For adults
Pure O: OCD with mental compulsions
Pure O, short for purely obsessional, is the name many people use for OCD without visible rituals. It almost always involves compulsions, but they happen in the head, which makes them hard to see from outside and easy to repeat many times a day.
What people mean by Pure O
When someone says they have Pure O, they usually mean that they do not wash, check doors or line things up, and that their OCD is a stream of unwanted thoughts: violent images, sexual thoughts they find repugnant, doubts about their relationship or their sexuality, fears of having sinned. The themes overlap with those of harm OCD, POCD and relationship OCD. A thought arrives, it feels important, and the mind sets to work on it. You go back over what happened, check whether you still feel the way you should, reason your way to a conclusion, feel better for ten minutes and then find a hole in the reasoning. Someone may spend a whole commute working out whether a thought about a colleague meant something and arrive at work exhausted, having said nothing to anybody.
Where the label misleads
The name gave people whose OCD looked nothing like handwashing a word that made them recognisable, but it suggests there is nothing to stop. If a therapist accepts that, treatment tends to drift towards discussing the thoughts or weighing up the evidence for them, and each of these works as more reassurance. When Williams and colleagues (2011) analysed the symptoms of 201 people in two OCD treatment trials and counted them, sexual, aggressive and religious obsessions, the ones usually labelled Pure O, grouped together with mental compulsions and reassurance-seeking. The authors concluded that a purely obsessional type with no compulsions may be a misnomer. Treatment that helps therefore starts by finding the compulsions.
Mental compulsions you may not have counted
A mental compulsion is anything you do in your head to reduce the distress of the thought, get certainty or cancel it out. Common examples are listed below.
- Reviewing. Replaying a conversation, a drive or an evening to check whether you did something wrong.
- Analysing. Working out what the thought means, why you had it and what kind of person has thoughts like that.
- Checking for a feeling. Scanning for arousal, love, anger or the sense of rightness that would settle the doubt.
- Neutralising. Replacing a bad image with a good one, saying a phrase or praying in a set way until the thought feels cancelled.
- Self-reassurance. Telling yourself “I would never do that” or listing the evidence that you are a good person.
- Suppression. Pushing the thought away the moment it appears, which keeps your attention on watching for it.
Alongside these there are usually visible behaviours that people do not count, such as searching online, asking a partner the same question, confessing, and avoiding places or people.
- Trigger: A memory of something you said years ago
- Obsession: What if I hurt someone and never knew?
- Feeling: Guilt, anxiety, a need to be sure
- Compulsion, in your head: Replaying the memory, arguing with the thought, checking how you feel
- Relief, for now: Settled for a minute, then a new angle appears
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: A quiet moment in the car, lying in bed, A conversation about the past, reading the news.
Where treatment steps in. You let the thought be there without reviewing, arguing or checking, and learn that you can carry the unanswered question without the ritual.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
How treatment works when the rituals are in your head
The treatment is exposure and response prevention (ERP). Exposure means approaching the thought, the situation or the doubt on purpose, and response prevention means not doing the compulsion afterwards. At first you keep a brief record of when the thought arrives and what your mind does next, so that we can see each mental ritual and when it happens. You cannot stop a thought from arriving, and trying to keeps your attention fixed on it. What you can learn to do is decline the next step, leaving a review unfinished or a question unanswered and returning your attention to what you were doing.
Because there is no door to touch, exposure uses the thought itself. That might mean writing the feared thought in plain words and reading it several times a day, listening to a short recording of the feared doubt without answering it, or going into situations that set off the doubt, such as the drive or the family meal, and not reviewing afterwards. We choose the steps together, starting with one that feels manageable, and nothing is sprung on you. The main thing you learn is that you can carry the anxiety and the unanswered question without doing the ritual, and this gets easier with practice. I give you an estimate of how long it is likely to take by the end of the first session.
What is not known
Trials of ERP include people with mainly mental OCD, but few have looked at them separately, so it is not known whether they respond as quickly on average as people with visible rituals. Mental compulsions are also harder to measure, so I track progress with standard, validated OCD questionnaires and with what has changed in your day.
Sources
- Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Liebowitz, M., Simpson, H. B., & Foa, E. B. (2011). Myth of the pure obsessional type in obsessive-compulsive disorder. Depression and Anxiety, 28(6), 495-500. onlinelibrary.wiley.com (opens in a new tab)
- National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline CG31 (2005; an update is in development). nice.org.uk/guidance/cg31 (opens in a new tab)
Common questions
Is Pure O a real diagnosis?
It is not a formal diagnosis. It is an informal name for OCD in which the compulsions are mostly mental rather than visible. The diagnosis is obsessive-compulsive disorder, and the diagnostic criteria have long included mental acts such as counting, praying and repeating words silently as compulsions. Using the term is fine if it helps you feel understood. It becomes a problem only if it leads you or a therapist to conclude that there are no compulsions to work on.
Is thinking about the thought the same as a compulsion?
Not always. A thought that arrives on its own is the obsession. What turns thinking into a compulsion is its purpose, so if you are going over something to get certainty, to feel settled or to cancel out the thought, that is a mental ritual. The same topic can come up in ordinary thinking without being a compulsion, and telling the two apart in your own case is one of the first things we work on.
How can you stop a compulsion that happens in your head?
At first you will not manage it perfectly. Mental compulsions tend to start automatically, so the early work is noticing them sooner. Once you can see one starting you can decline to finish it, by leaving the review half done or not giving yourself the answer, and returning your attention to what you were doing. Catching a ritual halfway through still counts, and people get faster at this with practice. The thought usually still arrives, and it matters less.
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Not sure whether this is the right fit?
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