By Carol Hevia, PsyD
This article was initially published in the Fall 2009 edition of the OCD Newsletter.
Case Example
Joe is a 25 year-old college drop-out who is currently unemployed and lives in an apartment above his parents’ garage. He has a lifelong history of OCD that began at age 8 when he was plagued with symmetry obsessions and scrupulosity. Now he is struggling primarily with obsessions that he will be contaminated by a former college roommate, Connor, who was wildly successful in academics and in the business world after graduation by being ruthless and nasty and by taking advantage of those who helped him and those who “got in his way.” Joe fears that if he comes into any kind of contact with his former roommate, he will be at high risk of becoming like him “ruthless uncaring and a cannibal of friends and foes.”
During college, Joe was so terrified that he would become like his roommate that he started to avoid all friends who had contact with Connor, as well as the library where Connor studied. Joe, like Connor, was a business major and began to avoid taking any courses that would be held in the business school on campus. This became very problematic when choosing which courses to take each semester, so he switched his major to Russian Studies because that department was housed on the other side of campus. However, if Joe happened to speak to a fellow classmate who had taken a course in the business building, he needed to immediately drop not only that particular course that they shared but also discard the clothes he was wearing at the time, his books from that class and any current term papers in progress.
Eventually these disruptions eroded his academic success; his grades dropped, he took a medical leave from college, and he returned home to live with his parents. Since he had shared a dorm room with Connor, he felt the need to discard all clothes, books, personal belongings, and even his computer, when he moved out of the dorm. But just like the college dorm room, it was inevitable that the house would become contaminated, for even when someone mentioned Connor’s name the obsessions would be triggered, and decontaminating the house became impossible due to Joe’s high OCD standards and rigid rules for decontaminating. The family had an apartment built over the garage so that Joe could keep his living quarters “free from Connor’s cannibalistic influence,” but then he stopped even stepping into his parents’ home for fear of exposure to Connor’s ruthless ways. When Joe tried to take college courses online he found that the contamination seeped into his garage apartment through the computer since Connor had an account on a social networking site online. When Joe reached the point where he was preparing to move into another apartment in a town twenty miles from his parents, and he was about to buy his fifth computer, and he no longer uttered any words with the letter “C” in it, he called a behavior therapist to get help.
Symptomatology of Emotional Contamination
Joe suffers from a subtype of OCD called Emotional Contamination. Emotional contamination is a lesser known symptom cluster of OCD in which the sufferer fears that contact with a person or place will somehow contaminate and endanger him. The worry can be that the individual with OCD is at risk to take on negative personality traits that the trigger person has, such as bossiness or nastiness, or that the sufferer will take on another’s entire personality. It is fairly easy for the individual with OCD to identify the person who triggers his obsessions. Sometimes it can be a “type” of person who represents a disability that one fears contracting, such as a blind person or a person with deformed limbs. The trigger can also be a geographical location, such as a college, funeral parlor, or cemetery. Sometimes a traumatic event “marks” the physical site and is the source of the initial contamination and subsequent danger. An example of this could be the break-up of a serious relationship, a death, or a suicide attempt. Then any contact with the place where the event took place is perceived as dangerous, as if the physical contact will generate bad luck and magically endanger the person with OCD. The feared bad luck can be very specific such, as a car accident, or it can be vague such as a general sense of impending doom. Two hallmarks of emotional contamination are the presence of magical thinking and superstitious behaviors. Both magical thinking and superstitions are clues that the sufferer believes in a phenomenon that is inconsistent with what is generally considered true and rational in the particular society in which he lives. The person with OCD often believes that random events and coincidences never occur and that all events are meant to happen, so they therefore hold special meaning and power. Any time a coincidence occurs the sufferer uses the coincidence as “factual evidence” that their superstitious beliefs have merit and that all others who try to dissuade them are wrong.
The exposure and subsequent obsessions are often “contained” through similar rituals to that of contamination fears. The person with OCD will avoid direct contact with the contaminated person and will clean him/herself thoroughly if he does touch the person or the person’s belongings. Contamination can “magically” spread through physical contact, such as a handshake or touching a pencil that the contaminated person recently used. Often as the OCD symptoms worsen the contamination from another person starts to look as serious as a true radiation contamination in that the person will actually throw out all clothes worn at the time of contact and vigorously scrub themselves down in a long shower.
The perceived danger of contamination can also be airborne, so that merely sharing air space with the trigger can put the person with OCD at risk to suffer a catastrophic consequence. The sufferer may cover his mouth with a barrier to protect himself from becoming “ill,” or might try to hold his/her breath when near the trigger. More often the ritual would be an “undoing” of breathing in contaminated air by breathing out in a ritualized fashion, perhaps with a neutralizing thought that safely “deactivates” the danger of the contaminated air.
Sometimes in emotional contamination the perceived danger can spread through language and speech, so that uttering a phrase or word that reminds one of the obsession can dramatically increase the perceived risk of danger. Thus, the individual with OCD avoids using specific words or names and he may even attempt to control others’ use of the trigger words in order to avoid escalating anxiety. The rituals can even spread to reading and writing; for example, the sufferer might avoid writing the trigger word or if he reads the trigger name he might engage in neutralizing rituals to undo the effect of reading the dangerous word. The neutralizing rituals may be to reread the trigger phrase while having a “good” or opposite thought, or to skip reading the entire page. The person with OCD may decide to cease reading altogether in an attempt to quell his/her anxiety.
As the sufferer becomes more symptomatic the contamination can generalize further – the individual letters or punctuation symbols become dangerous, as well, and the person writes words with letters left out so the reader must guess as to the exact content of the message.
Not surprisingly, exposure to the media whether in written form, television, or the internet can become problematic for the person with OCD. News related to the triggering topic can set a sufferer into a tailspin, so the bold type titles in a newspaper or magazine are initially skimmed in an effort to stay away from triggering topics, and eventually reading a newspaper is avoided altogether. Then, even touching the newspaper becomes an issue with which to contend. Particular television shows are avoided due to implied content, and the same holds true for known internet sites. However, as with other triggers and unchecked ritualistic behavior, generalization is inevitable and a further escalation of symptoms will occur if the OCD is left untreated. For example, the computer is no longer touched or used, the room that the computer is in is never entered, and the person can deteriorate towards residing in one room of their home and not venturing out due to potential danger from exposure to anything even remotely related to the contaminated person or place.
Treating Emotional Contamination
Exposures for emotional contamination will at first mimic germ and contamination exposures. Hand washing and showering frequencies are reduced in quantity and quality. The person touches contaminated items, uses previously avoided belongings, and then cross-contaminates from “dirty” to “clean” belongings. The ERP plans start to differ when the ERP is designed to expose the sufferer to avoided words and sounds. He may write one word or phrase repeatedly and then say it out loud. The written trigger is then hung up on the person’s door or walls, thus saturating both one’s awake and sleeping hours with the feared stimulus. Placing the triggering written work by one’s bedside is especially effective because sufferers often believe that they are more vulnerable to emotional contamination while they sleep.
Joe started twice weekly behavior therapy outpatient sessions. He made a list of worries and triggers, both physical and mental, and rituals. Together, he and his therapist rearranged the list into a hierarchy of feared situations and triggers using a SUDS rating of 1 to 10. He agreed to cancel plans to move from his garage apartment and he kept his fifth computer. His exposures started with saying and writing Connor’s name on sheets of paper and then hanging them around his computer and bed. His family learned about accommodation, and not only started to block verbal reassurance, but eventually, under the therapist’s guidance, began to say words with C, and even said the dreaded word, “Connor,” during ERPs. Once Joe experienced habituation to some of the initial ERPs his sense of direction in the treatment, his hope and his motivation dramatically increased and he was more able to take on challenging tasks since he knew that even when his anxiety was very high it would eventually drop, especially if he blocked ritualizing and retriggered himself when he slipped and ritualized. He started to drive to his old campus and progressed to sitting outside the business building. He started to socialize with other contaminated friends, use the internet again and signed up for a business class in accounting. He eventually started to email Connor himself which was at the top of his hierarchy. Even though they never became close friends, Joe was no longer haunted by Connor’s presence in his OCD life. When he would think of Connor, and even when he thought about the dreaded personality characteristics, he would not try to push the thought away but say to himself, “Yup that’s Connor – what a guy!” and go on with his day. Joe is now completing his third year in college and is majoring in Russian Studies with a minor in business.
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Carol Rockwell Hevia, PsyD, works as a behavior therapist at the OCD Institute at McLean Hospital. She has almost twenty years of treating children adolescents and adults with OCD.