Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Mental Compulsions in OCD: When OCD is invisible

By Stacy Quick, LPC

May 10, 20248 minute read

Obsessive-compulsive disorder (OCD) doesn’t always look like compulsively checking doors, washing your hands, or arranging objects in a perfectly straight line. Sometimes it looks like fighting a silent battle inside your head. Perhaps you mentally review something you said over and over again. You might reassure yourself to feel better when you have an intrusive thought. Or you may repeatedly rehearse an event in your head, feeling you need to be perfectly prepared. The list goes on.

If this resonates with you, there’s a name for what you’re experiencing: mental compulsions. While waging a hidden war within your mind can feel isolating, you’re not alone: “Almost everybody has mental compulsions,” says April Kilduff, MA, LCPC, LPCC, LMHC, a therapist and clinical trainer at NOCD. These are especially characteristic of what’s called Pure O OCD, but they can be present in any theme of OCD, and they can bring just as much distress as physical compulsions. 

Let’s take a closer look at mental compulsions, how they’re different from physical compulsions, and how you can free yourself from them.

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What are mental compulsions?

OCD involves two primary symptoms—obsessions and compulsions—that disrupt your life, cause a lot of distress, or take up a great deal of your time. Obsessions are unwanted and uncomfortable thoughts, images, urges, or feelings that keep popping up in your head. Compulsions are repetitive behaviors or mental actions you do to relieve the discomfort you feel or prevent an unwanted outcome. 

Obsessions and compulsions combine to form a vicious cycle. While doing compulsions may make you feel better for a moment, compulsions teach your brain that your obsessions actually pose a threat—but this isn’t actually true. In turn, this gives your obsessions power, causing them to come back stronger and more often. 

Some OCD compulsions are physical—you engage in them actively, and other people often see them happening. The most well-known example is compulsive handwashing: someone with OCD might feel the need to wash their hands five times in a row or else they’ll get horribly sick. Others with OCD might feel the need to confess their intrusive thoughts or check and recheck that the door is locked. 

But physical compulsions don’t tell the whole story. Many people with OCD struggle in ways others can’t see, engaging in mental compulsions: thoughts or mental actions they feel a need to do over and over again to respond to obsessions or stop something bad from happening. In some ways, these can be even harder to handle than physical compulsions. “It’s one thing to decide ‘I’m not going to wash my hands’,” says Kilduff. “It’s another thing to try and decide ‘I’m not going to think about this anymore’ when that is what your brain wants to think about.” 

Since they happen in your head, mental compulsions may go unnoticed by even your closest loved ones. Even you may not recognize exactly what’s happening. “People often don’t even realize they’re doing mental compulsions until we point out that they’re a thing,” explains Kilduff. In fact, mental compulsions can feel almost automatic. But make no mistake: you can learn to gain control over all compulsions, whether physical or mental.

Mental compulsions and “Pure O” OCD

“Pure obsessional” OCD—often shortened to “Pure O”—is a common but slightly misleading name for OCD that doesn’t involve any physical compulsions. But just because compulsions aren’t visible doesn’t mean they aren’t there, and that’s why many experts consider Pure O a misnomer. ​​In a 2011 study, researchers gave a survey to roughly 200 people with OCD and found that all participants reported at least one compulsion when mental compulsions and reassurance-seeking were included. 

In every case of ‘Pure O’ that I’ve seen, there were never only obsessions. They just engaged in mental compulsions they weren’t aware of.

April Kilduff, MA, LCPC, LPCC, LMHC

Types of mental compulsions

Mental compulsions can happen among people with any type of OCD. There are many different types of mental compulsions, but here are some of the most common:

Compulsive Prayer: While prayer is important to many people’s faith, it can also become compulsive. They may pray over and over again, try to pray “perfectly,” or restart a prayer if they get distracted. 

Counting: You might count anything in order to feel “just right” or drown out an obsession—steps, ceiling tiles, beats in a song—either out loud or in your head.

Emotional Checking: Compulsive checking doesn’t have to be physical. Emotional checking involves analyzing your emotions to make sure you’re having the “right” feelings.

Memory Hoarding: You might try to hang on to memories, thoughts, and experiences with perfect accuracy because you feel they’ll be crucial in the future.

Mental Checking: For example, you might scan through your memory to ensure you locked the door or that you know where your kids are.

Mental Reviewing: This could involve replaying a conversation you just had over and over again, or compulsively reviewing an event that happened years ago.

Rumination: Often referred to as “overthinking,” rumination involves compulsively analyzing or trying to solve a perceived problem. It can be especially tough to identify, and can last for weeks at a time.

Self-Reassurance: Reassurance doesn’t always have to come from the outside. You might try to relieve your distress by reassuring yourself that your fears aren’t true, rather than asking others.

Thought Replacement: You may try to replace “bad” thoughts, urges, or images with “good” ones, or say particular phrases in your head in an attempt to neutralize an obsession.

[Pull quote: “With harm OCD, I’ve worked with many people who try to ‘cancel out’ their intrusive thoughts about harm, or replace a disturbing mental image with something more positive.” – April Kilduff]

Thought Suppression: You might try to “drown out” an uncomfortable intrusive thought or distract yourself with something else.

How to identify mental compulsions

It’s usually easy to distinguish between an obsession and a physical compulsion. With mental compulsions, it’s usually trickier, since they take place mostly within your mind. But there’s a concrete difference between how obsessions and mental compulsions work.

The obsession is the subject matter of OCD—that unwanted thought, image, or feeling. Obsessions sneak up on you, and you use a mental compulsion to feel at ease.

April Kilduff, MA, LCPC, LPCC, LMHC

The obsession is the part that strikes unexpectedly and causes distress, while the compulsion is what you do to try to get rid of distress. For instance, if you have religious OCD, you might have an unwanted thought that goes against your faith—that’s an obsession. In response, you might pray repeatedly for forgiveness—that’s a mental compulsion. 

Now, how do you set apart mental compulsions from regular behaviors? You’ll need to understand your reason for doing it. Ask yourself the following questions:

  • Am I trying to relieve stress or anxiety?
  • Am I trying to make something feel ‘just right’?
  • Am I trying to avoid an imagined catastrophic outcome?
  • Am I looking for perfect certainty about my doubts?

These can all warn you that you may be performing mental compulsions. 

Get your life back from OCD

How can I stop mental compulsions?

When you engage in any kind of compulsion, you inadvertently teach your brain that you successfully avoided some kind of danger or threat—but your obsessions aren’t actually dangerous or threatening. To re-teach your brain and break the OCD cycle, you have to learn to stop engaging in compulsions, whether they’re physical or mental.

This is the goal of exposure and response prevention (ERP) therapy, considered the gold standard treatment for OCD.

“ERP involves gradually facing the fears that trigger your OCD while learning to resist the urge to perform compulsions, whether they’re physical or mental,” says Brittany Webb, LPC, of Better Minds Counseling & Services. In ERP, you’ll track your symptoms and collaborate with a specialized therapist to gradually put yourself into situations that trigger your obsessions.

You’ll start small and work toward more difficult therapy exercises. For example, if you have harm OCD and knives are a trigger for you, you may be asked to look at a picture of a knife, without distracting yourself, mentally repeating “I would never hurt someone,” or engaging in any other compulsion. Instead, you allow the discomfort and anxiety to pass on their own. Over time, you’ll face bigger fears, and learn that you can tolerate even your most distressing obsessions without resorting to compulsions.

Since mental compulsions often seem to happen automatically, it can be hard to resist them at first. Your therapist might begin by asking you to interrupt mental compulsions by leaning into uncertainty. For example, if you start to ruminate on existential doubts, you could resist rumination by saying “there may or may not be meaning to life” and sitting with the anxiety you feel. 

Kilduff recalls a patient who insisted he had no compulsions whatsoever, only to realize he did a number of mental compulsions. ERP involved “undoing” these compulsions—when he wanted to replace his “bad” thoughts with “good” thoughts, for instance, he began by intentionally thinking his “bad” thoughts again.

“Over time, he began to catch himself mid-mental compulsion and could shut it down. Eventually, he reached the point where he could sense the urge to do the mental compulsion and actively choose not to engage,” Kilduff recalls. “And at that point, the original obsessions became much less distressing.”

Though it may be hard to imagine, remember that OCD is manageable, whether your compulsions are physical, mental, or you struggle with both. With the right form of treatment, you can claim victory in the silent battle inside your mind.

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