pure o ocd case study

Overcoming OCD: a Case Study of “Pure O”

photo by Niklas Hamann

Is overcoming OCD even possible? When all your compulsions play out in your head?

Writer Jenni Brooks shares her personal journey of primarily obsessional OCD . 

How it all began

“When I was seven, I got scarlet fever . I was put on antibiotics and had two weeks off school. After that period was up, I seemed fine. Physically, at least.

After my first day back at school I watched the Guinness World Records on TV. There was a section in which a woman swallowed a sword and then pulled it up again without damaging her organs.

After the episode finished, I wondered what would happen if I went into the kitchen, picked up a knife, and swallowed it.

I remember thinking that thought was strange. I knew I didn’t want to ram a knife down my throat. But the more I thought about it the harder it was to stop thinking about it.

After that, I started getting many other disturbing thoughts. What if I stabbed my sister to death while she was sleeping? What if I gorged my own eyes out? Or if I shaved my head?

And then came my breaking point

I finally reached breaking point while on a family holiday to Greece a few months later. In a public bathroom I saw a bottle of bleach and wondered what would happen if I drank it.

This triggered a three hour meltdown . And afterwards I couldn’t even relax in our hotel room, because I knew there was a bottle of bleach next to the toilet.

Struggling to get therapy 

By: Ashlee Martin

After coming back from Greece, my parents took me to see my GP.  

I was referred to my local children’s hospital, because my GP thought I may have a rare condition called PANDAS Syndrome. This is where a strep infection triggers an autoimmune response that attacks part of the brain. It can cause a range of rapid onset neuropsychiatric conditions, including obsessive compulsive disorder (OCD) .

After one appointment at the hospital, the psychologist decided not to proceed with any treatment. My symptoms were too puzzling. I wasn’t displaying typical OCD symptoms , like excessive hand-washing. Instead, my main symptoms were excruciating intrusive thoughts with no overt compulsions.

I guess there just wasn’t as much talk then, even with mental health practitioners , about ‘ pure O ‘, primarily obsessional OCD. Where your compulsions take place in your mind. Which is why I’m writing this case study about overcoming OCD. So fewer kids like me get overlooked.

My OCD symptoms just got worse

After being discharged from hospital my symptoms didn’t get better, they got worse. And I also had the added guilt of believing that I made up my symptoms.

No one told me why I got discharged. I was left to assume that I had put it on for attention . After that I no longer felt able to tell anyone what I was going through.

I kept this up for six years. But when I was 13, I started having intrusive thoughts about sex.

I couldn’t make eye contact with my reflection in the mirror because I was so disgusted by my myself and my thoughts.

I couldn’t take it anymore. Finally I told my mum that I was still getting distressing thoughts. She then took me back to the doctor who referred me to mental health services.

A doctor who finally listens

photo by Humberto Chavez

The doctor was very patient. She asked my mum to leave the room so I could talk to her on my own. She told me that I wouldn’t tell her anything that would shock her, because she’d heard it all before.

This appointment in particular helped me a great deal, because it was the first time I ever really felt listened to .

The wait for an NHS therapist

Trying therapy with the nhs.

In the end I had a six-month course of cognitive behavioural therapy (CBT) on the NHS. I liked the therapist, but this sort of therapy focuses on looking at your unbalanced thoughts .

By: Joe Houghton

Because I was so ashamed of my thoughts , I didn’t feel comfortable enough to discuss them in much detail.

I tried another three months of CBT when I was seventeen, but it still wasn’t working for me.

Then when I was 19, I also had a course of exposure therapy for 6 weeks. Exposure therapy aims to expose sufferers to triggers, so that they feel more comfortable being around them. For instance, if a sufferer is fearful of germs, they may be made to not wash their hands after blowing their nose, just so that they can see that they wouldn’t catch a serious disease.

I didn’t have any overt triggers that exacerbated my symptoms because my OCD was purely focused on intrusive thoughts. So I didn’t find this type of therapy very helpful. I think you’d need to work with an exposure therapist who was a specialist is purely obsessional OCD to have results.

What therapy works for overcoming OCD?

In the end I decided to save up so I could get private therapy instead. Then I could see someone straight away , instead of going back to my GP to be put on yet another waiting list. I could also pick and choose which therapy was right for me .

In the past few months I have been seeing an integrative therapist . And I finally have a feeling I am moving forward. My therapist combines elements of different therapies, such as cognitive behavioural therapy (CBT) and dialectical behaviour therapy (DBT) ,  and mixes them together to make it more individualised for each client.

What is different this time is that my sessions are less focused on my symptoms themselves, and more focused on how they came about in the first place. I nstead of addressing my thoughts head on, we are instead going through the reasons as to why I’m having the thoughts.

At first, I was quite guarded with this new therapist, but this was probably because I had been disappointed so much in the past and I was doubtful that this type of therapy would work and see me overcoming OCD. But now I’m feeling hopeful.

Me, beneath the OCD

I have noticed that a lot of my thoughts seem to be orientated as to whether what I’m experiencing is true or false. Am I making up my symptoms? Am I actually good at my job? Did I accidentally kill someone 3 years ago?  

Now I know that the pattern of these thoughts stem from when I was little, and I was convinced I had made my symptoms up. This is why they have taken on that theme. I still subconsciously don’t know if my symptoms are real or fake.

Although my intrusive thoughts may never go away completely, knowing why these patterns re-occur has made my life a lot easier. I can rationalise my thoughts in a way I couldn’t before because I know why they are happening. I no longer feel defined by them.

You are not alone

If you have OCD, remember that your thoughts don’t define you, and having distressing thoughts doesn’t mean that you’re going to act on them.

Even though the thoughts you are having are horrifying and alienating, there are countless others who are going through the same struggle as you are. Just keep going.

Overcoming OCD is quite the battle. But whether I want them to or not, my intrusive thoughts have made me into who I am today, even though I am no longer defined by them.

Do you worry you might have OCD? Harley Therapy connects you with top London psychotherapists who offer therapy for OCD . from the comfort of our central London clinics. Alternatively, use our booking site to find UK-wide therapists for OCD as well as online counsellors you can talk with from home, therapists for all budgets. 

Jenni Brooks is a freelance blogger and journalist currently studying an MA Creative Writing at the University of Birmingham.

Hello, I enjoyed your story. It runs somewhat parallel to mine. Had major onset senior year of high school, had compulsions I had to get over first, hours in the bathroom, ruined vacations etc. went to Mclean hospital in Boston which I was told is the foremost ocd treatment center in America, maybe the world – not sure about that bit but it sounds good to me. Had an incredible time with other people with different kinds of terrible ocd, met some very informed and interesting therapists. Tried exposure response, didn’t work. Went back to Kansas, haven’t had a therapist since then. This was years ago at this point. When I got back I had a renewed energy to overcome my ocd and the ocd also kind of morphed into mental ocd and pure O after I got over the compulsions of which I had many – which cycled through a numerous amount of increasingly nuanced mental issues (themes) each digging into my mind deeper than the last and seeming more complex. My life has been consumed by ocd. I have been dealing with ocd digging in and weaving a complex tapestry of symptoms for long enough to become familiar with how it works and develop the skills myself to rationalize and overcome my ocd to a certain extent. My ocd has latched onto themes which seem impossible to shake but faith in myself never falters. Since ocd has taken over my life I have taken learning how to overcome it very seriously. I have been learning the steps purely through observing my own first hand experiences, finding the mental tools and awareness I need to move forward – and also with the major benefit of a great, smart, supportive family and friends. I like the idea of defeating it without a guide, so I’ve become my own guide and it has made me a greater and stronger person, for that I thank my OCD, though I’m not a master yet and still have many hurdles and changes in perspective to overcome. I’m 27 now and have been struggling hard living with ocd for a good 8 years. Recently I have been struggling with ocd with tv and videogames and social anxiety/issues. I’ve probably had ocd with tv and picture settings the whole time but right now I can’t be comfortable with the angle of the tv because it washes out the colors, I really like to get immersed and look at the scenery in games so this is a big problem. I can’t really sit down and enjoy a game anymore, I spend hours getting up and moving the tv or angle milimeters or centimeters and sit down get up and sit down over and over till the anxiety is too much to enjoy the game at all anymore, I don’t have an outlet to relax because my mind is constantly revving with overthinking and not being able to project myself in front of people because being funny requires good delivery and if you’re ridiculously awkward when it comes out like my ocd wants me to be then it doesn’t work. I can’t go to my parents to have a relaxed safe place and see the dogs because coronavirus and my dad is taking coronavirus really seriously because of heart issues. So I’m here trying to lift myself out of my depression and figure out the natural way to train myself and get over the social shit, tv I just have to sit with it but it’s really hard because I’m not enjoying the game while I’m playing, the hypersensitivity gives me a headache, I feel like whatever game I force myself to sit through will be a wasted experience because I can’t enjoy it, there are many factors – all the while my personality is being drained because my ocd (myself) will not allow me to have confidence, it will make me awkward through hypersensivity to muscular movements and intrusive thoughts and whatever it can pull out of me to make me awkward in front of people and not be able to be myself and be funny. Comedy is the greatest thing in life, one of the things I believe. OCD strips me of my ability to involve myself with it to a certain extent, and develop my personality with people. There are variables that change how I feel and how easy it is to deal with day to day. It’s always comforting so see a bit of a parallel story so thank you for sharing. I strive to learn every day but also to stop and relax and not think and not care. It’s a tough and depressing life but once I figure out how to pull myself up and out of my depression and anxieties and I will have complete control over myself, it will always be hard but I will feel I have all the tools necessary and will not lose those tools – an idea that also may be a bit ocd and somewhat false which I am just now realizing. Realizations happen all the time, it’s a good thing, they are signs of progress. I wanted to share my story, hope you see it, let me know if you do.

Hi Seth, thanks for the share. The post was by a guest writer. We find your story interesting. We encourage clients to realise that they are a person who happens to also have OCD, not just an OCD person. So we’d question what this gives you, this need to be seen as an unsolvable, more difficult than usual case, coupled with a refusal to seek support. Who would you be WITHOUT the diagnosis? And are you comfortable with that, deep down? Or are you more comfortable with being different and special? Would you be willing to give being a special case up? As we see many, many clients recover from OCD. But that requires properly and fully making the choice to get better and, yes, fully committing to finding support that works. Just because one place didn’t doesn’t mean another won’t, and the best recovery centre in the world won’t work if you deep down don’t want it to, despite protesting that all you want is to figure it out. Best, HT.

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'Pure O': An Overview of Pure Obsessional OCD

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

Pure O vs. OCD

Symptoms of pure o, getting diagnosed, other types of ocd, treatment for pure o.

Pure O, also known as purely obsessional OCD, is a form of OCD marked by intrusive, unwanted, and uncontrollable thoughts (or obsessions). While someone experiencing Pure O may not engage in obvious behaviors related to their intrusive thoughts, such as counting, arranging, or hand-washing, the disorder is instead accompanied by hidden mental rituals.

Pure O is sometimes mistakenly seen as a “less severe” form of OCD. For those who experience symptoms of this disorder, the characteristic intrusive thoughts can be very disruptive and distressing.

While people who do not report engaging in compulsions are sometimes referred to as having "pure O" or "purely obsessional OCD," this variant is not listed as a separate diagnosis in the DSM-5 , the diagnostic manual used by many physicians, psychiatrists, and psychologists.

While some studies have suggested there may be different subtypes of OCD, others suggest that the term "pure O" may be something of a misnomer. While people who experience these obsessions without any obvious behavioral compulsions, they do still engage in rituals that are mental and unseen.

"Recognition of compulsions performed by those previously considered purely obsessional can aid in the improved diagnosis and treatment of people with OCD," explains clinical psychologist Monnica T. Williams and her colleagues in their article "The Myth of the Pure Obsessional Type in Obsessive-Compulsive Disorder."

By understanding that such mental rituals exist, therapists and other mental health professionals can ask patients about these symptoms. Without such questioning and prompting, patients may be reluctant to describe the symptoms that they are experiencing or may not even be aware that they should discuss these symptoms.

Obsessive-compulsive disorder itself involves having reoccurring obsessions and behaviors (compulsions). For example, a person with OCD might have uncontrollable thoughts about germs and cleanliness that result in an urge to wash their hands over and over again.

People who experience a "purely obsessional" form of this disorder still experience a range of OCD symptoms , although the obvious compulsions are absent. According to the DSM-5, OCD is characterized by obsessions and/or compulsions.

Repeated intrusive images, thoughts, and impulses that create a great deal of distress

Making attempts to ignore, suppress, or neutralize the obsessive thoughts

Repetitive actions, either behavioral or mental, that a person feels compelled to perform as a result of obsessive thoughts

Engaging in actions intended to reduce distress related to the obsessions or preventing some dreaded event

Obsessions   are recurrent, persistent, intrusive, and unwanted thoughts, images, or urges that cause anxiety or distress. Obsessions often center on somatic, sexual, religious, or aggressive thoughts as well as concerns with things such as symmetry and contamination.

Compulsions

Compulsions , on the other hand, are repetitive behaviors or mental acts a person with OCD is driven to perform in response to an obsession or according to a rigid set of rules that govern them. Compulsions are clearly excessive or not connected in a realistic way to the problem they are intended to address.

In a 2011 study, researchers found that individuals who experience the "pure obsessions" (sometimes described as "taboo thoughts" or "unacceptable thoughts") also engage in mental rituals as a way of managing their distress. These rituals might include:

• Mentally reviewing memories or information
• Mentally repeating certain words
• Mentally un-doing or re-doing certain actions

People distressed by obsessive thoughts may also compulsively seek reassurance . This can be problematic because many patients may not even recognize it as a compulsion. Such reassurance-seeking may involve:

• Asking others for assurance
• Avoiding anxiety-provoking objects or situations
• Looking for self-assurance
• Researching online

An added complication of this symptom is that family and friends may become fatigued or annoyed by these constant requests for reassurance, which may be perceived by others as neediness.

Compulsions still exist in pure O, but they are much less obvious because they are almost entirely mental in nature.

In addition to experiencing obsessions and/or compulsions, the DSM-5 diagnostic criteria for OCD also stipulate the following:

• OCD symptoms must not be due to the physiological effects of a substance (such as a side effect of a medication or illicit drug). The symptoms must also not be due to the presence of some other medical condition.
• OCD symptoms are time-consuming, often taking more than one hour per day, or they must create significant distress or impairment in occupational, social, or other critical areas of life functioning.
• OCD symptoms are not better attributable to another mental disorder such as generalized anxiety disorder, body dysmorphic disorder , hoarding disorder , substance-related disorders , or major depressive disorder.

If you or someone you love are experiencing distressing symptoms that keep you from participating in everyday activities (such as eating, sleeping, or going to work), contact a mental health professional.

Although there is limited research on the exact causes of pure O, there are a variety of studies that have investigated OCD and its causes. These may include:

• Biological factors : MRI brain scans reveal structural and functional differences in neuronal (nerve) circuits in the brains that filter or "censor" the many thoughts, ideas, and impulses that we have each day.
• Family history : Research has been difficult due to the inability to recruit "pure" cases of OCD. However, studies have found pure O to be five to seven times more common in people who have relatives with OCD.
• Genetics : While researchers have yet to determine a single "OCD gene," the disorder may be related to variations in particular groups of genes.

Previous research suggests there may be as many as three to six subtypes of OCD, including the pure O form of the disorder. First described in a 1994 article in the Journal of Clinical Psychiatry , pure O was described as being composed of sexual, aggressive, and religious obsessions that were not accompanied by compulsions.

Later, research further divided aggressive obsessions into fears over impulsive harm and unintentional harm. Those thoughts centered on impulsive harm often focus on what is sometimes termed "taboo thoughts" related to sex, religion, and aggression. Some common types of OCD experienced by those with pure O might include:

• Harm OCD : Fears about causing harm  to oneself or others; variations include physical harm (aggression toward or killing oneself or another) and sexual harm, including harmful sexual behavior toward children
• Pedophilia OCD (pOCD) : Unwanted sexual thoughts and urges related to children, sometimes accompanied by rituals such as counting, washing, or prayers to "neutralize" such thoughts and urges
• Relationship OCD (ROCD) : Unwanted, intrusive thoughts that make people doubt their feelings of attraction or love for their partner as well as their own level of sexual desirability or long-term compatibility
• Sexual orientation obsessions in OCD (SO-OCD) : Extreme anxiety about sexual orientation; also called HOCD, or "homosexual OCD."

Treatment for OCD, including pure O, often involves the use of medication in combination with psychotherapy , which can include cognitive-behavioral therapy (CBT), support groups, and psychological education.

Psychotherapy

Research suggests that cognitive-behavioral therapy can be very effective at treating pure O. However, it is essential that therapists and other mental health practitioners understand the importance of addressing the underlying mental rituals that characterize this subtype of OCD.

If the therapist believes that the patient only suffers from obsessions and does not also treat the mental rituals that accompany these cognitions, the treatment will not be as complete or effective.

In 2011, researchers examined individual studies to see if certain symptom subtypes of OCD responded better to particular treatment approaches. They found that in the majority of studies, OCD characterized by religious and sexual obsessions without compulsions (i.e., pure O) was associated with a poor response to treatments using SSRIs and exposure and response prevention.

Exposure and response prevention, also known as ERP therapy, is a form of behavioral therapy also used in the treatment of other presentations of OCD. It involves a trained therapist helping a client approach a fear object without engaging in any compulsive behaviors.

Clients intentionally expose themselves to those things that trigger their obsessions or compulsions but are prevented from engaging in compulsive behavior or obsessive thoughts. The goal of such therapy is to teach patients how to manage their symptoms without acting upon compulsions. This increases distress in the short term, but can improve symptoms and behaviors over time.

Medications may include selective serotonin reuptake inhibitors (SSRIs) or the tricyclic antidepressant Anafranil (clomipramine). Second-generation antipsychotics, also known as atypical antipsychotic medications, are also used to augment SSRIs. One review suggested that approximately 40% to 60% of patients respond to treatment with SSRIs with a 20% to 40% reduction in OCD symptoms.

The specific treatment (or combination of treatments) depends on a patient's particular needs. For example, a therapist may use CBT alone if a patient is unable to or doesn't want to take medication. Or, they might prescribe medications alone to patients who aren't motivated to pursue exposure-based treatments or who don't have access to a CBT provider.

Although treatment for OCD usually entails consulting with a qualified mental health professional, there are a number of  OCD self-help strategies  that you can start using right now to help you or someone you love cope with pure O symptoms.

• Relaxation strategies : Given that stress is a major trigger of pure O symptoms, one of the best ways to cope is to learn and practice  relaxation techniques such as deep breathing, mindfulness meditation, or progressive muscle relaxation.
• Exercise : There is growing evidence that engaging in aerobic exercise can reduce the symptoms of OCD.  
• Support groups : Both online and in-person support groups can be of enormous benefit for people with pure O (as well as their loved ones ) by providing resources, information, or simply a compassionate, listening ear.

Pure O may not involve the outward behaviors that often come to mind when people think of OCD. However, the hidden mental rituals that characterize the purely obsessional form of the disorder are a type of compulsion, even though they may go unseen.

If you find yourself experiencing distressing obsessions and/or mental compulsions that are interfering with your daily life, consider talking to a mental health professional. They can help you understand your symptoms and find the best treatment to meet your needs. Though talking about your thoughts isn't always easy, it is the first part of getting the help you may need to find relief.

If you or a loved one are struggling with Pure O, contact the  Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline  at  1-800-662-4357  for information on support and treatment facilities in your area.

For more mental health resources, see our  National Helpline Database .

Stewart SE. Obsessive-compulsive disorder . In: Camprodon J, Rauch S, Greenberg B, Dougherty D, eds. Psychiatric Neurotherapeutics. Current Clinical Psychiatry . New York: Humana Press; 2016. doi:10.1007/978-1-59745-495-7_2

Williams MT, Farris SG, Turkheimer E, et al. Myth of the pure obsessional type in obsessive-compulsive disorder . Depress Anxiety . 2011;28(6):495-500. doi:10.1002/da.20820

Norman LJ, Taylor SF, Liu Y, et al.  Error processing and inhibitory control in obsessive-compulsive disorder: A meta-analysis using statistical parametric maps . Biol Psychiatry . 2019;85(9):713-725. doi:10.1016/j.biopsych.2018.11.010

Rahimi A, Haghighi M, Shamsaei F. Pure obsessive compulsive disorder in three generations .  Iran J Psychiatry Behav Sci . 2015;9(2). doi:10.17795/ijpbs1116

Baer L. Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders . J Clin Psychiatry . 1994;55 Suppl:18-23.

Starcevic V, Brakoulias V. Symptom subtypes of obsessive compulsive disorder: Are they relevant for treatment? . Aust N Z J Psychiatry . 2008;42(8):651-661. doi:10.1080/00048670802203442

Abramowitz JS, Deacon BJ, Whiteside SPH. Exposure therapy for anxiety: Principles and practice . Guilford Press; 2011.

Law C, Boisseau CL.  Exposure and response prevention in the treatment of obsessive-compulsive disorder: Current perspectives . Psychol Res Behav Manag . 2019;12:1167-1174. doi:10.2147/PRBM.S211117

Kellner M. Drug treatment of obsessive-compulsive disorder .  Dialogues Clin Neurosci . 2010;12(2):187-197. doi:10.31887/DCNS.2010.12.2/mkellner

Manjula M, Sudhir PM.  New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies .  Indian J Psychiatry . 2019;61(Suppl 1):S104-S113. doi:10.4103/psychiatry.IndianJPsychiatry_531_18

Abrantes AM, Brown RA, Strong DR, et al.  A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment . Gen Hosp Psychiatry . 2017;49:51-55. doi:10.1016/j.genhosppsych.2017.06.010

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

How does "Pure-O" obsessive-compulsive disorder impact on a patient's treatment plan?

Affiliation.

• 1 Brain Center Firenze, Firenze, Italy.
• PMID: 37856308
• DOI: 10.1080/14737175.2023.2273388

Keywords: CBT; OCD; Pure-O; SSRI; symptom dimensions; treatment preditctors.

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Pure O: What Is Pure Obsessional OCD?

October 2, 2023

Most people associate obsessive-compulsive disorder (OCD) with compulsive behaviors such as excessive double-checking appliances are off, incessant washing and cleaning, or obsessive arranging of things. However, not all types of OCD involve these stereotyped compulsions. One lesser-known form of OCD does not involve outwardly visible compulsive behaviors. It’s called “pure O” (short for pure obsessional OCD) or pure OCD. Let’s take a closer look at this often misunderstood OCD type.

OCD is typically associated with the compulsive behaviors mentioned above. But this is a very narrow and imprecise view of the condition, which affects an estimated 1.2% of U.S. adults. This stereotypical view also tends to minimize the pain, disruption, and distress the disorder causes. It underscores how OCD is frequently misunderstood —even amongst mental health professionals. Indeed, research shows that OCD is misdiagnosed 50% of the time.

Researchers and mental health experts have noted 5 subtypes of OCD, which are based on the grouping of symptoms. They include:

• Over-responsibility for harm (pathological doubt, somatic obsessions/checking, and reassurance-seeking compulsions)
• Taboo (aggressive, sexual, and religious obsessions/mental compulsions)
• Contamination (contamination obsessions/cleaning compulsions)
• Symmetry (symmetry obsessions/repeating, counting, and arranging compulsions)
• Hoarding (hoarding obsessions and compulsions)

WHAT IS PURE O?

Pure O is characterized by intrusive, unwanted, and uncontrollable thoughts (obsessions) as well as compulsions. However, in pure O, compulsions are of the “unseen” variety rather than the more recognized behaviors such as counting, arranging, or handwashing. Basically, an individual with pure O will have obsessive thoughts, but the “compulsion” response to the distressing thoughts manifests as mental behavior.

Estimates show that pure O accounts for about 10% of OCD cases. It is most often associated with two of the 5 OCD subtypes mentioned above: over-responsibility for harm and taboo.

MENTAL OBSESSIONS IN PURE O

The recurrent, persistent, intrusive, and unwanted thoughts, images, or urges (obsessions) that typically arise with pure O might include:

• Violent thoughts of harm (including sexual harm) towards oneself or others (called harm OCD)
• Inappropriate sexual thoughts about children (pedophilia OCD or POCD)
• Doubt about feelings of compatibility, attraction, or love for a relationship partner, as well as an individual’s own level of sexual desirability (relationship or ROCD)
• Extreme anxiety about sexual orientation (sexual orientation or so-OCD)
• Over-concern about purity/religion
• Existential fears

These thoughts are often quite disturbing as they can violate an individual’s moral character. Of course, people with OCD have no control over them, and they do not reflect their values or worth as human beings. However, they can be incredibly shaming for a person to experience, and they will not typically speak of them with others, making this form of OCD hard to detect.

It is now believed that the high degree of distress and shame in having such thoughts is what triggers compulsions—such as mental ruminations and reassurance seeking—in the less-visible form that defines pure O.

MENTAL COMPULSIONS IN PURE OCD

Interestingly, when pure O was first recognized nearly 30 years ago, it was thought to be a form of OCD that had obsessions only. It’s just recently that researchers have determined that pure OCD most definitely includes mental compulsions. Experts now consider the idea of obsessional OCD to be a myth or misnomer.

Research has found these types of mental compulsions to be most common with pure O:

• Persistent seeking self-reassurance causing disruption (such as excessive research online about pedophiles or ways to figure out one’s sexual orientation)
• Mentally repeating affirmations, mantras, or phrases
• Mentally reciting a poem, a specific song, or a prayer
• Mentally reviewing actions, thoughts, and memories
• Thinking about images that provide comfort or self-soothing
• Trying to “erase” memories or images
• Mental counting

This is not a complete list. Pure O shows up differently for each individual. Additionally, with particularly disturbing intrusive thoughts, such as violent harm and pedophilia, an individual might start to avoid certain people or situations.

EXAMPLES OF PURE O

To illustrate how pure O might look in an individual, here are a few possible examples:

• A deeply religious person starts to have intrusive, unwanted blasphemous thoughts. They are so disturbing that the person does not mention them to anyone. Instead, they engage in mental compulsions to control or stop their thoughts. They may recite a prayer mentally a certain number of times at the top of each hour. Yet, the intrusive thoughts continue.
• A new mother might have intrusive thoughts or images about hurting her newborn baby. She doesn’t want to hurt her baby, of course, and feels ashamed for having such thoughts. But she worries that the persistent thoughts mean she will. She might recite a song over and over to calm her anxiety and turn off the images. But they return.
• A man finds himself aroused thinking about his daughter’s 10-year-old friend. He is sickened by the images and his response to them. He both avoids his daughter’s friend and spends incessant amounts of time on the internet reading information about how to know if you’re a pedophile.

Confoundingly, the more an individual dislikes and tries to battle, control, or repress a disturbing or unwanted, intrusive thought, the more it will persist. Some experts believe that these disturbing thoughts can activate the fight-or-flight stress response , which further increases distress.

CAUSES AND TREATMENT OF PURE OCD

Scientists have yet to pinpoint an exact cause of pure O, but several factors are involved. Family history and genetics play a role. Pure O is 5 to 7 times more common in people who have relatives with OCD.

Brain-imaging studies have revealed differences in the frontal cortex and subcortical structures of the brain of pure O individuals. These brain areas are responsible for filtering our thoughts, ideas, and impulses, as well as our ability to control behavior and emotional responses.

A type of cognitive behavioral therapy (CBT) called exposure and response prevention (ERP) is the gold standard treatment for OCD.

With ERP, the therapist encourages the patient to allow the intrusive, unwanted, disturbing thoughts to exist. The patient observes these thoughts without engaging in mental compulsions, avoidance, or reassurance behaviors. The solution is focused on the behavior that can be controlled: Ceasing the compulsive response to obsessive thoughts.

There’s tremendous hope in this kind of therapy. Research has shown ERP to be effective in treating 80% of OCD cases.

If you’re struggling with obsessive thoughts and mental compulsions, know that there are proven solutions to control them. Seeking help from a mental health professional is the first step in the healing process.

OCD and other mental health issues can’t wait. At Amen Clinics, we’re here for you. We offer in-clinic brain scanning and appointments, as well as mental telehealth, clinical evaluations, and therapy for adults, teens, children, and couples. Find out more by speaking to a specialist today at 888-288-9834 or visit our contact page  here .

6 Comments »

This is so very helpful to me! Finally, an answer to what my young-adult son has dealt with occasionally. Our searches for the cause and remedy have been unfruitful. Now we can search for a therapist experienced in ERP. Thank you!

Comment by Millie — October 9, 2023 @ 7:50 AM

I am exactly what is stated in your description of PURE O, OCD. I know without a doubt. My Psychiatrists and Psychologists in past since 1984 have missed diagnosis of OCD. Have Panic disorder, anxiety, Depression, Schuzo-Affective Disorder. I need to tell someone my life events and experiences

Comment by Steve E Bartuseck — October 9, 2023 @ 8:59 AM

This was a very interesting read. I have read that CBT therapy can be harmful to people with ocd. Could you shed some light on this please

Comment by Mike Jackson — October 9, 2023 @ 12:55 PM

Wow I truly believe I struggled with this unfortunately for many years. It started when I became very religiously obsessed and involved in a church. I went to many therapists and no one could help me understand what I was experiencing. More people need to be aware of this.

Comment by Taylor Soto — October 9, 2023 @ 6:29 PM

Thank you for addressing this subject. I have learned of this disorder from the devastation it has inflicted on my brother his entire life. He’s tried to battle this demon for years and it’s constantly rearing its ugliness and shame in my brother daily. I’m not sure who he really is anymore.. it seems to take from him such power and leaves him more helpless in how to ordeal with then the next compulsion or just adds to the ones already there that he’s trying to deal with. It has been never ending and now he’s an older man – 75 yrs He’s tried so many things and seen so many therapists.. please assist my concerns as his last remaining family member that wants to see him get rest of some sort in this lifetime or what time he has left . Can you suggest to me a way to encourage him that perhaps there has been some better study now on what to do as to some one that suffers from this.

Comment by Lisa Livengood — October 10, 2023 @ 5:47 AM

hi!,I like your writing so much! share we communicate more about your post on AOL? I need an expert on this area to solve my problem. Maybe that's you! Looking forward to see you.

Comment by vorbelutrioperbir — November 25, 2023 @ 1:31 PM

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The Myth of the Pure Obsessional in OCD

The syndrome called “pure o” does not exist..

Posted April 29, 2021 | Reviewed by Davia Sills

• What Is Obsessive-Compulsive Disorder?
• Find counselling to treat OCD
• "Pure O" is a popular term describing a person who has OCD obsessions, but doesn't seem to have any compulsions.
• Despite appearances, all forms of OCD include both obsessions and compulsions; the compulsions may simply not be obvious from the outside.
• And the most shameful forms of OCD are more likely to have covert compulsions.

What is Pure O?

Some people with Obsessive-Compulsive Disorder (OCD) describe their symptoms as being purely obsessional, or “Pure O.” For OCD , the Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM-5)—which is the manual that determines the criteria for mental health disorders—recognizes a diagnosis if either obsessions or compulsions are present. However, there is some scientific disagreement as to whether it is possible to have obsessions without compulsions—which is often called “purely obsessional” or “Pure O.” Research and clinical observations indicate that virtually all patients with OCD have both obsessions and compulsions, although compulsions without clear obsessions are sometimes seen in children and those who feel a need for things to be “just right.”

Stigmatized categories of OCD

There are four major subtypes of OCD : contamination, doubt/harm, symmetry/arranging, and unacceptable/taboo thoughts. The unacceptable/taboo thoughts symptom dimension includes stigmatized obsessions that are often of a religious, sexual , or violent nature, causing sufferers to experience increased fear and usually shame . Traditionally, people in this group were referred to as purely obsessional due to their lack of observable compulsive behaviors . Even now, many people or websites refer to this as Pure O.

It is now apparent, however, that those who suffer from these thoughts do engage in compulsions, but these rituals tend to be mainly mental in nature (e.g., praying, mental review, listening to one’s heartbeat) or otherwise mostly covert (e.g., reassurance-seeking). This symptom dimension includes those whose obsessions tend to show up as intrusive, unwanted thoughts, urges, or mental images of acts that severely violate their personal morals or values. Examples include thoughts of sexually molesting children, indecent thoughts about religious figures, and sudden impulses to act out violently.

Health anxiety can look like Pure O

People with excessive health concerns are also often represented in this category in a few ways. Examples include worrying that they have mental health problems such as a cognitive decline , that they are going crazy, or even that they might commit suicide. As with all OCD obsessions, these are actually very different than having those conditions, because the person is worried about having or acquiring the condition rather than actually having a formal diagnosis.

While such people might sound purely obsessional, they are in fact doing compulsions, but these are just not very visible. In the case of cognitive decline concerns, a person could be doing activities such as checking their memory for mistakes or seeing how fast they can count backward from 100, wondering if it is slower than it used to be. If they have OCD-related fears about being suicidal , they might be constantly checking themselves for urges to hurt themselves, assessing their mood, or gauging how badly they really want to live versus die.

Likewise, they could have health concerns; they might worry that they are going to stop breathing or have a heart attack, so they may be constantly listening to their heartbeat or monitoring the quality of their breathing. Although violence is often a prominent theme in this particular category, those who have these thoughts usually have no history of violence, nor do they act on their obsessions; however, because such individuals think their OCD thoughts are dangerous and overly important, they put a lot of mental effort into trying to suppress them. Paradoxically, attempts at thought suppression have the unwanted effect of actually increasing anxiety and perpetuating symptoms. That is, purposefully trying not to think of a specific thing often has the opposite effect of making the thought more likely to return.

Covert compulsions are still compulsions

Some research suggests that those with unacceptable thoughts may suffer from more severe obsessions than those with other forms of OCD. So, while Pure O is a commonly discussed type of OCD, and these compulsions are not overly obvious (such as someone washing their hands), they are every bit as time-consuming and real as physical compulsions.

Alonso, P., Menchón, J. M., Pifarré, J., Mataix-Cols, D., Torrres, L., Salgado, P., & Vallejo, J. (2001). Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. Journal of Clinical Psychiatry, 62, 535–540.

Leonard, R. & Riemann, B. (2012). The co-occurrence of obsessions and compulsions in OCD. Journal of Obsessive- Compulsive and Related Disorders, 1, 211–215. doi:10.1016/j.jocrd.2012.06.002

Williams, M. T., Farris, S. G., Turkheimer, E. N., Franklin, M. E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553-558.

Williams, M. T., Crozier, M., & Powers, M. B. (2011). Treatment of Sexual Orientation Obsessions in Obsessive-Compulsive Disorder using Exposure and Ritual Prevention. Clinical Case Studies, 10, 53-66.

Monnica Williams, Ph.D., ABPP, is a licensed clinical psychologist and professor at the University of Ottawa in the School of Psychology, where she is the Canada Research Chair for Mental Health Disparities.

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Does Pure O Exist?

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

• ‘Pure O’ or ‘purely obsessional’ OCD is a term used to describe people who experience unwanted, intrusive thoughts (obsessions) without any visible ritual behaviors (compulsions).
• So, while the term “Pure O” is still sometimes used, multiple research studies suggest that true purely obsessional OCD does not exist.
• When you carefully assess for mental compulsions and subtle reassurance-seeking, almost everyone with OCD appears to have both obsessions and compulsions. It’s just that the compulsions aren’t always obvious, visible actions, like hand washing or checking .
• These mental rituals can be easily missed or not recognized as OCD symptoms, since they happen internally rather than being physical actions others can observe.
• The term “Pure O” is misleading and unhelpful because it may prevent people from recognizing mental compulsions, hindering proper diagnosis and treatment of their OCD .

The Myth of the Pure Obsessional in OCD

When researchers looked more closely at people who seemed to have “Pure O” or purely obsessional OCD, they found that mental rituals and reassurance-seeking were common compulsions that had been previously overlooked.

• Mental Compulsion : A ritual you feel driven to carry out in your mind. It could be mentally repeating certain words, images, numbers, or prayers, making mental lists, or reviewing thoughts or memories repeatedly. You do it to try to ease anxiety or fears caused by upsetting thoughts, but it can become a hard habit to stop.
• Reassurance-seeking: When a person repeatedly asks others or themselves for comfort, support, or confirmation to try to reduce anxiety or doubts related to their obsessive thoughts.

Covert compulsions are still compulsions

The unobservable nature of mental compulsions may cause them to be missed or mistakenly classified as an obsession.

 The most shameful forms of OCD are more likely to have covert mental compulsions.

For example, a study by Williams and colleagues published in the Journal Depression and Anxiety in 2011 did a detailed analysis of OCD symptoms in 201 patients.

They found that mental compulsions (like mentally repeating words or phrases) and reassurance-seeking behaviors loaded together with taboo thoughts (sexual, religious, or aggressive obsessions) had been considered signs of “pure obsessions.”

This suggests that people with these obsessions did have compulsions, too – just mental ones rather than physical actions. The compulsions were subtle and easy to miss without careful assessment.

Other research has found similar results. A 2003 study by Abramowitz and colleagues published in the Journal of Consulting and Clinical Psychology looked at OCD symptoms in 132 patients.

They found that among those with religious and sexual obsessions, mental rituals were actually the most common compulsion. This was true even though, at first glance, many seemed to have no compulsions.

Here are some examples of the kinds of mental rituals they observed:

• Mentally repeating prayers or religious phrases : For people with religious obsessions, a common mental compulsion was silently reciting specific prayers or religious statements over and over again in their mind.
• Mentally reviewing or analyzing thoughts : Another ritual involved going over intrusive thoughts in detail, trying to figure out their meaning or whether they were “good” or “bad” thoughts.
• Mentally undoing “bad” thoughts : Some people felt compelled to try to cancel out or neutralize an unwanted sexual or sacrilegious thought by thinking a “good” thought right afterwards.
• Mentally reassuring oneself : Patients would often try to calm their own anxiety about the thoughts by mentally telling themselves things like “It’s just a thought, it doesn’t mean anything about me.”
• Mental reviewing of memories : To try to reassure themselves that they hadn’t actually acted on a disturbing thought, some people would mentally replay memories in detail, looking for evidence that they hadn’t done anything wrong.
• Mentally checking or monitoring your emotions : Trying to figure out if your emotional reaction is “normal” or “appropriate.”

How to Identify Mental Compulsions

Identifying mental compulsions in “Pure O” can be challenging, as these rituals are often subtle and not as observable as physical compulsions.

By increasing awareness of your thought patterns and mental habits, you can start to identify the mental rituals that may be part of your OCD cycle.

• Look for patterns : Notice if there are certain mental actions you feel compelled to perform repeatedly, especially in response to specific obsessive thoughts or triggers.
• Monitor time spent : Pay attention to how much time you spend engaged in mental rituals like analyzing thoughts, mentally reviewing memories, or repetitive prayer or counting. Compulsions often take up significant time and interfere with daily activities.
• Notice feelings of anxiety or discomfort : Mental compulsions are often driven by a need to alleviate anxiety or discomfort caused by obsessive thoughts. If you find yourself feeling anxious or uncomfortable until you complete a certain mental action, it may be a compulsion.
• Look for rigid rules : Mental compulsions often involve strict, self-imposed rules about how many times to repeat a thought or prayer, or how perfectly a mental ritual must be performed.
• Observe avoidance behaviors : Avoiding certain situations, people, or objects that trigger obsessive thoughts can be a sign that you are engaging in mental compulsions to cope with the anxiety these triggers provoke.

Some common examples of mental compulsions in “Pure O” include:

• Repetitive prayer or mental phrases
• Mentally reviewing or analyzing thoughts
• Mental counting or list-making
• Mentally “undoing” or neutralizing bad thoughts with good ones
• Seeking reassurance from oneself through mental reasoning

Is Pure O in the DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is used by mental health professionals to diagnose conditions like OCD.

The DSM-5 criteria for OCD require the presence of obsessions, compulsions, or both. The manual defines compulsions as behaviors or mental acts that the individual feels driven to perform in response to an obsession or based on rigid rules. This definition includes both observable compulsions and mental rituals.

While the DSM-5 allows for a diagnosis of OCD based on obsessions alone, it does not formally recognize “Pure O” as a distinct subtype.

The concept of purely obsessional OCD may not accurately reflect the clinical reality, as mental compulsions and reassurance-seeking often accompany obsessions when assessed carefully.

Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 71 (6), 1049-1057.  https://doi.org/10.1037/0022-006X.71.6.1049

Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Liebowitz, M., Simpson, H. B., & Foa, E. B. (2011). Myth of the pure obsessional type in obsessive–compulsive disorder. Depression and Anxiety, 28 (6), 495-500.  https://doi.org/10.1002/da.20820

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Cannabis Improves Obsessive-Compulsive Disorder—Case Report and Review of the Literature

Natalia szejko.

1 Clinic of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany

2 Division of Neurocritical Care & Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, United States

3 Department of Bioethics, Medical University of Warsaw, Warsaw, Poland

4 Department of Neurology, Medical University of Warsaw, Warsaw, Poland

Carolin Fremer

Kirsten r. müller-vahl, associated data.

All datasets presented in this study are included in the article/supplementary material.

Although several lines of evidence support the hypothesis of a dysregulation of serotoninergic neurotransmission in the pathophysiology of obsessive-compulsive disorder (OCD), there is also evidence for an involvement of other pathways such as the GABAergic, glutamatergic, and dopaminergic systems. Only recently, data obtained from a small number of animal studies alternatively suggested an involvement of the endocannabinoid system in the pathophysiology of OCD reporting beneficial effects in OCD-like behavior after use of substances that stimulate the endocannabinoid system. In humans, until today, only two case reports are available reporting successful treatment with dronabinol (tetrahydrocannabinol, THC), an agonist at central cannabinoid CB1 receptors, in patients with otherwise treatment refractory OCD. In addition, data obtained from a small open uncontrolled trial using the THC analogue nabilone suggest that the combination of nabilone plus exposure-based psychotherapy is more effective than each treatment alone. These reports are in line with data from a limited number of case studies and small controlled trials in patients with Tourette syndrome (TS), a chronic motor and vocal tic disorder often associated with comorbid obsessive compulsive behavior (OCB), reporting not only an improvement of tics, but also of comorbid OCB after use of different kinds of cannabis-based medicines including THC, cannabis extracts, and flowers. Here we present the case of a 22-year-old male patient, who suffered from severe OCD since childhood and significantly improved after treatment with medicinal cannabis with markedly reduced OCD and depression resulting in a considerable improvement of quality of life. In addition, we give a review of current literature on the effects of cannabinoids in animal models and patients with OCD and suggest a cannabinoid hypothesis of OCD.

Introduction

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions. Obsessions are defined as recurrent and persistent thoughts, urges, or images that are intrusive, unwanted, and cause—in most individuals—marked anxiety and/or distress. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to the rules that must be applied rigidly ( 1 ). OCD is a severe and underdiagnosed mental disorder that causes substantial impairment in quality of life in the majority of patients. The prevalence of OCD is estimated to be around 2% to 3% ( 2 – 4 ). Up to this date, the only treatments approved for alleviation of OCD are cognitive-behavioral therapy (CBT) and pharmacotherapy with (selective) serotonin reuptake inhibitors ((S)SRI) ( 5 ). However, about one third of patients does not benefit from these treatment strategies, experiences recurrent episodes, or does not tolerate treatment with SSRI ( 6 , 7 ). In these otherwise treatment-resistant patients surgical intervention using deep brain stimulation (DBS) has been suggested as an alternative option. Thus, novel treatments and new pharmacological components are urgently needed to improve outcome in patients with OCD.

The pathophysiology of OCD includes the involvement of different neurotransmitter systems, the most important being the serotoninergic system ( 8 , 9 ). This serotonin hypothesis of OCD is mainly based on beneficial treatment effects of (S)SRI medication. In addition, a number of other pathways such as the GABAergic, glutamatergic, and dopaminergic have been suggested to be involved too ( 10 – 12 ). Accordingly, diverse brain regions have been suggested to be affected ( 13 , 14 ). Only recently, the ENIGMA-OCD Consortium ( 15 ) reported less segregated organization of structural covariance networks in OCD, reorganization of brain hubs as well as a possible signature of altered brain morphometry especially in those regions involved in brain development and maturation such as the cingulate and orbitofrontal areas.

Against the background of increasing acceptance of cannabis-based medicines (CBM) in various diseases ( 16 ), increasing evidence for a paramount role of the central endocannabinoid system (ECS) in brain development ( 17 ) and stress regulation ( 18 ) as well as the fact that the ECS is the most important neuromodulatory system in the brain ( 19 ), research was initiated to explore the role of the ECS in the pathophysiology of OCD ( 20 ). Although only a small number of studies in animals and humans have been published addressing this topic, most of the data support the hypothesis that CBM might be effective in the treatment of OCD.

The aim of this report is to increase the database by presenting an illustrative case of a patient with severe OCD, who markedly benefitted from treatment with cannabis and, in addition, to summarize available scientific evidence supporting the importance of the ECS in the pathophysiology of OCD.

Case Report

The male patient first presented in our outpatient clinic at the age of 22. Prenatal and perinatal development did not show any abnormalities and his medical history was unremarkable. Family history was negative without neurological and psychiatric diseases. Further history revealed that OCD symptoms already started in kindergarten age. At that time, he suffered from compulsions with the urge to constantly close the door and checking rituals accompanied by a just right feeling. During the following years, obsessions and compulsions exhibited a waxing and waning course without remission at any time. At the age of 17, in parallel to increased OCD symptoms, he developed a depressive episode with suicidal thoughts.

The diagnosis of OCD was made only one year before the first presentation in our clinic at the age of 21, after he had consulted his general practitioner, because his symptoms caused increasing problems in different areas of life, and he was worried that he would not be able to complete his training as animal keeper successfully. Therefore, pharmacotherapy with clomipramine was initiated with a maximal dose 25mg/d. Because of adverse events such as nausea and headache and because he felt no positive effect, he stopped medication after only one week.

During the first presentation in our clinic, the diagnosis of OCD according to DSM-5 was confirmed by one of the authors (KMV). At that time, the patient suffered from compulsions with repeated hand washing (up to 20×/day) and prolonged showering (up to 1h/day) including washing rituals as well as further rituals related to checking, ordering, and cleaning. In addition, he suffered from several obsessions such as contamination fear, sexual obsessions, repetition of same words, and magical thinking. He tried to neutralize these negative thoughts by imagining numbers. Several of these obsessions and compulsions were accompanied by a just right feeling. Altogether, he estimated to spent approximately 4 h a day on obsessive thoughts and compulsive behaviors. Non-surprisingly, OCD symptoms caused relevant problems in social life and at work. In his training as animal keeper, his boss and co-workers often exhorted him, mainly because of slowness due to his compulsions. At vocational school he had difficulties concentrating and learning. Due to his symptoms, he had stopped doing sports, neglected hobbies, avoided social contacts, and withdrew more and more socially. There was no evidence that his symptoms should be attributed to the effects of substance abuse or another medical condition.

The presentation in our clinic was motivated by the fact that he had noticed that use of cannabis alleviated his symptoms. He reported that he had started using cannabis recreationally at age 16. Because his symptoms markedly improved, he started to smoke street cannabis (mixed with tobacco) on a regular basis using 0.5 g cannabis three to four times per week (about 8 g/months). Use of street cannabis resulted in a constant and marked improvement of obsessions and compulsions of about 80% to 90% lasting for 12 to 15 h. In addition, his sleep improved because of a general feeling of relaxation, reduced OCD, and less rumination. No adverse events were reported. Despite these beneficial effects, he decided to stop using street cannabis on a regular basis at the age of 20, because he did not want to do anything illegal and because he was afraid of losing his driver’s license. Beside illegal use of street cannabis, the patient reported that he started smoking tobacco at the age of 15 (approximately 10 cigarettes/day). His further history of substance abuse was unremarkable. He reported not to drink any alcohol for several years.

We decided to initiate treatment with prescribed medicinal cannabis because of the diagnosis of severe OCD, due to the fact that the patient refused pharmacotherapy with (S)SRI as well as psychotherapy, and because of his reports of marked improvement after use of street cannabis. Before first prescription of medicinal cannabis, the patient stated that he has not smoked cannabis for about one year. Because THC content of street cannabis he had used before was unknown, we decided to test two different chemovars: Bedrocan containing 22% THC and <1% cannabidiol (CBD) and Bedrobinol containing 13.5% THC and <1% CBD. Both Bedrocan and Bedrobinol are produced by Bedrocan ® Company in compliance with the European Medicines Agency’s good manufacturing practice (GMP) standards and ISO 9001: 2015 Certificates. Since the patient reported much better effects using Bedrocan , treatment with this chemovar was implemented with a daily dose of 0.2 to 0.3 g. Immediate thereafter, he reported a marked reduction of obsessions and compulsions of about 70% as well as general relaxation, improved sleep, and concentration at school as well as overall improvement of his quality of life resulting in better social functioning and reduced problems at work. For example, he restarted to practice sports. Twenty months after initiation of medicinal cannabis therapy, he passed his final theoretical and practical exams as animal keeper, and his employer offered him a permanent position. During the last months, he slightly increased the daily dose of Bedrocan cannabis up to 0.7 g.

At baseline, before implementation of treatment with medicinal cannabis as well as three, five, and 20 months later, a variety of clinical assessments have been performed by a clinical psychologist and psychotherapist (CF) experienced in this kind of tests. Detailed results are provided in Table 1 . During the last follow-up visit, the patient reported an improvement of compulsions and obsessions of 90% to 95%. No side effects were reported. While in the past he had used street cannabis exclusively by smoking mixed with tobacco, after initiation of prescribed therapy with medicinal cannabis, he started inhale cannabis using a vaporizer in parallel. During the last follow-up visit, he reported to vaporize medicinal cannabis during the day and to smoke only once in the evening. However, for smoking he is mixing cannabis only with a small amount of tobacco (which is much smaller than in the past) and completely stopped smoking tobacco cigarettes.

Clinical assessments at baseline and at different time points after treatment with medicinal cannabis.

*the higher the score the better the quality of life.

OCD, obsessive compulsive disorder; OCI-R, obsessive-compulsive inventory—revised; OBQ-D, Obsessive-Beliefs Questionnaire—German version; QoL, quality of life; Y-BOCS, Yale-Brown Obsessive Compulsive Scale; BDI, Beck Depression Inventory; CGI-S, Clinical Global Impression—Severity Scale; CGI-I, Clinical Global Impression—Improvement Scale; QOLAS, The Quality of Life Assessment Schedule; SF-12, Short Form 12.

Evidence Supporting the Role of the ECS in the Pathophysiology of OCD: Data Obtained From Animal Studies

Most robust data suggesting an involvement of the ECS in the pathophysiology of OCD comes from animal studies. Although the most widely used animal model for OCD is marble burying based on the observation that rats and mice will bury either harmful or harmless objects in their bedding, this model is not ideal. Critics point out that the marble burying test reacts to two types of drugs, (S)SRIs and benzodiazepines, although benzodiazepines have no effects in patients suffering from OCD. Therefore, findings from this animal model should be interpreted with caution. Rueda-Orozco et al. ( 30 ) showed that administration of the anandamide receptor antagonist AM251 delays extinction of OCD-like behavior in a procedural memory task in rats presumably caused by impaired endocannabinoid activity in the dorsolateral striatum. Gomes et al. ( 31 ) used a mouse model and demonstrated that activation of CB1 receptors using WIN55.212-2 results in reduced OCD-like behavior as indicated by a significant decrease in the number of buried marbles. They also applied an inhibitor of the anandamide hydrolysis that led to decreased marble burying. Nardo et al. ( 32 ) described attenuating influence of CBD on marble-burying behavior in mice. After administration of meta-chloro-phenyl-piperazine (mCPP), a substance that enhances OCD, animals were treated either with CBD (30 mg/kg) or the SSRI fluoxetine (10 mg/kg) resulting in similar reducing effects on marble burying. In contrast, Umathe et al. ( 33 ) reported increased marble-burying behavior in mice after use of high doses of the endocannabinoid anandamide and its analogues AM404 or URB597, while low doses of these substances decreased marble-burying. Deiana et al. ( 34 ) determined pharmacokinetic profiles of several phytocannabinoids after acute single-dose intraperitoneal and oral administration in mice and rats. The pharmacodynamic-pharmacokinetic relationship of CBD (120 mg/kg, intraparenchymal and oral) was further assessed using a marble burying test in mice. All phytocannabinoids penetrated similarly the blood-brain barrier. In rats, oral administration of CBD inhibited marble burying matching its pharmacokinetic profile. Casarotto et al. ( 35 ) also showed inhibitory effects of CBD on marble burying behavior in C57BL/6J mice. Varvel et al. ( 36 ) conducted an interesting experiment aiming to test the hypothesis that elevated brain levels of anandamide may potentiate extinction in a fixed platform water maze task. They used mice genetically deprived of the enzyme fatty acid amide hydrolase (FAAH) that inactivates anandamide. Accordingly, mice treated with the FAAH inhibitor OL-135 did not display any memory impairment or motor disruption but did exhibit a significant increase in the rate of extinction. FAAH compromised mice exhibited a significant increase in acquisition rate. The authors concluded, that endogenous anandamide facilitates extinction through a CB1 receptor mechanism of action and FAAH inhibition represents a promising pharmacological approach to treat disorders such as OCD. Further evidence from the field of genetics was published by Imperatore et al. ( 37 ), who used a monoacylglycerol lipase (MAGL) knock-out mouse as a genetic model of congenital and sustained elevation of 2-arachidonoylglycerol (2-AG) levels in the brain. MAGL(−) mice demonstrated impaired CB1 signaling and anxiety-like behavior. Finally, Kinsey et al. ( 38 ) showed that inhibition of the endocannabinoid catabolic enzymes FAAH and MAGL elicits anxiolytic-like effects in the marble burying assay.

Studies in Patients With Pure OCD

Until today, only two case studies and one small controlled trial have been published reporting effects of CBM in a total of 14 patients with OCD ( 39 – 42 ). In 2008, Schindler et al. ( 41 ) described two patients with otherwise treatment-resistant OCD, who improved after adding dronabinol to preexisting treatments. The first patient was a 38-year-old woman with severe OCD and recurrent major depression, who had been treated with paroxetine (60 mg/d) and CBT with no improvement. Later on, therapy with clomipramine (300 mg/d) was initiated, which resulted only in a “partial response.” By chance, she discovered that smoking street cannabis improved her symptoms. Therefore, combined treatment with clomipramine and dronabinol (30 mg/per day) was started. After 10 days, OCD symptoms decreased by 50% (from 20 to 10 as measured by Yale-Brown Obsessive-Compulsive Scale, Y-BOCS). The second patient was a 36-year-old man with schizophrenia and OCD, who was admitted to hospital due to deterioration of psychotic and obsessive symptoms. The patient was previously treated with various antipsychotics such as haloperidol, olanzapine, risperidone, quetiapine, and aripiprazole as well as (S)SRIs without relevant effects. Even electroconvulsive therapy was performed without relevant improvement. After initiation of combined therapy with dronabinol (10 mg/d), clomipramine (150 mg/d) and clozapine (400 mg/d), OCD symptoms markedly improved within two weeks (from 23 to 15 according to Y-BOCS). Both patients reported no side effects.

In 2017, Cooper and Grant ( 40 ) reported about a 24-year-old male, who suffered a lacunar infarct of the left thalamus and thereafter developed persistent, repetitive, unwanted thoughts primarily related to doing unintentional harm or engaging in sexual acts with others. He had also a 10-year history of insulin-dependent diabetes and bipolar I disorder since age 16, which was stable on ziprasidone. His obsessions remained refractory to various agents used in monotherapy or combination (fluvoxamine, clomipramine, mirtazapine, risperidone, olanzapine, clozapine, ziprasidone, haloperidol, quetiapine, memantine, ondansetron, intravenous ketamine, N -acetylcysteine, gabapentin, clonazepam, plus mood stabilizing agents). Combination with dronabinol (20 mg/d) resulted in a marked improvement after two weeks of treatment (Y-BOCS score declined from 39 to 10) resulting in an amelioration of quality of life. In addition, for the first time he was able to tolerate CBT.

In 2020, the results of a trial were published using cannabinoid augmentation of exposure-based psychotherapy (EX) ( 39 ). Eleven unmedicated outpatients (18–60 years), who met DSM-5 criteria for OCD with at least moderate severity of symptoms (Y-BOCS ≥16), were assigned to either treatment with the synthetic THC analogue nabilone alone or a combination of nabilone+EX for 4 weeks. All participants received 1 mg nabilone twice a day orally. Nabilone was well tolerated, and no severe side effects occurred, but three participants withdrew because of increased anxiety. While monotherapy with nabilone resulted only in little symptom change (Y-BOCS decrease of 2.5 ± 3.6 after 4 months), combined treatment with nabilone+EX significantly improved the therapeutic effect of EX (Y-BOCS decrease of 11.2 ± 3.4) suggesting that nabilone can be used to augment treatment effects of EX in patients with OCD.

Studies in Patients With Tourette Syndrome and Comorbid Obsessive-Compulsive Behavior

Further evidence supporting beneficial effects of CBM in OCD comes from clinical studies in patients with Tourette syndrome (TS), a complex spectrum disorder characterized by motor and vocal tics. Up to 80% of patients with TS, in addition, suffer from psychiatric comorbidities, most frequently obsessive-compulsive behavior (OCB) and attention deficit/hyperactivity disorder (ADHD). While there is increasing evidence from retrospective surveys, case studies, and small randomized controlled trials (RCTs) that different CBM improve tics in patients with TS, in some of these studies, an improvement of OCB has also been described ( 43 – 48 ).

In a case study in a 16-year-old male with TS and comorbid OCB, rage attacks, sleeping problems, anxiety, and depression treatment with dronabinol (up to 33.6 mg/d) resulted in an improvement of both tics and psychiatric comorbidities including OCB ( 37 ). In a survey among adult patients with TS ( 39 ), 17 of 64 patients reported use of marijuana. Of these, 14 reported a reduction of tics and one a remission of OCB after use of cannabis. In a retrospective analysis efficacy and safety of smoked cannabis was investigated in 19 adults with TS ( 36 ). Of these, 15 patients were also diagnosed with comorbid OCD. In all of them, OCD improved according to Y-BOCS after starting treatment with cannabis. Only recently, results of a retrospective analysis (n=98) and an online survey (n=40) have been published in patients with TS, who had used different kinds of CBM including street cannabis, the cannabis extract nabiximols, dronabinol, and medicinal cannabis ( 38 ). In patients with comorbid OCD, improvement of OCD symptoms of 15% to 42% was reported.

In a single-dose RCT (n=12) using 5.0, 7.5, or 10 mg THC, a significant improvement of OCB was found compared to placebo (mean reduction of 4.83 ± 5.59 according to the Tourette Syndrome Symptom List (TSSL), p=0.041) ( 47 ). In contrast, in an RCT using up to 10 mg THC/d over 6 weeks in 24 patients no improvement of OCD was found ( 48 ). A summary of all studies in animal and humans is shown in Table 2 .

Studies in animals and humans investigating the role of the endocannabinoid system (ESC) in OCD.

OCD, obsessive-compulsive disorder; CBD, cannabidiol; FLX, fluoxetine; EX, exposure prevention therapy; TS, Tourette syndrome; RCT, randomized control trial; THC, tetrahydrocannabinol; CBM, cannabis based medicine; OCB, obsessive-compulsive behavior; Y-BOCS, Yale-Brown Obsessive Compulsive Scale; mCPP, meta-chloro-phenyl-piperazine; DZ, diazepam; MAGL, monoacylglycerol lipase; 2-AG, 2-arachidonoylglycerol; SSRI, serotonin selective reuptake inhibitor; FAAH, fatty acid amide hydrolase; MBB, marble burying behavior; N, number of participants.

The presented case report adds evidence to the hypothesis that modulation of the ECS by activating central CB1 receptors may improve OCD. Although in general our findings are in line with previous case reports ( 39 – 42 ), there are also some relevant differences: (i) while in all previous studies pure THC (dronabinol) or the synthetic analogue of THC, nabilone, have been used, our patient was treated with medicinal cannabis including more than 100 different cannabinoids; (ii) in previous case studies, preexisting treatment was augmented with CBM, while we used medicinal cannabis as monotherapy; and (iii) while all previously described patients were treatment resistant, in this case, the patient refused treatment with psychotherapy and had stopped medication with an (S)SRI due to adverse events after only one week. Thus, currently it is not only unclear whether CBM in general might be effective in the treatment of OCD, but also which cannabinoid or combinations of cannabinoids—and in particular the ratio of THC to CBD—is most effective and whether treatment with CBM should be used in monotherapy or in combination with (S)SRI or behavioral therapy.

Interestingly, neither our patient, nor those OCD patients described in the literature reported about clinically relevant adverse events. Most frequent adverse events associated with medically supervised treatment with THC and medicinal cannabis are dizziness, somnolence, drowsiness, problems with concentration, and tiredness, while severe adverse events occur only rarely. In general, CBM are well-tolerated, particularly when up-titrated slowly ( 49 ). It should be noted that our patient had used street cannabis (without negative effects) for several years, before treatment with medicinal cannabis was initiated. Thus, it cannot be excluded that CBM might be effective only in a subgroup of patients with OCD, who tolerate this kind of treatment well. In any case, before initiating treatment with CBM contraindications such as psychosis must be excluded, and patients must be informed about potential adverse events.

Currently, possible underling mechanisms of beneficial effects of CBM in OCD are unknown. However, it can be speculated that positive effects might be related to the well-known complex interplay between cannabinoids and serotonin (5-HT) function. In in vivo and in vitro studies, it has been demonstrated that cannabinoids modulate the activity of the 5-HT system at several levels. For example, it has been shown that activation of CB1 receptors affects the synthesis and release of 5-HT and that CB1 receptor agonists—depending on dose and duration of administration—either reduce or increase firing activity in 5-HT cells in the dorsal raphe nucleus [for review see: ( 50 )]. Thus, based on the serotonin hypothesis of OCD, it can be speculated that CBM improves OCD by modulating the serotoninergic system. However, one might also speculate that OCD is caused by a dysfunction within the ECS. Accordingly, CBM might ameliorate OCD via direct activation of the ECS or indirectly by reducing anxiety ( 51 ) and stress ( 52 ). In line with this hypothesis, it has been demonstrated that chronic stress leads to a downregulation of CB1 receptor signaling in brain regions involved in OCD such as hippocampus, striatum, nucleus accumbens, prefrontal cortex, dorsal raphe nucleus, amygdala, and hypothalamus [for review see ( 18 )]. Furthermore, an endogenous molecular mechanism has been identified in a specific cortico-striatal pathway that mediates the transition between goal-directed and habitual action strategies ( 53 ). Deletion of CB1 receptors from orbital frontal cortex neurons projecting to the dorsal striatum prevents mice from shifting from goal-directed to habitual action control suggesting that the emergence of habits depends on endocannabinoid-mediated attenuation.

However, we cannot entirely exclude that beneficial effects in the presented case are only caused by placebo effects and positive expectations or other possible confounders such as environmental, emotional or psychological factors that might have influenced OCD. It also cannot be ruled out that treatment with medicinal cannabis only indirectly influenced OCD symptoms by reducing stress or improving other symptoms such as anxiety, depression or sleeping problems.

There is increasing evidence that the ECS might be involved in the pathophysiology of OCD. In line with this hypothesis, from a limited number of case studies it is suggested that CBM might be effective in the treatment of OCD. However, so far it is unclear, which cannabinoids—in monotherapy of combination with other treatments—might be most effective and which patients might respond best.

Data Availability Statement

Ethics statement.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.

Author Contributions

KM-V and CF conceived and designed the study and acquired data. CF set up the electronic database. KM-V, NS and CF interpreted the data and reviewed and edited the manuscript. KM-V and NS wrote the original draft of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

@ICBTtherapist

• Catherine Goldhouse

I specialize in a particular type of OCD known as “Pure O” or purely obsessional OCD. My clients with Pure O often go for years undiagnosed with OCD because they have a storm of “what if” thoughts swirling around in their heads and the way they respond isn’t through hand-washing or double-checking the way it typically is when we think of OCD. Instead, they respond by ruminating, researching, and/or asking for reassurance.

We all have bizarre, disgusting, offensive, and twisted thoughts. For most people, these thoughts last for one moment and then go away. We don’t worry about them because we know they don’t reflect what we really think or feel or want. They are just random thoughts or images. If you’re dealing with Pure O, however, then you make meaning of these thoughts and wonder what having them says about you. Whenever you are triggered, you get flooded with “what if” thoughts and start creating a story in your head that makes you doubt yourself and what you know to be true.

Many people with Pure O suffer in silence. This is not only because they may not recognize what they are experiencing to be OCD but also because they are often too ashamed of the content of their “what if” thoughts to ask for help.

Some subtypes of Pure O include:

Sexual Orientation OCD:

Constant obsessions about your sexual orientation (ex: “Am I gay?”)

Afraid that you are in denial or somehow suppressing your true feelings

Fears that you will “turn” gay or straight, and that your relationships will fall apart

Obsessing over whether you acted in a way that was “gay” or “straight” with others

Hyperawareness of your body’s responses to certain people, images, or situations

Relationship OCD:

Doubts about your relationship (ex: “How do I know I really love this person?”)

Fears that you are not good enough for your partner

Questioning whether your partner really is “the one”

Pinpointing a “flaw” and deciding you couldn’t possibly be with someone who has it

Intrusive thoughts about harming yourself or others that make you question yourself (ex: "What if I secretly want to kill my family?”)

Fears that you will hurt yourself or others impulsively

Fixating on the idea that you could have inadvertently harmed someone and don’t know it

Fears that you are hiding your true nature from yourself and that you are truly aggressive and viscous

Existential OCD:

Ruminating about philosophical questions that cannot be answered (ex: “Am I real?”)

Questioning about the nature of self or reality

Fixating on the purpose and meaning of life

Obsessing over the concept of free will

Pedophile OCD

Unwanted harmful or sexual thoughts about children that make you question yourself (ex: “What if I am a pedophile?”)

Worrying that you might harm a child

Worrying that you harmed a child in the past and are in denial

Hyperawareness of your body’s responses around children

Scrupulosity OCD

Intrusive thoughts about violating your own religious or ethical beliefs that make you question yourself (ex: “What if I offended God? Am I immoral?”)

Fear of living in sin

Fear of doing something that violates or violated your ethical beliefs

Fear of praying incorrectly

Fear of going to hell

If you have Pure O, you ruminate compulsively and are desperate for some certainty, but no amount of research or reassurance seems to help. The anxiety that comes along with having these thoughts is agonizing and so you start avoiding certain things because you are afraid of bringing these thoughts on. For example, you avoid spending time with your young nieces and nephews because being around them brings up so much anxiety about the possibility of being a pedophile. Or perhaps you’re a new mom who has started to avoid being alone with your baby because you’re worried that you’ll be flooded with thoughts about hurting him and the shame and fear you know you’ll feel will be unbearable. Or maybe you avoid being in serious relationships because you know eventually you’ll start wondering if you really love your partner and will start compulsively researching articles on love or comparing your relationship to others and the doubt will get so loud that you won’t even be able to connect with this person when you’re around them anymore.

That’s the worst part of Pure O— you start missing out on life and distancing yourself from others because you’re so afraid of stirring up the anxiety.

In addition to having extensive training in Exposure and Response Prevention (ERP), I am one of the few therapists in this country who practices Inference-based Therapy (IBT), a cognitive behavioral therapy that can be used in conjunction with or provide a human alternative to ERP. The goal of IBT (also referred to as I-CBT) is to help you learn to trust yourself. OCD robs you of that. It makes you doubt who you are, what you really think, and how you really feel, both physically and emotionally.

In our first session, I will try to put you at ease by letting you know that I’ve heard it all and that none of your “what if” thoughts will shock me. Then, as we get to know each other, I will get a sense of your obsessions, your core fears, how much you’re ruminating, if you are dealing with any other compulsions (such as reassurance-seeking), and what you’ve been avoiding in your life to try to escape the anxiety. Together we will come up with a plan designed specifically for you to stop the suffering and avoiding.

If you are ready to rise above the noise in your head and start living life to the fullest, I can help.

* I want to be clear that sexual orientation OCD (or SO-OCD) is not about convincing someone that their sexuality is right or wrong or that a gay person “should” be straight (or vice versa). This post is meant to explain that one manifestation of OCD can be the endless questioning of one's own sexual identity and the tremendous anxiety and self-doubt that it can create.

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What is Inference-based Therapy (I-CBT)?