Am I a Monster? An Overview of Features and Treatment for POCD

Imagine one day that you are walking past an elementary school playground. You glance over at the children and, out of the blue, a thought enters your head: “Did I just look at those kids in a creepy way?” Your brain immediately begins to doubt/analyze whether your glance was creepy and you are flooded with terror: “Why would I be staring at kids?” “Do other people do this?” “Was I physically attracted to one of them?” “Is there something wrong with me?” “Did I do something inappropriate?” “Did I get aroused by the children?” “Am I a pedophile?” “Am I going to become a pedophile?” “What does this mean that I am even thinking these thoughts?”

The next time that you are in a similar situation, you were probably acutely aware and on guard for whether there were any intrusive thoughts present. Now whenever you walk by a school or a playground, you avoid eye contact with everyone. You check where your hands are to make sure that you wont accidentally touch a child inappropriately and you are on guard and panicked that you will experience more intrusive thoughts that suggest feelings for children. You may even check your genitals for signs of arousal. You worry others are looking at you and you may even begin to question what you have done. You feel your only option is to escape in order to protect the innocence of these children. You may feel that you are a monster and a bad person for having these thoughts in your brain. What you may not realize, is that you may be suffering from a very common form of Obsessive Compulsive Disorder (OCD), called Pure-O. And you are not alone.  

Purely-Obsessional OCD, also known as Pure-O, is one of the most common, yet lesser known, manifestations of OCD.  People with Pure-O experience minimal observable compulsions, compared to those who experience the typical form of OCD (checking, hand-washing, etc.). While ritualizing and neutralizing behaviors do take place, they are mostly of a cognitive basis.  The primary anxiety-reducing vehicle is mental rumination.

Purely-Obsessional OCD often takes the form of horrific intrusive thoughts of a distressing or violent nature and the sufferer spending a great deal of mental effort trying to check, neutralize, and avoid certain thoughts. The internal verbal behaviors encompass excessive ruminations, thought loops, mental checking, and mental avoidance of certain thoughts. Endless amounts of time is spent attempting to answer the unanswerable questions that the OCD posits. OCD is masterful at deceiving the sufferer by saying “if you just spend a little time on this question, you will figure it out and feel so much better!” Because the threat feels so real, it is extremely difficult to resist the siren’s call of mental rumination. The most imperative item on the agenda becomes gaining certainty. Often times, sufferers will replay past scenarios, making sure to examine every single “fact” that was present.

Within the subset of Pure-O, several themes tend to co-occur including fears related to pedophilia (pOCD) sexuality (hOCD), incest, bestiality and the primary romantic relationship (rOCD). This article concentrates on pedophilia OCD (pOCD). An individual living with pOCD can be simultaneously flooded with unwanted thoughts or images related to any and all of these themes. Patients have remarked, “if I am attracted to a child of the same sex then doesn’t that mean I’m gay and shouldn’t be married?” If left unchecked, pOCD can bleed into numerous areas in one’s life.

In contrast, the DSM-V defines pedophilia as “recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children.”  The diagnosis of pedophilia has absolutely nothing to do with the diagnosis of pOCD. Despite this clear distinction, your pOCD will undoubtedly be persuading you that you belong in the true pedophile category rather than the pOCD category, your therapist doesn’t really understand or your therapist is wrong. An individual living with pOCD is no more likely to be a pedophile than an individual who does not have pOCD. This is a disorder of anxiety and uncertainty, not sexual urges and behaviors. In regards to pOCD, the primitive worry-brain has randomly selected this theme as the topic that feels like it must be resolved immediately.

An individual suffering with pOCD will experience intrusive thoughts or images (spikes) accompanied by terrorizing anxiety. The OCD has the ability to produce doubt or question memories, real or imagined. Additionally, sexual urges are monitored and encoded as part of the evidence-gathering process. The presence of an erection or vaginal lubrication is closely examined for signs of arousal. Based on the importance that pOCD places on sexual attraction, your brain constantly draws attention to sexual arousal. This increased monitoring allows for a case of mistaken identity in which any microscopic movement is determined to be arousal towards children. Taken together, unwanted thoughts, images and urges can persuade an individual with pOCD that they are a sexual deviant.  

Among the many themes within OCD there is perhaps no theme that carries more shame, guilt, self-loathing and stigma than pOCD. Despite the fact that there is no tangible difference between OCD themes in terms of development, maintenance and treatment, those suffering with pOCD tend to take ownership of OCD and view themselves as repugnant, vile, terrible people. In line with this stigma, those suffering with pOCD are almost always hesitant to describe what they are experiencing to a psychologist (if they are lucky enough to recognize that this is OCD). The word “pedophile” or “molester” is often whispered inaudibly during the initial sessions. Descriptions of pOCD are typically preempted with questions regarding confidentiality or previous experience treating OCD or a warning that “you may judge me and think this is atrocious but here goes.” The idea of coming to therapy and talking about something that is deemed so shameful feels like an impossible undertaking. This is unfortunately reinforced by society and to a lesser extent, the mental health field, which does not have an adequate understanding of pOCD. Numerous therapists make the harmful mistake of informing someone with pOCD that this is not OCD, they are a dangerous individual and/or should be seeking sex therapy. Sadly, this promotes the message to the pOCD sufferer that they are horrible people who do not have OCD.

Spikes tend to revolve around past, current or future behavior.

Common past-oriented spikes

• “Did I ever do anything inappropriately sexual when I was younger?”
• “Did I do anything recently that was sexually inappropriate?”
• “Have I ever been attracted to an adolescent or child?”
• “Did I ever molest anyone?”
• “Could ambiguous action X be construed as sexual?”
• “Have I accidentally clicked on child porn?”
• “Does a person from my past know something that suggests I’m a pedophile?”

Common present-oriented spikes

• “Am I attracted to this 10-year-old in front of me?”
• “Was I just checking out this 13-year-old girl?
• “Did someone just notice me doing something strange?”
• “I should stand on the other side of the subway, away from this 6-year-old boy so that I don’t impulsively grope him.”
• “Am I sexually aroused by this little girl on TV?”

Common future-oriented spikes

• “How do I know I will never engage in pedophilic behavior?”
• “What if, one day, I really am attracted to children?”
• “What is the right way to hold/hug/change a child?”
• “What if I get arrested and go to jail?”
• “Will I be creepy or do something inappropriate when I have a baby?”

Reassurance seeking is common within this theme. Individuals with pOCD will ask friends and loved ones questions aimed at figuring out this threatening unknown. Endless hours are spent mentally ruminating in an attempt to alleviate anxiety. Checking the physical environment to ensure that insidious behavior has not occurred is also common. Incessant answer seeking also occurs on the Internet through Google searches and online forums. Common searches include looking up infamous pedophiles and comparing to oneself or sifting through legal jargon to prepare for feared consequences. The hope is to find a nugget of information from anyone, anywhere that will extinguish the horrific threat. The Internet can be an extremely debilitating weapon that leads individuals with pOCD down the proverbial rabbit hole.

There is a considerable amount of testing that takes place within this theme. Individuals with pOCD feel compelled to compare their thoughts, feelings, behaviors and sexual arousal when they are around adults and children. The hope is that this will serve as a pedophilia litmus test. As mentioned earlier, this inevitably yields a multitude of false positives that lends itself to further ritualizing. While all of these rituals serve to temporarily relieve anxiety, they ultimately prevent someone with pOCD from progressing in treatment.

Avoidance plays an important role in the perpetuation of pOCD. Individuals suffering with pOCD will do everything in their power to ensure that these fears do not come to fruition. As is the case with all forms of OCD, escape and avoidance maintain and exacerbate the anxiety. In response to an impulsivity fear, one may stand as far away as possible from a minor or escape the situation altogether. Avoiding children at parks, museums or near schools helps to ensure that these thoughts, images and feelings will not surface. In line with avoidance, some individuals may choose not to have children of their own in order to limit the danger that they feel they pose to children.

Treatment for pOCD entails engaging in exposure therapy while simultaneously addressing the shame resulting from stigma discussed above. Facing the fear head on while limiting ritualistic behavior is the most effective way to manage OCD. This includes intentionally placing oneself in situations that will progressively provoke more challenging unwanted intrusive thoughts and accompanying anxiety. An emphasis is placed on situations that are inducing a desire to escape or avoid. Sample exposure items include going to public parks, looking at pictures of children, watching movies such as The Lovely Bones or reading news stories about pedophiles.

The goal of these challenging exposure exercises is to let unwanted thoughts be present while allowing anxiety to dissipate organically. Taking this “risk” feels impossible but after engaging in exposures consistently and repeatedly, the rational brain (the real you) can dominate the conversation. When anxiety is allowed to naturally dissipate, threatening situations are no longer perceived as such and one does not feel relentlessly compelled to resolve questions related to potential for pedophilia. This theme can become irrelevant through exposures and response prevention.

Dr. Jordan Levy is a licensed psychologist in private practice in Manhattan at the Center for Cognitive-Behavioral Psychotherapy and in Livingston, New Jersey. He specializes in the treatment of Anxiety and Obsessive-Compulsive Disorder including the Purely-Obsessional subtype (Pure-O). He can be reached by email at DrJordanLevy@gmail.com or online at www.DrJordanLevy.com.