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The OCD & Anxiety Center of Cleveland provides therapy for anxiety disorders in children, teens, and adults. Jonah Lakin PsyD is a licensed clinical psychologist specializing in Cognitive-Behavioral Therapy (CBT) for Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD), social anxiety disorder/social phobia, agoraphobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

OCD & Anxiety Center of Cleveland blog about anxiety treatment

Anxiety Blog. Describes CBT principles involved in treatment for anxiety disorders in children and adults. Conditions discussed include: Obsessive-Compulsive Disorder (OCD), panic disorder, phobia, Generalized Anxiety Disorder (GAD),  social anxiety disorder/social phobia, agoraphobia, emetophobia (fear of vomiting), illness anxiety disorder, trichotillomania (hair pulling), & excoriation (skin-picking).

The misleading term "Pure O"

Jonah Lakin PsyD

People often believe that “Pure O” refers to a specific subtype of Obsessive-Compulsive Disorder in which a person experiences obsessions, but not compulsions. This is exactly what Pure O sounds like, even though it’s not accurate. The truth is that there is so such type of OCD in which a person has only obsessions and no compulsions. However, compulsions can sometimes be less obvious to outsiders and thus it can appear as though a person doesn’t have any compulsions. Individuals with less obvious compulsions therefore tend to be classified, inaccurately, as having Pure O. Because Pure O* is an inaccurate and misleading term I try to avoid using it. However, it’s hard to write a blog post about it without using the term, so I will use the asterisks to indicate that this term isn’t quite accurate.

First let’s define two terms that will help illustrate this point. I’m going to use a functional definition here rather than what you might find in a textbook. Obsessions refer to the anxiety that a person with OCD has. Compulsions refer to any effort to reduce this anxiety, whether it works or not. Because OCD is so distressing, people will go to great lengths to reduce or avoid their anxious feelings; therefore, all people with OCD engage in compulsions.

So what types of compulsions are harder to identify and lead to Pure O* classification? There are generally two types: mental compulsions and non-ritualized checking/reassurance compulsions.

Harm OCD, Health OCD, Homosexual OCD are often all grouped together under the term Pure O*. In Harm OCD a person because intensely distressed by unwanted intrusive thoughts of harming others; in Health OCD people become intensely distressed by unwanted intrusive thoughts that they are sick; in Homosexual OCD people become intensely distressed by unwanted intrusive thoughts that are homosexual in nature.

Each of these Pure O* subtypes result in tremendous uncertainty. A person with Harm OCD is uncertain what their thoughts mean and whether they’ll act on them or whether they are secretly a psychopath. In Health OCD, a person wants 100% certainty that they are healthy and not sick; they feel distressed when they are uncertain about their health status. In Homosexual OCD, a person becomes uncertain about what their homosexual thoughts mean, and whether or not they are gay.

Because each of these people is anxious and uncertain, they will engage in actions geared towards reducing their anxiety and their uncertainty. These actions are compulsions, though not ritualized ones. A person with Harm OCD may google search “Top 10 signs that you’re a psychopath” or “How do I know if I really am a murderer?” They research these things in the hopes that what they find online won’t match up with what they know about themselves. If they don’t have any of the top 10 signs of a psychopath, then they less uncertain that they could be a psychopath and will temporarily feel a sense of relief. A person with health anxiety may have a headache, and google search “how do I know if I have a brain tumor?” Again, the hope is that the signs and symptoms of a brain tumor will be different from what they are experiencing which will reduce their uncertain feeling that they have a brain tumor. The person with Homosexual OCD may google search “how do I know if I’m secretly gay?” for the same purpose as the other two; he’s hoping to find something that convinces him he’s not actually gay. In all these cases, a person feels anxiety due to uncertainty and then tries to research something to help reduce their uncertainty. The goal is to convince themselves that their worries are “just OCD” and therefore “not real.” In essence they are trying to convince themselves that they aren’t actually gay, sick or dangerous in some way. Therefore, all this google searching falls under the category of compulsive behavior. It is not, however, ritualized; people don’t typically go to the exact same website and read the exact same sentence everyday. They don’t feel the need to read the title a special number of times to feel better. Instead, these compulsions are geared towards reducing uncertainty and therefore will look different from day to day based on whatever the individual thinks will reduce their uncertainty in that moment.

Now if you’ve ever suffered from severe anxiety, you know that seeking this kind of reassurance doesn’t typically help for long. After all, you may find that you have 2 out of the 10 signs of being a psychopath which may actually make you feel worse not better. Or you may find that irritability is a sign of having a brain tumor, and lately you’ve been a bit more irritable than usual, does that mean you actually do have a brain tumor? Or you may see that your symptoms of homosexual OCD don’t perfectly line up with what you read online, does that mean you don’t actually have OCD, maybe you really are gay? Because 100% certainty is impossible to achieve, these compulsive efforts to achieve certainty often end up backfiring, or at the very least not working fully. Nonetheless, the individual with OCD engages in these behaviors in the hopes of achieving certainty and reducing distress and the behaviors are compulsions, whether or not they actually result in the desired outcome of escaping anxiety.

I’ve used the example of google searching here, although that’s certainly not intended to mean that’s the only way people check or seek reassurance. They may ask their friends or family: (harm) Do you feel safe around me? (harm) Have you ever had a thought about hurting someone else? (health) Do you think I have cancer? (health) Should I see a doctor? (Homosexual) Do you think I’m gay? (homosexual) Have you ever thought about a man naked while having sex? Or they may read books written by experts (or blogs such as this one) with the goal of trying to persuade themselves that they aren’t really dangerous, ill or gay? Just like with the google searching, these compulsions aren’t ritualized (they may vary in appearance from one episode to the next) and they don’t always result in relief or certainty.

Another type of compulsion that often occurs in Pure O* is mental compulsions. For instance, if I worry I might act on my unwanted intrusive thought of stabbing my partner, I might think to myself “be kind be kind be kind” to keep myself from hurting my partner. I feel like this makes me less likely to be violent so it is a compulsive effort to feel less anxiety. Or each time I have a sexual obsession that bothers me, I may try to neutralize it with a different thought to balance them out. Maybe I use a specific image of a man and women having sex and try to think of it until the first “gay” thought dissipates. These are both mental compulsions.

It is worth noting, however, that mental compulsions don’t have to be ritualized. In fact, ritualized mental compulsions are even more common. Just like google searching or seeking reassurance/checking with others, people try to achieve certainty in their own minds. For instance they may tell themselves something like this: “I had a thought of stabbing my partner, but I probably won’t do it. I love my partner, I don’t want to hurt them and I’ve never hurt anyone before before. My doctor says that these thoughts don’t mean anything, so I think I’m safe.” While this all seems quite logical and perhaps even useful, it is a compulsion. It is a mental process geared at reducing distress and uncertainty.

In summary, Pure O* is a misleading term. Pure O* is not a special type of OCD that involves obsessions without compulsions. Rather, compulsions are present in Pure O* but they are less obvious. Compulsions can be mental and/or non-ritualized and typically involve efforts to achieve certainty.

The material contained in this website is for informational and educational purposes only. It is not intended to diagnose or treat any mental health condition. It is not a substitute for psychological treatment provided by a licensed mental health provider. Nothing in this website should be construed as establishing a client-psychotherapist relationship between you and the OCD & Anxiety Center of Cleveland.