Pure Obsessional Obsessive Compulsive disorder, known as Pure O, is a type of Obsessive Compulsive Disorder (OCD) where the rituals are mainly mental, i.e. not easily noticed by others. Common symptoms of Pure O include recurrent unwanted thoughts, images, or sensations that elicit anxiety or distress,1 and a mental response to rid or neutralize the obsession. Despite the name, Pure O is OCD, and front-line treatment is Cognitive Behavior Therapy.
What Is Pure O?
Obsessive Compulsive Disorder (OCD) is a psychological disorder containing two parts: obsessions and compulsions. Obsessions are persistent and unwanted thoughts, feelings, images, or sensations that elicit distress or anxiety. Compulsions are what an individual does in response to the obsessions to try to neutralize, counteract, or get rid of the thoughts. To meet clinical criteria, the symptoms must interfere with important activities or cause significant distress.2
With that in mind, Pure O is a type of OCD where compulsions are completed mentally. Some may feel that they only experience obsessions, and not compulsions. That is typically not the case, and instead, mental rituals are occurring under the surface in a covert manner. Through psychoeducation in treatment, an individual can learn to identify mental compulsions.
Common Pure O Obsessions
Obsessions vary person to person, but there are common themes within OCD. Obsessions can elicit a strong emotional reaction due to the nature of their content. This is due to obsessional thoughts being ego-dystonic; meaning they are not in line with your personal belief system and it’s not the type of thought you’d expect yourself to have.3
Common obsessions in OCD include:
- Unwanted sexual thoughts may sound like:
- “What if I am a pedophile and don’t realize it?”
- “Am I sexually attracted to a family member?”
- “Am I gay and haven’t realized it yet?”
- “What if I am sexually attracted to animals?”
- Unwanted Harm thoughts may sound like:
- “What if I snap and stab someone?”
- “Why if I lose control and hurt someone I love?”
- “What if I hurt my pet accidentally?”
- “What if I ran somebody over while driving?”
- Religious or Moral Scrupulosity thoughts may sound like:
- “Did I offend god?”
- “What if I’m not living a life according to my religious or moral values?”
- “What if I wasn’t 100% honest?”
- “What if I accidentally cheated on a past exam?”
What Are Mental Compulsions?
Compulsions are defined as repetitive behaviors an individual uses to try to neutralize, investigate, counteract, or get rid of obsessions.4 In short, compulsions are what an individual does in response to the thoughts. With Pure O, most rituals are mental and not able to be outwardly observed by others.
Compulsions (both visible and invisible to others) are often exhaustive and frustrating for the individual engaging in them. They may want to get out the door for an important appointment, but feel as though they can’t until a ritual is completed. The problem with compulsions is that they reinforce the idea that you cannot tolerate the discomfort or anxiety you’re experiencing.
Common mental compulsions in Pure O include:
- Mental review or mental checking, such as:
- Mentally reviewing past events to see if you missed any important details
- Mentally reviewing a drive to see if you accidentally hit someone
- Mentally checking to see if you’re still “appropriately” horrified by the thoughts
- Mentally checking to see if you are sexually attracted to something forbidden
- Mentally checking to see if you’re still attracted to your partner
- Self-Reassurance
- Repeating self-reassuring statements such as “I’ll be okay”, or “don’t worry about this” “don’t be silly that’s irrational”
- Repeating positive self-affirmations
- Praying
- Silently repeating a prayer
- Praying for forgiveness due to unwanted thoughts
- Counting
- Silently counting (family members, numbers, etc.)
- Thought Neutralization
- Replacing “bad” words or thoughts with “good” ones through specific patterns
Although Pure O is a nickname for OCD without observable compulsions, there are sometimes overt, or visible, compulsions that are present as well.
Common examples of visible compulsions for those with Pure O are:
- Reassurance seeking
- Repeatedly asking someone if they think you did the right thing
- Repeatedly asking someone if they think you’d ever hurt anyone
- Repeatedly asking if something makes you a “bad person”
- Seeking reassurance from online forums or searches
- Confessing
- Sharing every detail of an interaction with a partner
- Overwhelming need to share a “bad” thing you might have done
- Avoiding
- Avoiding areas that could trigger obsessions (playgrounds, scary movies, songs, knives, etc.)
- Checking
- Checking bodily sensations
- Checking that things are “safe” or how they “should” be
The above compulsions are common, but this list is not exhaustive. Compulsions vary person to person and can change over time.
How Is Pure O Different From Typical OCD?
The name Pure Obsessional (Pure O) is a bit of a misnomer because it is in fact, OCD. There are both obsessions and compulsions present. With that in mind, it is a name that has helped many people seek out treatment who otherwise would not have.
Media and pop culture often incorrectly portrays OCD as solely related to hand-washing or organization. While OCD may present for some in this way, it is not the case for everyone. The name Pure O gives community to those who may not feel they fit the stereotypical OCD portrayal.
Pure Obsessional OCD Treatment
The gold-standard treatment for Pure O is Exposure and Response Prevention (ERP) and/or medication.5
These treatments have greatly improved prognosis for OCD.6 The promising outcomes referenced are largely due to ERP, a type of cognitive behavior therapy (CBT).
Therapy
Through working with an OCD therapist, individuals can expect to be treated with ERP. The goal in OCD treatment is to build skills to handle the presence of unwanted thoughts without engaging in compulsions. These skills develop through exposures, where the individual gradually exposes themselves to feared stimuli while resisting compulsions. When completing ERP, the individual often uses a hierarchy and gradually builds tolerance for more challenging exposures.
Pure Obsessional OCD is also treated with ERP, and studies have shown that individuals with covert compulsions also benefit as long as exposures are adapted.7 This can be done through the use of scripting or audio recordings.
Exposure and Response Prevention
As mentioned, Exposure and Response Prevention (ERP) is the gold-standard treatment for OCD. The ‘E’ in ERP references exposure, or facing your fears. The ‘RP’ in ERP is for response prevention, i.e. not engaging in a compulsion after doing so. Although this may sound frightening, ERP is collaborative and voluntary. Your therapist will never force you to do an exposure you’re not willing to do. Together you build a hierarchy and decide where you want to start. Oftentimes, this means taking a look at your values and what is most important for you. Your therapist may ask; what is important to you that OCD has gotten in the way of? This can be a jumping off point for value-driven exposure work.
Cognitive Behavioral Therapy
In conjunction with ERP, cognitive behavioral therapy (CBT) has also proven to be beneficial for OCD. 8 CBT for OCD most often focuses on distorted cognitions (or unhelpful thinking patterns) that may over-exaggerate the importance of thoughts. One may start to notice and label distortions, then explore how they influence compulsive behavior. This can be done with a thought record, which helps see where distortions may be influencing behavior.
Treatment Outcomes & Timeline
When treated with ERP and/or medication, treatment outcomes for OCD are highly promising. As stated by the International OCD Foundation, “The majority of people with OCD (about 7 out of 10) will benefit from either medication or ERP.”9
A provider may use a combination of assessment tools and self-reporting to track progress. This could include the Yale Brown Obsessive Compulsive Scale (Y-BOCS) and/or Family Accommodation Scale (FAS).
The treatment timeline for OCD treatment varies on symptom severity. There are many treatment options for OCD, including: outpatient, intensive outpatient, partial hospitalization program, residential program, or inpatient. Each program has a different timeline that often varies per patient.
Medication
Medication alongside therapy has been shown to be effective for OCD.10 The class of medications that are front-line treatment for OCD are selective serotonin reuptake inhibitors (SSRIs) including: fluvoxamine (Luvox) ,sertraline (Zoloft), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), clomipramine (Anafranil), venlafaxine (Effexor XR), and escitalopram (Lexapro).11 A physician or psychiatrist will work with a patient to find the right medication for them and to consider side effects or possible risks with the medications.
Lifestyle Changes
While ERP and/or medication are the gold-standard treatment for OCD, certain lifestyle changes may also aid in recovery. This can involve taking an inventory on sleep, caffeine intake, substance use, overall stress and exercise. A psychiatrist or therapist can work with the patient to assess their lifestyle and work on making healthy changes.
How to Get Help for Pure O
If you feel you may be struggling with OCD, don’t hesitate to ask for help. A good first step is visiting the International OCD Foundation’s website. IOCDF provides valuable resources to individuals, parents and families. Another great option for getting help is by using an online directory, where you can search for a therapist with specific qualifications, like someone who works specifically with people who have OCD.
Final Thoughts for Pure O
OCD can be debilitating and overwhelming. If you or someone you love is struggling with OCD, know you are not alone. Reaching out to a trusted friend or OCD specialist can be a scary, but powerful, first step.
