"Pure Obsessional" OCD & Covert Mental Compulsions
For many sufferers of OCD, their compulsions take the form of covert & mental compulsions, rather than overtly observable behavioural compulsions. This form of OCD was once thought to be rare (where in reality most sufferers of OCD present with at least some mental compulsions) and was mistakingly viewed to be a "Pure Obsessional" form of OCD due to the lack of recognition of sufferers' unobservable covert compulsions. Read more below.
Covert Mental Compulsions/Rituals
Mental compulsions, also known as mental rituals, play a significant role in Obsessive-Compulsive Disorder (OCD). While compulsions are often associated with observable behaviours, such as checking, washing, or counting, mental compulsions involve internal cognitive processes or mental acts. These rituals are performed to alleviate the distress caused by intrusive thoughts or obsessions, but instead prompt distress and trap the individual in the obsessive-compulsive cycle in the long term.
Types of Mental Compulsions:
Mental Checking/Reviewing: Repeatedly reviewing/scrutinising thoughts or memories to ensure that no harm has occurred or that a feared event did not happen, or e.g., to try and remember if their front door was locked. Individuals may also engage in mental review of past events or interactions to ensure that no mistakes were made and that everything is in order.
Reassurance-Seeking: Seeking mental reassurance by repeatedly asking oneself questions or seeking answers to doubts, either internally or through external means such as seeking reassurance from family or the therapist that their thoughts are not true.
Counting or Recounting: Mentally counting or recounting to neutralise feelings of anxiety or to prevent a feared event from occurring, this compulsion often functions as a problematic thought suppression strategy.
Praying or Repetitive Phrases: Engaging in mental rituals such as praying, repeating specific phrases, or engaging in mental chants/mantras as a way to prevent harm or to ensure safety, or as a way to suppress thoughts. Often these compulsions needed to be repeated until they satisfy some inner subjective criteria for what feels "just right".
Thought Suppression, Avoidance in Thought, Mental Distraction: Actively avoiding certain thoughts or images to prevent anxiety or discomfort, or trying to "block out" or suppress thoughts, prompting the thoughts to rebound more intensely and frequently, of to be stuck lingering in the back of their mind all day.
Mental Neutralisation: Engaging in mental actions or rituals to neutralise the perceived consequences of intrusive thoughts, such as mentally canceling out a negative thought with a positive one to prevent a bad outcome from happening, "testing" their reaction to a thought (e.g., picturing their partner and evaluating whether or not they experience loving feeling, or picturing something taboo to test if they experience arousal). They may also compare images in their mind, e.g., comparing an image of their partner with someone else to see if they are more attracted to their partner.
- Other forms of compulsive mental neutralisation may include:
- Thinking thoughts in reverse to "undo" them
- Mentally hoarding information, or compulsively creating pictures, maps, or lists in their mind
- Reassuring themselves internally
- Engaging in compulsive internal debates with their mind to disprove an intrusive thought
- Compulsively ruminating on thoughts or elaborating on intrusive imagery into a movie in their mind
- Compulsively replying to their thoughts with statements such as "no" or "I would never do that" or "its just OCD/an intrusive thought", or they may repeat these phrases sub-vocally under their breath.
Characteristics of Mental Compulsions:
Mental compulsions are not observable behaviours, making them harder for others to notice, and their "portability" unlike behavioural compulsions often reliant on a particular context (e.g., compulsive cleaning) allows for extremely high frequencies of compulsions, with some individuals exhaustingly engaging in mental compulsions all day long. Sometimes mental compulsions are not "ritualised", so they can be harder to spot - that is, the compulsion is not enacted in the same way each time, e.g., internal debates with their mind.
Impairment: Their covert nature can contribute to the person's ability to hide their OCD symptoms, where they may outwardly appear to be less impaired by their OCD than those with overt compulsions, even though this form of OCD may actually represent a more severe and insidious form of the disorder (see e.g., Sibrava et al., 2011). Mental compulsions can interfere with a person's ability to concentrate, make decisions, or engage in meaningful activities. The individual becomes fused with their intrusive thoughts, leading to a sense of cognitive entanglement and difficulty in breaking free from the mental rituals.
Given their covert nature, mental compulsions and other covert rituals often go unnoticed by both the sufferer and the therapist, creating a barrier to treatment as the compulsions are the main perpetuating factor of OCD. If an individual cannot see the mental compulsions driving their obsessions, they may feel powerless and unsure on how they are supposed to "resist" their compulsions.
The term "Pure-Obsessional" or "Pure-O" OCD is problematic:
Before the adequate recognition of mental compulsions by researchers and therapists, it was mistakingly believed that there was a form of OCD without compulsions, referred to as "pure-obsessional" or "Pure-O" OCD, and that this form of OCD was "impervious to treatment". However over time, especially following research conducted in the 1990's, recognition of these hidden compulsions has meant that treatment can successfully be applied to this form of OCD, where research shows that "Pure-O" OCD is equally responsive to treatment as other forms of OCD.
In fact, not only are mental compulsions common, but in the hundreds of patients with OCD that I have worked with, I have not only never encountered an individual with OCD who has no compulsions at all, but I have also never encountered an individual with any subtype of OCD without covert/mental compulsions. This is because "obsessing" is actually a compulsive thought process, as is ruminating/worrying in OCD.
For example, if someone has an intrusive thought that their front door might be unlocked, usually (at least in the earlier stages of OCD before compulsions have become habitual and exist without obsessional triggers as a result of high frequency of repetition), they would be unlikely to react to this thought by immediately driving home to check their front door. Instead, they are more likely to first engage in mental compulsions, such as mentally scrutinising their memory of leaving the house that morning to check if they locked the door. As a result of this mental compulsion generating increased anxiety and uncertainty, they feel compelled to then behaviourally enact compulsions such as going home to check their front door, i.e., the mental compulsions that occur in response to the initial intrusive thought, often precede the overt behavioural compulsions.
This is why the term "Pure-Obsessional" OCD may be harmful, as it depicts the false notion that there are no compulsions to resist, and may leave the sufferer feeling trapped and helpless. Moreover, the view of mental compulsions being "rare" is also problematic, because again, they are likely be present in every presentation of OCD, and without the therapist adequately assessing for a patients mental compulsions, treatment may ineffective, or limited in how effective it can be, where resisting compulsions becomes more difficult.
For example, say the individual in the example above who has been told their compulsion is just "checking behaviours" has learnt that the way out of their OCD is to resist their compulsions. The next time they experience an intrusive thought "maybe your front door was unlocked", they may try their best to resist their compulsion of driving home to check if the door is indeed unlocked. However, if while sitting there trying to resist this compulsion, they are still engaging in mental compulsions, such as reassuring themselves it will be okay, or scrutinising their memories to check if it was locked, trying to dismiss or reason with their thoughts "its just OCD you're being irrational", or trying to suppress the thought - then despite their best efforts to resist their compulsion of checking, they are still engaging in other compulsions in their mind. Where, as a result of continued compulsive engagement in their mind, they will likely not be able to calm down due to the mental compulsions continuing to generate distress, or the thought haunts them for hours due to the mental compulsions preventing the thought from leaving their awareness. They then might feel hopeless, that resisting the compulsion to drive home to check is simply too hard, or that resisting compulsions does not work for them, and reluctantly yield to the compulsive urge to go home and check their door, and subsequently even less likely to attempt to resist their compulsions again.
However, if this individual becomes aware of both their overt behavioural compulsions as well as their covert mental compulsions, and they resist the urge to engage in both, now they are in a position where their anxiety and compulsive urges will fade, and the thoughts have the opportunity to leave their awareness as they continue with the day - successfully engaging in response prevention. In fact, individuals I work with often find that when they truly relinquish all compulsions during response prevention, from the get go, resisting compulsions is actually the quickest route to feeling calm and clear when they are triggered, and the idea of compulsions providing "short-term relief" is erroneous: the person who has an intrusive thought and gives it no compulsive attention, will feel calmer more quickly than the person who compulsively ruminates and analyses, or fights with their thoughts in some way. To learn to do this, is easier said than done of course, and usually requires some fine tuning with the help of the therapist in learning how to resist compulsions effectively.
Treatment of Mental Compulsions
Cognitive Behavioural Therapy (CBT): Exposure and Response Prevention (ERP) is a key component of CBT for OCD. It involves gradually exposing individuals to anxiety-provoking thoughts, sensations, or situations while preventing the accompanying mental & behavioural compulsions. Exposure based treatments can also be adapted to address compulsions that have become very quick and automatic (sufferers of mental compulsions are more likely than any other subtype of OCD to report perceived automaticity of compulsions, see e.g., Starcevic et al., 2011), making them hard to resist at first. Through this process, the goal is to break the cycle of obsessions and compulsions, promote tolerance to uncertainty, and to reduce the anxiety attached to thoughts.
The aim of exposure based exercises, be it through CBT, ACT, or Metacognitive Therapy, is to not only to become less distressed by your intrusive thoughts and obsessions by habituating to them, but it allows you to finally convince that the fearful part of your mind (that part of your mind that won't listen to your logic, that tells you to engage in the compulsion "just in case") that the thoughts are not dangerous and do not come true; the compulsive urge, anxiety, and sensory discomfort will fade; the compulsion is not necessary to prevent feared outcomes from occurring; that you will not lose control; and that you can cope with discomfort. Most importantly perhaps, by resisting the urge to engage in your compulsions in response to obsessive thoughts, your brain will have a sudden realisation: that you're not responding to the obsession in the way you usually do, where it will subsequently realise that you have a greater repertoire of responses to your obsessions than just compulsions, and therefore it cannot predict & automate the onset of these compulsions after all. Where with time, exposure aims to gradually restore your sense of free will over your actions, allowing you to choose how you will respond to obsessions: with compulsions, or without.
Metacognitive & Mindfulness-Based Approaches: Mindfulness exercises (when applied in an OCD treatment congruent way) can help individuals observe their thoughts without judgment, reducing the urge to engage in mental compulsions.
Cognitive Restructuring and Increasing Metacognitive Awareness: Identifying and challenging distorted thought patterns and beliefs associated with the need for mental rituals - rather than arguing with the content of thoughts (which fuels the OCD further), this cognitive restructuring is focussed on addressing beliefs about the need to engage in the compulsion, their perceived utility or function, or in shifting the perceived lack of self-efficacy in resisting the compulsions that has developed over time due to the tendency of OCD to undermine the sufferer's sense of autonomy. Most individuals I work with feel this way at first, but over time this view of themselves as powerless to turn against can OCD diminish once they can see and resist their mental compulsions.
Psychoeducation: Understanding and addressing mental compulsions are crucial components of effective OCD treatment, while also helping individuals to understand how to resist their compulsions in an adaptive way to break free of the obsessive-compulsive cycle. The goal is to help individuals gain control over their thoughts (by learning to not try to control them), reduce anxiety, and improve their overall quality of life.