The most common association regarding people with Obsessive-Compulsive Disorder (OCD) are that these people are primarily concerned with germs and becoming ‘contaminated.’
This is the one variant of OCD that receives the most publicity, and optimistically, it is also among the most ‘treatable’ forms of OCD.
Most of the early studies on treatment for OCD focused on people struggling with contamination fears. Despite this early focus in the research literature, some continue to struggle following treatment, or fail to respond altogether. It has been my experience that there are some factors that weigh heavily in whether one successfully recovers from contamination OC. Among these factors are: 1) extent that others assume ‘responsibility’ for cleanliness, 2) extent of overvalued ideas, and 3) ability to engage in treatment related exercises. These areas will be considered later in this article.
Contamination OC may be defined as a pervasive sense of having some undesirable object(s) still on one’s body, even after washing. Many sufferers from contamination OC report a ‘radioactivity effect’ such that mere exposure or incidental contacts with an identified contaminant results in total contamination. This creates a vicious spiral where the sufferer becomes increasingly concerned over being clean, and is incapable of satisfactorily ridding themselves of the contaminant.
This form of OCD frequently manifests itself along a few major themes. These are as follows:
- Contamination results in harm to self or others
- Simple awareness that a contaminant is ‘just there.’
- Bugs, and concerns over bug related contamination (which is different from phobias related to insects).
- Washing rituals as efforts to remove undesirable thoughts or ideas.
Each of these major thematic presentations demand somewhat different approaches to treatment, but all four areas can be addressed using cognitive-behavioral therapy.
The purpose of this article is to consider each of these forms of contamination fears and how they manifest. Then, some general concerns relating to the assessment of symptoms is discussed. Finally, the methods of treatment are covered, with special attention given to treatments that are commonly offered, but also generally ineffective.
Symptoms of Contamination OCD
Although I have outlined four major ways in which contamination fears may present, there are two dominant overall concerns for people with contamination OC. One is a pervasive and unrelenting sense of doubt that they are clean enough. Imagine washing your hands in the dark, and there is low water pressure. After washing, you may wonder if you have completely washed your hands. Now, imagine that you or your child’s life depends on your hands being completely clean after washing in the dark with low water pressure. This is the kind of uncertainty and perception of necessity that people with contamination OC struggle with everyday while trying to cope with their fears. As people with this condition continue to engage in washing routines to alleviate the doubt about being clean, they typically suffer greater damage, as symptoms frequently worsen until it is as though they simply cannot get away from the sink. Essentially, as you wash and give in to the urge to assume perfect cleanliness, there is greater validation given to your brain’s concern over the necessity of being clean. What follows from this is a greater degree of vigilance for contaminants, and it becomes increasingly difficult to become as clean as necessary. As one person with this form of OCD once told me,
“It was simply horrible. I knew I was clean, but couldn’t help think that I might not be completely clean, and continued to wash. It would go on for about one hour. Then if I accidentally touched something I thought was dirty, I had to begin again. It seemed the possibilities for inadvertent contact were limitless.”
After a while, this person was no longer satisfied by using soap, but instead found that only using a disinfectant cleaner could bring comfort. She is no longer suffering to this degree, and only requires about one minute to wash, and does so only three times a day. This idea seemed impossible to her, and when I suggested that this might be possible when we started working together, she laughed and said she would probably prove me wrong. Fortunately, we collaborated to solve her problem and her condition has been improved to this degree for over three years.
The other dominant concern for people with contamination OC involves an intolerance of uncertainty. This is different from doubting in the following way. Again, if we were to think of washing in the dark, and still feel that there was in incomplete hand washing, most people without contamination OC would be relatively unconcerned. This is not so for those with contamination OC. The circumstances surrounding a less than perfect probability of being clean is frequently difficult to tolerate for people with contamination OC. In this case, the problem is quite frightening where one cannot help but feel that because they are ‘only 99% clean’ that the 1% left will be harmful, possibly fatal. Even when one can state that they feel this level of cleanliness is likely adequate, there is still a persistent fear that this time the remaining unclean portions will be harmful.
Reasons for Contamination OCD
People with contamination OC consistently cite a few distinct reasons for their concerns with dirt and germs, as listed earlier. One involves vulnerability to personal harm. That is, if they are not clean enough, then they will harm themselves somehow and be unable to cope with the consequences. This is the one that is most commonly associated with OCD. Indeed, in the movie As Good As It Gets, the screenwriters were depicting a character with a classic symptom of OCD (although the character portrayed by Jack Nicholson did not have the personality typical of people with contamination OC). Another reason cited is that they will inadvertently harm someone else by infecting others with a contaminant. This is also referred to as responsibility OC (See Guilt Beyond A Reasonable Doubt). Someone I recently treated, who had this form of contamination fear, reflected on his difficulties this way,
“I was always terrified that I would be responsible for someone becoming ill. I used to wash for 20 minutes, and in a special pattern designed to ensure that I was clean. I was reluctant even then to shake hands, but if I had not washed, I thought someone might get ill from being near my hands. I also had to shower a special way, in a pattern, beginning with my head and systematically working down to my feet. This took an hour. But at the time, it was worth it because I couldn’t cope with the idea that I would be responsible for someone else becoming sick.”
An important theme emerged for this person, that he would be responsible for others becoming sick. When someone has this form of contamination OC, the typical concern centers on responsibility and the ability to cope with feeling guilt (even if unlikely accurate) due to events due to their actions (or in the case of washing, incomplete action). If we were to depict this as a sequence, it would appear as follows:
- Feeling dirty
- Hand washing
- Doubt about cleanliness
- Increased washing
- Responsibility alleviated
People who have this form of contamination OC are frequently concerned that they will be ‘carriers’ of an illness. That is, they will not necessarily become sick with physical symptoms, but rampantly spread the disease. This problem has been exacerbated for some by the media attention given to air-borne bacteria and germs present on surfaces in the public. For example, products currently available to kill germs following contact with public areas have contributed to some with contamination OC finding their symptoms worsen. One well-known celebrity (with a talk show) has openly expressed his affinity for these products out of a concern with contracting an illness.
Among the illnesses most commonly feared by some sufferers include AIDS, Hepatitis, Sexually Transmitted Diseases (such as Herpes), the Ebola Virus, and even colds and flu. Areas most feared for people with contamination OC include hospitals, subways, public restrooms, drug stores and pharmacies, and any public place where there is a risk of encountering people with illnesses. This would encompass the concern that the contaminant is ‘just there,’ and therefore intolerable.
Another variety involves a concern over insects. However, people with this concern who have contamination OC are not worried about bug bites as much as they are worried that the insect has some contaminant that will result in harm to themselves or others. This is one way of distinguishing this problem from problems of other phobics (such as spider phobics, who primarily fear being bitten). In this case, all insects may be a source of extreme fear and worry over possible harm from developing an insect-borne illness.
Finally, people with contamination OC sometimes engage in washing rituals for contaminants that are actually thoughts. The “washing of ones’ sins” would be part of this concern. This is also a part of pure-obsessions, where most of the problem centers on forbidden thoughts or ideas. For example, I had treated a man who washed whenever he thought a blasphemous thought, or witnessed someone engaged in an activity that was not in keeping with certain superstitions. So someone failing to close an umbrella before entering a house would result in a washing ritual. Or if someone said ‘Nostrodamus was a fool.’ He used to compile a mental list through the day of each blasphemous thought or superstition violation, and wash for each one at the end of the day, sometimes lasting until the early morning hours.