Typically, the diagnosis of obsessive-compulsive disorder conjures images of clients spending endless hours washing their hands, straightening their desk, or repeatedly checking the stove and door locks. There is another manifestation of OCD that occurs when a client is tormented by horrific thoughts. These thoughts replay through their mind with abandon; the more they fight the thoughts the stronger the thoughts fight back. Some clients feel they are possessed, some think they are going insane, and most feel that the dreaded thoughts may suddenly become a reality. This subtype of OCD has historically been called “pure O” or pure obsessional type because the clients do not necessarily engage in outward repetitive behaviors.
The first client I treated for pure-O was a middle-aged firefighter back in Boston. He was dealing with some personal stressors with his family and one day he was in the fire station and upon seeing the fire hose had the automatic thought “what if I wrap the hose around my neck and hang myself?” The thought was repulsive and shocking to him and considerable anxiety ensued. He certainly did not want to die. He had the nagging follow-up thought, “what if I am going crazy and will snap and actually do it.” He tried to force the thought out of his head and it fought back by doubling in intensity. He prayed and prayed, but the thoughts got worse. He found that as he tried to fight these thoughts off, they spread to other areas. “What if I stab myself with this knife?” the thought would attack as he sliced some bread. He began to avoid knives, tools, ropes, and being alone. Any time he was alone, panic would ensue. The thoughts grew and began to include his wife and 2 year-old granddaughter. “What if I smash their heads into the wall?” the thoughts would provoke.
“Pure-O” focuses on that which we find most repugnant. Parents might be plagued by thoughts of stabbing or molesting a young child and may then spend every waking moment in a state of hyper-arousal, monitoring their every thought and action for signs of their thoughts coming true. As it turns out, these truly are not purely obsessions without compulsions. The difference here is that the ritualistic behavior may be less subtle than washing one’s hands. Any internal action one takes to negate these thoughts (trying to force the thought out, distraction, thought-stopping, praying, undoing “bad” thought with a “good” thought, etc.) is a ritual which serves to bring relief. Just as washing hands to ward off germs, the internal rituals briefly (or even intermittently) reduce anxiety, but then maintain or exacerbate the situation over the long-run. Avoiding feared situations, such as being with one’s child in order to save them from this imagined catastrophic harm is also a type of ritual which only exacerbates the disorder.
Thus, the truth about “Pure-O” is that it is not so pure after all.
To learn more about this type of OCD I recommend the following books:
Baer, Lee (2001). The Imp of the Mind. New York. Penguin Putnam, Inc.
Purdon, Christine & Clark, David (2005). Overcoming Obsessive Thoughts. Oakland, CA. New Harbinger Publications, Inc.
Eric Goodman, Ph.D.