Intrusive Thoughts & Pure-O OCD Therapy

What Is Intrusive Thought OCD (“Pure-O”)?

Intrusive Thought OCD — often called “Pure-O” — involves unwanted, repetitive thoughts, images, or impulses that feel disturbing, out of character, and often completely opposite of a person’s values. While the term “Pure-O” suggests “purely obsessions,” people with this subtype do in fact perform compulsions; these compulsions simply tend to be internal, mental, or subtle.

Common Types of Intrusive Thoughts

1. Harm or Violence

Fear of intentionally or unintentionally hurting someone, losing control, or causing an accident. These thoughts are not desires — they’re alarms. They terrify the person because they completely violate their values.

• Thoughts of stabbing, suffocating, or poisoning someone
• “What if I stab my spouse while they’re sleeping?”
• “What if I drown or suffocate my baby?”
• Images of pushing someone off a ledge or into traffic
• “What if I snap and hurt my child?”
• Fear of swerving into oncoming cars
• “What if I hit someone with my car and didn’t realize it?”
• Graphic mental images of violence or murder

2. Religious or Blasphemous Thoughts (Scrupulosity)

Worries about offending God, committing a sin, or failing religious obligations correctly. These thoughts arise from sensitivity, not disrespect.

• Sexual or violent thoughts during prayer
• Feared blasphemous or sinful thoughts
• Inappropriate thoughts about religious figures
• Worrying that prayers were done “wrong”
• Constant mental reviewing of spiritual mistakes
• Fear of hidden or unforgivable sins

3. Taboo or Inappropriate Sexual Thoughts (including POCD)

Intrusive, unwanted thoughts about topics that feel morally unacceptable. These thoughts cause shame, fear, and self-doubt — not because the person wants them, but because they don’t.

• Pedophilia-themed intrusive thoughts (POCD)
• Sexual thoughts involving children, despite deep disgust
• “What if I’m attracted to my niece / nephew / student / own child?”
• “What if I sexually touch a child or gave my own child a sexual act?”
• Fear of incest or sexual thoughts about family members
• Sexual thoughts about animals
• Violent or graphic sexual images
• Sexual thoughts about religious figures
• Unwanted arousal in response to disturbing thoughts (“Why did I feel that?”)
• Fear of acting inappropriately toward someone

These are ego-dystonic — completely opposite of the person’s values. The fact that they horrify you is proof they are OCD, not real desires.

4. Fears That Something Bad Will Happen (“Magical Thinking”)

This is extremely common in my practice. These thoughts are fears that simply having a thought can cause a catastrophe, especially involving people they love.

• “I just thought that my husband will die in a car accident, now it could happen?”
• “I just read the word kill, now someone I love may die”
• “What if my baby stops breathing in their sleep?”
• “What if my parent gets cancer?”
• “If I don’t say this prayer exactly right, something terrible will happen.”
• “I had a thought about death — is it a sign?”

People with OCD often feel responsible for preventing disaster. Compulsions — like praying, repeating phrases, mentally reviewing, or avoiding triggers — are done to keep others safe.

How Compulsions Show Up in Pure-O

Compulsions in Pure-O are often invisible but incredibly time-consuming:

• Mental reviewing or checking
• Praying “correctly” or repeating a prayer until it feels right
• Reassurance seeking
• Trying to suppress or replace the thought
• Mentally scanning for danger
• Avoiding situations, people, or triggers
• “Protective rituals” to keep others safe

A remarkable and important point: many people with this subtype perform compulsions not for themselves but to protect others — their children, spouse, parents, or friends.

This says something important about them: their compulsions come from love.
The suffering is real, but so is the goodness behind the worry.

Is Pure-O Harder to Treat?

Pure-O has a reputation for being harder to treat — but that’s a myth.

When treated properly with Exposure and Response Prevention (ERP), it responds just as well as other OCD subtypes.

The key is helping a person:

• understand the vicious cycle of OCD.
• learn to stop compulsions (especially mental ones)
• build tolerance for uncertainty
• and practice structured, appropriate exposures

With the right approach, people make meaningful, life-changing progress.

How Treatment Works

ERP involves gradually facing the thoughts or triggers while resisting the urge to perform compulsions.

Over time, the brain learns:

• “This isn’t dangerous,” and
• “I don’t need compulsions to handle this.”

This leads to less anxiety, fewer intrusive thoughts, and more confidence and control.