How to Treat Purely Obsessional OCD

13 November, 2020
In the following article, we present the most widely accepted psychological treatment for purely obsessional OCD or Pure-O.

Obsessive-compulsive disorder, or OCD, is a diagnostic category for people who exhibit obsessions and compulsions. In less prevalent cases, patients may seek treatment for symptoms based solely on obsessions. This condition goes by many names: primarily obsessional OCD, purely obsessional OCD, or simply Pure-O.

These obsessions are thoughts, recurrent and persistent impulses, or images that the patient experiences at different points. They’re like unwanted intruders which, in most patients, can cause anxiety or discomfort.

People who suffer from obsessions try by all means to ignore or suppress these thoughts, impulses, or images due to the discomfort they cause. They try to neutralize them with other thoughts or actions, thus creating a compulsion.

The problem of compulsion

Compulsions usually cause very short-term relief. The anxiety or tension the person feels due to their obsessions is negatively reinforced by their compulsive behavior.

This compulsion doesn’t allow the problem to go away. It ends up becoming chronic because the patient feels that it’s the only way to get rid of the anxiety and unpleasant thoughts that inhabit their mind.

Compulsions usually aren’t realistically connected to the fact that what the person fears won’t happen. Nor does the person realize that they’re clearly excessive. For example, a person may believe that if they clap their hands three times before leaving the louse, their spouse won’t suffer a traffic accident on their way to work.

However, patients that don’t manifest this kind of symptomatology, meaning those that don’t resort to compulsions to relieve their discomfort, are more complex.

Purely obsessional OCD is more difficult to treat. However, some psychological techniques can allow them to address the problem.

A woman with a cloud.

The key to curing purely obsessional OCD is habituation

The fact that compulsions reinforce obsessions in a negative way when practicing the compulsion leads to the non-habituation to anxiety or fear that they produce.

Therefore, the person continuously feeds these obsessions, and, by feeding them progressively, they get worse. Similarly, in purely obsessional OCD, treatment is based on habituation. In order for this to occur, it’s essential to expose the patient to the obsessions themselves.

Very often, this exposure is an aversive experience for the patients. Exposure with response prevention can lead to significant rejection and even abandonment of treatment. This is one of its disadvantages. However, to date, empirical evidence shows that these are the treatments that report the greatest therapeutic success in most patients who are able to complete them.

To safeguard this disadvantage, it’s essential to adapt to the patient’s capacity to tolerate anxiety. The therapist needs to respect the therapeutic window that will allow them to get used to the obsessions but without them becoming too terrifying. Finding this balance is the key to success.

Looking obsessions in the eye

The goal is for the patients to expose themselves to their thoughts or the images in their heads. They should do this in such a way that they voluntarily draw them out and “look them in the eye”. Habituation training arises from research by Salkowskis and Westbrock.

Therapists usually do this by asking the patient to record these obsessions and listen to them repeatedly until they get used to them. The predictability of the stimuli that the subject is exposed to is the key factor in this treatment.

By means of the recording, the patient can predict what they’re going to hear. This is unlike what normally happens with pure obsessions, which aren’t unpredictable.

In addition to the audio recording, other strategies can be used to present these thoughts to the patient in a predictable way. The patient can invoke them by repeating them during the session. Alternatively, they can write them down and re-read them until their anxiety goes away.

It’s necessary to clearly explain to the patient how anxiety works. You also need to explain that habituation follows a curve in which the anxiety first increases, but then, at a certain point, begins to decline. Psychoeducation facilitates adherence to treatment and promotes the therapeutic relationship.

A stressed woman.

The anxiety curve

The characteristic anxiety curve is like an inverted “U”. As we already stated, when people expose themselves to their fears (either through images, directly, or, in the case of Pure-O, by recording or writing), they’ll experience a substantial increase in anxiety.

This moment is key because the patient will think that they’re getting worse. They’re not wrong, because they’ll feel much more anxious. However, that rise in anxiety is finite. Physiologically, and inevitably, that rise has a limit.

When the discomfort reaches its peak, and if the patient doesn’t carry out any ritual, any type of obsessive behavior, or any other actions linked to avoidance, then the anxiety will start to decrease progressively.

Why does this happen? Firstly, on an emotional level, neither anxiety nor any other negative emotion, ever increases in a linear fashion. This isn’t the way it generally behaves. There has never been a case in which the emotion rises and rises until it kills someone. Far from it.

Moderating obsessions

On the other hand, the simple fact of a person becoming aware that their thoughts are biased or unrealistic allows them to change them into much more moderate ones. At this point, the anxiety will begin to lose attachments that helped it to grow.

In short, the fundamental thing here is for the patients who are going to expose themselves to their obsessions or to any other stimulus that causes anxiety know that perseverance and consistency are the keys to success.

Strangely enough, short exposure to the obsessions can produce an iatrogenic effect by which the patient doesn’t only fail to overcome their fear but actually increases it.

Tolerating this anxiety, in spite of the discomfort it can cause, is a crucial route to victory over the mental pain caused by these obsessions.

  • American Psychiatric Association (APA) (2014): Manual de Diagnóstico y Estadísitico de los Trastornos Mentales, DSM5. Editorial Médica Panamericana. Madrid.
  • Vallejo, P, M.A., Manual de Terapia de Conducta (2016). Editorial Dykinson-Psicología. Tomo I