Purely Obsessional OCD - Diagnosis and Treatment

Diagnosis and Treatment

Those suffering from Purely Obsessional OCD might appear normal and high-functioning, yet spend a great deal of time ruminating, trying to solve or answer any of the questions that cause them distress.

For example, an intrusive thought "I could just kill Bill with this steak knife" is followed by a catastrophic misinterpretation of the thought, i.e. "How could I have such a thought? Deep down, I must be a psychopath." This might lead a person to continually surf the web, reading numerous articles on defining psychopathy. This reassurance-seeking ritual will, ironically, provide no further clarification and could exacerbate the intensity of the search for the answer. There are numerous corresponding cognitive biases present, including thought-action fusion, over-importance of thoughts, and need for control over thoughts.

Despite how real and imposing the intrusive thoughts may be to an individual, the sufferer will probably never carry out actions related to these thoughts, even if one believes themselves capable of doing so. One of the reasons for this is because the person in question will go to extreme lengths to avoid circumstances which could trigger their intrusive thoughts.

The disorder is particularly easy to miss by many well-trained clinicians, as it closely resembles markers of generalized anxiety disorder and does not include observable, compulsive behaviors. Clinical "success" is reached when the Purely Obsessional OCD sufferer becomes indifferent to the need to answer the question. While many clinicians will mistakenly offer reassurance and try to help their patient achieve a definitive answer (an unfortunate consequence of therapists treating Purely Obsessional OCD as generalized anxiety disorder), this method only contributes to the intensity or length of the patient's rumination, as the neuropathways of the OCD brain will predictably come up with creative ways to "trick" the person out of reassurance, negating any temporary relief and perpetuating the cycle of obsessing.

The most effective treatment for Purely Obsessional OCD appears to be Cognitive-Behavioral Therapy. More specifically exposure and response prevention (ERP) as well as Cognitive Therapy (CT) which may or may not be combined with the use of medication, such as SSRIs. People suffering from OCD without overt compulsions are considered by some researchers more refractory towards ERP compared to other OCD sufferers and therefore ERP can prove less successful than CT.

Exposure and response prevention (ERP) of the "Pure-O" is theoretically based on the principles of classical conditioning and extinction. The spike often presents itself as a paramount question or disastrous scenario. A response that answers the spike in a way that leaves ambiguity is sometimes warranted. "If I don't remember what I had for breakfast yesterday my mother will die of cancer!" Using the antidote procedure, a cognitive response would be one in which the subject accepts this possibility and is willing to take the risk of his mother dying of cancer or the question recurring for eternity. No effort is expended in directly answering the question in an effort to find resolution. In another example, the spike would be, "Maybe I said something offensive to my boss yesterday." A recommended response would be, "Maybe I did. I'll live with the possibility and take the risk he'll fire me tomorrow." Using this procedure, it is imperative that the distinction be made between the therapeutic response and rumination. The therapeutic response does not seek to answer the question but to accept the uncertainty of the unsolved dilemma.