Is Pure O OCD Real?

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by recurring obsessive thoughts and compulsive behaviors. OCD affects about 1%¹ of the US population or about 2.2 million people.

The intrusive and undesirable thoughts, images, or urges in OCD cause distress and anxiety to the person, causing them to perform visible rituals (compulsions) to suppress this feeling of fear or despair (e.g., counting, checking, washing, etc.).

However, some people may experience mental compulsions, making it seem like it's a pure obsession without the compulsions — mainly because of the absence of visible behaviors or rituals. But does pure O OCD exist? Is pure O OCD real?

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What is pure O OCD?

Pure obsessional OCD (pure O OCD), or in short known as pure O, is a type of OCD that's characterized by intrusive thoughts, images, or desires but with no physically noticeable compulsions. Instead, people with pure O engage in repetitive, compulsive mental rituals to defeat these unsolicited mental preoccupations.

Pure O OCD compulsions purely take place in the mind. This makes diagnosing pure O difficult as there are no visible actions as in the case of traditional OCD. Besides, the hidden nature of pure O makes it seem like a less severe form of OCD.

Many affected individuals may go years without admitting to having obsessions or seeking treatment. However, these mental compulsions can be significantly stressful to the person and challenging to overcome.

How does pure O differ from OCD?

Previously, the lack of observable physical compulsions to counter obsessions made people think pure O is a “purely obsessional” type of OCD. In other words, you might think someone only experiences mental obsessions and no compulsive actions. However, studies² reveal that these “hidden” compulsive behaviors are present but occur within the mind alone, making the term “pure O” a contradiction of its actual description.

Classically, pure O and OCD are more or less the same. The DSM-5³ (a handbook mental health practitioners use to diagnose mental health disorders) doesn't list pure O as a separate diagnosis. Whether common OCD or pure O, you'll experience obsessions and/or compulsions if you have the condition.

The difference is that if it's pure O OCD, you won't show any visible repetitive behaviors, as these compulsions are wholly mental.

Another defining characteristic of people with pure O is the fear of sharing these experiences. The anxiety stems from the fear of getting judged. For example, "I fear someone will consider me sexually immoral if I tell them about my sexuality obsessions." Therefore, this can leave you to mentally deal with the thoughts by introducing other ideas to counter the obsessions.

Keep in mind that these obsessions don't represent who you are or your personality in any way. They should be taken only as mental misfires that can happen in anyone's mind. This understanding makes it easier to seek professional assistance to treat your pure O OCD symptoms.

Symptoms of pure obsessional OCD

The human imagination knows no boundaries. Everyone tends to have intrusive or unwanted thoughts at times. For example, while driving, one might think, "What might happen if I run over a pedestrian?"

The difference is that these thoughts only last for a short moment and disappear quickly in normal people. However, if you have pure O disorder, this thought might cause you anxiety and distress, leading to mental compulsions.

For example, you might think, "How can I think of harming someone? I must be a bad/violent person." Instead of being a one-time event, the obsessive and compulsive thoughts repeatedly return. Additionally, these disturbing thoughts, mental urges, or images seem difficult to control due to their repetitive nature.

You can tell if you might have pure O OCD by carefully analyzing your thoughts and how they affect your daily life. Some of the obsessions and compulsions to look out for include:

Obsessions in pure O

Obsessions are repetitive, persistent, invasive, and uninvited thoughts, mental images, or urges that result in anxiety and anguish. Obsessions can be different forms of cognitive questions, doubts, or fears, which vary from person to person — harm, sexuality, relationships, illness, accidents, morals, or religion. They might look something like:

  • Frequently being afraid that you aren't good enough for your partner or your partner isn't good enough for you (Relationship OCD or ROCD)⁴

  • Recurring thoughts that you might be homosexual when you're actually straight or vice versa (Sexual Orientation OCD or SO-OCD)⁵

  • Monotonous views, images, or scenes of you injuring yourself or others (Harm OCD)⁶

  • Persistent intrusive psychological thoughts or urges that you might molest or harm a child (Pedophilia OCD or pOCD)⁷

  • Consistent mental ideas or feelings that one considers inappropriate based on one's beliefs or religion (e.g., worship of the devil)

  • Obsessively paying attention to bodily functions like swallowing, breathing, and seeing

  • Recurrent thoughts that someone might say, write or think a bad thing about you

According to the DSM-5, these obsessions cause repeated attempts to either wave off (ignore), suppress, or defuse the thoughts. These attempts are what cause compulsive thoughts.

Compulsions in pure O OCD

Before further studies were conducted, it was generally believed that pure O patients ultimately experienced no compulsions because no observable physical behaviors could be seen. In one study⁸ in 1994, pure O was described as intrusive sexual, violent, and religious obsessions without compulsions.

However, a 2011 study⁹ revealed that “pure obsession” is actually a misleading term, as individuals with pure O reported engaging in unseen mental rituals to try and overcome intrusive thoughts. These compulsions manifest in the form of:

  • Silently repeating certain words or prayers in the mind

  • Revisiting, reviewing, or replaying past information, events, or memories

  • Trying to mentally undo or redo certain actions

  • Repeatedly seeking reassurance from people around you, family members, or clergy members

  • Avoiding objects, people, and places that may increase your intrusive thoughts

  • Going online to query for answers about doubts or fears

  • Checking how you feel, whether the thought is still there, the bodily reaction of your thoughts, answer-seeking

  • Self-assurance, e.g., assuring yourself that you'll not do the wrong, inappropriate, or sinful thing that you're obsessively thinking

If you've found yourself doing these actions, you could have pure O OCD, especially if these obsessions/compulsions disrupt and occupy a significant amount of time in your daily life.

Risk factors and causes of pure O

Although no definitive research or theory can explain the cause of pure O, many OCD researchers have suggested a few causes and possible risk factors of OCD.

Personal experience

Some theories suggest that you're likely to develop a pure O OCD from a history of personal experiences, such as:

  • A traumatic experience during childhood, such as abuse or bullying

  • If you were involved in a car accident

Biological factors

Biological studies and MRIs of the brain suggest differences in nerve circuits (neurons) in the brain that filter our thoughts, ideas, and impulses in people with pure O. The lack of the brain chemical serotonin might also play a role. However, it's unclear whether this is a cause or an effect of the condition.

Family history

Although research in this area is limited, some studies¹⁰ have found that people with relatives with OCD are five to seven times more likely to develop OCD or pure OCD.

Genes

Is pure O genetic? Seemingly, there is insufficient research to confirm that OCD is associated with genetic factors alone. A particular class of genes¹¹ could cause the condition, though the study fails to pinpoint a specific "OCD gene."

How is pure O OCD treated?

There is no one way to treat pure O. Available strategies only help manage the condition. A pure O OCD treatment plan may include medication, psychotherapy, or a combination. OCD support groups can also help manage OCD symptoms.

Nevertheless, pure obsessional obsessive-compulsive disorder treatment plans differ from one patient to another, depending on symptoms and severity.

Psychotherapy

As with other mental health disorders, cognitive behavioral therapy¹² (CBT) may be recommended by your doctor to improve your pure O symptoms. Exposure and response prevention (ERP), a form of CBT, has shown strong evidence — 80%¹³ people show improvement after about a dozen sessions. Clinical trials in the last two decades have placed CBT ahead of other treatment methods for OCD.

ERP helps the client approach or intentionally expose themselves to objects, thoughts, or situations that trigger their distress without engaging in compulsive behavior.

In the case of pure O, this might not be as effective as in typical OCD since compulsions are mental, but ERP still proves effective in pure O treatment.

Another variation of ERP, imaginal exposure,¹⁴ is also used by mental health providers. This involves penning down stories of the client based on their obsessions and using them as ERP tools. Facing these obsessions intentionally with the help of a practitioner can help you become less sensitive to your obsessive thoughts, images, or urges.

Acceptance and commitment therapy¹⁵ (ABT) has also shown positive results among people with OCD. This form of therapy teaches you to accept uncomfortable thoughts without judging yourself. It is a form of mindfulness therapy that makes the patient willingly experience obsessions without responding to compulsions.

It teaches the art of not attempting to control or eliminate intrusive thoughts but instead accepting them as natural responses to stressful life situations.

Medication

If your condition is severe or therapy sessions are not enough to alleviate symptoms, the doctor may add medication to your treatment plan. This includes selective serotonin reuptake inhibitors¹⁶ (SSRIs) or the tricyclic antidepressant Anafranil.

Typical antipsychotic drugs can also be used to complement SSRIs. Research¹⁷ has indicated that people experience improvement of OCD symptoms with medication treatment.

Other pure O management techniques

While psychotherapy and/or medication are the most effective treatment for OCD, other strategies can help you manage the condition. These include:

  • Engaging in exercises such as aerobics¹⁸

  • Engaging in in-person and online support groups

  • Practicing meditation or mindfulness and other relaxation techniques such as deep breathing can reduce stress, which is a major trigger of pure O

The lowdown

Though the term is a misnomer, pure O OCD is real and does affect many people. Since both obsessions and compulsions are entirely mental, this OCD can be challenging to diagnose and treat. Understanding the obsessions and compulsions to look for can help you seek medical attention and learn about the best treatment plan for you.

Untreated pure O can take over your life and cause isolation and a sense of hopelessness. However, managing your pure O is possible, and you can lead a normal life again! If you're experiencing obsessions or compulsions disrupting your day-to-day life, seek help from a mental health practitioner.

If your symptoms are mild, psychotherapy alone can help. However, if pure O symptoms are severe, your doctor might recommend that you combine therapy sessions with SSRI medication.

  1. Obsessive-compulsive disorder (OCD) | NIH: National Institute of Mental Health

  2. The myth of the pure obsessional type in obsessive-compulsive disorder (2011)

  3. Impact of the DSM-IV to DSM-5 changes on the national survey on drug use and health [Internet]. | NIH: National Library of Medicine

  4. ROCD: Relationship OCD and the myth of “The one” | OCD Center of Los Angeles

  5. Gay OCD / HOCD / Sexual orientation OCD | OCD Center of Los Angeles

  6. Harm OCD: Symptoms and treatment | OCD Center of Los Angeles

  7. Pedophilia-themed obsessive-compulsive disorder: Assessment, differential diagnosis, and treatment with exposure and response prevention (2018)

  8. Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders (1994)

  9. Myth of the pure obsessional type in obsessive-compulsive disorder (2011)

  10. Pure obsessive compulsive disorder in three generations (2015)

  11. Genetics of obsessive-compulsive disorder (2021)

  12. The treatment of obsessions (2008)

  13. Cognitive behavioral therapy of obsessive-compulsive disorder (2010)

  14. Imaginal exposure for OCD and anxiety | OCD Center of Los Angeles

  15. [Acceptance and commitment therapy] (2015)

  16. Selective serotonin reuptake inhibitors (2019)

  17. Long-term outcome in adults with obsessive-compulsive disorder (2014)

  18. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment (2017)

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