When people picture OCD, they usually think of hand washing or checking the oven. But for many people with OCD, almost all of the compulsions happen inside their head, or in conversations that look entirely ordinary from the outside. This form is often called "Pure O". The name is a little misleading, because there are compulsions involved. They are simply harder to see.
What mental compulsions look like
A mental compulsion is anything you do in your mind to reduce the anxiety caused by an intrusive thought, to check whether it means something, or to prevent a feared outcome. Common examples include:
- Reviewing - replaying a conversation, a drive home or an evening out, to make sure nothing bad happened
- Analysing - trying to work out why you had a thought and what it says about you
- Checking your feelings - testing whether you still love your partner (common in relationship OCD, or ROCD), monitoring your reactions to check your sexual orientation (sometimes called HOCD), checking whether a thought caused a reaction in your body (common in POCD), or checking whether you feel "right"
- Neutralising - replacing a bad thought or image with a good one, or saying a phrase or prayer to cancel it
- Comparing - measuring yourself against others, or against how you think a "normal" person would feel
- Arguing with the thought - building a case for why it can't be true
From the inside, these often don't feel like compulsions. They feel like thinking, or like sensible attempts to solve a problem. The giveaway is that they never really settle the question. The relief lasts minutes or hours, and then the doubt is back.
Rumination: why thinking harder doesn't help
Many people with OCD are skilled analytical thinkers, and they bring that skill to their intrusive thoughts. The trouble is that OCD asks questions that can't be answered with certainty: What if I'm a bad person? What if I don't really love them? What if I'm not the sexuality I thought I was? What if I did something and don't remember? Trying to answer them through reasoning turns into rumination, which can take up hours a day.
Rumination doesn't fail because you aren't thinking clearly enough. It fails because certainty isn't available, and every attempt to reach it reinforces the idea that you need it.
Reassurance seeking
Reassurance seeking is one of the most common compulsions in OCD, and one of the most easily missed. It can look like:
- Asking a partner, friend or family member whether something is okay, sometimes repeatedly
- Confessing thoughts or minor mistakes so someone else can tell you it's fine
- Searching online for stories, symptoms or statistics
- Asking a doctor, or a therapist, the same question in different ways
Reassurance works, briefly. That's why it's so compelling. But it also teaches you that you can't tolerate the doubt on your own, and it tends to need topping up more and more often. It can also put real strain on relationships, as the people closest to you are drawn into the cycle without either of you quite realising.
This is one reason I am careful in therapy not to become another source of reassurance. If every session ends with me telling you that you're a good person, you may feel better for an evening, but the OCD will have been fed rather than treated.
How treatment works for mental OCD
The treatment is the same as for other forms of OCD: CBT with exposure and response prevention. It just needs adapting.
- Exposure targets the thoughts and the uncertainty themselves, using approaches such as deliberately bringing the thought to mind, writing it down, or approaching situations that trigger it.
- Response prevention means learning to notice mental compulsions as they start and to step back from them: leaving the review unfinished, the question unanswered, the feeling unchecked.
- Reducing reassurance is done gradually and, where it helps, with the involvement of the people you usually ask, so they know how to respond.
Response prevention for mental compulsions is a skill, not a switch. Nobody stops ruminating by deciding to. It is learned through practice, and the first step is getting much better at spotting the compulsion early.
In my practice
A lot of people I see with OCD have had therapy before that focused on discussing their thoughts, and found it didn't help, or made things worse. That is often because the mental compulsions were never identified as compulsions. A large part of my early work with someone is mapping them precisely, so that treatment is aimed at the right target.
For more on how I work with OCD, including what to expect from the first sessions, see OCD therapy.
If any of this sounds familiar, you may find it useful to talk it through. I offer an initial assessment, online or in person in Queen's Park, and can tell you honestly whether I think treatment with me is the right fit.
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BABCP-accredited CBT therapist and EMDR Europe accredited practitioner, in clinical practice since 2015. Guy works with adults online and in Queen's Park, North West London, with a particular focus on OCD, anxiety and trauma. More about Guy