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Pure O: A Silent Battle

By Adam Grafa

Excessive hand washing, counting, putting everything in order just so, these behaviors are how most people imagine OCD. And, while that picture isn’t inaccurate, it is incomplete. There is another, more subtle subtype of OCD, where compulsions are mostly invisible. This subtype was initially called Pure O in the mistaken belief that sufferers have only obsessions and no compulsions.

OCD by the letter

To understand Pure O, placing it in the context of the broader OCD diagnosis is essential. 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?

With Pure O compulsions are predominantly invisible, and because of that, it is grouped with the other subtypes that have no visible compulsions. It came by its name because it was believed that Pure O sufferers had purely obsessive thoughts with no corresponding compulsions, and that belief took root because of the difficulty in distinguishing between the obsessive thoughts and the compulsive thoughts.

Pure O doesn’t readily conform to the more common conception of OCD, so many who suffer from it don’t realize that they are, in fact, suffering from OCD. Because it can be difficult to recognize it commonly goes undiagnosed or misdiagnosed, and because of that stays untreated, or treated incorrectly, more often than other OCD subtypes.

Some of the more common Pure O obsessions are:

  • Fear that you’re not good enough for your partner.
  • Fear of harming yourself, a loved one or a stranger.
  • Fear that you’re gay when you’re actually straight, or vice versa.

These obsessions lead to compulsive thoughts like:

  • Guilt for having the obsessive thoughts
  • Avoidance of people, places or things that are related to the intrusive thoughts
  • Seeking answers from others for the obsessive thoughts
  • Reassurance from authority figures or loved ones that you have the right answer
  • Researching online to find answers to your questions

Lucy Grantz, LMFT, treats OCD at Lyn Lake Psychotherapy and Wellness and sees the torment this form can cause, “When compulsions are mental, OCD can be especially difficult to spot, so people can go for years suffering needlessly.”

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 mental

  • Pure O compulsions are primarily mental, but they can also encompass physical behaviors like avoidance, online research and reassurance seeking

That it isn’t OCD but schizophrenia or borderline personality disorder instead

  • It is OCD….

That the intrusive thoughts are an accurate reflection of character and personality

  • Like other forms of OCD, the obsessions and compulsions 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.

How is Pure O treated?

The most effective treatments for Pure O are the same that are used for “traditional” OCD and are within the Cognitive Behavioral Therapy (CBT) model.

Exposure and Response Prevention (ERP)

ERP, as explained by the International OCD Foundation:

The Exposure in ERP refers to exposing yourself to the thoughts, images, objects and situations that make you anxious and/or start your obsessions. While the Response Prevention part of ERP, refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been “triggered.”

Lucy Grantz uses ERP in her OCD practice because “ERP targets OCD in a way other types of therapies don’t… it addresses the thought process while staying out of content. Some types of therapy are more focused on analyzing content or ‘figuring out,’ but with OCD both of those activities can be compulsions on by themselves and can exacerbate the distress.”

Acceptance and Commitment Therapy (ACT)

Psychology Today explains this approach:

Clients learn to stop avoiding, denying, and struggling with their inner emotions and, instead, accept that these deeper feelings are appropriate responses to certain situations that should not prevent them from moving forward in their lives. With this understanding, clients begin to accept their issues and hardships and commit to making necessary changes in their behavior, regardless of what is going on in their lives, and how they feel about it.

In some cases, these approaches are combined with medication as well as mindfulness practice.

Everyone has a little OCD, right?

Actually, no. Although it’s not uncommon to hear people jokingly say, “they are OCD about their favorite band” or that “everyone has a little OCD,” for the majority, those aren’t OCD. Habits, rituals, an intense interest in something are, for most people, normal, even enjoyable. For someone suffering from OCD those same thoughts can bring daily life to a grinding halt. Imagine a radio that only you can hear but it’s turned up so loud it drowns out everything else. The radio repeats the same frightening news, over and over; and you can’t turn it off. That’s closer to OCD.

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 can’t be dismissed, if they cause excessive stress and anxiety, and when managing that stress becomes so intrusive and time-consuming that it impacts regular activities, it might be OCD.

OCD Resources

These websites are focused on OCD and contain a wealth of helpful information:

www.iocdf.corg

www.intrusivethoughts.org

www.beyondocd.org

https://drmichaeljgreenberg.com/articles/

While it’s important to educate yourself about OCD, it’s even more important that you don’t fight it alone. Seek help from a therapist who specializes in OCD. IOCDF has a resource directory that you can use to find a therapist who can help:

https://iocdf.org/ocd-finding-help/find-help/

Type in your city of residence into the location field for a list of therapists near you who treat OCD.

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/