Sarah, a 19-year-old college student, is just hoping to make it until winter break. At home she can control many of the things that make her anxious. But at school, Sarah has to face new terrors every day. She has close friends and goes to class each day, but nobody seems to notice anything wrong. Even on the verge of panic, she pushes herself to keep behaving as she normally would.
For years there's been such a large gap between Sarah's inner state and what people see of her that she's starting to feel separated from her own life. She spends more and more time, and a huge amount of energy, dealing with the only thing that seems worthy of her attention—her own thoughts. They have so much weight; without careful supervision, Sarah feels sure they'll become reality. With each disturbing thought she fears herself a little bit more.
Right now, Sarah can't stop thinking about hurting someone on campus. There's nobody specific, but she's constantly having vivid thoughts about throwing people down the stairs or pushing them out of windows. When she takes the campus bus she thinks about grabbing the wheel from the driver and steering them straight into a crowd. Friend or stranger, young or old, it doesn't matter—nobody is safe from her violent thoughts. There's nothing she wants less than to hurt somebody else, and she never has. But none of that seems to matter to her obsessive brain.
When an on-campus counselor tells Sarah to just ignore her thoughts, she decides never to go back. She's only ever hinted at the problem with a few people, and they've all said the same thing. Reading that nobody else understands what it's like when your thoughts are constant, with no escape, Sarah decides to cope on her own.
Eventually she starts doing whatever it takes to get some relief. Stuck in a huge lecture hall, bombarded by violent images of herself becoming another one of the school shooters all over the news, she decides to come up with a mental list of twenty-five reasons she could never be a school shooter:
- Sarah thinks back to the time she skipped spring break and built houses for charity: a clear sign of caring about people.
- She reminds herself about a CNN article saying that 97% of school shooters are male.
- Everyone says school shooters are loners, she thinks, and I've always had a lot of friends.
- And so on...
But the ideas are slowing down, and fulfilling her mind's criteria is starting to feel like an impossible task. As she counts the number of things she's already come up with, she begins to forget the first few. By the time she counts sixteen, she's back to thirteen. So she puts a time limit on it: I have to come up with the full list by the time this lecture ends, or else I really am at risk of becoming a school shooter. Carefully angling her laptop away from the people around her, she begins to type as quickly as possible, searching for statistics, scouring her Facebook profile for photos of the good deeds she's done.
The people around her don't notice anything wrong, of course. There's nothing strange about hurriedly typing on your laptop during lecture, especially if you're on Facebook or reading articles. Sarah might look a little high-strung, might even have that reputation. But there'd be no reason to suspect that she's suffering so intensely from the symptoms of a mental health condition.
Why OCD causes so much distress
What Sarah experiences is very likely obsessive-compulsive disorder, or OCD, and it affects about 2.5% of the US population. Far from the fringe condition many of us picture, OCD is both common and underdiagnosed. And it's often severe, meaning Sarah's case is representative of how millions of people feel, in this country alone.
All types of OCD involve obsessions and compulsions—these are the primary symptoms that make up the disorder. Obsessions are intrusive and unwanted thoughts, images, and urges; compulsions are the repetitive behaviors someone uses in an attempt to get rid of the distress caused by their obsessions.
It's not difficult to understand why someone would feel intense anxiety when experiencing thoughts, images, and urges about hurting other people, all day and all night. Other types of obsessions, whether they involve harm or not, generate just as much distress. Nor is it surprising that anyone facing this much anxiety would like to get rid of it.
The trouble with OCD is that the perceived need to get rid of anxiety takes the form of compulsions. These behaviors bring only temporary relief so we perform them with increasing frequency, requiring significant time and energy. They also reinforce our belief that we can't cope with distress on our own, making obsessions more intense. Not to mention that compulsions detract significantly from our quality of life and draw us away from things we actually value—this is clear in Sarah's case.
In a way, Sarah's symptoms are especially tricky. To the observer, she doesn't have compulsions. She's not sitting in lecture cleaning her laptop over and over, praying out loud, or repeatedly asking other people to reassure her that she's not a violent person. Nor is she avoiding everything and spending all day in bed. There's no obvious reason someone else would intervene on Sarah's behalf and ask her what's going on. And so there's an even greater likelihood that she'll continue coping on her own until something forces the issue.
Though they shift over time (this is common), Sarah's obsessions are currently centered around the possibility that she'll harm someone else. In fact, this possibility exists for all of us, all the time, whether the harm would be intentional or accidental. Most people accept this fact passively, briefly considering it every once in a while. But Sarah's mind has latched onto it, and is constantly serving up unimaginably distressing thoughts. It's as if the obsessive mind is suddenly more imaginative than ever.
Pure OCD and hidden compulsions
There's little doubt that Sarah experiences obsessions, but it's less clear that she's using compulsions to get relief. Our cultural conception of OCD is unfortunately quite inflexible, hooked on stereotypical behaviors like hand-washing. This puts us at a great disadvantage when it comes to noticing, and responding to, more nuanced signs of distress. In other words, we're too hooked on the idea that OCD looks a certain way to think about other ways people would try to cope with constant, disturbing thoughts.
Eventually, psychologists like Dr. Steven Phillipson started to talk about Pure O (also known as Pure OCD or Purely Obsessional OCD), a form of OCD without observable compulsions. Dr. Phillipson acknowledges that this term wasn't meant to suggest a scientific difference—which would imply a different cause and treatment strategy—but to give people a new way to identify with their symptoms. The concept of Pure O is also a tool to help us recognize people without visible compulsions. Here's Chrissie Hodges, OCD advocate and Peer Support Specialist, talking about Pure OCD:
When Sarah forces herself to mentally draft a list of twenty-five reasons she could never be a school shooter, she's using a compulsion (mental checking) in response to her violent thoughts. She's reassuring herself that her thoughts couldn't actually come true, but the relief is fleeting. She might try to force thoughts out of her head by thinking other things—a type of avoidance—saying prayers in her head, reviewing her memories to check for warning signs, and so on. Anything she's repeatedly doing or thinking in an effort to get away from her thoughts is a compulsion.
Pure O itself comes in many forms, and people's obsessions can center around any topic. Common obsessions relate to relationships, sexuality, harm, contamination, responsibility, and religious or moral scrupulosity. Compulsions are just as varied, and tend to develop over time. Plus, as in Sarah's case, people's symptoms may change for any number of reasons.
Getting help for Pure OCD
People like Sarah tend to go a long time without getting help. Studies estimate that it takes eleven years, on average, for someone with OCD to get treatment. This delay may be even longer for those with Pure O, who are less likely to be spotted and offered support. Helping people learn about OCD and self-identify as someone who may need professional help is therefore especially important for people with this form of OCD.
The good news is that the fundamental aspects of OCD treatment work just as well for Pure O. Mental compulsions are compulsions too, and evidence-based therapies like exposure and response prevention (ERP) have a high rate of success. Sometimes working with your therapist to understand your mental compulsions can take a bit longer, and exposures may be tough to design as our minds slip quickly into old habits. But, with some practice and the attention of an OCD-trained therapist, Pure O is highly treatable.
This means people like Sarah will have to self-advocate and try something truly different to reverse the compulsive cycle that has built up in their minds. But the immense reward of winning your time and energy back from compulsions might be worth all the hard work.