OCD Awareness Week (#OCDweek), which runs from 12-18 October, is all about breaking down the myths that surround obsessive compulsive disorder. Over 200 million people worldwide live with OCD, and the stigma around the disorder can prevent access to timely, effective treatment. Here, one writer recounts her experiences of living with Pure O OCD.
When I was 11, I got an opportunity to become friends with the ‘cool kids’ at school. My best friend at the time wasn’t considered cool, so in order to secure the new friendships, I not only stopped being friends with her, but also actively made fun of her in the playground. This is an objectively horrible thing to do and I don’t want to make excuses, but on a normal day, I can take that memory and see the context around it — that I was a child, that I was desperate to be accepted, that I believed this was the only way to achieve that goal. I can see that I made a mistake and hurt someone, but I can also move on with my life. After all, I’m 30 years old now.
But that’s on a normal day. On a day when I’m struggling, I might experience the intrusive thought that “I’m a terrible person,” and run with it. My stomach drops, I feel a tightness in my chest, and my thoughts start to flood in a dozen at a time, each scarier than the last. On those days, I take that 11-year-old’s story (and other stories from when I messed up in my life) as evidence that I’m irredeemable as a human being, that all my friends and family will abandon me over it, and that I’ll have deserved it. My brain might even come up with ways that I might lose my job because of what I did in the past, or even go to prison.
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On those days, I might spend hours in my head trying to prove that I’m not actually a monster. I’ll go over those memories of making mistakes, trying to find the exact piece of evidence that will prove once and for all that I’m an acceptable person and that I deserve to enjoy a full life. But there is no certainty. For every argument my brain comes up with, there’s a counter-argument. Every time I recall a memory, it gets a little more distorted. I might spend a whole day, two days, a week trying to make sure that I’m safe, and still not be any closer to a definitive answer. This is what it’s like to live with Pure O OCD.
When most people think of OCD, they think of constant hand-washing or of flipping a light switch over and over. While OCD can and does absolutely present in those ways, the condition can look very different from that, too, as it does for me.
“Pure O, short for ‘purely obsessional’ OCD, is a form of OCD where the compulsions are largely internal and mental rather than outwardly visible,” says Dr. Elena Touroni, a consultant psychologist and co-founder of The Chelsea Psychology Clinic. “People experience intrusive, distressing thoughts (obsessions), and instead of engaging in physical rituals, they might carry out covert mental strategies to reduce anxiety or gain certainty.” Common compulsions in Pure O include “mental checking, rumination, seeking reassurance (internally or from others), replaying events, analysing emotions, or avoiding certain people, media, or situations,” says Dr. Touroni.
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The possible “themes” that can cause a Pure O OCD sufferer distress are endless. My example about thinking I’m a bad person over past mistakes might fall under either Moral OCD (also known as Scrupulosity OCD, characterised by over-concern with whether or not one is a good person), or Real Event OCD (where the sufferer becomes obsessed with a past event and believes they have done something unforgivable). Dr. Tracy King, a clinical psychologist who treats OCD in her practice, describes some of the other possible themes under the Pure O umbrella: related to Real Event OCD is False Memory OCD, wherein the brain literally makes up a past event, such as “What if I cheated and don’t remember?”
Then there’s Harm OCD, where intrusive thoughts might sound like “What if I stab someone with this knife?” In Relationship OCD (ROCD), an intrusive thought might be “What if I don’t really love my partner?” In Health OCD, a fear-inducing thought might be “What if I caught something by touching that doorknob?” In Sexual Orientation OCD (SO-OCD), the obsession might sound like “What if I’m gay/straight and in denial?” — in this case the distress around it might be that the person is already in a gay relationship, and their finding out they were straight would mean having to end the relationship.
If you’ve been diagnosed with OCD or recognise yourself in any of the above descriptions, it’s crucial to note that obsessions in OCD are ego-dystonic. This means “the thought or impulse clashes with your sense of self,” says Dr. King. “It feels alien, wrong, distressing. You don’t want it.” That’s why an OCD sufferer will do anything to try to “get rid” of the thought — unfortunately, though, performing compulsions only keeps them trapped in the OCD cycle.
So if engaging in compulsive behaviour doesn’t work to reduce distress, what does? Whether someone is suffering from Pure O OCD or “traditional” OCD, i.e. where the compulsions are more outwardly obvious, the treatment is often the same: Exposure and Response Prevention (ERP) is considered the gold standard. “ERP involves gradually and safely facing the feared thought or situation, while resisting the urge to engage in compulsions,” explains Dr. Touroni. “Over time, this retrains the brain to tolerate uncertainty and reduces the power of the obsession.”
In “traditional” OCD treatment, where compulsions are visible, exposures might look like the patient refraining from washing their hands after being on public transport, or actively cooking with a sharp knife. By contrast, “Pure O often requires imaginal exposure — deliberately thinking or writing about the feared scenario,” says Dr. King. “For example, someone with Harm OCD might write a story in which they hurt someone and sit with that discomfort, without ‘undoing’ it with reassurance or checking.”
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While there’s amazing evidence for ERP being a really effective treatment for OCD, I personally found it quite traumatising and had to swap it for gentler modalities such as Internal Family Systems (IFS), which is also known as parts work. I think it’s important to trust that you know yourself and your needs best, and to seek out a therapist who aligns with your needs.
“I’ve worked with many clients who’ve felt re-traumatised by ERP,” says Dr. King. “If someone has a background of complex trauma, or if their compulsions are wrapped up in survival responses, jumping into ERP too fast can backfire.” In those cases, the therapist would focus first on nervous system regulation, utilising modalities such as IFS and EMDR (Eye Movement Desensitisation and Reprocessing).
“We work gently, building tolerance for uncertainty without pushing someone beyond their window of tolerance,” explains Dr. King. “When OCD is interwoven with trauma — as it so often is — we have to go deeper than symptom management. We need to understand what the compulsions are trying to protect.”
When there’s a history of trauma at play, Dr. Touroni also adapts her therapeutic approach. “This might include building emotional regulation skills first, working on safety and trust in the therapeutic relationship, and integrating methods like compassion-focused therapy or schema therapy alongside ERP, when appropriate,” she says. “For some, it’s also about processing the trauma first, then returning to OCD work later.”
I never went back to ERP, but I am doing better these days: intrusive thoughts are less frequent, and I’m often able to nip a cycle of rumination in the bud. Ongoing therapy has been a great support, as has taking care of my physical health via supplementation, nutrition and exercise. Ultimately, it’s been about finding what works for me. If you’re dealing with OCD, that’s all I can wish for you, too.
If you are struggling with any of the issues raised in this article, you can find resources, advice and support at OCD UK.
