Differentiating Sexual Thoughts in Obsessive-Compulsive Disorder From Paraphilias and Nonparaphilic Sexual Disorders

Recurrent sexual thoughts characterize several different psychological disorders, most notably obsessive-compulsive disorder (OCD), paraphilias, and nonparaphilic sexual disorders (NPSDs). Many clinicians are aware of the rule of thumb that sexual thoughts in OCD are personally distressing, whereas sexual thoughts in paraphilias and NPSDs are not distressing to the individual experiencing these thoughts, and they rely on this heuristic to inform diagnosis. This is problematic because distress alone is not a reliable diagnostic differentiator; as a result, misdiagnosis is common. Given the negative consequences of misdiagnosis, including worsening of symptoms, treatment dropout, and potential harm to individuals experiencing these thoughts or those who are targets of these thoughts, the purpose of this paper is to help clinicians identify and differentiate repetitive sexual obsessions in OCD from repetitive sexual thoughts in paraphilias and NPSDs. A clinical case example is provided along with pivotal areas of questioning to aid in differential diagnosis.