Excessive hand washing, counting, putting everything in order just so: these behaviors are how most people imagine obsessive-compulsive disorder, typically referred to as OCD. And while that picture isn’t inaccurate, it is incomplete. There is another, more subtle subtype of OCD, where both obsessions and compulsions exist, but the compulsive behaviors are not apparent to anyone else. This subtype was initially called Pure O in the mistaken belief that sufferers have only obsessions but no compulsions. Although it is not an official diagnosis (people with Pure O are still diagnosed with OCD), this variation of the disorder often looks quite different from what we consider “typical” of OCD.
OCD by the letter
To understand Pure O, it is essential to place it in the context of the broader OCD diagnosis. As mentioned earlier, OCD stands for Obsessive Compulsive Disorder, and according to the DSM*, the obsessions are defined as:
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
According to the National Institute of Mental Health (NIMH), OCD appears first as obsessive thoughts, commonly put into groups called subtypes:
- Fear of germs or contamination
- Unwanted forbidden or taboo thoughts involving sex, religion, and harm
- Aggressive thoughts towards others or self
- Having things symmetrical or in a perfect order
The DSM defines compulsions, the flip side of the OCD coin, as:
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
For those suffering from OCD, compulsions are the mechanisms they use to manage stress caused by their unwanted thoughts. NIMH lists some of the more common compulsions as:
- Excessive cleaning and/or handwashing
- Ordering and arranging things in a particular, precise way
- Repeatedly checking on things, such as continually checking to see if the door is locked or that the oven is off
- Compulsive counting
How is Pure O Different?
Pure O came by its name because it was initially believed that Pure O sufferers had purely obsessive thoughts with no corresponding compulsions. This belief took root because of the difficulty in distinguishing between the obsessive thoughts and the compulsive thoughts that follow.
Some of the more common Pure O obsessions are:
- Thoughts that you’re not good enough for your partner.
- Thoughts of harming yourself, a loved one or a stranger.
- Thoughts that you’re gay when you’re actually straight, or vice versa.
- Thoughts of committing a horrible or unthinkable act that is in complete violation of your personal values.
These obsessions lead to compulsive behaviors such as:
- Continually ruminating about the obsessive thoughts in an attempt to prove they are inaccurate.
- Avoidance of people, places or things that are related to the intrusive thoughts.
- Seeking answers from others regarding the obsessive thoughts.
- Seeking reassurance from authority figures or loved ones that you have not acted – nor will you act – on your intrusive thoughts.
- Researching online to find solutions or reassurance for your intrusive thoughts.
- Silently praying or repeating certain mantras in an attempt to neutralize the intrusive thoughts or prevent you from carrying out the unwanted behaviors.
- Checking your body’s reactions for proof that the intrusive thoughts are incorrect (e.g., that you are not sexually attracted to children, etc).
Because the obsessive thoughts typically involve content that is extremely embarrassing, shameful, or even illegal, sufferers of Pure O often keep these thoughts and related compulsions to themselves. Moreover, since this form of the disorder doesn’t readily conform to the more common conception of OCD, many people who suffer from it don’t realize that they have OCD. To make matters worse, mental health professionals don’t always recognize this form of OCD for what it is, since it doesn’t present in the same way as other forms of OCD. Consequently, people with Pure O are at risk of being undiagnosed or misdiagnosed, and thus their condition might remain untreated – or treated incorrectly – for years.
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Pure O misconceptions
- That there are no compulsions
- Pure O has compulsions like any other OCD subtype, but they are primarily mental instead of physical, so they can be harder to identify
- That the compulsions are only internal
- Pure O compulsions are primarily internal (i.e., thoughts), but they can also include physical behaviors like avoidance, seeking reassurance, and self-monitoring.
- That it isn’t OCD, but schizophrenia or borderline personality disorder instead
- People with any form of OCD often fear they are “going crazy,” or that they have a psychotic disorder, such as schizophrenia, or a personality disorder, such as borderline personality disorder. But obsessions and compulsions are distinct from delusions or hallucinations. People with OCD are aware that their obsessions are not logical, whereas someone suffering from a psychotic disorder believes what they are hearing, seeing or thinking is real, no matter how improbable.
- That the intrusive thoughts are an accurate reflection of character and personality
- Like with all forms of OCD, the obsessions and compulsions present in Pure O are a function of the disorder and do not represent who a person is. The majority of Pure O sufferers know that their intrusive thoughts are irrational and feel tremendous shame about them. In fact, this form of OCD often seems to prey on a person’s values by creating fears that the person is the opposite of who they are and want to be.
How is Pure O treated?
The most effective treatments for Pure O are the same that are used for “traditional” OCD, including cognitive and behavioral therapies, as well as medication.
Exposure and Response Prevention (ERP)
Perhaps the most common approach to treating OCD, the Exposure in ERP refers to exposing yourself to the thoughts, images, objects and situations that make you anxious and/or start your obsessions. The Response Prevention part of ERP refers to learning how to stop yourself from engaging in the compulsive behavior. By repeatedly exposing yourself to the thoughts you are trying to avoid, and then preventing yourself from avoiding them or carrying out rituals to neutralize them, the obsessive thoughts lose their power. Typically, a therapist will assist in the response prevention process – teaching the client skills for managing their distress while preventing them from engaging in their compulsive behaviors – until the person is able to do so on their own.
Acceptance and Commitment Therapy (ACT)
In Acceptance and Commitment Therapy (ACT), clients are taught how to accept that their intrusive thoughts exist but are harmless on their own, and in doing so, the client slowly begins to tolerate these thoughts and no longer needs to devote all their energy to fighting them. While learning to accept these thoughts without reacting to them takes time and practice, research on ACT for OCD points to this intervention as a very effective treatment for all forms of the disorder.
Oftentimes, these treatment approaches are combined with medication to enhance their effectiveness.
How do I know if I have OCD?
Everyone has random, odd, even inappropriate thoughts on occasion and most people can quickly dismiss them, so having those types of thoughts doesn’t automatically qualify as OCD or Pure O. If these thoughts cannot be dismissed, if they cause excessive stress and anxiety, and if managing that stress becomes so intrusive and time-consuming that it impacts regular activities, it is definitely a good idea to schedule a psychological assessment to determine what is causing your symptoms, and what your options are for treatment.
At LynLake Centers for Wellbeing, we offer comprehensive psychological assessments from experienced, licensed clinical psychologists. We also have compassionate, non-judgmental therapists who are trained in treating OCD. Contact us today to learn more about how we can help.
OCD Resources
These websites are focused on OCD and contain a wealth of helpful information:
https://drmichaeljgreenberg.com/articles/
Articles
https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
https://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy
https://www.intrusivethoughts.org/ocd-symptoms/pure-ocd/
https://iocdf.org/about-ocd/ocd-treatment/