Pure O: the silent struggle of Obsessive-Compulsive Disorder

Understanding a lesser-known yet deeply impactful form of OCD

When people hear “OCD,” they often picture someone compulsively washing their hands, checking locks repeatedly, or arranging items with surgical precision. These visible behaviours are hallmarks of Obsessive-Compulsive Disorder but what if the battle wasn’t visible at all?

There’s a lesser-known and often misunderstood form of OCD called Pure O short for Purely Obsessional OCD. Unlike traditional OCD, which involves outward, physical compulsions, Pure O is marked by internal mental rituals. This makes it harder to recognise, and even harder to explain to others. Yet for those who experience it, the distress is very real.

What is Pure O?

Pure O is not “just having obsessive thoughts.” It’s a chronic, tormenting loop of unwanted, intrusive thoughts (obsessions) followed by internal attempts to neutralise or make sense of them (compulsions). These compulsions are invisible to the outside world but relentless in the mind of the sufferer.

Dr Ashish Arora, Consultant Psychiatrist at Schoen Clinic Chelsea, explains:

“Pure O is not fundamentally different from other forms of OCD; the compulsions are simply internal rather than external.

These mental rituals such as rumination, silent reassurance-seeking, or avoidance can be just as disruptive and exhausting.”

Common themes in Pure O

Pure O often revolves around deeply sensitive or taboo topics, making sufferers feel ashamed, frightened, or confused. Some common subtypes include:

• Harm OCD – Fear of accidentally hurting someone or oneself.

• Sexual Orientation OCD – Intrusive doubts about one’s sexuality.

• Relationship OCD (ROCD) – Obsessive questioning of one’s love or compatibility in a relationship.

• Religious/Scrupulosity OCD – Overwhelming fear of committing a sin or being morally flawed.

• Health Anxiety OCD – Obsession with undiagnosed illnesses, often without physical symptoms.

Dr Arora explains, “These thoughts are ego-dystonic - meaning they go against the person’s core values which is why they provoke such intense distress. Many sufferers worry they’re “going crazy” or fear they’re a bad person, when in reality, these thoughts are just symptoms of a treatable disorder.”

How is Pure O different from classic OCD?

Traditional OCD involves outward compulsions (like checking or cleaning), while Pure O revolves around:

• Mental reassurance – Internally trying to “prove” something isn't true.

• Rumination – Endless mental debate over a thought or fear.

• Silent rituals – Counting, praying, or mentally repeating phrases to “cancel out” bad thoughts.

• Avoidance – Dodging situations, people, or media that might trigger intrusive thoughts.

• Excessive analysis – Replaying conversations or actions in one’s mind to seek certainty.

Dr Ashish Arora, Consultant Psychiatrist

Because these behaviours aren’t visible, Pure O often goes unrecognised or misdiagnosed — sometimes as anxiety or depression. This can leave sufferers feeling isolated and misunderstood.

“Many patients struggle in silence,” says Dr Arora.

“They believe their thoughts are unique or shameful, when in reality, they’re textbook OCD symptoms. Early diagnosis and intervention can change lives.''

Treatment options: there is hope

Despite how overwhelming Pure O can feel, recovery is absolutely possible. With the right support, people can learn to manage their symptoms and live fulfilling lives.

1. Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP)

This gold-standard therapy helps individuals confront intrusive thoughts without engaging in mental compulsions. Over time, the brain learns that it doesn’t need to “solve” or neutralise these thoughts.

“ERP helps patients realise that thoughts are just thoughts,” explains Dr Arora. “You don’t have to respond to them. That’s a powerful shift.”

2. Medication

SSRIs like Fluoxetine or Sertraline can help regulate brain chemistry and reduce the intensity of obsessions and compulsions. Medication is often combined with therapy for best results.

3. Mindfulness & Acceptance-Based Therapies

Approaches like Acceptance and Commitment Therapy (ACT) or Mindfulness-Based Cognitive Therapy (MBCT) teach people to observe thoughts without judgment, reducing the need to respond to them.

Finding the right support

Pure O is real. It’s not a character flaw. It’s not a personal failing. It’s a mental health condition — and it’s treatable.

If you or someone you love is struggling with intrusive thoughts and internal compulsions, know that you are not alone. There is expert help available. At Schoen Clinic Chelsea, professionals like Dr Ashish Arora specialise in OCD and understand the unique presentation of Pure O.

Final thoughts: from darkness to light

Living with Pure O can feel like being stuck in a mental prison trapped by thoughts you never asked for and rituals you can’t explain. But there is a way out.

With awareness, compassion, and the right treatment, people with Pure O can reclaim their peace of mind, rebuild their confidence, and return to the lives they were meant to live not controlled by fear, but grounded in freedom and clarity.

You are not your thoughts. You are the awareness behind them.

Contact our team in London today if you need support. Were here to help.

This page was reviewed and approved by Dr Ashish Arora on 10.04.2025