Awhile ago I wrote about pure O OCD. This is one form of OCD that fascinates me a little more than the others simply because it seems a little odd. Pure O- OCD? So just obsessions? Then how is it still classified as OCD? Wouldn’t it just be “OD”? 

In my understanding (which, granted, is pretty limited to hearing some stories from people in group sessions), those with Pure O have intense obsessions but don’t necessarily feel the need to follow through with physical compulsions. I think this clarification is important to discuss. For one, can a recurring obsession eventually be qualified as a compulsion? Maybe you check things on the Internet to see if your thoughts and obsessions have validity. Or maybe something happens and you think of that one thing over and over and over again. Is that a compulsion now rather than obsession? Can a compulsion be mental?

Mental compulsions

I think compulsions can definitely be mental. Those of us with OCD are extremely skilled at hiding our compulsions, so having mental compulsions is the ultimate cover up– engaging in compulsions without even outwardly doing anything!

Personally, when my contamination obsessions were more intense, I would think through scenarios and try to convince myself for or against various possibilities. Like, does a wash machine cycle really kill germs or viruses? Would I need to bleach? Use high temperatures? Both? What are the statistics on how much bacteria is left on underwear after washing and drying? Thoughts like these would cycle through my mind over and over again. Sometimes I would try to answer these questions in my mind on my own, other times I would do Internet searches (just a side note, you can usually find anything you are looking for on an Internet search, as well as another site claiming the exact opposite). So, before engaging in physical compulsions (like washing with hot water or with bleach), I would have these mental compulsions resulting from the obsession of “having to clean XY or Z completely.”

Fighting them

I think it can be hard for us to accept and acknowledge mental compulsions. Why? Well, for one, we usually don’t want to do so. Mental compulsions can be so much harder to fight. They are much sneakier than the outward, physical compulsions. They live inside our own brain and can initially seem like normal thoughts. How do we fight our own minds and our own thoughts?

Well, one way we can fight them is by not seeking reassurance. Sometimes that means we don’t ask someone we trust to tell us what we want to hear: “Does this chicken look cooked enough?” “How long does the flu virus live?” “Is it possible to get such and such diseases in this way?” Other times that means that we don’t seek reassurance from the Internet or other sources. Don’t do those searches. Just be uncomfortable. Resist the compulsion and be willing to live in uncertainty.

Overall, be aware of any mental compulsions that pop up. Instead of over analyzing and trying to decide why they are there, focus on fighting them by doing the opposite of what the OCD wants you to do. It can be hard to stop thinking about something, so instead, confront it. Dr. Reid Wilson’s book “Stopping the Noise in Your Head” has some great tips on how to do this and why it’s important. I definitely recommend checking out that book if you think you have mental compulsions or pure O-OCD.

How do you handle mental compulsions? Do you think they exist?

Category : CBT

12 thoughts on “Mental Compulsions”

  1. More on Mental Rituals By Seth J. Gillihan et al

    In their investigation on the pure obsessional type of OCD, Williams et al. (2011) point out that the unobservable nature of mental compulsions may cause clinicians to miss them or mistake them for obsessions. Whereas the form of obsessions and compulsions may be the same, the function is very different.

    For example, obsessions and mental compulsions both may involve numbers; the number ‘‘6’’ may increase anxiety (obsession) due to its association with the devil whereas ‘‘3’’ may be repeated mentally to neutralize the feared outcomes associated with the thought of ‘‘6’’ (ritual).

    For this reason, it is crucial to distinguish between obsessions (intrusive worries that increase anxiety) and mental compulsions (mental acts that are intended to
    decrease anxiety).

    Common mental compulsions include:

    Self-reassurance

    Special prayers, often repeated in a set manner

    Wishing or ‘‘should’’ statements (e.g., wishing something to be different)

    Mental repeating of special words, images or numbers

    Mental counting

    Mental list making

    Mental reviewing (reviewing thoughts, feelings, conversations, or actions)

    Mental erasing of unpleasant mental images

    Mental undoing
    Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes. For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress.

  2. OCD & Checking: Part 2 (Mental Checking)
    by Steven J. Seay, Ph.D.
    Mental checking can involve mentally analyzing whether or not a behavior was completed properly.
    Behavioral Checking (Overt Checking)
    Many examples of compulsive checking rituals in OCD involve direct inspection of a target stimulus by sight, sound, or feel.
    Common OCD checking behaviors include relocking doors, visually examining the position of one’s parking brake, or holding one’s hands above stove burners in order to detect warmth.
    Behavioral checking is often accompanied by the thought, “Did I do it the right way?”
    These checking behaviors are often referred to as behavioral checks, manual checks, or overt checks. Overt rituals (by definition) are visible behaviors that can be perceived by external observers. However, in some cases, overt rituals may be subtle or purposefully hidden in order to avoid embarrassment.
    Mental Checking (Covert Checking)
    In contrast, other compulsive checking rituals can only be perceived by the individual engaging in the behavior. These types of OCD rituals are thought-based and are sometimes referred to as mental checking or covert checking rituals.
    Mental checks are often accompanied by thoughts such as, “Did I do it the right way?”, “Am I feeling the right way?”, or “Did I do this for the right reason?”
    Mental checking is the cognitive counterpart of behavioral checking, and many covert checking rituals overlap extensively with the mental rituals that characterize Pure-O OCD.
    Whereas overt checking involves obtaining evidence directly from the current physical environment (i.e., obtaining visual, auditory, or tactile feedback from physical objects or behaviors), mental checking typically involves an evaluation (or reevaluation) of information already obtained. This information may exist in the form of memories, feelings, motivations, or other internal states of being.
    Mental checks can occur both in the presence and absence of a given target stimulus. Individuals may engage in mental checking rituals shortly after an event, but covert checking is not bound by time or space. Some people with OCD continue to check hours, days, or even years after the original event. For example, some individuals may review or check the content of conversations that occurred many years ago.
    Let’s identify some examples of mental checking. This list is not exhaustive but is intended to illustrate the diversity of situations in which mental checking might be present.
    Examples of Mental Checking
    1. Memory Checking Rituals – Reviewing one’s memory to “make sure” or verify that a behavior was completed properly.
    Did I lock the door? Was the stove really off? Was the “H” on the faucet handle facing the way it normally does when it’s off? I know the answer was “B”, but did I circle “A”? Was that sound similar to the sound of a stick hitting the underside of my car, or did it sound “wet”?
    This mental ritual involves retrieving memories or trying to recreate mental pictures of past events. These images are then mentally examined, checked, or scrutinized to determine if a specific criterion has been met. For example, one might try to remember the exact angle of a stovetop dial in order to obtain reassurance that the gas valve has been closed. Memories in any sensory modality can be mentally retrieved and checked – sights, sounds, or physical sensations. Because there is often OCD doubt about whether these mental images do, in fact, represent what one has actually seen, mental checks often fuel additional behavioral checks.
    Other memory checking rituals involve categorization and probability estimation, which are more complicated processes than when one evaluates a simple dichotomy. With these more complex rituals, multiple possible outcomes are considered, each of which differs with regard to its undesirability. These checks occur in nearly all forms of OCD, including contamination OCD and hit-and-run OCD.
    2. Feeling Checking Rituals – Comparing current feelings to how they “should” feel.
    Do I feel as secure in my relationship with God as I should? Did my prayer feel genuine?
    This mental checking ritual is based around comparing one’s current emotions to an idealized version of how they should be. This desired feeling state may be based on history (i.e., previous feeling states) or on aspirational feeling states. These symptoms often characterize scrupulosity, ROCD, and HOCD. For example, scrupulosity often involves a discrepancy between how “close” or “connected” one should feel in their relationship with God vs. how they actually feel at a given moment. There may also be perceived discrepancies related to feelings of “genuineness” about one’s prayers.
    3. Relationship Checking Rituals – Comparing current relationships to how they “should” be.
    Am I still in love with my partner? Does the fact that I found that other person attractive or had that dream mean that I should end my current relationship? Do doubts about my current relationship mean that there’s somebody better out there for me?
    These checking rituals are often based around the premise that if one is in the “right relationship,” one shouldn’t experience any doubts about their relationship or their partner. Individuals with these types of OCD checking rituals compare current relationships to past relationships or to potential idealized future relationships. They often experience significant doubt and distress about their personal relationships and may have a history of relationship “ping pong.” They may worry about “missing out,” hurting their partner’s feelings, or not “being on the right path.”
    These types of symptoms often characterize ROCD. In addition to the symptoms described above, ROCD may also involve making faulty inferences about one’s future behavior on the basis of their current doubts (see Intention Checking rituals below). For example, one might infer that having doubts about one’s current relationship might mean that they secretly want to cheat (or will cheat) on their partner (despite having no desire to do so). Parallel symptoms can also characterize scrupulosity, in which individuals may worry that they secretly want to reject God and/or worship the devil.
    4. Intention Checking Rituals – Examining one’s own motivation for engaging in particular behaviors.
    Am I changing my child’s diaper because I thought it was really soiled or because I wanted to look at my child’s private parts (postpartum OCD)? Does the fact that I noticed that person’s attractiveness mean that I want to have a relationship with them? Does the fact that I’m clenching my fists in anger mean that I want to punch or harm that person? Does the fact that I’m having suicidal thoughts mean that I want to kill myself (suicide obsessions)? What kind of person would be having these kinds of thoughts?
    These checking rituals cause one to question their own motivations for engaging in certain behaviors which commonly results in extreme guilt, shame, or confusion. These types of checking rituals are often present in OCD characterized by harm, sexual, or suicide obsessions, as well as in cases of HOCD, ROCD, and scrupulosity.
    Individuals with these types of rituals often assume that their thoughts have significant meaning. They might think that all thoughts are purposeful or may reflect one’s “true” character or desires. This is problematic in that these types of rituals often involve morally taboo topics or unwanted thoughts.
    These rituals are sometimes called “figuring out” rituals, as they involve trying to understand the “real” reason for doing something. They also are frequently accompanied by reassurance seeking rituals. Reassurance seeking rituals may involve other people (“Do you think I could ever do that?”) or may consist of personal attempts to convince oneself that one’s behavior is motivated by sound reasons.
    5. Sensation Checking Rituals – Attempting to understand the meaning of physical sensations in one’s body.
    Does that tingling sensation in my groin mean that I want to have a sexual
    relationship with that person? Does that fluttering in my chest mean that I’m about to lose control and scream something inappropriate?
    This type of mental ritual involves trying to figure out the meaning of specific bodily sensations. Individuals with these types of compulsions often become hyper-attuned to small changes in their own physiology. Sensations associated with this type of ritual are often sexual, violent, or frightening in nature.
    6. People Checking Rituals – Mentally reviewing the meaning of other people’s behaviors, words, or facial expressions.
    Did his expression indicate that I insulted him? Did she invite me to lunch because she really wanted to see me, or because she thinks I’m pathetic? If I hadn’t locked the door, wouldn’t my spouse have said something? If I had left the gas stove on, wouldn’t my kids have commented on the smell?
    These rituals involve reviewing other people’s actions, words, or facial expressions in order to better understand their reactions or intentions. These rituals can also involve establishing the safety of current situations by reducing doubt and uncertainty through reassurance or diffusion of responsibility. For example, “If that person wasn’t concerned, then I shouldn’t be concerned either” or “If this situation is really dangerous, then that person would have taken proper precautions.”
    7. Understanding/Information Checking Rituals – Mentally replaying conversations or reviewing written materials to check their content.
    Did I really understand their advice? Did I express myself properly? Did I leave any important information out that could cause something bad to happen? Did I understand what I just read?
    These rituals involve a fear of misunderstanding and/or miscommunicating information. Individuals with these types of rituals may fear that they have misunderstood something that was said to them, or they may be afraid of mispeaking or leaving out essential details when talking to others. This fear is based around the idea that something important might be missed, or that there is a moral imperative to avoid misleading other people.
    Common forms of OCD that are based around this ritual include OCD perfectionism (rereading, rewriting rituals), and moral OCD based around the fear of unintentionally lying to others. Many individuals with these types of compulsions do not recognize that they have OCD.
    As you can see, covert checking is incredibly diverse and can be easily overlooked. Whether behavioral or mental, checking rituals provide short-lived reassurance that ultimately backfires and reinforces OCD. The most effective treatment for OCD is exposure and response prevention (ERP).

  3. Mental Rituals in Obsessive-Compulsive Disorder
    By Seth Gillihan
    As I mentioned in a previous post, there are common therapist mistakes in exposure and response prevention (ERP), the best psychotherapy for OCD. One of these mistakes is not knowing how to help individuals whose compulsions (or “rituals”) are primarily mental.
    Mental compulsions involve doing something in one’s head in response to an obsession in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes.
    For example, a person with religious obsessions may fear that her children will become sick if she thinks blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind, she will repeat to herself a memorized prayer about the greatness of God along with requests for her children’s protection.
    Other common types of mental compulsions include:
    • Reassuring oneself that “everything is OK”
    • Wishing or ‘‘should’’ statements (e.g., wishing something to be different)
    • Silently repeating special words, images or numbers
    • Counting and re-counting
    • Making mental lists
    • Reviewing thoughts, feelings, conversations, or actions
    • Erasing unpleasant mental images
    • “Un-doing” something in one’s mind
    Some individuals with OCD describe themselves as “pure obsessional” or “Pure O,” meaning they have obsessions without compulsions. However, what appears to be “Pure O” typically turns out to involve mental compulsions, which functionally are the same as compulsions that are visible to others (such as repetitive hand washing). Both types of compulsions are meant to reduce the chance of something bad happening, and to reduce the person’s distress.
    In every instance of “Pure O” that I’ve encountered, mental compulsions have been present, which is in line with research findings.
    In a study of over 1000 OCD sufferers, every single person was found to have both obsessions and compulsions–including the one percent of individuals who initially thought they had only obsessions. A related study reported that individuals who supposedly have “Pure O” engage in mental compulsions and reassurance seeking.
    Does it matter that “Pure O” actually includes rituals, or is it an academic distinction without a difference? In practice it probably matters a great deal.
    One of the crucial components of exposure and response prevention, obviously, is preventing the compulsions.
    If the OCD sufferer (or therapist) doesn’t recognize mental compulsions and reassurance seeking as compulsions, then treatment will not effectively target these behaviors.
    As a result the person is likely to stay stuck with the OCD. When the compulsions are recognized for what they are, they can be treated just like any other ritual in ERP.
    The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress.
    Some clinicians may fail to recognize covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another in a jumbled mess, some causing distress and some intended to relieve that distress, the compulsions can be hard to identify.
    The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is:
    • Obsessions increase anxiety.
    • Mental compulsions are intended to decrease anxiety.
    Once a person knows what his or her mental rituals are, they have to be eliminated.
    During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures. These kinds of private rituals undermine the exposures and can prevent the person from getting better.
    As discussed on a post on Janet Singer’s OCD Talk blog, ERP for mental rituals requires doing the opposite of the rituals and allowing oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts.
    Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals. For example:
    1. Reading things out loud that provoke obsessions so the mind is not free to perform mental compulsions
    2. Using exposure statements, such as saying “I’m friends with the devil,” instead of engaging in a ritualized prayer
    3. “Spoiling” the ritual by saying an exposure statement if the person realizes he or she performed a mental ritual

    One response that’s typically not helpful is to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession.
    These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause.
    A more effective long-term solution is to answer obsessions with exposure statements that acknowledge uncertainty: “I can’t know for sure that I locked the door”; “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as examples, these principles apply to any obsessional content.
    The bottom line is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals.
    Armed with knowledge about how to recognize mental compulsions, determination to conquer them—and often with the help of a skilled therapist—individuals with mental compulsions can live more enjoyable and fulfilling lives.

  4. Mental Rituals: Not All Compulsive Behaviors are Physical
    By Jacqueline Marshall, June 20, 2014
    Not all compulsive OCD behavior is physical. Compulsive, ritualistic behavior to relieve anxiety can also be mental.
    An obsession is a repetitive, disturbing thought, image, or attitude that causes distressing anxiety. Compulsions, or compulsive behaviors are rituals performed repeatedly to temporarily relieve obsession anxiety. Compulsions can be physical behaviors such as hand-washing, or mental actions such as counting.
    Examples of Mental OCD Rituals
    The word “mental” (as in mental ritual) refers to any internal data such as thoughts, physical sensations, feelings, impulses, urges, or images.
    Mental Review. Also called replaying, retracing, rewinding, or ruminating, reviewing involves mentally going over and over a past event or interaction. The reviewer hopes to resolve the situation, relieving uncomfortable feelings and thoughts.
    Theorizing. To theorize, a person first replays something that happened and then adds a hypothetical element to it—something that could have taken place, but did not. The purpose is to determine if the feared situation can be handled without compromising one’s values or morals. This is also called scenario twisting and hypothesizing.
    Neutralization. Thought neutralization is silently saying words or entertaining thoughts that are the opposite of intrusive unwanted thoughts. The “good” thoughts are believed to render the “bad” thoughts harmless.
    Reverse Rumination. In reverse rumination, an individual imagines a future event to examine it for the possibility of catastrophe. It involves thinking over (and over) a future interaction or performance in the hopes of alleviating distress over what might happen.
    Self-Reassurance. By mentally repeating reassuring statements to themselves, people with OCD create a sense of certainty that the negative consequences of a thought will not happen. It is a compulsive use of positive affirmation to dispel anxiety.
    Self-Punishment. If someone believes they have committed an unforgivable error and should not be allowed to get away with it, they might compulsively dwell on negative self-talk and guilt feelings to punish themselves. The discomfort of escaping justice is avoided by doing this.
    Compulsively Praying. Prayer can be used to block the intrusion of unacceptable thoughts. Instead of praying to spiritually connect with a deity, the person with OCD is avoiding or neutralizing distressing images or ideas.
    Treatment
    These, and other types of mental rituals, are usually treated using cognitive-behavior therapy (CBT), which helps people examine and change how they think about things. Additionally, the practice of mindfulness allows people with OCD to identify and observe mental urges as they arise, look at them without judgement, and process what is occurring.
    Although some people with OCD are diagnosed as purely obsessive, or “Pure O,” some professionals now believe that either mental or behavioral compulsions (or both) are always part of the OCD disorder.

  5. Mental Rituals, OCD, and ERP
    Adapted from ocdtalk, Janet Singer
    Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes. For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.
    The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress.
    Some clinicians may fail to identify covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another, some causing distress and some intended to relieve that distress, it can feel like a jumbled mess and the compulsions can be hard to identify. For this reason OCD with mostly or only mental rituals is often mistakenly labeled “Pure Obsessional” (or “Pure-O”) OCD.
    The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is: Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.
    Common mental compulsions include:

    Self-reassurance

    Special prayers, often repeated in a set manner

    Wishing or ‘‘should’’ statements (e.g., wishing something to be different)

    Mental repeating of special words, images or numbers

    Mental counting

    Mental list making

    Mental reviewing (reviewing thoughts, feelings, conversations, or actions)

    Mental erasing of unpleasant mental images

    Mental un-doing
    Once a person knows what his or her mental rituals are, it is crucial that the person eliminate them in order to recover from OCD.
    During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures. These kinds of private rituals undermine the exposures and can prevent the person from getting better.
    As discussed on an earlier post, ERP for mental rituals requires one to do the opposite of the rituals and allow oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts. Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals. One solution is for the person with OCD to read out loud material that provokes obsessions (either in vivo or imaginal exposure—…) so that the mind is not free to perform mental compulsions. It can also be helpful to say exposure statements to prevent mental compulsions, such as saying “I’m friends with the devil” instead of engaging in a ritualized prayer. Exposure statements should also be used if the person realizes he or she performed a mental ritual—what is often called “spoiling” the ritual.
    A final point that we highlight in the article is that it’s usually counterproductive to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession.
    These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause. A more effective long-term solution is to answer obsessions with exposure statements that recognize uncertainty: “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as an example, these principles apply to any obsessional content.
    The bottom line of this discussion is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals. Armed with knowledge about how to recognize mental compulsions, determination to conquer them, and often with the help of a skilled therapist, individuals with mental compulsions can live more enjoyable and fulfilling lives.

  6. Mental Rituals
    From anxietysecrets.com
    Compulsions do not have to be behavioral (the way they are portrayed in the movies). They can also be mental. A person may engage in a mental ritual to try counteracting the obsession. For example, a person may have an intrusive image of doing something taboo like harming a child. In order to counteract this obsessive thought, the person may engage in a mental ritual of repeating a prayer or religious image to try and replace the thought.
    There is a mistaken belief that a person with Pure Obessional OCD suffers with obsessions but not with compulsions. This is simply not the case. A person with pure obsessions engages in many rituals, but the rituals are mental – not behavioral. A mental ritual is performed solely in the mind. A person might try counteracting “negative thoughts” with “positive thoughts.” A person might use the mind to review things, check one’s sanity, count things, make lists of things, suppress thoughts, compulsively reassure oneself, compulsively pray or repeat words, etc.
    Mental Rituals may consist of:
    • Replacing negative thoughts with more positive ones.
    • Overanalyzing behavior, thoughts, or other events in order to reduce the intrusive thought.
    • Counting or repeating “good” numbers.
    • Repeating phrases, words, prayers, confessions, mantras, or images in order to counteract the unpleasant thought or image.
    • Trying to control a thought through thought suppression or other thoughts.
    • Repeatedly checking the mind to gain some sort of evidence.
    • Repeatedly checking one’s body to gain some sort of evidence.
    • Repeatedly reassuring oneself in a way that replicates how someone else would reassure.
    • Superstitious rituals that are performed solely in the mind.
    Some frustrating thoughts that fuel the fire of OCD:
    • If I act on these thoughts, I can prevent something bad from happening.
    • Why is this happening to me?
    • I have no future. I will be like this forever.
    • I don’t want to do that, but what if I lose control and do it?
    • What if I secretly want to do that?
    • What if I lose all control over my actions?
    • I need to know everything will be okay

  7. Pure-O OCD (Pure Obsessional OCD): Hidden Rituals
    by Steven J. Seay, Ph.D.
    “Pure-O” OCD, or Pure Obsessional OCD, is a relatively less common form of OCD that seemingly differs from classic presentations of the illness. What distinguishes Pure Obsessional OCD from classic OCD is that in Pure-O OCD, symptoms are predominantly obsessive (rather than compulsive) in nature. Although individuals with Pure-O OCD frequently experience intense and distressing obsessions, they typically report few (if any) overt compulsive behaviors. However, in almost all cases, pure obsessionals do engage in a variety of rituals. These rituals just manifest as mental compulsions rather than behavioral compulsions.
    Unfortunately, most psychologists haven’t been trained in how to ask the types of questions that are necessary to identify these “hidden rituals.” As a consequence, these rituals often go undetected. Because effective treatment requires consistent response prevention, a failure to recognize and resist mental compulsions makes true exposure and response prevention (ERP) impossible. Treatment then proceeds in an ineffective and haphazard way, with neither the patient nor the therapist any the wiser.
    Not surprisingly, treatment for Pure-O OCD often fails. However, treatment failure occurs not because the patient is an ERP non-responder, but rather because the most important part of treatment (i.e., response prevention) was unknowingly omitted. Sadly, many individuals with OCD wrongly get labeled as being treatment refractory (treatment resistant), even though they have never undergone a single course of response prevention that appropriately targets their very real mental compulsions.
    Remember, not every ritual consists of an observable behavior.
    Pure-O Mental Compulsions
    • Trying to “figure out” why you’re having a certain thought.
    • Trying to counteract, neutralize, or balance out negative thoughts with positive thoughts.
    • Trying to forcefully control an obsessive thought.
    • Trying to “figure out” what type of person you are (e.g., questioning your own morality).
    • Avoiding certain situations, people, or activities so that you don’t have an obsession.
    • Reassuring yourself (e.g., telling yourself, “I’d never do that.”).
    • Postponing certain behaviors or thoughts until “the right time” or until “they feel right.”
    • Repeating thoughts, phrases, or words in your head.
    • Repeatedly praying or asking for forgiveness (in a way that is not typical for others who share your faith).
    • Getting stuck in an OCD doubt/reassurance loop.
    • Asking questions and seeking reassurance from others.
    • Over-analyzing one’s own behavior or body and trying to do things “normally.”

  8. “Pure-O” OCD: Common Obsessions & Mental Rituals
    Posted by Steven J. Seay, Ph.D.
    The obsessions experienced by individuals with “Pure-O” OCD are commonly accompanied by mental compulsions.
    As a follow-up to my previous post on Pure-O OCD, I thought it might be helpful to identify some obsessions that are commonly reported by individuals with Pure Obsessional OCD. These same obsessions may also be experienced by individuals with non-Pure-O forms of the disorder. Keep in mind that some of these symptoms are quite common (when experienced in a limited form) and may or may not represent an underlying psychological condition. If you experience symptoms like these, consult with your doctor for clarification. I am also available to conduct assessments and provide treatment if you’re located in South Florida (Palm Beach Gardens, Jupiter, West Palm Beach, Fort Lauderdale, Boca Raton, Boynton Beach, & Miami).
    Remember that most people who have Pure-O OCD actually perform compulsions. These compulsions just tend to be mental rather than behavioral in nature. Mental rituals are varied and include such activities as repeating certain words or phrases in one’s head, counting, intentionally thinking “positive thoughts” to counteract “negative thoughts”, pre-planning words before speaking, making mental lists of similarities between one’s own experience and others’ experiences, conducting online research to prove or disprove a fear, or repeating/restarting prayers due to distraction or worry that one’s prayers are not 100% genuine.
    For some individuals, mental rituals also include complex cognitions. Complex mental rituals often begin simply with one of the following statements or questions and then take on a life of their own:
    OCD Mental Rituals
    • “I would never do that…but what if I do?…I don’t want to…but what if I secretly do?”
    • “Why is this happening?”
    • “When will this stop?”
    • “I can’t live this way…”
    • “I need to know…”
    • “I’ll never be strong enough to face this…”
    • “I wouldn’t be having these thoughts if I didn’t secretly want this…”
    • “Maybe I need to act on these thoughts to finally be rid of them and feel closure…”
    • “It’s always going to be this way…”
    • “I can’t take the chance, because if I did…”
    • “If I could just figure this out, I would be able to move past it and it wouldn’t bother me anymore…”
    Such thoughts usually begin innocently enough, but in the case of mental rituals, they become repetitive, desperate, and counterproductive. The reason these thoughts are so seductive is because they have the semblance of being helpful. People often feel that by engaging with these thoughts, they are somehow making progress in solving their own mental puzzle. In some ways, this parallels the way that chronic worriers ruminate and prepare for every possible contingency (even remote ones that other people would consider unreasonable).
    With OCD, you cannot get better by “figuring it out” in your head. This won’t happen today, tomorrow, or even a year from now. OCD does not yield to insight. Overcoming OCD requires active non-avoidance and actually confronting the very things you fear.
    See if you can imagine how the following obsessions might give rise to complex mental compulsions/rituals.
    Pure-O OCD Obsessions
    Harm-related obsessions
    • Fear of harming self or others (e.g., stabbing, hitting, shooting, suffocating, or poisoning)
    • Fear of wanting to harm self or others
    • Fear of hitting someone while driving (“Hit-and-run” OCD)
    • Fear of leading to someone’s accidental injury or death
    • Fear of assaulting or killing strangers

    Religiously- or morally-themed obsessions (often referred to as religious scrupulosity)
    • Fear/doubt about one’s faith, fear that one might not truly believe in God
    • Fear of being damned or committing an “unpardonable sin”
    • Repetitive sacrilegious thoughts (desecrating religious icons, imagining nude images of Jesus/Mary/Pope/priests/rabbis or other religious persons)
    • Fear of being sexually attracted to religious figures
    • Fear of secretly wanting to worship the devil or becoming a Satanist
    • Excessive concern about past mistakes or previous decisions

    Obsessions focusing on sexuality or romantic relationships
    • Fear of being gay (also referred to as Homosexual OCD, or “HOCD”), when the person is actually straight
    • Fear of being straight, when the person is actually gay or bisexual
    • Fear of being attracted to children (i.e., pedophilia)
    • Fear of being attracted to animals (i.e., bestiality)
    • Fear of being attracted to dead things or dead people (i.e., necrophilia)
    • Fear that one might cheat on his/her partner or spouse (infidelity-related)
    • Fear that one might want to cheat on his/her partner or spouse

    Obsessions about acting on an unwanted impulse (also see harm obsessions above)
    • Fear of acting in a sexually inappropriate manner (e.g., exposing one’s genitals to others, flashing people)
    • Fear of shouting or screaming obscenities
    • Fear of committing arson
    • Fear of attacking police, taking firearms/guns from police and using them on self or others
    • Fear of accidentally talking about robbing a bank (while at a bank)
    • Fear of accidentally talking about terrorism/hijacking (while at an airport)
    • Fear of throwing important items (e.g., keys, wallets) in places where they cannot be retrieved (e.g., lakes, shredders, elevator shafts, public mail receptacles)
    • Fear of confessing to crimes (that one did not commit)

    Obsessions involving health or bodily sensations (somatic obsessions)
    • Hypervigilance/hyper-awareness of bodily sensations/getting attention “stuck” on thinking/analyzing various autonomic processes (breathing, heart rate, swallowing, blinking, eye “floaters”, flickering of the visual field)
    • Persistent feelings of unreality, depersonalization, or derealization
    • Fear of having or developing a chronic, progressive illness (AIDS/HIV, ALS, Alzheimer’s Disease, cancer)

    Obsessions involving”mental contamination” or “emotional contamination”
    • Fear of being changed irreparably by exposure to certain ideas
    • Fear of physically or mentally transforming/turning into other people
    • Fear of changing or losing one’s sense of self due to direct or indirect contact with others
    • Superstitious fears regarding omens or signs of “bad luck”
    • Fear that if one sees a certain “sign”, one will have to take an unwanted action (e.g., commit a crime, kill self, murder someone)
    • Fear that one is destined to complete an unwanted action, and that exposure to certain stimuli will make this more likely to happen (e.g., fear that hearing about famous serial killers will make one commit murder)

  9. Pure Obsessional OCD — Symptoms and Treatment
    By Stacey Kuhl Wochner, LCSW Social Work Today Vol. 12 No. 4 P. 22

    Internal obsessions and compulsions are unseen but can be just as ritualistic and disruptive as visible ones.
    When most people think about obsessive-compulsive disorder (OCD), they probably imagine the most widely known forms of compulsive behavior, such as repeated hand washing or checking a door to make sure it is locked. However, there is a form of OCD, sometimes referred to as pure obsessional OCD (Pure O), where obsessions and compulsions take place internally.
    Since individuals with Pure O are often unaware they are being plagued by OCD and much of what they experience happens inside the mind, they often suffer in silence. Pure O is commonly misunderstood by others and, at times, misdiagnosed and mistreated by mental health professionals. As a result, an individual often concludes that he or she is internally flawed, evil, or psychotic, and the terror and isolation often experienced with Pure O is compounded.
    For example, one evening a new mother was placing her infant in her crib. Something in her mind told her to smother the baby with a pillow. Terror overcame the woman. She gazed at the baby girl, so delicate and helpless. The mother knew she was the one responsible for the girl’s safety, so she had an overwhelming urge to determine what the thought meant. The anxiety of doing this was painful, and she was plagued with incessant internal questions, such as “Does this thought mean that I could actually harm my child?” “Should I make sure I am never alone with the baby?” “I have been tired from staying up with the baby at night. Is it possible that I am angry with the her?” and “What makes me different than the mothers in the news who actually harm their children?” This line of mental analysis serves as the compulsion. The more time spent seeking certainty, the more confused and realistic the fear seems.
    The human brain naturally generates nonsensical and often bizarre thoughts, even for those without OCD. A study conducted by Rachman and de Silva (1978) found that healthy college students reported having thoughts with common OCD themes, such as violence, forbidden sexual acts, and urges to do inappropriate things in public. The difference is that when individuals without OCD experience ego-dystonic thoughts, meaning they are the opposite of an individual’s true nature, desires, values, and self-image, the brain responds differently.
    OCD is both genetic and learned. The structures that are impaired in the OCD brain create sensitivity to uncertainty and a decline in one’s ability to feel complete (Grayson, 2003). This leads to more value placed on incoming thoughts and relentless overresponding in the form of compulsions.
    Obsessions Found in Pure O: Obsessions are intrusive and unwanted thoughts, images, impulses, or sensations. These mental intrusions are ego-dystonic. This contributes to the panic and internal resistance that accompanies such thoughts.
    While obsessions can take on any theme, the following are several categories of obsessions commonly experienced with Pure O:
    • thoughts about harming oneself or others;
    • thoughts about abhorrent sexual activity, such as pedophilia or incest;
    • persistent doubt about one’s sexual orientation;
    • persistent doubt about one’s romantic partner;
    • antireligious thoughts; and
    • thoughts about normally unnoticed somatic functions, such as blinking, swallowing, or breathing.
    For example, a newly married husband and wife were sitting across the table from each other having breakfast. The husband glanced at his wife and a thought intruded: “She is not very pretty.” He got chills up his spine and tightened his grip on his coffee cup. He became preoccupied with repetitive doubts, such as “Why did I have that thought?” “Is she not pretty enough for me?” “Can I be happy with her?” “What if I have children with her and then have to leave my family?” “Maybe I shouldn’t have children with her.” “Am I a bad person for having this thought?” “It’s not like I am Brad Pitt.” On the way to work he noticed an attractive female, which triggered more anxiety and subsequent mental questions and answers.
    Mental Compulsions — Playing by OCD’s Rules
    The label Pure O, in addition to the covert nature of mental compulsions, causes some clients to mistakenly believe they do not carry out their compulsions. With OCD, compulsions are always present, whether mental rituals or observable compulsions. Since individuals with Pure O fear the negative consequences of harmful, violent, or sexually inappropriate thoughts, they perform compulsive mental processes to neutralize fear.
    Mental compulsions function as a method of figuring out the meaning of thoughts and serve as a desperate attempt to reduce anxiety and distress many fear will never go away.
    For example, a nursing student is sitting in a classroom listening to a lecture. When the instructor says certain “bad” words, such as death, disease, metastasis, or cancer, she becomes very distressed. Her friend’s mother died of cancer a few months ago, and she has been worrying about the health of her family ever since. She begins to develop a process to protect her family from harm. Every time she hears an uncomfortable word, she recalls an image of her mother’s friend on one side of a very high wall and her family safely on the other side. At times, an image of one of her family members ends up on the wrong side of the wall. She then closes her eyes and counts silently—one number to represent each loved one. If she makes a mistake, she must start again, and before she knows it, the class is over. This becomes very distracting, and her grades drop dramatically.
    Because individuals with OCD are particularly sensitive to uncertainty, performing mental compulsions allows them to feel that everyone they are thinking about is safe. This philosophy backfires because the thoughts are treated as if they are valuable and therefore become stronger.
    This leads to a vicious cycle of intrusive thoughts and mental neutralizations that build in intensity and frequency. There are innumerable ways in which individuals engage in mental compulsions and, at times, may become wrapped up in this process for most of the day. Here are a few examples:

    • Mental reassurance: This is someone’s attempt to provide reassurance that feared consequences will not occur or that thoughts do not mean anything. A person may examine whether having thoughts of harming others means he or she is evil or bad, even when the person does not fear that he or she will act on the thought.
    • Mental review: An individual will review his or her memory to gain certainty about events that already occurred. Clients may think about a time when they were holding a child and have a “memory” about touching the child inappropriately. The more an individual attempts to gain certainty about the memory, the more memory distrust emerges.
    • Compulsive prayer: This is when someone mentally recites special words or prayers to neutralize unwanted thoughts. For example, when a woman was saying her bedtime prayers, the word “Satan” could be heard during the prayers. She continued praying until the intrusion was gone.
    • Wishing: Someone may spend a great deal of time wishing his or her thoughts would cease and fantasizing about how life could be without obsessions (Grayson). Wishing is counterproductive and functions the same way as other compulsions, magnifying the importance of thoughts.
    • Overt compulsions: In addition to mental compulsions, individuals with Pure O also engage in observable compulsions, such as reassurance seeking, avoidance, and repeating behaviors, to neutralize thoughts. For example, if a client has a “bad” thought when starting his car, he may restart the car while matching it to a “good” thought.
    Cognitive Behavioral Therapy for Pure O
    Most clients enter treatment with the goal of stopping their obsessions. However, their attempt to get rid of unwanted thoughts is the problem. A more reasonable goal is to change the individual’s relationship with and reaction to intrusive thoughts.
    The following forms of therapy may prove beneficial when treating those with Pure O:
    Mindfulness-Based Cognitive Therapy
    Acceptance and commitment therapy (ACT) is a type of mindfulness-based cognitive therapy that teaches clients to regard “internal private experiences” as normal rather than viewing them as problems that need to be fixed. Uncomfortable thoughts, feelings, images, urges, and sensations are all part of the human experience. If we view them as problems, they become problematic. ACT has various techniques to help clients use mindfulness to observe their thoughts rather attaching to and becoming overwhelmed by them.
    Russ Harris, in The Happiness Trap: How to Stop Struggling and Start Living, discussed a skill called cognitive defusion, which helps an individual create room for intrusive thoughts. A client thinks, “I am a bad person.” To practice defusion, you would restate the thought: “I just had a thought that I am a bad person” or go a step further and say, “I just noticed I had a thought that I am a bad person.” This allows clients to occupy the same space with their thoughts but from a different vantage point. Instead of being crunched in a small closet with their thoughts, they are now in a gymnasium with them.
    ACT also stresses showing irreverence to internal private experiences and instead choosing to live life based on one’s values. Someone may value building relationships with others. If this person is living in accordance with his values, this person will decide to go to his nephew’s birthday party even though he may have harming thoughts that appear when he sees children. Living life despite obsessions takes the power away from them.
    Cognitive Restructuring
    Helping clients identify their distorted thinking patterns can assist in the treatment of Pure O. Cognitive restructuring that involves recognizing and reframing cognitive distortions can help clients make logical choices about how to respond to their thoughts.
    When using traditional cognitive therapy, encouraging clients to repeatedly convince themselves of the irrationality or absurdity of their thoughts mimics the way they engage in mental compulsions. Instead, teach clients to use alternative thoughts that encourage them to sit with uncertainty, accept thoughts and feelings, and recognize that exposure is the best option.
    Exposure and Response Prevention
    Exposure and response prevention (ERP) is a type of behavioral therapy that involves exposure to an obsession paired with prevention of the neutralizing ritual using a structured, hierarchical method. Imaginal exposure is a component of ERP when using it to treat Pure O. A client may be asked to conjure a feared image and hold it in his mind for a period of time.
    Writing or saying words or phrases that elicit anxiety is another method. Some words that could be related to harm include “blood,” “murder,” “slash,” “kill,” or “dismember.” The slow progression ends up with clients writing scripts about harming someone in more detail. These scripts can be recorded and listened to periodically throughout the day. Clients are also asked to do physical exposures such as holding a knife or watching a murder-themed movie.
    The purpose of exposure therapy should never be reassurance or safety but to become accustomed to moving forward in life in the face of inevitable uncertainty (Grayson). The goal of ERP is to consistently increase anxiety levels and attempt to keep them high, eventually failing because of the habituation process. The natural by-product of exposure is habituation. An individual will eventually decondition the anxiety that has been paired to his obsessions. When thoughts do arise, the relationship with them is one of openness and acceptance. Intrusive thoughts may even come less frequently after one has learned to live with them.
    Lower Resistance and Win
    When encountering a mountain lion on a hike, everything inside you urges you to run but knowing that will only encourage the lion to chase you, you logically decide against that response to stay alive. Clients can learn to use logic to respond to their OCD in a new way. The clients who improve are the ones who realize that the thoughts don’t actually have to go away. With treatment, clients can expect to take their lives back from their OCD and start living again.
    — Stacey Kuhl Wochner, LCSW, provides psychotherapy for individuals and groups with obsessive-compulsive disorder and obsessive-compulsive spectrum disorders at the OCD Center of Los Angeles (www.ocdla.com).

  10. Pure Obsessional OCD (Pure O) – Symptoms and Treatment
    By OCD center of Los Angeles

    Some individuals may suffer from “Pure Obsessional OCD” (sometimes called “Pure O”) in which they report experiencing obsessions without observable compulsions. These obsessions often manifest as intrusive, unwanted thoughts, impulses or “mental images” of committing an act they consider to be harmful, violent, immoral, sexually inappropriate, or sacrilegious. For individuals with Pure Obsessional OCD, these thoughts can be frightening and torturous precisely because they are so antithetical to their values and beliefs.
    Symptoms of Pure OCD
    Symptoms of Pure Obsessional OCD vary widely from person to person. Some examples of common obsessions seen in Pure Obsessional OCD are:
    • recurrent intrusive harm thoughts or mental images of physically assaulting or killing one’s spouse, parent, child, self, friends, or others (sometimes called “Harm OCD”)
    • repeatedly worrying that one has or will run over a pedestrian while driving a vehicle (sometimes called “hit and run OCD)
    • excessive fears that one might accidentally cause harm to other people (i.e., burning down the house, unknowingly poisoning others, inadvertantly exposing others to toxic chemicals)
    • persistent fears of molesting a child (sometimes called “pedophile OCD” or “POCD”)
    • recurrent fears that one might be a homosexual, when in fact he or she is not (sometimes called “Gay OCD” or “Sexual Orientation OCD” or “Homosexual OCD” or “HOCD”)
    • excessively worrying that one does not actually love his/her partner, or is not with the “right” person (sometimes called “relationship OCD” or “ROCD”)
    • repetitive thoughts that one has said or written something inappropriate, such as swearing at ones employer or writing hate-filled letters to a friend
    • persistent intrusive thoughts or mental images that one considers to be sinful, sacrilegious or blasphemous, such as wanting to worship Satan or have sex with Christ
    • recurrent fears that one is sinning or not living (or thinking) in a manner that is congruent with their religious, moral, or ethical values (sometimes called “Scrupulosity”)
    • repeatedly thinking about benign somatic issues such as breathing, swallowing, blinking, eye “floaters”, ringing in the ears, digestion, where ones eyes are looking, physical sensations in a specific body part, etc. (sometimes called “sensorimotor OCD” or “somatic OCD)
    However, it should be noted that the term “Pure Obsessional OCD” is somewhat of a misnomer. While it may at first appear that these individuals experience obsessions without compulsions, a careful assessment almost always uncovers numerous compulsive behaviors, avoidant behaviors, reassurance-seeking behaviors, and “mental compulsions,”. These behaviors are not as easily observed as other, more obvious OCD symptoms, such as hand-washing and lock-checking, but they are clearly compulsive responses to unwanted obsessions. Some common examples of compulsions seen in Pure Obsessional OCD include:
    • avoiding numerous situations in which one fears the possible onset of unwanted thoughts
    • repeatedly asking for reassurance that one has not and/or will not commit an act that one perceives as being “wrong” or “bad”
    • compulsively “checking” one’s body in an effort to get evidence that one is not sexually attracted to someone who he/she considers inappropriate (especially in cases of POCD, HOCD, and ROCD)
    • silently praying or repeating certain phrases in an effort to counteract or neutralize thoughts that one considers to be sinful, immoral or sacrilegious
    • performing superstitious behaviors in an effort to ensure that bad things don’t happen (i.e., counting, tapping, knocking on wood)
    • repeatedly confessing to people, even total strangers, that one has had thoughts which he or she considers to be unacceptable
    • continually ruminating about obsessions in an attempt to prove to oneself that he or she has not done and/or will not do anything “wrong” or “inappropriate” or “sinful”

    Treatment of Pure OCD
    For many years it was thought that Pure Obsessional OCD was next to impossible to manage because there were no behaviors to treat, only thoughts. However, a specific type of Cognitive-Behavioral Therapy (CBT) known as “Exposure and Response Prevention” (ERP) has proven to be very successful in the treatment of Pure Obsessional OCD. Using ERP, clients learn to directly face their fears of specific thoughts, and to proactively challenge the compulsive and avoidant behaviors they have been using to cope with these thoughts. Another CBT technique that is extremely valuable is called “Cognitive Restructuring”, in which clients learn to challenge the validity of the unwanted thoughts that are causing them so much distress.

    Additionally, a variant of ERP has been developed that has also been found to be extremely effective for the treatment of Pure Obsessional OCD. This method, sometimes called “imaginal exposure,” involves using short stories based on the client’s obsessions. These OCD stories are audiotaped and then used as ERP tools, allowing the client to experience exposure to situations that cannot be experienced through traditional ERP (e.g., killing one’s spouse or molesting a child). When combined with standard ERP for the above-noted compulsions, and other cognitive-behavioral techniques, this type of imaginal exposure can greatly reduce the frequency and magnitude of these intrusive obsessions, as well as the individual’s sensitivity to the thoughts and mental images experienced in Pure Obsessional OCD.

    One of the most effective CBT developments for the treatment of Pure Obsessional OCD (“Pure O”) is Mindfulness-Based Cognitive-Behavioral Therapy. The primary goal of Mindfulness-Based CBT is to learn to non-judgmentally accept uncomfortable psychological experiences. From a mindfulness perspective, much of our psychological distress is the result of trying to control and eliminate the discomfort of unwanted thoughts, feelings, sensations, and urges. In other words, our discomfort is not the problem – our attempt to control and eliminate our discomfort is the problem. For an individual with Pure Obsessional OCD (“Pure O”), the ultimate goal of mindfulness is to develop the ability to more willingly experience their uncomfortable thoughts, feelings, sensations, and urges, without responding with avoidance behaviors, reassurance seeking, and/or mental rituals.
    Using these CBT tools, clients learn to more effectively respond to distorted, unwanted thoughts, and to resist the urge to do compulsive and avoidant behaviors.

  11. Pure O: How do I tell the Difference between Obsessions and Compulsions? OCDblogspot.com
    There’s been discussions lately on the OCD support lists about how to tell the difference between an obsession and a compulsion, if it’s all thoughts, as in “Pure O.” My understanding is that the initial thought is the obsession, and the cascade of thoughts afterwards are the compulsion. For me it would be something like, “What if I said the wrong thing?” as the obsession, followed by trying to figure out if I did indeed say the wrong thing, including retracing my words, trying to account for all of them, which is the compulsion.

    The irony is that the compulsion is supposed to be what reduces the anxiety produced by the obsessive thought, and yet, when I used to say “I wish I could stop obsessing about this” what I really meant was the whole flood of compulsions. I fly into compulsing so quickly that it seemed quite dubious that the initial thought was causing the anxiety–surely all the retracing, figuring out, analyzing, and research were the obsession right? How could they possibly be a way to lower my anxiety??

    But what I learned during exposure therapy was that compulsions only provide short term relief, and in some cases, very very short term, and then they rebound with their own additional suffering, taking up mental space and energy, and that if I challenged myself to refrain from figuring out an obsessive thought, that my anxiety level immediately spiked, and that was a sign that the compulsion was serving its function of a short term hit of relief, even if I couldn’t see it as it happened.
    My husband had the flu this week, and he gave this analogy–the virus is the obsession, and the immune system response is the compulsion. When we are sick, what makes us feel lousy isn’t the virus itself, but the attack of the immune system on the virus. In the case of our bodies, for the flu or other illnesses, we actually want the immune system to attack, but OCD is more like an allergy, where our immune system attacks something harmless like pollen, mistaking it for an invader. I know the things we obsess about don’t seem harmless, and that they are often about things important to us, but our full blown compulsions cause us more misery in many cases than the initial obsession.

    In the midst of my worst OCD flare ups, I had glimpses of how destructive the compulsions were, but I was so scared by the obsessive thought that I clung to my compulsions. I finally hit a low point with my health anxiety, that even though I was terrified of getting treatment, I knew I couldn’t continue on the way I was going and have any kind of life. If you are like me, you probably also spend time trying to figure out if something is an obsession or a compulsion, and wanting to know for sure which it is. Another lovely complication of the OCD! Take your best guess.

  12. OCD and Mental Checking
    Monday, December 7th, 2009 Obsessive-Compulsive Disorder (OCD) OCD Center of LA
    If you are faced with the challenge of Pure Obsessional OCD (also known as “Pure O”), then chances are you’ve completed your first round of obsessions and compulsions before you’ve even gotten out of bed each day. Before you open your eyes, the wheels in your OCD machine start turning, and a sort of science fiction scan of your brain begins searching for evidence of “it”. Whatever “it” is, “it” is sure to be in there somewhere.
    Perhaps it takes a few moments, or maybe it takes no time at all for the OCD search engine to drum up some piece of the broken puzzle. But inevitably, you find what you are looking for. The obsession is still there, still unresolved, still malicious and unfair. The lump in your throat swells and the other physical symptoms of anxiety begin to surface. Something is wrong and the day has only just begun.
    Immediately, your OCD brain begins to engage in a series of mental exercises pitting the unwanted thought against reality, trying to force them to match up or reveal themselves as permanently incongruent. Someway, somehow, you have to get that sense of closure to indicate that “it” is not you. Otherwise, you may never get out of bed.
    This is “mental checking”, and it is a common feature of Pure Obsessional OCD. The scan feels like an automatic part of life, no different than the first yawn or stretch. It happens throughout the day, often without you really being conscious that you are doing it. When it is not automatic, it presents itself as necessary, like the annoying reminder message for your computer’s antivirus software. It is important to realize that mental checking is a compulsion. And despite its automatic presentation, it is subject to the same treatment mechanisms employed when challenging other OCD compulsions with Cognitive Behavioral Therapy (CBT).
    In short, mental checking is a behavior. It is the act of looking for your OCD obsession with the presupposition that you will in some way be able to squash it and get relief. Furthermore, since we always find what we are looking for when what we are looking for is evidence to justify action, we feel we need to do something about the obsession. This follow-up compulsion is a form of mental ritual aimed at neutralizing the OCD thought. It may be playing an event over in your head to make sure it was handled appropriately (also known as retracing), or it may be repeating a series of “good” thoughts to outweigh the so-called “bad” ones. But the initial behavioral compulsion that puts this OCD cycle into motion is the mental checking, and it is among the more challenging behavioral compulsions to resist because it often appears to precede the unwanted thought.
    For people with Pure Obsessional OCD, there are three opportunities to challenge mental checking, listed here in decreasing order of difficulty:
    • preemptive resistance
    • concurrent resistance
    • retrospective resistance
    Preemptive resistance may appear impossible until you are well into a course of Cognitive Behavioral Therapy (CBT). Preemptive resistance requires that you have an awareness of your OCD tendency to check. If you have developed this awareness, you are more able to see opportunities for mental checking before they happen, and to see them as opportunities to resist checking. If you have OCD, you may feel an urge to check when you become aware of the absence of your obsession. Use this urge as evidence that you should re-direct your focus, rather than seeking certainty that the obsession has been dealt with. In other words, the urge is your clue – it is your signal to resist doing the compulsion.
    Somewhat more tangible an objective is concurrent resistance. If you have already begun mental checking, you are already down the path to digging up an otherwise dormant, unwanted thought. This is where you can jump in and say, “Wait! This is mental checking! This is OCD, and I don’t need to do this!” At that moment, the challenge you face is to pull yourself back to the present. What matters now is not whether your obsession has been dealt with. What matters now is interrupting and stopping the pointless mental compulsion.
    Finally, retrospective resistance may at times be the only tool left in your OCD toolbox. You have already searched for and found the obsession. You have already tried some compulsive mental exercises in an effort to make the obsession go back to where it came from. But all is not lost. You can still use the power of mindfulness and clinical self-observation to fully acknowledge that this was mental checking. Take this opportunity to remember what it felt like to look for the obsession. Identify that urge, and acknowledge that it sent you down the path of grappling with the same old OCD junk. You might be surprised how effective this post-compulsion labeling is in helping you better develop the skills of concurrent and preemptive resistance.
    We often find ourselves sending the wrong message to the OCD brain when we engage in compulsions. We feel fear and engage in a mental (or physical) behavior to flee from that fear. The brain remembers this as evidence that the behavior saved us from the fear. But a more effective message to send to our brains is that the behavior is pointless and so is the fear. (For more information on this process, see our previous post on Exposure Therapy for OCD and Anxiety.) So even if OCD may have won a skirmish on the mental field by pushing you into a bout of mental checking, you can still win the battle by reminding yourself that what happened was nothing more than a compulsion. Next time it won’t be so easy to fool you.
    Now get out of bed.

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