What is “Pure-O” OCD and How is it Treated?
Article by Max Maisel, PhD Clinical Psychologist Practicing in Redondo Beach and Los Angeles, California
In my experience, OCD is one of the most misunderstood psychological conditions. Typically, when people hear the term "OCD," they think of compulsive handwashing, ordering objects, or repeatedly checking the oven.
Unfortunately, due to improper representations in the media, some people have come to associate OCD with more or less positive traits or idiosyncrasies (e.g. valuing cleanliness, conscientiousness, or orderliness). Let me just say this before we get into "Pure O" OCD. OCD is NOT an adjective (e.g. "oh, I'm just OCD"). OCD can be a debilitating mental health condition that causes immense pain and suffering. When people do check or wash as part of their OCD ritualizing, it is because they are feeling incredibly uncomfortable or scared and feel they have little to no control over these behaviors.
Okay, now that we have that out of the way, on to "Pure O" OCD, or Purely Obsessional OCD. You may have noticed how I keep writing "Pure O" with quotation marks. This is because the term "Pure O" is actually a misnomer. There is no such thing as OCD without the "C" ("compulsions"). In "Pure O," however, the compulsions are invisible, as they happen in your mind! Many manifestations of OCD involve physical compulsions (behavior that is done repeatedly to cope with an intrusive thought and help the sufferer feel better). These may include handwashing, checking locks, repeating behaviors, ordering items, asking a loved one for reassurance, and many more. They are "physical" as they can be seen from the outside.
When somebody is doing a mental compulsion, nobody else can see them do it. Examples of mental compulsions include rumination (trying to mentally solve an unsolvable problem), overanalyzing, thought suppression, prayer, self-reassurance, thought replacement, paying attention, and worrying. Essentially, anything your mind does to try to gain reassurance or cope with an intrusive thought or mental obsession. It's common for most OCD sufferers to have both physical and mental compulsions. However, we might call it a "Pure O" presentation when primarily the compulsions are mental in nature. At this point in the literature, "Pure O" is not a separate subtype in the DSM-V. We call it "Pure O" just to help understand the subjective nature of the disorder, but it's technically lumped together with all other forms of OCD.
Although it's a misnomer, many of my clients have found the term incredibly helpful. When people are suffering with incredibly disturbing intrusive thoughts or feel stuck in a never-ending hamster wheel of trying to solve unsolvable mental problems, it's far too easy for them to feel broken or weak in some ways.
To realize that their condition is a medically recognized one, shared with tens of thousands of other people, can be an absolutely life-saving epiphany. You may be wondering if "Pure O" is more difficult to treat than traditional forms of OCD? Absolutely not! For all OCD forms, it's essential to have a solid understanding of your OCD's landscape (the triggers, the purpose of the compulsions, sneaky forms of avoidance) and how OCD works (e.g. OCD is a disorder of uncertainty, and treatment lies in accepting uncertainty rather than trying to solve an unsolvable problem or seek short-term, false reassurance).
The one tricky part is learning how to differentiate an intrusive thought from a mental compulsion, which can be subtle and nuanced. Intrusive thoughts or obsessions (note that the terms are used interchangeably) are fundamentally out of our control. They are events of the mind, just as a rumbling stomach is the event of a belly, or a tension headache is an event of your head.
It's easy to not identify with these physical sensations (nobody says "I am a stomachache," we say "I have a stomachache"). With OCD intrusive thoughts, we need to take a step back and see thoughts as simply thoughts. The brain generates thoughts, and it's your job to differentiate which thoughts you engage in and which thoughts you ignore or dismiss. We do not stop or control thoughts that pop into our minds. In fact, the more you don't want a thought, the more likely your brain is to generate it.
Mental compulsions, on the other hand, are the mental behaviors we do after an intrusive thought is generated. Mental compulsions are actions, in that you actively cope or respond to the fear or discomfort caused by a scary or unwanted thought. In Exposure and Response Prevention, the gold standard treatment for OCD, you will learn how to differentiate uncontrollable intrusive thoughts from more controllable mental compulsions, and over time your OCD won't be able to help but fade away.
While your mental compulsions may not be controllable at the moment, through your OCD treatment journey, you will learn ways to take the reins back from OCD and get back in the driver's seat of your life. This includes identifying subconscious beliefs that drive your thinking behind mental compulsions, learning ways to flexibly manipulate your attention, and identifying with and connecting to the core values you have that compulsions take away from. It's important to remember that whether you struggle with "Pure-O" OCD, physical compulsions, or a combination, the content of OCD (or the specific themes that bother you) is ultimately irrelevant for treatment.
To learn more about Pure O manifestations of OCD and how to find relief from intrusive thoughts, please reach to Beachfront Anxiety Specialists by calling (213) 218-3080 or by sending a message through the CONTACT PAGE. Clinicians treat anxiety online or in-person in our offices in Redondo Beach and Los Angeles, CA.