Jasleen Kaur¹, Poonam Bharti², Ramita Goel³, Vimal Satodiya^4*

¹Junior Resident, Department of psychiatry, Maharishi Markandeswar Institute of Medical Sciences and Research (MMIMSR), Mullana, Ambala, Haryana, India

²Professor and Head of Department, Department of psychiatry, Maharishi Markandeswar Institute of Medical Sciences and Research (MMIMSR), Mullana, Ambala, Haryana, India

³Senior Resident, Department of psychiatry, Maharishi Markandeswar Institute of Medical Sciences and Research (MMIMSR), Mullana, Ambala, Haryana, India

⁴Staff Psychiatrist, Ca Dept of Correction & Rehabilitation, CA, USA

^*Corresponding Author: Vimal Satodiya, Staff Psychiatrist, Ca Dept of Correction & Rehabilitation, CA, USA.

Abstract
Introduction
A patient showing repetitive thoughts (obsessions) and repetitive actions (compulsions) could be diagnosed with obsessive-compulsive disorder (OCD). These obsessions can lead to disgust, particularly when they involve inappropriate sexual thoughts. Adolescents, especially teenagers, have reported experiencing sexual obsessions and guilt. Studies suggest that around 4% of children with OCD deal with obsessions involving forbidden or aggressive sexual thoughts.

Case Report
A 20-year-old medical student from a divorced family has undergone two years of treatment for concerns like headaches, fatigue, agitation, sexual issues, and sleep disruptions. Increased aggression and irritability, even during minor conflicts, led to inpatient care for diagnosis and treatment. Intrusive sexual thoughts about peers, followed by compulsive masturbation, were disclosed during inpatient unit rounds. The patient also experienced disturbing thoughts about religious idols, inducing shame and guilt. Exposure to explicit internet content intensified these thoughts, causing severe anxiety and college absenteeism.

Result
The patient tried various treatments but didn’t fully recover. The patient was diagnosed with severe OCD. CBT sessions twice weekly using ERP (Exposure and Response Prevention) therapy showed a 15-30% improvement. Initially on 20mg Fluoxetine, later 80-100mg, and prescribed benzodiazepines for anxiety. Over a year, combined therapy reduced YBOCS score from 26 to 14, improving distress and academic performance by 40-50%.

Conclusion
This highlights the importance of thorough investigation, particularly for patients who present with enduring treatment histories for various somatic complaints. An in-depth analysis with a high index of suspicion is warranted. For this patient, the intervention ultimately encompassed higher doses of SSRIs and the implementation of planned psychotherapy.

Keywords: Adolescent, OCD, Sexual obsessions, mental health

Introduction
A patient displaying frequent, repetitive thoughts and sensations (obsessions), along with an urge to repetitively perform habitual actions (compulsions), may receive a diagnosis of obsessive- compulsive disorder (OCD) [1]. The patient might also experience a sense of disgust in response to these obsessions, particularly in cases where the obsessions involve obscene, inappropriate, or unacceptable sexual imagery and ideas. Children, especially teenagers, have reported experiencing sexual obsessions and the profound feelings of guilt that accompany them. Phenomenological studies indicate that approximately 4% of children with OCD [2] grapple with obsessions featuring ‘forbidden, aggressive, or perverse sexual thoughts, images, or impulses.’

Case Report
A 20-year-old single male medical student, originating from a divorced family has been under treatment for the last two years due to a range of concerns, including headaches and somatic symptoms like fatigue, occasional agitation, sexual dysfunction, and disrupted sleep. As relayed by the patient’s mother, he has shown a gradual increase in verbal aggression and irritability, even in situations involving minor disagreements. Due to these issues, the patient was managed inpatient to facilitate diagnostic clarification and treatment. During inpatient unit rounds, when the patient was interviewed, he disclosed experiencing repeated intrusive and undesirable sexual thoughts involving his female classmates and friends, often followed by compulsive masturbation. During visits to idols of goddesses, he reported experiencing blasphemous thoughts, which subsequently induced feelings of shame.

The nature of these thoughts was profoundly disturbing, encompassing repetitive and explicit imagery, including mutilation and sexually explicit scenarios concerning his female friends. These thoughts ranged from ideas of slicing female breasts to disturbing acts like mixing and feeding urine to a partner or creating additional anatomical openings in the female reproductive tract. Additionally, the patient experienced thoughts about consuming the small intestine after engaging in sexual activity with a partner. His sexual obsessions were self-directed, leading to intense feelings of guilt [3].

The intensity of these thoughts seemed to escalate after exposure to explicit content on the internet or while scrolling through Instagram. These thoughts and mental images triggered intense anxiety in the patient, leading to severe academic absenteeism in college.

There was no pertinent positive medical, surgical, or family history. There was no history of any substance abuse or dependence or treatment in the past.

Result
Previously, the patient underwent treatment involving amitriptyline and clonazepam, followed by sertraline with risperidone. More recently, he received treatment involving gabapentin. Despite these interventions, he reported that his recovery was incomplete.

Later on, the YBOCS checklist indicated a diagnosis of OCD, predominantly of the sexual obsessional type. Initially, his YBOCS scale score was 26 out of 30, displaying severe symptoms.

CBT (Cognitive Behavioural Therapy), specifically Exposure and Response Prevention (ERP) therapy, was administered twice weekly for approximately 90 minutes [4]. During therapy sessions, the patient’s subjective units of distress (SUDS) were assessed every 10 minutes. The patient reported a 15-30% improvement in his obsessional thoughts because of therapy.

The pharmacological intervention included the use of Fluoxetine. Initially, the patient was prescribed (20mg) orally twice daily, which was later increased to a daily dosage of 80-100mg.

Additionally, the patient was prescribed zolpidem (5mg) and etizolam (0.25mg) orally once daily to alleviate anxiety symptoms associated with his intrusive thoughts.

Over one year, the patient’s overall condition displayed marked improvement through psychological and pharmacological therapies. The YBOCS rating, initially at 26/30, significantly decreased to 14/30, indicating a notable reduction in symptoms.

Furthermore, the patient experienced a gradual decrease in subjective distress levels due to successive ERP sessions. Concurrently, the patient’s academic performance witnessed a substantial enhancement of 40-50%, aligning with his satisfaction.

Conclusion
This case highlights the importance of thorough investigation, particularly for patients with enduring treatment histories for various somatic complaints. In such instances, an in-depth analysis with a high index of suspicion is warranted. For this particular patient, the intervention ultimately encompassed higher doses of SSRIs and the implementation of planned psychotherapy.

Consent: Written informed consent from every participant was taken after explaining the purpose of the study.

Contributors: The following authors were responsible for drafting of the text, sourcing, and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: JK, PB, RG, VS. The following authors gave final approval of the manuscript: JK, PB, RG, VS.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for-profit sectors.

Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

Competing Interests: None declared.

References

1. Freund B, Steketee G (1989) Sexual history, attitudes and functioning of obsessive-compulsive patients. Journal of sex & marital therapy. 15(1): 31-41.
2. Kuty-Pachecka M (2021) Sexual obsessions in obsessive- compulsive disorder. Definitions, models and cognitive- behavioural therapy. Psychiatria Polska. 55(1): 39-52.
3. Clark DA (2005) Intrusive thoughts in clinical disorders: Theory, research, and treatment. Guilford Press. 
4. Monzani B, Jassi A, Heyman I, Turner C, Volz C, et al. (2015) Transformation obsessions in paediatric obsessive-compulsive disorder: Clinical characteristics and treatment response to cognitive behaviour therapy. Journal of Behavior Therapy and Experimental Psychiatry. 48: 75-81.