Pure OCD: when pure isn't necessarily better

It is widely known that OCD consists of obsessions and compulsions. In more cases than not, obsessions are mental and

covert (hidden) such as thoughts about harming others, health, contamination, relationships, sexuality or suffering. Whereas the compulsions are overt (physical, obvious, visible) such as repeating, checking, avoiding, cleaning, counting or praying.

Pure O describes OCD where the compulsions aren’t visible. For this reason we see Pure O not so much as a sub-type, but as a symptom set, since people with Pure O can have the same obsessions as people with physical compulsions. Pure O compulsions might involve:

• Going over conversations mentally

• Trying to recall events just as they happened

• Trying to recall a memory perfectly

• Trying to order events according to a timeline

• Mentally counting

• Mentally neutralising (replacing a negative thought with a positive thought)

• Re-ordering thoughts

• Re-ordering words before speaking

• Mentally avoiding

• Mentally replacing thoughts

• Obsessively thinking (ruminating)

• Problem solving

• Analysing

• Evaluating

• Comparing

There are some subtypes of OCD that are less likely to manifest with hidden compulsions. For example, contamination or health OCD are less likely to present with hidden compulsions since the first tends to involve cleaning, checking, disposing and avoiding and the second tends to involve bodily checking, online researching, tests & medical check-ups. There are however, some sub-types, such as relationship OCD, existential/metaphysical OCD or even HOCD, that might easily present with no physical symptoms.

Since CBT or REBT doctrines are firmly based in behaviour work, it can be tough for therapists to treat people with Pure O. Helping a client intervene in their physical compulsions is possible but how do therapists intervene in mental rituals? Or thinking? There is no doubt that it is harder to help a client resist what is going on in their head. Part of the solution is for the therapist to identify the core belief that drives these symptoms and focus on developing new rational beliefs alongside some robust work on desensitisation. This often means that the therapist has to concentrate on habituating a client to themes, ideas and concepts rather than physical things. Not only that but it is possible to interrupt thoughts and mental rituals. It takes patience and repetition but it can be done. We never seek to ‘stop’ thoughts or get rid of them but we work on a client being able to tolerate them and not respond, physically or mentally. We often work with Pure O but what we need to do now is to raise awareness of the lesser known Pure O symptoms since mental rituals are every bit as disabling as physical ones. Sadly, sufferers are less likely to present for therapy, or present later, since it takes time for them to realise what they are dealing with. Physical symptoms are more obvious to a person and the people around them whereas mental symptoms are more private, ambiguous and often humiliating.

It has been encouraging to see more social media interest in Pure O, particularly on our @ocdexcellence Instagram account. Also see my @healthhackers chat with Gemma Evans on 'Unwanted thoughts and mental compulsions - understanding ‘Pure O’.