Most likely diagnosis: Obsessive-Compulsive Disorder (OCD) — sexual obsessions with religious compulsions (scrupulosity), with secondary panic/anxiety symptoms

Why this fits

• Sexual images of having sex with people she finds unappealing ("dark people") or any man she sees — described as unwanted and distressing, occupying most of her day, every day. This is the hallmark of an ego-dystonic intrusive thought, not a wish or fantasy she enjoys.
• Per Kaplan & Sadock's classification of OCD obsession content, "sexual (concerns about unwanted sexual images or impulses)" is one of the recognized primary symptom dimensions of OCD, alongside contamination, symmetry, and religious themes - Goldman-Cecil Medicine.

• She began waking for Tahajjud (a voluntary pre-dawn prayer) specifically after the sexual thoughts started, and "never misses" it — a rigid, driven behavior performed to neutralize guilt/distress from the taboo thoughts. This is textbook scrupulosity — "excessive praying or religious concerns out of keeping with the patient's background," listed as a recognized OCD symptom dimension in Kaplan and Sadock's Synopsis of Psychiatry (Table 9-2).
• Clinically this is the same mechanism described in "pure-O"/taboo-thought OCD, where mental rituals (praying, undoing, checking one's own mind) replace visible compulsions like handwashing.

• Panic attacks (1-2/day), tremor of hands and feet, and disturbed sleep all emerged after the obsessions began and have progressively worsened — consistent with the intense, near-constant anxiety generated by unwanted sexual obsessions escalating into panic attacks and autonomic symptoms (tremor), rather than being the primary disorder themselves. Comorbid panic symptoms and anxiety are common in OCD, and this may represent secondary/comorbid panic disorder superimposed on a primary OCD picture.
• Timeline is coherent for OCD: obsessions (5 months) → compulsion onset (5 months, immediate) → secondary anxiety/tremor (3 months) → panic attacks (1 month) → sleep disturbance (2 months) → hospital presentation triggered by the most disruptive/visible symptom (panic attacks), which is a very typical presentation pattern - families/patients often present because of panic attacks while the underlying OCD (especially taboo/sexual obsessions) goes unspoken due to shame.

What to rule out / clarify before finalizing

1. Insight - confirm she recognizes the thoughts as unwanted/irrational and distressing (ego-dystonic), not thoughts she believes are true or externally imposed (ego-syntonic) - this differentiates OCD from a psychotic process. Her description ("thoughts she doesn't like") supports OCD.
2. Organic causes of tremor - thyroid function, caffeine/stimulant use, medication exposure - anxiety-driven tremor is common but should not be assumed without basic screening.
3. Panic disorder vs. panic secondary to OCD - determine whether panic attacks are cued specifically by the intrusive sexual thoughts (situational, in which case they're part of the OCD anxiety response) or occur unpredictably/uncued (favoring a separate comorbid panic disorder).
4. Trauma history - rule out sexual abuse or trauma exposure, since intrusive sexual content can occasionally reflect PTSD-related intrusions rather than OCD; the absence of a described traumatic event and the presence of a clear neutralizing ritual favors OCD here.
5. Developmental/cultural context - in religious households, an increase in devotional practice can be normative; what makes this pathological is the compulsive, guilt-driven, rigid, distress-relieving quality tied directly to obsessive content, not devotion for its own sake.

Suggested management direction (once confirmed)

• First-line: Cognitive Behavioral Therapy with Exposure and Response Prevention (ERP), adapted sensitively for religious/cultural content (working with, not against, her faith framework).
• Pharmacologic: SSRI (e.g., fluoxetine, sertraline) at OCD-range dosing if symptoms are moderate-severe or impairing function, per standard pediatric OCD guidelines.
• Address panic symptoms concurrently, as they may resolve as the core OCD is treated, or need adjunct anxiety-focused intervention if persistent.

Why her denial doesn't rule it out

1. Avoidance is itself a trauma symptom, not proof of irrelevance. Not consciously ruminating on the abuse is consistent with avoidance/suppression, a core feature of trauma-related processing. Patients - especially children - very often cannot or will not verbally link current symptoms to a past abuse event, particularly when there's shame, cultural stigma, or fear of blame involved. Absence of conscious preoccupation does not equal absence of causal contribution.
2. "Mental contamination" and unacceptable-thought pathways. Research on sexual trauma and OCD shows that in survivors of sexual trauma, the "unacceptable/taboo thoughts" OCD dimension (which is exactly her presentation - unwanted sexual images with people she dislikes) correlates most strongly with PTSD symptom severity of any OCD dimension. The mechanism proposed is mental contamination - feelings of internal "dirtiness" or violation from the abuse that later resurface as intrusive, morally repugnant sexual imagery, even without explicit memory retrieval (source: PMC review on OCD symptoms and mental contamination following sexual trauma).
3. Childhood trauma as a documented risk/severity modifier for OCD. Two systematic reviews confirm that childhood trauma, including sexual abuse, is a non-specific but real risk factor that can precipitate onset and increase severity of OCD symptoms, particularly obsessions with taboo/unacceptable content:
   • Baldini et al., 2025, systematic review on childhood trauma and OCD
   • Destrée et al., 2021, systematic review on childhood trauma and OCD symptom severity
4. The compulsive praying fits a guilt/undoing response. If the abuse left an unconscious residue of shame or "badness" around sexuality, the Tahajjud ritual can be doing double duty - neutralizing both the taboo obsessional content and any residual guilt tied to the earlier abuse, even if she doesn't link the two herself.

Clinical implication

• This does not necessarily change the working diagnosis of OCD with sexual obsessions and religious (scrupulosity) compulsions - that formulation still best explains the obsession-compulsion structure and the panic/anxiety that followed.
• But it means the abuse should be recorded as a likely precipitating/vulnerability factor, not dismissed just because she denies active thoughts about it.
• Practically: don't press her to "connect the dots" prematurely - this can increase shame and shut down disclosure. Instead:
  • Screen quietly for other PTSD features (nightmares, hypervigilance, startle, avoidance of abuse-related reminders, numbing) since comorbid PTSD-OCD is common after sexual trauma and changes treatment sequencing.
  • Keep therapy trauma-informed - if using ERP for the OCD, a clinician trained in both OCD and trauma should monitor whether trauma content emerges during exposure work, since unprocessed trauma memories can resurface once compulsions (praying) are reduced.
  • Consider referral for trauma-focused therapy (trauma-focused CBT or EMDR) as an adjunct if abuse-related material does surface, rather than assuming standard OCD-only ERP will address everything.