In considering a diagnosis of OCD, each of the three letters of the acronym are important. Obsessions are intrusive thoughts, images, nonsense words or music that create anxiety, uncertainty or distress. Compulsions are the behaviors that people do in an attempt to relieve the distress caused by the obsessions. A person only merits the diagnosis of Disorder if these to create clinically significant distress, or in some way interferes with the person’s functioning.
As both the clinical and lay terminology has developed, these words have been used for multiple things, sometimes obscuring these definitions. For example, being “obsessed” with a rock star usually it means that the person enjoys those thoughts, and simply does them to great extent. Similarly, when someone says, “I’m compulsively neat”, they generally mean that they are fastidious and enjoy being that way. Also, certain behaviors are called “compulsive behaviors” (like gambling, overeating, etc.) when they really should be called “impulsive behaviors” because the person likes doing them at the moment, but regrets the behaviors later on.
When OCD was first described, compulsive behaviors were assumed to be visible or noticeable to the outside person. Hand-washing, checking, repeating and counting were all noticeable to others. Sometimes, however, certain individuals would express having terrible anxiety about repeated thoughts, but display no outward behavior as a result of these obsessions. These people were described with the term “pure O”, to suggest that they had pure obsessions with no compulsions. However, the more we have learned about the nature of behavior (and, consequently, the nature of compulsions), the more we have realized that we were simply looking in the wrong place.
It turns out that not all behaviors are visible. Remembering is a behavior invisible to the outside world. So are things like mentally counting, repeating things in one’s head, reassuring oneself, weeding out the options in a decision, “replaying a mental videotape”, and “trying to figure it out”. In other words, mental behaviors are behaviors. They are simply a different group of behaviors from physical behaviors. That means that mental compulsions are also compulsions, just different ones from the physical compulsions. Most people with obsessions actually have mental rituals that they do to serve the same function as other people’s physical rituals. In addition to the examples listed above, sometimes avoidance (and its cousins, indecision and procrastination) and ritualistic distraction serve the same purpose.
If you ask a person with self-described “pure O” what they do to relieve the anxiety or uncertainty caused by their obsessions, they will usually report some kind of mental activity that serves this purpose. They are either trying to figure out why their fear won’t happen, replaying what they did in their head to videotape to prove that they didn’t do something wrong, reassuring themselves either actively or passively, or intentionally trying to have a “good thought” to replace a bad one. The bottom line is that there is no such thing as pure O; there are simply rituals that we can’t always see!