"Pure O" is the name often given to OCD where the obsessions are obvious but the compulsions seem to be missing. There is no hand washing, no checking the oven, nothing anyone else would notice. Just distressing thoughts that won't go away.
The name is a little misleading. In almost every case, there are compulsions. They are simply happening in your head, or in conversations that look entirely ordinary from the outside. Recognising them is the key to effective treatment.
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 work out 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), 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, which is a form of self-reassurance
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. I write about this in OCD and intolerance of uncertainty.
Why Pure O is so often missed
Because nothing is visible, Pure O can go unrecognised for years, sometimes even by professionals. It may be mistaken for general anxiety, depression or simply "overthinking". The person themselves may not realise it is OCD at all, particularly if their idea of OCD is about cleanliness or order.
It is also hard to talk about. The themes of Pure O are often the most distressing ones: harm, sexual thoughts, doubts about a relationship, religion or morality. Many people keep their thoughts entirely to themselves, convinced they would be judged or misunderstood.
How Pure O is treated
Pure O responds to the same treatment as other forms of OCD: CBT with exposure and response prevention. The difference is that the compulsions are hard to see, sometimes even for the person doing them, so treatment depends on identifying them accurately first. Exposure and response prevention are then adapted to work with thoughts and mental acts rather than visible behaviours.
Learning to step back from a mental compulsion is a skill, developed gradually and with guidance. Nobody stops ruminating simply by deciding to, and trying to force it usually turns into another form of mental checking. With the right approach, though, Pure O is very treatable.
In my practice
A lot of people I see with Pure O 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. You can read more about how I work on my OCD therapy page.
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