Pure O: What Is Pure Obsessional OCD?

Most people associate obsessive-compulsive disorder (OCD) with compulsive behaviors such as excessive double-checking appliances are off, incessant washing and cleaning, or obsessive arranging of things. However, not all types of OCD involve these stereotyped compulsions. One lesser-known form of OCD does not involve outwardly visible compulsive behaviors. It’s called “pure O” (short for pure obsessional OCD) or pure OCD. Let’s take a closer look at this often misunderstood OCD type.   An individual with pure O will exhibit obsessive thoughts, but the “compulsion” response to the distressing thoughts and images manifests as mental behavior instead of the more common visible compulsive behavior.

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OCD BASICS

OCD is typically associated with the compulsive behaviors mentioned above. But this is a very narrow and imprecise view of the condition, which affects an estimated 1.2% of U.S. adults. This stereotypical view also tends to minimize the pain, disruption, and distress the disorder causes. It underscores how OCD is frequently misunderstood—even amongst mental health professionals. Indeed, research shows that OCD is misdiagnosed 50% of the time. Researchers and mental health experts have noted 5 subtypes of OCD, which are based on the grouping of symptoms. They include:

• Over-responsibility for harm (pathological doubt, somatic obsessions/checking, and reassurance-seeking compulsions)
• Taboo (aggressive, sexual, and religious obsessions/mental compulsions)
• Contamination (contamination obsessions/cleaning compulsions)
• Symmetry (symmetry obsessions/repeating, counting, and arranging compulsions)
• Hoarding (hoarding obsessions and compulsions)

WHAT IS PURE O?

Pure O is characterized by intrusive, unwanted, and uncontrollable thoughts (obsessions) as well as compulsions. However, in pure O, compulsions are of the “unseen” variety rather than the more recognized behaviors such as counting, arranging, or handwashing. Basically, an individual with pure O will have obsessive thoughts, but the “compulsion” response to the distressing thoughts manifests as mental behavior. Estimates show that pure O accounts for about 10% of OCD cases. It is most often associated with two of the 5 OCD subtypes mentioned above: over-responsibility for harm and taboo.

MENTAL OBSESSIONS IN PURE O

The recurrent, persistent, intrusive, and unwanted thoughts, images, or urges (obsessions) that typically arise with pure O might include:

• Violent thoughts of harm (including sexual harm) towards oneself or others (called harm OCD)
• Inappropriate sexual thoughts about children (pedophilia OCD or POCD)
• Doubt about feelings of compatibility, attraction, or love for a relationship partner, as well as an individual’s own level of sexual desirability (relationship or ROCD)
• Extreme anxiety about sexual orientation (sexual orientation or so-OCD)
• Over-concern about purity/religion
• Existential fears

These thoughts are often quite disturbing as they can violate an individual’s moral character. Of course, people with OCD have no control over them, and they do not reflect their values or worth as human beings. However, they can be incredibly shaming for a person to experience, and they will not typically speak of them with others, making this form of OCD hard to detect. It is now believed that the high degree of distress and shame in having such thoughts is what triggers compulsions—such as mental ruminations and reassurance seeking—in the less-visible form that defines pure O.

MENTAL COMPULSIONS IN PURE OCD

Interestingly, when pure O was first recognized nearly 30 years ago, it was thought to be a form of OCD that had obsessions only. It’s just recently that researchers have determined that pure OCD most definitely includes mental compulsions. Experts now consider the idea of obsessional OCD to be a myth or misnomer. Research has found these types of mental compulsions to be most common with pure O:

• Persistent seeking self-reassurance causing disruption (such as excessive research online about pedophiles or ways to figure out one’s sexual orientation)
• Mentally repeating affirmations, mantras, or phrases
• Mentally reciting a poem, a specific song, or a prayer
• Mentally reviewing actions, thoughts, and memories
• Thinking about images that provide comfort or self-soothing
• Trying to “erase” memories or images
• Praying
• Mental counting

This is not a complete list. Pure O shows up differently for each individual. Additionally, with particularly disturbing intrusive thoughts, such as violent harm and pedophilia, an individual might start to avoid certain people or situations.

EXAMPLES OF PURE O

To illustrate how pure O might look in an individual, here are a few possible examples:

• A deeply religious person starts to have intrusive, unwanted blasphemous thoughts. They are so disturbing that the person does not mention them to anyone. Instead, they engage in mental compulsions to control or stop their thoughts. They may recite a prayer mentally a certain number of times at the top of each hour. Yet, the intrusive thoughts continue.
• A new mother might have intrusive thoughts or images about hurting her newborn baby. She doesn’t want to hurt her baby, of course, and feels ashamed for having such thoughts. But she worries that the persistent thoughts mean she will. She might recite a song over and over to calm her anxiety and turn off the images. But they return.
• A man finds himself aroused thinking about his daughter’s 10-year-old friend. He is sickened by the images and his response to them. He both avoids his daughter’s friend and spends incessant amounts of time on the internet reading information about how to know if you’re a pedophile.

Confoundingly, the more an individual dislikes and tries to battle, control, or repress a disturbing or unwanted, intrusive thought, the more it will persist. Some experts believe that these disturbing thoughts can activate the fight-or-flight stress response, which further increases distress.

CAUSES AND TREATMENT OF PURE OCD

Scientists have yet to pinpoint an exact cause of pure O, but several factors are involved. Family history and genetics play a role. Pure O is 5 to 7 times more common in people who have relatives with OCD. Brain-imaging studies have revealed differences in the frontal cortex and subcortical structures of the brain of pure O individuals. These brain areas are responsible for filtering our thoughts, ideas, and impulses, as well as our ability to control behavior and emotional responses. A type of cognitive behavioral therapy (CBT) called exposure and response prevention (ERP) is the gold standard treatment for OCD. With ERP, the therapist encourages the patient to allow the intrusive, unwanted, disturbing thoughts to exist. The patient observes these thoughts without engaging in mental compulsions, avoidance, or reassurance behaviors. The solution is focused on the behavior that can be controlled: Ceasing the compulsive response to obsessive thoughts. There’s tremendous hope in this kind of therapy. Research has shown ERP to be effective in treating 80% of OCD cases. If you’re struggling with obsessive thoughts and mental compulsions, know that there are proven solutions to control them. Seeking help from a mental health professional is the first step in the healing process. OCD and other mental health issues can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page here.