When we picture OCD, it’s easy to imagine soap, locks, or neatly aligned objects. But not all compulsions leave visible traces. For many patients, the compulsions unfold entirely in the mind—silent, repetitive acts that can be just as exhausting and disruptive as outward rituals. These are the mental compulsions, and they deserve as much attention as washing or checking.

What Are Mental Compulsions?

Mental compulsions are covert rituals performed in thought rather than action. Common examples include:

• Silently repeating prayers or words.

• Mentally “erasing” or “neutralizing” a bad thought with a good one.

• Reviewing past events endlessly to check if harm was caused.

• Counting, calculating, or creating mental lists.

To the outside world, the person looks still. Inside, their mind is running on a treadmill.

What the Data Show

In the Brazilian multicenter study of more than 1000 OCD patients, over 56% reported mental compulsions.

Importantly:

• Mental rituals almost never existed alone. Nearly every patient with mental compulsions also had overt behavioral compulsions.

• The most common symptom dimensions linked to mental rituals were:

  • Symmetry/ordering (e.g., mentally organizing or checking).

  • Aggression obsessions (e.g., replacing violent images with “safe” thoughts).

  • Sexual/religious obsessions (e.g., praying mentally to cancel out taboo thoughts).

• They were less frequent in contamination-related OCD, and rarest in hoarding.

This means that even in “Pure-O” OCD, the compulsion side is usually there—just harder to see.

Why They Matter

For clinicians:

• Assessment: Without asking directly, clinicians may miss these rituals. Patients may describe only “obsessions,” yet their mental neutralizations fit the OCD cycle.

• Treatment planning: Mental rituals must be targeted in ERP (Exposure and Response Prevention). Otherwise, patients may comply with visible exposure exercises while covertly neutralizing anxiety.

• Differentiation: Helps separate OCD ruminations from those in generalized anxiety disorder or depression, where repetitive thinking lacks a compulsive quality.

For patients:

• Recognizing mental rituals as part of OCD is often a turning point. It shifts self-blame (“why can’t I stop overthinking?”) to understanding (“this is part of the disorder, and it can be treated”).

ICD-11’s Step Forward

ICD-10 never mentioned mental compulsions, treating compulsions only as repetitive behaviors. ICD-11 corrected this gap, explicitly including repetitive mental acts in the definition of compulsions. This change brings diagnostic systems closer to lived experience, and prevents patients from falling through the cracks simply because their OCD is less visible.

The Clinical Challenge

ERP for mental compulsions can be harder to structure, since rituals are silent. But with awareness, therapists can design exposures that block both overt and covert rituals—whether that means resisting mental reviewing, or sitting with taboo thoughts without neutralizing them.

The lesson is simple but profound: if you don’t look for mental compulsions, you’ll miss them.

About the Author

I’m Dr. Srinivas Rajkumar T, MD (AIIMS, New Delhi), Consultant Psychiatrist based in Chennai. Through my clinical practice and writing, I aim to make psychiatry more understandable and less intimidating.

📍 Mind and Memory Clinic, Apollo Clinic, Velachery, Chennai (Opp. Phoenix Mall)
📞 +91 85951 55808
🌐 srinivasaiims.com