Mental Compulsions and “Pure O” OCD

The stereotypical image of obsessive-compulsive disorder (OCD) is a person with rigid behaviors they feel compelled to repeat: handwashing, lining up objects symmetrically, locking and unlocking doors over and over again. But not everyone with OCD engages in compulsive behaviors you can see. Some kids with OCD experience what are called mental or internal compulsions, which happen only in their minds. And these compulsions are just as real and disruptive as the physical kind.

In information about this kind of OCD, the term “pure O” sometimes crops up. “Pure O” stands for “purely obsessional” and implies that the person only experiences obsessions — unwanted thoughts or worries — without compulsions. However, the term “pure O” is usually misleading. It’s extremely rare for people with OCD to experience obsessions without any compulsions at all. Much more often, the compulsions are present — they’re just invisible.

“If you know what questions to ask, you’ll be able to find compulsions that kids are doing, even though they may not recognize them as compulsions,” says Jerry Bubrick, PhD, a clinical psychologist and director of the Obsessive-Compulsive Disorder Service at the Child Mind Institute.

All kids with OCD experience obsessions — things they can’t stop worrying about. Different kids have different obsessions, but some common ones include fear of germs, extreme worries about safety, and fear that they might do something violent. These obsessive thoughts cause a lot of anxiety, and kids develop compulsions — things they do to alleviate that anxiety. They’re often called rituals because they have to be repeated in exactly the same way in order to make the anxiety stop. 

Children and teenagers with mental compulsions have the same kinds of intrusive thoughts as kids with other forms of OCD, but their compulsions are different. Instead of physical rituals, they carry out rituals in their thoughts.

Some common kinds of mental compulsions include:

• Replaying memories or conversations. For example, a child who is afraid of harming others might think through past interactions over and over again, trying to prove to themselves that they didn’t offend or hurt anyone. They might also compulsively recreate an action in their minds, correcting something that went wrong or trying to be sure it went right.
• Counting. Kids might count to a certain number in their heads or silently count objects around them.
• Reassuring themselves. A child might have an intrusive thought about something bad happening and then think over and over, “That won’t happen.”
• Repeating words mentally until they feel “right.” Kids with OCD often describe repeating a word or phrase until it feels “just right,” although they may not know why.
• Making lists. Kids may compulsively review mental lists, sometimes related to their obsessions. For example, they might list ways that they can avoid germs or reasons why they’re not a bad person.

“Often, it’s some sort of mix of internal and external compulsions,” says Dr. Bubrick. For instance, a child might organize objects compulsively and repeat words in their head. But it’s also possible for kids to experience only mental compulsions, with no visible rituals. And they might not recognize it for what it is, especially if their OCD is undiagnosed.

OCD with primarily internal compulsions is no less (or more) severe than any other form of OCD. “Severity really depends on how much the symptoms are interfering with the child’s life,” Dr. Bubrick notes. “If the intrusive thoughts and compulsions take up less than an hour a day, it’s there but it’s not really interfering. The more the symptoms interfere with your ability to be social, or be at school and keep up your grades and maintain your life, the more severe the condition is rated.”

From the outside, it can be very hard to tell that a child is experiencing mental compulsions, and it’s easy to misinterpret their behavior.

“There’s a lot of overlap and misdiagnosis with things like ADHD and depression,” says Dr. Bubrick. “If I’m sitting in class and I’m thinking, ‘Did I turn off the stove? I think I turned off the stove, but did I?’ and then the teacher calls on me, I don’t know the answer. So it might look like to a teacher that I have an attention problem.” Kids might also spend so much time on their internal compulsions that they become isolated or withdrawn, which can look like depression at first glance.

If you notice these or any other big changes in your child’s mood or behavior — changes in appetite or sleep habits, dropping grades, not wanting to see friends — it’s a sign that something significant is going on, even if it’s not OCD. “If you’re seeing any one of these signs or multiples of them, it’s time to have a conversation with the kid,” Dr. Bubrick says. And if talking it over doesn’t lead to solutions, a mental health professional can help.

Kids whose compulsions are mainly internal may also have some compulsive outward behaviors, though they can be hard to recognize. A very common one is reassurance-seeking, in which a child asks a parent or other trusted adult about their fears over and over again. For example, they might ask, “I didn’t cheat on my test, did I?” or “Did we forget to lock the door?” Getting reassurance reduces their anxiety briefly, but then it comes back, so they ask again. Repeated questions like these can be a sign of OCD.

Dr. Bubrick also notes that sometimes kids will be so ashamed or afraid of an obsessive thought (for example, a fear of harming a family member) that they can’t say it aloud. They might ask parents to talk, and then say something like, “Actually, I don’t want to say it.” These kinds of conversations can be confusing and frustrating for parents, but they’re often a sign that the child needs treatment. “If you’re stuck in these repeated conversations with your kid,” says Dr. Bubrick, “it’s time to ask for help.”

If you think that your child might have OCD, the first step to helping them feel better is getting a thorough evaluation from a specialist.

“If you don’t ask, most people won’t tell you that they do mental rituals,” Dr. Bubrick says. “Sometimes there’s so much shame and embarrassment with these symptoms that kids, even with their parents, won’t admit to having them. So then it really becomes important to find a specialist because there are ways of asking these questions that normalize it for kids, that make it easier for them to open up.”

Once a child with mental compulsions has an accurate diagnosis, treatment itself looks a lot like behavioral treatment for other forms of OCD, though it can be a bit more challenging. “It can be hard to treat kids with mental rituals because you just don’t know what they’re thinking about during sessions,” says Dr. Bubrick. “They could be reassuring themselves while you’re talking to them. That’s why the treatment has to be more conversational — it has to happen out loud.”

Clinicians guide kids through a form of cognitive behavioral therapy (CBT) known as “exposure with response prevention.” The idea is that although kids can’t control their obsessive thoughts, they can learn to control their reactions to them — even when those reactions are mental rituals.

For example, says Dr. Bubrick, a child who is obsessed with fears of offending people can practice talking back to that fear. “They might have an intrusive thought about offending someone, and then they can react by saying: ‘Yes, I did offend someone. It was horrible, and I’m not going to have any friends.’ When you head it out loud, you’re able to hear how ridiculous it sounds.” With the clinician’s support, kids can practice tolerating their anxiety without relying on mental rituals, and the anxiety diminishes over time.

Support from parents is also a crucial part of treatment. Parents can help kids practice the skills they’re learning in treatment at home, and they can also learn how to respond to kids’ external compulsions in more helpful ways.

Even before your child gets a diagnosis, Dr. Bubrick adds, it’s helpful to validate how challenging their experience is and offer support actively. Let them know that you see they’re going through something hard and that you’re there to help — that kind of acknowledgement can make a big difference to kids who are struggling with an invisible challenge. Having your support can make it easier for them to share details about what they’re going through, and then you’ll be better equipped to find them the treatment they need.