Purely Obsessional OCD

Primarily Obsessional Obsessive-Compulsive Disorder (also commonly called Purely Obsessional OCD, Pure-O, OCD without overt compulsions or with covert compulsions) is a lesser-known form or manifestation of OCD. For people with primarily obsessional OCD, there are less observable compulsions, compared to those commonly seen with the typical form of OCD (checking, counting, hand-washing etc.). While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination.

Common themes
Primarily obsessional OCD has been called "one of the most distressing and challenging forms of OCD." People with this form of OCD have "distressing and unwanted thoughts pop into [their] head frequently", and the thoughts "typically center on a fear that you may do something totally uncharacteristic of yourself, something ...potentially fatal...to yourself or others." The thoughts "quite likely, are of an aggressive or sexual nature."

The nature and type of primarily obsessional OCD varies greatly, but the central theme for all sufferers is the emergence of a disturbing intrusive thought or question, an unwanted/inappropriate mental image, or a frightening impulse that causes the person extreme anxiety because it is antithetical to closely held religious beliefs, morals, or societal mores. The fears associated with primarily obsessional OCD tend to be far more personal and terrifying for the sufferer than what the fears of someone with traditional OCD may be. Pure-O fears usually focus on self-devastating scenarios that the sufferer feels would ruin their life or the lives of those around them. An example of this difference could be that someone with traditional OCD is overly concerned or worried about security or cleanliness. While this is still distressing, it is not to the same level as someone with Pure-O, who may be terrified that they have undergone a radical change in their sexuality (i.e.: might be or might have changed into a pedophile or become homosexual), that they might be a murderer or that they might cause any form of harm to a loved one or an innocent person, or that they will go insane.

They will understand that these fears are unlikely or even impossible but the anxiety felt will make the obsession seem real and meaningful. While those without primarily obsessional OCD might instinctively respond to bizarre intrusive thoughts or impulses as insignificant and part of a normal variance in the human mind, someone with Pure-O will respond with profound alarm followed by an intense attempt to neutralize the thought or avoid having the thought again. The person begins to ask themselves constantly "Am I really capable of something like that?" or "Could that really happen?" or "Is that really me?" (even though they usually realize that their fear is irrational, which causes them further distress) and puts tremendous effort into escaping or resolving the unwanted thought. They then end up in a vicious cycle of mentally searching for reassurance and trying to get a definitive answer.

Common intrusive thoughts/obsessions include themes of:
 * Responsibility: with an excessive concern over someone's well-being marked specifically by guilt over believing they have harmed or might harm (either on purpose or inadvertently) someone.
 * Sexuality: including recurrent doubt over one's sexual orientation (also called HOCD or "homosexual OCD"). People with this theme display a very different set of symptoms than those actually experiencing an actual crisis in sexuality. One major difference is that people who have HOCD report being attracted sexually towards the opposite sex prior to the onset of HOCD, while homosexual people whether in the closet or repressed have always had such same sex attractions for lifelong. The question "Am I gay" takes on a pathological form. Many people with this type of obsession are in healthy and fulfilling romantic relationships, either with members of the opposite sex, or the same sex (in which case their fear would be "Am I straight?").
 * Violence: which involves a constant fear of violently harming oneself or loved ones or persistent worry that one is a pedophile and might harm a child.
 * Religiosity: manifesting as intrusive thoughts or impulses revolving around blasphemous and sacrilegious themes.
 * Health: including consistent fears of having or contracting a disease (different from hypochondriasis) through seemingly impossible means (for example, touching an object that has just been touched by someone with a disease) or mistrust of a diagnostic test.
 * Relationship obsessions (ROCD): in which someone in a romantic relationship endlessly tried to ascertain the justification for being or remaining in that relationship. It includes obsessive thoughts to the tune of "How do I know this is real love?" "How do I know he/she is the one?" "Am I attracted enough to this person?" or "Am I in love with this person, or is it just love?" "Does he/she really love me?" and/or obsessive preoccupation with the perceived flaws of the intimate partner. The agony of attempting to arrive at certainty leads to an intense and endless cycle of anxiety because it is impossible to arrive at a definite answer.

Diagnosis and treatment
Those suffering from primarily obsessional OCD might appear normal and high-functioning, yet spend a great deal of time ruminating, trying to solve or answer any of the questions that cause them distress.

For example, an intrusive thought "I could just kill Bill with this steak knife" is followed by a catastrophic misinterpretation of the thought, i.e. "How could I have such a thought? Deep down, I must be a psychopath." This might lead a person to continually surf the web, reading numerous articles on defining psychopathy. This reassurance-seeking ritual will, ironically, provide no further clarification and could exacerbate the intensity of the search for the answer. There are numerous corresponding cognitive biases present, including thought-action fusion, over-importance of thoughts, and need for control over thoughts.

Despite how real and imposing the intrusive thoughts may be to an individual, the sufferer will probably never carry out actions related to these thoughts, even if one believes themselves capable of doing so. One of the reasons for this is because the person in question will go to extreme lengths to avoid circumstances which could trigger their intrusive thoughts.

The disorder is particularly easy to miss by many well-trained clinicians, as it closely resembles markers of generalized anxiety disorder and does not include observable, compulsive behaviors. Clinical "success" is reached when the Pure-O sufferer becomes indifferent to the need to answer the question. While many clinicians will mistakenly offer reassurance and try to help their patient achieve a definitive answer (an unfortunate consequence of therapists treating primarily obsessional OCD as generalized anxiety disorder), this method only contributes to the intensity or length of the patient's rumination, as the neuropathways of the OCD brain will predictably come up with creative ways to "trick" the person out of reassurance, negating any temporary relief and perpetuating the cycle of obsessing.

The most effective treatment for primarily obsessional OCD appears to be Cognitive-Behavioral Therapy. More specifically exposure and response prevention (ERP) as well as Cognitive Therapy (CT) which may or may not be combined with the use of medication, such as SSRIs. People suffering from OCD without overt compulsions are considered by some researchers more refractory towards ERP compared to other OCD sufferers and therefore ERP can prove less successful than CT.

Exposure and response prevention (ERP) of Pure-O is theoretically based on the principles of classical conditioning and extinction. The spike often presents itself as a paramount question or disastrous scenario. A response that answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not seek to answer the question but to accept the uncertainty of the unsolved dilemma.

Books

 * The Imp of the Mind: Exploring the Silent Epidemic of Obsessive Bad Thoughts by Lee Baer, Ph.D.
 * The Treatment of Obsessions (Medicine) by Stanley Rachman. Oxford University Press, 2003
 * Brain lock: Free yourself from obsessive-compulsive behavior: A four-step self-treatment method to change your brain chemistry by Jeffrey Schwartz and Beverly Beyette. New York: Regan Books, 1997. ISBN 0-06-098711-1.
 * The OCD Workbook by Bruce Hyman and Cherry Pedrick.