“Pure O” OCD

a man clutching his head in pain with squigly lines drawn around him

Joe Borders, MFTJoe Borders,

Marriage and Family Therapist

In Roseville and Sacramento

July 3, 2018

“Pure O” OCD

Most people are familiar with obsessive compulsive disorder (OCD) in some way, but have you ever heard of “pure O” OCD? when the subject of OCD comes up, most people think of compulsions like hand washing, organizing, and checking behaviors. Compulsions are behaviors that people feel an irresistible urge to perform. In OCD these behaviors typically come about as a means to manage feelings of stress and anxiety that are brought about by obsessive thoughts. These obsessive thoughts can be just as much or more of a problem than compulsions. Many people don’t think about this aspect of OCD.

An OCD Diagnosis Does Not Require Compulsions

If you read over the diagnostic criteria put out by the American Psychological Association (APA), you will see that a diagnosis of OCD does not require a person to struggle with compulsions. A person with OCD can have trouble with obsessions, compulsions, or both.

OCD Diagnostic Criteria

A.    Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

2.The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

What is “Pure O” OCD?

Despite the common depiction of OCD being all about compulsions, it can also have a lot to do with obsessive thinking. When people exhibit patterns of obsessive thinking without any problems surrounding compulsions, they are often said to have “pure O” OCD. It is estimated that up to 60% of people struggling with OCD exhibit no overt compulsions and could be classified as having pure O OCD.

People who struggle with pure O OCD find themselves obsessing over things that they can’t get out of their heads. This will no doubt sound familiar to most readers. We all have times when we obsess over something and just can’t get around it, but people who struggle with pure O OCD experience frequent, pervasive, and intrusive obsessive thoughts that they have trouble with on a regular basis.

How is this Different from Generalized Anxiety Disorder?

When talking about pure O OCD, some people ask how it is different from other diagnoses like generalized anxiety disorder (GAD). It’s important to make the distinction here between anxiety and obsessions. Obsessions are thoughts you can’t get out of your head. Anxiety is a feeling of unease typically caused by things like fear, worry, and stress. Obsessions can cause anxiety, and for most people they do. But pure O OCD is distinguished by obsessive thinking being the primary symptom.

Pure O OCD Can Be Really Hard

Pure O OCD can be really difficult and can cause a lot of suffering for people who struggle with it. The most common problem I hear people talk about is the preoccupation/fear that their obsessions will manifest into some kind of reality. This is actually what I typically think of as being the defining factor of pure O OCD: obsessive thoughts that people worry will become a reality in some way.

Someone might have obsessive thoughts about hurting someone and they might fear that they will actually do that someday. I once listened to a podcast on NPR that talked about a Dr. somewhere who specialized in working with these kinds of cases. He kept a bunch of knives and other weapons in his office and integrated them into his therapy, inviting patients to hold the weapons and sit with the fact that they were able to attack him but did not.

How Does Pure O OCD Happen?

OCD can come about for a variety of different reasons, but pure O OCD is primarily caused by a person coming to believe that some of their thoughts are dangerous, forbidden, evil, or bad. This can come about through trauma, abandonment, childhood relational problems, and issues surrounding shame. All of this has to do with the idea of having thoughts that are not “ok”, that the person feels like they have to get rid of somehow. Therein is where the problem lies. You can’t get rid of thoughts…they’re something that just happens, but the more you try to fight a thought, the more you’re going to think about it. TACOS! are you thinking about tacos now? Try to stop thinking about tacos and see what happens :-p. Pure O OCD is essentially a broken pattern of attempting to battle thoughts that a person thinks of as bad.

How Therapy Can Help

People who struggle with pure O tend to find themselves thinking that simply having a thought makes them more likely to act on it. This is the most common thing I see in therapy in cases of pure O. People talk about having negative, “bad”, or “evil” thoughts that they think make them “bad” or “evil” people who are likely to act on those thoughts. Therapy helps people in cases like this in some key ways:

  1. Helping people to see the difference between thoughts and actions.
  2. Recognizing that having a thought does not mean we have to act on it.
  3. Combating the idea that there are forbidden “bad” thoughts.
  4. Exploring any history that might have contributed to certain thoughts being seen as bad.
  5. Challenging the assumption that having a thought makes a person likely to act on it.
  6. Building coping skills.
  7. Learning to accept thoughts and knowing that they will pass.

If you or someone you love is struggling with OCD or obsessive thoughts, therapy might be helpful to you. Take a look at our therapists who specialize in OCD. You might also benefit from talking to someone who practices acceptance commitment therapy, mindfulness based cognitive therapy, EMDR, or brainspotting.

About the Author

Joe Borders, MFTJoe Borders is a marriage and family therapist located in Roseville and Sacramento. He is primarily a sex positive gender therapist, but also specializes in working with couples, teens, addiction, and the LGBTQ community. Joe is also the owner and founder of SacWellness. You can find out more about him by visiting his sacwellness listing or by visiting his website: therapy and counseling in Roseville and Sacramento



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