I have been dealing with Pure O most of my life. At 43 I had my first real anxiety attack over it - eventually I went to McClean OCD ?Institute for 2 months in Massachusetts. Thes past two weeks have been difficult. I have been told that OCD is caused by deep root of shame or toxic shame where one thinks and believes there is something inherently wrong with oneself. So one feels dirty all the time (hour long showers) or one is self sabotaging (skin picking) or one's mind reacts excessively to bad thoughts because when you feel shameful you feel like you have no defense, your not clean or you deserve destruction. Sometimes, especially with harm OCD, when you have thoughts of harming yourself or others, the thoughts are shame scenarios and are really centered around YOU and not the person (with self harm - its you imploding on yourself) your thoughts are using as the "victim" in your thoughts. This is why your mind picks the ones you most care about as the target because it creates that much more shame. We obsess because we have shame, which means we have no assurance within ourselves to reference so we obsess over thougts because we are constantly checking for a reference and anxiety is a result of not geting the response we want. I really believe shame is the root of OCD.