Pure O OCD: Signs, Symptoms & Treatments

What Is Pure O OCD?

Pure O OCD (also known as Pure O or pure obsessional OCD) is a type of obsessive compulsive disorder in which 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 during treatment with a therapist, someone can learn to identify their mental compulsions.

To meet clinical criteria for OCD, the symptoms must interfere with important activities or cause significant distress.²

But Can You Have OCD Without Compulsions?

Compulsions are a key criterion for diagnosing OCD, but pure O OCD involves someone completing the compulsions in their mind instead of acting them out. They will likely have compulsions you can’t see, and they will visualize their compulsions.

Pure O OCD Vs. Typical OCD

The name Pure Obsessional (Pure O) is a bit of a misnomer because it is, in fact, a type of OCD and 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 portray 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 O OCD Symptoms

All versions of OCD involve symptoms of obsessions and compulsions, but for pure O, the compulsions happen mentally. This could involve mental review or mental rituals to complete the OCD cycle.

Common Pure O Obsessions

Obsessions vary person to person, but there are common themes around OCD symptoms. 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, 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, 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, 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?”

Unwanted thoughts about a relationship, like:

• “Is he not having fun with me because he doesn’t think this movie is funny?”
• “What if we are bad for each other?”
• “Do we have anything in common?”
• “Is he pretending to like me?”

Pure OCD Mental Compulsions

OCD compulsions are defined as repetitive behaviors used to try to neutralize, investigate, counteract, or get rid of obsessions.⁴ Compulsions are what an individual does in response to these 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 exhausting 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 reviews or mental checking: 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, etc.
• Self-reassurance: Repeating self-reassuring statements such as “I’ll be okay,” “don’t worry about this,” or “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, stairs, etc.)
• Thought neutralization: Replacing “bad” words or thoughts with “good” ones through specific patterns.
• Avoidance: Avoidance is usually considered a behavior, but with Pure O OCD, the avoidance can be mental avoidance. Here, the person will work to avoid thinking about the triggering issues, whether it is a person, place, thing, or situation.
• Reassurance seeking: As a way to manage the obsessions, the person with this form of OCD may constantly seek out reassurance and positivity from people in their life. This may seem benign at first, but over time, it can become overwhelming or exhausting for the other people.

Pure O OCD Examples

Although pure O OCD can look different for everyone, the general features are obsessions centered on imperfection or incompleteness, followed by mental compulsions. Some people may even develop mental rituals, where they must complete a series of mental compulsions following a trigger. Sometimes people with pure O may not even realize they are acting out compulsions, since they exist within a person’s mind instead of through visible, outside behaviors.

Here are some examples of what pure O could look like:

• Someone experiences intrusive obsessions around being a “bad” person. Their compulsion becomes completing an extensive prayer every three hours and then mentally reviewing life events which “prove” they are a “good person.”
• Someone experiences intrusive images of cheating on their partner, which cause significant distress. To cope, they begin to repeat “I love my partner” five times every time they experience this intrusive image. They believe that this neutralizes the “bad” thought.
• Someone experiences intrusive thoughts about harming their child. Since this causes a great deal of anxiety, they seek constant reassurance from their partner, family, friends, and professionals that they aren’t “a violent person.” They also visualize past experiences with their child that “prove” they love them and won’t hurt them.

What Does Pure OCD Feel Like?

For some people, pure O OCD may feel like a race where they are always trying to catch up, or it could feel like a never-ending staircase. Pure O OCD causes a person’s thoughts to be so consumed with obsessions, there could be little room for anything else.

How Do I Know If I Have Pure OCD?

It can be hard to know if you have pure O OCD, anxiety, or negative thoughts related to another issue altogether—however, there are some questions you can ask yourself, including:

• Where are these thoughts coming from?
• Are these thoughts causing me anxiety?
• How do I want to act on these thoughts?
• Can I control these thoughts or are they controlling me?
• Do I need to complete a form of compulsion or ritual after having these thoughts? (The result of this question in particular could be a sign of OCD)

What Causes Pure OCD?

OCD has several risk factors that influence the presentation of the condition. Some potential causes include:⁵

• Biological factors: Biological factors, like dysfunction in some areas of the cortex, striatum, and cerebellar networks in the brain, have been noted in people who have OCD symptoms.
• Family history: Having a family member with OCD adds to the risk of developing OCD. If a family member had symptoms early in life, the risk is even greater.
• Genetics: OCD has a genetic component, and researchers are working to isolate if specific genes are connected to OCD.
• Stress or trauma: Stress and trauma, especially during early childhood, raises the risk of many psychological conditions, including OCD. OCD may be produced by acute or chronic stress.

Getting an OCD Diagnosis

A therapist and psychiatrist would work together to come up with your diagnosis based on a number of sessions and assessments of your symptoms. The psychiatrist would be the one to make an official OCD diagnosis while the combination of this team would help to identify what subset of OCD an individual may be dealing with.

Can Someone Get a Formal Pure O Diagnosis?

Pure O is not a formal diagnosis someone can receive. Pure O OCD is one of the subtypes of OCD, which was born out of professional observations and dialogue with members of the OCD community. These subtypes do not exist in the DSM-5, which is the standard for mental health diagnoses. Instead, someone who relates to pure O OCD symptoms may receive a diagnosis of OCD and learn about strategies to challenge their specific subtype through therapy sessions.

Purely Obsessional OCD Treatment

Treatment for pure O OCD would be the same as for any other type of OCD: The gold-standard treatment for OCD is exposure and response prevention (ERP) and sometimes medication.⁶ These treatments have greatly improved prognosis for OCD.⁷

ERP for Pure O

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 for OCD, the person often creates a fear hierarchy with their therapist and gradually builds tolerance for more challenging exposures. Studies have shown that people with covert compulsions (like in Pure O) also benefit as long as exposures are adapted.⁸ This can be done through the use of scripting or audio recordings.

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.

OCD Medication

OCD medication alongside therapy has been shown to be effective for many people.⁹ The class of medications typically used to treat OCD are selective serotonin reuptake inhibitors (SSRIs).¹⁰ 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 and OCD coping skills 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, which provides valuable resources to individuals, parents and families. Another great option for getting help is by using an online therapist directory, where you can search for a therapist with specific qualifications, like someone who works specifically with people who have OCD. You can also use more specific OCD resources like NOCD to get help from home.

How to Cope With OCD Intrusive Thoughts

Coping with OCD can be challenging and can interrupt your day to day activities, however there are ways to cope in a way that will allow you to still have quality of life.

Here are some tips for dealing with pure O and any OCD-related intrusive thoughts:

Find the Relaxation Strategies That Work for You

Relaxation strategies are important for OCD as it can be hard to remove yourself from your intrusive thoughts. Breathwork, gratitude journaling and meditation for OCD can help to ground you in the present moment instead of allowing your intrusive thoughts to take over.

Join a Support Group

A support group is a great way to cope as it can help you find new ways to cope and give you community. Speaking with your primary care doctor, psychiatrist, or therapist can all be helpful ways to find a support group. Lots of online OCD resources exist that could help you find the right support group for you.

Get Plenty of Exercise

Exercise releases chemicals in the brain to help relax, energize, and stabilize your mind and body. Exercise can be a good way to redirect intrusive thoughts and give you the push you need to work through the thoughts and move on to a thought that feels better and more grounded in reality.