All About Pure O (Purely Obsessional OCD)

When people think of OCD, they usually picture something pretty obvious, like being overly concerned with order, washing hands over and over, and double-checking locks before leaving their house.

And while that makes sense considering the stigma surrounding OCD (we DO have a blog for that here btw), the tricky part is OCD doesn’t always look like this. Sometimes it can look completely invisible on the outside. That’s where “Pure O” comes in. The name is short for purely obsessional OCD, and it’s a very misunderstood form of OCD! 

Today, we want to talkto  you through what Pure O really is and how we help our patients find relief through therapy treatments here at Soultality Psychotherapy in Cambridge, MA.

What Exactly IS Pure O?

Before diving straight into what Pure O is, first, we want to make sure you know what makes up OCD. There are two parts to OCD: unwanted intrusive thoughts, images, or urges that cause distress, PLUS the compulsions people do to try to find relief from the intrusive thoughts. 

With Pure O, those compulsions aren’t external like traditional OCD; the compulsions are internal. It can look like replaying conversations in your head, trying to reassure yourself during situations, or running through mental “what if” scenarios that feel like it’s on an uncontrollable loop.

And because the compulsions don’t appear like rituals on the outside, Pure O often leaves people feeling confused, frustrated with themselves, and isolated. On the outside, they look calm, but internally, their brains are constantly trying to create relief from their intrusive thoughts. 

One of the hardest parts about Pure O for people is that it just feels like thinking. This misunderstanding is painful because it makes people less likely to get help or leads to treatments that don’t address the real issue. 

Different ways Pure O Can Present Itself

Another interesting fact about Pure O is that it can work itself into all sorts of different types of OCD. Think of it as OCD’s way of adding an amplifier to whatever a person is already struggling with. The intrusive thought pops up, and instead of creating a physical compulsion, Pure O creates mental compulsions like replaying, analyzing, reassuring, or debating with themselves.

Here’s what that can look like in different forms of OCD:

Harm OCD

Imagine you’re chopping veggies for dinner when suddenly you get a mental image of stabbing your partner. Terrifying, right? While most people would just shake off the thought and continue cooking, Pure O combined with Harm OCD makes that image feel important and defining. 

Instead of moving on, people with Pure O may spend hours reassuring themselves that they’d never do something like that, review past “proof” of them cooking to reassure themselves that they’re safe, or they may silently repeat phrases that counteract the intrusive thought. 

Relationship OCD (ROCD)

Relationship OCD creates obsessive thoughts and compulsions about the relationship itself. With traditional ROCD, the intrusive thoughts like “what if my partner ISN’T the one?” lead to compulsions like excessive reassurance seeking or even avoiding their partner altogether. 

But with Pure O, the compulsions become internal. People experiencing ROCD & Pure O may find themselves replaying conversations word-for-word, comparing their partner to past relationships, or listing reasons that they should feel differently. This leads people to feel trapped in their heads, trying to find certainty. With these types of internal compulsions, certainty cannot be found, no matter how long they spend thinking about it.

Sexual Orientation OCD (SO-OCD)

This form of OCD latches onto identity fears with intrusive questions like, “What if I’m secretly gay/straight and I’m lying to myself?” When Pure O comes into play, it amplifies these thoughts by sending people into constant mental compulsions, like testing past attractions they’ve had or spiraling if they can prove/disprove the theory. When SO-OCD and Pure O are combined, the person is looking for answers internally about their sexual orientation, but can never seem to settle on an answer.

Scrupulosity/Religious OCD

Religion and moral themes can be especially painful when Pure O is involved. A seemingly normal thought like, “Am I being religious enough?” or, “Have I offended God by xyz event?” won’t just go away with Pure O. Instead, the Pure O keeps people mentally replaying conversations for slip-ups, silently reciting prayers, or going over religious teachings in their head for reassurance. 

Existential OCD

Big philosophical questions about life, purpose, and reality can seem fascinating, until Pure O and Existential OCD can turn thoughts like, “What if NONE of this is real?” into endless mental debates. People experiencing this may find themselves analyzing reality, scanning for “proof” that life is real, or rehearsing arguments in their head that never seem to resolve. 

No matter how Pure O shows up, the key to healing isn’t from trying to solve the intrusive thoughts; it’s learning how to stop engaging with the thoughts. (That’s where therapy comes in!)

How Therapy Helps Pure O

We use Exposure and Response Prevention therapy (ERP) to help people with Pure O. We’ve had patients come to us before who have tried ERP and had it not be successful, but the problem wasn’t in the ERP itself. The problem was in the compulsions that weren’t being addressed. 

You see, standard OCD has more physical compulsions. So while the patient may have had ERP to help with those compulsions, patients who also struggle with Pure O have mental compulsions. This can lead to the patient rationalizing and obsessing over the treatment, leading it to not be as effective.

At Soultality, we treat the WHOLE person. And when we see that someone is struggling with mental compulsions, we adjust our ERP approach to help our patients learn how to respond to their intrusive thoughts without engaging mentally.

This means learning things like:

Non-engagement responses

Instead of spiraling into “what if they’re mad at me?” we help our patients find new responses that don’t lead to engagement. A good counter response could be, “Maybe, I don’t know.” It’s simple, short, and doesn’t lead to engagement or overthinking.

Sitting with uncertainty

For someone struggling with Pure O, this is incredibly difficult, but also life-changing. Pure O is fed on engagement. When we work with patients and teach them how to sit with uncertainty and NOT engage with the intrusive thought, with practice, they eventually get to a point where they don’t HAVE to respond.

Recognizing the real compulsion

The intrusive thoughts themselves aren’t always the problem; it’s the urge to reassure and jump through mental hoops to figure it out that keeps the cycle going. When our patients learn that THIS is the real compulsion, the intrusive thoughts feel less scary.

With time and practice, we can teach the brain to learn new patterns. This is the beginning of freedom for people struggling with Pure O. 

We Believe There Is Freedom From Pure O

And if you’re struggling with insidious intrusive thoughts, you may feel like nobody else gets it, or like therapy can’t help with something that “only lives in your head.” 

But that ^^^ may just be another intrusive thought.

Pure O is real, and it is treatable! If this blog made you feel seen, please schedule a complimentary therapy consultation. At Soultality Psychotherapy in Cambridge, MA, we believe that with the right approach, you can get your energy, your peace, and your life back. Schedule your next appointment today.