Obsessive compulsive disorder (OCD) is an anxiety and stress related condition where a person has a recurring, intrusive thought that triggers distress, and responds to that thought with some type of behavior to relieve that stress. For example, they may have a recurring fear that they are going to catch an illness (obsession) they respond by washing their hands (compulsion).
Obsessions, as recurring thoughts, all occur behind the scenes in a person’s mind as these intrusive thoughts enter. The compulsions, however, are most often associated with visible behaviors, such as repeatedly checking locks, praying, or organizing objects to prevent a feared outcome. “Checking behavior,” which is a common type of compulsion, is an example of this. Fear a house fire, check your stove. Fear cancer, check your body for lumps, and so on.
But for some individuals, the compulsions related to OCD – in particular the checking behaviors – can be largely cognitive. Rather than physical actions, their compulsions take the form of internal checking or mental reassurance-seeking, which can be just as disruptive and difficult to manage but may not be as visible to others.
These cognitive checking behaviors are often misunderstood or minimized because they do not involve outward action. But they represent a key component of OCD in many individuals, particularly in subtypes such as Pure-O (Primarily Obsessional OCD), where rituals are primarily mental.
What Is Cognitive Checking in OCD?
Cognitive checking refers to mental processes intended to reduce anxiety, neutralize intrusive thoughts, or confirm a sense of certainty. These behaviors are not voluntary in the traditional sense and are performed in response to obsessive fears or doubts.
Rather than relying on external validation, individuals with OCD may turn inward – attempting to reassure themselves through memory reviews, mental repetition, or internal analysis.
Cognitive checking behaviors can vary widely depending on the content of the individual’s obsessions. However, certain patterns are frequently observed across multiple OCD subtypes.
These may include:
- Mentally reviewing past events to confirm one’s actions or intentions.
- Repeatedly analyzing whether a thought was “normal” or “bad”
- Trying to determine whether a feeling or physical sensation felt “right” or “complete”
- Rehearsing or repeating mental phrases or images to counteract a distressing thought
- Conducting internal debates to assess the likelihood of having caused harm or made a mistake
- Attempting to visualize a task being completed (e.g., imagining that the stove was turned off)
- Mentally “checking” one’s own emotional or physiological state for signs of danger or illness
- Imagining a violent or sexual act to see if it feels appealing to do and to test the response in their body
These processes often occur automatically and can take up significant mental energy. The person may spend hours trying to arrive at a sense of certainty or moral clarity, without ever feeling fully reassured. These checking behaviors may also themselves trigger further obsessions.
For example, a cishet person with a religious background may have intrusive thoughts about “sin,” and – for their checking behavior – they may imagine someone of the same sex in a sexual way to test whether they’re attracted to the sex, something that would be a sin in their beliefs. Even though the answer is “no,” the checking behavior itself (imagining someone in a sexual way) can then trigger more intrusive thoughts, which in turn trigger more checking behaviors.
Why Cognitive Checking Is Often Misunderstood
Because these behaviors are not outwardly visible, they can be easily missed by clinicians, family members, or even the individuals experiencing them. Unlike behavioral compulsions, which can often be observed or tracked, internal rituals tend to blend into everyday thought processes – making it difficult to identify when normal self-reflection crosses into compulsive territory.
This can delay diagnosis or lead to incorrect labels such as “overthinking,” “guilt-prone,” or “ruminative,” without addressing the obsessive-compulsive nature of the symptoms. Similarly, a person with these intrusive thoughts may be misunderstood if they share the thoughts with others. For example, there are those with intrusive thoughts about harming themselves or others. They have no intention to harm anyone, but they fear that if they tell people about the intrusive thought or the compulsion, the other person may misunderstand it as a desire and shame them as a result. This is why those with internal, cognitive compulsions can struggle to even seek treatment, worried that their thoughts may be misunderstood.
Implications for Treatment and Support
Cognitive checking behaviors require a treatment approach that goes beyond behavioral modification. Exposure and Response Prevention (ERP), the gold standard for OCD, is still applicable – but must be adapted to target mental rituals specifically.
This might involve deliberately resisting the urge to review a memory, tolerating the uncertainty of not knowing, or practicing mindfulness-based interventions that discourage internal engagement with the obsession.
As therapists, it is our role to listen, understand the difference between these types of checking behaviors and desires, and make sure that we’re able to help those with obsessive compulsive disorder find relief that can help them manage their symptoms. For more information, please reach out to us today.