Pure-O OCD

What is Pure Obsessional OCD?

“I can’t stop thinking about this. I feel terrible and so uncertain about everything. But, if I just think about it again, or think about it in the just the right way, or if I had just done it that way back then, then everything would finally be OK. Let me just plan it out, again, and I’ll be fine…”

Many people suffering with Obsessive Compulsive Disorder (OCD) feel like they are trapped within their own thoughts. More to the point, it can feel like they are stuck behind an invisible electric fence that limits where they go and how they get there, and the livable space inside the gated area seems to get smaller every day.

Pure-O, or Pure Obsessional OCD, is a sub-category of Obsessive Compulsive Disorder consisting of primarily, if not exclusively, mental or covert compulsive behavior. Typically, OCD manifestations that earn the Pure-O title are generally more abstract, thought intensive, and introspective. These include, but are not limited to, obsessions focusing on existential and immaterial matters as well as one’s character, sexuality, morality, future, past, spirituality, behavioral quality, or certainty.

Other sub-type names describe the cluster of obsessions and themes, such as HOCD dealing with thoughts about sexual orientation, Contamination dealing with cleanliness, Harm OCD focused on whether one will become is already is a violent murderer, or Scrupulosity dealing with issues of morality and spirituality, etc. Pure-O describes the ways in which the OCD cycle is experienced.

As an analogy, consider Pure-O not like a different shade of paint in the color spectrum of obsessions, but rather like the difference between brushed on paint and spray paint. While they appear to be vastly different because of their very different application methods, steps, and container, it’s important to remember they are both still paint can both can come in any color.

What is OCD

OCD, like other anxiety spectrum disorders, is a reinforced cycle of trigger, obsession, and action. Anything we see, think, feel, or experience can trigger an obsession. These triggers can be both external and internal.

For example, triggers can be things we see, or interactions we have, or they can be mental images, or internal physical sensations. The brain sees all these triggers and tries to predict and anticipate potential pitfalls, problems, and dangers, yet it generally overestimates the level of dangers involved or makes grossly exaggerates the possible consequences of a given circumstance. The brain, while being a wonderful protector, is at best an “amateur” prognosticator. This prediction usually exists in an “if ____, then ____” or “What if ….” story structure. The Feared Story is usually about what will happen to you or others unless you do something, i.e. a compulsion, to stop it.

What Are Compulsions in OCD and Pure-O OCD?

Compulsions are anything an OCD sufferer tries to do to either eliminate the anxiety or achieve a certain level of confidence that they are safe. These can be both overt, i.e. visible and external, or covert, i.e. internal and hidden from others. The average OCD sufferer will have a combination of both overt and covert compulsions. Once these compulsions are executed, the OCD sufferer regains a sense of peace, relief, and confidence that they are “OK”. This feeling, however, is only temporary and will eventually require more compulsive acts to regain the same sense of normalcy.

Common overt compulsions include:

• Hand washing or cleaning
• Organizing and arranging
• Hiding or moving dangerous items
• Tapping
• Opening or closing doors
• Re-entering rooms
• Asking others for reassurance
• Confession

Common covert compulsions include:

• Mentally replaying a previous interaction
• Reviewing memories
• Repeated prayer or mantra in one’s head
• Checking for physical sensations
• Evaluating emotions (past, present, or future)
• Changing an aspect of a memory to see how one would respond differently, or how it would potentially change the outcome
• Attempting to predict the outcome of events
• Mentally crafting statements to ensure a desired outcome or avoid a feared outcome

The Misconception of Pure-O

The mistake that many people make about Pure-O is that they don’t believe the sufferer has any compulsions. As the name suggests, “purely” obsessional OCD only has obsessions or obsessional thinking without any awareness compulsive behaviors. Some may argue that they only have the obsessional thoughts then don’t do anything about them. Others believe they only have “obsessions all day,” but cannot identify anything they are specifically doing to neutralize or combat the thought.

This understanding of Pure-O is misleading to both the average therapist and OCD sufferer because it can make them fear that Pure-O is a different disorder or is less treatable than traditional subtypes. This is not the case. So-called “Purely Obsessional” or “Primarily Obsessional OCD” is simply Obsessive Compulsive Disorder manifesting with more, or only, covert compulsions.

“Unique” is a Double-Edged Sword

Given the subtle variation in the compulsion manifestation of this subtype, Pure-O receives mixed reviews within the OCD community. On one hand, those with more overt compulsive symptoms have reported a form of envy for those manifestations with more covert compulsions. Overt compulsive behaviors are harder to hide, making it more difficult to “pass” as a person without OCD in their office or family. Furthermore, having highly observable compulsions, like walking in and out of doors or washing hands to the point of bleeding, requires more explanation to the uninitiated, which can be exhausting. Therefore, being able to “get away with” one’s compulsions secretly seems like a relief. To the contrary, those with Pure-O will disagree.

Those suffering with Pure-O sometimes develop a sense of hopelessness given their inability to shut of the brain and the thinking process. While one can physically resist compulsions washing their hands or turn their computer off before logging into WebMD, they can’t stop the mental barrage of questions and images. Therapists’ guidance to “resist compulsions” seems unhelpful if the person with Pure-O believes they don’t have compulsions. Remember, they have unrelenting obsessions! Knowing that Pure-O does in-fact contain compulsions only goes so far to quell a lingering “poor prognosis” fear. This dark perception of Pure-O is one of the first distorted thoughts to challenge in treatment.

The Act of Thinking in Pure-O is Still A Compulsive Act.

Pure-O is a misnomer as a stand-alone OCD subtype as it exists within many other OCD manifestations. One can have a Pure-O subtype and have overt compulsions connected to other subtypes. One can have a more overt type of OCD and experience Pure-O aspects in addition to their overt compulsions.

While there are some unique compulsion types within Pure-O that are thought based, it ultimately amounts to a compulsion. While covert, the intentional action of thinking, reviewing, considering, planning, or evaluating are all considered compulsive acts and should be treated just like compulsions.

Some examples of covert compulsions in Pure-O OCD within Subtypes

HOCD– playing through all memories of previous relationships and evaluating your feelings of love or arousal on an arbitrary “over-under” scale

Pedophile OCD– Reviewing one’s history with and around children searching for any potential feelings of arousal or attraction.

Contamination– Reminding oneself of times they’ve touched doorknobs and nothing happened

Relationship OCD (ROCD)- Comparing current relationship to previous partners or friends and playing out fake relationships with them to see if you’d be happier or more fulfilled.

Religious Scrupulosity– Repeatedly praying in one’s mind to edge-out “bad” thoughts, or to maintain a divine sense of connection.

Harm OCD– repeating “I’m safe and a not a murderer” in one’s head while using knives around others.

Existential OCD- holding the phrase “nothing is real” in mind in just the right way.

Pure-O is just as treatable as traditional OCD subtypes

Pure-O is treated using a combination of Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and mindfulness based approaches, such as Acceptance and Commitment Therapy (ACT).

Cognitive Behavioral Therapy

CBT is the main therapeutic model used to treatment OCD and other anxiety disorders. Broadly speaking, this technique works to help someone challenge the truthfulness of the feared story, called Cognitive Restructuring, in order to build a firm grounding from which they can move forward with different actions.

Cognitive Restructuring, for someone with Pure-O, can be a major stumbling block. Truthfully, it can be problematic for many OCD subtypes, but Pure-O sufferers often struggle with this step as it mirrors their compulsive attempts at certainty. Some with Pure-O are already reviewing memories of past outcomes, presenting counter evidence to their feared stories, and using logic to undermine their obsessive thoughts.

So, while for some Cognitive Restructuring can be a revolutionary tactic against their OCD, it can also be counter-productive. Discerning which it will be requires some discussion between therapist and client along with periodic re-assessment throughout the therapeutic process. Ultimately, to whatever degree Cognitive Restructuring is done, the client must grow their willingness to engage their fears, which is where Exposure and Response Prevention comes in.

Exposure and Response Prevention

Traditional OCD treatment uses ERP as a framework of systematically facing one’s fears. Over repeated exercises, the OCD sufferer will experience a progressive reduction in the subjective experience of distress and discomfort associated with the triggering thought, image, item, or event.

ERP consists of two components, Exposure and Response Prevention. Both are necessary for recovery. Exposure can be intentional or incidental. Simply by living life, the OCD sufferer will encounter those triggers and they can work to tolerate their existence and presence in their life. Within the context of therapy, client and therapist would work together to develop a list of triggering stimuli and intentionally set out to face them. This slow and steady process can start small, like writing it down or looking at a picture of it, then progressing toward the triggering situation in real life, or in vivo.

Response Prevention is the more difficult part. The OCD “response” is the compulsion. So, compulsion prevention. In traditional OCD treatment, this could look like resisting washing hands, not changing the channel, driving on the freeway, making and holding eye contact, or continuing through a flubbed prayer, just to name a few. Over time, the OCD sufferer will learn that they are able to face their fear without the need complete their compulsive action or ritual while also surviving and not being completely destroyed by their fear.

Response Prevention within Pure-O includes resisting engagement in mental, or covert, compulsions. While the sufferer cannot control the presence of their thoughts, they will learn through treatment that they have control over which thoughts they actively engage with and support. The goal of ERP for Pure-O is to build awareness of these internal compulsions and work toward reducing one’s active participation in them.

Acceptance and Commitment Therapy

Mindfulness-based approaches, such as Acceptance and Commitment Therapy (or ACT), offers a wealth of tools and perspectives that help the Pure-O sufferer approach their fears while takin the risk to reduce their reliance on internal compulsions.

ACT helps by helping people acknowledge that they are not their thoughts, but are someone experiencing thoughts, feelings, images, sensations, emotions, and urges. By recognizing that they are separate from these experiences, and not in control of them, they can learn to allow them to come in and out of one’s life. ACT also helps to provide a framework to face and experience greater amounts of anxiety and discomfort, whether it’s thoughts, mental images, fears of the future, or memories from the past.

Learning to allow for the presence of thoughts is one thing, but then what? Use ACT, client and therapist work together to consider what is most important in the client’s life, then work to engage a life that increasingly focuses on value-driven action. The OCD sufferer never enjoys their compulsions, though they appreciate the anxiety reducing results. So, instead of doing things they don’t care about (compulsions), ACT helps the OCD sufferer redirect their attention away from unwanted and unnecessary behaviors, and toward those actions that actually fill them with a sense of meaning and purpose.

To learn more about compulsions, including covert compulsions found in Purely Obsessional OCD, please listen to the FearCast Podcast.