”Pure Obsessional” Obsessive Compulsive Disorder: An Overview

While most of us are familiar with the symptoms of Obsessive Compulsive Disorder, such as excessive hand-washing, repeatedly checking the locks on a door, etc., not many are familiar with the purely psychological or non-physical manifestation of OCD.

Pure-O or Pure Obsession OCD is a form of OCD wherein an individual experiences an onslaught of disturbing images or thoughts with no outward action or intention to act on those impulses.

All non-clinical individuals experience unwanted or negative thoughts; however, we tend to dismiss them as the brain’s tricks on us. However, those with this specific manifestation of the disorder fear being a bad person or a monster for having such thoughts and, worse, being unable to control them or stop their occurrence.

Is it Different From OCD?

Clinically, the DSM-5 (the standard handbook for diagnosing mental health issues) does not differentiate between them; they both fall under the single mental health condition category of OCD.

In fact, according to renowned clinical psychologist Monnica T. Williams and her colleagues, who documented their findings in the article titled The Myth of the Pure Obsessional Type in Obsessive-Compulsive Disorder, “Recognition of compulsions performed by those previously considered purely obsessional can aid in the improved diagnosis and treatment of people with OCD.”

People who have OCD battle compulsions, obsessions, or both. The subtle difference lies in the fact that those with Pure-O have less evident physical compulsions because the obsessions are primarily at a mental level and thus invisible to observers.

What are the Causes?

Although there isn’t much research on the specific causes responsible for developing Pure-O, several overlapping factors have been identified while investigating OCD and its causative factors. They range from the classic nature v/s nurture debate to genetic factors. Let’s delve into this one by one.

• Neurotransmitters: Neurotransmitters are chemicals in the brain that regulate mood, behavior, and other bodily functions. Imbalances in neurotransmitters like serotonin, dopamine, and glutamate have been linked to OCD. In particular, low levels of serotonin have been associated with its symptoms, including intrusive thoughts.
• Brain structure and function: Neuroimaging studies have found differences in brain structure and function between people with OCD and those without the condition. Specifically, researchers have identified changes in the activity and connectivity of brain regions involved in regulating thoughts and emotions.
• Family history: Studies have pointed towards a significant correlation between first-degree relatives of OCD patients and their predisposition to develop the same. However, due to the difficulty segregating pure cases of OCD, the evidence is inconclusive. McKeon and Murray observed “a greater rate of mental illness in the first-degree relatives of OCD probands.”
• Genetic makeup: While scientists are yet to identify a single gene responsible for developing obsessive-compulsive disorders, however, candidate gene studies have pointed out specific gene variants that are responsible for “a small portion of the total genetic risk to OCD and related disorders.”

A history of personal trauma can also exacerbate the risk of developing mental and behavioral compulsions.

Common Symptoms

According to the DSM-5, this disorder is characterized by the presence of obsessions and/or compulsions. And people with Pure-O exhibit a range of mental obsessions, compulsions, or both.

Obsessions refer to repetitive and unwanted thoughts, images, or urges that persist over time and intrude upon one’s mind, causing anxiety or distress. For those with this condition, these thoughts often cause anxiety or distress and may focus on issues like bodily concerns, sexuality, religion, aggression, symmetry, and contamination. Those with Pure-O OCD also admit to having “taboo” or “unwanted” triggering thoughts about these issues. They may also experience flashes or images of causing harm to people. They fear being a “monster” because of getting such thoughts and either flee the situation or seek reassurance from others.

Some common examples of irrational obsessions include severe doubts about one’s sexual orientation, persistent thoughts about doubting one’s love for their partner, a feeling that one might cause accidents by ramming a vehicle into a tree, etc., or constantly questioning their religious identity.

On the other hand, compulsions are repetitive actions or mental processes that affected individuals feel compelled to perform in response to an obsession that governs them. These are excessive and not realistically related to the underlying problem. In a study conducted in 2011, it was found that individuals with “pure obsessions” also engage in mental rituals as a means of managing their distress. Mental rituals can involve activities such as:

• mentally reviewing memories or information
• repeating certain words
• or undoing or redoing certain actions in their mind

People who experience obsessive thoughts may also compulsively seek reassurance but may not realize this behavior is a compulsion. Seeking reassurance can involve:

• asking others for assurance
• avoiding anxiety-provoking objects or situations
• looking for self-assurance
• extensive online researching

One challenge of this symptom is that constant requests for reassurance may cause family and friends to become fatigued or annoyed, perceiving the reassurance-seeking behavior as neediness.

Thus, while compulsions are also present in pure-O, they do not manifest physically.

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The Different Types

Pure-O OCD was first listed in a 1994 Journal of Clinical Psychiatry, describing it as “being composed of sexual, aggressive, and religious obsessions that were not accompanied by compulsions.” Pure-O was considered a subtype of the three to six divisions of OCD in early scientific literature. The following are some common kinds experienced by those living with Pure-O.

• Harm: This includes having vivid thoughts or images about causing harm to oneself or others. This could consist of acts of sexual violence towards children or family members and friends. For example, a father may feel ashamed if he feels a groinal response while bouncing his daughter on his lap.
• Pedophilia: Let’s understand this with an example: a primary school teacher gets vivid visuals of a particular student performing oral intercourse on them. Disturbed by this, they choose to take a day off and not report to work to avoid seeing that child. Or a mother hugs her son and feels a sudden spurt of vaginal lubrication and since then, avoids any contact with her family members. These unwanted, disturbing thoughts are often accompanied by rituals such as washing, counting, or praying to “neutralize” such visuals and urges.
• Relationship: In such instances, a person constantly doubts their level of love and attraction for their partner and sometimes even their sexual desirability in the long run.
• Sexual orientation obsessions in OCD: Those with SO-OCD harbor unhealthy levels of obsessions over their own sexual inclination and can spend insane amounts of time wondering.

How is it Diagnosed?

At this juncture, it is important to reiterate the fact that while all of us are given to double-check certain things, to be diagnosed with clinical OCD, it is important to meet the following diagnostic criteria:

• Spending hours on obsessions, compulsions, or both disturbs the quality of work and life balance. This, in turn, leads to significant distress or disturbance in all spheres, such as social, occupational, and other critical areas of the individual’s life.
• The symptoms must not result from the physiological effects of a psychoactive substance such as a medication or an illicit drug. The symptoms must also not result from the manifestation of some other medical condition.
• It must be established for a fact that OCD symptoms are not attributable to or have roots in other mental disorders such as hoarding disorders, excoriation disorders, major depressive disorders, body dysmorphic disorder, or generalized anxiety disorder.

Also, OCD does not know gender barriers and has a similar tendency to manifest in both men and women of all races, cultures, and ethnicities. Over 2.3% of people in their lifetime might develop this disorder. While symptoms are known to creep up in young adulthood or late adolescence, they might begin as early as early childhood and the beginning of adolescence. It can be more challenging to spot these patterns in the young ones as they might go to greater extents to hide the outward manifestations of such symptoms.

How to Deal With It

Now that we are familiar with the causes, symptoms, and types of Pure-O, let’s have a look at the treatment options and coping methodologies to manage the ills of this disorder.

• Treatment: The treatment often involves a conflation of medication and psychotherapy (CBT, for instance), joining support groups, and effective dissemination of psychological education.
  • Psychotherapy: While cognitive-behavioral therapy can be extremely effective in treating Pure-O, therapists must get to the root of the mental rituals accompanying the patient’s obsessions. Until that happens, the treatment will not be considered complete or effective.
    Exposure and response prevention have been successfully used to treat forms of OCD. The goal of this treatment is to help patients manage their fears and compulsive routines without falling into the rituals that such situations may entice. And while it may be more effective for the different forms of OCD with overt compulsions, in the case of pure-O, the “response prevention” aspect of ERP may involve resisting the mental rituals or mental avoidance behaviors that are associated with the obsessions.
    While this may increase distress in the short term, it has been found to be effective in the long run in managing obsessions and compulsions.
  • Medication: Medications such as SSRIs (Selective Serotonin Reuptake Inhibitors) or the tricyclic antidepressant Anafranil (clomipramine) are commonly used to treat OCD, and in some cases, second-generation or atypical antipsychotic medications may be added to augment the effects of these medications. According to a review, Drug treatment for obsessive-compulsive disorder, “approximately 40% to 60% of patients respond to treatment with SSRIs with a 20% to 40% reduction in the symptoms.”
    The treatment course can be tailor-made to suit the bespoke needs of a particular patient. For instance, if a patient is unwilling to take medication, they can be given CBT. If someone doesn’t have the option or access to a CBT provider or the willingness to explore psychotherapy, they might be prescribed a course of medications.
• Coping: While consulting a mental health professional for effective treatment and coping strategies is highly recommended, one can also try certain self-help strategies to get relief and lead a holistically healthy life.
  • Relaxation strategies: As per the results of a study conducted by Manjula M, and Sudhir PM, stress is one of the major triggers of Pure-O symptoms; therefore, it is advisable to learn and implement relaxation methods such as mindfulness, meditation, deep breathing, and progressive muscle relaxation.
  • Aerobic exercise: Studies have demonstrated a significant reduction in symptoms by regular indulgence in aerobic exercise.
  • Support Groups: Both online and offline support groups for those with Pure-O symptoms, along with their loved ones, can enormously benefit them with a safe space for venting, compassionate and empathetic listening, resources, and a repertoire of information on how to tackle and mitigate the disease symptoms.

Help is always at hand, and you do not need to battle the symptoms alone.

Seek Help From a Licensed Therapist With DocVita Today

Since there aren’t many physical manifestations of Pure-O, it can be hard to diagnose the symptoms in a loved one. However, if someone seeks constant assurances or confesses about continual unwarranted or disturbing thoughts, please let them know there is absolutely no need to live this way without seeking treatment. Trained, qualified and empathetic mental health professionals are just a couple of clicks away at your favorite mental health portal DocVita where you can seek counseling for obsessive-compulsive disorders. Log in today and get set on the path to holistic recovery from the confines of your home!