A private, outpatient treatment center specializing in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder (OCD) and related anxiety-based conditions. Specialized treatment for OCD and related anxiety conditions at the OCD Center of Los Angeles. Serving clients in California and internationally.
OCD and GAD both thrive on our over-attention to unwanted thoughts.
People struggling with Obsessive Compulsive Disorder (OCD) are often misdiagnosed as having other psychological conditions. One of the most common misdiagnoses for this population is Generalized Anxiety Disorder (GAD). This diagnostic problem arises for two reasons. First, the distinction between OCD and GAD is somewhat vague. And second, many treatment providers have only a limited understanding of the varying ways in which OCD can manifest. While this issue may seem like an esoteric concern to some, making a proper diagnosis is important for those struggling with either condition, as the primary treatment for OCD is different than the treatment for GAD.
The Difference Between OCD Thoughts and GAD Thoughts
There are two essential differences between GAD and OCD. First is the nature of the thoughts involved. While unwanted thoughts are central to the diagnosis of both GAD and OCD, the unwanted thoughts experienced by those with GAD tend to focus on common, real-life concerns such as work, school, family, relationships, health, and financial issues. These are issues that most people worry about to some degree, but people with GAD worry about to such an extent as to significantly interfere with their daily functioning.
Contamination OCD – Obsessions about dirt and germs, and their impact on the sufferer or others (i.e., getting a disease from incidental contact with a suspected contaminant, etc.). When most people think of OCD, this is what they think of.
Homosexual OCD (HOCD) – Also known as Sexual Orientation OCD, or SO-OCD. Obsessions in HOCD focus on the fear that your sexual orientation is not what you think it should be. For straight people, HOCD obsessions focus on the fear that they are secretly gay or bi. For gay people, SO-OCD obsessions focus on the possibility that they are secretly straight or bi.
Note that this is not an exhaustive list of the many variations of OCD, and is meant only to demonstrate some of the more prevalent variants of the condition. People with OCD can (and do) obsess about just about anything. That said, OCD obsessions are often about things that are highly improbable, and are frequently founded on the flimsiest of evidence. For example, a person with Harm OCD may think, “I enjoyed that horror film about a serial killer, so I must secretly be a serial killer myself”, while someone with POCD may think “I thought that child was cute – so I must be a pedophile!”
The line between OCD and GAD may at times be somewhat grey, and is to a certain extent arbitrary. The simplest way of conceptualizing the difference is to think of it as being a matter of both content and degree. GAD obsessions are generally focused on common, everyday concerns, while OCD obsessions tend to be significantly more unrealistic. Also, while someone with GAD (or anyone for that matter) may experience unwanted thoughts similar to those experienced by people with OCD, they are generally able to quickly write those thoughts off as being unrealistic. They are unlikely to become consumed by these thoughts, and will usually revert back to obsessing about more mundane concerns.
On the other hand, for people struggling with OCD, these atypical thoughts are not fleeting or incidental – they occur with great frequency, and are experienced as deeply intrusive and unwanted. Furthermore, these types of obsessions cause incredible amounts of distress in the sufferer, often because the thoughts directly conflict with how the individual sees him/her self. Someone with OCD may spend hours, or weeks, or even years tortured by the idea that these profoundly distressing thoughts may be a legitimate indictor of who they are as a person. For example, people with Religious Scrupulosity are often devoutly religious, and are devastated by the thought of acting or thinking in a manner that is contrary to their faith. Likewise, those struggling with POCD are universally horrified by the idea of sexually molesting a child.
The second primary difference between GAD and OCD is the sufferer’s behavioral response to their obsessional thoughts. In GAD, the primary (but not the only) behavioral response is to excessively worry about the issues that are causing them to feel anxious (more on this later). While people with GAD often spend great amounts of time ruminating about issues that concern them, they do not generally exhibit the classic compulsive symptoms seen in OCD, such as hand washing and door checking. Instead, in GAD, worrying is often both the obsession and the primary compulsion.
For example, someone with GAD may repeatedly have the thought “What if I don’t get that job and I end up going broke”. The initial appearance of this thought could be conceptualized as an obsession. Someone with GAD might then respond to this obsession by compulsively ruminating about the possibility of not getting the job they want, and then going broke, all in an attempt to resolve the anxiety that arose in response to the initial obsessive thought.
Conversely, those with OCD exhibit numerous compulsive behavioral responses to their unwanted thoughts. Some of these responses are fairly obvious and overt, such as repeated hand washing or lock checking. These behaviors are done in an attempt to reduce or eliminate anxiety related to their unwanted obsessions. Additionally, many people with OCD, especially those with variants of OCD that are frequently (and misleadingly) called “Pure O”, also exhibit numerous compulsive behaviors that are far less obvious to those unfamiliar with the subtleties of OCD. These more covert compulsions may include the following:
Avoidant Compulsions – People with OCD often avoid doing mundane tasks that others do without hesitation, such as driving or shopping, or even touching certain items such as doorknobs or telephones. This avoidance behavior is done in an effort to prevent the onset of intrusive thoughts, and the unwanted feelings and sensations that come with them.
Reassurance Seeking Compulsions – Many OCD sufferers compulsively seek reassurance that they have not said or done anything that they fear would confirm the legitimacy of their unwanted thoughts. Compulsive reassurance seeking is frequently done by repeatedly asking others questions related to one’s obsessional thoughts, and may also include compulsive internet searching about their intrusive thoughts.
Mental Compulsions – Individuals struggling with OCD often have elaborate mental rituals that nobody can see, as they are occurring solely in the mind of the sufferer. These can include such things as compulsively praying or counting, or compulsively reviewing and countering their unwanted thoughts, all in an attempt to reduce the anxiety caused by their obsessions.
Unfortunately, most people don’t realize that these behaviors are compulsions, and that all compulsions actually make obsessions worse in the long run. For many people struggling with OCD, these types of less obvious behavioral compulsions are repeated over and over again, and are the most time-consuming feature of their struggle. Their OCD is essentially a nonstop battle that is hidden in plain sight. Even those closest to them often have no idea just how much of their life is consumed by these covert, never-ending compulsions.
While those with GAD do not generally exhibit the more obvious compulsive behaviors such as hand washing and door checking, it is not unusual for them to perform some covert compulsions. For example, someone with GAD may avoid certain situations, or seek reassurance in an effort to tame their anxiety about a particular real-life concern. Likewise, an individual struggling with GAD may do mental compulsions in order to cope with unwanted anxiety-provoking thoughts. For example, they might compulsively conduct contingency planning in their mind in order to feel less anxious about a feared potential health crisis or job loss. But while people with GAD may display some of these sorts of behaviors, the impact on their daily functioning is generally not as pronounced as it is for those with OCD.
While most people with GAD do not have OCD, it is fairly common for people with OCD to also have GAD. The simplest way to conceptualize this is that some people with OCD tend to over-think “real-life” issues just as they overthink the mostly implausible obsessions that cause them so much distress.
It is also worth noting that the symptoms of both OCD and GAD tend to spike during times of stress. It is not uncommon for people with OCD and/or GAD to experience a significant increase in their obsessionality when faced with normal life stressors such as taking tests, graduating from college, dealing with coworker conflicts, managing relationship issues, getting married, having children, etc.
Misdiagnosing OCD as GAD, and Vice-Versa
GAD is occasionally misdiagnosed as OCD, but OCD is frequently misdiagnosed as GAD, and one reason for this is fairly simple – most psychotherapists do not even remotely understand the various ways in which OCD is expressed in those suffering with the condition. Unfortunately, many mental health treatment providers conceptualize OCD as being solely about the more obvious outward manifestations of the disorder such as hand washing or door checking. But many people with OCD, especially those with the more obsessional “Pure O” variants, exhibit no externally observable compulsions whatsoever. When faced with a client reporting anxiety symptoms that they don’t understand, many psychotherapists simply use GAD as a sort of fallback diagnosis.
The real culprit here is that many graduate schools do a miserable job of teaching prospective psychotherapists about the complexities of OCD. Most graduate school psychotherapy programs provide nothing more than a cursory, extremely limited overview of the various psychological disorders, without providing an in-depth understanding of any specific condition, including OCD.
The only way that most psychotherapists can develop a more comprehensive understanding of OCD and its treatment is to consciously seek out specialized training beyond what they learn in graduate school. This can be done by taking post-graduate continuing education courses that are required to maintain one’s license. There are also advocacy organizations such as the International OCD Foundation that provide highly specialized training.
Unfortunately, most treatment providers never seek out this extra training because they don’t realize just how little they know about OCD – they don’t know what they don’t know. In lieu of having gained this sort of specialized training, the best thing that most therapists can do to ensure that their clients with unwanted thoughts are properly diagnosed is to refer them to a therapist who specializes in OCD. The bottom line is that an OCD specialist will be able to more accurately distinguish between GAD and OCD, while a more general therapist is unlikely to fully understand and identify certain OCD symptoms.
The most effective treatment for both OCD and GAD is Cognitive Behavioral Therapy (CBT). However, it is important to note here that CBT is not a singular technique, but rather a broad range of interventions. The specific CBT intervention that is usually best for GAD is substantively different than the CBT technique that is most effective for the treatment of OCD.
Because those with GAD generally do not have as significant of a behavioral reaction to their anxiety-producing thoughts, the primary treatment for GAD is usually a specific CBT technique called Cognitive Restructuring. Using this technique, the individual with GAD learns to more effectively identify their anxiety-producing thoughts, and to challenge their accuracy and importance. With Cognitive Restructuring, the individual develops their ability to not immediately buy into their irrational thinking, and to instead consider other more realistic possibilities.
While Cognitive Restructuring can also be helpful for some with OCD, it is crucial to realize that this technique has the potential to be problematic for this population. It is not unusual for those with OCD to use Cognitive Restructuring compulsively in an effort to reduce the anxiety they are experiencing in response to their obsessive thoughts. While this is both predictable and understandable, it is also entirely counterproductive. A compulsion is still a compulsion, even when done in the guise of treatment.
The most effective, evidence-based treatment for OCD is a specific form of Cognitive Behavioral Therapy called Exposure and Response Prevention, or ERP. This treatment focuses on gradually and repeatedly exposing OCD sufferers to the very thoughts and situations that they fear. This might include something as simple as having the person with OCD touch doorknobs over and over again without washing afterwards, or something more complex such as repeatedly driving on busy streets despite their fear that they will run someone over, or changing their child’s diapers on a regular basis, despite the fear that they are secretly a pedophile.
The reasoning behind ERP is that repeated exposure to uncomfortable thoughts and situations leads to habituation, and to learning a new ways to respond to your unwanted thoughts. Simply put, this just means that the more you face your fears, the less scary they become. If you struggle with OCD, Exposure and Response Prevention will assist you in learning four valuable lessons that help you better manage your obsessional anxiety:
1) If you face your anxiety instead of running from it, you discover that the feared outcome almost never occurs.
2) Even if the feared outcome does actually occur, it is unlikely to be anywhere close to catastrophic. Less than ideal perhaps, but not the end of the world.
3) If you don’t respond to anxiety by doing compulsions, your anxiety will usually decrease (or even disappear) anyway, just by virtue of letting yourself get used to its presence in your mind. In other words, you will learn that you don’t really need the compulsions.
4) Most importantly, you’ll learn that you are far more capable of tolerating your anxiety than you previously realized.
As noted earlier, the line between OCD and GAD may at times appear fuzzy or arbitrary. Some would even argue that GAD is essentially a variant of OCD in which the obsessions are simply more focused on “real life” concerns, or that GAD is “OCD Lite”. Further muddying the distinction between these two conditions is the fact that, while ERP is the treatment of choice for OCD, it sometimes has a place in the treatment of GAD as well.
Specifically, the more compulsive an individual’s GAD gets, the more it should be treated like OCD. If an individual with GAD exhibits any of the classic compulsive symptoms that are often seen in OCD (i.e., repetitive hand washing, door checking, etc.), it would be wise to treat those specific behaviors with the same ERP approach used for the treatment of OCD.
Likewise, if someone with GAD displays covert behavioral compulsions that are tangible, such as avoidance behaviors, reassurance seeking, and certain mental compulsions such as repetitive praying or counting, then ERP is appropriate. However, some mental compulsions may be extremely difficult to target with ERP. All of which brings us back to the lack of a perfect distinction between these two conditions, and between their respective treatments.
Finally, it is also worth noting that some more recently developed CBT techniques can be applied with equal value to both OCD and GAD. These newer techniques, such as Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), are often described as Mindfulness Based CBT, or “third wave” CBT. These approaches are grounded on the premise that unpleasant thoughts and feelings are a normal part of the human experience, and that trying to control them actually makes them worse. This “third wave” approach focuses instead on accepting the presence of unwanted thoughts and feelings, without making an effort to reduce or eliminate them.
While we humans cannot control the thoughts that pop into our heads, the good news is that we don’t have to. Whether you struggle with OCD, GAD, or both, the various CBT techniques described above can provide you with a fuller, more realistic perspective towards any intrusive, distressing thoughts that you experience, while giving you the tools you need to more effectively respond to them.
•Tom Corboy, MFT, Lauren McMeikan, MFT, and Crystal Quater, MMFT, are psychotherapists at the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD and related anxiety-based conditions. In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, home visits, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
Everybody experiences unwanted thoughts from time to time, but people with Pure Obsessional OCD (aka, “Pure O”) often feel completely overwhelmed by intrusive, distressing thoughts. Tom Corboy, MFT of the OCD Center of Los Angeles discusses Pure O and its many permutations.
People with Pure O struggle with a seemingly endless litany of unwanted thoughts.
When most people think of OCD (if they think of OCD at all), they think of obvious compulsive behaviors such as repeated hand washing or door checking. This is likely because they have seen television news reports about OCD that focus on these sorts of overt compulsive behaviors. Or perhaps they’ve seen films like The Aviator or As Good As It Gets or Matchstick Men that showcase characters doing these or similar compulsive behaviors.
But these obvious compulsions are really just the tip of the OCD iceberg. Many people with OCD exhibit few, if any, of these outwardly observable compulsions. Based on my 25 years of experience specializing in the treatment of OCD, I posit that the great majority of people with this condition actually struggle with what is colloquially known as Pure Obsessional OCD, or “Pure O”, in which their behavioral symptoms are more subtle, and often unrecognized as “compulsions” by anyone, including themselves. In fact, the great majority of calls we receive at the OCD Center of Los Angeles are from people who are struggling with Pure O. Which begs the question…just what exactly is Pure O?
What is Pure O?
First, let’s be clear in noting that there is nothing even remotely “pure” about Pure O. In fact, it would not be a stretch to say that Pure O doesn’t really exist, or is at the very least a significant misnomer. Every single person I have ever treated for Pure O has exhibited numerous compulsions. In fact, I would argue that it is the compulsions that really define the disorder.
Simply put, Pure O is nothing more than a widely-accepted slang term for the various subtypes of OCD in which the compulsive behaviors are less obvious to the outside world. Not non-existent – just less obvious. As anyone who has ever been “caught” doing their compulsions will tell you, hand washing, door checking, and other outwardly physical compulsions are quite obvious to just about anyone who is paying attention. In fact, it is this visual obviousness that makes these types of compulsions so appealing to screenwriters and tv news crews. Conversely, while people with Pure O may do these sorts of behaviors, their more painful struggle is generally with the three following types of compulsions, all of which are far less outwardly obvious:
Avoidance compulsions – Avoiding situations in which you anticipate experiencing unwanted thoughts, feelings, urges, or sensations.
Reassurance-seeking compulsions – For example, repeatedly asking others to confirm that you did or did not do something, or that something you did or thought was not “bad”.
Mental Compulsions – There are various ways in which people with OCD do mental compulsions. Some simple examples include repeatedly reviewing a past event in your mind in an effort to prove you did not do something horrible, or purposely calling up a “bad” thought in order to check if it still causes you distress, or ritualistically praying in an attempt to eliminate “bad” thoughts.
It is important to emphasize here that Pure O is not separate from OCD, nor is it some sort of “new” or “special” type of OCD. It is simply shorthand for OCD in which the individual’s compulsions are more focused primarily on these three types of behaviors. And while these behaviors are more hidden than overt compulsions such as hand washing or door checking, they are done with the exact same intent – to quell anxiety related to the individual’s unwanted obsessive thoughts.
There are a number of OCD subtypes that are generally considered to be part of the Pure O spectrum, including, but not limited to, the following:
Harm OCD – Obsessing that you have harmed someone, or want to harm someone. Common Harm OCD obsessions focus on the fear that one might purposefully cause harm, such as stabbing, suffocating, strangling, or shooting people, or on accidentally causing harm, such as running over pedestrians while driving or accidentally poisoning family members.
HOCD, aka Sexual Orientation OCD – Obsessing that your sexual orientation is not what you think it should be. For straight people, HOCD focuses on obsessions that they are secretly gay or bi. Likewise, there are also people who are gay or bi who obsess that they are secretly straight.
Trans OCD (TOCD) – Obsessing that your gender is not what you think it should be. For most people with Trans OCD, the fear is that they are secretly transgender. Conversely, there are also people who are transgender who obsess that they are in denial and that they are actually cis-gender.
Pedophile OCD (POCD) – Obsessing that you are secretly a pedophile. It is important to note that people with POCD are not pedophiles, but are consumed by the fear that they secretly are.
Relationship OCD (ROCD) – Obsessing that you actually do not love your spouse or partner, or that you are secretly not attracted to them. In some cases, the obsessions in ROCD may focus on feelings towards non-romantic relationships such as friends or family members.
Religious Scrupulosity – Obsessing that you are not living your life in perfect accordance with the precepts of your religious faith. Religious Scrupulosity can occur in people of any faith.
Moral Scrupulosity – Similar to Religious Scrupulosity, except that the obsessions in Moral Scrupulosity focus not on religious faith, but rather on the fear that one is not living according to their personal moral beliefs and values.
In each of these OCD subtypes, the individual may perform a certain amount of obvious OCD compulsions, such as washing or checking. For example someone with Harm OCD may compulsively check that the stove burners are turned off for fear of causing a gas explosion that would potentially kill their entire family. Likewise, a straight person with HOCD might feel compelled to wash after driving through a gay neighborhood. But people with Pure O will likely be far more impacted by the hours of less obvious compulsions they perform, most or all of which will be completely unnoticed by others.
Furthermore, even obvious compulsive behaviors such as repetitive hand washing and door checking are often done as a response to unwanted, highly distressing Pure O thoughts. For example, some people who compulsively wash their hands do so not out of fear that they themselves will get sick, but rather for fear of transmitting some horrible disease to others. In other words, their handwashing is often a function of Harm OCD in which they fear being responsible for harm coming to other people. Ditto for the door checker whose compulsive checking is often done with the intent of ensuring that they are not responsible for leaving the doors unlocked, through which someone might easily break into their home and kill their family.
Room 101…or Why Pure O is So Devastating to Sufferers
Anyone who has gone to high school in the US over the past 50 years is likely to have been assigned to read George Orwell’s dystopian novel 1984. In that book, the thought police have a special room – Room 101– that they use when trying to break the will of people who dare to think freely. It is in Room 101 that the thought police use people’s biggest fears against them. As described in 1984, Room 101 is where “they threaten you with something – something you can’t stand up to – can’t even think about.” The main character in 1984, Winston Smith, is terrified of rats. In order to get Winston to turn on his lover, the thought police put two rats in a small cage, and then place the cage over his face. The only thing separating the rats from Winston’s face is a small door inside the cage. Faced with his biggest fear, Winston completely gives in. He turns on his lover rather than face the rats.
Essentially, Pure O is Room 101. It is your mind acting as the thought police and threatening you with your worst fear. For Winston, it was rats, so the thought police put rats in a cage and put the cage over his face. For people with Pure O, it can be any thought you don’t want. Murder, pedophilia, sexual orientation, eternity in hell – whatever you “can’t stand up to – can’t even think about”.
Over-Attending, Over-Valuing, and Over-Responding
In Pure O, the fear of the thought itself is the motivator for the compulsive behavior. After all, what is Pure O but unwanted thoughts (i.e., obsessions) that we“can’t even think about”, along with our over-reaction to said thoughts (i.e., compulsions). Seen this way, Pure O is basically a phobia of your own thinking – a fear of your own mind and what it might come up with next.
In Pure O, there is a three-step process by which your personal internal thought police are using the fear of your own thoughts to make you miserable:
Over-attending – People with Pure O pay way too much attention to their thoughts. They actively monitor their thinking to see if they are having thoughts that they don’t think they should be having. This occurs in two different ways. One is by monitoring thoughts that happen to arise spontaneously in their consciousness. A second way is that they actually go looking for unwanted thoughts. Countless clients we have treated over the years have reported that they will purposely dredge up their unwanted thoughts so that they can evaluate whether or not they are having an appropriate level of disgust or discomfort in response to those thoughts. This is rather like poking a stick in your eye to see if it will hurt, and invariably leads to the next step in this maladaptive process.
Over-valuing – It is quite reasonable to evaluate the world. It’s what the human brain does, all day long. But evaluating your thoughts to determine whether or not those thoughts are “ok” or “acceptable” or “accurate” is problematic. If you focus on evaluating your thoughts, you will start to believe that all of your thoughts are actually important and worthy of evaluation. But the truth is that much of what we think is completely and utterly unimportant. It’s just mental static that does not warrant your time or attention. Your brain keeps churning, 24 hours a day (yes, even when you are sleeping), and most of what it comes up with doesn’t merit attention or evaluation. Most of your thoughts are not good or bad – they are just present in your consciousness, with no particular importance. They just pop into your mind unbidden and do not automatically indicate anything whatsoever about your character or intent.
Over-responding – Unfortunately, after spending so much time and mental energy paying attention to your thoughts, and evaluating them as being bad and unacceptable, it is only natural that you would respond to them. We humans naturally want to solve problems, especially problems that make us uncomfortable. And if you have determined that your thoughts are a problem, you are likely going to be anxious and uncomfortable with those thoughts. You are going to want to try to find a way to get rid of them, or to at least minimize their impact. This is the compulsive side of OCD, and it is a trap. Whether you try overt compulsions, avoidance, reassurance-seeking, or mental compulsions, you are merely going to make your OCD worse. Every second that you spend trying to fix or eliminate your unwanted thoughts, you are reinforcing the belief that they are important, and must be controlled. But you can’t control your thoughts, and in trying to do so, you are doomed to failure. You are digging the ditch deeper and deeper, and pretty soon, it is going to be very difficult to climb out of the hole you have made for yourself.
The bottom line is that the great majority of your thoughts do not need to be monitored, evaluated or responded to. They are just the idle chatter of the thinking machine in your head. A far better way of addressing Pure O thoughts is to just let them exist, without attending to them, or valuing them, or responding to them. Just let them exist unanswered. They are just thoughts.
Confirmation Bias in Pure O
Another way of viewing how Pure O wreaks such havoc is through the lens of “confirmation bias”, which is a term in cognitive science for “the tendency to search for, interpret, favor, and recall information in a way that confirms one’s preexisting beliefs or hypotheses.” (Plous, Scott (1993), The Psychology of Judgment and Decision Making, p. 233) Put more simply, confirmation bias is the all-too-human trait of cherry picking information that supports and confirms what we already believe, while ignoring and rejecting evidence to the contrary. It is because of confirmation bias that people with Pure O blindly over-value unwanted thoughts that are backed by little or no evidence.
For example, a 57-year-old man who has had Harm OCD for 40 years may have recurring thoughts about stabbing his grandchild. When he experiences these thoughts, he immediately thinks, “See, I am a monster who wants to kill his own grandchild”. But in jumping to this baseless conclusion, he is over-valuing the thought about stabbing his grandchild as being “meaningful” and “accurate”, while ignoring the fact that he has had these kinds of thoughts for 40 years without ever acting on them. Because of confirmation bias, he views the “bad” thought as being more important, more meaningful, and a more accurate indicator of his character and intent than all of the 40 years of evidence that indicate he is not a killer despite having these unwanted thoughts.
Ego-Dystonic Thoughts vs. Ego-Syntonic Thoughts
To fully grasp the concept of Pure O, it is necessary to understand the difference between ego-syntonic thoughts and ego-dystonic thoughts.
Ego-syntonic thoughts are thoughts which reflect our true values, beliefs, and intent. For example, if I were to have the thought, “I like ice cream”, that would be an ego-syntonic thought because…I really, really like ice cream. Conversely, if I were to have the thought “I want to kill grandma”, that would be an ego-dystonic thought, because I really don’t have any desire or intent whatsoever to kill my grandmother.
The difference between ego-syntonic thoughts and ego-dystonic thoughts has nothing to do with any objective definition or measure of what people see as “good” or “proper” or “healthy”, but rather is based entirely on the subjective values of the individual. Basically, ego-syntonic thoughts are consistent with how we see ourselves, while ego-dystonic thoughts are inconsistent with how we see ourselves.
For example, some individuals like the idea of sex with people of the same gender, while others do not. The issue is not sexual orientation in and of itself, but the individual’s subjective values and beliefs about him/her self. So if a person sees him/her self as “straight”, yet has repeated, unwanted thoughts about being gay, those thoughts are ego-dystonic. Likewise, if a person sees him/her self as “gay”, yet experiences repeated, unwanted thoughts that they are secretly straight, those thoughts are also ego-dystonic.
People with Pure O get stuck precisely because of how they react to their ego-dystonic thoughts. For example an individual with Relationship OCD may have the unwanted thought that they do not actually love their spouse. They see themselves as someone who loves their spouse, and are quite distressed that they repeatedly experience thoughts that they do not. They over-attend to these unwanted thoughts, compulsively monitoring them in an effort to discern how they “really” feel. They also over-value these unwanted thoughts by assuming that these thoughts are important and meaningful. Confirmation bias kicks into gear, leading them to notice these thoughts more often than all of the many loving thoughts they have about their spouse, and to give these thoughts much more weight than all of those loving thoughts. They then over-respond to these thoughts, doing all sorts of compulsive behaviors that are designed to alleviate their doubt, but which actually make it much worse. In fact, in most cases, the only “evidence” they have that they don’t love their spouse is the presence of the unwanted thoughts, which is really no evidence at all.
Often, people with Pure O obsess that they are in denial about their true self. They spend much of their time locked in an internal battle with themselves trying to determine who they really are and what they really want. It’s as if they see themselves as a Russian nesting doll in which there is a “different” self secretly hidden inside their allegedly “fake” outer self. But this is nonsense. There is no secret deep-seated self that you have been keeping hidden from the world all these years through an elaborate and unknown process of denial. There is just you and your values and your choices. As the ancient Roman philosopher Seneca said, “You are your choices”. I don’t recall any philosopher ever saying anything like “You are your unwanted thoughts”.
The bottom line is that you are not responsible for the unending stream of thoughts that pop into your consciousness. Thoughts just happen, and many (most?) range anywhere from unimportant to ridiculous. If you were to keep a running log of all of the thoughts you have in a given day, you would quickly discover just how few are actually meaningful or important.
Think of it this way – if our thoughts are evidence of our true character and intent, then just about everybody is a murderer, as most of us have at some time or another thought of killing someone, even if only while watching a movie or reading a book in which a murder takes place. Think of all of the people who have written books or made movies about killers. Are they all killers themselves? They have all clearly had thoughts about murder, otherwise there would be no way for them to have created stories about such things. Years ago, at the annual conference of the International OCD Foundation, there was a presentation entitled “If Stephen King Can Do It, Why Can’t I?”, the joke being that Stephen King took all of his thoughts about crazy killers and turned them into millions of dollars…all without having to kill even one person in real life!
Treatment of Pure O
Some people have the mistaken belief that Pure O is somehow “special” or “different”, and as such is unresponsive to treatment, but that is simply not the case. Pure O responds quite well to treatment, so long as the therapist actually knows understands OCD and has the proper training. The most effective, evidence-based treatment for Pure O is the exact same treatment that works for all forms of OCD, namely Cognitive Behavioral Therapy (CBT), with an emphasis on a specific CBT technique called Exposure and Response Prevention (ERP). Check back to this blog in the future to read our follow-up article on treatment considerations for Pure O.
•Tom Corboy, MFT is the founder and executive director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions. In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.