<![CDATA[Sexual orientation-related obsessions in adolescents with obsessive-compulsive disorder (OCD) may be overlooked when compulsive behaviors intended to neutralize distressing thoughts resemble problematic sexual behavior. Religious guilt and comorbid depression may further complicate diagnostic recognition. This case report aimed to describe the clinical phenomenology, differential diagnosis, management, and short-term clinical course of sexual orientation-related obsessions accompanied by a severe depressive episode with psychotic symptoms. A descriptive clinical assessment was conducted involving a 15-year-old boy through psychiatric interviews, mental status examinations, collateral information from family members, and repeated assessments using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Treatment included sertraline, aripiprazole, psychoeducation, supportive psychotherapy, exposure and response prevention (ERP), and behavioral activation. The patient experienced recurrent, unwanted, ego-dystonic sexual thoughts and engaged in masturbation three to five times daily as a compulsive behavior intended to alleviate anxiety and seek reassurance about his sexual orientation. His CY-BOCS score decreased from 34 at admission to 17 on the fourth day of hospitalization but subsequently increased to 26 at the one-month postdischarge follow-up. Compulsive behaviors persisted, and the patient had not resumed school attendance despite reported adherence to medication. This clinical course suggested that environmental restrictions during hospitalization might have influenced the observed reduction in symptom severity, although a causal relationship could not be established. The case underscored the importance of assessing the psychological function of repetitive behaviors, identifying comorbid depressive symptoms, and evaluating suicide risk. Continued psychiatric follow-up and contextual assessment are essential for monitoring recovery, while the findings from this single case cannot establish treatment effectiveness or be generalized to broader adolescent populations.]]>
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