Clomipramine and h-ocd/intrusive thoughts

[StuB]

(This will be lengthy, complicated and most likely a bit incoherent. I've posted it on a few forums, partly to get a range of opinions, but also to basically get it off my chest. To anyone who manages to get through it all and makes sense of it - i'm very grateful for your patience!)

Hi everyone,

Firstly a bit of history. I'm a 24 year old male. My OCD first got really bad back when i was 19, initially revolving around handwashing which was itself linked to germ phobia, emetophobia etc. Over the years i've made improvements in this area (the handwashing takes about 5-10 minutes rather than 2 hours now!), but there's still work to be done.

The second main element of my OCD developed about 18 months after that. Commonly known as P-OCD online, it was based around terrifying and very real-seeming intrusive thoughts that i might be a paedophile. At first this brought me to the point of contemplating suicide, but after opening up to my then-psychologist about it, i started to gradually get the thoughts into perspective. It still flares up from time to time but i feel much more in control of it.

I had taken the beta-blocker propanolol for a brief period back in 2008, but before this year, i'd never really used medication due to my overblown fears of the potential side effects. Three months ago i started taking the tricyclic anti-depressant clomipramine. Due to the concern over side effects as well as my IBS, the doctor recommended that i increase the dosage very gradually - i'm only now up to 60mg per night. I'd perhaps felt a slight improvement in my mood and slight easing of general anxiety, but developemnts from the past few weeks have left me unsure of whether to keep increasing the dosage.

Except for a brief period in my early teens, i've been fairly comfortable with my sexuality - to use totally unscientific figures, about 80% heterosexual and 20% homosexual, basically 'a bit bi'. I'm capable of a homosexual response, but my gut preference has definitely been for girls/women, especially in any romatic/relationship sense.

Over the last few weeks, though, as the clomipramine's started to kick in a bit more, there seems to have been a weird shift in my sexual responses. Basically, my heterosexual response seems to have decreased significantly and my homosexual response seems to have increased somewhat. I'm still capable of a heterosexual response, but it definitely seems to have been reduced. As should be clear, i'm not homophobic (at least not in terms of anyone else's sexuality), but it's REALLY unsettled me for some reason. The thought patterns emerging from the whole thing do seem very OCD - it's making me miserable, i'm terrified that i'll end up incapable of a heterosexual response and my brain keeps testing me/bombarding me with open-ended questions which leave me feeling very confused and alone. Unlike the P-OCD, my core dislike for what the thoughts are suggesting isn't moral - it simply doesn't feel right for me. The idea of actually being gay rather than slightly bi doesn't seem at all liberating to me - it's just depressing me.

At least in part due to severe social anxiety, i've never been in a sexual relationship or had a girlfriend. I've also been VERY isolated from my peer group in recent years.

Another factor which might have been instrumental in recent weeks relates to a computer CBT course i've been taking. It's proved quite useful and given me a few ideas for controlling general anxiety and depression, as well as getting me out of the house a bit more. The confusion starts when i mention the attractive 20 year old girl who has been assigned to help me with the therapy - i developed a bit of a thing for her pretty much from the beginning, although i've found it surprisingly easy to talk to her given my usual awkwardness around the oppostie sex. I haven't taken the 'crush' too seriously - it's probably got more to do with the fact i've barely encountered any girls of my own age over the past four years. On the other hand, it did get me thinking in more general terms about how i'd eventually like to end up in a relationship once i'd gotten my problems and anxieties under control. I also realised, to my confusion, that my attraction to the girl seemed to be purely on a romantic level - for some reason i found it very hard to think of her in a sexual way. At first i assumed this was to do with anxieties, but then i started to wonder whether my heterosexual instincts were really becoming diminished. I then asked myself "could anyone but me manage to develop a crush on a girl and then convince themselves that they were turning gay all within the same week?" This helped to ease my concerns for a few days, but they now seem to be taking over again and i feel really helpless. Which brings me to typing this message.

The question "is the clomipramine turning me gay?" sounds pretty ridiculous i'll admit, but to frame it another way, could the clomipramine be doing something strange on a hormonal level which might present as a shift in sexual tendencies? On the other hand, working with the idea that this IS H-OCD, might the clomipramine be actively causing the new intrusive thoughts/making them worse and should i think seriously about whether continuing with this medication is going to help or hinder me? Or perhaps might the whole thing be related to anxieties surrounding my attraction to the CBT girl?

I realise that this is a bit of a mess, but the situation is really getting me down, so i'd be very grateful for any advice.

Thanks for reading.

[Mr.Jitters]

Hey StuB,

Welcome to the site. I hope you manage the find the answers that you're looking for here.

It sounds like your mind isn't giving you a moment's rest, and that would appear to be the problem. The transporters and receptors that clomipramine targets are in no way responsible for, or able to alter, human sexuality. The reason you were prescribed clomipramine however, can cause distressing obsessive thoughts regarding your sexual identity, as you well know. It's entirely possible that the medication is having an activating effect and any distress will be reduced as you begin to feel the benefits of the drug, but you should speak to your doctor to find out if this the case, or whether a different medication or even a different dosage may be more suitable for you.

Is there a reason that you're on Clomipramine rather than an SSRI?

I'd also ask you if there were a possibility that you'd misinterpreted your feelings towards the woman helping you with CBT? It's entirely possible to misinterpret the feeling of gratitude or comfort as something else. It's also entirely possible that you're just attracted to her on an emotional level, rather than a sexual level, or excited by the anxiety free contact with a woman of your own age.

I'm sorry I can't be more help to you, but I honestly hope that you find what you need and can start to feel better soon.

Kam

[StuB]

Hi Kam,

Thanks for the reply. Yes, my mind is constantly racing and asking me questions. Deep down, i don't think i really suspect the clomipramine is changing my sexuality, but this medication is apparently known to disrupt libido, which i think must be exacerbating the situation with my intrusions. Also, as you say, it may be triggering something since it's early days for me and these pills, but it could hardly be triggering in a more distressing way. I've just been sat in my room most of the evening trying to watch some DVDs but feeling like i'm on the verge of tears the entire time.

I intend to go and see my doctor in the week about this, even if it means postponing my next CCBT appointment. As for the CBT girl, yes, i'm pretty sure my feelings emerged from the relief of being around (and not particularly nervous with) a girl of roughly my own age for the first time in years. The attraction seemed to be on an entirely emotional level which was kind of what confused me - to be frank, though, she's very good-looking (probably a bit out of my league TBH!) and i can imagine myself being physically attracted towards her if my libido were operating as it usually does! Basically, i was floating on air for about three days after our session, then it's been a pretty steep descent over the fortnight since.

Oh, and as for the clomipramine-over-SSRIs question, i was under the impression that it was both a more established drug and less likely to cause negative side effects. Is this true in your experience? Would you recommend something else? Honestly, i wouldn't mind the clomipramine taking away my libido entirely (i hear SSRIs can have a similar effect), but it seems - or at least the converging events seem - to be doing it selectively and in a very disconcerting manner.

Anyway, thanks again,
StuB.

[Mr.Jitters]

No problem at all, sorry I couldn't be more help. You seem to have a very good handle on this, if only your mind would let you rest!

Clomipramine is well known to cause sexual dysfunction, and all TCAs can depress libido as you rightly say, as can many SSRIs.

It's important to remember that if you've spent a while adjusting to thoughts while unmedicated - and then something changes in your body as a result of medication, this change can certainly be distressing and manifest in many different ways.

All of these medications disrupt these functions by altering our mood, reaction to stimuli and by way of their anticholinergic and antiadrenergic side effects. There's nothing more sinister than this happening.

Clomipramine generally works very quickly on depression and anxiety, but can take several months to become effective when treating OCD, and it's been my experience that it's activating effect is a mofo even when treating low level anxiety. A chance to talk to your doctor about this and evaluate the situation should help, so good luck.

Clomipramine is definitely the more established medication when dealing with OCD, but generally has more side effects than SSRIs, though it's less likely to induce anxiety and insomnia or suicidal thoughts in young people when you first start taking it than SSRIs. It's usually prescribed as a second line treatment if SSRIs aren't suitable because of its higher side effect profile, or if your clinician deems it the most appropriate treatment for you ( http://www.nhs.uk/Conditions/Obsessi...Treatment.aspx )

It sounds as though it's still early days for your CBT, too. How do you think this is affecting you?

As I'm intolerant of SSRIs, I've taken many different TCAs including clomipramine since I was a teenager, and I've found that the disruption to my libido has eased within two or three months of treatment.

I also know what it's like to feel like you're on the verge of tears all the time. And while it may not be the most masculine, or dignified of strategies - I've learned the importance of letting it out rather than pushing it back. It can bring some peace, and a welcome opportunity to veg in front of some DVDs.

Hoping you feel better soon.

[StuB]

Hehe, yeah, i'm quite good at saying what's wrong but not the best at doing much about it!

My suspicion is that when i go to see my GP this week, he might recommend that i give it a bit more of a chance despite the fact that i've been feeling pretty awful at times these past few days. I imagine an SSRI could potentially be just as confusing. All of this really flags up the fact that i need some proper CBT, the computer CBT having been useful in some ways (not least as a way of getting me out of the house) but not really that strongly related to my OCD issues - more general depression and anxiety.

I was just wondering, does 'activating effect' simply refer to temporarily worsening symptoms? I'm not entirely au fait with the jargon.

[Mr.Jitters]

That's something that most of us here have in common, don't worry.

If you've been feeling that awful, there are a number of options you and your doctor could decide on. Whether that's some mild tranquillisers or counselling while the clomipramine does its thing, or changing medication altogether. Generally SSRIs have a more pronounced activating effect than TCAs - which does usually mean a temporary worsening of symptoms (or a whole host of new ones!) while your body's chemistry is essentially being artificially altered by medication, until you become used to it, and the medication can have its desired effect.

You're entirely correct that you should be receiving specialised CBT treatment to address your OCD, it's your right to access these services. Hopefully your doctor will be able to help you access these services. While you're gaining some benefit from your online CBT course, and that's great, condition specific treatment is obviously the best way forward. Most areas have local support groups and group CBT and the two charities listed in the link above should be able to help you find one close to you if you think that would be helpful. I've found this route can be quicker than waiting for a GP referral, but demand both anyway. Ultimately, if you're having trouble functioning in a way that's comfortable for you, it's your doctor's responsibility to provide all the help that they can.