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Abstract

Obsessive–compulsive disorder (OCD) is one of the common psychiatric disorders. Despite being one of the basic aspects of biology, the sexual functioning in OCD patients has not received much attention, with there being very limited research on sexuality in these patients. In this review article, we try to take a look at the research on sexual functioning, sexual dysfunctions, and neurobiology of sexual dysfunctions in the anxiety disorders in general and in OCD specifically. We also take a look at the research on relationship functioning in the patients with OCD, a recently proposed entity, relationship-related obsessive compulsive phenomenon, at the sexual obsessions, and the sexual functioning in patients on active treatment for OCD. The overall research suggests that we should always take into account the sexual life and functioning of patients presenting with OCD.

Keywords

Basics of sexuality legal aspects sexual abuse sexual disorders

Introduction

Obsessive–compulsive disorder (OCD) is a commonly occurring psychiatric disorder.¹ It is classified under anxiety disorders in the International Classification of Diseases 10 and under the obsessive compulsive spectrum disorder in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Sexuality is defined by the World Health Organization as follows:

A central aspect of being human throughout life encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.

It is one of the important aspects of human life, and sexual health determines the overall quality of human life.² Despite that, sexuality has not had much attention in research with respect to OCD. Sexuality is a complex phenomenon which is influenced by multitude of factors including the sociocultural context, interpersonal relationship and communication, underlying psychiatric disorder, pharmacological treatment, and other cognitive factors. All these factors are interlinked and work by influencing and interacting with each other. Some types of obsessions are known to be sexually explicit in nature and are distressing for the patient. But there is a need for thorough exploration of current data on sexuality and/or sexual health and OCD. Thus, in this narrative review, we try to look at the aspects of OCD which are relevant from sexual point of view. For the ease of comprehension, we have arbitrarily discussed different aspects of OCD and how sexuality is influenced due to OCD.

Anxiety Disorders Comorbid Sexual Dysfunctions

Anxiety, induced by any cause and resulting in increased sympathetic tone, can be a distracting influence from erotic stimuli leading to impaired sexual arousal.³ A vicious circle of anxiety/dysfunction/performance anxiety can arise just like in Honeymoon impotence.^{4, 5} Anxiety symptoms if present in patients with arousal disorders can result in poorer treatment outcomes. Studies have shown presence of anxiety disorders, from 2.5% to 37%, in patients with erectile dysfunction.^{6, 7} A study describing 103 patients with involuntary genital and clitoral arousal (hyperarousal syndrome) in which anxious experience triggered the arousal in one-third and anxiety-related symptoms such as anxious preoccupations, panic attacks, and obsessive–compulsive (OC) symptoms were seen in significant number of patients.⁸ Not only desire and arousal but orgasm can also be negatively affected. Widely accepted phenomenon is that anxious thoughts or feelings disrupt female orgasm.^{9, 10} Fear of failing to meet the partner’s expectations or the performance anxiety is one of the more common causes of premature ejaculation (PE).^{11, 12} This has been hypothesized as being caused by a sympathetic hyperactivity that reduces ejaculation control.¹³ During intercourse the worry/thoughts about sexual performance/adequacy may distract the person from sensations that arise before orgasm and ejaculation. It has been reported that 25.5% to 47% patients with premature ejaculation have social phobia.^{14, 15} Relationship between performance anxiety and retarded ejaculation is not clear, though some investigators have suggested a link.¹⁶ In Dyspareunia, high levels of anxiety have been demonstrated.^{17, 18} It has been suggested in the hypervigilance associated with anxiety, attention is allocated to threatening stimuli during intercourse.^{19, 20}

Sexual Dysfunctions Secondary to Anxiety Disorders

Sexual dysfunctions are commonly reported in anxiety disorder patients. 75% patients with panic disorder have been reported to have sexual problems, most common among them being sexual aversion disorder.^{21, 22} In social anxiety disorder, 30% patients have been reported to have sexual dysfunctions, with arousal disorder and orgasm–ejaculation disorder being most common.²³ Studies have reported high prevalence of premature ejaculation (47%), and retarded ejaculation (33%) in patients of social anxiety disorder.^{22, 23} Women with social phobia were found to have desire disorders (46%) and pain during sex (42%), in significant numbers.²³ 69% patients with posttraumatic stress disorder were found to have erectile dysfunction, problems in orgasm, and reported poor sexual satisfaction.^{24, 25} Kendurkar in 2008,²⁶ reported that 64% patients with generalized anxiety disorder have either decreased desire or arousal.

Neurobiology of Sexual Dysfunctions in Anxiety Disorders

There have been studies showing hyperactive response in the amygdala to threat and reduce interconnectivity between areas responsible for emotional processing, such as amygdala and insula, and areas involved with regulation, such as dorsolateral and medial prefrontal cortex, rostral anterior cingulate cortex, and hippocampus, which might result in biased appraisal of emotional stimuli and other’s intentions.^{27, 28} Increased noradrenergic activity over the frontal cortex has been suggested to reinforce the cortico-striato-thalamo-cortical circuit, associated with worriness.²⁹ All this, overall, results in the person getting distracted from the sexual cues and fantasies and focusing on intrusive thoughts, like getting concerned about the erection.^{30, 31} Although studies for neurobiological model are lacking, the common presence of anxiety in patients with impaired orgasm and ejaculation does provide support for a causal role for anxiety. Premature ejaculation has been found to be more related to “state anxiety” than to lifelong anxious traits,³² and is likely the result of increased sympathetic supply to the spinal generator of ejaculation.^{33, 34} In delayed or absent ejaculation, the anxious patient prioritizes stressful stimuli which, if not affecting arousal or causing increased sympathetic outflow, competes with the sexual stimuli resulting in impeded sexual enjoyment that is necessary for proper limbic-hypothalamic and oxytocinergic circuits in the brain to result in orgasm and ejaculation.

Sexual Dysfunctions in Obsessive–Compulsive Disorder

With regard to sexual dysfunctions in OCD there are several classical studies that have shown that sexual dissatisfaction and sexual dysfunction in OCD can range from 54% to 73% patients.^35–37 But these data are complicated by factors such as lesser rates of marriage, difficulties in intercourse, and lesser sexual experience in patients with OCD.³⁸ A study in 1987 found that 9% of the female patients had anorgasmia, 22% had problems in sexual arousal, whereas in males 25% had reduced sexual arousal, 12% had early ejaculation, 6% had problems in erection, and 39% of the subjects had dissatisfaction with their sexual life.³⁹ A study in 1989 found 12% subjects to be suffering from anorgasmia.³⁶ A study found higher rates of anorgasmia, decreased sexual arousal, and sexual avoidance in patients with OCD when compared to those with generalized anxiety disorder.³⁵ A study assessing subjective appreciation of sexuality and sexual functioning in female patients with OCD and healthy subjects, controlling for the effects of treatment and subtype of OCD, showed in OCD patients reduced or absent desire for sex, moderate to severe disgust from sex, reduced or absent of pleasure in thinking about sex, lack of or lesser sexual arousal, difficulty in getting orgasm, unsatisfactory orgasm, and absence of pleasure in sexual acts.⁴⁰ Patients with OCD had similar frequencies of sexual intercourse to normal controls, even though they more frequently reported to fear sexual intercourse and found it less pleasurable. Moreover, not much difference was reported for different severities of the disorder or the different subtypes of obsessions, the sexual dysfunction was not found to be restricted to patients with contamination-related obsessions. The onset of the SD within the course of OCD has been of interest as well. Although most patients reveal sexual problems after the start of pharmacological management, some authors have reported high rates of sexual dysfunction even before the onset of OC symptoms, 20% according to one study.³⁶ In 2002, it was reported that male subjects with OCD had a lower age at the time of first masturbation and the first nocturnal emission, and infrequent orgasm among female and male patients with OCD occurred in 63.6% and 57.1%.²⁶ 60.6% of female patients had sexual avoidance, anorgasmia was seen in 24.2% of the female patients, and the severity of the OCD did not correlate with the severity of the sexual problems.²⁶ When a study compared sexual dysfunction in OCD and social anxiety disorder (SAD), it was found that OCD patients had more difficulty in reaching the orgasm and less frequent effective erections.⁴¹ It has been explained to be because of the need of the OCD patients to remain in control, whereas the orgasm requires complete abandonment of self-control.^{42, 43} Hence, there is a consensus regarding the frequency and types of sexual dysfunction an OCD patient can suffer from, but many of these studies suffer from methodological flaws like absence of placebo group, baseline assessment, ie, prior to the onset of the pharmacological treatment and failure to use validated rating scales.

OCD and Relationship Functioning

Relationship problems are some of the common causes of sexual dysfunction or poor quality of sex.⁴⁴ With regard to OCD there is quite consensus that people with OCD have social skill deficits are often dissatisfied and avoidant in their relationships, and have difficulties in interpersonal relationships, are often comorbid with OCD and are less likely to get married.⁴⁵ Significant marital problems and distress have been reported for OCD patients. 47% do not have a partner, or have had intercourse in years.³⁶ Besides social skill deficits other reasons have been proposed to be involved in trouble establishing and maintaining relationships in OCD, like excessive need to control their thoughts and to take control,⁴² high disgust sensitivity,⁴⁶ and concealing of obsessional belief may hamper the person’s capacity for intimacy, because their revealing the obsessions will probably increase their occurrence and may lead to shame and embarrassment.⁴⁷ Regardless the type of symptoms, OCD impacts more than just the patient. Often it is difficult for the partner to understand the cognitions and behavior leading to frustration, feeling that the other person is doing this on purpose, or the thoughts that the other person is crazy thus losing respect for them. Hence, OCD patients are more likely to get separated or divorced.⁴⁸ There are 3 specific things to talk about with respect to OCD and relationships: accommodation, criticism, and effective communication. Accommodation is the participation of a family member to participate in their loved one’s OCD rituals, assisting with the avoidance or helping the partner solve problems stemming from OCD. Accommodation can be subtle, eg, partner who makes the bed a certain way because an OCD patient has obsessions about the need for symmetry and exactness and needs the bed to be made in a specific manner, or, extreme, eg, a partner who showers many a time a day because her loved one with OCD believes she may become contaminated by contact with her partner.⁴⁹ It can also be voluntary or demanded/requested.⁵⁰ Accommodation is seen in 40% to 88% of relatives to some degree.^{38, 51} But accommodation ultimately strengthens OCD, affects relationship functioning, and diminishes treatment effectiveness.⁴⁹ Criticism is another aspect, in the form of expressed emotions. It can lead to hostility, conflict, and emotional distancing, and can exacerbate relationship distress and anxiety.³⁸ Higher rates of expressed emotions lead to poorer treatment outcomes.⁵² Criticism can be of three types: hostile criticism, nonhostile critical comments, and perceived criticism. Hostile criticism is making personal derogatory remarks and has negative impact on relationship and treatment outcome.⁵³ Nonhostile critical comments can be for eg a partner communicating that your OC symptoms are interfering with his ability to go out in the evening. It can have positive impact on relationship and treatment outcome.⁵³ It has been demonstrated that the severity of the symptoms is not related to a relative’s hostility toward them but instead are related to how critical a patient perceives their partners or relatives to be and it can have negative impact on relationship and treatment outcome.⁵³ OCD can have impact on communication not just in the partners but also among family.⁵⁴ In families with someone suffering from OCD there is less healthy communication, affective involvement, and general functioning, as compared to other affected families. Communication patterns that exhibit empathy, hopefulness, assertiveness, and acceptance are more positively associated with good treatment outcomes.⁵⁵ All these aspects interact and decide how OCD couples perceive their relationship and how the couples rate their relationship satisfaction.⁵³ Obsession severity is negatively correlated with relationship satisfaction.⁵⁵ An interesting study in 2007 studied the effect of OCD on romantic functioning. Research was addressed to 3 specific points of romantic functioning: intimacy, relationship satisfaction, and self-disclosure. Negative associations existed between the symptom’s severity and all the domains of romantic love.⁵⁴

Relationship-Related Obsessive–Compulsive Phenomenon

In 2012, Guy Doron et al proposed the concept of relationship-related obsessive–compulsive phenomenon.⁵⁶ Here, the relationship or the relationship partner becomes the focus of the obsessive–compulsive symptoms. 2 types of ROCD have been proposed: relationship-centered ROCD (ROCD type I) and partner-centered ROCD (ROCD type 2). In ROCD type 1, OC phenomena can be related to the patient’s feelings for the partner, like continuous reassessment of love for the partner, the feelings of the partner toward the patient, like continuous doubting partner’s love for self, or if the relationship is just “right,” like checking and rechecking whether the relationship feels right. In ROCD type 2, there can be increasing focus on the partner’s perceived deficits that may relate to physical appearance, emotional stability, sociability, morality, intelligence, and competence. Relationship-related obsessions may manifest as intrusive thoughts (is this the right person?), images (eg of previous partners), or urges (eg to break the current relationship). The compulsive behaviors can be for example repeatedly checking their own feelings and thoughts toward the partner or the relationship, comparing the partner’s characteristics or behaviors with other people, seeking reassurance, or reassuring self. ROCD symptoms can often be distressing, as they might be contradictory to what the person is actually experiencing in the relationship, for example the person might know that they are loved but still cannot stop themselves from questioning their own or their partner’s feelings, or they might be contradictory to personal values such as appearance of a person should not be a factor when going for a relationship. This kind of intrusive thoughts can be unacceptable and unwanted, and can bring feelings of guilt and shame because of their occurrence and/or content. This kind of repeated checking of one’s feelings toward the relationship or partner and vice versa can damage emotional bonds, escalating the already existing fears and doubts related to the relationship, and can cause increase in relationship distress. The continuous preoccupation with the perceived shortcomings of the partner may damage idealized perceptions of the relationship and/or partner.

Sexual Obsessions

Despite being one of the common features of OCD, sexual obsessions have not received much attention in research. Feeling embarrassed in talking about them or denying them altogether could be the reason hindering their assessment. There can be different kinds of intrusive, distressing obsessive thoughts with sexual content such as having sex with family members, children, or animals, regarding one’s sexual orientation, or getting engaged in sexually aggressive behavior. Sexual obsessions are believed to be very common in general population,⁵⁷ with some believing that sexual obsessions originate from normal unwanted thoughts.^{58, 59} The differentiating feature between the unwanted intrusive thoughts of the normal person from the obsession in a person with OCD lies in the meaning the person with OCD attaches with the unwanted intrusive thought. The cognitive bias of “thought-action fusion” in the person with OCD could be the maximizing factor making the obsessive thought equivalent to its behavioral manifestation.⁶⁰ It is also believed that in a sexually repressive society, individuals with negative beliefs about sex more frequently have sexual obsessions.⁶¹ 20% to 30% of individuals with OCD report having sexual obsessions.⁶² They have been reported in cases having history of sexual abuse and in children⁶³ as well.⁶⁴ About 13.3% individuals with OCD at any given time have sexual obsessions.⁶⁵ Persons with sexual obsessions were more likely to have aggressive and religious obsessions and the onset of OCD at an early age (15.1 ± 5.6 years) compared to persons without sexual obsessions (19.0 ± 10.3 years).⁶⁵ Sexual obsessions tend to be more commonly reported in men⁶⁶ and in patients with tic disorders,⁶⁷ poorer response to treatment,⁶⁸ poorer insight,⁶⁹ and poorer sexual satisfaction;³⁶ thought studies showing contradictory results have also been reported.⁶⁵ The inclusion of sexual obsessions with aggressive or religious obsessions in the earlier studies could be the reason behind these discrepancies.

Sexual Dysfunctions Associated with Treatment of OCD

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine, a tricyclic antidepressant, are most commonly and are considered the most efficacious for the treatment of OCD. It is believed that SSRIs cause more sexual side effects than tricyclic antidepressants.⁷⁰ The sexual side effects due to SSRIs have been reported to range from low percentage to almost 80% of patients.⁷¹ The great variety in the percentages of incidence of sexual side effects, as reported by different studies, could be due to reasons such as less reporting of sexual side effects by the patients, lack of use of validated rating scales, etc.^{72, 73} Both the SSRIs and clomipramine increase the synaptic levels of serotonin and stimulation of the postsynaptic serotonin receptors is believed to be resulting in sexual side effects.⁷⁴ With the SSRIs, all the stages of the human response cycle can be affected, resulting in side effects such as decreased sexual desire, decreased arousal, and delayed ejaculation.⁷¹ It is important to take into consideration the sexual functioning in the patients undergoing treatment for OCD due to several reasons. The doses required in the treatment of OCD may be higher than used for depression, leading to greater chances and severity of sexual side effects.⁷⁵ Many of the patients who do not respond to single drugs may require combination with drugs like antipsychotics and other SSRIs, further complicating the situation with respect to sexual side effects.⁷⁶ Sexual side effects are some of the worst tolerated side effects⁷⁷ and, according to studies, 20% to 40% patients consider dropping out of treatment for this reason.⁷⁶

Conclusion

Sexuality in OCD is a subject which has not been given enough attention in research despite a strong possible link between some OCD features and sexual functioning. Sexual dysfunctions are commonly found in patients of OCD. They can be part of the disease process of OCD and also can be treatment emergent. In addition, they can severely affect the relationships as well. Even lesser focus of research has been on sexual obsessions. Overall, the sexual functioning should always be kept in mind when it comes to OCD patients, as sexual dysfunction can have profound negative impact on the quality of life of the patient and can even lead to patient to discontinue the treatment.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Sadock

Ruiz

Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences . Walters Kluwer; 2015.

Eisen

Mancebo

Pinto

Impact of obsessive-compulsive disorder on quality of life. Compr Psychiatry . 20061;47(4):270-275.

Barlow

DH.

Anxiety and its disorders: the nature and treatment of anxiety and panic . Guilford Press; 2004.

Johnson

Masters

WH.

Human sexual inadequacy . Boston, MA: Little, Brown; 1970.

Shamloul

Case Report: Management of Honeymoon Impotence. J Sex Med . 2006;3(2):361-366.

Mallis

Moysidis

Nakopoulou

Papaharitou

Hatzimouratidis

Hatzichristou

Psychiatric morbidity is frequently undetected in patients with erectile dysfunction. J Urol . 2005;174(5):1913-1916.

Farre

Fora

Lasheras

MG.

Specific aspects of erectile dysfunction in psychiatry. Int J Impot Res . 2004;16(S2):S46.

Leiblum

Nathan

SG.

Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther . 2001;27(4):365-380.

Zuk

The case of the female orgasm. Perspect Biol Med . 2006;49(2):294-298.

10.

Meston

Levin

Sipski

Hull

Heiman

. Women’s orgasm. Annu Rev Sex Res . 2004;15(1):173-257.

11.

Hawton

Catalan

Prognostic factors in sex therapy. Behav Res Ther . 1986;24(4):377-385.

12.

Dunn

Croft

Hackett

GI.

Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health . 1999;53(3):144-148.

13.

Williams

Secondary premature ejaculation. Aust N Z J Psychiatry . 1984;18(4):333-340.

14.

Tignol

Martin-Guehl

Aouizerate

Grabot

Auriacombe

Social phobia and premature ejaculation: a case-control study. Depress Anxiety . 2006;23(3):153-157.

15.

Corretti

Pierucci

De Scisciolo

Nisita

Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders. J Sex Marital Ther . 20061;32(2):183-187.

16.

Althof

Leiblum

Chevret-Measson

Psychology: psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med . 2005;2(6):793-800.

17.

Nunns

Mandal

Psychological and psychosexual aspects of vulvar vestibulitis. Sex Transm Infect . 1997;73(6):541-544.

18.

Granot

Friedman

Yarnitsky

Zimmer

EZ.

Enhancement of the perception of systemic pain in women with vulvar vestibulitis. BJOG . 2002;109(8):863-866.

19.

Dove

Wiederman

MW.

Cognitive distraction and women’s sexual functioning. J Sex Marital Ther . 2000;26(1):67-78.

20.

van den Hout

Barlow

Attention, arousal and expectancies in anxiety and sexual disorders. J Affect Disord . 2000;61(3):241-256.

21.

Kaplan

HS.

Anxiety and sexual dysfunction. J Clin Psychiatry . 1988;49 Suppl:21-25.

22.

Figueira

Possidente

Marques

Hayes

Sexual dysfunction: a neglected complication of panic disorder and social phobia. Arch Sex Behav . 2001;30(4):369-377.

23.

Bodinger

Hermesh

Aizenberg

Sexual function and behavior in social phobia. J Clin Psychiatry . 2002;63(10):874-879.

24.

Cosgrove

Gordon

Bernie

Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology . 2002;60(5):881-884.

25.

Kotler

Cohen

Aizenberg

Sexual dysfunction in male posttraumatic stress disorder patients. Psychother Psychosom . 2000;69(6):309-315.

26.

Kendurkar

Kaur

Major depressive disorder, obsessive-compulsive disorder, and generalized anxiety disorder: do the sexual dysfunctions differ. J Clin Psychiatry . 2008;10(4):299.

27.

Clayton

El Haddad

Iluonakhamhe

Ponce Martinez

Schuck

AE.

Sexual dysfunction associated with major depressive disorder and antidepressant treatment. Expert Opin Drug Saf . 2014;13(10):1361-1374.

28.

Pietrini

Godini

Lazzeretti

Neuroimaging and neurobiology of social anxiety. Rivista di Psichiatria . 2010;45(6):349-360.

29.

Shackman

Tromp

Stockbridge

Kaplan

Tillman

Fox

AS.

Dispositional negativity: an integrative psychological and neurobiological perspective. Psychol Bull . 2016;142(12):1275.

30.

Beck

Barlow

DH.

The effects of anxiety and attentional focus on sexual responding—II: cognitive and affective patterns in erectile dysfunction. Behav Res Ther . 1986;24(1):19-26.

31.

Carvalho

Nobre

Biopsychosocial determinants of men’s sexual desire: testing an integrative model. J Sex Med . 2011;8(3):754-763.

32.

Corona

Petrone

Mannucci

Psycho-biological correlates of rapid ejaculation in patients attending an andrologic unit for sexual dysfunctions. Eur Urol . 2004;46(5):615-622.

33.

McMahon

Jannini

Serefoglu

Hellstrom

WJ.

The pathophysiology of acquired premature ejaculation. Translational Androl Urol . 2016;5(4):434.

34.

Xia

Chen

The sympathetic skin response located in the penis as a predictor of the response to sertraline treatment in patients with primary premature ejaculation. J Sex Med . 2014;11(11):2801-2808.

35.

Aksaray

Yelken

Kaptanoğlu

Oflu

Özaltin

Sexuality in women with obsessive compulsive disorder. J Sex Marital Ther . 2001;27(3):273-277.

36.

Freund

Steketee

Sexual history, attitudes and functioning of obsessive-compulsive patients. J Sex Marital Ther . 1989;15(1):31-41.

37.

Staebler

Pollard

Merkel

WT.

Sexual history and quality of current relationships in patients with obsessive compulsive disorder: a comparison with two other psychiatric samples. J Sex Marital Ther . 1993;19(2):147-153.

38.

Steketee

Disability and family burden in obsessive-compulsive disorder. Can J Psychiatry . 1997;42(9):919-928.

39.

Monteiro

Noshirvani

Marks

Lelliott

PT.

Anorgasmia from clomipramine in obsessive-compulsive disorder: a controlled trial. Br J Psychiatry . 1987;151(1):107-112.

40.

Vulink

Denys

Bus

Westenberg

HG.

Sexual pleasure in women with obsessive-compulsive disorder. J Affect Disord . 2006;91(1):19-25.

41.

Fontenelle

de Souza

de Menezes

Sexual function and dysfunction in Brazilian patients with obsessive-compulsive disorder and social anxiety disorder. J Nerv Ment Dis . 2007;195(3):254-257.

42.

Bucci

Mucci

Volpe

Merlotti

Galderisi

Maj

Executive hypercontrol in obsessive–compulsive disorder: electrophysiological and neuropsychological indices. Clin Neurophysiol . 2004;115(6):1340-1348.

43.

Steinberg D. The erotic impulse: Honoring the sensual self . JP Tarcher/Perigee; 1992.

44.

Crowe

Couple relationship problems and sexual dysfunctions: therapeutic guidelines. Adv Psychiatr Treat . 2012;18(2):154-159.

45.

Angst

Gamma

Endrass

Obsessive-compulsive severity spectrum in the community: Prevalence, comorbidity, and course. Eur Arch Psychiatry Clin Neurosci . 2004;254(3):156-164.

46.

Thorpe

Patel

Simonds

LM.

The relationship between disgust sensitivity, anxiety and obsessions. Behav Res Ther . 2003;41(12):1397-1409.

47.

Newth

Rachman

The concealment of obsessions. Behav Res Ther . 2001;39(4):457-464.

48.

Regier

Narrow

Rae

DS.

The epidemiology of anxiety disorders: The epidemiologic catchment area (ECA) experience. J Psychiatr Res . 1990; 24:3-14.

49.

Calvocoressi

Mazure

Kasl

Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior. J Nerv Ment Dis . 1999;187(10):636-642.

50.

Abramowitz

Baucom

Wheaton

Enhancing exposure and response prevention for OCD: a couple-based approach. Behav Modif . 2013;37(2):189-210.

51.

Calvocoressi

Lewis

Harris

Family accommodation in obsessive-compulsive disorder. Am J Psychiatry . 1995;152(3):441-443.

52.

Chambless

Bryan

Aiken

Steketee

Hooley

JM.

Predicting expressed emotion: a study with families of obsessive-compulsive and agoraphobic outpatients. J Fam Psychol . 2001;15(2):225.

53.

Chambless

Steketee

Expressed emotion and behavior therapy outcome: A prospective study with obsessive–compulsive and agoraphobic outpatients. J Consult Clin Psychol . 1999;67(5):658.

54.

Abbey

Clopton

Humphreys

JD.

Obsessive-compulsive disorder and romantic functioning. J Clin Psychol . 2007;63(12):1181-1192.

55.

Black

Gaffney

Schlosser

Gabel

The impact of obsessive-compulsive disorder on the family: preliminary findings. J Nerv Ment Dis . 1998;186(7):440-442.

56.

Doron

Derby

Szepsenwol

Talmor

Tainted love: exploring relationship-centered obsessive-compulsive symptoms in two non-clinical cohorts. J Obsessive-Compulsive Relat Disord . 2012;1(1):16-24.

57.

Julien

O’Connor

Aardema

Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: a critical review. Clin Psychol Rev . 2007;27(3):366-383.

58.

Salkovskis

PM.

Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behav Res Ther . 1989;27(6):677-682.

59.

Rachman

A cognitive theory of obsessions. Behav Cogn Ther . 1997;35(9):793-802.

60.

Rachman

Obsessions, responsibility and guilt. Behav Res Ther . 1993;31(2):149-154.

61.

Wetterneck

Smith

Burgess

Hart

JM.

Distress from sexual thoughts: do religiosity, emotions, and thought appraisal matter. J Cogn Psychother . 2011;25(3):189.

62.

Rasmussen

Tsuang

MT.

Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry . 1986;143(3):317-322.

63.

Swedo

Rapoport

Leonard

Lenane

Cheslow

Obsessive-compulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry . 1989;46(4):335-341.

64.

Freeman

Leonard

HL.

Sexual obsessions in obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry . 2000;39(2):141-142.

65.

Grant

Pinto

Gunnip

Mancebo

Eisen

Rasmussen

SA.

Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Compr Psychiatry . 2006;47(5):325-329.

66.

Lensi

Cassano

Correddu

Ravagli

Kunovac

Akiskal

HS.

Obsessive-compulsive disorder: familial-developmental history, symptomatology, comorbidity and course with special reference to gender-related differences. Br J Psychiatry . 1996;169(1):101-117.

67.

Zohar

Pauls

Ratzoni

Obsessive-compulsive disorder with and without tics in an epidemiological sample of adolescents. Am J Psychiatry . 1997;154(2):274-276.

68.

Alonso

Menchon

Pifarre

Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry . 2001;62(7):535-540.

69.

Mataix-Cols

Rauch

Baer

Symptom stability in adult obsessive-compulsive disorder: data from a naturalistic two-year follow-up study. Am J Psychiatry . 2002;159(2):263-268.

70.

Steffens

Krishnan

Helms

MJ.

Are SSRIs better than TCAs? Comparison of SSRIs and TCAs: a meta-analysis. Depress Anxiety . 1997;6(1):10-18.

71.

Rosen

Lane

Menza

Effects of SSRIs on sexual function: a critical review. J Clin Psychopharmacol . 1999;19(1):67-85.

72.

Balon

SSRI-associated sexual dysfunction. Am J Psychiatry . 2006;163(9):1504-1509.

73.

Montgomery

Baldwin

medications:

Riley A. Antidepressant

A review of the evidence for drug-induced sexual dysfunction. J Affect Disord . 2002;69(1-3):119-140.

74.

Segraves

RT.

Effects of psychotropic drugs on human erection and ejaculation. Arch Gen Psychiatry . 1989;46(3):275-284.

75.

Bloch

McGuire

Landeros-Weisenberger

Leckman

Pittenger

Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Mol Psychiatry . 2010;15(8):850.

76.

ÁL

Montejo

Rico-Villademoros

Spanish working group for the study of psychotropic-related sexual dysfunction. Changes in sexual function for outpatients with schizophrenia or other psychotic disorders treated with ziprasidone in clinical practice settings: a 3-month prospective, observational study. J Clin Psychopharmacol . 2008;28(5):568-570.

77.

Cutler

AJ.

Sexual dysfunction and antipsychotic treatment. Psychoneuroendocrinology . 2003; 28:69-82.

Obsessive–Compulsive Disorder and Sexuality: A Narrative Review

Abstract

Abstract

Keywords

Introduction

Anxiety Disorders Comorbid Sexual Dysfunctions

Sexual Dysfunctions Secondary to Anxiety Disorders

Neurobiology of Sexual Dysfunctions in Anxiety Disorders

Sexual Dysfunctions in Obsessive–Compulsive Disorder

OCD and Relationship Functioning

Relationship-Related Obsessive–Compulsive Phenomenon

Sexual Obsessions

Sexual Dysfunctions Associated with Treatment of OCD

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References