What is Pure-O?
Many individuals with Obsessive Compulsive Disorder (OCD) will often go undiagnosed for years. Two factors play into this – one, the disorder is still misunderstood, especially when it comes to specific themes of OCD, and two, many individuals have mental compulsions that go unseen to the untrained eye. My mentor, Dr. Steven Phillipson, coined the term Purely Obsessive or “Pure-O” during his work with OCD in the late 1980s. Throughout my training with him, I was able to understand how OCD can present itself without any or very limited behavioral compulsions. An individual with Pure-O will have an intrusive thought or image paired with an uncomfortable emotion such as anxiety or guilt. This individual will then engage in mental compulsions to try and attempt to reduce the emotion and eliminate the intrusion. Just like any behavioral compulsion, mental compulsions will reinforce the intrusive thought/image and emotions/body sensations associated with it. This means that the more an individual tries to extinguish the feared thought/image, the more it sticks around, becoming an “obsession.” Individuals with Pure-O will typically try to seek answers and certainty. However, the answers found from mental compulsions or reassurance-seeking will never feel like “enough,” so the individual will continuously feel trapped or stuck in cycles of obsessions and mental compulsions.
Examples of mental compulsions:
- Mental rumination (e.g., analyzing, answer-seeking, ineffective problem-solving)
- Thought/image stopping (e.g., mentally pushing away intrusions, saying STOP or NO internally)
- Internal checking (e.g., feelings, body sensations, groinal responses, etc..)
- Mental replay (e.g., memories, social interactions, events, etc..)
- Mentally dispelling or protecting oneself or others from thought/image
- Thought neutralization (i.e., replacing a “bad” thought/image with something “good”)
- Receptive mental activity (e.g., mantras, numbers, etc..)
- Mentally playing out future scenarios repetitively to “prepare” for the feared outcome
- Mental reassurance (e.g., self-reassure, repeating reassurance from others)
- Mental self-punishment (e.g., I don’t deserve X because I think/believe/did Y)
Pure-O vs. GAD
Unfortunately, many practitioners only diagnose OCD if the individual displays behavioral compulsions (e.g., checking, ritualizing, etc..) and misdiagnose a Pure-O client with a different disorder such as Generalized Anxiety Disorder (GAD) or, even worse, a psychotic disorder. It is essential to understand the differences and similarities between Pure-O and GAD, and yes, you can meet criteria for both. It is helpful to think of GAD as a global worry of everyday stressors, while OCD will focus on particular obsessions. Individuals with OCD can have multiple obsessions or different intrusive thoughts throughout the day, but usually, the individual is narrowed in on one obsession at a time. I tell my clients that their OCD themes are different actors on a stage, and one may have the spotlight while the others are still in the background. Obsessions are also typically more irrational and tend to be generated from a random intrusive thought/image. These intrusions will also tend to be ego-dystonic, meaning separate from our values or belief system. Individuals with GAD will have general worries about school, work, health, etc., which will be ego-syntonic (i.e., aligned with values and beliefs). Lastly, the most significant difference is individuals with OCD will engage in either behavioral or mental compulsions to alleviate the distress paired with the obsession.
Some similarities between the two diagnoses include avoidance behaviors, reassurance-seeking, and difficulty tolerating uncertainty. There is unhelpful mental rumination in both OCD and GAD, which will reinforce symptoms in both disorders. Those with OCD and GAD will also have cognitive distortions (i.e., unhelpful thinking patterns), which will impact how they feel and behave. However, those with strictly GAD will be able to reframe their cognitive distortions and be satisfied with answers to their worries. Therefore, GAD responds well to Cognitive Behavioral Therapy (CBT) skills such as cognitive reframing or coping strategies. Those with OCD will not be able to move on from an obsession and feel like nothing will be able to give them relief. This is precisely why GAD and OCD are treated differently and why the individual must be diagnosed correctly. CBT techniques that are used to treat GAD will reinforce OCD symptoms. The more the individual engages with the obsession as they would with “cognitive reframing” or “finding evidence for or against a thought,” the bigger the obsession grows.
ERP for Pure-O
Implementing Exposure and Response Prevention (ERP) for Pure-O is possible, even though there are no behavioral compulsions. You just need to get creative with exposures! I use a combination of both Acceptance and Commitment Therapy (ACT) and ERP to treat Pure-O effectively. Through ACT mindfulness and defusion skills, you can learn how to separate from thoughts/images and disengage from mental compulsions. I cannot stress enough how important mindfulness is in treating Pure-O. Many clients will talk about how mental compulsions feel so automatic and impossible to disengage from. I totally understand this, and yes, it is easier to walk away from a sink and not wash your hands than disentangle from your mental compulsion. We can’t walk away from our own brains!
However, it is possible to build more mindful awareness through meditative exercises. The more you become aware of how you respond to thoughts and images flowing through your consciousness, the easier it is to disengage. Many clients will ask me, “How do I do response prevention if my compulsions are mental?” We target those compulsions with disengagement phrases instead of engaging with them. For example, if my OCD voice gives me the thought, “What if you want to harm your partner right now?” A mental compulsion would look like trying to “figure out” if I want to harm my partner, leading this thought to be reinforced and uncomfortable emotions to begin to grow. If I use a disengagement phrase as stated below, I am engaging in response prevention and, therefore, not reinforcing the thought.
Examples of disengagement phrases:
- Good one!
- I don’t know.
- Thanks for sharing that.
- That’s creative.
- I’m not answering that question.
- Thanks for trying to protect what I love, OCD!
- I’m choosing to stay in the present moment.
It is crucial to note that disengagement phrases are NOT intended to get “rid” of a thought/image (that would make it a compulsion). The goal is to continuously disengage from the thought, even if it occurs multiple times throughout the day. This is where the third element comes into play – willingness. We need to be willing to have intrusive thoughts and images (see Living WITH OCD post for more info) and then skillfully disengage from them. As for exposures, this will depend on your obsession, and everyone’s exposures will look different based on their obsessions, avoidance behaviors, etc. Pure-O exposures aim to demonstrate willingness around intrusive thoughts/images. We’re saying, “Okay, OCD, I am engaging in this exposure to bring on this thought/image and whatever emotion/sensation comes up with it!” This is then followed by response prevention (i.e., disengagement phrases).
Examples of Pure-O exposures
- Writing out intrusive thoughts/core fears & reading them throughout the day
- Imaginal exposure of intrusive thought/image
- Articles on theme
- Videos/Documentaries on theme
- Detailed narrative/script on theme
- Engaging in activities/behavior associated with theme
Exposures are best developed with a trained OCD therapist, especially one familiar with Pure-O. Please note this post is to provide psychoeducation, not to encourage you to be your own therapist. This post is also not meant to be used to help self-diagnose. If you believe you have OCD or particularly Pure-O, speak to a trained professional to receive a diagnosis and proper treatment. Remember, if you put in the work and learn ACT and ERP, it is possible to get unstuck from the cycle of Pure-O mental compulsions and get back your mental freedom!