OCD, Pure O and Anxiety: Understanding Differences and Why Treatment for Anxiety with OCD requires different approaches
OCD Obsessive Compulsive Disorder - Washing Hands
Anxiety is something almost everyone experiences from time to time. It’s part of being human — a natural response to stress or perceived threat. But when anxiety takes over, it can feel overwhelming, all-consuming, and difficult to control.
For many people, anxiety doesn’t exist on its own. It can appear as part of Obsessive Compulsive Disorder (OCD), including a form often called Pure O (Purely Obsessional OCD). Compulsive actions such as hand washing or locking the door 30 times before leaving or repetitive unhelpl thoughts are some examples. While these experiences share features with anxiety, they are not identical. And that distinction matters, because the treatment for each can look quite different.
Anxiety and How It Shows Up
At its core, anxiety is about worry and fear. It often brings:
Racing thoughts about “what if” scenarios.
Physical symptoms such as a fast heartbeat, tight chest, or sweaty palms.
A sense of dread or being “on edge.”
Avoidance behaviours — staying away from situations that might trigger worry.
Anxiety disorders (like Generalised Anxiety Disorder or Panic Disorder) are usually focused on the feeling of fear itself and the belief that something bad might happen. Treatment often involves recognising unhelpful thought patterns, learning calming strategies, and gradually facing fears in a safe, structured way.
OCD: When Anxiety Becomes Cyclical
OCD is closely linked to anxiety but takes a different form. In OCD, anxiety is triggered by intrusive thoughts or fears — for example, “What if I didn’t lock the door?” or “What if I contaminate someone with germs?” These thoughts create distress, and the person feels compelled to carry out rituals or behaviours (compulsions) to try to reduce the anxiety.
Common compulsions include checking, cleaning, counting, or seeking reassurance. But the relief from these behaviours is only temporary, and the cycle of thought-anxiety-compulsion soon repeats.
Pure O: The “Hidden” Form of OCD
In Pure O, the compulsions are mostly mental rather than physical. Someone might:
Mentally review past events over and over.
Silently repeat phrases or “neutralising” thoughts.
Constantly seek certainty or reassurance internally.
From the outside, it can look like the person is “just anxious,” but the inner world is filled with exhausting mental rituals. This makes Pure O particularly misunderstood and misdiagnosed — often being mistaken for generalised anxiety.
Why Treatments Are Different
Even though anxiety, OCD, and Pure O all involve worry and fear, the treatment goals are different:
For anxiety disorders:
The focus is on learning to calm the nervous system.
Challenging catastrophic thinking.
Building tolerance for uncertainty in manageable steps.
Using relaxation, grounding, or mindfulness to reduce overall stress.
For OCD (including Pure O):
The treatment often involves Exposure and Response Prevention (ERP), a type of therapy that gently helps you face intrusive thoughts without performing compulsions.
The aim isn’t to “get rid of the thoughts” (we can’t control what pops into the mind), but to change your relationship with them so they lose their power.
Rather than calming down in the moment, the focus is on breaking the cycle of compulsions — even though this may feel more uncomfortable in the short term.
It’s worth noting, however, that research is somewhat divided on whether ERP should be seen as the “gold standard” for OCD and Pure O. While many people benefit significantly, others find it too overwhelming or not effective on its own. This has led to an increasing interest in alternative and integrative approaches, reminding us that treatment needs to be tailored to the individual.
Different Treatment Approaches for OCD and Pure O
Because OCD and Pure O show up in different ways, therapists often draw on a variety of approaches beyond ERP. These may include:
Cognitive Behavioural Therapy (CBT) – helping you identify and reframe distorted thought patterns that feed anxiety and compulsions.
Acceptance and Commitment Therapy (ACT) – focusing on building a new relationship with intrusive thoughts, so they no longer dictate your actions or sense of self.
Mindfulness-based approaches – teaching you to notice thoughts without reacting to them, which can be particularly helpful in Pure O where the compulsions are mental.
Medication – in some cases, doctors may prescribe medications to help reduce the intensity of symptoms and make therapy more effective. This must be discussed with your GP and is not something therapist get involved with.
Compassion-focused therapy – addressing shame and self-criticism, which are often deeply entwined with OCD and Pure O.
Different people respond to different methods, and what works best often depends on the unique combination of anxiety, OCD, Pure O, and personal circumstances.
Why Getting the Right Support Matters
If OCD or Pure O is treated as “just anxiety,” the strategies might unintentionally make things worse. For example, relaxation or reassurance might reduce anxiety temporarily but reinforce the OCD cycle in the long run because the root of the obsessive behaviour or thoughts is not addressed.
On the other hand, if generalised anxiety is treated like OCD, the structured exposure work may feel overwhelming and miss the underlying need for calm and self-regulation. In this case the root of anxiety is not obsessive behaviour or thoughts.
This is why having the right assessment and a therapist who understands the differences is so important. Each person’s experience is unique, but recognising whether the struggle is primarily anxiety, OCD, Pure O, or a mix helps shape the most effective path forward.
Moving Towards Relief
Living with anxiety, OCD, or Pure O can be exhausting — but it doesn’t have to stay this way. With the right support, it is possible to:
Reduce the hold intrusive thoughts have on your life.
Break free from cycles of worry and compulsion.
Build a calmer, steadier relationship with your thoughts and emotions.
At Yateley Therapy Space, I offer a supportive environment where you can explore these experiences safely. Together, we can find an approach that works for you and your specific challenges.
✨ This is the first in a series of blogs exploring how anxiety interacts with other conditions and circumstances. In future posts, I’ll be looking at anxiety in ADHD, autism, chronic pain, menopause, and more.
