While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination.
[3] Primarily obsessional OCD takes the form of intrusive thoughts often of a distressing, sexual, or violent nature (e.g., fear of acting on impulses).
The distinction between the presence of subclinical symptoms and a clinical disorder requires assessment of a number of factors, including the individual's level of distress and impairment in functioning.
"[5][page needed] The nature and type of primarily obsessional OCD vary greatly, but the central theme for all affected is the emergence of a disturbing, intrusive thought or question, an unwanted/inappropriate mental image, or a frightening impulse that causes the person extreme anxiety because it is antithetical to closely held religious beliefs, morals, or societal norms.
(even though they usually realize that their fear is irrational, which causes them further distress)[7] and puts tremendous effort into escaping or resolving the unwanted thought.
[27] Those with primarily obsessional OCD might appear typical and high-functioning, yet spend a great deal of time ruminating, trying to solve or answer any of the questions that cause them distress.
On the other hand, a therapeutic response (one that will help interrupt the cycle of obsessing) is one that answers the spike (intrusive thought) in a way that leaves ambiguity.
Although resisting the need to reassure oneself and perform compulsions will initially cause anxiety to increase, refusing to practice compulsions over an extended period of time will eventually cause anxiety around their intrusive thoughts to decrease, making them less prevalent (e.g. they will begin to occur less often), and less distressing when they do occur.
Acceptance and commitment therapy (ACT) is a newer approach that also is used to treat primarily obsessional OCD, as well as other mental disorders such as anxiety and clinical depression.
[35] Singers George Ezra, Christian Lee Hutson, and Luke Combs suffer from primarily obsessional OCD.
[39] According to The Guardian, sufferers of Pure O generally praised the show's relatability but felt that Marnie's condition was not treated with the appropriate level of gravity.