You may be familiar with some of the symptoms of obsessive-compulsive disorder (OCD). Oftentimes, OCD is associated with very obvious and visible compulsions—like excessively washing hands, ritualistically double-checking things like turning the stove off, and other physical behaviors.
But you might be surprised to learn that many people with OCD don’t exhibit any physical or visible symptoms. In other words, you can’t see that a compulsion is happening, even though it is. It’s just that the obsessions and compulsions take place in someone’s mind.
This is called Pure Obsessional OCD (or “Pure O”, as it’s sometimes called). Since it’s not talked about very much, you might think it’s rare, but as an OCD specialist who treats the condition professionally, I want to emphasize that it’s actually quite common—and with the help of a thoroughly trained specialist, it’s very treatable. Read on to learn more about it, and how to get help.
What is Pure OCD?
Pure obsessional obsessive-compulsive disorder (OCD) is a subtype of OCD that’s characterized by intrusive thoughts, images or urges without any visible physical compulsions. “Pure O” OCD differs slightly from other types of OCD because its compulsions primarily take place in a person’s head rather than through visible actions. This could manifest as mentally replaying events over and over again in your mind, silently repeating phrases in your head, becoming hyper-aware of normal bodily sensations — just to name a few.
Though they can take many forms, these intrusive thoughts generally center on themes of harm, relationships, sexuality and gender, and religious or moral questions. These ideas and images can feel like an attack on a person’s sense of self and they often come with guilt and shame.
Many people with pure OCD are terrified of sharing these experiences for fear of being judged. It’s common for people with “Pure O” OCD to feel like they are the only ones dealing with this. Because their experience is internal, there often aren’t obvious visual clues an outside observer might notice to identify someone with pure OCD, but that makes it no less distressing.
What does Pure OCD feel like?
Although it might sound surprising, it is relatively common to have a disturbing or immoral thought, impulse or urge — regardless of OCD diagnosis. The difference is, for people without OCD, these thoughts tend to last only a few seconds and don’t cause significant distress. A person may be driving and suddenly think to themselves, “What would happen if I drove off this bridge?” But they’ll shortly dismiss the idea and move on.
For someone with pure OCD, these intrusive thoughts can be frequent and highly distressing. They will identify with this thought and feel convinced it reveals something about who they are as a human being. They might think, “I just had a dream about harming someone — that means I must be a violent person.”
It can feel impossible to separate oneself from these thoughts when they occur. The experience can feel so real, they can’t imagine their thoughts are actually from OCD. Someone with pure OCD may want to prove or disprove one of their intrusive thoughts (for example: “I would never jump off this ledge, but how can I know for sure?”), feeling unable to tolerate any uncertainty about them. A person with pure OCD may even doubt their diagnosis. They might think, “Maybe this time, my thoughts actually mean I want to hurt someone.”
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Examples of pure OCD obsessions
People with pure OCD experience unwanted obsessive thoughts, impulses and urges. Here are just a couple examples of common themes:
- Jennie is sharpening her pencil in a classroom when she suddenly has the thought, “This pencil is really sharp,” followed by an intrusive image of herself hurting a classmate with the pencil. She may start thinking, “I could actually hurt someone. I shouldn’t be in this class. I need to leave right now or I could endanger the other classmates.”
- Taylor is watching a movie with his partner and thinks, “That’s weird. Why didn’t he laugh at that part? Does he not find it funny?” He might start thinking, “What if we’re not meant to be together? I’ve always found a shared sense of humor really important. Now that I think about it, what if we have nothing in common?”
Examples of pure OCD compulsions
People with pure OCD engage in mental compulsions (rather than physical ones) in an attempt to alleviate their anxiety. Here are some examples of what that might look like:
- Mental review: Someone with pure OCD may engage in excessive mental review as a way to relieve their anxiety. To continue our earlier example: even though fellow students may see Jennie busily absorbing the lecture material, in her head, she’s reviewing every past interaction with students she can remember. After class is over and Jennie is at home, she might mentally review her day at school, searching for proof that she did not stab anyone and is not a murderer.
- Mental rituals: Someone with pure OCD may create certain mental rituals they must accomplish in order to reassure themselves their intrusive thoughts are untrue, or that they aren’t a bad person. For example, after our earlier scenario, Taylor might decide to repeat specific words, images or numbers each time he has a negative thought. He might decide to repeat to himself, “I love my partner,” five times to neutralize a negative thought or think of a photograph where they are at the beach having a great time.
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What’s the Best Treatment for Pure OCD or Pure Obsessional OCD?
Even though pure OCD compulsions are often not noticeable from an outside perspective, they are best treated like all types of OCD compulsions: with exposure and response prevention (ERP) therapy. ERP is considered the gold standard for OCD treatment, backed by decades of rigorous clinical research.
For pure OCD, a trained ERP therapist will be able to help you identify your mental compulsions and work with you to come up with the best course of treatment for exposure to them.
If you’ve ever tried not thinking about something, you know how difficult it is to control your thoughts. ERP therapy takes the opposite approach: Instead of trying to make yourself stop your obsessive thoughts, you welcome them.
Let’s say that each time you’re driving, you can’t stop seeing mental images of your car running over a pedestrian. This scene starts appearing in your mind every time you drive past a school or busy street downtown. As a way of coping, you’ve started counting to seven in your head each time you see an image like this. This strategy worked at first, but lately it has been less effective. So, as a way to take extra precaution, you’ve decided to count to 49 instead of seven.
I may ask you to welcome the intrusive image of running over a pedestrian without trying to make it go away. You might think, “Welcome it? No way! That’s terrible. I just want these images to stop.” But instead of trying to suppress them, a therapist like me may ask you to put your full attention on these thoughts. This teaches your brain a new response to your intrusive thoughts and shows you that they don’t have to keep you from living your life.
The progress you can make through personalized ERP treatment is remarkable. This active, guided treatment helps you build tools to distinguish yourself from your OCD thoughts, making it far easier to let them come and go without engaging in compulsions or avoidance. When I lead collaborative treatment with people who struggle with pure OCD, I find that the tools they develop can last for a lifetime, entirely changing their relationship with uncertainty and anxiety.
How to get help for Pure O OCD
If you’re struggling with pure OCD, there is help available. When obsessions and compulsions are purely mental—and therefore invisible to the untrained eye—even mental health professionals may not identify all the symptoms that feed the OCD cycle and make it worse over time. However, therapists with intensive, specialized training in OCD and ERP therapy, like myself and my colleagues here at NOCD, can provide an accurate diagnosis and personalized treatment plan to put you on the path to recovery—just as we do for others every day.
All of our therapists specialize in OCD and receive ERP-specific training and ongoing guidance from our clinical leadership team. Many of them have dealt with OCD themselves and understand how crucial ERP therapy is.