How to recognize the symptoms of Pure OCD, even though people display no visible compulsions

• Pure OCD is a form of OCD where people have obsessions, but no visible compulsions.
• Whereas someone with typical OCD may display compulsions like obsessive cleaning or hoarding junk, people with pure OCD have mental compulsions like silent counting or repeating phrases in their heads. 
• Pure OCD can be treated in similar ways to typical OCD, like with cognitive-behavioral therapy, exposure and response prevention therapy, and medication.
• This article was medically reviewed by David A. Merrill, MD, PhD, psychiatrist and director of the Pacific Neuroscience Institute’s Pacific Brain Health Center at Providence Saint John’s Health Center in Santa Monica, California.
• Visit Insider’s Health Reference library for more advice.

Purely Obsessional OCD (Pure OCD or Pure O) is an often overlooked form of obsessive-compulsive disorder. Here’s what you need to know about the symptoms and treatment options for Pure OCD, and what makes it different from traditional OCD.  

What makes Pure OCD different from traditional OCD? 

People who have OCD typically have obsessive thoughts that result in visible compulsions like obsessive cleaning. But for people with Pure OCD, these compulsions are often hidden. 

Instead, these invisible compulsions often take the form of mental rituals. Some examples include:

• Silent counting
• Mentally replaying events over and over again
• Repeating phrases in your head
• Obsessively examining bodily sensations

“While it is true that they do not have visible behaviors they feel compelled to do in response to their obsessions, most people living with Pure O have mental compulsions,” says Gail Sartz, MD, an associate professor of psychiatry at the New York Presbyterian Hospital, Weill-Cornell Medical College. 

These mental compulsions are the person’s way of dealing with the anxiety these thoughts cause them. “Even though the person feels like not having to do them, they feel they must do them, just like behavioral compulsions,” says Sartz.

Symptoms of Pure OCD

Symptoms of Pure OCD vary from person to person, but some common symptoms include obsessive thoughts that are violent, sexual, or religious in nature. Examples include:

• Intrusive thoughts about intentionally causing self-harm and harm to others
• Persistent fears over causing unintentional harm to themselves or others
• Persistent fears about engaging in repugnant sexual acts like molesting a child 
• Obsessively thinking about somatic issues such as breathing or swallowing
• Thoughts questioning the nature of themselves or reality 
• Intrusive thoughts that they might consider to be sacrilegious or blasphemous 
• Repetitive thoughts that they've said or done something inappropriate

In order to relieve the distress brought on by these obsessive thoughts, people with Pure OCD will engage in compulsive behaviors like the following:

• Repeatedly seeking reassurance that they won't act on obsessive thoughts  
• Avoiding places and situations that may trigger obsessive thoughts 
• Confessing to people, even random strangers, about having unacceptable thoughts 
• Engaging in superstitious behaviors in an effort to prevent bad things from happening 

Diagnosis of Pure OCD

Pure OCD can be difficult to diagnose. This is because the presence of overt compulsions is usually required to improve the diagnostic accuracy of OCDs. 

However, according to the DSM-5, which is the main diagnostic tool for experts, OCD is diagnosed when there is a presence of obsessions, compulsions, or both. This means that the presence of just obsessive thoughts can be evidence enough for a diagnosis of OCD. 

Treatment of Pure OCD

Treatment for Pure OCD can be challenging because unlike most types of OCD, there are no obvious compulsive behaviors to treat. 

"Pure OCD is a little more difficult to treat initially. This is because it is much harder to prevent mental activity than [physical] behavior," Sartz says. "However, a trained professional can determine which mental activity is a compulsion and how you can prevent doing it." 

Therapy, medication, or a combination of both is usually used to treat Pure OCD. Here's how: 

Exposure and Response Prevention Therapy 

Exposure and Response Prevention (ERP) has proven to be very successful in the treatment of Pure OCD. 

"This means that the patient exposes themselves to thoughts that trigger their obsessions, and then prevents themselves from acting on the mental compulsion that follows. This may be difficult at first but over time the obsessive thoughts and mental compulsions will dissipate," says Sartz. ERP takes place under the supervision of a mental health professional. 

Mindfulness-Based Cognitive-Behavioral Therapy (CBT)

This form of therapy teaches people with Pure OCD that intrusive thoughts are normal and everyone experiences them. In particular, mindfulness-based CBT tries to teach people with OCD that intrusive thoughts have no power over them and shouldn't be a source of distress. 

Medication

Your doctor may prescribe medication if therapy alone is not showing results. Medication may include selective serotonin reuptake inhibitors (SSRIs) like fluoxetine and paroxetine or serotonin and norepinephrine reuptake inhibitors (SNRIs) like venlafaxine and duloxetine.

The bottom line 

Pure OCD is an uncommon form of OCD that can be difficult to diagnose and treat. While people with this form of OCD might not engage in observable compulsions, they experience mental compulsion that can be just as disruptive. Knowing what obsessive thoughts and mental compulsive behaviors to look out for is important to help you figure out the best course of treatment for you.