Obsessive Compulsive Disorder

Yes, technically, you can have OCD without compulsions. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), OCD is diagnosed when someone suffers significantly from obsessions OR compulsions. The diagnosis does not require both. However, expert OCD researchers and clinicians believe that this is based on a misleading technicality. The DSM criteria were developed with a distinction between internal events (thoughts, images, urges–i.e., obsessions) and external events (observable ritualistic actions, like hand-washing–i.e., compulsions). This distinction is many decades old, and it is not up to date with current research and clinical expertise. Contemporary OCD experts recognize that compulsions are often mental—for instance, repetitive counting or mental checking—and what matters most is not the internal/external distinction but rather the function of the behaviour. If something is done repetitively to reduce anxiety, it is a compulsive behaviour, even if it is internal or mental. Therefore, in practice, it is rare to have obsessions without any compulsions whatsoever. There are usually at least mental rituals, such as reviewing and analyzing thoughts. Still, the DSM distinction has some practical value because not everybody knows how to properly assess OCD, and some clinicians may overlook mental compulsions. Therefore, the DSM’s allowance for a diagnosis on the basis of just obsessions prevents some sufferers from slipping through the cracks.

Yes, you can treat “Pure-O” OCD with ERP even when there are no obvious compulsions or rituals. “Pure-O” is a term used by the OCD community to refer to OCD that is “purely obsessional”, meaning there are no compulsions. However, there is a misconception about what counts as a compulsion. Many people believe that a compulsive ritual has to be externalized—like washing hands, or checking the stove. However, compulsive behaviours can be predominantly mental. “Pure-O” is not truly “purely obsessional”. It is just that the compulsions are internal and invisible. The most common compulsion in “Pure-O” OCD is to repeatedly check and monitor internal experiences, such as thoughts (Did I think anything wrong or bad?), feelings (Am I attracted to my partner?), and sensations (Did I just experience sexual arousal in an inappropriate way?). Reassurance-seeking is another common compulsion in “Pure-O”. Many sufferers search repeatedly and excessively for reassuring information, be it through online research, or by asking others for their perspective. ERP therefore is just as applicable for “Pure-O” OCD as it is for other common subtypes. While Exposure (E) helps sufferers confront anxiety provoking situations, Response Prevention (RP) helps them reduce the internalized rituals and reassurance-seeking that keep OCD alive.  

Yes, technically, you can have OCD without obsessions or intrusive thoughts. OCD is diagnosed when someone suffers significantly from obsessions or compulsion. A diagnosis does not require both. However, many compulsions have an obsession behind them, even if this is just an an urge to ritualize, without an obvious intrusive thought or image. This often occurs when OCD has been present for many years. Over time, the urge to ritualize becomes stronger and stronger and the intrusive thoughts and images that initially triggered the urge become so automatic that they escape awareness. When this happens, there is a strong link in the brain between a situation and an action and no conscious thought is needed to connect the two. However, that does not mean that the obsessional beliefs are not still operating underneath the surface. An experienced OCD therapist can help you identify the beliefs and fears that are driving your rituals.

OCD is commonly a disorder of doubt. Individuals with a professional diagnosis will often struggle with this question, even after a diagnosis is given. If you are doubting a diagnosis that has already been made by a qualified professional, ask yourself if this question is fuelled by uncertainty and fear, and whether you really need to be assured. If you do not have a diagnosis yet, seek out a qualified mental health professional to conduct an assessment. An assessment will not only answer your diagnostic question, but will provide helpful recommendations for the distress you are experiencing.  

A key part of therapy involves preparing for ERP with cognitive therapy. This includes exploring thoughts, beliefs, and expectations that are making you too scared to change, or even preventing you from seeing that a new way of coping is possible. In the preparation phase, your therapist patiently and supportively seeks to understand how your beliefs may be blocking you from moving forward, and will help you look at things in a new way so that you feel more trusting, confident, and willing to experience temporary discomfort for the sake of lasting relief from OCD. 

The best thing you can do to enhance the success of ERP is to follow through. At the end of the day, all the power for change lies with you. One of the most important factors in the success of ERP is the client’s willingness to experience some anxiety and discomfort in the short term in order to establish long-term resilience to OCD. A trained OCD therapist will understand that this does not necessarily come easily and will work with you to develop your willingness to power forward. Once you and your therapist are on the same page about the goals and pace of therapy, make sure to “go all the way”. Engage in your exposures without resorting to safety behaviours. Do the homework that is assigned. And commit fully to acceptance of uncertainty and discomfort. As you find success in your therapy, you will notice your willingness increase, and you may be surprised by how quickly you can move forward from intrusive thoughts and rituals when you are fully committed.