Pure-O OCD

Pure obsessional obsessive-compulsive disorder (OCD) is a subtype of OCD that’s characterized by intrusive thoughts, images or urges without any visible physical compulsions. Pure OCD differs slightly from other types of OCD because its compulsions primarily take place in a person’s head rather than actions. Though they can take many forms, these intrusive thoughts generally center on themes of harm, relationships, sexuality and religious or moral questions. These ideas and images can feel like an attack on a person’s sense of self and they often come with guilt and shame. That’s where the mental compulsions come in: to help people cope with those thoughts. (It is possible to have pure OCD and experience no compulsions at all — but this is a rarer form of the subtype.) Many people with pure OCD are terrified of sharing these experiences for fear of being judged. It’s common for people with pure OCD to feel like they are the only ones dealing with this. Because their experience is internal, there often aren’t obvious visual clues an outside observer might notice to identify someone with pure OCD, but that makes it no less distressing.

Pure OCD symptoms

Although it might sound surprising, it is relatively common to have a disturbing or immoral thought, impulse or urge — regardless of OCD diagnosis. The difference is, for people without OCD, these thoughts tend to last only a few seconds and don’t cause significant distress. A person may be driving and suddenly think to themselves, “What would happen if I drove off this bridge?” But they’ll shortly dismiss the idea and move on.

For someone with pure OCD, these intrusive thoughts can be frequent and highly distressing. They will identify with this thought and feel convinced it reveals something about who they are as a human being. They might think, “I just had a thought of harming someone — that means I must be a violent person.”   For someone with pure OCD, it can feel impossible to disassociate from these thoughts. The experience can feel so real, they can’t imagine their thoughts are actually from OCD. Someone with pure OCD may want to prove or disprove one of their intrusive thoughts (for example: “I would never drive off a bridge, but how can I know for sure?”). This doubt then latches on to anything that feels even remotely uncertain. A person with pure OCD may even doubt their diagnosis. They might think, “Maybe this time, my thoughts actually mean I want to hurt someone.”
 

Examples of pure OCD obsessions

People with pure OCD experience unwanted obsessive thoughts, impulses and urges. Here are some examples of common themes:
• Harm: Jennie is sharpening her pencil in a classroom when she suddenly has the thought, “This pencil is really sharp,” followed by an intrusive image of herself hurting a classmate with the pencil. She may start thinking, “I could actually hurt someone. I shouldn’t be in this class. I need to leave right now or I could endanger the other classmates.”  

• Relationships: Taylor is watching a movie with his partner and thinks, “That’s weird. Why didn’t he laugh at that part? Does he not find it funny?” He might start thinking, “What if we’re not meant to be together? I’ve always found a shared sense of humor really important. Now that I think about it, we have nothing in common.”  

• Religion: Francis is attending a religious service and suddenly thinks of something funny. He begins asking himself, “I can’t believe I almost just laughed during Mass. There must be something wrong with me. Should I confess? Am I going to hell?”
 
• Sexual images: Jules is in the middle of an important meeting when they suddenly experience intrusive images of their manager naked. The images feel so alarming, Jules tries to push them out of their head, but that doesn’t help. Instead, more images keep popping up.  

Examples of pure OCD compulsions

People with pure OCD engage in mental compulsions (rather than physical ones) in an attempt to alleviate their anxiety. Here are some examples of what that might look like:

• Mental review: Someone with pure OCD may engage in excessive mental review as a way to relieve their anxiety. For example, if Jennie has fears of harming a classmate with her sharp pencil, she might spend the entire class mentally reviewing all the proof she can come up with that she has not gotten out of her chair and stabbed someone. She may decide that she needs to review everything she has done since she entered the classroom over and over again before she can relax. Even though fellow students may see Jennie busily absorbing the lecture material, in her head, she’s reviewing every past interaction with students she can remember. After class is over and Jennie is at home, she might mentally review her day at school, searching for proof that she did not stab anyone and is not a murderer.
   
• Mental rituals: Someone with pure OCD may create certain mental rituals they must accomplish in order to reassure themselves their intrusive thoughts are untrue, or that they aren’t a bad person. For example, Taylor listens to his partner talk and thinks, “I hate you. Why did I agree to marry you?” This thought is so alarming, he might decide that each time this thought pops into his head, he has to think of five positive qualities about his partner, or else their relationship will fall apart. Taylor might also decide to repeat specific words, images or numbers each time he has a negative thought. He might decide to repeat to himself, “I love my partner,” five times to neutralize a negative thought or think of a photograph where they are at the beach having a great time. Mental rituals can also include reciting special prayers or mantras in one’s head. For example, Taylor might continually pray that his negative thoughts are removed from his mind. Taylor might also excessively ruminate on his thoughts and what it might mean, without a specific ritual.

• Reassurance Seeking: Someone with pure OCD might also excessively reassure themselves as a way to relieve their anxiety. For example, if Sam has fears of unintentionally embarrassing his wife in public, he might continually say to himself, “I won’t embarrass my wife” or, “I am not an embarrassment and she would tell me if I was.” Sam’s self-reassurance might make him feel better in the moment, but will only provide temporary reassurance before his obsessions begin again. Further, Sam might have to think the “right” thought which could cause him to be stuck in an unending cycle of trying to prevent his feared outcome from occurring.  

Pure OCD treatment: ERP therapy

Even though pure OCD compulsions are often not noticeable from an outside perspective, they are best treated like all types of OCD compulsions — with exposure and response prevention (ERP) therapy. ERP is considered the gold standard for OCD treatment; 80% of people with OCD experience positive results from therapy. The majority of patients see results within 12 to 25 sessions. As part of ERP therapy, you’ll track your obsessions and compulsions and make a list of possible ways to face your fears. You’ll work with your therapist to slowly put yourself into situations that bring on your obsessions and the accompanying anxiety or discomfort. Exposures will be mindfully created so that you’re gradually building toward your goal rather than moving too quickly and getting completely overwhelmed. For pure OCD, a trained ERP therapist will be able to spot your mental compulsions and be able to work with you to come up with the best course of treatment for exposures to them. The idea behind ERP therapy is that exposure to these thoughts and the discomfort is the most effective way to treat OCD. When you continually submit to the urge to do compulsions, it only strengthens your need to engage in them. On the other hand, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to respond and will very likely experience a noticeable reduction in your anxiety as you provide yourself with opportunities to change your learning and practice living with uncertainty.

Examples of ERP OCD exposures

 If you’ve ever tried not thinking about something, you know how difficult it is to control your thoughts. ERP therapy takes the opposite approach: Instead of trying to make yourself stop your obsessive thoughts, you welcome them. Let’s say that each time you’re driving, you can’t stop seeing mental images of your car running over a pedestrian. This scene starts appearing in your mind every time you drive past a school or busy street downtown. As a way of coping, you’ve started counting to seven in your head each time you see an image like this. This strategy worked at first, but lately it has been less effective. So, as a way to take extra precaution, you’ve decided to count to 49 instead of seven. An ERP therapist may ask you to welcome the intrusive image of running over a pedestrian without trying to make it go away. You might think, “Welcome it? No way! That’s terrible. I just want these images to stop.” But instead of trying to suppress them, a therapist may ask you to put your full attention on these thoughts. This teaches your brain a new response to your intrusive thoughts and shows you that they don’t have to keep you from living your life. Eventually, you will begin to distinguish yourself from your OCD thoughts, and it will become easier to let them come and go without engaging in compulsions or avoidance. As part of ERP treatment, you may be asked to drive without performing your counting ritual. This will take a gradual approach. For example, if not counting to 49 is too stressful at first, you may start by waiting for 30 seconds before this ritual starts. Then you’d work your way up to two minutes. Eventually, you may find you’re able to experience an intrusive thought with less stress or urges to count. Once you become more familiar with these thoughts and allow the thoughts to exist without responding via compulsion, they might begin to feel less alarming. By confronting these thoughts without compulsion, you start to learn that their feared outcome won’t occur, that you can manage the outcome if it does occur, and that you can tolerate the anxiety or distress that arises when they have intrusive thoughts. In some cases, people find that their anxiety subsides to the point where they no longer experience intense fears related to their thoughts.

How to get help for Pure O OCD

When pure OCD is untreated, it can take over a person’s ability to think about anything other than their intrusive thoughts and lead to isolation from others and a sense of hopelessness about one’s life. Since there’s no visible evidence of their experience, it’s more common for people with pure OCD to delay treatment for longer than for people with other OCD sub types.  If you’re struggling with pure OCD, there is help available. To learn more about pure OCD and how it’s treated with ERP, you can schedule a free call with the OCD Global clinical team and find out how this type of treatment can help you.   All of our therapists specialize in OCD and receive ERP-specific training and ongoing guidance from our clinical leadership team. Many of them have dealt with OCD themselves and understand how crucial ERP therapy is. OCDGlobal offers live face-to-face video therapy sessions with OCD therapists, in addition to ongoing support on the OCD Global telehealth app, so that you’re fully supported during the course of your treatment. You can also join our PURE OCD community and get 24/7 access to personalized self-management tools built by people who have been through OCD and successfully recovered