Does Pure O Exist?

Key Points

• ‘Pure O’ or ‘purely obsessional’ OCD is a term used to describe people who experience unwanted, intrusive thoughts (obsessions) without any visible ritual behaviors (compulsions).
• So, while the term “Pure O” is still sometimes used, multiple research studies suggest that true purely obsessional OCD does not exist.
• When you carefully assess for mental compulsions and subtle reassurance-seeking, almost everyone with OCD appears to have both obsessions and compulsions. It’s just that the compulsions aren’t always obvious, visible actions, like hand washing or checking.
• These mental rituals can be easily missed or not recognized as OCD symptoms, since they happen internally rather than being physical actions others can observe.
• The term “Pure O” is misleading and unhelpful because it may prevent people from recognizing mental compulsions, hindering proper diagnosis and treatment of their OCD.

The Myth of the Pure Obsessional in OCD

"Pure O" is an online term, not a medically recognized subtype of OCD. It's a phrase used to describe a form of OCD, but it's not considered a separate diagnosis by mental health professionals.

When researchers looked more closely at people who seemed to have “Pure O” or purely obsessional OCD, they found that mental rituals and reassurance-seeking were common compulsions that had been previously overlooked.

• Mental Compulsion: A ritual you feel driven to carry out in your mind. It could be mentally repeating certain words, images, numbers, or prayers, making mental lists, or reviewing thoughts or memories repeatedly. You do it to try to ease anxiety or fears caused by upsetting thoughts, but it can become a hard habit to stop.
• Reassurance-seeking: When a person repeatedly asks others or themselves for comfort, support, or confirmation to try to reduce anxiety or doubts related to their obsessive thoughts.

Covert compulsions are still compulsions

The unobservable nature of mental compulsions may cause them to be missed or mistakenly classified as an obsession.

 The most shameful forms of OCD are more likely to have covert mental compulsions.

For example, a study by Williams and colleagues published in the Journal Depression and Anxiety in 2011 did a detailed analysis of OCD symptoms in 201 patients.

They found that mental compulsions (like mentally repeating words or phrases) and reassurance-seeking behaviors loaded together with taboo thoughts (sexual, religious, or aggressive obsessions) had been considered signs of “pure obsessions.”

This suggests that people with these obsessions did have compulsions, too – just mental ones rather than physical actions. The compulsions were subtle and easy to miss without careful assessment.

Other research has found similar results. A 2003 study by Abramowitz and colleagues published in the Journal of Consulting and Clinical Psychology looked at OCD symptoms in 132 patients.

They found that among those with religious and sexual obsessions, mental rituals were actually the most common compulsion. This was true even though, at first glance, many seemed to have no compulsions.

Here are some examples of the kinds of mental rituals they observed:

1. Mentally repeating prayers or religious phrases: For people with religious obsessions, a common mental compulsion was silently reciting specific prayers or religious statements over and over again in their mind.
2. Mentally reviewing or analyzing thoughts: Another ritual involved going over intrusive thoughts in detail, trying to figure out their meaning or whether they were “good” or “bad” thoughts.
3. Mentally undoing “bad” thoughts: Some people felt compelled to try to cancel out or neutralize an unwanted sexual or sacrilegious thought by thinking a “good” thought right afterwards.
4. Mentally reassuring oneself: Patients would often try to calm their own anxiety about the thoughts by mentally telling themselves things like “It’s just a thought, it doesn’t mean anything about me.”
5. Mental reviewing of memories: To try to reassure themselves that they hadn’t actually acted on a disturbing thought, some people would mentally replay memories in detail, looking for evidence that they hadn’t done anything wrong.
6. Mentally checking or monitoring your emotions: Trying to figure out if your emotional reaction is “normal” or “appropriate.”

How to Identify Mental Compulsions

Identifying mental compulsions in “Pure O” can be challenging, as these rituals are often subtle and not as observable as physical compulsions.

By increasing awareness of your thought patterns and mental habits, you can start to identify the mental rituals that may be part of your OCD cycle.

1. Look for patterns: Notice if there are certain mental actions you feel compelled to perform repeatedly, especially in response to specific obsessive thoughts or triggers.
2. Monitor time spent: Pay attention to how much time you spend engaged in mental rituals like analyzing thoughts, mentally reviewing memories, or repetitive prayer or counting. Compulsions often take up significant time and interfere with daily activities.
3. Notice feelings of anxiety or discomfort: Mental compulsions are often driven by a need to alleviate anxiety or discomfort caused by obsessive thoughts. If you find yourself feeling anxious or uncomfortable until you complete a certain mental action, it may be a compulsion.
4. Look for rigid rules: Mental compulsions often involve strict, self-imposed rules about how many times to repeat a thought or prayer, or how perfectly a mental ritual must be performed.
5. Observe avoidance behaviors: Avoiding certain situations, people, or objects that trigger obsessive thoughts can be a sign that you are engaging in mental compulsions to cope with the anxiety these triggers provoke.

Some common examples of mental compulsions in “Pure O” include:

• Repetitive prayer or mental phrases
• Mentally reviewing or analyzing thoughts
• Mental counting or list-making
• Mentally “undoing” or neutralizing bad thoughts with good ones
• Seeking reassurance from oneself through mental reasoning

Is Pure O in the DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is used by mental health professionals to diagnose conditions like OCD.

The DSM-5 criteria for OCD require the presence of obsessions, compulsions, or both. The manual defines compulsions as behaviors or mental acts that the individual feels driven to perform in response to an obsession or based on rigid rules. This definition includes both observable compulsions and mental rituals.

While the DSM-5 allows for a diagnosis of OCD based on obsessions alone, it does not formally recognize “Pure O” as a distinct subtype.

The concept of purely obsessional OCD may not accurately reflect the clinical reality, as mental compulsions and reassurance-seeking often accompany obsessions when assessed carefully.

Sources

Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 71(6), 1049-1057. https://doi.org/10.1037/0022-006X.71.6.1049

Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Liebowitz, M., Simpson, H. B., & Foa, E. B. (2011). Myth of the pure obsessional type in obsessive–compulsive disorder. Depression and Anxiety, 28(6), 495-500. https://doi.org/10.1002/da.20820