Pure O OCD
There are many different kinds of OCD and Pure O OCD, also known as Pure Obsessional OCD, can seem like one of the hardest to control
because most of the symptoms happen beneath the surface, rather than alongside any observable effects on behaviour. It’s commonly defined as the experience of acute obsessions without the manifestation of any compulsions that are outwardly observable. The obsessions may take the form of intrusive thoughts and impulses that you are seemingly unable to resist, be they violent, harmful, negative, sexual, immoral or otherwise.
Symptoms of Pure O OCD can be hard for others to notice, meaning that it can be all the harder to find help with. They can include intrusive thoughts and imagery of harming those close to you, excessive fears of violence, accidentally causing harm or sexually inappropriate or abusive behaviour. Pure O OCD can also crossover with Scrupulosity OCD, including recurring fears that one is living a sinful lifestyle or the manifestation of sacrilegious thoughts and imagery.
Though compulsions may not be outwardly noticeable, Pure O OCD can lead still lead to them, though they may be subtler. Common compulsions can include avoiding situations which have led to obsessions in the past, asking for reassurance that one will not act on their obsessions, checking one’s body for signs of sexual arousal when faced with sexually inappropriate obsessions, or confessing about obsessions, even to strangers. Other compulsions may be more internal, such as performing mental rituals for some measure of thought suppression or practicing cognitive avoidance to ignore stimuli that lead to obsessions. While these mental compulsions can provide some relief, it is often short-lived. Here’s a case example of Pure O OCD.
Living with Pure O OCD – A case example
Joshua was a 24-year old man with a young family, a wife he had been married to for three years and a son still under a year old. Working in a coffee shop, he was the primary financial support of the family while his wife was on maternity leave. He had been diagnosed with anxiety in
the past but wasn’t aware of any obsessive-compulsive behaviour though he had learned about and complained of intrusive thoughts in the past.
With the birth of his son, however, Joshua’s Pure O OCD came to the forefront. Some level of fear over the safety of one’s child is natural, but Joshua began to have vivid images of dropping his child or otherwise getting into gruesome accidents while he was holding, changing, or feeding him. These intrusive thoughts would grow over time, until the point that he would experience them even when he was away from his wife and child.
Despite the fact that these incidents happened only in his mind and never manifested in reality, Joshua felt a growing guilt for the images and scenarios he was obsessing over. Over time, he started limiting his contact with his child, straining his relationship with his wife. This did not
provide any relief from the obsessions, however, and he would soon begin frequently calling his wife from work, asking after the safety of their son. This continued when his wife returned to work and he was calling their childminder instead for constant reassurance that his child was safe.
The constant concerns about his son’s safety made Joshua feel unfit to be a father, irresponsible, and a constant source of danger to his own family, made worse as the obsessions extended to intrusive thoughts about harming his wife as their relationship deteriorated.
What keeps Pure O OCD going?
Like other forms of OCD, Pure O OCD does not impact the person only through the intrusive thoughts that are the primary symptom of the condition. The mental process of appraising the obsessions also have a profound negative mental impact, as well. In Joshua’s case, he started to believe “having this thought means that I am a terrible father and an abusive husband.”
It is this appraisal itself that creates the distress, rather than just the obsession. We all have fears that are contrary to our reality and thoughts that do not match our values and beliefs, but many of us move past them without issue. With OCD, these intrusions often relate to our deepest held values and lead to appraisals that make us believe we are betraying or living contrary to them, also known as “ego dystonic” thoughts.
It isn’t just the case with harmful or violent behaviour against loved ones. A religious person may have ego dystonic thoughts about sacrilege and religious taboos. People may have intrusive thoughts about acting against their sexual preference. In the case of Pure O OCD, the overestimation of the importance of these thoughts leads to anxiety, uncertainty, and poor self-esteem. This can also manifest in the physical sensations of anxiety, including occasionally panic attacks.
Compulsions are behaviours that those with OCD employ to prevent intrusions from coming true or to reduce their levels of distress. In typical OCD this might mean hiding dangerous objects or checking five times that every electrical appliance in the home is off. In the case of Pure O OCD, the compulsions are much subtler. Typically Pure O “behaviours” can include the repetition of a mantra, the practice of cognitive avoidance (trying to suppress the negative thoughts) and may include staying away from stimuli of intrusive thoughts, such as Joshua’s subconscious avoidance of his own family. While providing immediate relief to anxiety, these reductions are often short lived as the individual fails to find out exactly what would happen, both in relation to their intrusions and their distress, if the compulsion had not been carried out.
CBT treatment for Pure O OCD
The treatment with the best evidence for working with Pure O OCD is Cognitive Behavioural Therapy (or CBT) with a focus on Exposure and Response Therapy (ERP). Here, we’re going to look at the different exercises and therapy practices employed in treating Pure O OCD, what they involve, and how they work.
Exposure and response prevention for Pure O
Exposure and response prevention (ERP) is one of the most strongly evidenced treatment interventions for OCD. Deliberately and gradually,
the OCD suffer is exposed to intrusion triggers. Ritual prevention (or response prevention) is where we teach ourselves not to rely on compulsions as a way of dealing with our distress.
Through the habituation process, we can reduce the anxiety associated with exposure triggers without any reliance on compulsions. Over time, we habituate to more and more triggers, to the point that we can tolerate intrusions and realise they are harmless, preventing the harmful appraisals after. In the case of Joshua, his intrusions led him to believe he was a dangerous father and husband. In order to treat this, we can take multiple approaches, including having him carry a piece of paper saying “I want to hurt my wife” with him through the day. Then, he may occasionally read this (discretely) and practice not apologizing for his thoughts or not calling home.
This method can cause severe anxiety to begin with, but the habituation process causes it to decrease over time. With the repetition of
the scenario, he learns to tolerate the anxiety, sees that his intrusions have no impact on his behaviour, and that they are in reality harmless.
Theory A vs Theory B
Theory A vs Theory B is a CBT technique that teaches us to look for an alternate explanation for our problem and to build evidence for two explanations of the OCD to see which is more likely to be true. It relies on building a psychological interpretation to contrast and conflict against the OCD sufferer’s own interpretation.
In Joshua’s case, his interpretation, or Theory A, is “I am a bad/harmful/abusive husband and father.” Whereas, the psychological interpretation, or Theory B, may be along the lines of “I am worried that I am a bad/harmful/abusive husband and father”, which is distinctly different.
Evidence for Theory A in this case may include “I have intrusive thoughts of harming my child and wife, so I try to mentally ignore them or use work as an excuse to avoid them”. Whereas, the evidence for Theory B may include thoughts like “I feel terrible about my thoughts, so I feel
guilty about them and apologise for them, signalling that I do care for my wife and child and do not want any harm to come from them.” It is important to “build a case” for both Theory A and Theory B, but in the overwhelming majority of cases, we tend to find that Theory B is often the more supported one
From there, we move on to behaviour. If Theory A is true, then Joshua’s compulsions might seem like an appropriate reaction to him. If Theory B is true, however, then the appropriate behaviour is instead to spend more time with his wife and child and to ensure he is supporting them and
caring for them. Theory A vs Theory teaches us how to get to grips with the underlying concerns contributing to our OCD and to deal with them in a way that is healthier.
Behavioural experiments in Pure O
With Pure O OCD, obsessions and the appraisal that follow are often accompanied by anxiety and distinct fears of what their obsessions could lead to. These perceived consequences are a great source of distress, but by habituating to them, we can diminish the impact they have. This, in turn, can reduce the compulsive behaviours taken to avoid them.
Another strategy we can use is the behavioural experiment. This is where we set up an experiment to test out our beliefs about our intrusions. For example, we might design an experiment to test out the need and ability to control our thoughts. The belief to be tested may be “I should be able to control my thoughts at all times”, and the alternative may be something like “I do not have to control my thoughts, as nothing bad will happen if I don’t.”
In Joshua’s case, he believes that if he doesn’t control his thoughts, he may cause harm to his wife and child. However, how does he believe this will happen, and when? Will he do it intentionally or accidentally? Confronting these thoughts in detail can help us create experiments. For
instance, we can test out what happens if Joshua has lunch with his wife without controlling his thoughts. He may make a prediction that something bad will happen if he doesn’t control his thoughts, or that his distress will be excessive if he doesn’t. When he returns, we evaluate what happened. Did the feared consequence occur? If not, what did happen? What does this say about OCD? What does this mean for the future?
We have only begun to cover the basics of Pure O OCD and how CBT can help treat it. It can be much more distressing and difficult for
the sufferer than simply reading about an example of it, however, so help is essential. If you’re struggling with Pure O OCD and you want help, get in touch with me, George Maxwell, at firstname.lastname@example.org or call 07887 701 176.