Differentiating Sexual Thoughts in Obsessive-Compulsive Disorder From Paraphilias and Nonparaphilic Sexual Disorders (2016)

Cognitive and Behavioral Practice

Available online 3 August 2016

Rachel A. Vella-Zarb,

Jacqueline N. Cohen

Randi E. McCabe,

Karen Rowa



  • We present the major differences between recurrent sexual obsessions in OCD versus recurrent sexual thoughts in paraphilias and nonparaphilic sexual disorders
  • We provide key areas of questioning to help clinicians make an informed differential diagnosis
  • We demonstrate how this questioning may be helpful using a challenging clinical case example


Recurrent sexual thoughts characterize several different psychological disorders, most notably obsessive-compulsive disorder (OCD), paraphilias, and nonparaphilic sexual disorders (NPSDs). Many clinicians are aware of the rule of thumb that sexual thoughts in OCD are personally distressing, whereas sexual thoughts in paraphilias and NPSDs are not distressing to the individual experiencing these thoughts, and they rely on this heuristic to inform diagnosis. This is problematic because distress alone is not a reliable diagnostic differentiator; as a result, misdiagnosis is common. Given the negative consequences of misdiagnosis, including worsening of symptoms, treatment dropout, and potential harm to individuals experiencing these thoughts or those who are targets of these thoughts, the purpose of this paper is to help clinicians identify and differentiate repetitive sexual obsessions in OCD from repetitive sexual thoughts in paraphilias and NPSDs. A clinical case example is provided along with pivotal areas of questioning to aid in differential diagnosis.


  • obsessive-compulsive disorder;
  • paraphilia;
  • sexual disorder

Address correspondence to Rachel Vella-Zarb, Ph.D., Vancouver CBT Centre, Suite 302-1765 West 8th Ave. Vancouver, BC V6J 5C6.