A Look into Pure-O OCD

You may have heard the term ‘pure-O’ OCD and wondered what it actually means! This article will take you through what pure-O is, why the term can be controversial, and what you can do if you feel you have symptoms of pure-O.

What is Pure-O OCD?

Pure-O stands for Purely Obsessional OCD. Pure-O can be defined as, “a form of OCD in which a person experiences obsessive, unwanted thoughts without visible compulsions or rituals.” This means that while an individual may be diagnosed with OCD and struggle with obsessions, their compulsions tend to be carried out within their mind, rather than displayed outwardly.

Individuals with pure-O experience obsessive thoughts, often based around a specific topic or theme. They find these thoughts very distressing, often fearing that their thoughts may have negative consequences. In response to these obsessions, they carry out compulsions mentally to try to alleviate the anxiety and distress, or to ‘prevent’ something bad happening as a result of their thoughts. Sometimes a rise in these intrusive thoughts in response to a trigger is referred to as a ‘spike’.

Just as with other forms of OCD, carrying out compulsions actually makes the anxiety worse in the long term and perpetuates the OCD cycle. This cycle can consume many hours of the day depending on the severity of the individual’s OCD. It can have a severe detrimental impact on their ability to function, to focus on a task, to work and carry out other daily functions.

How is pure-O different from OCD?

It can be confusing, but pure-O is OCD. All OCD involves both obsessions and compulsions, including pure-O. Pure-O is different from other types of OCD simply because the compulsions are internal (in the patient’s mind), rather than something carried out physically. Other forms of OCD have outward manifestations of compulsions, such as repeated cleaning, re-arranging, physically checking and so on.

Intrusive thoughts vs pure-O

Since pure-O doesn’t involve outward compulsions, it can be difficult to detect, even for the individual struggling with the disorder. It’s important to distinguish between regular intrusive thoughts and pure-O. We all have intrusive thoughts, but those without OCD don’t attach significance to these thoughts. Someone without OCD might have an intrusive thought and think ‘that was strange’, then let the thought pass and not dwell on it any further.

People with pure-O find their thoughts extremely distressing, anxiety-provoking and attach great significance to them. This article from Dr. Jordan Levy and Dr. Jan Weiner explains that, “what ignites the symptoms of Pure-O is not the experience of intrusive thoughts but actually one’s reaction to them.”

When an individual with pure-O has an intrusive thought, it’s very difficult for them to get rid of it. It immediately puts them on edge, in a state of fear or stress which evokes the ‘fight or flight’ response. They may feel that the thought makes them a bad person, or that something bad is going to happen as a result of their thought. They then carry out mental compulsions to try to ‘cope’ with the thought.

Is pure-O less severe than other forms of OCD?

Pure-O is certainly no more or less severe than any other forms of OCD. Severity of symptoms depends on the individual’s experience, and not the type of OCD they have. Compulsions are disruptive and distressing, whether they are carried out within your mind or physically.

Everyone’s experience is valid, and all OCD symptoms are incredibly challenging to live with. This 2019 article on pure-O states that, “Pure O is sometimes mistakenly seen as a “less severe” form of OCD, yet those who experience symptoms of this disorder find that the characteristic intrusive thoughts can be very disruptive and distressing.”

Controversy around Pure-O OCD

Some professionals and mental health charities don’t agree with the term pure-O, making it a somewhat controversial topic. Let’s take a look at why this controversy exists.

Why is the term pure-O controversial?

The term pure-O is a nickname for this type of OCD symptoms (although a very widely used one within the OCD community), rather than an official medical diagnosis. Therefore some people feel that it shouldn’t be referenced. The charity OCD UK explains that, “it’s merely a phrase. It’s certainly not a medically listed term.”

Some professionals feel that the term pure-O isn’t accurate or helpful, because it implies that compulsions aren’t involved, when in fact they are, they’re just not outwardly displayed. Going back to OCD UK again, they reference this stating, “They’re all compulsions (mental or physical), which is why the term ‘Pure O’ is both unhelpful and imprecise.”

However, despite these valid opinions, pure-O is used as standard throughout many online resources and used by some professionals, so it’s important to understand fully what it means. Many individuals feel that pure-O is the term which fits their symptoms best, which is also entirely valid.

Is pure-O a ‘real’ diagnosis?

Pure-O is a widely used term to describe the type of OCD we’re discussing. Those who struggle with this type of OCD have symptoms which are very real, and completely valid. However, the term isn’t officially recognised as a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is the diagnostic criteria published by the American Psychiatric Association, which mental health professionals often refer to when making a diagnosis.

Dr. Steven Phillipson was one of the first psychologists to begin using the term pure-O. He states that, “this term wasn’t meant to suggest a scientific difference – which would imply a different cause and treatment strategy – but to give people a new way to identify with their symptoms.”

OCD Action states that, “individual people with OCD often choose to use these terms to label what they are experiencing, and can find comfort or a sense of community in knowing that there are so many others out there experiencing what they are, that there is a term for it.” Fundamentally the term is there to help people who have this type of symptoms to feel included within the OCD diagnosis, and to have a way to recognise and describe their symptoms accurately.

Types of Pure-O obsessions

There are a number of types of intrusive thoughts that those with pure-O can struggle with. You might hear these referred to as subtypes of pure-O. As with the term pure-O, these terms are not individual professional diagnoses of OCD subtypes, but rather terms for OCD symptoms which are used within the OCD community to help people better understand their disorder. An individual may experience only one type of these obsessions, or they may experience multiple types. The type of obsessions experienced may also change throughout an individual’s life.

It’s important to remember that these thoughts do not reflect what the individual actually feels or thinks about any situation. The thoughts do not carry meaning outside of the anxiety the individual attaches to them. Obsessive thoughts don’t mean that the person is at risk of actually carrying out these actions: we will discuss risk further later on in this article.

This article from the Anxiety and Depression Association of America, written by Patricia Thornton, PhD explains that, “This type of OCD is very difficult for patients, because the thoughts are morally reprehensible and completely out of character for them.”

Pedophilia OCD (pOCD)

Pedophilia OCD can be defined as involving, “unwanted thoughts, images, and urges related to sexual attraction toward or molestation of children.” The individual will typically struggle with a deep amount of shame and embarrassment at having these thoughts. Spikes of pOCD can be in reaction to the past (for example, obsessing over whether they did anything sexually inappropriate when they were a child); the present (such as wondering if they were aroused by a child that walked past them); or the future (such as worrying about whether they will ever engage in pedophilic behavior, or worrying about whether they will get into trouble as a result of their thoughts).

It’s vital to emphasise that having pOCD does not mean that the individual is a pedophile. Their intrusive thoughts may make them feel as though they are, and will make them doubt themselves. This understandably can be one of the most distressing, shame-filled forms of pure-O. Due to this deep seated shame and worry about how others will perceive their thoughts, many people with this type of intrusive thoughts don’t seek help.

Unfortunately, a lot of professionals don’t understand the difference between pOCD and pedophilia, which can be extremely damaging if an individual has tried to reach out for help. However, it’s vital if you have these intrusive thoughts to reach out for help despite this and to advocate for yourself, because a mental health professional with the appropriate training will be able to help you get your life back. There is hope and help available to stop these thoughts infiltrating your life.

Harm OCD

Harm OCD involves intrusive thoughts about causing harm to oneself or others, often those the individual is close to such as family members and friends. These thoughts or images which run through the individual’s head can be very graphic and extremely distressing. The individual might fixate on accidental or deliberate harm, and feel a great deal of responsibility for the safety of others. They are likely to feel that they are an aggressive and dangerous person, even when faced with evidence to the contrary.

Sexual orientation obsessions OCD (SO-OCD)

You might also hear this referred to as homosexual OCD or shortened to HOCD. This type of obsessive thought revolves around worries about sexuality, for example an individual may worry that they are gay or bisexual when they’re straight, or visa versa. They may fear that they have hidden sexual desires. This could also involve fears about other people thinking they appear gay or straight, when they identify as the opposite. Around 10% of people with OCD are estimated to have SO-OCD.

Relationship OCD (ROCD)

You might see this referred to as Relationship Substantiation. An individual struggling with this type of obsession will struggle with intrusive thoughts and doubts about how they really feel about their partner. They may also worry about how their partner views them, or feel that they are not enough. Doubts may center around worries about how to tell whether this person is ‘the one’. As we’ve discussed, this doesn’t necessarily reflect their actual views and feelings, and can occur within an otherwise healthy relationship.

The mental health organisation Made of Millions Foundation explains that these obsessions can include, “a preoccupation with doubting the relationship or whether their spouse is ‘the one,’ and/or doubting the overall level of attractiveness, sexual desirability, or long-term compatibility.”

Religious OCD

You may also hear this referred to as scrupulosity. Religious OCD is defined by religious obsessions. These intrusive thoughts can revolve around constant worries about doing the right thing morally or religiously, whether or not the person follows a particular religion. The individual may fear doing something that God would not ‘approve of’. This article from Beyond OCD explains that, “They are convinced that they have sinned in the past or will sin in the future, will disappoint God, or be punished if they fail to be ‘good enough.’”

Thoughts about somatic functions

The word ‘somatic’ means ‘in relation to the body’. These obsessions focus on aspects of the body or bodily functions. The individual may be extremely aware of bodily functions which are automatic, such as swallowing or breathing. The New England OCD Institute explains that, “the person with OCD is mentally checking how their body feels at any given moment.”

They may fear choking or not breathing properly for example. If they also struggle with pOCD, they may be constantly checking for signs of arousal. Alternatively the hyper awareness itself may be the cause of fear, for example fearing that they are never going to be rid of this constant attention to every breath they take. This can be very distressing for the individual. This type of obsession can also make individuals very aware of other people’s bodily functions, such as the noise of someone else breathing loudly or chewing.

Pure-O compulsions

Rumination

Mental rumination means that the individual will go over and over thoughts, situations, and feelings revolving around their obsessions in their mind to try to cope with them. This can make it extremely difficult for a sufferer to focus on their day to day life, causing disruption to their routine and quality of life.

Mental reassurance

The individual may repeatedly examine intrusive thoughts to try and reassure themselves that they are not a bad person, or that nothing bad is going to happen as a result of their thoughts.

Reassurance seeking

Any form of OCD can involve seeking reassurance from others. With pure-O these reassurance seeking behaviours are carried out to try to ease the guilt, shame or anxiety which come with intrusive thoughts. This may involve asking loved ones questions or looking for answers online. The individual may try to ‘prove’ to themselves that they are not at risk of acting on their thoughts, or may seek information about ‘risk factors’ to ensure they don’t fit the criteria for acting on their thoughts.

Mental checking

An individual may check over things in their mind, such as specific thoughts (often in a specific order) or past memories. They may go through actions they’ve taken, either recently or further in their past, and go over them, possibly re-doing those actions mentally.

Physical self-checking

This involves the individual checking their body for any signs that their intrusive thoughts could be true. The charity OCD Action describes physical self-checking as, “checking for physical responses that deny or confirm the intrusive thoughts (such as groinal responses)”.

Compulsive prayer

Compulsive prayer refers to an individual mentally repeating specific words, phrases or prayers in their mind to try to relieve their intrusive thoughts.

Wishing

Someone with pure-O may spend a great deal of time wishing their thoughts would go away and that they could be free of their OCD. They may imagine what their life would be like if it wasn’t overcome with obsessions. This may sound harmless, but is actually perpetuating the OCD cycle the same way as other compulsions, as it plays into these thoughts being very important.

Thought neutralising

When someone with pure-O has a ‘bad’ thought, they may try to neutralise this thought by actively thinking of something good. They may feel that the good thought ‘cancels out’ the bad thought.

Avoidance

A common way those with pure-O try to deal with their obsessions is to avoid any situation or person which may trigger their intrusive thoughts. An individual who struggles with relationship OCD may avoid being in relationships, for example. Someone who experiences intrusive thoughts about harm may hide anything they could use to harm themselves, or avoid people they have intrusive thoughts about harming.

‘Giving in’

Someone who is struggling with these thoughts may ‘give in’ to their thoughts: this simply means they may accept their thoughts as ‘true’, essentially accepting that they are a bad person. They may do this in the hope that if they come to terms with this, it will stop the thoughts plaguing them, and they may be able to move on with their lives. Unfortunately as with the other compulsions, this doesn’t reduce OCD symptoms.

Pure-O risk

It’s so important to distinguish between the intrusive thoughts which come with pure-O and a person who is at risk of causing harm to others. These are two very different things. Someone with pure-O is no more likely to act on their intrusive thoughts than any other person in the world. In fact, their whole disorder focuses around being so distressed and ashamed of these thoughts because their own beliefs and personality do not align with the thoughts they’re having.

This article from Stacey Kuhl Wochner who provides therapy at an OCD centre explains this stating: “They are experiencing thoughts that are ego-dystonic, meaning they are distressing, unacceptable, and inconsistent with their identity and how they choose to behave.”

A professional who is well educated in OCD and experienced in the difference between intrusive thoughts and the risk of actions, will be able to assess an individual properly and tell the difference between the two. This detailed study on the topic explains that, “Provided the clinician has appropriate expertise in OCD, there are very rarely any serious doubts about the diagnosis.” The study also explains clearly that there is no record of a person with OCD acting on their intrusive thoughts. It goes on to explain that, “the person is no more likely to act on their intrusions than a person with height phobia is to jump off a tall building.”

What to do if you think you have symptoms of Pure-O

This all sounds worrying but there are lots of ways patients can effectively treat and manage pure-O, just like other types of OCD. Individuals can reduce and even gain remission from their symptoms, and go on to live a happy full life.

If you think you have symptoms of pure-O, it can be really distressing. However it’s important to remember that you are not a bad person, and that things can get better! Let’s take a look at what you should do if you feel you have symptoms of pure-O.

Don’t panic

Although this is much easier said than done, if you think you have symptoms of pure-O, try not to panic. If you’re recognising your symptoms, this is in fact a good thing because it means you can seek help and regain the control you may have lost.

Monitor your symptoms

Before and during seeking treatment it’s a great idea to monitor your symptoms and keep note of them. This helps the professionals to get a clearer view of how your OCD is affecting you, and how any treatments they implement may be working.

Seek treatment

When you’re ready, you should seek treatment. It can be really difficult to reach out for treatment when you live with pure-O, because these thoughts can be really embarrassing and you may feel very ashamed. However, it’s vital you do reach out for help even though it’s difficult, because your OCD won’t go away on it’s own. You need help in order to overcome your disorder.

Seeking treatment typically starts with your GP, or your mental health professional if you already have one. Be clear about what you’re experiencing and ask to see a mental health professional for a psychological assessment. This is an assessment to help figure out what you’re experiencing with the aim of giving you an accurate diagnosis, and therefore the right treatment.

Once you have a diagnosis you will likely be monitored going forward to ensure you have the support you need. You will then be able to receive treatment, either in person or using online resources such an online OCD therapy programme.

Advocate for yourself

When you see your GP, it’s important to note that they may not be very well versed in OCD. This isn’t to put you off, but rather to let you know that you may need to advocate for yourself. It’s important you get a referral (or a self-referral) to see a mental health professional: they are educated and trained in OCD, and will be able to help you to get the diagnosis and help you need.

You can advocate for yourself in a number of ways including:

• Taking someone to appointments with you for moral support
• Writing down what you want to cover in the appointment to ensure you don’t miss anything if you get flustered
• Being calm, clear, firm and persistent with medical professionals
• Asking to be referred to a mental health professional
• Taking information with you to help your GP direct you to the right help, such as this GP Ice Breaker (Harm OCD version) provided by OCD UK
• Asking for a second opinion if you feel you aren’t getting anywhere
• Making a complaint if you feel you are treated unfairly
• Seeking a professional advocate to help you fight for your rights (you can access resources for this online, through your local council or through mental health charities)

Put therapy into practice

Once you’re receiving treatment, it’s vital you are dedicated to what you’re learning. You must put the therapy techniques you learn into practice in your own time and be consistent in order to see results, even when it’s really tough.

Seek support

You don’t have to do this alone: support is a vital factor when dealing with OCD. You should seek support which works for you, whether this is support from your loved ones, finding a local support group, or seeking support from others who understand online.

Be kind to yourself

It can be really difficult to be kind to yourself when you live with pure-O. You might hold a lot of guilt and embarrassment, and feel quite bad about yourself. However this only makes it all the more important to actively try to be kind to yourself. Build yourself up when you can: focus on the good things about yourself . Encourage yourself gently when you’re able. Be compassionate and kind to yourself, trying to treat yourself as you would treat someone you love if they were going through a mental illness.

Practice self-care

Part of this self-kindness is ensuring you practice self-care, which can often be neglected when you live with OCD. Self-care refers to anything you do to take good care of your physical and mental health, for example keeping up with personal hygiene; eating well; exercising; maintaining social connections; making time for fun and more. Try to make this a priority in the best way you can.

Pure-O OCD treatments

You can access these treatments through a referral from your doctor or mental health professional; seek them privately; or access them from your own home through a OCD therapy website or an app.

Cognitive Behavioral Therapy (CBT)

CBT is usually the starting point for most OCD treatment. CBT teaches the patient to recognise and replace negative thought patterns, with positive helpful coping strategies and behaviours.

Exposure and Response Prevention (ERP)

ERP is a type of CBT which helps the individual to face their fears in a gradual, manageable way. It has proven results for those with OCD and is typically the first line of treatment. During ERP an individual will be guided through producing a hierarchy of their fears and anxieties, for example what they fear may happen if they don’t carry out a mental compulsion in relation to pure-O.

The individual will be guided through facing things they’ve been avoiding, such as certain situations or images which will trigger their intrusive thoughts. They will be asked to face their obsession without reacting with a compulsion. This sounds worrying and it can be tough, but it’s done under guidance and in manageable, bite-sized steps so it doesn’t overwhelm you. Over time and with guidance, the patient learns that their fears were unfounded, and begins to actively break the cycle of OCD.

Mindfulness-Based Cognitive Therapy

Mindfulness in itself can be a very positive way to reduce stress and anxiety for those with OCD. When mindfulness is combined with other psychological therapies, it can be particularly useful for OCD patients. Mindfulness-based cognitive therapy utilizes the relaxing qualities of mindfulness combined with CBT techniques, to help OCD patients gain greater understanding of their OCD and gain control over their symptoms.

Acceptance and Commitment Therapy (ACT)

Rather than trying to change negative thoughts as with CBT, ACT focuses on accepting that negative thoughts are just that, thoughts. Rather than attaching significance to these thoughts, ACT works on allowing the individual to let negative thoughts pass them by. The therapy focuses on understanding that thoughts don’t need to lead to actions. ACT also helps the individual to commit to positive, useful coping strategies to tackle their OCD and break the cycle.

Medication

Just as with other types of OCD, medication can be useful to help relieve symptoms, particularly when used in conjunction with psychological therapy. The medication typically recommended for those with OCD are Selective Serotonin Reuptake Inhibitors (SSRIs), which are a form of antidepressants. They help to regulate and balance the chemicals in the brain to better control an individual’s mood and anxiety levels.

Whatever treatment options you are offered, take your time to do your own research and figure out what feels best for you. Whether it’s seeing a therapist in person or seeking help in the comfort of your own home via online therapy, things can get better! Remember that all forms of OCD can be treated, and that you do not have to struggle on alone!

References

Dr. Jordan Levy , Dr. Jan Weiner, (2020), “Pure O: An Exploration into a Lesser-known Form of OCD”. Made of Millions.

Kendra Cherry, (2019), “Primarily Obsessional OCD Symptoms and Treatments”. Very Well Mind.

OCD UK, (2020), “Does Pure O Exist?”

Patrick Carey, (2019), “When terrifying thoughts are a sign of Pure OCD”. Nocd.

OCD Action, (2020), “What is ‘Pure O’?”

Patricia Thornton, PhD, (2018), “Demystifying Mental Compulsions and “Pure-O”” Anxiety and Depression Association of America.

Made of Millions, (2020), “Living with Sexual Orientation OCD”.

Beyond OCD, (2019), “Recognizing and Counseling People Who Have Scrupulosity”.

New England OCD Institute, (2018), “Somatic Compulsions”.

Stacey Kuhl Wochner, LCSW, (2012), “Pure Obsessional OCD – Symptoms and Treatment”. Social Work Today, Vol. 12 No. 4 P. 22

David Veale, Mark Freeston, Georgina Krebs, Isobel Heyman & Paul Salkovskis, (2009), “Risk assessment and management in obsessive–compulsive disorder”. Advances in psychiatric treatment, vol. 15, 332–343

OCD UK, (2020), “GP Ice Breaker (Harm OCD version)”.