Repugnant obsessions: A review of the phenomenology, theoretical models, and treatment of sexual and aggressive obsessional themes in OCD

•Repugnant obsessions – unwanted sexual/aggressive thoughts – are a common OCD theme.•Clinically distinct, linked to covert actions, self-testing, and ego-dystonicity.•Negative self-beliefs have been proposed as particularly important.•Specialized cognitive techniques required, with emerging evidence of success.

Obsessive–compulsive disorder (OCD) is a highly disabling psychiatric disorder, characterized by the occurrence of intrusive, unwanted thoughts (obsessions), which lead to the performance of repetitive compulsions and/or rituals in order to reduce distress and prevent feared outcomes from occurring. In particular, one grouping of obsessive themes that has been highlighted in the clinical literature involves the predominance of thoughts that are highly repugnant to the individual; specifically, unwanted sexual or aggressive thoughts. Compared to other OCD themes, these thoughts may have distinct clinical characteristics, such as being linked to different forms of compulsions including covert rituals and thought-suppression, being linked to greater distress, and being rated as being more ego-dystonic. Theoretically, different mechanisms have been proposed that may underlie these obsessions, for example the meaning that the thought has for the individual has been highlighted, and the theme of obsessions has also been linked with negative self-related beliefs. Finally, such repugnant thoughts may also require specialized techniques in cognitive behavioral therapy. This review outlines such clinical, theoretical and treatment-related aspects of this theme of OCD, and thereby highlights the impact of content on form in this disorder.