Pure O: A Form of OCD That Defies Definition

Pure O is a form of Obsessive Compulsive Disorders in which a person is faced with continuous, intrusive thoughts.

Pure O is a relatively new label for a form of Obsessive Compulsive Disorders.

(Photo: iStock)

“Is there some no-man’s land between morality and madness where I can park my mind?”

A nervous laugh follows the question and still seems too tired to fulfill its own fate.

Y has been coming to therapy for half a year now and we have established a mutual math adding protocol and satire to conversations that are rhizomatic, unconfined and open to interpretation.

When Y first stepped into my office, he was precise from the word go. He had an expedient degree of self-awareness, a history of therapeutic engagement and attested to comparative success within the format of one-on-one counseling. He had a carefully sorted file and an affable personality. A quick scan of his medical history and his affect combined with physical presentation indicated no particular skew except for the dark circles under his eyes, a gift of insomnia which is now almost an inbuilt feature for our whole generation.

‘I am not the wash-your-hands-20-times a day sort of OCD guy’

The psychiatrist’s diagnosis spelled it out as obsessive-compulsive disorder with mild depression and was followed by a list of medications he is on currently. He said he had been doing fine till he moved cities recently and was now dealing with bouts of hyper-anxiety followed by complete zombie-like “unexistence”. Clients in therapy have a way of illuminating their own conditions without recognizing how profoundly touching it can be for the therapist. He felt he needed a more thorough form of therapy that worked with some of the “deeper” issues he experienced. He immediately prefaced his prognosis – “I am not the wash-your-hands-20-times a day sort of OCD guy.”

“What sort of an OCD guy are you then?”, I asked without recognizing how deep that question would cut.

Y revealed that he didn’t come to me plainly for therapy. He had a theory about his condition and he wanted to test it for validation. Given the paucity of open-minded practitioners in our field of work within this country, he had either met with complete negation or quick rejection whenever he broached the subject. No one, he surmised, seemed to want to discuss the furthest limits of what he thought he was experiencing.

“I think I have Pure O”, he let out without blinking. ‘My mind can’t seem to delink sex and death. It just won’t shut up. That is why am always on the brim of an ominous panic.”

The silence in the room was interrupted by a malfunctioning air-conditioner which essentially recognizes two temperatures – Homage to the Pleistocene and Dante’s Purgatory. It switched off mid-conversation and right after Y’s revelation, groaned a little before sounding like a fighter jet taking off.

“Would you like some tea?”, I offered while thumbing through this file.

“I can’t stop thinking these horrible things. Why do I have to be like this? And yes, tea would be good”, he tilted his head back as if trying to prevent a nosebleed.

Beyond the Labels

The Diagnostic Statistic Manual stations OCD under the larger umbrella of anxiety disorders.(Photo: iStock)

Pure O is a relatively new label for a form of Obsessive Compulsive Disorders in which a person is faced with continuous, unwanted and intrusive thoughts without visible compulsions or rituals associated with them. These thoughts mostly pertain to topics tabooed in so-called polite society. We understand OCD mostly through an exaggerated and often blurry lens propped against pop cultural motifs. This makes us believe that everyone who frets over having neatly organized closets or stocking up on a truckload of hand-wash liquid is a prospect. While it is true that these might be certain common manifestations of OCD, like any other mental health condition, it is spread across a wide spectrum and is rarely so slim in its radius.

Yes, I have therapy clients who will enter my own office by turning the door handle 3 times or those who skip page 13 in every book they read. However, beyond the slippery mythopoeia, these are not fully representative of what OCD can be for different people across a range of demographics.

The Diagnostic Statistic Manual stations OCD under the larger umbrella of anxiety disorders because its occurrence causes periods of bearable to intense anxiety as well as severe panic attacks in certain cases.

OCD splits itself into obsessions and compulsions which usually combine in some way or another. The awareness of how intense the obsessions and compulsions are can further be distinguished across three levels, we clinically refer to them as insight specifiers – there is fair insight where someone recognizes that their inherent OCD beliefs are factually incorrect or unlikely to become real. Then there is low or poor insight which essentially translates to holding OCD beliefs as genuinely possible. Finally, there is absent insight which staggers over to delusional thinking because in these cases, a person is fully convinced that their OCD beliefs are true to the word.

In Pure O, clients/patients usually have clear to somewhat poor insight but it is rarely absent. Apart from that what makes it slightly different from the standard understanding and display of OCD is that most people who deal with it don’t feel like doing something explicit by way of compulsive ritualization. In a manner of speaking, the repetition in Pure O is not directed behaviourally but is purely cognitive. It occasionally feels like a ticking time-bomb between your ears.

Those who identify with suffering from Pure O speak foremost of the ceaseless mental hiss of their brain-chatter.

Rose Cartwright’s “Pure” is one of those rare books that aims to take a closer look at what life with Pure O feels like for an average individual. It sifts through her own trials with episodes of obsessive ideation about sex, catastrophes and abuse (one of the more common criterion for Pure O) with audacity draped in dark humor.

She references Munchausen syndrome – a complex psychiatric affliction where someone feigns psychiatric trauma and/or severe physical distress to gain sympathy and attention. We all have faked a few “headaches in my stomach” moments as kids but this particular illness runs deep, to the extent that those who are strongly gripped by it will wound themselves, rub dust in their wounds to make their condition more believable.

Cartwright mentions how compulsive lying became a second habit as a young teenager just so she could have someone like a parent or a teacher hold her close physically. She lists how deeply embedded thoughts of sexual acts and imagery pervade her everyday life even at the most humdrum of time and places. Cartwright’s memoir is a direct shift in the generalizations associated with OCD. It is not always about cleanliness and routines. It is also about questioning the discrete codes we assign to mental health. The mind is a Mobius strip where it is really hard to separate the individual from the experience. The book, which has now been turned into a TV show, hopes to destigmatize the lives and experiences of those who battle Pure O.

Is Pure O ‘Real’?

On the flip side, there are those who contest the very idea of Pure O as a viable category over and above having “evil thoughts”. Some psychologists decry the critical marker which separates Pure O from other forms of OCD – that of separating thoughts into obsessions and compulsions, further questioning if we can truly distinguish between the two.

Pure O is defined by the presence of purely obsessive thoughts. These thoughts circle 7 general themes including violence, sex and sexuality (extending to fears of pedophilia), religion mired with blasphemy, relationship obsessions, health. There are ideas about responsibility and capacity for harm and the nature of existential pain. The chief cause for torment in Pure O is the inability to regulate or guide unwanted and seemingly “bad” thoughts linked to these themes.

My client Y, for instance, can’t stop thinking about sex and death even at the most mundane and unrelated places like an office meeting or buying an ice-cream. As we discussed in a session, it is a painful ouroboros with the serpent eating its own tail. Some studies have proven that most people who experience OCD made admissions towards both obsessive and compulsive behaviours with rare occurrence of either existing in isolation.

Groups like OCD-UK refuse to acknowledge Pure O because they find the current definitions for it limiting as well as “unhelpful and imprecise”. There is a feeling among support communities as well as mental health practitioners that someone suffering from OCD might not be able to recognize their own compulsions or perhaps articulate them in a way that was decipherable. This doesn’t mean that they are not experiencing those compulsions or are only dealing with extreme obsessions. According to its critics, Pure O is unreliable in its typecasting.

In a session with Y, I recalled a quote from Novalis - "Sense that sees itself is spirit."

In practice, the idea of healing is non-linear and often implies a shift in understanding that peace is not the absence but the acceptance of chaos. Irrespective of whether there is universal legitimacy for his struggle, Y fights it on a daily basis. He has chosen to accept his challenge and acknowledge his strength while affirming his own survival every day. He no longer refers to his inner self as if it were contaminated, but recognizes that we are not meant to be just a sum of our parts.

(Scherezade Sanchita Siobhan is a clinical psychologist, community catalyst and author)