and he lost several kilograms of his weight in the past 3-4 months. The patient did not mention the symptom of masturbating, but he reported indulging in watching porn excessively. The patient did not possess any other symptom related to obsessive-compulsive disorder (OCD) or any other history of any mental disorder.

Patient 3
Patient 3 was a 23-year male engineering student and residing in the hostel. He reported sexual obsession of three-year duration. He started to watch porn and masturbation in irst year due to peer pressure. Soon he started indulging in this behavior to reduce the obsessive thoughts that continued for three years. He started to avoid college and classes, and going home. He also experienced increased social withdrawal, as well as reported symptoms of sadness, confusion, excessive smoking and weight loss.

Patient 4
Patient 4 was 23-year male student. He reported the symptoms of the sexual obsession of one year of duration and reported poor appetite, poor sleep, severe weakness in legs and genital area due to excessive masturbating, around more than 10 times a day. He had been recurring doubt that he was sexually impaired and masturbated excessively to prove this. He reported attempting to initiate intercourse with a prostitute where due to excessive performance pressure he could not perform, which led him to the thought related to the problem with his genital area.

Patient 5
Patient 5 was 28 years unmarried male who reported symptoms of the sexual obsession of oneyear duration.This led to him masturbating frequently (8-10 times a day) due to which he started exhibiting various physical complaints like severe weakness in legs and genital area, loss of appetite, and loss of sleep. His daily functioning was impacted severely due to the continuous masturbation as well as rumination about the same.

Patient 6
Patient 6 was 37 years married male who reported obsessions with one-year duration. He recently gotten married and reported excessively intrusive thoughts about doubts of being sexual impaired. He indulged in watching excessive porn and subsequently high frequency of masturbation to prove that he was not sexually impaired. He was extremely stressed due to these thoughts and compulsions that affected his sexual performance negatively.

Patient 7
Patient 7 was 28 years unmarried male who reported with the obsession of exhibitionism with two-year duration where he would gain relief and pleasure from masturbating in front of women.He reported spending his parent's money on prostitutes.He reported complaints included being unable to concentrate, having thoughts of the sexual nature about his own sister, obsessively sleeping with his mother/grandmother. His obsessive thoughts hampered his daily functioning. He used to walk naked in the park late at night to search women to control the intrusive obsessive thoughts.

Patient 8
Patient 8 was 50 years married male engineer, reported sexual obsession with three years of duration. He revealed having a tendency of passing urine at public places, masturbating publicly, especially in women presence dominated areas. He was not able to control his obsession. He used to feel extreme pain, choking, and breathlessness. His compulsive behavior started affecting his daily life to such an extent that he planned to get the divorce since he could not cope. He identi ied the symptoms and looked at the treatment but could not get help because he wanted to get treatment from a female doctor.

Patient 9
Patient 9 was 26-year unmarried male engineer, reported obsession with two years of duration. He discussed the symptoms related to excessive masturbation, excessive porn watching, and searching for girls on social dating sites as well. He aimed to approach them to establish the sexual relationships, reported being obsessive about establishing the sexual relationships with unknown women and masturbating in front of them.

Patient 10
Patient 10 was 21-year male engineering student, revealed obsession with the duration of one-year. He developed deviant/indifferent the sexual interest (watching the sexual activities with humans and animals-bestiality) due to his peer pressure. He reported poor concentration, frequent headaches, mood swings, and academic failure (failed in two semesters). He also reported excessive porn watching, frequent masturbation, up to 10 times a day and obsessive thoughts that could not be stopped. He reported that he damaged his phone and his laptop to prevent from compulsively masturbating, but his obsession could not be stopped.

Patient 11
Patient 11 was 24 years married male who has revealed the sexual obsession with the duration of one-year. He reported that he started masturbating more than 12 times during a day due to which he experienced excessive weakness, feelings of sadness, mood swings and inability to concentrate on work. He had break up with a girl due to family distress. He stopped his business due to his compulsive behavior. He also displayed symptoms of suicide ideation.
A review of the cases brings forth some common symptomology that is presented by the 11 patients. The patients display an obsession with the act of sex and experience discomfort if unable to control their urges. It was observed that patients reported symptoms for 1 year or more with no history of any other mental disorders.

DISCUSSION
The present paper deals with an important concern, the prevalence of sexual obsessions in OCD. Sexual obsession in OCD has not been acceptable to the individual. The patients in the present study are hyper-focused or ixated on sexual acts and images to the point where their personal and professional day-to-day functioning affected. They experienced problems with physical and mental health, including symptoms like loss of appetite, irregular sleep, severe weakness due to excessive masturbation, acute distress, anxiety, low mood, feelings of guilt, loss of concentration and attention, loss of well being, and somatic symptoms like headaches. Patients also have trouble in coping with their work or academics, affecting the professional aspect of their lives. They are unable to report to work or the academic institution due to their symptoms, spending time inside their rooms. Most patients reported inability concentrating, lack of attention, and presence of intrusive, circular thoughts that negatively affected their motivation and ability to perform in their professional lives. Another aspect that was affected was the social and interpersonal relationships. Patients reported social withdrawal, with some experiencing irritability when around family members, while some reported high levels of loneliness.The symptoms they presented with also fractured their relationships with their considerable family members and friends. These symptoms often also turn into compulsive acts that are deviant in nature (like exhibitionism, voyeurism, bestiality, etc.). Individuals suffering from OCD consider their sexual obsessions as morally wrong, errant, or as the possible basis of a failure of control or terrible actions. It is suggested that individual may expose a type of withdrawn self-hate and show a way out to the person's crisis (Bordeleau, 1994). This study focuses on the issue that is relatively ignored in the literature. Further investigation is needed to test this hypotheses and it would be worth to be tested. Sexual obsessions may turn around a number of factors. General factors include unusual behaviors, incest, pedophilia, profane thoughts mingling religion and sex, AIDS, unfaithfulness, and, certainly, homosexuality.

CONCLUSIONS
From the trends observed, it is evident that these set of symptoms reported by the patients are outside the preview of general obsessive-compulsive disorder (OCD). The severity of the dysfunction experienced by patients calls for specialized treatment. Hence, it is recommended that there should be a sub-category of obsessive-compulsive disorder (OCD) that deals completely with sexual obsession to identify and treat the patients suffering from these particular problems. So in conclusion, it can be stated that sexual obsessions in OCD patients are quite widespread. More researches in this ield are needed which should replicate studies of clinical correlates of sexual obsessions in OCD. Upcoming research should also aimed at important pubertal factors which may add to the etiology of these meticulous obsessions.