‘Pure O’ is a term that’s been used to describe types of OCD in which the person doesn’t do any compulsive activities that other people can see. The term is misleading, as discussed below, but is used in this article because it’s popular among OCD sufferers.

If you’re reading this article, you’re probably an OCD sufferer, someone close to an OCD sufferer, or a therapist. Before we get further into what Pure O is and how to get rid of it, it’s important to acknowledge the hell in which a Pure O sufferer lives. Someone with Pure O wakes up with the bad thoughts in the morning, spends the day trying to function despite them, and goes to bed with them at night. Anxiety triggers are everywhere, and if one of those triggers is bad enough it can ruin the rest of the day or longer. Meanwhile, the sufferer tries to stay focused and to pretend everything is okay. S/he usually doesn’t access support from other people because s/he’s so afraid of what they’d think if they knew about the thoughts. If you are someone, such as a therapist or loved one, without Pure O, it’s unlikely you can imagine just how constant and controlling these thoughts are, and how utterly impossible it can be to escape them for even a few minutes. If you have Pure O, I have two things to say to you: first, I am sorry that you are suffering so much in silence; second, congratulations, you have a very treatable problem, and once you can get to someone who knows how to treat Pure O, you can have your life back within a few months of hard work. The rest of this article is addressed to the Pure O sufferer; everyone else is invited to listen in.

Let’s start with a brief explanation of how OCD works, which is actually pretty simple:

Basically, you’ve got something called obsessions, which in this context means thoughts that bother you, and you’ve got something called compulsions, which means anything you feel compelled to do in order to get rid of the anxiety caused by the obsessions.

Now we need to introduce two more concepts – the rebound effect (Wegner et al., 1987) and habituation (Thompson & Spencer, 1966) – but they’re simple so bear with me:

The rebound effect is the idea that the more you try not to think of something, the more you think of it. Like, if I tell you to close your eyes for 10 seconds and try not to think of a pink elephant, in all likelihood you’ll spend 10 seconds thinking about pink elephants. In OCD land, this means that the more you try to push bad thoughts away, the more they fill your head. (Please note that the rebound effect doesn’t apply to all types of thoughts, and that confusion about this can make OCD worse; for more information see How to Stop Compulsive Thinking.)

Habituation means getting used to something. You know how people who live in loud cities don’t seem to notice the noise? That’s because they’re used to it. Habituation is that simple. The more you’re exposed to something, the less it bothers you, and the less you notice it. When we’re treating any anxiety disorder, including OCD, habituation is the key concept. Like, if you had a fear of dogs, we’d expose you to dogs (first a picture of a fluffy little one, then a YouTube video of one, then maybe a live toy poodle, then bigger dogs and more contact, etc.) until you habituated to dogs entirely and they no longer made you anxious. This process is extremely effective, but it’s also really counterintuitive: it means running toward the thing that scares you instead of running away from it.

Now let’s apply these concepts to OCD: If you become aware of an uncertainty that triggers fear, and you immediately do something (a compulsion AKA a ritual) to try to get rid of the uncertainty, you cause a rebound effect and you don’t get any habituation. This means that you end up thinking about the uncertainty more and more, and that it never stops triggering fear. It’s like if you were at a loud party and you kept on going outside to get away from the noise: Every time you walked back in, it would be just as loud, whereas if you just stayed inside you would probably get used to it like everyone else.

Many compulsions are things you can see a person do, like checking locks, washing hands, or repeating an activity, but other compulsions are mental, meaning they’re going on in a person’s mind and aren’t physical behaviors you can see. OCD without visible compulsions is what some people have called “Primarily Obsessional OCD” or “Pure O” (Baer, 1994). This suggests that no actual compulsions are involved, but as you now understand, that’s not actually the case. Even though it’s the term used in this article, “Pure O” is a complete misnomer (Williams et al., 2011).

“I get that there’s this idea of mental compulsions, but how do they actually play out in a person’s head?”

Here are some examples:

Let’s say a person is religious and has an experience that triggers uncertainty about their belief in God, and this scares them. The person may then try to escape the fear by eliminating that uncertainty through analytic thought (i.e., figuring out how to be certain that God exists, perhaps by thinking, “There are people I respect who believe in God,” “I remember that book I once read that convinced me there is a God,” “I know there’s a God because I feel God when I pray”). On the surface, this might seem like reasonable self-talk, but it’s actually all an effort to escape the uncertainty, and thus all compulsion.

Similarly, let’s imagine a person who has an experience that triggers uncertainty about their sexual orientation, and is scared by this. They may then try to escape the fear by eliminating that uncertainty through analytic thought (i.e., trying to figure out their sexual orientation, or trying to figure out how to be certain they’re straight — or gay — perhaps by imagining attractive men and then attractive women over and over again, or reviewing the evidence over and over again); this mental activity is all compulsion because it’s aimed at neutralizing the fear by eliminating the uncertainty.

There is just as much compulsion going on in Pure O as in any other type of OCD, it’s just that you can’t see it because it’s thought-based. Some people call this “mental compulsion” or “covert compulsion.” It doesn’t matter what you call it; the point is that it’s all just as compulsive as washing your hands or checking the stove repeatedly. Pure O might be better termed Secret C, but we don’t need more terms. Point is, it’s all OCD and the treatment is the same: If you work hard on tolerating the uncertainty without doing anything to get rid of it, it will eventually stop bothering you so much.

“But I don’t want to get used to horrible sexual or aggressive thoughts! That would make me a bad person, or make it more likely that those things will actually happen!”

It’s completely normal and understandable for you to feel that way, and at the same time, unfortunately, that way of thinking maybe part of why you’ve been stuck for so long. The idea that tolerating the thoughts makes you a bad person or makes it more likely something bad will happen are both misconceptions commonly held by people with OCD (Salkovskis, 1985). In fact, these beliefs are likely part of how OCD develops in the first place, because they make a person think that bad thoughts matter a lot and that s/he has to push them away (Salkovskis, 1985; Purdon & Clark, 2002). In reality, everyone has random awful thoughts – but most people hardly notice them, and thus don’t start a vicious cycle of pushing away and rebounding (Moulding et al., 2014).

“So what does treatment look like?”

Treatment consists of doing the things that usually trigger fear, and that would usually lead to compulsion, and then learning to tolerate the uncertainty, without doing anything to make it go away. Below is a description of the treatment process, but it’s important that this process be undertaken with a trained therapist. For multiple reasons, it takes an outsider’s perspective for this treatment to work.

The first step in the treatment process is identifying all of your triggers, obsessions, and compulsions. This process should also shed light on the core fear underlying the OCD, which explains why a certain type of uncertainty is so intolerable to you. Identifying this is an important part of understanding and subsequently dismantling the disorder.

Next, you work on learning to track the process of being triggered → feeling scared → engaging in undoing, thought suppression, or analytical thinking in a futile attempt to get rid of the uncertainty.

Once you understand the above, you’re ready to begin exposure exercises. This entails constructing a list of all the things and activities that trigger the fear associated with the uncertainty, in order, from those that would trigger just a tiny amount of fear to those that would make you scream, cry, or run away if you had to do them. Now you’re ready for ‘exposure exercises.’ Guided by your therapist, you start with one of the easiest ones, purposefully exposing yourself to the uncertainty, but choosing not to engage in the analytic thought process aimed at achieving certainty. You sit there, aware of the uncertainty, and sweat it out. The fear eventually recedes on it’s own. This procedure is repeated, during sessions and at home, with each of the triggers on the list, until the scariest thing on the list no longer scares you and you can confront it without the need to do any compulsions at all.

To be clear, habituation isn’t the only process at play during exposure therapy. You’re also likely to have new experiences, test out new ways of feeling and behaving, challenge some of the assumptions behind your old behavior, and learn new things about yourself. As you progress, you can and should bring up these topics with your therapist.

“But I’m already letting the thoughts in – all the time! That’s the problem!”

“Letting the thoughts in” is probably compulsion hiding out as exposure. If you are trying to figure something out, it’s compulsion. The goal is to remain aware of the uncertainty, not to think analytically about it.

“But how will I ever know if the thoughts are real?”

Excellent question.

Until you can tolerate uncertainty without trying to do something about it, you probably won’t be able to take in any information that would actually help you to sort things out. Compulsive thinking backfires; instead of making things clearer it makes things more confusing. As if you didn’t know that already.


“Okay, fine, but once I’m done with treatment, the thoughts will go away, right? It’s just OCD, right?”

If you’re someone with Pure O reading this article, you’re probably hoping you’ll get some reassurance out of it, like a line that says, “Lots of people think they’re gay when they have OCD, but it’s totally not true!” I can’t give you that line because that would be malpractice. It wouldn’t help you and it would further fuel the obsessive-compulsive cycle.

What I will do is warn you that reading this article because you want reassurance that “it’s just OCD” is compulsion, and that the only way out of the hell of Pure O is to stop hanging on to false reassurances and to get into therapy with someone who knows how to do CBT for OCD (the treatment is also known as ERP or ExRP, which stand for exposure with response prevention). Maybe you’re thinking, “I’m just educating myself about my disorder!” That may be true, but if you’re feeling anxious and this article is making you feel better, then reading it is compulsion and is just fueling the cycle.

You can’t outsmart OCD on your own, so let’s find you a therapist…

A great resource for finding an OCD therapist is the IOCDF directory:
https://iocdf.org/find-help/

Even if someone is in the directory, you should still call and ask questions. Most therapists will be happy to spend a few minutes talking with you on the phone and determining if you’re a good match. Here are some questions to ask:

Are you trained in CBT? The right answer is “yes.” “No, but I have worked with OCD using XYZ” is a wrong answer.

Do you have experience treating OCD, and specifically OCD about (insert your topic here)? The right answer is, again, “yes.” It’s okay if they haven’t treated your exact type of OCD, as long as they have experience with Pure O. “No, but I have experience with other anxiety disorders” is a wrong answer.

Do you do exposure with response prevention (AKA ERP AKA ExRP)? The right answer is still “yes.” Anything else is a wrong answer. “I do CBT but I’ve never heard of exposure with response prevention” is a wrong answer.

For approximately how many sessions do you usually see patients with OCD? The right answer is something like, “Every case is different, but usually (something in the ballpark of 15-25 sessions or 3-6 months).

Do you take my insurance? If you don’t take insurance, do you offer a “sliding scale” (meaning lowering the fee to make it affordable)? There’s no right answer here, but you need to be realistic about whether you can afford to do a full course of treatment with this therapist. Doing a handful of sessions is not going to work with OCD, so you need to be able to commit from start to finish.

Books

There is no replacement for a therapist, but if you can’t or aren’t yet ready to seek help from a therapist, check out these titles in the meantime:

The Imp of the Mind by Dr. Lee Baer

Getting Over OCD by Dr. Jonathan Abramowitz

The OCD Workbook by Dr. Bruce Hyman and Cherlene Pedrick

I hope this article gave you a better understanding of how Pure O and its treatment work, as well as hope that you can get past it. I’ll leave you with one last piece of advice: People with OCD tend to be more prone to thinking and planning than to trying things out. When it comes to OCD treatment, however, you won’t get better unless you actually do it. Please go find a therapist who can help you, and take back your life.

References

Baer, L. (1994). Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. The Journal of Clinical Psychiatry, 55, 18-23.

Moulding, R., Coles, M. E., Abramowitz, J. S., Alcolado, G. M., Alonso, P., Belloch, A., Bouvard, M., Clark, D. A., Doron, G., Fernández-Álvarez, H., García-Soriano, G., Ghisi, M., Gómez, B., Inozu, M., Radomsky, A. S., Shams, G., Sica, C., Simos, G., Wong, W. (2014). Part 2. They scare because we care: The relationship between obsessive intrusive thoughts and appraisals and control strategies across 15 cities. Journal of Obsessive-Compulsive and Related Disorders, 3, 280-291.

Salkovskis, P. M. (1985). Obsessional compulsive problems: a cognitive-behavioral analysis. Behaviour Research and Therapy, 23, 571-583.

Thompson, R. F., & Spencer, W. A. (1966). Habituation: A model phenomenon for the study of neuronal substate of behavior. Psychological Review, 73, 16-43.

Wegner, D. M., Schneider, D. J., Carter, S. R., White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5-13.

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 & Anxiety, 28, 495-500.