If
you are continuously struggling with intrusive,
persistent and highly distressing thoughts, doubts, memories or mental images,
you may be suffering with Primarily Obsessional OCD. This is also commonly known as Pure “O” OCD.
We
provide specialist treatment for Pure “O” OCD, using evidence based cognitive
and behavioural strategies from the fields of CBT, ACT, IBT and an adapted form
of Exposure and Response Prevention (ERP).
Whilst
the published research shows that there are many similarities between Pure “O” and
other OCD subtypes, the CBT and ERP process is adapted to target the internal mental processes that maintain the problem. This requires the support of an experienced and professionally qualified OCD expert.
We
find that many of our OCD clients come to us having struggled with highly
distressing thoughts over many years, or where other types of counselling or
psychotherapy have been found to be ineffective in the treatment of Pure “O”
OCD.
To
book an initial intro call with a Pure “O” specialist, you can email
The
term Pure “O” OCD was first used by Dr Steven Phillipson from the Centre for
Stress and Anxiety Management in 1991.
Based
on many years of first hand experience working with OCD patients, Phillipson
described an internal or mentalised form of OCD, involving persistent and
distressing intrusive thoughts, which he called “Spiking”, followed by attempts
to control the intrusions through the mental process of rumination.
Whilst
it was initially believed that this form of OCD did not involve observable compulsions,
Phillipson identified internal attempts to stop, check, avoid, neutralise or
control intrusive thoughts and doubts through internal mental compulsions.
Pure “O” is
therefore understood as an internal or covert form of OCD, in which the
compulsions are internal mental acts to prevent or avoid the distressing intrusions
and related obsessional worries. The term Pure “O” should therefore be seen as a shorthand label for
describing an internalise form of OCD, where the spike, the obsession and the
compulsion are primarily internal mental
processes.
Unlike other forms of OCD however, the compulsions are primarily internal mental acts or routines and difficult to externally observe. The line between obsessions and mental compulsions is therefore frequently blurred and difficult to distinguish.
The
trigger or intrusion phase involves a preoccupation with unwanted, persistent
and highly distressing thoughts, memories or images. These Pure “O” spikes
activate the primary OCD doubt.
Primary
doubts can be internally generated irrational thoughts about safety, security,
symmetry, danger, threat, responsibility or losing control.
If
left unchecked, primary doubts cross over from normal every-day doubts, into
internally generated and imagined doubts that are highly irrational, defy direct
experience and undermine the individual’s own integrity and common sense. This
leads to the second phase of obsessional worry.
The
second phase in the Pure “O” loop involves obsessional worry, over-analysis, fixation,
rumination, cognitive distortion, Perfectionistic thinking and high levels of emotional distress.
The
individual becomes entangled and embroiled in a relentless struggle with their
own thoughts, losing the distinction between observable, testable and rational threats versus internally imagined or
hypothetical possibilities.
Obsessions
paradoxically revolve around issues that are highly important or sensitive to
the individual. This can include obsessional worry about:
Obsessional
worry leads to a desperate and urgent need to disprove or eliminate all
feelings of uncertainty or discord, by
compulsively testing, checking, stopping, neutralising, controlling or avoiding the obsessional thoughts.
The
Pure “O” Compulsion involves internal
compulsions to mentally avoid, stop, control, resist,
deflect, neutralise or outthink the distressing intrusions. Typical mental
compulsions include:
These
desperate attempts to disprove, escape or control the distressing intrusions, paradoxically
lead to increased levels of hypervigilance, doubt, preoccupation and rumination.
This
creates and maintains a Pure “O” vicious cycle, in which the individual’s attempts
to avoid or stop the unwanted thoughts, fuels increased levels of
preoccupation, doubt and mental resistance.
Over
time, this vicious cycle becomes automatic and reflexive. The trigger becomes synonymous with
the primary doubt, creating automatic mental associations and increasing the
individual’s sensitivity and hypervigilance to the problem.
In Pure “O” OCD, magic numbers
or words therefore become associated with the probability of something bad happening, testing
memory or replaying past events becomes
associated with doubting memory, mantras, compulsive praying or mental repetitions,
become associated with illness, bad luck or danger.
As
Pure “O” OCD is primarily an internal mentalised process, it’s often difficult to
separate the intrusions, irrational doubts and
obsessions from the mental compulsions .
Terms
such as intrusion, doubt, worry and rumination are used on an interchangeable
basis to describe internal mental processes, without accurately distinguishing between
the Pure “O” doubts, obsessions and mental compulsions.
This
distinction is however important to effective and targeted psychological therapy.
Understanding where the intrusive doubts and obsessions finish and where the
mental compulsions begin, is relevant to the effective application of CBT, ACT,
IBT and ERP.
To
understand the difference between the Pure “O” intrusive doubts, obsessions and
mental compulsions, we must first identify the intention or function behind the
behaviour at each stage of the Pure “O” cycle.
The Psychology of Intrusions and Doubts
In Pure “O” OCD, individuals are triggered by situations or intrusive
thoughts that are repugnant and distressing.
This is maintained by selective focus of attention, problems with
confirmation bias and conditioned association between the mental compulsion and
the intrusive thought or doubt.
Rather than being rationally dismissed or filtered as random unwanted
thoughts, Pure “O” intrusions activate underlying personal doubts about safety,
security, responsibility, integrity and self-control.
Therapy should therefore address focus of attention errors, problems
with conditioned associations and confirmation bias.
The Psychology of Pure “O” Obsessions
All
human obsessions are fundamentally rooted in an evolutionary need to maintain
hypervigilance and flag potential threat, disorder, vulnerability or loss.
This
is part of a hard-wired protective /
learning mechanism for scanning our environment, ensuring survival, readiness and
competitive advantage.
In
all forms of OCD, obsessional thinking crosses the line between the rational
appraisal of probable external hazards, into the irrational misappraisal and escalation of internally imagined or hypothetical
risks.
Obsessions
involve problems with faulty and distorted thinking processes, misappraisal and
misattributions and disproportionate and catastrophic evaluations.
Rather
than acting as a protective and adaptive learning mechanism, OCD obsessions are
Egodystonic, distort reality and lead to excessive psychological distress.
From
a Pure “O” treatment perspective, it’s therefore important to focus on altering
and de-escalating the faulty thinking processes that maintain obsessions and lead
to distress. This includes addressing obsessional factors including responsibility
bias, thought action fusion, perfectionistic and catastrophic thinking.
This
is covered in the section on the therapy process.
The Psychology of Pure “O” Mental Compulsions
Pure
“O” OCD compulsions are a maladaptive response to perceived threat, loss or the
exploitation of potential advantage.
Whereas
Pure “O” obsessions are about searching for potential threats, mental
compulsions are about preventing, avoiding, controlling or neutralising the obsessional distress.
In
spite of their egosyntonic intentions, Pure “O” OCD compulsions take up
significant time and energy, prevent the disconfirmation of the feared
situation, feed vulnerable and low coping beliefs, create conditioned associations with irrational
doubts and lead to significant functional impairment.
From
a Pure “O” treatment perspective, it’s therefore important to identify and
understand the internal mental actions taken to avoid or alleviate perceived
threat and distress. Here, the objective is to
expose, suspend, eliminate, learn,
challenge, alter or use alternative and adaptive behavioural strategies, to the
Pure “O” compulsion.
Whilst
it’s important to identify the Pure “O” obsession and mental compulsion using a
process known as functional analysis and formulation, it is also important to
recognise that individuals suffering with Pure “O” often think and respond in a
seamless chain. This means that worry or rumination can be part obsession and
part compulsion, depending on the context and function of the behaviour.
From
a therapy viewpoint, your therapist should have the qualifications, skills and
clinical experience to understand and guide you through this process in a
practical and relatable manner.
Working
with a properly qualified, skilled, experienced and accredited therapist will
help you to develop an understanding of each stage of the Pure “O” process, identify
the cognitive processes and behaviours that maintain the problem and most
importantly, learn new techniques for tackling the Pure “O” doubt, the
obsessional thinking and mental compulsions.
The psychological assessment and treatment process for Pure "O" OCD typically involves 8-12 therapy sessions, when delivered by a qualified and experienced OCD specialist. This will always depend on the level of complexity and any other psychological or developmental factors identified during the initial assessment.
At Good CBT we draw upon the current evidence base to combine mainstream Cognitive Behavioural Therapy, including Exposure and Response Prevention (ERP), with a specialist form of CBT known as Inference Based Therapy (IBT). Strategies from Metacognitive Therapy and Acceptance and Commitment Therapy (ACT), are also integrated where relevant. The treatment plan normally includes:
The therapy process may also be supported by behavioural activation, behavioural experiments and mindfulness based exercises to improve mood, alter maladaptive beliefs and improve focus of attention skills. We also work closely with our Consultant Psychiatrist and we can organise medication assessments and reviews where appropriate.
following the initial assessment you will receive a written report, detailing the psychological factors that trigger and maintain the problem and an outline of the therapy plan. Appointments are normally held on a weekly basis and include a full 60 minute session, with a structured agenda, discussion, techniques and agreed practice activities. To find out more about the therapy process and to book an initial informal call, email
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