Have you ever thought of having sex with someone inappropriate, swerving the car off the road, or blurting out something shocking in a social situation? Most people have such unwanted thoughts from time to time. And most people are able to dismiss them. But for a small number of people such thoughts become intrusive, pervasive and a waking nightmare.
These people suffer from Pure-O (Pure-Obsessions), a crippling but rare form of Obsessive Compulsive Disorder (OCD). The main feature is persistent and intrusive thoughts of a sexual, abusive or racist nature, often including harming others. And it's hard to think of a more pernicious and misunderstood mental illness.
Whilst research shows that Pure-O sufferers are often the most principled amongst us, the potency of this disorder lies in its ability to shatter people's moral foundations. Unable to dismiss their thoughts, they attributed catastrophic meaning to them, seeing them as indicators of their true personality. And unable to ignore them, they became locked into a debilitating mental struggle to try to disprove them as again and again they are forced to confront their worst possible fears.
My client Pete (name changed), a 37yr old PhD student, has collaborated with me to write this piece. In his words:
Living with Pure-O at its worst was frightening, shameful and at times made me despair... It made me think the worst of myself...My obsessions include(d) horrible words, derogatory terms for black people, homosexuals, words or sentences surrounding violence, physical and sexual in nature. Words like "rape", "rape victim", "b****h", "slut", "f*g", "n****r"...I started to obsess over these words, which undermined my sense of self, made me fundamentally question my ideals...I started to hate myself and tried to understand how I had possibly gone so far wrong to be "deep down" thinking all of this nasty stuff. I felt like I had lost the real sense of who I was...
Unlike other forms of OCD, there is no external sign of the torment (i.e. hand washing, lock checking) instead the attempts to combat the obsessions are all mental...
I tried desperately to neutralise the bad thoughts/words/sentences by a variety of mental rituals. Sometimes I would say the opposite and remind myself constantly that this is what I thought and believed, at other times I would repeat certain positive words like "love"...other times I would 'morph' words so that I would avoid saying the entirety of the 'bad thing'
But trying to rationalise them, avoid them, disprove them only serves to maintain and add fuel to the most awful question of all - is this who I am? Understandably Pure-O carries intense levels of shame, which makes people reluctant to seek help. But there is an effective treatment, with an 80-90% recovery rate. It is called ERP - Exposure and Response Prevention (ERP) and comes under the umbrella of Cognitive Behavioural Therapies (CBT).
Contrary to what the Pure-O sufferer thinks, the content of the thoughts is not important for treatment. It is the meaning attributed to them and the compulsions to disprove them that need to be targeted. The aim is to repeatedly expose sufferers to their unwanted thought whilst not engaging in their usual response i.e. to understand them or make them go away. And through exposure, the brain habituates to these uncomfortable thoughts and learns to see them for what they are, just thoughts. Try yourself repeating a word for two minutes... after a while the word loses any meaning. In our sessions, Pete recorded the problematic words, repeating them over and over into the recorder. He would then replay the recording between sessions until his anxiety at hearing the words diminished.
At times it was difficult to convince myself to do it as it was extremely unpleasant and other times it was just a plain nuisance, but most of the time it helped if I found the time/effort/strength to do it.
Whist the causes of this disorder are largely unknown there is thought be a genetic component, and medication that blocks the re-uptake of Serotonin helps. But fortunately knowing why is not necessary to break free from the hell of Pure-O. Pete has made a good recovery, and no longer meets the requirements for official diagnosis of OCD. And like most mental battles there is the potential for it to ambush again. But next time, he'll be ready.
Pure-O is not something you solve and never have to deal with again...but now it no longer plays an hour-by-hour role in my life. I have come to recognise it both as separate from me and a part of my make-up, and I am, most of the time, able to see the difference between the sorts of thoughts OCD throws through my mind, and the sorts of thoughts that are genuinely mine.
I would like to thank Pete for his contribution to this article.