Arch Sex Behav

DOI 10.1007/s10508-017-1031-4

ORIGINAL PAPER

Pedophilia-Themed Obsessive–Compulsive Disorder: Assessment,

Differential Diagnosis, and Treatment with Exposure and Response
Prevention
Simone Leavell Bruce1,3 • Terence H. W. Ching2 • Monnica T. Williams2,3

Received: 2 December 2016 / Revised: 12 June 2017 / Accepted: 28 June 2017

 Springer Science+Business Media, LLC 2017

Abstract Fears of sexually harming children are fairly common Introduction

among clients suffering from obsessive–compulsive disorder
(OCD), yet these symptoms are largely unrecognized and fre- Obsessive–compulsive disorder (OCD) is a severe and disabling
quently misdiagnosed by mental health professionals. Specifi- condition consisting of intrusive obsessions and repetitive com-
cally, clients with pedophilia-themed OCD (P-OCD) experi- pulsions. OCD tends to be particularly persistent, highly comor-
ence excessive worries and distressing intrusive thoughts about bid with other psychiatric disorders, associated with great func-
being sexually attracted to, and sexually violating, children. Express- tional impairment across multiple domains, and correlated with
ing these concerns may provoke misjudgments from uninformed a significantly higher mortality rate from both natural and unnat-
mental health professionals that a client is presenting instead with ural causes compared to the general population (Kessler, Berglund,
pedophilic disorder. This misdiagnosis and subsequent improper & Demler, 2005; Meier et al., 2016). Pedophilia-themed obses-
interventions can then contribute to increased fear, anxiety, and in sions may produce an even greater level of discomfort, anxiety,
many cases, depression, in affected clients. Therefore, it is imper- and shameforsufferersdue to thedistasteful andoffensive nature
ative that mental health professionals first possess a good under- of the obsessions. When the OCD is severe and persistent, clients
standing of this common manifestation of OCD. As such, in this are often unable to manage the disorder without specialized psy-
article, we described obsessions and compulsions typical of chological intervention.
P-OCD, in order to inform the reader of the distinctive differ- The most prevalent symptom dimensions in obsessive–com-
ences between P-OCD and pedophilic disorder. Information pulsive disorder (OCD) are contamination concerns and com-
about how to assess for P-OCD symptoms is then provided, pulsive cleaning, doubts about harm and compulsive checking,
followed by suggestions on how to tailor aspects of exposure symmetry/orderingconcerns,andunacceptablethoughts(Abramow-
and response prevention to treat this specific form of OCD. itz et al., 2010; Abramowitz, Franklin, Schwartz, & Furr, 2003;
American Psychiatric Association (APA), 2013; Leckman et al.,
Keywords Obsessive–compulsive disorder
Pedophilia
1997; Pinto et al., 2008; Williams et al., 2014a). While much
Exposure and response prevention
DSM-5 research has been undertaken to better understand contamina-
tion concerns and compulsivechecking (e.g., Ball, Baer, & Otto,
1996), there has been less research attention on the unaccept-
able thoughts symptom dimension, which includes violent, reli-
gious, sexual, and otherwise taboo and morally repugnant obses-
sions (e.g., Pinto et al., 2007). This disparity is alarming, espe-
& Simone Leavell Bruce
sleavell@spalding.edu
cially since unacceptable thoughts in general have been associ-
ated with poorer treatment outcomes, compared with other OCD
1
Department of Psychology, Spalding University, Louisville, symptom dimensions (Williams et al., 2011; Williams, Mugno,
KY 40203, USA Franklin, & Faber, 2013).
2
Department of Psychological Sciences, University of The specific subset of sexual obsessions, found within the
Connecticut, Storrs, CT, USA unacceptable thoughts symptom dimension, may involve fears
3
Louisville OCD Clinic, Louisville, KY, USA about engaging in sexually aggressive behaviors, fears about

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one’s sexual orientation/identity changing, or unwanted sexual ferentiate between pedophilic disorder and pedophilia-themed
thoughts and fears about children(i.e., pedophilia-themed OCD OCD.
[P-OCD];Pintoetal.,2007).Grantetal.(2006)foundthatapprox-
imately 24.9% of individuals with OCD had experienced sex- Obsessions in P-OCD
ual obsessionsatsomepointduringtheirlives.Additionally, Wil-
liams and Farris (2011) found that 16.8% of individuals seeking As previously mentioned, sexual obsessions in OCD can man-
treatment for OCD reported current unwanted sexual obsessions. ifest as P-OCD. Clients with P-OCD typically fear that they are
However,becausethestronglystigmatizedcontentsofsuchobses- sexually attracted to children, including their own, if they have
sions tend to increase symptom concealment due to shame or any.Somemayalsofearthattheywillcommitsexualcrimesagainst
embarrassment (Cathey & Wetterneck, 2013; Newth & Rach- children, either consciously or unconsciously. Essentially, clients
man, 2001), actual prevalence rates are likely much higher than with P-OCD suffer from recurring mental thoughts and images
indicated. Despite the considerable prevalence of sexual obses- of children in sexualized contexts, which elevate doubts about
sions among clients with OCD, many mental health profession- whether they will engage in acts of sexual violation toward them
als are still inadequately informed in terms of recognizing, assess- (e.g., O’Neil et al., 2005). It is important to remember, however,
ing,and/ortailoringspecificsoftreatment toclients’intrusivesex- that one of the ways P-OCD is distinct from pedophilic disorder
ual thoughts (e.g., Glazier, Calixte, Rothschild, & Pinto, 2013). is that the intrusions in P-OCD are ego-dystonic (i.e., distress-
The situation is especially dire in regard to the recognition, ing) and cause severe shame, disgust, and anxiety in sufferers
assessment, and treatment of symptoms of P-OCD, perhaps due (Gordon,2002). In contrast, in pedophilic disorder, thethoughts
to the lack of educational resources for clinicians. For example, are usually ego-syntonic (i.e., clients with pedophilic disorder
existing clinician guides and self-help books for OCD tend to enjoy and are sexually aroused by sexualized thoughts and ima-
omit the topic of P-OCD, or even sexual obsessions in general ges of children). Clients with P-OCD fear that they may actually
(e.g., Foa & Kozak, 1997; Foa, Yadin, & Lichner, 2012; Schwartz, enjoy or find pleasure in these images. As a result, clients with
1996). Additionally, the only cognitive behavior therapy (CBT)- P-OCD can spend several hours throughout the day worrying
oriented books that explicitly broached the topics of unwanted aboutthepossibilityofpedophilictendencies.Additionally,clients
sexual, violent, or blasphemous obsessions unfortunately con- with P-OCD tend to endorse high impairment and dysfunction
ceptualized such symptoms as constituting‘‘pure-obsessional’’ inprofessional,academic,andsocial/interpersonalcontexts,because
OCD (see Clark, 2007; Purdon & Clark, 2005). This neglects of the amount of time and mental resources they devote instead
the strong presence of mental compulsions in clients (described in to their pedophilia-themed worries (Moulding et al., 2014).
detail further below) that often operate undetected in maintaining
this form of OCD. The aforementioned books also frequently Compulsions in P-OCD
lumped together symptoms in the unacceptable thoughts dimen-
sion in exploring possible CBT techniques, instead of detailing Clients who suffer from P-OCD tend to engage in many types
treatment strategies and examples specific to P-OCD. Further- of repetitive rituals, whether overt or covert. For OCD in gen-
more, our review of the related extant scientific literature yielded eral, mental compulsions are a common group of covert repet-
only a case report of a married, 35-year-old father of two chil- itive rituals. However, individuals with covert compulsions may
dren who presented at a psychiatry clinic with distressing intru- be erroneously labeled as‘‘pure obsessionals,’’because of the lack
sions of sexual aggression toward his son (O’Neil, Cather, Fishel, of observable physical or behavioral rituals (e.g., Baer, 1994).
& Kafka, 2005), aswell asa review articleabout repugnant obses- While no studies have yet been conducted to determine exactly
sions in general that referenced this case in a cursory discussion of which types of compulsions are most common among P-OCD
P-OCD (Moulding, Aardema, & O’Connor, 2014). Therefore, no sufferers specifically, recent research has indicated mental com-
work has yet been published with P-OCD as its dedicated focus, pulsions or rituals to be very common among individuals with
with specific recommendations about the use of existing mea- unacceptable thoughts in general, consistent with clinical obser-
sures and methods to assess for such symptoms, details on how vations (Williams et al., 2011, 2013). Drawing from available
todifferentiateP-OCDfrom pedophilicdisorderinthediagnostic literature and our clinical experience, we describe a few types
process, as well as content examples for clinicians to incorporate ofcovertandovertcompulsionsthat havebeenobservedinclients
intoappropriatelytailoredexposuretherapyforclientswithP-OCD. with P-OCD.
We address these gaps here.
The examples and recommendations contained within this Mental Compulsions
manuscript are intended to demystify this often misunderstood
OCD subtype for clinicians and researchers. Psychiatrists, social Covert, mental compulsions in P-OCD often include excessive
workers, psychologists, sex therapists, and many others working mental review of one’s interactions with children (Moulding
with those who report unusual and inappropriate images and/or et al., 2014). The mental review process may involve mentally
thoughts involving children will benefit from learning to dif- replaying past scenarios or situations in which children were

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present, in order to check for any sexually inappropriate thoughts mentally repeating his‘‘safe word’’provided distraction and some-
or actions during one’s interactions with oraround children. Clients what reduced his anxiety. The client also reported inserting‘‘safe
with P-OCD who engage in mental review may ask themselves images’’ into his mind whenever intrusive sexual mental images
questions such as,‘‘When I was talking to that little boy, did I abouthisdaughterarose.Specifically,hewouldimmediatelythink
think about or look at his genitals?’’or‘‘When I was changing of and hold an appropriate, non-sexual image of his daughter in his
my daughter’s diaper, did I look or touch her vagina longer than mind to try to cancel or block out the disturbing one. For example,
necessary?’’ Mental review of interactions with children can ifanintrusivesexualimageofhisdaughtercametomind,hewould
haunt clients with P-OCD as they attempt, albeit unsuccessfully, attempt to replace that with a‘‘safe image’’of his daughter sitting in
to ascertain whether or not they have violated the children a chair smiling. He would also sometimes try to replace any intru-
sexually. Although it seems reasonable that repeated checking sive sexual image of his daughter with an image of his wife’s face.
will facilitate more confidence in one’s convictions, research According to the client, these‘‘safe images’’allowed him to defuse
shows that repeated checking tends to reduce the clarity of, and his obsessions and move forward with whatever task was inter-
hence confidence in, one’s memory for any particular event, both rupted by the disturbing obsessions. In these examples, the act of
in people with and without OCD (Hout & Kindt, 2004; Radom- intentionally replacing a negative thought or image with some-
sky & Alcolado, 2010; Radomsky et al., 2006). In some cases, thing good or positive perhaps serves the function of mentally
the backfiring effects of mental reviewing a perceived pedophilic ‘‘undoing’’ the anxiety-provoking obsessions, in order to pre-
eventcanevenbethetriggerthatbringsP-OCDsymptomstotheir vent their contents from becoming reality (see Starcevic et al.,
peak. P-OCD sufferers who engage in mental review can spend a 2011). However, similartothebackfiring effects ofmental review,
lot of time that could otherwise be devoted to other daily activities these mental compulsions ironically strengthen the pedophilia-
tryingtoconvincethemselvesthat theydidnot commitpedophilic themedobsessions,becauseoftheexcessiveattentionandinflated
acts. Unfortunately, time wasted in mental review paradoxically personal significance attached to them and negative reinforce-
increases anxiety in the long run and strengthens clients’ P-OCD ment experienced in the moment.
symptoms, due to the exaggeratedsignificance that they, by virtue
of their mental compulsions, attach to their pedophilia-themed Somatic Checking
worries.
Rumination, whether focused on the probable causes, situa- Somatic checking in OCD refers to checking one’s body for
tional factors related to, or legal and social implications of their sensations, often in response to OCD-related stimuli or triggers.
self-perceived pedophilic behaviors, also occurs in clients with Clients who suffer from other forms of OCD may also engage in
P-OCD. Because rumination elicits strong emotional reactivity somatic checking (e.g., in sexual orientation-themed OCD or
to theirpedophilia-centric thoughts, clientswith P-OCD are likely SO-OCD; Williams, Slimowicz, Tellawi, & Wetterneck, 2014b;
to constantly question themselves about whether or not they are Williams, Tellawi, Davis, & Slimowicz, 2015). However, clients
actually pedophiles (e.g., O’Neil et al., 2005). Rumination in with P-OCD may specifically check their body for signs of sexual
P-OCD, in this sense, appears to be linked to the use of mental arousal or attraction to children. In the somatic checking process,
review in an attempt to achieve some form of resolution of this any physical sensation or movement experienced in the genital
uncertainty, or some semblance of confirmation that no sexually region in the presence of children and/or during pedophilia-
inappropriate or perverse actions occurred in interactions with themed obsessions may be misinterpreted as a sign of sexual
children. These mental compulsions alleviate anxiety only tem- arousal or attraction. For example, a father with P-OCD may
porarily; when doubt about self-perceived pedophilic tendencies be overly cautious while changing his child’s diaper, because
reenters themind, the self-reinforcing cascade of mental compul- of the fear that he may be sexually aroused by this otherwise
sions restarts. innocuous act. During diaper changes, he may be hypersensi-
Othermentalcompulsionsmayinvolverepeatingcertainwords, tive and excessively focused on sensations in his genital region.
phrases, or visual images multiple times, in an effort to soothe This exaggerated attention to his genital region can in turn—
or distract oneself from triggering situations and events (Sibrava, and expectedly so—result in vague genital sensations, there-
Boisseau, Mancebo, Eisen, & Rasmussen, 2011). For example, foreproviding (erroneous)‘‘evidence’’ofhisworst fear.In another
one male client in our clinic had suffered from pedophilia-themed example, allowing a child to sit on a P-OCD client’s lap would be
obsessions involving his daughter and would repeat the word highly anxiety-provoking, because of the close proximity between
‘‘Facebook’’in his mind several times, whenever he experienced the client’s genitals and the child’s body. The principal fear here
upsetting, pedophilia-themed intrusions and related triggers. is that sexual pleasure would be derived from this close contact,
He referred to the word‘‘Facebook’’as his‘‘safe word’’as it was in addition to the possible perception that serious sexual harm
associated with positive family-related feelings that seemed to would be inflicted on the child as a result of what the client views
counter his disturbing obsessions about his daughter. To him, as inappropriate physical contact.

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Reassurance-Seeking the perceived danger of pedophilia-themed obsessions, as well

as the need to control or neutralize them.
Due to the taboo nature ofunacceptable thoughts, such as obses-
sions about sexual harm toward children in P-OCD, clients often
seek reassurance in various forms to try to reduce the anxiety Assessment of P-OCD Symptoms
elicited by the intrusive thoughts (Calvocoressi et al., 1995; Wil-
liams et al., 2011). Reassurance-seeking can take many forms, Assessment Using Clinical Measures
including constantly reassuring the self, persistently seeking reas-
surancefrom others, confessing to others, or compulsively search- Many clients enter treatment presenting with OCD symptoms
ing the Internet and/or scrutinizing relevant reading materials for in the othermoreextensivelyresearchedsymptom dimensions,so
explanationsforone’sobsessions(Williamsetal.,2011).InP-OCD, it is likely that commonly used measures will be able to adequa-
for example, clients will often compulsively ask parents, other tely detect and assess these symptoms. However, it can be dif-
family members, spouses/partners/significant others, and close ficult to assess for P-OCD symptoms as there are few measures
friends about whether or not they have committed a sexually inap- that adequately screen for or measure sexual obsessions or other
propriate act toward a child who may have been in close prox- types of taboo and repugnant obsessions. Nonetheless, there are
imity at a recent event. Typically, clients with P-OCD will con- a few viable options.
tinue to seek reassurance about the absence of sexual harm toward The Yale–Brown Obsessive–Compulsive Disorder Scale—
a child in an event that occurred several months or even years ago. Second Edition (Y-BOCS-II; Storch et al., 2010) is a gold stan-
While clients perceive obtaining reassurance as morally neces- dard measure of past and current (i.e., within the past 30 days)
sary, it causes much family stress because of the strain put on OCD symptoms and their severity among clients diagnosed
loved ones who become targets for reassurance (Calvocoressi with OCD, having demonstrated good psychometric proper-
et al., 1995). ties in terms of reliability and validity in the original validation
study with a sample of130 OCD patients. In theSymptom Check-
list component of the Y-BOCS-II that is divided into items assess-
Avoidance ingobsessions,compulsions,and avoidance, therearea few items
that attempt to capture P-OCD concerns. For example, Items 18
In order to prevent the manifestation of self-perceived pedophilic and 19 (‘‘forbidden or improper sexual thoughts or images’’and
tendencies, clients with P-OCD may avoid children at all costs. ‘‘experiences unwanted sexual impulses’’) assess for pedophil-
Avoidance of triggering objects and other related stimuli (e.g., ia-themedobsessionsexplicitly,whileItems9and10(‘‘fearmight
baby strollers, maternity magazines, children’s cartoons, tele- harm self or others because not careful enough’’and‘‘fear might
vision shows and movies with child actors or about child mole- harm self or others on impulse’’) may uncover obsessions about
station, news articles about convicted pedophiles) is also very feared, unintentional sexual violation of children, if accompa-
common among clients with P-OCD. Additionally, there are a nied by appropriate probing and requests for elaboration. Items
variety of other scenarios or situations that sufferers may avoid assessing compulsions seem to tap into the mental compulsions
to prevent distress. Some of these include being alone with chil- and reassurance-seeking commonly observed in clients with
dren (even children they are related to or directly responsible for), P-OCD(e.g.,Items44and55:‘‘askingforreassurance’’and‘‘men-
and actually touching or looking at children. However, engaging tal rituals [other than checking or counting]’’). There are also
inavoidancebehaviorsthatclientswithP-OCDerroneouslybelieve items applicable to avoidance behaviors seen in P-OCD (e.g.,
will protect children from the sexual abuse they fear they may Items 59 and 62: ‘‘avoids doing things, going places or being
perpetrate will only serve to maintain the disorder. This is, again, with someone because of obsessions’’and‘‘avoids contact with
due to the inordinate personal significance associated with such people, children or animals because of unwanted impulses’’). If
fearsthatparadoxicallystrengthenstheseobsessionsandtherelief clientsendorseP-OCDsymptomsthroughthese items,theimpact
experienced upon fleeing the feared situation. Steering clear of of such symptoms on clients’ functioning can then be assessed
children only increases dysfunction in P-OCD. For example, a using the ten-item Severity Scale component of the Y-BOCS-
mother with P-OCD may avoid seeing her child naked for exten- II. Total scores range from 0 to 50, with higher numbers indicat-
dedperiodsoftime.Shemayhavetosufferthroughdiaperchanges ing greater severity.
and bath time and may rush through these activities to avoid look- Another option is the Obsessive–Compulsive Inventory—
ing at parts of her child’s body (e.g., genitalia) that she fears might Revised (OCI-R; Foa et al., 2002). The OCI-R is an 18-item,
causeherto become very anxious. Shemay also shirk herduties to self-report instrument that assesses the degree of distress asso-
bringherchildtoschool,recitals,orsoccergameswhereotherchil- ciated with washing, obsessing, hoarding, ordering, checking,
drenarealsopresent, possiblyleadingto spousal discord.Although and neutralizing symptoms in the past month on a five-point
avoidance is not necessarily considered a compulsion, it does, as Likert scale, with higher scores indicating greater OCD symp-
mentioned, serve the same maladaptive function of reinforcing tom severity. The OCI-R has demonstrated sound psycho-

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metric properties and appears to be useful for assessing OCD problematic thoughts and the need to disclose them. Clients may
symptoms in clinical samples (e.g., Huppert et al., 2007). Unfor- have already suffered negative experiences with previous treat-
tunately, the OCI-R does not contain any items that specifically ment providers after disclosing their P-OCD concerns. Because
and explicitly assess for P-OCD concerns. It does, however, of this possibility, greater sensitivity and well-informed clinical
contain two thematically broad items (i.e., Items 12 and 18: judgment must be exercised when assessing for P-OCD in a
‘‘I am upset by unpleasant thoughts that come into my mind (semi-)structured interview. Being cognizant of the element of
against my will’’and‘‘I frequently get nasty thoughts and have ego-dystonicity in such thoughts, as well as the particular men-
difficulty in getting rid of them’’) which P-OCD sufferers may tal and/or behavioral compulsions that can occur in P-OCD, can
endorse. Clinicians should then encourage clients to elaborate help in this process. There are a few comprehensive (semi-)struc-
on what these endorsements refer to, in order to ascertain the turedinterviewinstrumentsavailabletoassessforP-OCDtovary-
presence of P-OCD concerns. ing extents.
Lastly, the psychometrically sound, 20-item Dimensional The mini-international neuropsychiatric interview (M.I.N.I.;
Obsessive–CompulsiveScale(DOCS; Abramowitz et al., 2010) Sheehan et al., 1998), now in its seventh edition in English, is a
assesses OCD symptom severity on the basis of four symptom brief, fully structured diagnostic interview currently validated
dimensionspertainingtocontamination-related concerns, respon- against criteria for major psychiatric disorders contained in the
sibility for harm, unacceptable thoughts in general, and concerns fourth edition of the Diagnostic and Statistical Manual of Men-
about symmetry/completeness. For each symptom dimension, a tal Disorders (DSM-IV; APA, 1994) and the tenth revision of
brief description and examples of related obsessions and com- the International Statistical Classification of Diseases and Related
pulsions are included for respondents to read before responding. Health Problems (ICD-10; World Health Organization [WHO],
Thereafter, individuals rate their severityon five five-point-scale 2010). It takes approximately 15–20 min to administer and con-
items assessing: (1) the amount of time spent on obsessions and tains a module to screen for OCD symptoms. However, this mod-
compulsions; (2) extent of avoidance of triggers; (3) degree of ule is more likely to capture more well-known presentations, like
distress from symptoms; (4) level of functional interference; and contamination-related concerns. For example, while the section
(5) difficulty disregarding obsessions and refraining from acting on obsessions does include some verbiage that may signal intru-
oncompulsions.Therefore,intermsofassessingP-OCDconcerns, sive, ego-dystonic sexual thoughts (and, in fact, comes with a
the Unacceptable Thoughts subscale of the DOCS appears to prompt for the interviewer to exclude excessive worries about the
fare better than the two items on the OCI-R due to its more elab- negative consequences of genuine sexual deviations that clients
orated emphasis on unacceptable thoughts. In fact, there is even otherwise find pleasure in), the section of the module devoted to
a more specific version of this subscale that targets sexual obses- compulsions does not adequately capture mental compulsions
sions. Wetterneck, Siev, Adams, Slimowicz, and Smith (2015) typically observed among unacceptable/taboo forms of OCD.
adapted the contents of the Unacceptable Thoughts subscale of Instead, the M.I.N.I. mostly targets physical compulsions (e.g.,
the DOCS in developing the 5-item Sexually Intrusive Thoughts direct queries about whether or not clients repeatedly wash their
Scale (SIT), in order to target overall severity of a wide range of hands or otherwise clean excessively), which tend to be more
sexual obsessions (e.g., obsessions about rape and other forms frequently seen in more widely known forms of OCD. Therefore,
of sexual violence toward others, SO-OCD concerns, P-OCD although time-efficient, the M.I.N.I. may not be optimal for
concerns). This new scale has exhibited good psychometric pro- uncovering the full range of P-OCD symptoms in any partic-
perties and appears to be distinct from the Unacceptable Thoughts ular client.
subscale of the DOCS. If the DOCS and SIT appeal to clinicians, A widely used semi-structured diagnostic interview used
we recommend that clinicians first use the DOCS to assess OCD to assess for OCD is the Structured Clinical Interview (SCID),
symptoms comprehensively. If P-OCD concerns surface upon now in its latest research (SCID-5-RV; First, Williams, Karg,
review of clients’ responses, we recommend clinicians to then & Spitzer, 2015a) and clinician versions (SCID-5-CV; First,
use the SIT to more accurately assess P-OCD symptom severity, Williams, Karg, & Spitzer, 2015b), which were developed in
to avoid conflation with violent and blasphemous obsessions that accordance with criteria for major psychiatric disorders estab-
are also targeted by the Unacceptable Thoughts subscale of the lished in the fifth edition of the DSM (DSM-5; APA, 2013).
DOCS. That being said, to date there has been no research to Interviewers need to be adequately trained in its administration
determine which measures are most effective in identifying due to its length and complexity. After assessing for the presence
P-OCD. of obsessions and/or compulsions, the SCID’s module for OCD
approaches diagnosis in general terms. Specifically, there are
Assessment Using a (Semi-)Structured Interview questionsaboutwhetherclientsengageinobsessivethoughtsmore
than they think is normal and/or whether they act on compul-
Participating in the assessment process can be especially chal- sions more than they think they should. These questions seek to
lenging for clients experiencing pedophilia-themed obsessions, assess clients’ level of insight into whether the time spent on
primarily due to the disturbing and stigmatized contents of their obsessions and compulsions is excessive. The OCD module

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then requires clients to quantify the level of impairment they be encouraging and non-judgmental in their requests for clarifi-
experience by asking how often other life tasks are interrupted cation or elaboration of these topics. For example, it may be help-
by their OCD symptoms, as well as how much anxiety is expe- ful for clinicians to normalize the presence of unacceptable
rienced during an obsessive–compulsive episode. However, the thoughtsby explaining that all peopleexperience unpleasant and
adequacy of the SCID in detecting P-OCD remains question- distasteful thoughts on occasion. If the client has difficulty ver-
able, mainly because it does not inquire specifically about sex- balizing their obsessions, it may be helpful for the clinician to
ualobsessionspertainingtopedophilia-themedconcerns.Assuch, begin describing some common obsessions that have been dis-
P-OCDsymptomsmaybemissedentirelyinthediagnosticprocess. closed by other clients with P-OCD. For example, the clinician
Another semi-structured diagnostic interview that can be may say,‘‘Some people with unacceptable/taboo forms of OCD
usedtoassessforOCD istheAnxietyandRelatedDisordersInter- may experience upsetting thoughts about children or may see
view Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014). themselves in inappropriate situations with children.’’It is impor-
Again, due to its length and complexity, interviewers need to be tant to ensure that the client understands the clinician’s descrip-
adequately trained in the administration of the ADIS-5. Similar tion is meant to be broad and general, and not one that neces-
to the SCID, in the ADIS-5’s module for OCD, there are ques- sarily represents their specific obsessions. Developing good rap-
tionsthatassessclients’symptomseverity,levelofinsight,amount port with clients throughout the assessment can also facili-
of resistance against obsessions and compulsive urges, and the tate more forthcoming disclosure.
extent of avoidance of triggering stimuli and situations. How- Once clients feel confident and safe enough to open up about
ever, the ADIS-5 does a better job than the SCID in assessing their obsessions involving pedophilic themes, they may some-
fordifferentmanifestationsofOCD.Specifically,theOCDmodule times begin with a thorough backstory detailing the plausible
in the ADIS-5 provides a more comprehensive range of obses- events that may have triggered these thoughts. Throughout this
sions and compulsions for clients to endorse by listing different narrative, clinicians may repeatedly hear clients state adamantly
OCDsymptomdimensions.Althoughitdoesnotspecificallymen- that they never had these issues in the past when in the presence
tion P-OCD symptoms, a client with pedophilia-themed obses- of children. Clients may also ask repeatedly for reassurance from
sions and compulsions may still likely relate to the sections con- clinicians (e.g.,‘‘Do you think I am a pedophile?’’). It is highly
cerned with‘‘unwanted sexual thoughts/images’’and/or‘‘aggres- likely that although the numerous times clients are or have been
sive urges.’’Additionally, the section designed to capture com- reassured that they are not in fact pedophiles, both in and out-
pulsions mentions‘‘internal repetition,’’which may account for side of a clinical setting, they will continue to doubt this infor-
covert rituals like mental compulsions.Therefore, to maximize mation. Clients may also express feeling as though they did not
its potential for assessing many important symptom manifes- give enough information to help clinicians really determine whe-
tations in a client with P-OCD, interviewers using the ADIS-5 ther they are actually pedophiles. Getting a detailed history of
will be well served by being informed about the different symp- treatment(s) they may have received in the past is useful, as many
toms, particularly mental compulsions, as well as compulsive clients may have sought treatment (or at least a diagnostic assess-
somatic checking and reassurance-seeking, that are prototyp- ment) from several other providers as a form of compulsive reas-
ical of P-OCD. One drawback, however, is that the format of surance-seeking, despite the initial discomfort in disclosure.
the ADIS-5 can be cumbersome for the interviewer. It is important to note that clients with P-OCD feel distress
specifically because of the fear that they are horrible people who
Assessment Using a Clinical Interview are sexually attracted to children, and/or that they are likely to
commit sexual harm toward children, even though they are extre-
An unstructured clinical interview is often the best clue for clin- mely disinclined to do so. They have not actually committed
icians that a client is presenting with P-OCD. Nonetheless, many pedophilic crimes and are highly disturbed by intrusive pedo-
clients with P-OCD who seek treatment are reticent to disclose philia-themed thoughts and images. Importantly, they do not
the taboo thoughts they have been having out of shame or fear of experience any pleasure when these thoughts and images per-
legal or social punishment that they believe will accompany this sist. Instead of approaching children, they may go to great lengths
disclosure (Cathey & Wetterneck, 2013; Newth & Rachman, to avoid contact with children. Sometimes, these fears go much
2001). In most cases, clients have already done copious amounts further than that of being sexually attracted to children. Many
of online research to determine the root cause for the manifes- clients go on to worry that they will be deserted by their loved
tation of intrusive pedophilia-themed thoughts. Despite having ones and be imprisoned indefinitely. Some others may decide
recognized their symptoms as constituting OCD, many clients that they will never have children and that they should never be
still resist the idea that they are suffering from a mental disorder. around children due to their worries about sexually harming chil-
Instead, they may feel they should be blamed and punished for dren unknowingly. It is unfortunate that many clients prematurely
having such thoughts. Therefore, whenever clients broach topics make very definite decisions about their lives because of these
with pedophilic themes in relation to their presenting issues, clin- fears. Therefore, a differential diagnosis from pedophilic disorder
icians should be sensitively attuned to their hesitation (if any) and is crucial in the assessment process, not only to aid in proper

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treatment, but also to destigmatize these thoughts and their form of OCD, in order to accurately obtain a differential diagnosis
effects on important life decisions for clients with P-OCD. from pedophilic disorder.
There are significant distinctions in presentation between a
Differential Diagnosis genuine pedophile and one who suffers from P-OCD (Purdon,
2004), as shown in Table 1. The term‘‘pedophile’’refers to an
Despite the availability of certain assessment tools and meth- individual who suffers from pedophilic disorder, in which there
ods to detect P-OCD to varying extents, the disorder is frequently isastrong,dysfunctional sexual attractiontochildren,whichmay
misdiagnosed. For example, a recent study assessed clinicians’ include child molestation. When individuals with pedophilic dis-
ability to correctly identify common symptom presentations of order come in contact with children, they are likely to experience
OCD (Glazier et al., 2013). All participants were members of sexual arousal toward them. Any fear or anxiety about this sexual
the American Psychological Association and were randomly attractionislikelyattributabletosociety’scriminalizationofthose
recruited across the 50 states. Of the participants, 81.8% were who prey on children sexually, rather than the awareness of their
doctoral-level psychologists, 81.3% were licensed, and over half desire to become intimately close to children. Additionally, indi-
reported a CBT orientation. Each participant was instructed to viduals with pedophilic disorder tend to prefer the company of
provideadiagnosticimpressionofoneoutoffiverandomlyassigned children, instead of age-appropriate companions. Furthermore,
OCD symptom vignettes. Results indicated that 42.9% misiden- individualswith pedophilicdisorder arelikelytoengage in groom-
tified sexual obsessions about children, with over a third wrongly ing behaviors toward a child by finding opportunities to gain their
classifying the problem as pedophilia. In contrast, only 15.8 and trust. For example, they may feign interest in activities that the
28.8% misidentified contamination-based and religious obses- child enjoys, and may slowly get the child more comfortable with
sionsasbeingindicativeofOCD,respectively.Primarycarephysi- inappropriate touching by creating opportunities to play-fight or
cians fared even worse, with 70.8% misdiagnosing P-OCD (Gla- wrestlewiththechild.Theymayalsoseekopportunitiestobealone
zier,Swing,&McGinn,2015).Thisdisproportionatelyhighdegree with their victims, leading to more intimate, inappropriate touch-
of misidentification of P-OCD symptoms, even among trained ing. Individuals with pedophilic disorder experience sexual grati-
professionals, calls into question the likelihood that people with fication from child grooming interactions (Lang & Frenzel, 1988).
P-OCD will obtain a proper diagnosis and appropriate treatment. In sharp contrast, clients with P-OCD do not find the con-
In another unfortunate example from our clinic, a male client tents of their obsessions pleasant or sexually arousing. Instead,
experiencing severe pedophilia-themed obsessions about his clients experiencing obsessions about sexual contact with chil-
daughter described in the intake session how he became so over- dren are repulsed by these sexually explicit thoughts and gra-
whelmed with the intrusive thoughts and images that his wife phic images. Additionally, clients with P-OCD are generally
escorted him to the emergency room. After the client described avoidant of children. They may take extreme measures to avoid
his obsessions, the psychiatric staff, being unaware of the dis- contact with even their own children. They may even isolate them-
tinctions between P-OCD and pedophilic disorder, reported him selves away from others, in order to decrease the perceived like-
to Child Protective Services, which resulted in restrictions on his lihood that they may sexually violate or molest a child. Notably,
contact with his daughter. Naturally, these events were traumatic as observed in our clinic, many clients with P-OCD state that they
for the client and his family. Had the psychiatric staff at the hos- would rather commit suicide than hurt a child. Despite these stark
pital been knowledgeable about P-OCD and its distinctions from differences, many uninformed treatment providers misdiagnose
pedophilic disorder, this client could have avoided these unnec- P-OCD clients’ symptoms as pedophilic disorder and proceed to
essary consequences. It is highly possible that many clients face subject these clients to legal entanglements, which only exacer-
ridicule and scrutiny when trying to find help, due to the appar- batetheirsymptomsandconfirm theirworstfears.Clinicianswho
entpovertyofknowledgeaboutP-OCDinclinical practice.There- are unsure as to whether a client is experiencing P-OCD should
fore, the onus is on clinicians to be aware of the presentation of this ask the client to describe their interaction with children. For

Table 1 Differential diagnosis: P-OCD versus Pedophilic Disorder

Pedophilic disorder P-OCD

Sexual attraction to children Fear of sexual attraction toward children

Prefers the company of children and desires to be intimately close with them Avoids or minimizes contact with children or reminders
Performs grooming behaviors toward children for sexual contact due to feared thoughts
Experiences sexual gratification from sexual contact with children Experiences extreme distress and possible suicidality
with feared thoughts or reminders

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example, one may ask,‘‘Tell me about the last time you had a Abramowitz, Whiteside, & Deacon, 2005; Rosa-Alcázar, Sán-
conversation with a child’’or‘‘How often do you spend time with chez-Meca, Gómez-Conesa, Marı́n-Martı́nez, 2008; Williams,
children?’’It may also be helpful to assess their reactions to inter- Powers, & Foa, 2012). As a form of CBT, Ex/RP consists of
actionswithchildrenbyasking,‘‘Whatisitlikeforyoutobearound specific interventions targeting the affective, behavioral, and cog-
children?’’In our clinic, clients with P-OCD rarely experience nitivebasesofOCDsymptoms,includingpsychoeducation,invivo
positive reactions when in close proximity to a child and will and/or imaginal exposures, and response prevention (Foa et al.,
often describe unpleasant emotional and physiological symp- 2012). At the core of Ex/RP is the process of confronting OCD-
toms as a result. relatedtriggersthattypicallyinducedistress(i.e.,exposure),while
DSM-5 criteria allow the diagnosis of pedophilic disorder refraining from acting on compulsive urges to ritualize that usu-
in individuals who have not aggressed against children if their ally function to reduce that distress (i.e., response prevention).
sexual urges are intense or distressing (APA, 2013). Indeed, there In doing so, over time, the self-reinforcing cycle of obsessions
are some with a pedophilic sexual orientation who chose not to and compulsions will be broken. Traditionally, the way that Ex/
act on these urges. Such individuals may be distressed about their RP is thought to work in treating OCD is through repeated ses-
attraction to children due to their own personal morals or religious sions in which clients gradually habituate to the distress evoked
beliefs, and in such cases it could be said that the pedophilic urges by exposure to OCD-related stimuli without acting upon their
are ego-dystonic. It can be difficult to differentiate between ego- triggeredcompulsions,resultingintheeventualextinctionofobses-
dystonicpedophiliaandP-OCD.Thelevelofsexualarousalcaused sional distress and associated urges to ritualize (Abramowitz,
by children is a key distinguishing feature between pedophilic Deacon, & Whiteside, 2011; Foa et al., 2012; Huppert & Roth,
disorder and P-OCD. To determine this, clinicians may ask ques- 2003). However, other mechanisms have been proposed, includ-
tions like, ‘‘Do your sexual fantasies include young children?’’, ing inhibitory learning and cognitive flexibility (Craske, Treanor,
‘‘Are you more sexually aroused by images of children or images Conway, Zbozinek, & Vervliet, 2014; Twohig, Whittal, Cox, &
of adults?’’, and‘‘Do you ever masturbate to thoughts or images of Gunter, 2010). Whilethere areadequate cognitive treatments for
children?’’ The use of child pornography is a strong diagnostic OCD, our article will specifically focus on the use of Ex/RP to
indicator of pedophilic disorder (APA, 2013). This line of ques- decrease OCD symptoms.
tioning, however, will be alarming to people with P-OCD, who While Ex/RP has been found to beeffective for treating OCD
may then become concerned that the clinician may perceive them in general, clients with P-OCD may require more treatment ses-
to be sexually deviant. sions than other forms of OCD, due to the guilt, shame, and moral
One might wonder if phallometric assessment, or plethys- repugnance associated with having obsessions of this nature. In
mography, could assist with differential diagnosis. One issue with fact, studies have found that clients with sexual obsessions are
this approach is that those with P-OCD will often become sex- more treatment-resistant than those with other forms of OCD.
ually aroused by‘‘forbidden’’images simply because of height- For example, Williams et al. (2014a) found that although clients
ened anxiety. Indeed, many with P-OCD complain of physical improved substantially,thosewithunacceptablethoughtsimproved
sensations they refer to as a‘‘groinal response,’’and experience less when treated with Ex/RP, compared to other OCD symp-
embarrassment and fears about what it could mean. Physiolog- tom dimensions. Additionally, a long-term follow-up study of
ical reactions can include increased heart rate, sweating, and some OCDclientstreatedwithmedicationandbehaviortherapyshowed
degreeoftumescenceorlubrication,whichthesuffererthenmisin- that sexual and religious obsessions were uniquely predictive of
terprets as an indication of desire or intent. For this reason, it is poorer treatment outcomes over time (Alonso et al., 2001). One
possible that the very process of phallometric assessment may reason unacceptable/taboo forms of OCD is more difficult to treat
cause overwhelming anxiety and distress in such clients. Most may be due to the high levels of distress these clients experience,
phallometric research has been focused on identifying risk in sex makingitdifficultforclientstobecomefullycompliantduringthe
offenders (McPhail et al., 2017), so at the present time there is no treatment process. Additionally, the mental compulsions and reas-
research to support the use of such techniques for identifying surance-seeking behaviors that predominate in clients with unac-
anxiety-related conditions. However, differences in plethysmo- ceptable/taboo forms of OCD are often missed by mental health
graphic findings between people with pedophilic disorder and professionals (Williams et al., 2011). The following sections will
P-OCD is an interesting area of inquiry that warrants further discusstheprimarycomponentsofEx/RPandhowitcanbeapplied
research. to P-OCD, with the aforementioned considerations in mind.

Psychoeducation
Treatment with Exposure and Response Prevention
Providing clients with psychoeducation prior to implementing
Exposure and response prevention (Ex/RP) has been supported Ex/RP is vital. Psychoeducation can first involve normalizing
as an effective, evidence-based treatment program for OCD in clients’ P-OCD symptoms by educating them on the prevalence
adults and children (Abramowitz, Taylor, & McKay, 2009; of unwanted sexual thoughts, that such thoughts are a common

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occurrence in the general population (Rachman & de Silva, 1978), Clients can be educated on how, for example, mental compul-
and that they should not be afraid of discussing them openly in sions, which often provide initial relief from the distress caused
therapy. Communicating that the mere existence of such thoughts by pedophilia-themed obsessions, unfortunately backfire in the
is not an indication of sexual deviance can often be the first step in long term by reinforcing the OCD cycle, making the recurrence
decreasing clients’ distress. of such obsessions more likely, consequently increasing levels
It is also helpful for clients with P-OCD to understand that of functional impairment. Clients can also be made aware that
they experience such great distress because they may tend to catas- Ex/RP seeks to disrupt this relationship between obsessions and
trophicallymisinterpretunwanted pedophilia-themedthoughts as compulsions, to bring about symptom improvement.
particularly dangerous and/or revelatory of their‘‘true nature’’ Lastly, psychoeducation informs clients about the process of
(Rachman,1997,1998;Salkovskis,1985,1999;Wetterneck,Smith, Ex/RP and explains the rationale for employing this treatment.
Hart, & Burgess, 2011). This discussion can be linked to elabora- A detailed rationale is imperative prior to implementing Ex/RP,
tion of the cognitive processes that may contribute to P-OCD. because many clients are disinclined to participate due to the aver-
For example, thought–action fusion (TAF) refers to a set of irra- sive nature of exposures. Helping clients understand the reasons
tional beliefs that having certain thoughts will make one more for and evidence behind Ex/RP plays a key role in preparing them
likelytocommitactsinaccordancewiththethoughts,orthatsuch for the treatment and increasing compliance throughout the course
actshavealreadybeencommittedsimplybyhavingsuchthoughts of Ex/RP (Piacentini et al., 2011). For example, clients can be
(Shafran, Thordarson, & Rachman, 1996). Clients with P-OCD informed that the response prevention component of Ex/RP seeks
whostronglyendorseTAFbeliefswillmisinterprettheirpedophil- to alter their behavioral and affective responses to triggering stim-
ia-themed thoughts as indicative of a desire to sexually harm uli and distressing obsessions in order to weaken the OCD cycle,
children, an increased likelihood of actually committing such which will also bring about a change in cognitive processes rela-
acts, or even the erroneous conclusion that they must have already ted to the maintenance of their P-OCD symptoms. Furthermore,
sexually harmed children in the past. Such beliefs are subsumed clientsshould be informed ofall specificaspectsofEx/RP,such as
underthebroadercognitivedomainofoverimportanceofthoughts the use of a subjective units of distress scale (SUDS) to quantify
(Obsessive Compulsive Cognitions Working Group, 2005), which and track changes in theintensity of anxiety experienced through-
has been shown to have some specificity to unacceptable obses- out the treatment process (Wolpe, 1969).
sions (Wheaton, Abramowitz, Berman, Riemann, & Hale, 2010).
Specifically, clients with P-OCD who strongly endorse overim- In Vivo Exposures
portance of thoughts ascribe exaggerated personal significance to
their pedophilia-themed obsessions and, as a result, manage these In vivo exposures involve confronting actual stimuli or situations
obsessions maladaptively with compulsions. Similarly, clients that trigger OCD symptoms and should be tailored to address
with P-OCD can also engage in compulsions to address their the core obsessional fears of clients with P-OCD (e.g., being sex-
distressing obsessions when they overestimate the threat of their ually attracted to children, and/or that one is capable of sexually
pedophilia-themed thoughts forcommitting sexual harm toward harming a child accidentally or intentionally, resulting in criminal
children, or when they are unable to tolerate the uncertainty of prosecution or public censure). Prior to conducting in vivo expo-
whether or not they are actually pedophiles (Viar, Bilsky, Arm- sures,cliniciansandclientsshouldcollaboratetoidentifyandrank
strong, & Olatunji, 2011). Other maladaptive thought control obsessional triggers based on client-reported SUDS ratings. This
strategies can also maintain P-OCD. For instance, when clients allows for an in vivo exposure hierarchy to be created, starting
with P-OCD experience thoughts about inappropriately touch- fromtheleastdistressingtriggertothemostdistressingone.Table 2
ing children, they tend to try to suppress such thoughts (Weg- illustrates a sample hierarchy developed for a male P-OCD client
ner, Schneider, Carter, & White, 1987), and/or blame themselves whosecorefearrevolvedaroundsexuallyabusinghisinfantdaugh-
as self-punishment (Jacoby, Leonard, Riemann, & Abramowitz, ter. It is also helpful to identify compulsions (particularly mental
2016),whichparadoxicallyincreasesthefrequencyofsuchthoughts rituals) and avoidance behaviors for each trigger if possible, in
due to their increased personal significance and perceived danger. order to address these behaviors whenever they surface during
This is in sharp contrast to how individuals without OCD are able in vivo exposure.
to easily dismiss unwanted thoughts without resorting to such Initial in vivo exposures should occur in-session with clini-
strategies. Therefore, providing psychoeducation on the dysfunc- cians guiding clients through the exposure. Clinicians should start
tional cognitive processes relevant to P-OCD can decrease clients’ with a moderate-SUDS trigger on the hierarchy, before confron-
misevaluation oftheirthoughts andtheir meaningand importance, ting more distressing triggers (Barlow, 2014). For example, clin-
helpingthemviewtheirunwantedthoughtsinamorerealisticman- icians can begin treatment with a hierarchy item rated at a SUDS
ner(seeWhittal,Woody,McLean,Rachman,&Robichaud,2010). level of 45, such as having clients write‘‘I am a pedophile’’repeat-
Furthermore, psychoeducation also includes discussion of edly on a sheet of paper. This allows for flexibility in moving
the functional relationship between obsession and compulsions, down the hierarchy should the initially chosen trigger be too
to provide further insight into how their symptoms are maintained. daunting for the client to start with. During the exposure, clin-

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Table 2 Sample in vivo exposure hierarchy promote learning, although early success is important because if
Exposures SUDS
anxiety becomes too high, clients may reject Ex/RP altogether.
After exposures are completed in the office, therapists should take
1. Eating food shaped like female genitalia (e.g., pizza, wedge of 35 some time to discuss the experience and what was learned from it.
cheese)
While many in vivo exposures take place within the therapy
2. Looking at a picture of children in bathing suits 40 office, some exposures may require visits to alternative settings.
3. Watching a movie containing brief sexual violence 50 For example, a client may identify‘‘being around children’’as a
4. Eating food that reminds client of male genitals (e.g., a 60 high-SUDS trigger. Therefore, to confront this trigger, the clin-
banana)
ician can accompany the client to a local park or playground
5. Changing daughter’s diaper while in presence of wife 60
where children are present. While this particular exposure may
6. Watching a music video with a little girl dancing (e.g.,‘‘Elastic 70
Heart’’by Sia)
be assigned as a homework activity, the clinician may need to
guide the client through this process initially if it proves to be
7. Holding daughter on lap 75
too anxiety-provoking for the client to complete alone.
8. Writing a story about becoming a pedophile 80
Flexibility and creativity in exposure setting selection and plan-
9. Watching a sexually explicit movie 80
ning are crucial to successful treatment. In addition, given the
10. Being alone with daughter 80
taboo nature of this form of OCD, it is very important that clin-
11. Watching movie/documentary/news video clip about 90
pedophiles icians are comfortable working with P-OCD clients in address-
12. Bathing with daughter 90 ing their symptoms. Specifically, clinicians need to be able to
13. Changing daughter’s diaper all alone 95
demonstrate exposures to certain taboo triggers (e.g., watching
video clips containing implied sexual abuse of children) with-
out appearing anxious or disgusted, in order to effectively model
icians should monitor clients for rituals and/or avoidance behav- how to participate in exposures to clients.
iors, such as joking about the task or not focusing directly on the
words they are writing because their attention is distracted by
the performance of mental compulsions (Gillihan, Williams, Imaginal Exposures
Malcoun, Yadin, & Foa, 2012). Clients should engage in expo-
sures for approximately 30–60 min, or until their SUDS levels Imaginal exposures are unique and effective interventions that
for the trigger have decreased to at least half of the peak level of allow clients with P-OCD to confront their obsessional fearsin a
anxiety.Longerexposuresallow moretimeforhabituation; more way that otherwise would not be possible or plausible in the con-
intensive or pervasive obsessions may require longer periods of text of an in vivo exposure (Freeston et al., 1997; Gillihan et al.,
time to achieve habituation (Foa & Kozak, 1986). Once clients 2012). Imaginal exposures are often based on a script created in
have habituated to lower- and moderate-SUDS triggers, clinicians collaboration between clinicians and clients detailing a story about
can then move clients up the hierarchy to more challenging and the worst possible outcomes for clients’ core obsessional fears
distressing exposures. (Foa et al., 2012). Importantly, the imaginal exposure script des-
As anxiety decreases to specific exposures and clients move cribes, in great detail, negative events that occur as a direct result
up their hierarchies, therapists should find ways to revisit expo- of having the obsessions and not engaging in compulsions. When
sures that were previously addressed and incorporate elements conductingimaginal exposures,clientsarerecommendedtoclose
of several different fears into exposure exercises. For example, their eyes and imagine the created scenario in as much visual detail
a client who previously habituated to eating foods that resem- as possible while being read to, or listening to a recording of, the
ble genitalia like bananas and pizza, may then revisit this expo- script. Clients should also be instructed to listen to the recording
sure by sharing these foods with a child within the context of shar- of the script daily as a homework activity. Table 3 displays a sam-
ing a snack with the child. Adding this extra component into the ple imaginal exposure script developed for the male client with
exposure increases the intensity by exposing the client to mul- P-OCD fears of sexually abusing his infant daughter described
tiplecontextswhich invokefearand anxiety. Theclient mayhave previously.
habituated to eating foods that resemblegenitalia and being alone
with a child when these exposures were done separately; how- Response Prevention
ever, merging them together presents a novel exposure for the
client to approach. Craske et al. (2014) refer to this strategy of An integral component that accompanies exposures in the pro-
combiningpreviously addressed exposures as deepened extinc- cess of Ex/RP for P-OCD is response prevention. Response pre-
tion in her inhibitory learning approach to enhancing exposure. vention, as the name suggests, refers to refraining from engaging
Also, it should be noted that it is not always necessary for clients in compulsions or rituals used to decrease anxiety resulting from
to habituate to a given stimulus to improve. Craske et al. recom- an obsessive cascade triggered during exposures. Response pre-
mend varying the difficulty of exposures randomly in order to vention in conjunction with exposure has been found to provide

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Table 3 Sample imaginal exposure script

‘‘I have been having the fear of harming my daughter for the last few months. Things got so bad that I came to treatment to help me get over my
worries. My therapist told me I had to stop avoiding my daughter because this only made my fears worse. The one fear that haunts me the most is
feeling attracted towards her private parts and losing control of myself during diaper changes. I was sure that exposing myself to my daughter’s
genitals would only make my fears come true and that I would inevitably hurt my daughter, but I went ahead and tried anyway. Eventually it got
easier and I thought I had gotten over the fear. I was able to touch her and wipe her diaper area without looking away and I had no problem with this
at all, but then one day I realized while I was doing this that I was becoming sexual aroused. I was shocked and couldn’t believe this was
happening. I thought that my therapy was supposed to keep this from happening but I realized that my therapist did not realize she was working
with a true pedophile. The anxiety has come back but I know that since I am getting aroused that this means I am sexually attracted to my daughter!
She is getting older and her vagina looks more womanly so it makes sense that I am attracted to her in this way. All of this feels very real but there is
nothing I can do about it. I know my wife will not be able to handle the news that I am attracted to my daughter, so I keep it a secret and I keep
changing her diapers and I keep getting sexually aroused by this. The last few times, I became so aroused that I was about to lose all control. I was
going to jump on her but fortunately my wife walked in and prevented the tragedy. My daughter will definitely be harmed by this but it is not my
fault I am a pedophile. Had I known maybe I would not have had children. None of this matters now though. I know that I must try to hold back
from jumping on my daughter but I know any moment it can happen. I will lose control of my body and mind and it will happen. I only hope my
wife does not find out. My daughter is too young to know that this is wrong. Had I not come to treatment, I probably will never have realized that I
am a pedophile, but now that I know I do not really have OCD, I have to accept that I am a pedophile who is on the verge of harming my daughter.
There is no turning back now. I actually like the feelings’’

superior effects in comparison with exposure alone (Foa, Steke- external environment and participating in activities that shift
tee, Grayson, Turner, & Latimer, 1984). attention away from obsessions and anxiety. For example, a client
As previously noted, reassurance-seeking is a compulsion may be instructed to spend some time focusing on their surround-
typically observed in P-OCD. For example, clients may expe- ings (e.g., mindfulness activities) or engage in a conversation with
rience the obsession,‘‘What if I am a pedophile?’’In an effort a family member or friend about something pleasurable. Active
to reassure themselves, they may think,‘‘No, I am sure I am not engagement in these tools aids in preventing the ruminative pro-
at all attracted to children and do not ever want to hurt them.’’ cess (mental compulsions) that strengthens the OCD. When used
Additionally, clients may seek direct reassurance from others, consistently clients may experience a decrease in intensity of their
as exemplified by their asking their clinicians, ‘‘How sure are obsessions and decreased pressure to perform compulsions.
you that I am not a pedophile?’’In relation to response preven- Psychoeducation plays a key role in helping clients become
tion for a P-OCD-related exposure, clients are instructed to refrain aware of when they are performing mental compulsions, how
from engaging in these types of reassurance-seeking. It is impor- these compulsions ultimately reinforce OCD symptoms, and how
tant for clinicians to anticipate and detect reassurance-seeking toappropriatelyengageinresponsepreventiontobringaboutsymp-
when it appears, and to assist the client in refraining from seek- tom improvement. Furthermore, it is helpful for clients to realize
ing reassurance. This can be done by explaining to clients the that by complying with response prevention instructions, they are
symptom-reinforcing effects of such compulsions, as well as alsoputtingthemaladaptivecognitiveprocesses(e.g.,overimpor-
reiterating the rationale for response prevention during Ex/RP. tance of and need to control thoughts) implicated in their OCD to
In similar fashion, clinicians can remind clients to refrain from the test. For example, by realizing that the anxiety accompanying
engaginginmentalrituals(e.g.,usingpositive,innocuousthoughts pedophilia-themedobsessionstriggered during exposure will nat-
to neutralize pedophilia-themed thoughts, or engaging in mental urallydecreaseorbebettertoleratedovertime,clientswillthereby
review of past events as a form of self-reassurance that they did learn not to catastrophize about their unwanted thoughts, and that
not commit pedophilic acts) during exposure. suchthoughtswillfadeawayevenwithoutcontrollingorsuppress-
Clinicians should provide guidance and support on how the ing them.
client should respondwhen theurge to do acompulsion becomes
difficult to resist. Clients are often instructed to‘‘lean into’’their Treatment Outcomes
anxiety bydisruptingthe cognitive ruminations with statements
that do not contradict the obsessions. For example, when clients Because there is little research addressing the effectiveness of
havetheobsession,‘‘WhatifIamapedophile?’’theymaybeinstruc- Ex/RP for P-OCD specifically, it is unclear what percentage of
ted to address that obsession by saying,‘‘I may be a pedophile’’ clients find Ex/RP a successful treatment approach at this time.
or‘‘I don’t know if I’m a pedophile.’’Such statements provide As stated earlier, clients with sexual obsessions may be consid-
the client with opportunities to practice tolerating the uncertainty ered more treatment-resistant and may improve less than those
that accompanies pedophile-themed obsessions. The use of these with other subtypes of OCD. However, from our experience
types of statements should be practiced during individual sessions working with this population, clients who engage in treatment
sothatclinicianscanmonitortheclients’levelofanxietyandensure fully (e.g., attend sessions regularly, commit to daily exposure
thattheyarebeingusedproperly,withoutcompulsions.Otherstrate- homework, and to response prevention) benefit greatly from
gies used to prevent the use of compulsions include focusing on the treatment and enjoy a return to a level of functioning similar to

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that prior to the onset of P-OCD symptoms. For 25 clients trea- sistent for all manifestations of OCD, current treatment man-
ted at our clinic with Ex/RP for primary P-OCD concerns, the uals tend to be written in more general terms without providing
mean Y-BOCS-II Severity Scale score dropped from 31.2 (SD = specific examples for the unique symptoms found in P-OCD.
8.2) to 13.6 (SD = 6.9). Clients had a median number of 35 visits Therefore, it is hoped that the clinicians can benefit from the
(including consultation, assessment, and treatment). Many of information provided in this article, in ensuring that clients with
these clients were also treated for comorbid conditions (such as P-OCD do receive an accurate assessment and correct diagno-
major depressive disorder) and few clients dropped out once sis, as well as optimal therapy, in order to improve their treatment
treatment started (8%). outcomes.
For example, a married father who sought treatment from Finally, future research needs to further assess treatment out-
our clinic was diagnosed with severe OCD. His pedophilic fears comes for this particular clinical population, as well as examine
were so impairing that he was unable to change his daughter’s potential modifications to Ex/RP and other modalities that may
diapers, bathe her alone,or allow her to sit onhis lap due to intru- improve treatment outcomes. Assessment tools that can be used
sive images and distressing worries that he may become sexu- to effectively distinguish P-OCD from pedophilic disorder are
ally aroused by her. After several months of twice weekly ses- also needed to assist mental health professionals less familiar
sions and daily homework, this client was able to enjoy a consid- with the disorder. Such measures may also help to further iden-
erable amount of symptom reduction. Without needing super- tify factors implicated in the development, maintenance, and treat-
vision from his wife or asking for reassurance, he was able to ment of such symptoms.
care for his daughter’s daily needs in a similar fashion to other
typical fathers. While his obsessions were still present on most Acknowledgements The authors would like to thank Jessica Combs,
Psy.D., and Judy Mier-Chairez, B. S., for their assistance with earlier drafts
days, he was able to resist compulsions (i.e., response preven- of this article, and Chandler Smith for help with data entry.
tion) and continue engaging with his daughter. His obsessions
were weaker and less frequent, and he was easily able to dismiss Compliance with Ethical Standards
them when they occurred. This outcome is considered ideal for
P-OCD sufferers, as they must learn to accept the presence of Conflict of interest The authors declare that they have no conflict of
interest.
obsessions and learn to resist compulsions to receive optimal
benefit from Ex/RP.

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