Pure obsessional OCD (obsessive-compulsive disorder) is when one struggles with obsessive thoughts, but doesn’t act on them. Since this removes many of the complications associated with the disorder, it may be assumed this subtype isn’t so bad. Still, pure obsessional OCD can come with its own complications.

Pure Obsessional OCD Defined

Pure obsessional OCD is a form of obsessive-compulsive disorder where you struggle with intrusive thoughts, but don’t act on them. In other words, you won’t have compulsive behaviors commonly associated with OCD.

Still, obsessive thoughts can be detrimental. Beyond the fact that they get in the way of daily responsibilities, they can leave you feeling ill or violent. ¹

Common OCD Behaviors & How PO-OCD Differs

OCD is a cyclical pattern. It starts with obsessive thoughts that are difficult to ignore. These are followed by ritualistic behaviors to relieve the thoughts. ² These behaviors may look like:

• Checking (i.e. you double-check to make sure doors are locked)
• Counting
• Frequent handwashing
• Organization of things (notably, in a symmetric manner)

In pure obsessional OCD, these behaviors are not observed. However, the thoughts that typically lead to these behaviors are still present.

With that, pure obsessional OCD creates its own behaviors. These are often based on thought patterns. For example, you may perform a mental review, consciousness ritual, or seek reassurance.

Subtypes

Pure obsessional OCD always leads to uncomfortable thoughts. These usually result in the following four subtypes: ³

• Harmful Obsessions – Causing harm to yourself or others (i.e.) sexual violence on romantic partners).

• Pedophilic Obsessions – Sexual thoughts toward children.

• Relationship Obsessions – Doubts about your attraction toward your romantic partner. You may also doubt your own attractiveness or sexual ability.

• Sexual Orientation Obsessions – The fear that you’re unaware of your true sexual orientation.

Symptoms

The responses to these subtypes are not typical of OCD. In other words, they don’t usually result in an outward expression. Most pure obsessional OCD responses are internal and rooted in self-conscious rumination, such as: ⁴

• Mentally replaying events over and over
• Monitoring your verbal and physical behavior
• Silently asking yourself questions about your identity and actions

However, pure obsessional OCD may create subtle signs. These include:

• Asking others for reassurance (i.e. asking a romantic partner if they find you attractive).
• Avoiding people, places, or situations that are related to obsessions (i.e. pedophilic obsessions may avoid parks).
• Use rituals or behaviors to “protect” yourself from obsessive thoughts (i.e. praying).

Causes

The causes for pure obsessional OCD are similar to that of typical OCD. While there is no singular cause for OCD, researchers believe they’re genetic, trauma-based, and related to brain function abnormalities. ⁵

Of those, the most notable are genetics. If a close family member (i.e. parent, sibling) has OCD, you are much more likely to struggle with the condition.

Still, this isn’t to undermine the fact that your environment and trauma play a significant role. For example, if you always seek reassurance from a romantic partner, you’re in a relationship environment. On top of that, this reassurance-seeking may be a result of childhood trauma (i.e. not having a parent around).

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are another common cause of OCD. This condition can lead to major distress where someone develops obsessional thoughts (and, potentially, compulsive behaviors) to cope with it. ⁶

Diagnosis

It’s more difficult for your healthcare provider to come to a pure obsessional OCD diagnosis than that of typical OCD. The simple reason is you are not presenting physical behaviors to indicate OCD symptoms.

Since this is an internal condition, most people are diagnosed when they seek out treatment. Still, loved ones may notice the subtle signs mentioned above. ⁷

To be diagnosed with pure obsessional OCD, you must go through a three-step assessment:

• Psychological Evaluation – Background your history. This may include your health history, current symptoms, and a timeline of how those symptoms developed.

• Diagnostic Criteria Inquiry – Questions and answers to determine whether or not you struggle specifically with pure obsessional OCD.

• Physical Exam – To ensure that there isn’t another condition that has caused pure obsessional symptoms.

Diagnostic Criteria

For typical OCD a diagnostic criteria usually includes: ⁸

• Persistent thoughts, urges, or images that are experienced. Sometimes these experiences are unwanted, intrusive, or disturbing. 
• Attempts are made to ignore or suppress these disturbances.
• Repetitive mental acts to relieve obsessions.
• Obsessions are time-consuming, cause distress, or impair daily functions.

Treatment

To treat pure obsessional OCD, you must receive coaching that interferes with your rumination processes. This process is complicated as it requires internal intervention rather than external.

Cognitive behavioral therapy (CBT) is the most common way to properly process thoughts, emotions, and actions. This talk therapy forces you to come face-to-face with obsessions and develop coping mechanisms to overcome them. ⁹

Exposure and response therapy may also be beneficial. This will identify what triggers your pure obsessional OCD. From there, you will be exposed to these triggers to develop a proper response. ¹⁰

On top of this, some types of medication may help with symptoms. Still, these medications are used for traditional OCD. As a result, they may not be as effective for pure obsessional OCD.

References

¹ Williams MT, Farris SG, Turkheimer E, Pinto A, Ozanick K, Franklin ME, Liebowitz M, Simpson HB, Foa EB. Myth of the pure obsessional type in obsessive–compulsive disorder. Depress Anxiety. 2011 Jun;28(6):495-500. doi: 10.1002/da.20820. Epub 2011 Apr 20. PMID: 21509914; PMCID: PMC3227121.

² Singh A, Anjankar VP, Sapkale B. Obsessive-Compulsive Disorder (OCD): A Comprehensive Review of Diagnosis, Comorbidities, and Treatment Approaches. Cureus. 2023 Nov 17;15(11):e48960. doi: 10.7759/cureus.48960. PMID: 38111433; PMCID: PMC10726089.

³ Torres AR, Shavitt RG, Torresan RC, Ferrão YA, Miguel EC, Fontenelle LF. Clinical features of pure obsessive-compulsive disorder. Compr Psychiatry. 2013 Oct;54(7):1042-52. doi: 10.1016/j.comppsych.2013.04.013. Epub 2013 Jun 6. PMID: 23746710.

⁴ Smith JM, Alloy LB. A roadmap to rumination: a review of the definition, assessment, and conceptualization of this multifaceted construct. Clin Psychol Rev. 2009 Mar;29(2):116-28. doi: 10.1016/j.cpr.2008.10.003. Epub 2008 Nov 5. PMID: 19128864; PMCID: PMC2832862.

⁵ Jalal B, Chamberlain SR, Sahakian BJ. Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction. Brain Behav. 2023 Jun;13(6):e3000. doi: 10.1002/brb3.3000. Epub 2023 May 3. PMID: 37137502; PMCID: PMC10275553.

⁶ Bernstein GA, Victor AM, Pipal AJ, Williams KA. Comparison of clinical characteristics of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and childhood obsessive-compulsive disorder. J Child Adolesc Psychopharmacol. 2010 Aug;20(4):333-40. doi: 10.1089/cap.2010.0034. PMID: 20807071; PMCID: PMC3678581.

⁷ Fenske JN, Schwenk TL. Obsessive compulsive disorder: diagnosis and management. Am Fam Physician. 2009 Aug 1;80(3):239-45. PMID: 19621834.

⁸ Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.13, DSM-IV to DSM-5 Obsessive-Compulsive Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13/

⁹ Gragnani A, Zaccari V, Femia G, Pellegrini V, Tenore K, Fadda S, Luppino OI, Basile B, Cosentino T, Perdighe C, Romano G, Saliani AM, Mancini F. Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder: The Results of a Naturalistic Outcomes Study. J Clin Med. 2022 May 13;11(10):2762. doi: 10.3390/jcm11102762. PMID: 35628888; PMCID: PMC9145175.

¹⁰ Hezel DM, Simpson HB. Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian J Psychiatry. 2019 Jan;61(Suppl 1):S85-S92. doi: 10.4103/psychiatry.IndianJPsychiatry_516_18. PMID: 30745681; PMCID: PMC6343408.