More than half of the clients who come to see me for treatment struggle with what many refer to, colloquially, as “Pure O,” or “Pure/Primarily Obsessional OCD.” The term “Pure O” is meant to describe a subtype of OCD that exists largely in one’s head with little to no obvious, outward compulsive behaviors. Many clients who present for help describe their symptoms as “anxiety” or “feeling like I just can’t shut my brain off.” Few clients, prior to receiving treatment, actually recognize their internal thought struggles as a form of OCD. In this post, I examine the OCD subtype of “Pure O” and suggest directions for treatment.
About “Pure O”
There are many OCD subtypes that fall under the “Pure O” umbrella: POCD (pedophile OCD), Harm OCD, Sexual Orientation/Homosexual OCD, Relationship OCD, Religious OCD/Scrupulosity, Health-Related OCD, and Perfectionism/Some types of symmetry OCD. Essentially, anything you can fixate on in your head can become “Pure O.”
Common Symptoms of “Pure O”: Persistent ruminating (going around and around on a thought endlessly), mental checking, mental review of memories or behaviors, avoidance of people/places/situations, reassurance-seeking (this symptom is especially common with POCD and Relationship OCD), and bodily sensations including arousal, increased heart rate, labored breathing, chest tightness, and hyper-focus on body parts or functions.
The Vexing Misnomer
“Pure O” is an outdated and problematic term for many reasons. While it does capture the essence of the obsessive struggle in one’s head, it neglects to acknowledge the presence of compulsive behaviors. “Pure O” is a misnomer because:
- It implies an absence of compulsions — all forms of OCD involve obsessions (thoughts) and compulsions (behaviors). A compulsion is anything someone with OCD does to alleviate or neutralize their “negative” feelings of anxiety, discomfort, or disgust. For many people with “Pure O,” their compulsions will be mental compulsions where they try to ‘undo’ their distressing thoughts or compulsively seek evidence to prove the thoughts wrong.
- It makes it more difficult to apply ERP or gain cooperation with the client to engage in ERP — it can sometimes be challenging to devise a strategic treatment plan for “Pure O” because the exposures are less obvious than, say, exposing a person’s hands to a contaminant. For OCD clinicians, there is sometimes more legwork to be done on educating a “Pure O” client about how their symptoms make sense in the context of OCD and clinicians must call on more creativity in the counseling room to devise exposure opportunities.
- It ignores mental compulsions — this is the main reason the term “Pure O” is problematic. All people with “Pure O” experience compulsions. Once many of my clients become aware of their compulsive behaviors, they are often surprised by how much more frequently the compulsive behaviors are happening than the actual intrusive thought! Examples of compulsive behaviors in “Pure O” include asking other for reassurance (that your relationship is okay, that your partner has not cheated, that you are not gay or a pedophile, etc), mentally reviewing memories or behaviors to make sure you didn’t harm someone, reciting prayers in your head compulsively, adding up numbers or arranging images/letters in your head until they “feel right.”
- It implies that treatment is not as accessible for people with “Pure O” — because many people with “Pure O” don’t understand that they have OCD the same as any other person with OCD, they are often hesitant to engage in more traditional ERP treatment strategies. Clinicians and clients alike must be cautious when using CBT techniques to treat “Pure O” because some cognitive restructuring formats might place too much emphasis on debating the validity of the intrusive thought which can send the client back into a ruminative anxiety spiral. In this case, ACT approaches may be more useful.
- It creates a divide between types of OCD — I have heard some clients say that “Pure O” is preferable to other forms of OCD simply because the name implies it is “pure” or “pristine” or because the compulsions are often not as obvious to the outside world as with other OCD-spectrum disorders such as skin-picking, trichotillomania, or excessive hand-washing. Whether or not there is truth to this, it is important for people with “Pure O” to recognize their symptoms as a subtype of OCD just like any other type of OCD and to seek appropriate help.
Treatment for “Pure O”
ERP CAN be used for Pure O! Work with a knowledgeable OCD specialist to develop imaginal exposure ‘scripts’ as well as to determine if there are any other forms of ERP that may be be applicable. Do in vivo exposure — go to the church or mosque you’ve been avoiding and stay there without completing compulsions. Create an exposure with your partner around your greatest relationship fears. Again, work with a therapist to make sure there are no ethical dilemmas to work around. Working with a therapist knowledgeable about ACT and how to promote acceptance of your internal experience as well as a mindful stance (“Be Here. Right Now.”) may be particularly helpful in treating “Pure O.” Reach out to other who are impacted by OCD, get active, find your community. A great place to start is the IOCDF’s website.
Tips on creating imaginal exposure scripts: https://ocdla.com/imaginal-exposure-ocd-anxiety-4847