Primarily Obsessional OCD Symptoms and Treatments

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When people think of obsessive-compulsive disorder (OCD), they tend to focus on the most obvious compulsions, such as repetitive hand-washing, cleaning or checking on things, or an extreme need for symmetry.

While the compulsions are more noticeable, they are only one aspect of this disorder. The obsessional component tends to get overlooked. In some cases, people experience these obsessions without engaging in the behavioral compulsions that are often considered a hallmark of OCD.

This presentation of the disorder is sometimes referred to as Pure O, also known as purely obsessional OCD or primarily cognitive OCD.

What Is Pure O?

Pure O is a form of OCD marked by intrusive, unwanted, and uncontrollable thoughts (or obsessions). While someone experiencing Pure O may not engage in obvious behaviors related to their intrusive thoughts, such as counting, arranging, or hand-washing, the disorder is instead accompanied by hidden mental rituals.

Pure O is sometimes mistakenly seen as a “less severe” form of OCD, yet those who experience symptoms of this disorder find that the characteristic intrusive thoughts can be very disruptive and distressing.

While people who do not report engaging in compulsions are sometimes referred to as having "Pure O" or "Purely Obsessional OCD," this variant is not listed as a separate diagnosis in the DSM-5, the diagnostic manual used by many physicians, psychiatrists, and psychologists.

Common Symptoms of OCD

OCD itself involves having reoccurring and obsessions and behaviors (compulsions). For example, a person with OCD might have uncontrollable thoughts about germs and cleanliness that result in an urge to repeatedly wash his or her hands over and over again.

People who experience a "purely obsessional" form of this disorder experience a range of OCD symptoms, although the obvious compulsions are absent. According to the DSM-5, OCD is characterized by obsessions and/or compulsions.

Obsessions

Obsessions can center on somatic, sexual, religious, or aggressive thoughts as well as concerns with things such as symmetry and contamination.

  • Repeated intrusive images, thoughts, and impulses that create a great deal of distress
  • Making attempts to ignore, suppress, or neutralize the obsessive thoughts

Compulsions

  • Repetitive actions, either behavioral or mental, that a person feels compelled to perform as a result of obsessive thoughts
  • Engaging in actions intended to reduce distress related to the obsessions or preventing some dreaded event.

In addition to experiencing obsessions and/or compulsions, the DSM-5 diagnostic criteria also stipulate the following:

  • OCD symptoms must not be due to the physiological effects of a substance (such as a side effect of a medication or illicit drug). The symptoms must also not be due to the presence of some other medical condition.
  • OCD symptoms are time-consuming, often taking more than one hour per day, or they must create significant distress or impairment in occupational, social, or other critical areas of life functioning.
  • OCD symptoms are not better attributable to another mental disorder such as generalized anxiety disorder, body dysmorphic disorder, hoarding disorder, substance-related disorders, or major depressive disorder.

Symptoms of Pure O

There are two characteristic symptoms that are sometimes used to distinguish Pure O.

Mental Rituals to Reduce Distress

Such rituals can include mentally reviewing memories or information, mentally repeating certain words, mentally un-doing or re-doing certain actions.

Repeatedly Seeking Reassurance

This reassurance-seeking can be problematic because many patients may not even recognize it as a compulsion. Such reassurance-seeking may involve:

  • Asking others for assurance
  • Avoiding anxiety-provoking objects or situations
  • Looking for self-assurance
  • Researching online

An added complication of this symptom is that family and friends may become fatigued or annoyed by these constant requests for reassurance, which may be perceived by others as neediness.

Previous research suggests there may be as many as three to six subtypes of OCD, including Pure O form of the disorder. First described by Baer in a 1994 article in the Journal of Clinical Psychiatry, Pure O was described as being composed of sexual, aggressive, and religious obsessions that were not accompanied by compulsions.

Later, research further divided aggressive obsessions into fears over impulsive harm and unintentional harm. Those thoughts centered on impulsive harm often focus on what is sometimes termed "taboo thoughts" related to sex, religion, and aggression.

In a 2011 study, researchers found that individuals who experience the "pure obsessions" (sometimes described as "taboo thoughts" or "unacceptable thoughts") also engage in mental rituals or reassurance-seeking as a way of managing their distress.

Compulsions still exist in Pure O, but they are much less obvious because they are almost entirely cognitive in nature.

Common Treatments for Pure O

Treatment for OCD, including Pure O, often involves the use of medication in combination with psychotherapy, which can include cognitive-behavioral therapy, support groups, and psychological education.

Cognitive Behavioral Therapy

Research suggests that cognitive-behavioral therapy (CBT) can be very effective at treating Pure O. However, it is essential that therapists and other mental health practitioners understand the necessity to also address the underlying mental rituals that characterize this subtype of symptoms.

If the therapist believes that the patient only suffers from obsessions and does not also treat the mental rituals that accompany these cognitions, the treatment will not be as complete or effective.

Medications

Medications may include selective serotonin reuptake inhibitors (SSRIs) or the tricyclic antidepressant clomipramine. Some side effects associated with the use of SSRIs include

  • Anxiety
  • Gastrointestinal upset
  • Insomnia
  • Sexual side-effects
  • Sleepiness

One review of the research has suggested that approximately 40% to 60% of patients respond to treatment with SSRIs with a 20% to 40% reduction in OCD symptoms.

The specific treatment (or combination of treatments) depends on a patient's particular needs. For example, a therapist may use CBT-alone if a patient is unable or simply doesn't want to take medication. Or they might prescribe medications alone to patients who aren't motivated to pursue exposure-based treatments or who don't have access to a CBT therapist.

Exposure and Response Prevention

In 2011, researchers examined individual studies to see if certain symptom subtypes of OCD responded better to certain treatment approaches. They found that in the majority of studies, OCD characterized by religious and sexual obsessions without compulsions (i.e., Pure O) was associated with a poor response to treatments using SSRIs and exposure and response prevention.

Exposure and response prevention, also known as ERP therapy, is a form of cognitive-behavioral and exposure therapy. It involves a trained therapist helping a client approach a fear object without engaging in any compulsive behaviors.

Clients intentionally expose themselves to those things that trigger their obsessions or compulsions but are prevented from engaging in compulsive behavior or obsessive thoughts. The goal of such therapy is to teach patients how to manage their symptoms without acting upon compulsions in order to relieve mental distress.

How Pure O Differs From OCD

So, what makes Pure O different from the traditional diagnosis of obsessive-compulsive disorder?

While some studies have suggested there may be different symptoms subtypes of the disorder, one study suggests that the term Pure O may be something of a misnomer. While people who experience these obsessions without any obvious behavioral compulsions, they do still engage in unseen mental rituals.

"Recognition of compulsions performed by those previously considered purely obsessional can aid in the improved diagnosis and treatment of people with OCD," explains clinical psychologist Monnica T. Williams and her colleagues in their article "The Myth of the Pure Obsessional Type in Obsessive-Compulsive Disorder."

By understanding that such mental rituals exist, therapists and other mental health professionals can ask patients about these symptoms. Without such questioning and prompting, patients may be reluctant to describe the symptoms that they are experiencing or may not even be aware that they should discuss these symptoms.

A Word From Verywell

Pure O may not involve the outward behaviors that often come to mind when people think of OCD. However, the hidden mental rituals that characterize the purely obsessional form of the disorder are a type of compulsion, even though they may go unseen.

If you find yourself experiencing distressing obsessions and/or mental compulsions that are interfering with your daily life, consider talking to a mental health professional. They can help you understand your symptoms and find the best treatment to meet your needs. Though talking about your thoughts isn't always easy, it is the first part of getting the help you may need to find relief.

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