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Pure O: The Unseen OCD

Pop culture has given most people a general sense of OCD, and even sparks some very negative perceptions of what OCD is and is not. You've probably heard somebody in your life comment on how they are "So OCD...." regarding a particularity in their life. While there is a quite a bit of overlap in the process of somebody who is particular versus somebody who is diagnosable OCD, they are not the same.

Even within OCD, there may be an underlying process or connection between their obsession and compulsive behaviors; however, the content of their intrusive thoughts vary on complex levels. The generalization techniques implemented in the gold standard treatment for OCD may address multiple contamination fears, even though the individual fears may be very different.

What about those individuals who don't have what we would call overt compulsions? Overt compulsions are compulsions that we can see. The ones that are identifiable behaviorally such as compulsive prayer rituals, the perpetual washing of hands, or incessant tapping and checking behaviors can be easily spotted. Other forms of compulsive behaviors, known as covert compulsions, are much more elusive and difficult to identify. These are often an identifiable trait of what is known as "Pure O" OCD.

Made of Millions Foundation, a mental health advocate group, defines Pure O as:

"...a type of OCD in which a sufferer engages in hidden compulsions. Instead of combating their intrusive thoughts with visible rituals such as hand-washing or counting, they perform repetitive, mental rituals to minimize stress." (

The Purely Obsession OCD sufferer has components we would come to expect: Intrusive thinking patterns that cause distress in the sufferers life in combination with compulsive, ritualistic modes of operating that create impairment in social, personal, or occupational realms; along with actions taken to reduce the distress. The only difference from "traditional", pop culture OCD, is that their compulsions are mainly covert in nature.

Covert compulsions are mental rituals that aim to reduce the suffers levels of anxiety by checking their behaviors against a number of checklists, comparisons, and often reassessing

their behaviors to make sure they are "safe". For instance, somebody who is struggling with intrusive thoughts regarding their sexuality could engage in overt or covert compulsions. Overt compulsions may include pornography viewing to ensure they are still aroused by "heterosexual" content. Covert compulsions may be a comparison analysis between how they view men versus women, if they find themselves having any positive feeling towards a member belonging to the same sex. They may also review their sexual history to affirm their sexuality.

Many individuals who struggle with religious, or scrupulous OCD may have ritualized prayers they repeat over and over until it feels as though they "got it right." These can be covert, or overt in nature. Often, the covert compulsions can be quick reminders about their faith, such as "praise Jesus," or "I rebuke the devil." These mental assurances allow the sufferer to avoid the discomfort of any questioning of their faith, or some catastrophic outcome that would end in their eternal suffering. Unfortunately, the certainty, and alleviation of distress these remarks or covert rituals bring about, is quickly minimized due to the bombarding nature of obsessions. Compulsions only bring about small instances of comfort, right before we recognize the next discomforting intrusive thought.

Exposure therapy with response prevention can still work well with individuals who present with Pure O OCD. We would first want to be mindful about the types of mental/covert compulsions each individual engages in, and encourage them to prevent those responses, checking, and self reassurance seeking in order to allow them to habituate to the distress of the uncertainty they feel. We can also encourage them to behave in ways, with in-vivo exposures, that bring about the intrusive thinking patterns and not allow them to engage in mental rituals. Often increasing their cognitive load with recorded scripts make it difficult for sufferers to focus on combating them.

Whether compulsions are overt or covert, exposure therapy with response prevention has a lot to offer sufferers. If you or somebody you know suffers with Pure O OCD, please don't hesitate to give me a call at 405-513-0282 or email at

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