“Pure O” OCD (or OCD with Intrusive Thoughts)

The phrases “Pure O” or “purely obsessional” OCD have been used interchangeably over the last 10-15 years in prominent OCD books, in the scientific literature (see Williams et al, 2011), online, in social media among those with lived experience, and among those with OCD who are providers and advocates who themselves have suffered with “Pure O” OCD. It is not an official clinical term, it is not a formal diagnosis or medical term approved within the professional community. Notable disagreement within the professional community is ongoing, whether the term is helpful or hurtful to OCD sufferers, the lay community, and professionals unfamiliar with OCD and its treatment options.

“Pure O” is most commonly understood to consist of non-stop repetitive thoughts that are disturbing and overwhelming. The “Pure O” sufferer finds him or herself thinking about and questioning topics that are existential, perverse, taboo, sexualized, or seemingly harm focused. Given many of these themes, “Pure O” can also be triggered by and/or result in physical symptoms that are upsetting and confusing, such as physical pain, sexual arousal or physical changes in one’s genitals (often called groinals), oversensitivity to breathing or heartbeat functions, etc. As a result, this individual commonly reports experiencing obsessions without observable compulsions, since intrusive unwanted thoughts lead to more worries, questions, fear, and wondering about the presence of these disturbing thoughts. Therefore, the common assumption is that, collectively, everything that is going on in his/her head is obsessional. This, however, is likely not true, even if it all feels like obsessions. There are almost always compulsions associated with obsessions, but many are truly not observable because they are of the mind. These are called mental rituals.

Obsessional topics or themes most commonly associated with intrusive thoughts include:

Harm OCD (this is not the acronym HOCD, that is something else, see below): A preoccupation with one’s own actions or thoughts that suggest that “I might hurt myself or someone else,” intentionally or accidentally, including loved ones, strangers, animals, and kids. Suicide-themed OCD falls into this area and is commonly confused with suicidal ideation or intent associated with various mood disorders such as depression or Bipolar Disorder.

Sexual Orientation OCD (previously called homosexual OCD or HOCD for short): Though this can appear very similar to normative questions about one’s own sexuality and sexual interests, the struggles here are more intense, and there are more frequent and disruptive questions and actions focused on understanding or proving whether the individual is “truly” attracted to the same sex or opposite sex. There are concerns and questions about genitals (called “groinals”) or other bodily reactions to various stimuli, and there is often a disregard for clear and consistent thoughts and actions towards sexual partners that the person actually desires or has had wanted experiences with in the past.

Pedophilia OCD (POCD): Like other themes, there is no intent or desire to actually harm or engage in sexual activity with the person of focus (in this situation a child), and even thinking about the possibility is terrifying and disturbing. But the POCD sufferer worries excessively about the possibility of actually engaging in sexual activity with a minor. Thinking about or being near children is often overwhelming, leading to avoidance of kids (behavioral compulsion).

Moral/Scrupulosity/Religious OCD: A preoccupation with and excessive guilt around one’s actions and thoughts that might be perceived as immoral, inappropriate, or unethical. There is a clear right vs wrong mentality and an internal battle focused on what it means to be a “bad” person. Oftentimes, religious beliefs, the relationship to God, or blasphemous and sacrilegious themes arise, as well.

Relationship OCD (ROCD): A preoccupation with familial, social, romantic, or other relationships whereby the person worries about the justification to stay in the relationship, wondering (mental ritual) how they will ever know if this is the right relationship for them if they are really attracted to their partner (mental ritual), if they are really are loved by them (mental ritual), questioning if the relationship is good for them or if their partner “is the one” (mental ritual). ROCD often demands the sufferer go to great lengths to prove the worthiness or value of the partner or relationship, which paradoxically disrupts the relationship and can push the other person away.

Existential OCD: With so much anxiety about reality, the future, the universe, the way the world works, and even the nature of self, sufferers here obsess about topics that often have no end, and no answers, keeping the individual in a constant state of angst (obsessions) and questioning everything around them (mental ritual).

Body-focused/Somatic OCD: Preoccupation and worry about the presence of normal and basic bodily functions and sounds that most everyone experiences (e.g., yawning, breathing, swallowing, blinking, heart beating), leading to hyper monitoring of them (mental ritual), trying to recreate them (behavioral ritual), wonderment (mental ritual) if they are actually working properly or waiting around and questioning (mental ritual) if they might stop all of a sudden.

Mental Rituals

In “Pure O” OCD, or OCD with more severe intrusive thoughts, it can be very confusing as to what the symptoms actually represent. Some of the thoughts are obsessions and many others are compulsions (as described above in the various themes, called mental rituals). Mental rituals are as real and destructive (short-term) and unhelpful (long-term) as behavioral rituals. They are intentional and controllable. They are not obsessions and they do not fix OCD. The function of them, the purpose of them, and why they are showing up is no different than any visible, behavioral compulsion. That is key and cannot be overstated. Mental compulsions/rituals maintain the disease cycle of OCD as do behavioral rituals. Examples of mental rituals include: silently counting, thinking lucky or special phrases, mentally replaying previous experiences, questioning the meaning of bodily reactions, visually repeating words or images in your head, excessively wondering or asking many questions to yourself about the past, present, or future events when there is truly no answer, and more.

What is tricky is for OCD sufferers (and their loved ones) to understand the difference between obsessions (unwanted recurring “stuff”) and other thought content that might look like an obsession (because it can happen all day long, feel completely involuntary, and create more angst) but, in fact, represents a mental compulsion/ritual.

So here we are, thoughts. Unintentional, anxiety-ridden thoughts (obsessions) vs Intentional, anxiety-fighting/questioning thoughts (mental rituals). And this is where Pure O rears its ugly head and where all the controversy and confusion lies.

***To learn more about “Pure O” and the controversy surrounding the term, please read Dr. Spitalnick’s blog post: “Pure O”: What is it? Is it real? Is it a diagnosis? What does it mean? Should we stop using the term? Why are there quotes around the term?***