Intrusive thoughts (or Pure O OCD)
Intrusive thoughts (or Pure O OCD): one of the least widely known types of OCD but also one of the most prevalent and distressing. This is by far the most common type of OCD we treat at the OCD Clinic, with over 75% of clients presenting with intrusive thoughts as their primary problematic issue.
When non-sufferers think about obsessive compulsive disorder they usually associate OCD with contamination, checking, hoarding or ordering. What is much less widely appreciated is that there are millions of sufferers worldwide whose OCD does not fit into these ‘traditional’ categories.
Often clients present having gone months or even years without realising that their dark or uncomfortable thoughts can be diagnosed as OCD. Sometimes there have tried other therapies that have not helped or may even have had a therapist who has made things worse by a fundamental lack of knowledge about OCD and the varieties it can take. Such therapists offer may unhelpful advice about the nature of the intrusive images and what forms and maintains them.
In today's environment clients often discover the true nature of their anxiety by researching online or a chance reading of an article. The realisation can come as a relief, though often does not come with an easy self managed solution. Despite this people can battle on with self-help books, or endless online research looking for a eureka moment. But Pure O or intrusive thoughts OCD is notoriously difficult to self treat. This is because the primary intervention, exposure and response prevention (ERP) can be difficult to implement without expert guidance. Some of the more common types of intrusive thoughts are outlined below:
Harm OCD and Self Harm OCD: Involves fear of causing harm to others or ourselves. These intrusive thoughts can be of a range of different types of images and fears. Sufferers may get images of themselves pushing someone in front of a train or bus. Or perhaps images of picking up a household knife and stabbing a loved one. Sufferers worry that they might be “going crazy” or be a secret psychopath. The problem may develop to the point that the sufferer stops taking public transport, or removes the knives from their house. Whilst this may bring temporary relief it rarely solves the problem.
Self harm OCD: A related fear is that the sufferer may harm themselves and may go as far as kill themselves. Reading about suicide or watching a TV program that deals with the issue causes extreme anxiety. Images of themselves jumping off a bridge or hanging themselves can play on a loop inside their heads. This condition is often misdiagnosed as depression with suicidal ideation or intent, and needs expert care to distinguish whether it is OCD or something else. As a very general guideline, those with OCD will become very fearful in thinking about suicide, those with actual suicidal intent usually have a different response.
Sexual Assault or Paedophilia OCD: These forms of OCD contain thoughts of a sexual nature involving violent or disturbing images and fears. Such thoughts often include fears around sexual assaults of children or adults. Sufferers can fear that they are at risk of carrying out these assaults, or that they might have done so in the past or may be capable of doing so in the future. There can be great distress of the thought of being such an abuser and the effect on the victims. Often there is extreme distress at the thoughts about how being exposed will affect our families, friends and our own wider reputation. Even if the person is convinced they would not carry out such an act, the simple fact that they are having such thoughts and doubts can be deeply disturbing in itself.
Extreme Sex OCD: Sufferers are plagued with intrusive sexual thoughts of a disturbing graphic nature that go against the person's normal sexual interests. Images of relatively extreme sexual partners, sexual activities or situations cause the sufferer to doubt and question themselves. This often leads to people worrying about what sort of person they might be and getting extremely upset about the unhelpful conclusions they may come to.
Homosexual OCD and Trans OCD: Fears around sexual identity and whether one might be homosexual or transsexual. Sufferers obsess about whether they find people of the same gender sexually attractive or whether they might really be trans but haven’t realised it yet. This can be a difficult condition for the sufferer to recognise, as they often assume their discomfort stems from the difficulty many actual gay or trans people experience in coming to terms with their identity and indeed coming out. Most often those presenting with this type of OCD are not, in fact, homophobic or transphobic in the sense of judging people who happen to be gay or trans in a negative sense. What they are afraid of is that their identity is not certain to them, and that this is perceived as being very threatening.
Relationship OCD: Sufferers can become obsessed about their relationship, and whether they should be with their partner. They might find themselves recognising someone who is not their partner as being physically attractive, and being deeply disturbed by the idea that this means they are with the wrong person. Or perhaps they might not 100% feel like being intimate with their partner on an occasion and misinterpret this as some kind of fundamental problem with the relationship. This time of OCD is often increased at some of the key moments in a relationship like moving in together or getting married.
Existential OCD: Sometimes the concerns are of an existential nature with questions about being and existence causing extreme anxiety. Am I real? Why are we here? What happens when we die? Does life have any great purpose or is it all just a cosmic accident? Is there a God? It might be normal for someone to ponder the greater questions of reality at some point in their life. What distinguishes such normal questioning from existential OCD is the unhelpful levels of distress and discomfort the sufferer experiences when pondering such ‘big’ questions.
Bodily functions or Somatic OCD: A less common but no less distressing form of OCD. Sufferers experience excessive awareness of benign bodily functions such a blinking or breathing. People can become hyper aware of noises in their environment, or focus on things within their field of vision. For example becoming obsessed with the ‘floaters’ in their eyes.
Religious OCD and Scrupulosity OCD: Although these types of OCD are often connected, they can manifest as separate conditions. Religious OCD involves excessive concern that one might be committing some level of offence against a higher power, most usually God, Allah or Jehovah. These transgressions are often feared in terms of the impact they might have for life after death, and whether the sufferer will be punished in the afterlife for these mistakes. Compulsions can include excessive prayer, or trying to play back past events in the attempt of achieving certainty that no blasphemy or sin has been committed.
Scrupulosity OCD is an excessive concern that one might be unwittingly breaching some sort of moral code. The concern that such lapses might reflect badly on the person's character, and be indicative of them being a bad person or immoral in some way. Excessive guilt can feature strongly in a range of OCD presentations, and is an important component in Scrupulosity OCD.
We should finish by briefly mentioning a misnomer about Pure O OCD. Before you keel over in fright let me clarify me say that intrusive thoughts OCD definitely exits. But though the compulsions may not be visible, it doesn't mean they don't exist. Rather they are more covert or hidden then a more obvious form of OCD such as checking. For example, a person with homosexuality OCD might compulsively check if they are attracted to their same sex friends, or check with themselves if they are aroused when looking at an image of a celebrity in a picture.
All OCD will have a compulsive element to it, though it might sometimes take an experienced therapist to help you understand your own compulsions.
Once thought impossible to treat due to the covert nature of the unhelpful behaviour to be challenged, modern techniques such as imaginal exposure as part of the exposure and response prevention brings about excellent results for sufferers.