#(due to OCD based fear of contamination issues)

[lunar-wandering]

Did you get to eat? Just been worried that you didn't in all honesty.

i had rice and a sandwich

[roxineedstosleep]

Idk if this is a request or something but I just wanted to get it out there before I forget it. How would the batfam react to a batsis coming from the last of us universe?( the last of us is a zombie apocalypse type game.) How would they react to all of batsis PTSD from being born in a world over ran by zombie’s and learning to survive at a young age. How would they help them? How would they react if they ever were transported to there(batsis) world?

Don't worry, the truth is that I also questioned several times the reaction of an OC insert or Reader with the passage of time, characters who lived that situation.

Also, sorry if it’s a quite large, but I get exited about this, I was also thinking and thingking about this kind of situtation or scenario and could mange myself about it.

The Last of Us, I know it's based on a video game (comic too or at least I saw several fanmade ones, sorry I don't know much about it, my thing about apocalypse was The Walking Death). And from what I understand, since I get a lot of it on my TikTok feed (thanks Pedro Pascal, I love you in all your ways) I know that the way the infected are handled and the ways of contagion are pretty fucked up.

I mean, at least in TWD the bites were the sure shit, with a good body protector you could get away with it until you got to a safe place…. but that spore stuff? that's a fucking nightmare.

Not only should you avoid being bitten, you should avoid being in contact with any highly contagious source. Food, water, air that's been "stored", spaces that are too enclosed/humid and dark (from what I see I know it's a type of fungus, fungi spread better in those conditions)… I mean, really scary.

I think the only ones who could be saved from those situations would be those who live in sanctuaries in the middle of nowhere (highly extreme climates, like snowy and deserts) or those who reach space. In that situation, which I mentioned a little earlier, the situation for Batsis would be a little worse.

Caves? First place of contagion, unfortunately.

Away from all the PTSD that Batsis must surely have from the traumatic situation of living there…. I don't think it can get much better.

Let's play a bit of a game about it, as I love the What Ifs.

Should it be Batsis from an Apocalyptic Universe coming to a "Healthy" Universe, and by healthy I can even mean post Covid0s universe like ours.

In going from a sick world to a healthy one:

She wouldn't really know how to adapt, it's one thing if the situation was with her being an adult and she at least knew that much about what it meant to have a routine within the normal. Sure, Bruce and the boys would do their best to make her feel safe in many ways, but it wouldn't be possible to make her feel safe at all. She grew up, matured, and developed in that world where every breath could mean having a fucking killer fungus inside her.

Did you ever see videos of people with OCD or germaphobia during the pandemic? Many had breakdowns at such a level that they could become paralysed with fear, breakdowns or hysteria. She would refuse to leave her safe areas, no matter how hard her father and siblings tried to convince her that the rest of the mansion was safe to walk through.

The garden? She refuses to even look at it, places where the spread of spores is more likely due to all the wind and pollination (I've never known bugs or birds to be immune, but considering they can move around because of the pollination issue I don't doubt that any place free of nature is free of risk or cross-contamination).

The cave? The last time one of her brothers tried to get her down to be checked in the medical wing, she almost slit his throat with her own fingernails. She won't go down there, that place is dark, with an uncovered water source and full of dampness… Can't you see that one of those swollen beaks is probably there?

I think she would have serious problems with food, or so I think. Not that she wants to be mean to her, really. But from what I understood a little from seeing at least the first chapters of the series, and also played with several seasons of TWD, she herself would have to see how they prepare the food to avoid contamination or fear of spoiled food. I feel like she would be safe with canned food, specifically canned food that is older than a month before it all goes down the drain. After that, she would obsessively look at the factory's provenance and be in an internal binger over the places that were dropped one by one until she was sure she was safe to eat.

So I don't see her eating with her brothers or her father something that is homemade or from scratch. Unfortunately not. Especially the flours, since they are the crops that were the first to fall before the fungi. I'm sure she would calm down a bit if Alfred showed her the family garden and the fungicides they keep in the barn. If it's not that, will she walk away or not hesitate to spit it out?

To sleep? I think so, I think she would settle, but she is hidden to avoid any risk. Next to Dick, she's the best at hiding in the high and least expected places. After she was found napping in her chandelier, where she had no nightmares or panic attacks, they decided they would let her sleep there. At least until she gets used to the idea that a return portal isn't going to be there anytime soon.

Her father and her brothers would be there for her, don't doubt it. They would love her, they would try to understand her limits, to know that she went through that terrible place to destroy the mind of a poor girl. I mean, Ella was very lucky to have reached an age of near adulthood... Do you know what that mean?

She is happy to have her brothers and her father and her grandfather back in her life. Every day she prays to all the gods she knows, to thank for not having to return to that place. But, even though she has the support of her family, the trauma cannot be reversed.

After those, which I do know are several problems to overcome, I truly believe that she would panic or become hypervigilant when there is a man, who is not from her family, near her... and for sad reasons.

In itself, for a world without the problems of the apocalypse, it is already dangerous to be a woman. Now that the whole world, morale and the little security we had has gone down the drain? I feel like it's even more dangerous. If I remember correctly there is a movie that touches on that subject. Of the possible life of women within a post-apocalyptic world. The SA would be the bread of every day, kidnappings and assaults for the possibility of being able to repopulate the earth would not be strangers. Even more so if we don't talk about ultra-religious cults that try to sell the idea of a woman's sacrifice to "heal" the masses.

Do you see what I'm going to? The fact that she survived childhood and was into young adulthood means that she had to be protected and she knew how to defend herself against all of that. And even more so because, despite everything, she could never fully forgive Bruce for what he did to her and her brothers.

Earlier I mentioned that only the most privileged could be inside those sanctuaries or even reach space to be safe from earth, right?, well. There goes a bit of the matter.

Bruce decided to stay.

For the general public, Bruce Wayne, his children and his closest friends went to one of the many earthly sanctuaries as soon as things turned terribly ugly, but not before sending all his employees safely to a compound of National security.

But Batman? Batman, Robin, and the rest of the bat family stayed to wear out their souls, their safety, and their lives for a city full of killer mushrooms.

She remembers how at first the whole family agreed to stay in the city to find a cure with the help of the League. But over time, when Alfred fell ill, Tim was infected, when Duke had to amputate his arm, Jason almost got infected and Dick was not found for months (not counting attempted assaults on S and others to kidnap her). things in the family got much worse.

Robin in case he was a child soldier, but at this point he looked more like a killing machine than a human being, she herself tried to find a cure and it was more risky and almost impossible over the time to find users who did not have advanced disease or who were immune.

She begged her father that at least the LG members with higher immunity would take care of the safety of the earth, that she and her siblings could be moved to the moon base. Superman, Wonder Women and Mr. Martian could easily handle the situation without going on a death streak every time they breathed, she and her brothers were not that lucky.

But Bruce didn't listen to her, no by any chance.

One by one they began to fall, all her family started to died, even her father amputated his leg after a bad mission plan, until, in an intent of being helpfull (she had simply fled across town looking for medicine for her father's fever), a porthole opened and she fell to that new world where his father and brothers were safe.

Did she ever forgive Bruce for that? No, even in that world where none of that happened, she couldn't forgive the fact that her mother decided to sacrifice himself and his siblings when they could have found another way to save themselves.

Bruce? He will never forgive himself when he finds out that it was his fault and his stubbornness that caused his family to perish. Even more so when he finds out that his daughter, with whom he fought the most and argued about escaping the planet to be save, in any case put his integrity at risk for wanting to save him from a fever that would have killed him anyway at the end of the day.

It hurts Dick to see how Batsis always jumps on him and the rest of his brothers to see if they have any bites or open wounds, Jason is destroyed to see how his sister shakes like a leaf, but he allows anyways to Damian to take her to the garden to get fresh air. Tim watches, in dispair, as she tries to learn all the first aid techniques and amputation procedures, because she is afraid to come back at any time and not know how to do it; Bruce cries when he sees how his daughter, his sweet girl, stores as much food as he can in hidden corners of the mansion and high on the roof; Damian can't help but feel weak when he sees, clearly sees and notices, how his sister is starving to eat any home-cooked food, but they end up throwing up when he takes a tentative bite and must go back to the canned goods.

It hurts everyone, it tears them apart, and she suffers in the process too. Of course, she no longer has to run for her life every hour, she can breathe easy, she can have all the canned goods she wants and she knows that her brothers and her father will be with her after she closes her eyes and opens them again. .

Psychiatric treatments only work in part, therapies are somewhat slow and not easy to achieve. I mean, no one can tell a specialist doctor that she comes from another universe, Harley Queen could be an option, she herself knows a lot of shit about the multiverse and astuff, but even after a general check-up she had told Bruce, no matter how much treatment she could give him toast to Batsis, poor kid would be scarred forever.

At least the therapies help with the issue of food and hypervigilance. Outside of that, she will always need the support of others to get through everything else.

[psychopatois]

Understanding OCD: Exploring the Various Subtypes

This is a continuation/part 2 of the original post under the same title "Understanding OCD."

Overview

The symptoms of OCD manifest differently across individuals. Experts, including clinicians and researchers, propose that OCD can be categorized into distinct types based on the symptomatic patterns observed. This categorization has led to the identification of various subtypes.

The 5 Main Subtypes

Contamination Obsessions with Washing/Cleaning Compulsions typically involve a significant preoccupation with contamination fears, driving individuals to engage in excessive washing or cleaning in an attempt to alleviate distress.

Harm Obsessions with Checking Compulsions are characterized by severe thoughts of potential self-harm or harm to others. People may adopt checking rituals as a means to mitigate these anxieties. For instance, the fear of a house fire might lead one to repeatedly drive by their home for reassurance, or the belief that merely thinking about a catastrophic event could make it happen.

Obsessions without Visible Compulsions typically involve experiencing persistent, unwelcome thoughts of a sexual, religious, or aggressive nature. To cope with the anxiety these thoughts induce, mental rituals, such as repeating specific words, counting, or praying mentally, are often performed. A common avoidance strategy is steering clear of anything that triggers these thoughts, such as the intrusive fear of committing assault.

Symmetry Obsessions with Ordering, Arranging, and Counting Compulsions involve an overpowering need to order and reorder objects until they feel "just right." This may extend to repetitive thoughts or utterances until a task is completed to perfection. These activities can be motivated by the belief that they will prevent harm.

Hoarding is now identified as a separate condition within the Obsessive-Compulsive and Related Disorders category, as per the DSM-5-TR. It is marked by obsessive fears of losing items that may be needed in the future, as well as excessive attachment to objects, which often leads to significant distress and can impair employment stability. Unlike other OCD subtypes, compulsive hoarding can manifest without other OCD characteristics.

Additional Subtypes Not Officially Recognized in the DSM

There exist a variety of subtypes that, although not formally acknowledged within the Diagnostic and Statistical Manual of Mental Disorders (DSM), have been identified and discussed by mental health professionals and researchers. These subtypes are not officially classified within the DSM due to varying reasons, including insufficient empirical evidence or the need for further study. This exploration into unlisted subtypes underscores the complexity of diagnosing and treating mental health issues, highlighting the ongoing need for research and more inclusive diagnostic tools that can adapt to the nuanced nature of psychological well-being.

Relationship OCD involves individuals experiencing obsessive and compulsive thoughts concerning their romantic relationships. This form of OCD is characterized by severe fears and doubts about the solidity of their relationship, including worries over whether their partner truly loves them, an excessive concern for their partner's happiness, or persistent questioning of whether their partner might find someone more suited to them.

"Just Right" OCD is identified by the persistent feeling that certain things are not positioned or done 'just right.' Individuals with this subtype may engage in compulsive behaviors, such as counting, straightening, touching, tapping, or lining items up in a specific order to alleviate these feelings.

False Memory OCD entails individuals frequently battling doubting thoughts. For example, they might be plagued by worries over actions they may have inadvertently taken in the past, such as fretting over whether they accidentally stole something or forgot to pay for an item at a store.

Magical Thinking OCD manifests as a belief in the cause-and-effect relationship between certain behaviors and completely unrelated outcomes. An individual might, for instance, believe that something terrible will befall a loved one if they do not perform a specific action, like checking their phone at 8:15 PM every night, even though there is no logical connection between the two events.

These various forms of OCD highlight the complexity of obsessive-compulsive disorders, showcasing that its manifestations can extend far beyond the more commonly recognized symptoms and behaviors.

Disclaimer:

This content is based on DSM-5 research and insights. Although I am a certified/licensed Registered Behavior Technician (RBT) and can offer insights into mental disorders, remember this information is educational only and not a substitute for professional advice.  If you or someone you know shows symptoms of a mental illness, consult a qualified healthcare professional for an accurate assessment and tailored treatment. Always prioritize your mental health and seek support from professionals. Remember, help is available, and you're not alone.

[thenamesblurrito]

Cybertronian neurodivergence and mental health

Psychiatry is a fairly well developed science on SNAP’s Cybertron, if only to better control people and fix them to serve the state. Or, on a darker note, to label dissenters and revolutionaries as mentally unstable and thus not worth listening to. People like Rung, Froid, Minitron, and Trepan are well-known figures in their field, but counselors and therapists are relatively common across Cybertron, mostly attached to corporations or funded by the state with the express goal of keeping everyone working smoothly. Even Beta Trion has a counseling license, which is why she’s one of the counselors at the JAAT.

Warning for discussion of mental illness, “normative” psychiatry, and discussion of ableism. Please note that this is a noncomprehensive list, and none of these terms are one-to-one representatives of human conditions, they’re only based off of them. The worldbuilding I’m doing here is not a statement about any real neurodivergence, mental illness, psychiatric system, or actual human being, and the values of the society I’m creating are very much opposite of my own.

Nonstandard circuitry

The Cybertronian term for neurodiversity. A convenient catch-all for any processors with “deviations” from forging, instead of issues developed over time. Those that make it difficult to easily sort mecha into functions or workspaces are usually called disorders and stigmatized in general society, and those that can be harnessed to improve or increase the amount of work a mech does are praised as dutiful, with all their detrimental symptoms ignored.

The state-controlled psychiatric system is hardly a neutral party in this, meaning every diagnosis, every medical file, every prescription, and every patient and practitioner is another cog in the machine, another manner of control. On a person-to-person level, there often is a genuine desire to help individuals and improve lives, but someone with a diagnosis of nonstandard circuitry will always have that marked as part of their ID. Their employers can see and use that. Because of the way everyone is assigned a function, a nonstandard individual won’t often struggle to find a job, but the types of jobs available to them will change.

Mostly, people have to choose between pursuing an evaluation and diagnosis to get help if they’re struggling, and avoiding diagnosis to have another aspect of themselves dissected into a set of manacles to chain them to their assigned function. Black market therapy has a strong, widespread community, but psychiatric mediations are too heavily controlled to be easily taken or copied, and bootlegs are dangerous.

Hyperfunction

A spectrum of several related conditions with related symptoms that vary in strength and effect. According to the diagnostic standards, a hyperfunctional person has a notable imbalance between social comfort and expertise in personal interests. For routines, skills, and subjects they are driven by or attracted to, they excel, hence they term “hyperfunction”, referring to their above-average ability in their particular areas of interest. This makes them very valuable to functionism, even if their interest turns to a detrimental obsession that interferes with the rest of their life.

Hypercalculative Regulation Hyperfunction

Based on autism. Mecha with HRH develop in a different manner than standard mecha, often struggling to learn common social norms and rules while soaking up all information of interest at a level higher than their peers. Their sensory nets are queued to different impulses, meaning relatively inconsequential feelings or sensations can become catastrophically painful, but certain stimulations are soothing and fun. They often require routine of some sort, predictable procedural schedules or actions they can rely on, with difficulty adjusting to unexpected change. Each individual will often connect with one or several particular special interests, becoming notable in their expertise. While each person is different and these interests usually have nothing to do with their frame’s function, they can often be assigned to work within their special interest, as their passion is valuable. Transmutate has been diagnosed with HRH. Prowl and his trine are likely on the upper end of this spectrum, although they’ve deliberately avoided evaluation.

Hypercalculative Divergent Hyperfunction

If HRH is comparable to the defunct distinction of “high functioning” or “mild” autism, HDH is “severe” autism. The two are just different levels of the same nonstandard circuitry, but functionism puts emphasis on diagnosing according to how easily someone can be used, thus the differentiation of “severity”. Going from the self-contained routine hyperfunction of HRH, mecha with HDH cannot function as a normal member of society. Common elements are a total lack of social skills to the point of little or no language development, aversion to touch and comfort, hypersensitivity, and meltdowns in response to an unpleasant situation. While mecha like these can be given work of sorts, they are considered more trouble than they’re worth, and often live a life of near-indentured servitude under adult caretakers.

Persistent Compulsion Hyperfunction

Based on OCD. Most commonly known by the flagship symptom of a compulsion to follow organization and routine, PCH has a much, much broader effect than that. A mech with PCH has to deal with intrusive thoughts and anxiety, often concerning contamination, violence, loss of control, or loss of morality. Relatively minor rituals like keeping symmetry and order in one’s physical environment keep some of the fear away, but often this can degenerate into complicated and objectively useless routines to assuage the intrusive thoughts, like checking precisely twenty times to see if the door has been locked. Compulsions like this can be draining and time consuming, even becoming dangerous in some cases, and only reinforce the fear after providing temporary relief. The meticulous and careful procedure of a mech with PCH is valuable for jobs that require thorough work, but more debilitating symptoms are usually shut down and medicated until the individual is competent enough to work again. Minimus has minor PCH, undiagnosed, but it may worsen as he ages. Fixit has been diagnosed with PCH and takes medication for it.

Executive Disregulation Hyperfunction

Based on ADHD. Commonly described as “an impulsivity in pursuing fulfillment”, it’s characterized by a short attention span, emotional disregulation and sensitivity, periods of intense energy and lethargy, inability to start or complete tasks, and chasing stimulation until said stimulation no longer provides entertainment. Because of their poor ability to regulate their executive function, many undiagnosed mecha are called lazy or idiotic for being unable to perform relatively simple actions or habits. Conversely, a subject that piques their interest will receive their full attention and effort. The adult Fireflight and the younglings Hot Rod, Skywarp, and Misfire all have EDH, although none of them are diagnosed.

Triple Fracture

This is the condition Blitzwing has due to his triple changer frame. It isn’t seen in any other frametype, hence it’s name. Triple-changers are uncommon enough to be easily targeted by the prejudices of functionism, but not the easily suppressed rarity that functionists wish they were. Aside from greater strength, durability, and flexibility, two alt modes don’t have much of an adverse effect on their physical health. The biggest negative stereotype about them is their “insanity”.

While nonstandard circuitry comes in many forms, the most feared and misunderstood version is triple fracture. It’s a mental disorder that occurs in less than five percent of triple-changers, but nevertheless it has gained synonymy with that frametype. For our case study, Blitzwing's processor functions in three sections: responsive, reactionary, and deflective. His responsive instincts manifest as the personality slice nicknamed “Icy”. This is the calmest, most well adjusted side of him, capable of taking time to think through and settle on a genuine response to a situation, but likely to switch out under duress. His reactionary instincts are nicknamed “Hothead”, and this is the personality slice that has an immediate reaction to stress, and who uses over-the-top anger and bluffing to push back against whatever is making him feel threatened. His deflective instincts show up as “Random”, acting out and adopting an attitude opposite of the mood around him to divert attention from the actual stressor and onto his own actions, which gives him a modicum of control.

He isn’t three separate people, and he isn’t even really three separate personalities. The different nicknames for the different personality slices are more of a tool for him to describe his current feelings than a set of actual names. He simply doesn’t have the ability to rationally choose a response to stimuli because of the three different filters his processor uses to perceive the world. Even his occasional crazier or more violent episodes occur because his instincts are trying to defend him. Triple fracture cannot be medicated either, because what might stabilize one slice will unbalance the other slices, and the processor as a whole will suffer. However, a triple changer with a good support system and coping mechanisms is perfectly capable of living a normal life, personality slices and all. They aren’t inherently bad, either. Blitzwing can more easily stand up for himself when in Hothead mode, and is very good at telling jokes and playing a room when in Random mode.

Modal Triple Fracture

Exactly like the above, except locked into what form a mech is currently in instead of switching out according to a situation. Sky Lynx has modal triple fracture. His responsive personality slice is tied to root mode, reactionary tied to beast mode, and deflective tied to shuttle mode. He stays in root mode most of the time to keep the most rational part of himself at the forefront.

Modal Personality Disorder

Sort of related to triple fracture, modal personality disorder causes a drastic mood swing whenever a mech transforms between root and alt mode, usually between a calm demeanor and a high-energy or intense demeanor. Unlike triple fracture, this does not involve separate personality slices, only mood swings. Since it’s caused by a specific variation in the morphcore section of the processor which controls the t-cog, it’s considered a processor malfunction type of nonstandard circuitry. It occurs more in modal frames than other frametypes. The adult Road Rage and the youngling Cliffjumper both have MPD, although only Road Rage is diagnosed. Diagnoses are disproportionately more common among beastformers, because of the stigma of “beast instincts” overwhelming one’s sapience.

Submechanoid Psychosis

A punitive psychiatric term based on the now defunct inadequate personality disorder. Colloquially known as feral syndrome, this term is less a genuine condition and more an excuse to label unsatisfactory beastformers as less than people. It refers to beastformers and occasionally toolformers who are violent, unintelligent, or otherwise have a personality not perfectly suitable to subservience. Many beastformers with genuine MPD are deliberately misdiagnosed with submechanoid psychosis. If Grimlock were ever to undergo an evaluation, he would likely be diagnosed with this, although he actually has MPD. Riptide, if he were a beastformer, would also probably be labeled as submechanoid.

Neurasthenia

Based on the now defunct neurasthenia. The condition of the high castes, neurasthenia causes fatigue, dissatisfaction, anxiety, migraines, weakness, and depression. It isn’t nonstandard circuitry, but rather a condition caused by too much stress and/or too little stimulation. It’s mostly diagnosed in upper class individuals, following the theory that the constant scrutiny of being an upper class example to society is chronically nervewracking. The symptoms and causes are poorly defined, with contradicting opinions from different psychological practices. The most common listed source of neurasthenia is overworking within an intangible function, such as the performance and emotional labor of a public figure. Prescribed treatments usually including some form of physical work with tangible results, so as to rejuvenate an individual’s motivation with real, concrete evidence of their ability and accomplishment.

Defunctional Disorder

Based on clinical depression. Characterized by lack of interest, demotivation, low moods, and lethargy and exhaustion, defunctional disorder is a relatively common mental illness. It can be caused both by forged nonstandard circuitry and stress from one’s situation. It’s labelled for the way it makes an individual less likely to adequately perform their function, but it has significant effect on day-to-day life and habits outside of work. A mech affected by defunctional disorder may fall into despair and hopelessness, self-hatred, or utter numbness, and may consider self harm or suicide. Dead End, Sideways, Swerve, and Buzzsaw all have defunctional disorder. Only Dead End and Buzzsaw have been diagnosed, but neither are medicated. Many people believe Alpha Trion must have it, hence his drinking problem.

Baseline Alarm Disorder

Based on paranoid personality disorder and anxiety. BAD often shows up as a comorbid condition with PCH. It’s caused by a constant triggering of a mech’s internal preservation and security systems, conjuring a sense of doom and danger at all times regardless of the current situation. Considered a processor malfunction type of nonstandard circuitry, a mech will suffer from paranoia, anxiety, illogical suspicion or mistrust even of a situation they know to be safe, panic attacks with acute physical fear responses, and intense stress and energy drain. Red Alert, Breakdown, and Spinister all have BAD, but only Spinister is diagnosed. He’s medicated, which is what inspired his fascination with medical mechanics.

Overclocking

A poorly defined “disorder”, overclocking refers to a processor overworking itself, moving too quickly to follow itself. This is usually a symptom of a larger condition, often HRH or EDH, but it’s also diagnosed as a standalone condition. Overclocking is characterized by scattered or nonsensical trains of thought, manic energy and following exhaustion, difficulty forming words or coherent sentences, abrupt movement coupled with aborted actions, uncontrollable tics, and a continual sense of restlessness, urgency, or inability to pause. It isn’t exactly rare on Cybertron, but it’s almost never diagnosed on Velocitron. An overclocking Cybertronian seeing a Velocitronian psychiatrist is unlikely to receive a diagnosis, but a Cybertronian psychiatrist is likely to label a normal Velocitronian as overclocking, simply due to their often speedy nature and cultural behavior. Blurr has a stutter, is quick and clumsy, and speaks with the typical speed of a Velocitronian, which means he would likely be incorrectly diagnosed with this condition.

Sporadic Hang Syndrome

This condition is basically the opposite of overclocking, instead causing a mech’s processor to pause, buffer, and/or restart a certain task or thought, often repeatedly. Some people have these problems only with certain actions or feelings, some only deal with it in stressful situations, and some have persistent trouble no matter what’s going on. Symptoms include freezing mid-word or action, forgetfulness, repetition of the same word or action, uncontrollable tics, and random and/or triggered long periods of “blankness” of no movement or sensation, the processor caught in an unresolved task or thought loop.

Autoexecution Syndrome

Caused by an error in loading and running scripts in the processor, a mech with autoexecution syndrome struggles with choices, changing routines, and executive function. Symptoms include improper ending of the recharge cycle, low impulse control, intrusive thoughts and acting before thinking, and compulsion to complete a sequence or routine before doing anything else. While it’s related to PCH and can be comorbid with it, autoexecution syndrome lacks the fear and anxiety aspect of PCH and is classified as processor malfunction nonstandard circuitry. Hubcap has autoexecution syndrome and is medicated for it.

Information Creep

Based on dementia and Alzheimer’s. A condition gained later in life rather than forged nonstandard circuitry, information creep occurs in a very old mech who’s running out of memory storage space. It’s occasionally called blurred data. Eidetic decay is normal in older memories as they are compressed and reformatted for deeper storage, but at some point the memory file itself becomes too corrupted to read or is deleted completely. A mech that has reached old age is almost certain to get information creep at least on a small scale. The condition becomes debilitating when the corruption starts encroaching on large portions of the memory, even into short-term memory. It causes difficulty knowing where or when one is, uncertainty as to who others are or what their significance is, problems following conversations, and anywhere from general absentmindedness to total loss of interaction with external stimulation. One would think that size null mecha are more prone to this, but that isn’t true. The percentage of size null mecha who suffer from more than just slight information creep is much lower than the percentage of older modern mecha who suffer the same. Medics and psychiatrists are unsure as to why.

Overwritten Information Creep

Similar to the above, except not caused by age, rather by an error in the processor that overwrites stored data rather than making a new folder in chronological order. This is uncommon, but can affect any age. Mecha affected will find themselves losing time, forgetting pieces of or entire memories no matter how recent or vivid, losing track of possessions, getting lost easily, and having difficulty connecting information with its source or correlation. Although no one pays attention to him enough to notice, Rung has overwritten information creep, hence his chronic forgetfulness.

Primus Apotheosis

A relatively recent term coined by Froid, primus apotheosis is suspected to affect 2% of all adults who have come in contact with the vigilante factions operating in Iacon. It’s characterized by excessive admiration or obsession with one or multiple faction members, idealization of their teachings to the point of blindly following, dysmorphia in their own frames and irrational belief that they ought to look more like these vigilantes, and abnormally increased interest for people and subjects outside of their assigned function, class, and cultural background. So far, a youngling’s typical overenthusiasm for a new interest has proven indistinguishable from primus apotheosis, so diagnoses are limited to adults. The condition is practically guaranteed in any survivor of relic corruption, usually with especially strong frame dysmorphia. Froid has had to do the majority of diagnosing himself, because that insufferable fool the Academy has hired as their chief counselor has the audacity to claim “primus apotheosis is absolute nonsense”.

Pathological Dissent

A punitive psychiatric term based on the now defunct sluggish schizophrenia, drapetomania, and general political abuse of psychiatry. Mecha diagnosed with pathological dissent are, without fail, rebels and activists of some sort. The official diagnosis claims that these people are “neurologically incapable of being satisfied with their inbuilt function”, therefore the state must take custody of them for their own health and wellbeing. It is by far the most dangerous label any individual could ever acquire. Froid and several others have remotely diagnosed the vigilante faction members with pathological dissent, and Impactor was also diagnosed with it prior to his execution.

[fitabouts]

Anxiety: Information, Signs, symptoms, types & treatment

Everyone has a feeling of anxiety at some point in their lives, whether it is about preparing for a job interview, the possibility of meeting a partner's family for the first time, or the possibility of parenthood. When we associate stress with changes in our mental state, perhaps experienced as anxiety or apprehension, and physical symptoms such as heart rate and adrenaline, we also understand that it only temporarily gives us Is likely to affect until the source of our concern has passed. We have learned to face it. Stress, therefore, is a category of emotions that does a positive function of alerting us to the things we may need to worry about: things that are potentially harmful. More importantly, these feelings help us to evaluate potential threats and respond appropriately, perhaps by sharpening our reflexes or focusing our attention. We all experience anxiety; It is a natural human condition and an important part of our life. Anxiety helps us identify and react to danger in 'fight or flight' mode. This can motivate us to meet tough challenges. The 'right' amount of anxiety can help us perform better and encourage action and creativity.

When you are anxious, what happens to your body?

Anxiety can create many sensations in your body as it develops for danger. These sensations are called "alarm responses", which occur when the body's natural alarm system (the "fight-flight-freeze" response) is activated. Rapid heartbeat and rapid breathing;Rapid heartbeat and rapid breathing;Sweating;Nausea and stomach upset;Dizziness or lightheaded;Tight or painful chest;Numbness and tingling sensations;A false (Unreality) or bright vision;Heavy legs;Suffocating sensations;Hot and cold flashes. Flight-Flight-Freeze:-Our body's flight-flight-freeze response can be activated when there is a real threat, such as the arrival of a black bear while hiking in the forest. In this case, you can flee (eg, running away from the bear), freeze (eg, hold steady until the bear passes), or fight (eg, waving and waving your arms to look big and scary). But this reaction can also occur when something looks dangerous but does not actually occur, such as being interviewed for a job. For example, you may feel jealous, sideways, or uncomfortable. You can fight people (fight) or have a hard time thinking clearly (freeze). These feelings may be enough to make you want to avoid doing an interview (flight). Many people stop doing or going for things that make them feel anxious.

How does anxiety work?

Anxiety not only affects your body but also affects your thoughts and behaviors. Therefore, anxiety has three parts: physical symptoms (how our body reacts), thoughts (what we say to ourselves), and behavior (what we do, or our actions). Learning to recognize these signs of anxiety can help you become less afraid of it.

How to Identify anxiety disorders?

Identify psychological symptoms:-frequent or excessive worry, poor concentration, specific fears or phobias e.g. fear of dying or fear of losing control.Identify physical symptoms:-Fatigue, irritability, sleepiness, general discomfort, muscle tension, stomach upset, sweating and difficulty in breathing.Identify behavior change:-Includes procrastination, avoidance, difficulty making decisions, and social withdrawal.

What are the symptoms?

While there are many types of anxiety disorders, there are some common signs and symptoms. Feeling:-Most of the time, very worried or scared;Tension and edge;Nervous or scared;Coward;Irritable, excited;You're worried you're crazy;Isolated from your body;Feeling that you may vomit.Thinking:-'Everything is going wrong';I can die ';'I can't handle the way I feel';But I can't pay attention to my concerns;'I don't want to go out today';'I can't calm myself down'.Experience:-Sleep problems (no sleep, wake up often);Pounding heart;To sweat;'Pins and Needles';Stomach ache, flatulence;Dizziness;Twigs, shaking focusing on problems;Excessive thirst. When these constantly take repetitive thoughts and feelings, we may feel overwhelmed, lose sleep, feel exhausted, and begin to avoid social situations. Some of these symptoms may also be signs and symptoms of other medical conditions, so it is best to always see your GP so that they can examine them properly.

When does anxiety become a problem?

Anxiety is a problem when your body reacts as if there is a danger when there is no real danger. It is a very sensitive smoke alarm system in your body.Anxiety problems are common. One in four adults will have anxiety disease in their lifetime.

What are the types of anxiety disorders?

Mental health disorders including:-Generalized anxiety disorder;Social phobia;Specific fear;Obsessive-compulsive disorder (OCD);Panic disorder;Separation anxiety disorder;Agoraphobia;Post-traumatic stress disorder (PTSD).Other types of disorders include:-Substance/drug-induced anxiety disorder;Anxiety disorder due to a medical condition. It is important to seek help to manage severe anxiety. There are many effective remedies for anxiety, and you may feel better. 1. Panic Disorder (without AGORAPHOBIA) A panic attack suddenly appears (such as shaking, sweating, heart pulsation), which is followed by another panic attack for at least a month. Agoraphobia can occur by panic attacks when someone persists or ends - with marked distress - specific states. Such as living outside the house alone, getting crowded or standing in a row. 2. Specific phobia A specific phobia includes a "fear and persistent fear of clearly understood, marked objects or situations". There are five subtypes of specific phobias: Animal types:- such as fear of mice or spiders;Natural environmental types:- such as fear of storm or elevation;Blood-injection-injury types:- such as fear of seeing blood or receiving injections;Situational types:- such as fear of public transport, elevators or enclosed spaces;Other types:- such as fear of choking or vomiting. 3. Social phobia A social phobia includes "a marked and persistent fear of social or performance situations that may be lead to embarrassment". Fear may be associated with most social situations related to public performance or social interaction, such as attending small groups, meeting strangers, dating, or playing sports. 4. Obsessive-compulsive disorder This includes recurrent inclinations or passions that are too severe to induce significant loss seal distress or time-consuming. Passion calls or "intrusive" thoughts, urges or pictures that come to mind repeatedly on the surface, such as concerns about contamination (eg, touching the door handle) or doubting (eg, am I Can I close the door?). Compulsions are behaviors or "rituals" that a person tries to reduce or suppress their obsessive thoughts (eg, washing hands, checking). 5. Acute stress disorder This can happen after someone experiences, witnesses or is confronted with an incident or situations that are real or threatened with death or terrible injury or threat to the physical integrity of themselves or others. The disorder occurs within a month of the traumatic event. Distracting memories of a traumatic event creates an emotional response and creates a sense of relief to the event. 6. Post-traumatic stress disorder PTSD involves the development of symptomatic symptoms after exposure to extreme traumatic stress. A person's response to the event must have intense fear, helplessness, or panic. Symptoms usually begin within three months of trauma, although there may be a delay of months or years before symptoms appear. The traumatic experience repeatedly relies upon through intrusive memories, disturbing dreams, and flashbacks. 7. Generalized anxiety disorder GAD includes extreme anxiety and anxieties, having more days than most events, for a period of at least six months, about multiple events or activities. GAD's specialty is "difficulty controlling anxiety".

Treatment for Anxiety disorders

Many psychological treatments - such as relaxation exercise, meditation, biofeedback and stress management - can benefit from anxiety disorders. Many people with anxiety disorders also benefit from supportive counseling or couple or family therapy. However, experts agree that the most effective form of treatment for anxiety disorders is cognitive-behavioral therapy (CBT). Medications have also been shown to be effective, and many people receive CBT and medication in combination. 1. cognitive-behavioral therapy CBT is a brief, problem-focused approach to treatment based on the cognitive and behavioral aspects of anxiety disorders. Typically, CBT consists of 12-15 weekly 1 hour sessions. In the initial sessions, the person with the anxiety disorder works with the therapist to understand the person's problems. An individual's symptoms of anxiety are assessed within a cognitive-behavioral framework, and the goals and functions of therapy are established. As therapy progresses, a person with an anxiety disorder is assigned behavioral and cognitive functions to learn skills to reduce anxiety symptoms. As symptoms improve, the physician also focuses on underlying issues that may pose a risk for "relapse", which is used to describe the withdrawal of symptoms. 2. Medication Research has shown that people with anxiety disorders often benefit from medications affecting various neurotransmitters, especially serotonin, norepinephrine, and GABA. Medications can help decrease symptoms of anxiety, especially when mixed with CBT. 3. Antidepressants Antidepressants are the first medication commonly prescribed for the treatment of anxiety disorders. These drugs are safe, effective, and non-narcotic, and have not been shown to have any long-term effects. The disadvantage of antidepressants is that they usually have side effects. For most people, the side effects are mild and short-lived, an easy trade-off for the benefits of the drug. For others, the side effects may be more distressing. People often experience the side effects of an antidepressant in the first few weeks of treatment, before undergoing its benefits. For best results, antidepressants should be taken regularly, usually once or twice each day. These and all medicines should only be taken as prescribed. Taking more or less than the prescribed dose can prevent the medicines from working, and some symptoms may worsen. 4. Benzodiazepines Benzodiazepines are a group of drugs that increase the activity of the GABA neurotransmitter system. BZDS reduces anxiety and excessive excitement and makes people feel calm and calm. They also cause drowsiness, which makes it easier to fall asleep and sleep at night. BZDS is often used to treat generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. The advantage of BZDS is that it can rapidly relieve and control anxiety. BZDS most generally used to treat anxiety disorders are clonazepam (Rivotril), alprazolam (Xanax) and lorazepam (Ativan). Common side effects:- drowsiness, fainting, dizziness and loss of balance; The effects are most severe when BZDS is combined with alcohol or with other sedatives. 5. Herbal Therapies Over the years, many herbs have some effect on mood and mental health. Although many plants may contain active ingredients that may be somewhat effective in relieving various symptoms, their effectiveness has not been formally tested. The herbal industry is unregulated, meaning that the quality and effectiveness of herbal products are not consistent. Opposing effects are possible, as are toxic interactions by additional drugs. If you are counting herbal medicines, you should discuss this with your doctor and review the medicines that you are already taking. Some herbal products have remedial effects and are believed to reduce symptoms of anxiety. Read the full article

[tolvoofovlot]

OCD,Symptoms, Resources, Treatments(Reposted)

This is a repost of something I wrote on a forum for a thread on OCD.

OCD, or Obsessive-Compulsive Disorder. You may have heard of it, but do you know what it is? Do you have it and want to talk about it or what methods help you or haven’t worked for you? Do you want to learn more about OCD? This is a thread about OCD, the disorder of the brain that effects many people worldwide.

https://www.youtube.com/watch?v=tnzz-eFmKaw[

There is a lot of misinformation out there about OCD, especially due to media portrayals of it. Things like the above can contribute to this. And while they said the video was supposed to poke fun at people who don’t have OCD, when you go through comments or many reactions people thought it was an accurate portrayal. Things like Monk, and other portrayals and stories even when the intentions are good can cause problems. On top of the fact that often studios find accurate portrayals not marketable or too frightening so they require changes to happen to characters and stories.

https://iocdf.org/blog/2017/11/02/how-the-media-gets-ocd-all-wrong-uk-based-podcast-helps-ocd-sufferers-find-recovery/

https://www.gamespot.com/articles/neverending-nightmares-how-ocd-inspired-a-psychological-horror-breakthrough/1100-6414083/

Some things whether intentional or not can give people an idea of what it is like. Neverending Nightmares is a game inspired by OCD, the creator has it and it helps to portray it as the horror it can be. Silent Hill is often my go to example, while that’s not the intent, of what OCD is like for me. So there are also things that don’t directly depict characters with OCD but are inspired by it or are supposed to evoke similar feelings.

So what is OCD then? It is an anxiety disorder, it is a way your brain functions, or how it dysfunctions. Technically you can have symptoms of OCD but not be diagnosed with it. Unless it is negatively impacting your life it is not considered OCD typically. There is also OCPD, or Obsessive-Compulsive Personality Disorder, which is a separate thing that shares similarities but is seen as not as negative and more useful. The distinction between the two can be difficult, with the most basic being that those with OCPD typically see it as mostly positive while those with OCD typically see it as wholly negative.

https://www.ocduk.org/ocd/types/

There are also multiple types of OCD. It can manifest in many forms, and it is possible to have one or some forms and not others. What are the main ones is often debated, and lots of people have broad categories they fit under but have more specific obsessions and thoughts. Some common things are Contamination, Intrusive Thoughts, Hoarding, Symmetry. Hoarding is often associated with OCD and many who have it Hoard but it can also be a symptom seen in a lot of other disorders. Symmetry, or Order, is about making sure things are exactly perfect. This is one people do commonly think of, such as ensuring that things are symmetrical, that things are categorized. Contamination is somewhat commonly known about, in regards to physical contamination or a fear of being contaminated by touching things and needing to be clean. This is a part of why hand washing rituals are so common, but Contamination can be mental. Like thinking about a contaminated thing contaminating your very mind. And then there are Intrusive Thoughts. Intrusive Thoughts can be hard to explain to those who don’t have them. It is like having a second brain, or a separation from your self and your brain. Your brain can feed you thoughts that you don’t believe or think yourself, or it can be obsessed thinking that others can more easily stop thinking about. Intrusive Thoughts can almost be compared to hallucinations, except instead of seeing/hearing/feeling things in your environment, it is like having thoughts projected into your head.

There are other symptoms, such as body picking(Skin picking, hair plucking, nail biting, ), tics, checking(Checking things to make sure they are in the right order, doors closed, doors lock, stove off, etc). Many behaviors due to OCD are not considered rational, and even those with OCD can recognize what they are doing as irrational yet do it anyway. It is a sort of cognitive dissonance that is common in those with OCD, they recognize what they are doing and why it is wrong but do it anyway. Though it should be mentioned OCD is usually not something that will result in harming others, but instead just the self. Those with OCD have lower rates of aggression towards others as it is mostly self-destructive. Thoughts about harming others won’t likely cause someone with OCD to hurt others, but rather hurt themselves to stop the possibility of hurting others.

What needs to be understood too is how obsessive thoughts lead into rituals. Often it is not that you need to do a ritual just to feel calm, that can be a way it works, but is usually the safest way to explain it. Rather than that if you don’t perform a ritual you’ll die, or someone you love will die, or the universe will explode killing all life. Often those with OCD feel immense pressure to do these things because they’re worried nebulous or specific bad things will happen if they don’t. And if you address it, it doesn’t make sense. I know that I’m not Thanos and I don’t have the infinity gauntlet, but also if I don’t wash my hands three times my dogs will explode before my eyes and I can now hear the whimpers from their heads attached to bloody torsos as they look at me asking why I didn’t just wash my hands three times. Which if I mess up doesn’t really happen because it is irrational, but deep down I believe that will happen every time.

Something to keep in mind is OCD is also tailor made to each individual’s brain. A common obsession is one that is a fear of secretly being a pedophile. It’s not because our brains are wired to think that, it’s because OCD often tries to convince you that you are a worthless monster that deserves to die. Since pedophiles are commonly considered the worst type of people, those with OCD often have that fear. If you thought people who put pineapple on pizza genuinely deserve to be executed, and have OCD, you might be afraid of the possibility that you secretly like pineapple on pizza. It is a kind of horrifying concept but it is genuinely your own brain trying to hurt, and even kill you.

https://www.youtube.com/watch?v=8dR8xVqSfXc

OCD is both less common than people think, but actually very common. Not every person who is anal about things has OCD, though it can also be dangerous to gate-keep people just because they don’t have explicitly observable symptoms since many might not be open about it or have outward rituals. Over 1% of people have it in one form or another. In the above clip is Leonardo DiCaprio, who famously had OCD playing Howard Hughes depicting real symptoms of OCD he had such as hoarding jars of his own urine(Though the nudity thing is actually related more to a nerve disorder from crashing planes). It can be tricky with historical figures because unless we have explicit detailed recordings of every thought they had and thing they did, we can’t actually know. Howard Hughes was far more explicit so we do know he had it.

https://iocdf.org/

There are quite a few organizations around the world for OCD since it is actually very common. You can usually google for local resources and support groups. A thing about OCD is while it is incurable, it is manageable. While it isn’t entirely understand where it comes from, there is medicine that can really help people and therapy is very useful in treating OCD. CBT(Cognitive Behavioral Therapy) is considered by many to be the most successful way to manage OCD. People with OCD will live their lives with it, and suicide rates are high for those with OCD, but for those with treatment it is much lower. Try to ask your doctors or therapists about it if you think you have it based on some of what you can read above, it can’t hurt to check though if you don’t have explicit symptoms don’t worry about it most people still don’t have it, roughly between 1–2% of the population do.

http://beyondocd.org/

Now I want to stress that if you can, please do try to seek help. OCD has claimed many lives when left untreated. And while you can learn CBT yourself it is better done with professional assistance. Certain forms of meditation that are good for anxiety can help, but therapy and medication can be very important. Electroconvulsive therapy can help in extreme cases, but is typically a last case scenario. I have used Clomipramine and it has helped, though I’m off it currently due to insurance. It is cheap depending on where you are, and effective, but it does have some strong side effects like body temperature control being lost and sexual arousal becoming incredibly difficult. OCD can also develop in children and manifest early, but early symptoms are rare and it can be very hard to diagnose children with OCD.

https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610

CBT being the most effective treatment for OCD does not mean it will work for everyone, but it can be very helpful. It is about altering how you think and recognizing what kind of thoughts you are having and how to diffuse them, how to dismantle negative thinking, and more constructively think. It is best done with the aid of a therapist. Please seek professional help, especially when doing Exposure Therapy. Exposure is in bits forcing yourself to deal with things that are upsetting. Whether it is physical, emotional, mental. If you can’t touch things, being slowly made to touch things, maybe at first it is a door knob, maybe later it is a toilet seat. For emotional, maybe it is talking a bit about a trauma, then later being more detailed. Again it is gradual, and is to make it not so drastic when you have to confront these issues. But it should be done with a therapist, you need someone to teach you and you need someone who can recognize when you’re being pushed too far and might have a severe episode or are being harmed.

For much of my life growing up I thought I was the only person with these thoughts and feelings in the world. So I hid them, worried everyone would think I’m a freak, crazy, that I need to be in an asylum. But I want everyone to know you are not alone out there, if you have OCD in some form there are others like you going through similar experiences, and people out there you can talk to, and ways to get help. For me therapy was the biggest gain I ever had on my OCD, whether it was in group sessions or private ones.

https://lilywilliamsart.com/portfolio/ocdcomics/

Some comics by Lily Williams on OCD.

Broodhollow is a webcomic by Kris Straub about a man with OCD. It is a cosmic horror and mystery series both about real symptoms of OCD as well as the cosmic horrors that effect the town of Broodhollow. You might notice horror is the main way to convey what living with OCD is like, there is a good reason for this because of how it catastrophizes situations and how it can warp your understanding of the world around you.

http://broodhollow.chainsawsuit.com/comic/2012/10/06/book-1-curious-little-thing/

I wanted to pepper this a bit with both media about OCD people can check out as well as resources that can aid people. As well as facilitate people sharing their own experiences and asking questions that can help them understand things.

https://www.nami.org/Learn-More/Mental-Health-Conditions/Obsessive-compulsive-Disorder/Support

https://www.ocdaction.org.uk/

https://thesecretillness.com/

And I know suicidal thoughts are a common part of OCD. I am chronically suicidal myself. But if you believe you are at risk and are considering suicide please seek help, if you can contact professionals for help, contact your doctors/therapists if you can, or use the below link for the suicide hotline in the USA. As well as other sites for helping you find local hotlines.

https://suicidepreventionlifeline.org/

http://suicidehotlines.com/

http://www.suicide.org/international-suicide-hotlines.html

https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines

[i-am-very-very-tired]

Abstract Presented is a case report of exposure and ritual prevention (EX/RP) therapy administered to a 51-year-old, White, heterosexual male with sexual-orientation obsessions in obsessive-compulsive disorder (OCD). The patient had been previously treated with pharmacotherapy, resulting in inadequate symptom reduction and unwanted side effects. OCD symptoms included anxiety about the possibility of becoming gay, mental reassurance, and avoidance of other men, which resulted in depressive symptoms and marital distress. The patient received 17 EX/RP sessions, administered twice per week. The effect of treatment was evaluated using standardized rating instruments and self-monitoring by the patient. OCD symptoms on the Yale-Brown Obsessive Compulsive Scale (YBOCS) fell from 24 at intake to 3 at posttreatment and to 4 at a 6-week follow-up, indicating minimal symptoms. Improvement also occurred in mood, quality of life, and social adjustment. Issues concerning the assessment and treatment of homosexuality-themed obsessions in OCD are highlighted and discussed. Keywords: obsessive-compulsive disorder, case study, cognitive-behavioral therapy, sexual obsessions, sexual orientation, treatment, exposure and response prevention, homosexuality 1 Theoretical and Research Basis Obsessive-compulsive disorder (OCD) is estimated to occur in 1.6% to 2.3% of the general population (Kessler et al., 2005; Ruscio, Stein, Chiu, & Kessler, 2010). It is a disorder marked by significant distress and interference in daily activities. The hallmark features of this disorder include both obsessions and compulsions. Obsessions are intrusive thoughts, impulses, or images that cause distress and increased anxiety. Compulsions are behaviors performed to decrease anxiety or distress associated with obsessions and may be either mental or physical. Both obsessions and compulsions come in many different forms and each individual’s symptom presentation is different. Obsessive thoughts can range from the fear of becoming ill due to contamination to fear of harming one’s child. Similarly, compulsions can include everything from repeated and excessive hand washing to mentally reviewing the child’s daily activities to ensure that the child was not accidentally harmed during the day. Many studies have been conducted to describe subtypes of OCD across different symptom clusters, and there has been some agreement between researchers as to which symptoms tend to cluster together. Typical OCD symptom clusters include harming fears, contamination fears, unacceptable thoughts, symmetry/arranging, and hoarding symptoms (Abramowitz, Franklin, Schwartz, & Furr, 2003). Much research has been carried out on primary symptom presentations that include checking and contamination concerns (Ball, Baer, & Otto, 1996), but one area that has seen little research has been the sexual obsessions (Gordon, 2002). Similar to other types of obsessions, sexual obsessions can take many different forms. For example, this type of obsession could include fears of molesting a child, fears associated with sexual orientation, fears of engaging in inappropriate sexual activity, or intrusive sexual images. As with all obsessions, sexual obsessions must be considered intrusive and unwanted and should not include sexual thoughts or images that the patient finds pleasurable. Some examples of compulsions that might accompany sexual obsessions include checking arousal levels to determine attraction, maintaining sufficient physical distance from others to ensure that inappropriate touching does not occur, or mental reassurance that one is not sexually deviant. The limited research into this topic has shown that approximately 10.5% of treatment-seeking OCD patients report sexual obsessions as their primary symptom (Foa et al., 1995). Current and lifetime prevalence of sexual obsessions among this group, regardless of whether they are considered a primary symptom, is 16.8% and 26.3%, respectively (Williams & Farris, 2011). Given these rates, it appears that such obsessional content is common in OCD. One particular form of sexual obsessions that has received even less attention in the literature is sexual-orientation fears, which may include a fear of experiencing an unwanted change in sexual orientation, fear that others may perceive that one is homosexual, or fear that one has latent homosexual desires. Lifetime rates for homosexual obsessions have been reported at 9.9% and 11.9% among research and treatment-seeking populations, respectively (Pinto et al., 2008; Williams & Farris, 2011). To date, the only published work on homosexual obsessions has been a qualitative book chapter (Williams, 2008). This dearth of literature may be reflective of the often misunderstood nature of homosexual obsessions and sexual obsessions more generally. Sexual obsessions are often mis-diagnosed or missed completely by clinicians who are unfamiliar or inexperienced with this form of OCD (Gordon, 2002). It is important to note that sexual obsessions are very different from thoughts and fears an individual might experience if he or she was conflicted about his or her sexual orientation and are not simply a reflection of the individual’s sexual attraction to a particular gender. Although homosexual obsessions are an often misunderstood symptom of OCD, the treatment—exposure and ritual prevention (EX/RP) therapy (Kozak & Foa, 1997)—follows the same structure as any other form of OCD, although there is some evidence that those with sexual obsessions may spend more time in therapy than those without these symptoms (Grant et al., 2006). EX/RP is a form of cognitive behavioral therapy that has been empirically supported for use with OCD (Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000). From a cognitive behavioral perspective, obsessions are maintained through use of rituals that serve to decrease the anxiety or distress the individual feels as a result of the intrusive obsession. Because the ritual immediately reduces the distress, the individual fails to learn that the obsession does not represent a real threat. Without such awareness, the individual comes to believe that the ritual is the only means by which to decrease the anxiety felt following an obsession while reinforcing the danger that the obsession represents. EX/RP therapy is a two-pronged approach that aims to expose the patient to the feared stimulus (the object of the obsession) while eliminating the ritual. Through this process, the patient is able to learn that the feared outcome is unlikely to occur even when a ritual has not been performed (Kozak & Foa, 1997). In the case of a patient with sexual-orientation obsessions, the process remains the same. The patient is asked to expose himself to the feared stimulus, that is, he might be homosexual, and to also refrain from any rituals he uses following such an obsession, that is checking arousal levels, self reassurance, and so on. Throughout the course of treatment, patients are asked to engage in increasingly more challenging exposure tasks while continuing to refrain from the use of rituals and avoidance to decrease anxiety and distress. 2 Case Presentation The patient was fully consented as to the content of this manuscript. To maintain confidentiality, all demographic information was altered. “Simon” (not his actual name) is a 51-year-old, White male who works in finance in middle management. He graduated from college with a 4-year degree and obtained a master’s degree from a state university prior to entering the finance industry. He is married with two children and identifies his religious affiliation as Catholic. 3 Presenting Complaints During his initial evaluation, Simon described frequent fears that he might be “gay” despite a lack of physical attraction to other men. Many of these fears involved the concern about what might happen if he were gay, including having to leave his wife and children, concern about being ostracized by his family and friends, and fear of enjoying a sexual relationship with another man. Simon also described significant concern related to the fear that he had been gay all along and did not know it, thus perhaps had been lying to himself about his true sexuality. In addition, he indicated that he was occasionally distressed by fears that he might do something sexually inappropriate, like grabbing another man’s rear at work. Simon reported feeling significant distress when these thoughts occurred and stated that these thoughts occupied several hours per day. Initially, Simon had some difficulty identifying the compulsions that resulted following his obsessions. He indicated that he maintained physical distance from other men. If another man walked into a room, particularly in his office at work, he would place his hands behind his head in an effort to avoid touching them. He also sought reassurance from his father and mental health professionals about his sexuality. In addition to these compulsions, Simon reported that he was engaging in a great deal of avoidance behaviors in an attempt to minimize number of obsessions he was having as well as the distress he felt around other men. He was avoiding many activities including his children’s sporting events, one-on-one meetings at work with males, and movies or television shows featuring masculine characters. Because of the extent of his avoidance, Simon’s initial OCD severity score (based on the Yale-Brown Obsessive-Compulsive Scale [YBOCS]; Goodman et al., 1989), which fell in the moderate range, may be a low estimate of the actual severity of his symptoms. Simon’s obsessions related to sexuality were causing him a considerable amount of distress and were affecting his quality of life across several domains. Most notably, his relationship with his wife was suffering. This included a decrease in sexual activities, due to the fear that he would have obsessions during sex, and poor communication. In addition, he reported avoiding social interactions due to the discomfort of being around other men, which extended to activities with his family outside the home. Because of this extensive avoidance, Simon’s pleasurable activities were severely limited and he was experiencing significant symptoms of depression in addition to the symptoms associated with his OCD. At the time of his intake, Simon’s depressive symptoms included sadness, loss of interest in activities, fatigue, loss of libido, and passive suicidal ideation. He stated that decrease in libido coincided with initiation of a selective serotonin reuptake inhibitor antidepressant (SSRI). By the time Simon started EX/RP therapy and began eliminating avoidance, he was indicating a significant increase in depressive symptoms, including feelings of guilt, decrease in pleasurable activities, tension, irritability, psychomotor retardation, fatigue, weight loss, and passive suicidal ideation. Simon also described periods of crying between sessions and significant depressive rumination. He reported at intake that he experienced some social anxiety specifically related to public speaking. 4 History Simon stated that he started having worries about being gay at age 12. He also reported that he had experienced some obsessions related to the fear of harming himself or others in the past, but this was not a current concern for him. In college, Simon saw a psychologist periodically for supportive therapy. He continued to see this particular clinician for 10 years but was never diagnosed with OCD. After that initial therapist, he was seen by several other clinicians for brief periods of time. Four years prior to coming to treatment at this time, he was examined for 1 year by a psychologist who treated him using exposure techniques for OCD. Simon described this treatment was somewhat helpful but with very difficult homework, which ultimately resulted in his leaving the treatment before its completion. In addition, Simon had tried an SSRI at that time with minimal symptom reduction and significant side effects. Simon described growing up in a large family of four children with one brother and two sisters. He described a distant relationship with his brother because of distress related to his brother’s sexual orientation. Simon described a similarly distant relationship with his mother whom he portrayed as very anxious. He did indicate that he had a close relationship with his father and stated that they spoke nearly every day. 5 Assessment Included in the EX/RP treatment protocol is a strong emphasis on understanding not just the obsessions and compulsions but also both internal and external stimuli that trigger intrusive thoughts, images, and impulses. This thorough assessment is considered an important step in understanding the individual’s case formulation. Because each individual’s OCD is very different, understanding both the symptoms and avoidance strategies is essential to inform the treatment plan. During the first two EX/RP sessions, Simon was evaluated to help determine what his particular triggers were along with any avoidance strategies he was using. Simon was asked to describe situations in which he experienced intrusive thoughts about being gay. He described having these distressing thoughts when he saw what he considered to be a masculine looking man or images in magazines or on television representing masculinity. He also reported that seeing two men talking to each other could trigger thoughts about possibly being gay. In addition, Simon described sexual side effects related to his SSRI and reported that the loss of sexual interest in his wife would also trigger his concerns about being gay. To monitor his progress throughout treatment, Simon was given several assessment measures on a monthly basis. These assessments included both self-report questionnaires and clinician-administered symptom assessments. The following assessments were used throughout Simon’s treatment. YBOCS The YBOCS (Goodman et al., 1989) is a clinician-administered, semistructured interview used to assess both the presence and severity of both obsessions and compulsions. The YBOCS has been shown to have good reliability and validity. Hamilton Depression Scale (HAM-D) The HAM-D (Hamilton, 1960) is a clinician-administered interview designed to assess current symptoms of depression. It has been found to be highly reliable and sensitive to changes in severity throughout treatment (Dozois & Dobson, 2002). Brown Assessment of Beliefs Scale (BABS) The BABS (Eisen et al., 1998; Eisen et al., 2001) is a semistructured interview consisting of seven items all rated on a Likert-type scale. This scale is designed to measure the level of insight the patient has into the obsessional beliefs they are experiencing. The BABS has been found to have excellent interrater reliability and test–retest reliability as well as a high level of internal validity. Obsessive Compulsive Inventory–Revised (OCI-R) The OCI-R (Foa et al., 2002) is a self-report questionnaire designed to assess the presence of various symptoms of OCD. It consists of a total score as well as several subscales. This measure has been found to have good reliability and validity. Quality of Life Satisfaction Questionnaire (Q-LES-Q) This (Endicott, Nee, Harrison, & Blumenthal, 1993) self-report measure is designed to assess satisfaction of the patient across multiple domains of functioning over the past week. This measure has been found to be both reliable and valid while reflecting changes following treatment (Kocsis et al., 1997). Social Adjustment Scale–Self Report (SAS-SR) The SAS-SR (Weissman & Bothwell, 1976) is a self-report measure designed to measure functional impairment in a variety of psychiatric populations. Fifty-four items measure functioning across multiple domains including social interactions and work functioning. 6 Case Conceptualization Simon’s symptoms can be best understood with a cognitive-behavioral conceptualization of OCD. The intrusive, distressing thoughts Simon experienced are similar to those experienced by a large majority of the general population (Rachman & de Silva, 1978). Thus, it was not the thoughts themselves but Simon’s response to them that was creating his difficulties. In Simon’s particular case, he experienced frequent intrusive thoughts about possibly being gay. Simon interpreted these thoughts as significantly distressing and made efforts to avoid thinking similar thoughts in the future. These avoidance strategies included avoidance of “sporty” men or media representations of “masculine” men. In addition, he avoided being in confined areas with other men. When forced to be in such situations, he would create physical distance between himself and the other man. These avoidance strategies served to decrease the anxiety Simon was experiencing in the short term. By removing himself from stimuli that prompted the intrusive thoughts, he was able to decrease the frequency of the thoughts. However, despite his attempts at avoidance, he was unable to completely avoid intrusive thoughts, and their continued presence caused him increased distress over time. In addition, Simon’s avoidance eliminated many social and family activities from his life and caused him difficulties in his job. Increased social isolation and job stress contributed to both his symptoms of depression and his continued belief that intrusive thoughts were highly problematic. Avoidance of the thoughts also served to reinforce the idea that the thoughts were indeed threatening by proving that if he avoided the feared stimuli (i.e., other men) that nothing bad (i.e., participating in sexual activity with another man) would happen. Because his strategy of avoidance worked temporarily reducing anxiety, Simon saw avoidance as a necessary strategy. Thus, in the future when an intrusive thought about being gay occurred, Simon avoided other men or created physical distance when total avoidance was not possible. In this way, Simon continued the cycle of intrusive thought, avoidance, and temporary relief from anxiety. 7 Course of Treatment and Assessment of Progress Simon came to the center as part of a larger research study examining the augmentation of SSRI treatment for OCD with either EX/RP, risperidone, or pill placebo. Assessments were conducted by master’s or doctoral-level independent evaluators, including the second author, at regular intervals before, during, and after treatment, which was every 4 weeks up to week 32. All evaluators were blind to the patient’s treatment condition. At his initial baseline evaluation, Simon had a score of 24 on the YBOCS, which is above the clinical cutoff for study inclusion. At that point, Simon was taking 60 mg of citalopram as an antiobsessional and 0.5 mg of lorazepam as needed, used infrequently for anxiety. Because Simon had only partially responded to this regimen, this was augmented with risperidone to enhance the effect of the SSRI, titrated up to 2.5 mg per day. He was able to consistently take these medications as prescribed on a daily basis. He initially showed some improvement following the addition of risperidone but had significant side effects, including musculoskeletal rigidity, weight gain, and decreased libido. Because of these side effects, risperidone was discontinued at week 8, citalo-pram was increased to 80 mg at week 12, and Simon assigned to a clinician to receive EX/RP therapy starting at week 16. He was maintained on 80 mg of citalopram and 0.5 mg of lorazepam as needed throughout his time in psychotherapy. His YBOCS score at week 12 was a 9, which is in the borderline range and is indicative of his improvements while on the risperidone. Following his discontinuation of risperidone, his YBOCS increased prior to the initiation of exposure session in EX/RP therapy. Sessions 1 to 2 The first two sessions were devoted to assessment of symptoms and current functioning along with in-depth psychoeducation about OCD and the rationale for EX/RP treatment. Simon’s EX/RP therapy was provided by the first author. Psychoeducation specific to Simon’s symptoms included information about normal patterns of sexual arousal, including the fact that heterosexual people may occasionally feel attracted to people of the same sex and may find these thoughts pleasant or unpleasant (Renaud & Byers, 1999). During these initial sessions, the therapist instructed Simon in completing self-monitoring forms to track his rituals throughout the day. Between Sessions 1 and 2, the patient only completed 2 days of monitoring. Importance of daily monitoring was addressed again during the second session to help the patient understand that the monitoring is vital in the treatment planning process. In addition, in the second session, a preliminary hierarchy was created using some of the internal, external, and avoidance cue. Table 1 lists the final items in the hierarchy, and during treatment session the item was practiced and/or assigned as homework. Table 1 Table 1 Scores on Outcome Measures by Treatment Phase Session 3 Starting in Session 3, exposure exercises either imaginal or in vivo were conducted in session and assigned between sessions for continued practice. Imaginal exposures were used when in vivo exposures were not possible. In the case of Simon, imaginal exposure focused on all the things that would be bad if he were in fact homosexual. In vivo exposure focused on creating physical proximity to other men and contact with materials related to homosexuality (e.g., magazines, movies, etc.). In Simon’s third session, the therapist reviewed his self-monitoring of rituals. The majority of situations that triggered obsessions for Simon were times he was in close physical proximity to other men. The fear hierarchy was refined during this session as well. Following the completion of the fear hierarchy, an initial in vivo exposure was started. During the session, Simon had a conversation about gay marriage legislation with another man while his therapist periodically recorded his rating of distress. Distress was rated using the Subjective Units of Distress/Discomfort Scale (SUDS), with 100 being the highest level of distress possible and zero being perfectly relaxed. During this 20-min exposure, Simon’s SUDS (0–100) peaked at 20 and dropped off to 5 by the end of the exercise. Following successful completion of the in-session exposure exercise, the therapist discussed with Simon the daily between-session exposure he would need to complete. Simon was instructed to continue monitoring his rituals and to draft an imaginal exposure script outlining his fears about being gay. In addition, Simon was instructed to initiate one-on-one conversations with other men during the week. Session 4 Simon did not complete any of his ritual monitoring prior to his fourth session but did engage in some of the in vivo exposure exercises between sessions. Simon was also able to engage in one-on-one conversations with other men and record his SUDS during the activity. He also drafted an imaginal exposure script that he then read aloud in session. Simon reported significant feelings of depression during and following his imaginal exposure exercise at home. He indicated that he experienced some physiological arousal related to the story, which made him feel depressed. Psychoeducation about physiological arousal was provided to help the patient understand some of the misinterpretation of physiological cues that contribute to and maintain some of the OCD thoughts. He was informed that being physiologically aroused by a stimulus is not the same as wanting that stimulus. For homework, Simon was instructed to listen to the recording of the imaginal exposure script, continue recording rituals, watch a movie with a gay theme, and to locate men’s magazines to bring to the following session. Session 5 Simon’s homework was reviewed at the beginning of his fifth treatment session. He completed both his ritual monitoring forms and his exposure exercises. Simon listened to the imaginal exposure six times during the week and experienced a drop in his SUDS. He also watched the homosexual-themed movie Milk in its entirety. However, Simon reported flipping through the men’s magazines rather than staring at a single image, which was not resulting in the habituation needed for the exposure to be effective. Therefore, during the session, Simon stared at one image at a time for a prolonged period of time with his therapist and recorded his SUDS. During this exposure, Simon’s SUDS peaked at 30 and remained at 25 even after the exposure had ended. For homework, Simon was instructed to continue looking at a single image in the magazines, listening to the imaginal exposure, and recording rituals, and to rewatch the most distressing scenes from the movie Milk. Session 6 Prior to Simon’s sixth session, he listened to the imaginal exposure several times, watched the movie Milk, and looked at pictures in men’s magazines. Simon reported significant anxiety while watching the movie as indicated by a SUDS level of 60. Simon continued to report significant feelings of depression during completion of his homework. He was able to identify the belief that if he were gay, he would be “no good.” Simon was instructed to draft a new imaginal exposure outlining what it was about being gay that would make him “no good.” For homework, Simon was also instructed to continue looking at men’s magazines, listening to the new imaginal exposure tape, and watching most distressing scenes from Milk. In response to obsessions that Simon might experience on a daily basis, he was instructed to mentally “agree” with the thoughts. For example, if he had the thought “What if I am really gay?” then rather than engage in mental reassurance, he was to mentally respond with, “Yes, I am just gay, and that makes me no good.” Session 7 Simon reported that he was able to listen to his imaginal exposure, and he created a new one prior to the next session. He also watched distressing scenes from the movie and looked at men’s magazine pictures. During the session, Simon read the new imaginal exposure and worked with the therapist to add more detailed information about all the bad things he believed would happen if he was gay. He then made an audio recording of the new imaginal exposure to listen at home. Simon also did an in vivo exposure involving reading information he found online related to the experience of being gay. For homework, Simon was assigned to listen to the new recording, rent and watch a new movie with homosexual themes, visit a gay bookstore or reading room, and purchase some gay-themed magazines. Session 8 Following Session 7, Simon’s therapist had an unexpected medical leave and a new therapist, the third author, was assigned to complete Simon’s treatment. Prior to the eighth session, Simon repeatedly listened to his imaginal exposure, watched the homosexual-themed movie Brokeback Mountain, and stared at pictures in gay men’s magazines. As this was his first meeting with his new therapist, a large portion of the session was spent getting acquainted. An in vivo exposure was also conducted using the magazine pictures. Simon was instructed to continue listening to the imaginal exposure, watching movie scenes, and staring at men’s pictures in the gay magazines. Session 9 Prior to his ninth treatment session, Simon again watched Brokeback Mountain, listened to the imaginal exposure, and sat in close physical proximity to other men for homework. During the session, Simon and his therapist stared at a picture of men engaging in sexual activity with other men. Simon’s SUDS peaked at 40 while staring at this picture, which was significantly lower than he expected. By the end of the session, his SUDS had dropped to 30. Simon was instructed to continue listening to his imaginal exposure and to look at the picture from the session at home before his next session. Sessions 10 to 17 Simon continued listening to his imaginal exposure between sessions. He also made an effort to be in close physical proximity to other men and to engage in one-on-one conversations with men at work and at his children’s athletic events. Starting in his 10th therapy session, Simon watched sections of homosexual pornography with his therapist. The therapist reminded Simon that it was normal to feel a certain amount of sexual arousal while watching sexual activities, even though in this case the activities only involved men. During the exposure, Simon’s SUDS peaked at 40, which was again lower than he expected. This exposure was repeated in all the following treatment sessions to ensure habituation. Simon was instructed to watch segments of the pornographic DVD at home between sessions. He was also asked to engage in normal activities he had been avoiding, such as having sex with his wife and talking with other men at a sports bar. At the top of the hierarchy, Simon and his therapist went together to a gay bar as an in-session exposure. While at the gay bar, Simon’s SUDS peaked at 25 and dropped to 15 by the end of the exposure. By the final session, Simon reported a peak SUDS level of 5 while watching homosexual pornography. Toward the end of treatment, discharge planning became a focus during therapy sessions. Discharge planning largely involved the discussion about relapse prevention, progress made in therapy, and developing a plan in the event of symptom reoccurrence. Simon’s discussion of relapse prevention with his therapist focused on continued naturalistic exposures, “spoiling” rituals when they happen, and calling his therapist with any questions or concerns that might arise in the future. Outcome Evaluation By the end of treatment, Simon reported that he was no longer bothered by his obsessive-compulsive symptoms. His symptoms were evaluated 12 days after his last treatment session for his post-treatment assessment. Self-report and clinician-administered measures of OCD all indicated substantial decreases in symptom severity. His score on the YBOCS fell from 24 at intake to 3, an indication of minimal symptoms. Similarly, his score on the OCI-R fell from 8 at baseline to 2. On the BABS, he endorsed the belief that “if I have thoughts of being gay, I would be really uncomfortable and worthless,” which fell from a score of 14 to 0. His depressive symptoms that peaked during his risperidone treatment at 16 fell to 1 after treatment. His quality of life improved from a Q-LES-Q score of 54 to a 70 at follow-up. The SAS-SR measure of social adjustment difficulty decreased from 2.05 to 1.67. Interestingly, all of Simon’s improvements occurred quite abruptly from the early stage of treatment to the first midtreatment assessment. Table 1 presents his progress on all measures. Figure 1 illustrates the decrease in OCD severity based on the YBOCS and OCI-R scores. Figure 1 Figure 1 Changes in symptoms over time weeks in treatment The EX/RP therapy was clearly effective in ameliorating Simon’s symptoms of OCD. His decrease in depressive symptoms could have been due to the improvement in his OCD symptoms, the direct result of the behavioral activation implemented early in treatment, or a combination of the two. 8 Complicating Factors As with most treatment options, there were some challenges throughout the course of treatment. Simon appeared to understand both the cognitive behavioral model for OCD and the treatment rationale for EX/RP therapy. Initially, he was having some difficulty following through with homework assignments, particularly self-monitoring and imaginal exposure exercises. His depression was interfering with his ability to work on the imaginal exposures because of an increase in depressive symptoms following the exercise. The imaginal exposure focused on a detailed sexual encounter with a man, which resulted in physiological arousal that increased depressive rumination and obsessive thoughts. This was addressed in session by explaining that exposure exercises were intended to increase anxiety but not depression. Simon was asked to draft another imaginal exposure that focused more on his perceived negative consequences of being gay rather than the physical relationship he would have with another man. Simon was also offered additional between session contacts with the therapist if he found that his depressive thoughts were increasing significantly. Another significant problem that occurred in treatment was the unplanned switch in therapist midway through treatment. This transfer was due to an unexpected medical leave of the first clinician. This switch resulted in a significant delay between sessions. In addition to the delay, Session 8 was primarily to allow the new clinician to become acquainted with the patient and treatment thus far. Although this somewhat slowed down the progression of treatment, it did not result in a regression to previous symptoms or any other significant distress to the patient. This was likely due in part to the fact that the client continued to engage in daily homework exercises during the break in treatment. 9 Follow-Up At the end of treatment, the patient was offered the opportunity to call his therapist or to schedule a booster session if he experienced any difficulties following termination. At the time of termination, his YBOCS total score was 3, which falls within the normal range, indicating that Simon was no longer experiencing any significant symptoms of OCD. At the 6-week follow-up assessment, his YBOCS score remained in the normal range indicating that not only had he significantly improved but also that he maintained his gains in the 6-week period following termination of treatment. His 6-week follow-up scores on all measures are shown in Table 1. Three months after the conclusion of treatment, he was contacted by his first therapist by phone for a follow-up report and reported no difficulties. To date, Simon has not requested a booster session. 10 Treatment Implications of the Case Because of the sensitive nature of unwanted sexual thoughts, stigma surrounding homosexuality, and great potential for misdiagnosis, it is critically important that sexual-orientation symptoms in OCD be readily identified and well understood by clinicians (Williams, 2008). To date, very little information about the prevalence, correlates, or treatment of sexual-orientation obsessions and related compulsions has been published. Sexual-orientation obsessions are distressing to those experiencing them and often misunderstood by clinicians treating them. More research is needed to raise awareness about this particular symptom of OCD. However, at this time, it appears that EX/RP therapy is effective in the treatment of this OCD presentation, despite being understudied. 11 Recommendations to Clinicians and Students The success of EX/RP therapy in this case suggests that sexual obsessions in OCD are not different from other types of OCD except in the specific content. The primary reason for bringing special attention to this particular form of obsessions is the common misdiagnosis or lack of diagnosis in those patients with sexual-orientation obsessions. Individuals presenting for treatment with OCD should be asked about sexual content in the same way they are asked about other types of obsessions. It is important to differentiate those with intrusive unwanted sexual obsessions from those who may be experiencing distress related to dissatisfaction about their actual sexual orientation, as EX/RP therapy is not supported or validated as a means of sexual-orientation reassignment. Sexual-orientation obsessions can be differentiated from true sexual-orientation concerns in the type of distress they produce. Sexual obsessions are ego-dystonic and are experienced as unwanted, intrusive thoughts. For someone identifying as homosexual, this would likely not be the case. Sexual thoughts about same-sex partners would be considered pleasurable rather than simply distressing, though such patients may also feel guilt and discomfort about having enjoyable same-sex thoughts. It is possible in some cases that patients may be distressed because they are actually gay or bisexual and also have OCD. Therapists are urged to use caution and sensitivity to explore this possibility, as most OCD patients with sexual-orientation obsessions are not gay and questioning them in this manner can increase distress and damage rapport (Williams, 2008). For those patients presenting with sexual obsessions in OCD, EX/RP therapy continues to be an effective treatment. Sexual-orientation fears would be considered part of the symptom dimension sometimes called “unacceptable thoughts,” “taboo thoughts,” or “pure obsessional.” These types of obsessions tend to be coupled with covert compulsions, such as mental rituals, checking arousal levels, and reassurance seeking (e.g., Abramowitz et al., 2003). Therefore, like in the case of Simon, extensive probing may be necessary to uncover all rituals and avoidances. In addition, imaginal exposure will likely be an important component to treatment. Other than the specific items on the treatment hierarchy, we believe there are likely to be no differences between the necessary treatment approach for this presentation of OCD and any others. It is expected that individual hierarchy items vary from patient to patient. Exposures can be designed to target the fears present in sexual-orientation obsessions just as effectively as with any other form of OCD, so clinicians should aggressively treat this symptom presentation without hesitation. ​ Table 2 Table 2 Exposure Hierarchy With SUDS by Treatment Session Acknowledgments Funding This work was supported by the National Institute of Health/NIMH Grant “Maximizing Treatment Outcome in Obsessive-Compulsive Disorder,” 3 R01 MH045404-19 (PI: Edna B. Foa). The authors would like to acknowledge the additional members of the patient’s treatment team, including Edna Foa, PhD, and the independent evaluators for the patient, including Elyssa Kushner, PhD, Mike Ferenschak, MA, Jackie Halpern, MA, study nurse, Pat Imms, RN, and psychiatrist C. G. Hahn, MD, PhD. Biographies • Monnica T. Williams, PhD, is an assistant professor of psychology at University of Pennsylvania in the Center for the Treatment and Study of Anxiety. She completed her undergraduate studies at Massachusetts Institute of Technology and University of California, Los Angeles, and received her doctoral degree in clinical psychology from the University of Virginia. • Marjorie Crozier, MA, is a doctoral candidate in clinical psychology at LaSalle University. Her research and clinical interests are focused in the area of child and adult anxiety disorders. She is currently a practicum student at University of Pennsylvania in the Center for the Treatment and Study of Anxiety. • Mark Powers, PhD, is an assistant professor and codirector of the Anxiety Research & Treatment Program at Southern Methodist University. He received his bachelor’s degree at the University of California at Santa Barbara and his master’s degree in psychology at Pepperdine. He received his PhD in clinical psychology from University of Texas at Austin. Footnotes Declaration of Conflicting Interests The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article. Article information Clin Case Stud. Author manuscript; available in PMC 2011 Dec 6. Published in final edited form as: Clin Case Stud. 2011 Feb; 10(1): 53–66. doi: 10.1177/1534650110393732 PMCID: PMC3230880 NIHMSID: NIHMS333837 Monnica T. Williams,1 Marjorie Crozier,2 and Mark Powers3 1University of Pennsylvania, Philadelphia 2LaSalle University, Philadelphia, PA 3Southern Methodist University, Dallas, TX Corresponding Author: Monnica T. Williams, Center for Mental Health Disparities, University of Louisville, Psychological & Brain Sciences 2301 South Third Street, Louisville, KY 40292, Email: ude.ellivsiuol@smailliw.m Copyright notice and Disclaimer References Abramowitz JS, Franklin ME, Schwartz SA, Furr JM. Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology. 2003;71:1049–1057. [PubMed] Ball SG, Baer L, Otto MW. Symptom subtypes of obsessive-compulsive disorder in behavioral treatment studies: A quantitative review. Behaviour Research and Therapy. 1996;34(1):47–51. [PubMed] Dozois DJA, Dobson KS. Depression. In: Antony MM, Barlow DH, editors. Handbook of assessment and treatment planning for psychological disorders. 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