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What is the Purely Obsessional "Pure O" Subtype of OCD?

Dr. Mestechkina shares with the Zencare community ways that Pure O distinguishes from more traditional forms of OCD.

What is Pure O?

Purely Obsessional, or Pure O, is a mental health condition in which individuals experience obsessions, such as intrusive and distressing thoughts, images, or impulses. It is a subtype of Obsessive Compulsive Disorder (OCD).

The term ‘Pure O’ may be misleading, as it implies that those with Pure O only experience obsessions (the “O” of Pure O). People with Pure O do also experience compulsions – that is, behaviors or rituals performed to neutralize the obsessions and associated distress.

It is the nature of these compulsions that distinguishes Pure O from more traditional presentations of OCD – e.g., excessive hand washing, counting, and checking. Instead, the compulsions in Pure O are purely cognitive.

These mental acts may take on several forms, such as:






Attempting to push the thought away

These compulsions are often motivated by the intolerance of uncertainty.

Note: Experiencing intrusive thoughts is very common. In fact, the majority of people without OCD experience very similar types of thoughts as people with OCD. The difference is that for people experiencing OCD, those thoughts come with a false alarm signal. The thoughts may seem very important, imminent, and threatening.

The good news is that there are many research-supported strategies that can help manage these thoughts and feelings more effectively. Learning what these strategies are, and gaining expertise in using them, can allow people to lively freely from their OCD and make choices in line with their goals and values.

How common is Pure O?

OCD affects between 1-3% of the population and is seen equally amongst adult men and women. (However, men tend to develop symptoms at a younger age than women.)

What are some symptoms of Pure O OCD?

The overarching symptom of Pure O OCD is performing mental acts in an attempt to neutralize or undo an intrusive thought, image, or urge, and/or to obtain certainty and eliminate anxiety. These may include:



Answer seeking

Reassurance seeking


Testing behaviors


This can lead to:

Elevated levels of anxiety and guilt

Difficulty concentrating

Difficulty falling asleep

Avoiding commitments or enjoyable activities due to fear of experiencing intrusive thoughts and distressing feelings

What are some different themes of Pure O?

There are many examples of Pure O themes that people experience. These may include thoughts about:

Harming others (questioning whether you would hurt or kill others, often loved ones)

Harming yourself (questioning whether you would hurt or kill yourself)

Pedophilia (questioning whether you are attracted to, or would hurt, children)

Relationship substantiation (questioning whether you are in the “wrong” romantic relationship or uncertainty about whether you are attracted to your partner)

Sexuality (heterosexual people questioning whether they may be gay, and vice versa)

Religious scrupulosity (questioning if you offended or upset your god, did not practice religion the “right way,” whether you sinned or are going to hell, etc.)

Responsibility (questioning whether you unintentionally caused harm to others by doing something or by not doing something to prevent the possibility)  

Somatic (being hyper aware of bodily experiences such as swallowing, chewing, and breathing, and worrying about being focused on it indefinitely)

What should I look for in treatment for Pure O?

When looking for a therapist to treat Pure O, it is important to become an educated consumer and look for a therapist with particular expertise.

The treatment can be very different than the type of work that can help other mental health issues and at times can seem counterintuitive. In fact, there are some therapeutic techniques that may even fuel one’s obsessions and worsen symptoms.  

It is important to work with a mental health professional who practices cognitive behavioral therapy (CBT), particularly a technique known as exposure and response prevention (ERP/ExRP). It can also be helpful to look for someone who practices acceptance and commitment therapy (ACT) and/or mindfulness-based therapy. Look for someone who has expertise in treating Pure O specifically and knows how to apply therapeutic techniques when compulsions are not observable but purely mental.

Find a therapist who specializes in treating Pure O. Get educated. Learn about Pure O and treatment. Discuss with your therapist about whether consulting with a psychiatrist may be appropriate.


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