Exposure Therapy for HOCD?
Porn-related HOCD may call for its own treatment protocol
Intrusive worries that someone has become gay—although he (she) has been straight for years with no doubts—have gained the label HOCD, homosexual obsessive-compulsive disorder. More properly such worries would be called sexual orientation obsessive-compulsive disorder because they also strike gay people who suddenly wonder if they are straight.
Therapists who treat HOCD, such as Steve Seay PhD, often recommend a standard OCD treatment: Exposure & Response Prevention. "Exposure" refers to willingly entering situations that are likely to trigger compulsions, and "response prevention" refers to purposefully inhibiting one’s coping rituals. For example: resisting the urge to wash one's hands compulsively in certain situations.
Yet the scientific reason that exposure therapy often helps with some forms of OCD is the very reason that it can backfire in the case of porn-related HOCD.
Some experts conceptualize OCD as sharing important elements of behavioral addiction because of the role that reward plays. The OCD sufferer keeps performing his particular rituals because they trigger the neurochemicals associated with reward. Relief feels good.
When the OCD sufferer consistently denies himself this neurochemical reward ("response prevention"), his triggers gradually lose their power. Why? They no longer lead to rewarding feelings. No hands are washed. No relief. No reward. Eventually the brain says, "Meh...no point in getting activated by that germy doorknob because I'm not going to get a neurochemical reward."
The same principle operates in addiction recovery. Abstain from the "rewarding" behavior for long enough, and (after a period of intense withdrawal discomfort) the brain eventually stops activating the related brain circuits with the same vengeance. This gets easier as the entire constellation of addiction-related brain changes reverses itself.
Two types of HOCD
Briefly, the difference between HOCD and porn-related HOCD is:
- OCD + homosexual fears (or event) = HOCD
- Years of porn use + distress about escalation to gay/transsexual porn = porn-related HOCD
Random events in life, such as unthinking comments by peers at vulnerable moments, can cause some people to start questioning their sexual orientation compulsively (HOCD).
However, today an emerging impetus for HOCD is chronic overstimulation, which leaves the brain less responsive to everyday pleasures and thus desperate for sensation. Highspeed pornography makes chronic overconsumption easy. Compared with erotica of the past it's so stimulating that, in some users, it produces addiction-related brain changes. No wonder. Quite apart from nonstop sexual titillation, today's Internet porn activates the brain's reward system for all evolutionarily salient stimuli, augmenting memory formation (wiring):
- Strong emotions, such as surprise, fear, disgust, anxiety,
- Seeking and searching, and
- Anything that violates expectations, including danger.
Moreover, it's possible that those who develop HOCD may have brains that are particularly plastic for some reason. According to a Chinese study, those with OCD tendencies prior to exposure to the Internet face increased risk of addiction.
In any event, a porn addict's brain can grow numb to normal pleasure even as it becomes hyper-reactive to select cues. Here's a guy describing a common progression, which is often reported by those who slip into porn-related HOCD:
29 y/o with 17 years of MO (to softcore and imagination) and 12 years of masturbating, escalating to extreme/fetish porn. I started to lose interest in real sex. The build up and release from porn became stronger than it was from sex. Porn offers unlimited variety. I could choose what I want to see in the moment. My delayed ejaculation during sex became so bad that sometimes I couldn't orgasm at all. This killed my last desire to have sex.
Classic sexual conditioning
Once this degree of desensitization has set in, the stage is set for porn-related HOCD. Non-conforming porn violates expectations, releases more dopamine and norepinephrine than earlier porn genres, and furnishes the extra kick that fires up sluggish (addicted) reward circuitry. A user may begin to question why he can get off to fetish porn with transsexual/gay action yet not be attracted to real sex partners who aroused him in the past.
His brain, however, automatically begins to wire its sexual response to this novel, stimulating genre—in a classic case of sexual conditioning. As explained in an earlier post, sexuality can be conditioned to most anything, even the smell of death, so it's not surprising that many of today's porn users report that their porn tastes morph all over the place as their pleasure response declines.
Now, our user may find that he can only climax to his latest (and therefore most stimulating) genre. If it's one that he views as inconsistent with his underlying sexual orientation, the shock value is greater...and releases even more stimulating/anxiety-producing neurochemicals. His arousal is heightened, in part, by his own stress. Three guys describe their experience:
First guy: I seriously thought I was turning gay. My HOCD was so strong at that time, I was contemplating taking a dive off the nearest high-rise. I felt so depressed. I knew I loved girls and I can't love another dude, but why did I have ED? Why did I need transsexual/gay stuff to jolt me into arousal?
Second guy: The scary thing is that I've been seeing women as crazy attractive, and men or the idea of men pretty nonsexual. As a gay man who's pretty much exclusively had relations with other men since high school, this is kind of weird. Even when I see "ugly" ladies walking on the street, I can't help but picture what it'd be like to have crazy sex with them right there. Will it stop? Is it reversible?
Third guy: The first two days I had serious anxiety, almost wanting to kill myself because I lost all attraction towards any female. These thoughts make me think that I am gay, making me question what I do, what I say, making me sick. I can't eat. I think intrusive thoughts...making me feel like I'm gay, when I know I'm not.
The users' desperation to understand whether their sexual orientation has suddenly changed can lead to constant, compulsive "testing" and other reassurance rituals. As with other varieties of OCD (including non-porn-related HOCD), the testing and searches for reassurance offer temporary relief. Each "test" reinforces the unwanted arousal—either with rewarding relief, or electrifying distress if the test fails. In this way, they reinforce the problematic triggers.
What's a therapist to do?
Keep in mind that behavioral addictions and compulsions run on reward. We know from addiction therapy that addictions gradually heal as those rewards are no longer forthcoming due to abstinence. Slowly, the brain weakens related pathways.
The therapist may best be able to help by correctly evaluating the rewards behind a particular client's HOCD. If his motivating reward is primarily relief from "testing" or from repeatedly declaring his orientation has changed (to get the temporary relief of certainty), then exposure and response prevention (no more testing or anxiety-motivated declarations) may do the trick.
In the case of porn-related HOCD, however, the rewards of addiction may comprise the lion's share of the client's challenge. There could well be two addictive rewards in the mix: fear and sexual arousal.
Fear as reward
Distress may not sound rewarding but fear activates the reward circuitry of the brain in some folks. Think roller coasters and horror films. To a brain desperate for sensation (due to the brain changes brought on by chronic overstimulation/addiction), fear-induced activation can register as especially compelling. It jacks up both dopamine and norepinephrine (a form of adrenaline).
But there's more going on at a biological level. The stress neurochemical cortisol can also heighten rewarding effects by triggering the release of dopamine. Eventually, brain changes can make someone hyper-responsive to stressful cues. Research confirms that extreme stress and drugs of abuse both increase the strength of related (addiction) brain pathways. Researchers believe cortisol thus plays a pivotal role in reward-related behavioral pathologies.
The situation is akin to BDSM, where physical pain heightens a person's sexual buzz because of the effects on the brain. In HOCD sufferers, arousal and panic achieve a similar end. Bottom line: Despite intense emotional or physical discomfort, heightened arousal can make a behavior very hard to stop (addictive).
The HOCD sufferer's brain has learned to obtain part of its reward from its own distress. Worse yet, when the sufferer tries to give up porn, his anxiety will naturally increase for an extended period. Withdrawal raises anxiety in all recovering addicts, fueling powerful cravings for more stimulation quite apart from HOCD concerns.
For HOCD sufferers this predictable increase in anxiety tends to set off intense spikes (panics about orientation) and frantic "checking," often driving them back into addiction. Indeed, some report that their HOCD fears were trivial until they quit porn. As the addicted brain targets the strongest "fix" it can think of: panic+checking+sexual arousal to HOCD-related stimuli, straight feelings seem to evaporate.
Sexual arousal as reward
An addiction to Internet porn is an addiction to an orgasm-aid. Sexual arousal is the most powerful natural reward the brain can produce. Yet arousal from porn's constant novelty (each scene offers another hit of stimulating neurochemicals) can produce a surprisingly potent reward. Sex, or even orgasm, may pale in intensity as porn addiction progresses and response to everyday pleasures declines. Some users end up hooked on the neurochemical buzz from edging to novel porn for hours, intentionally deferring, or avoiding, climax.
The brain evolved to assume that a source of intense sexual arousal is a potential fertilization opportunity. If someone arouses himself with something that releases maximum dopamine and norepinephrine, the brain will automatically wire it up as "valuable." It doesn't matter if it's not consistent with his innate sexuality—because the brain measures salience according to levels of reward circuitry activation, not orientation. (It just so happens that in a brain responding normally to pleasure, stimuli appropriate to one's orientation generally produce the most satisfying feelings.)
Not surprisingly, sensitized brain pathways for intense sexual cues are different from less stimulating cues (even sexual ones). We can unwire the latter with relative ease, but not the former. This has been demonstrated in research, as recounted by James G. Pfaus et al:
Lalumière and Quinsey (1998 ) reported significant conditioned genital arousal in heterosexual men to a picture of a moderately attractive, partially nude woman that was paired with a video depicting highly arousing sexual interaction. A control group that received access to the picture alone (without the video) showed habituation [instead]. (emphasis added)
As explained above, for porn-related HOCD sufferers sexual cues are especially intense because they are heightened by the neurochemical effects of fear.
Exposure therapy backfires when porn addiction is present
For the Internet porn addict using standard HOCD therapy, exposure to real gay men doesn't address the source of his HOCD conditioning—which is not to humans or sex with humans, but rather to pixels. Yet if he tries exposure therapy with gay porn, he is engaging in the precise behavior to which he is addicted. One can't cause an addict to habituate by providing the very cues he's hooked on!
This is why exposure therapy could well be all wrong for guys trying to unravel porn-related HOCD. It's like having an alcoholic drink more on the theory that she will get bored with drinking, or a gambler place more bets until he habituates. In an addict, continued use only deepens the addiction ruts in the brain. Exposure therapy may thus deliver an unproductive mixed message to a porn-addicted HOCD sufferer instead of promoting useful conditioning (habituation).
So where does one start? Porn addicts need to eliminate Internet porn use above all. As their brains return to balance many also notice that confusing sexual cues lose their power.
If porn addicts with HOCD try to use related cues for a therapeutic purpose instead of abstaining from them they're strengthening their behavioral-addiction neural pathways. This is a Catch 22. The addict (and perhaps his therapist) may wrongly conclude that his persistent, powerful response to problematic cues is not HOCD, but rather "proof" that his sexual orientation has mysteriously transformed.
The point is that addiction presents an obstacle for standard OCD Exposure & Response Prevention therapy. Even if a porn addict stops seeking the reward of relief (from testing or analysis), exposure to porn still "rewards" him by activating his sensitized addiction pathways.
What does help?
We are not therapists. However, we have read self-reports by a number of former Internet porn users who describe themselves as suffering/recovering from HOCD (sample self-report). We'll summarize their experience in case it proves useful.
Guys report that giving up the reward of Internet porn and temporarily giving up the reward of sexual activity (other than relaxed, affectionate partner sex) both help resolve their HOCD. As they stop reinforcing their prime reward (porn use), their brains gradually look around for, and wire to, other sexual rewards. This can take months. In light of these guys' experience, therapists may want to invite clients to disconnect from Internet porn for a few months before introducing exposure therapy (if ever).
At first, guys may not respond normally to partners, although relaxed affection is soothing (perhaps because it releases oxytocin). Also, until the worst of the addiction withdrawal has passed, they also often experience more excruciating HOCD spikes.
Those recovering report that if they can accept the intrusive HOCD thoughts without distress, they sidestep the neurochemical reinforcement of fear. In addition, they find it helpful to learn to live with uncertainty about their sexual orientation and to avoid all testing and efforts to "figure out the truth." That way they also stop the rewarding reinforcement of fleeting relief and "certainty."
In other words, the HOCD sufferer needs to work on stopping stop three rewarding habits: Internet porn use, relief seeking and distress.
One man's self-report
This man's report is interesting because he began by weakening the porn reward, only to find that he hadn't dealt with the fear and relief (checking) rewards.
I'm now over 3 months without porn, but I had sunk into a stupor of constantly checking various HOCD message boards. I was spending hours every day on those sites, sometimes checking them as much as several times an hour: at work, while I was driving, in bed at night, etc. etc. etc. Really bad 'checking behavior.' My brain was being rewarded when I would read something that reassured me, and it would fire up and freak out when I read something that spiked my anxiety.
I had also expanded my checking onto other message boards, including gay and bisexual boards. This just perpetuated the spiral. I wasn't sleeping much on account of all my anxiety, and I wasn't really present in my life. I was either on these boards or worrying about what I read on them. Constantly. My relationship was suffering. Sometimes, alone at night, I would go on 2-3 hour binges of HOCD checking on internet message boards, and then feel awful afterward.
I decided I would stop. My mate deserves someone who is present, not totally distracted. Since then, I have only had one 15-minute session, checking for replies. I've had to struggle to resist temptation, but the result is that I feel SO much better.
It's really pretty remarkable. My HOCD has decreased significantly now that I am not constantly signaling to my brain "THESE HOCD THOUGHTS ARE IMPORTANT" by going on the boards and engaging in checking and reassurance. I hadn't read a book in months, but I'm now on my second one since I gave up the boards. My free time at night is now spent either with my girlfriend or reading by the fire. I'm sleeping a lot better.
Yes, I still get the occasional spike when I see an attractive guy. And then from the checking with thoughts of him. But it's gotten to be a lot less, and that thought fades a lot faster.
I now think that my HOCD may have been due to the fact that when I finally overdosed on PMO after years and years of it, I lost much of my attraction to real women. Without it women and men started to look the same to me, and BAM worries about being gay erupted.
Schwartz's non-exposure therapeutic approach
There is an existing therapeutic system for treating OCD that doesn't advocate exposure. Psychiatrist Jeffrey Schwartz developed it. (Read a description taken from Doidge's The Brain That Changes Itself.)
Schwartz teaches his patients how neuroplasticity works so they understand that their compulsion is arising from an unwanted, overly active brain loop (not unlike addiction). He then explains that the brain's wiring can be changed with conscious effort.
In some ways, it's the very opposite of exposure therapy. Instead of attempting to habituate via exposure, one attempts to rewire the brain by shifting gears the instant a related cue pops up. Schwartz suggests switching to a pre-selected constructive activity.
The goal isn't to avoid discomfort by seeking relief, but rather to activate unrelated brain pathways in lieu of the problematic ones so the brain disconnects from its former "rewards," and perhaps even comes to associate anxiety with a productive task.
As an aside, HOCD expert Fred Penzel also discourages exposure therapy for porn addicts, despite the fact that he recommends Exposure & Response Prevention therapy in classic HOCD cases.
Hopefully, researchers will soon determine which protocols work best for which HOCD sufferers. Many of those affected are desperate to resolve their anxiety. Indeed, of all the recovering porn addicts who visit our site, the HOCD guys suffer the worst and relapse the easiest.
At present, many are hesitant to seek help for fear that well meaning therapists will tell them they are gay (or straight) when they know they are not.
Porn-related HOCD sufferers generally have no idea how to rewire because the standard therapy doesn't work, and the most promising solutions feel so counter-intuitive (they have to walk away from relief, from analysis, and from sexual arousal for a time). Most won't figure it out without informed professional assistance. To progress, they may need to find a therapist well versed in both addiction and the role of abstinence in unhooking the brain from unwanted "rewards."