Mental rituals and Pure O: OCD is more than handwashing

Visible checking behaviour can make the mechanism clear: the action is intended to create certainty, but the doubt returns. The same mechanism is at work in mental rituals.

For others, the attempt to create certainty takes place entirely in the mind. The mental actions can be just as time-consuming and distressing without anyone around them noticing.

What are mental rituals, and what does Pure O mean?

Pure O is an informal abbreviation of purely obsessional OCD. The term is used for OCD in which the compulsions are mainly mental or otherwise not apparent to other people. It can, however, be misleading because mental rituals, avoidance, reassurance seeking or other OCD strategies are often present. Pure O is therefore not a separate diagnosis, but a term for an OCD pattern that takes place mainly in the mind.

Pure O is one way of understanding mental rituals. However, rituals are not limited to one type of OCD; they can occur across themes and alongside visible compulsions.

Not all analysis, prayer or internal dialogue is a ritual. What matters is its function: whether the activity is repeated to neutralise a thought, remove discomfort or obtain certainty that does not last.

Rebecca’s prayers and phrases are mental rituals. Because she performs them in her mind, they are not visible to others. Such rituals can be performed quickly and discreetly, including during everyday activities or in the middle of a conversation.

Mental rituals occur across OCD themes

Mental rituals can form part of any OCD theme and help maintain the disorder. They are used to reduce discomfort, settle doubts that OCD makes difficult to leave unresolved, and achieve a sense of certainty that rarely lasts. Once a ritual has brought short-term calm, it becomes a natural strategy to return to.

Four forms of mental rituals and other OCD strategies are particularly difficult to notice: neutralisation, reviewing and reconstructing past events, testing behaviour and self-punishment.

Neutralisation using thoughts and mental imagery

When an unwanted thought causes anxiety or discomfort, the person may try to neutralise it. Neutralisation is a visible or mental response intended to make the thought less threatening or significant. It may also be intended to reduce the doubt triggered by the thought. Examples include handwashing, prayer or a reassuring counter-image.

A counter-image is used to counter a distressing thought with a reassuring or positive mental image. One example is a mother who is afraid of harming her children. When the thought appears, she brings a counter-image to mind to reassure herself that she loves her children and could never hurt them.

Responding to a distressing thought with a more positive perspective is not in itself a ritual. It can become neutralisation if the person feels they must use the positive thought to cancel out the feared thought or create certainty.

A counter-image can briefly reduce discomfort, but using it can also maintain the OCD pattern.

Reviewing and reconstructing past events

Reviewing past events involves mentally reconstructing a sequence of events. Its purpose is to determine whether the person has put themselves or others in danger.

Thinking back on a situation is not in itself a ritual. Reconstruction becomes an OCD strategy when it is repeated to remove doubt or reach a level of certainty that memory cannot provide.

After every visit to the toilet, a man with a fear of bacteria meticulously retraces everything he has touched. He tries to determine whether he followed the safety rules intended to protect him from bacteria.

After school, a teenager reviews the entire day and everyone he came close to, to make sure he did not accidentally stab anyone with a knife. The analysis demands a degree of certainty that memory cannot provide.

Testing behaviour

Testing behaviour involves examining thoughts, feelings or bodily sensations to determine whether something feels right, wrong or revealing. It may involve washing repeatedly until it feels right or checking whether the body responds in a particular way.

Testing behaviour can occur across all OCD themes. It occurs, for example, with sexual obsessions and doubt about sexual orientation. The testing arises from the demand for certainty that can develop within the OCD pattern and can lead to repeated examinations of thoughts, feelings and bodily reactions. OCD often latches on to what matters to us and to our personal values.

At a family birthday celebration, a young man is sitting on the sofa when his five-year-old nephew climbs onto his lap. He suddenly begins to doubt whether his reaction to the situation could mean he was sexually attracted to children. To obtain certainty, he starts checking his body and genital area to see whether he is responding sexually. At the same time, he fears that the anxiety or heightened attention will create a sensation that OCD can use as evidence.

The intense focus on the genital area can make ordinary or anxiety-induced sensations more noticeable. The sensations may then be mistaken for physical arousal. The more he tests, the more significance even small bodily changes acquire.

Within the OCD pattern, such a sensation may feel like confirmation of what he fears. The testing behaviour may then lead to safety behaviour and avoidance. The young man may begin to keep his distance from children or avoid situations where children are present. Later, the avoidance may be interpreted as further evidence that the suspicion must be justified. In this way, both the testing and the avoidance can become new evidence for the suspicion and gradually weaken his trust in his own judgement.

When self-punishment becomes an OCD strategy

Self-punishment can become an OCD strategy when the person imposes a punishment on themselves to neutralise a thought, make up for a mistake or restore the feeling of having acted responsibly. The punishment need not be physical. It may consist of going without something enjoyable, putting daily life on hold or denying themselves certain opportunities.

Choosing not to play computer games is not in itself a ritual. In Robert’s case, the ban is linked to mistakes in his phrases and to thoughts that OCD labels as forbidden. When he follows the rule, he may briefly feel that he has paid for the mistake and that order has been restored.

When the punishment brings short-term relief, Robert may learn that an unwanted thought or a mistake requires punishment. This gives the thoughts greater significance, and OCD can set more and more rules for what he may and may not do. Over time, self-punishment can restrict both enjoyment and freedom in daily life.

How are mental rituals treated in OCD?

Mental rituals can be difficult to recognise, even for the person themselves, because they often blend into the ordinary stream of thought and become almost automatic over time. For some people, mental rituals occur alongside visible rituals; for others, much of the OCD pattern takes place in the mind.

Treatment therefore begins by mapping out both visible and mental rituals. In exposure and response prevention, the person practises allowing doubt and discomfort to remain without neutralising, analysing or testing. The aim is not to stop thoughts from arising, but to change the response that brings short-term calm and keeps the OCD pattern going.

It is not enough to remain in the triggering situation if the person continues to analyse, neutralise or test mentally at the same time. Response prevention must therefore be adapted to the function of the ritual and include both visible and hidden responses.

When mental rituals, avoidance and other safety strategies are also identified, treatment can address the entire pattern that keeps OCD going.