by Fred Penzel, PhD
This article was initially published in the June 2000 edition of the OCD Newsletter.
On the surface, the contamination fears associated with OCD don’t seem to be a very complicated subject. After all, dirt, germs, washing — what could be simpler? Actually, when you take a closer look, contamination is quite a bit more complicated than that.
First of all, this problem breaks down into two parts contamination obsessions and decontamination compulsions. Let us first examine the nature of obsessive contamination fears. Unlike the popular view, contamination isn’t simply limited to dirt, germs, and viruses. It can also include such things as:
- bodily excretions (urine, feces)
- bodily fluids (sweat, saliva, mucus, tears, etc.)
- household chemicals
- broken glass
- or sticky substances
- people who appear unwell shabby or unclean
- spoiled food
- soap (really!)
- dead animals
This list is by no means complete. There are practically no limits to the things that can be contaminating. From my own experience, I would guess that the fear of certain illnesses may still the leader. Many years ago cancer was one of the more commonly feared illnesses, but in the last two decades or so this seems to have been replaced by AIDS.
One unusual belief sufferers have is that very small amounts of contaminants can cover very large areas. For example, they may believe that a drop of blood or urine can somehow be spread to coat entire rooms, or even everything they own.
There is also a whole category of fears of contamination of a stranger and more magical type, which could include:
- names (of illnesses, disabilities, people who are ill, or disabled, or who have died)
- places where bad things have happened
- mental images
- overweight or unattractive people
- bad luck
Obviously, logic has little to do with these fears. The belief here is that these names, images, concepts, or the characteristics of certain people can be magically transferred, simply by thinking about them or by coming into casual contact with them. They can be every bit as disabling as the items on the previous list.
There is a further category that includes things that are more vague. For instance, there are some sufferers who fear to touch the floor, the ground, outdoors, or any public objects. When questioned about what it is they fear, they can only reply “I don’t really know, it just feels dirty to me.” There are also cases where a sufferer will get the idea that another person is contaminated in some way, although they cannot exactly say why. It may be a total stranger or a member of their immediate family.
Compulsions are the usual responses of sufferers to these fears. They may involve any protective act that an individual carries out to avoid becoming contaminated or to remove contamination that has somehow already occurred. Compulsions of this type may include:
- excessive and sometimes ritualized hand washing
- disinfecting or sterilizing things
- throwing things away
- frequent clothes changes
- creating clean areas off-limits to others
- avoiding certain places or touching things
Another form of compulsion can include double-checking by a sufferer to make sure that they have not become contaminated, or asking others for reassurance that this has not happened. Sufferers will sometimes repeatedly ask others to check parts of themselves they cannot reach or see, or things they cannot go near. Some will go as far as to make lists of things they believe may have happened in the past, so as not forget this vital information.
In an attempt to keep clean and minimize compulsions, some sufferers will create two different worlds for themselves; one clean and one dirty. When contaminated they can move freely about their dirty world and touch and do anything, since everything in it is already contaminated. Nothing in it has to be cleaned or avoided. Clothes that are considered contaminated must be worn when living in this zone. This dirty world usually takes in most of the outside world, and can also include parts of their home or work areas. It may even extend to having a dirty car to be driven only when contaminated. They may also be able to live freely in their clean world as long as they themselves are clean when they enter it and also stay that way. The clean world is usually a much more restricted area than the dirty one, and is often limited to special places at home or at work. There may also be a clean car which can only be driven when clean. The two worlds may exist side-by-side like parallel universes that are never allowed to meet.
For magical types of contamination the solution is often a magical decontamination ritual designed to remove or cancel out the problem, thought, name, image, or concept. Saying special words or prayers, thinking opposing or good thoughts to cancel out bad thoughts, and doing actions in reverse, are just some of the compulsions that can be seen. Sometimes the usual washing or showering may even be part of the magical ritual.
“Washers” as they are referred to are probably the most visible among those with contamination obsessions. It is not unusual for them to wash their hands fifty or more times per day. In more extreme cases, hands may be washed up to 200 times per day. Showers can take an hour or longer, and in severe situations can last as long as eight hours.
Obviously, washers go through large amounts of soap and paper towels (used in preference to cloth towels which can only be used once and create laundry). Alcohol preps and disinfectant hand wipes are also popular. Their hands often become bright red and chapped with cracked and bleeding skin. Antibacterial soaps, peroxide, and disinfectants, such as Lysol, can be used to excess by some, causing further skin damage. I have even worked with several people who poured straight bleach on their hands and bodies, resulting in chemical burns.
Compulsive showering and washing are really quite futile, as the relief from anxiety only lasts until the washer contacts something else that is seen as contaminated. Washing may in some cases be strongly ritualized. It may have to be done according to exact rules, which if not followed force the sufferer to start all over again. Counting may also be part of a washing ritual to ensure that it has been done long enough period, or a certain number of times. In order to cut down on washing, sufferers sometimes resort to using paper towels, plastic bags, or disposable gloves to touch things.
In some cases, family members have been drawn into the sufferer’s web of compulsions. They are made to reassure to clean things that cannot be approached, to check the sufferer or the environment for cleanliness, or to touch or use things that are thought to be contaminated. This type of help, of course, doesn’t really help, as it only locks the sufferer into the illness and increases helplessness. It also leads to resentment and fighting, as family members feel increasingly imposed upon and their lives become limited. This is especially true when a family member is seen as the source of contamination.
To further complicate our contamination picture, there is a variant that veers off into what is known as “hyper-responsibility.” This is where instead of being fearful of becoming contaminated, sufferers fear spreading contamination to others. The types of contamination that can be spread to others are about the same as those that trouble other sufferers. Generally speaking, so are the types of avoidance and decontamination compulsions. There is not only a fear of possibly harming others, but also a fear of having to live with the resulting guilt. There are also some that suffer from both types of fears at the same time.
Having briefly covered this very complex topic, the next question would be what can be done about these problems? To those of you familiar with OCD, the answer should be obvious — behavioral therapy and possibly medicine. Behavioral therapy would be in the form of Exposure and Response Prevention (ERP). This remains the most widely used and accepted form of behavioral treatment for OCD. This type of therapy encourages patients to gradually encounter increasing doses of that which is contaminated, while resisting washing, checking, avoiding, or conducting magical rituals. By staying with the anxiety, sufferers come to learn the truth of the matter — that nothing really happens when they face their fears, and that their efforts at taking precautions serve no real purpose. Gradually, patients learn to merge their clean and dirty worlds as they cease to protect themselves. They also concentrate on learning to accept that there will always be a certain amount of risk in life that can never be eliminated, and that life can still be enjoyed and lived freely in spite of this fact. By trying to eliminate risk, they come to see that along with it they will eliminate their ability to function. I like to tell my patients that “When everything is contaminated, nothing is contaminated.”
Therapeutic encounters are like small experiments to test patients’ theories about the dangers of their particular type of contamination. Treatment is tailored to each particular person’s symptoms and is done at their own pace. If a feared substance or situation is too difficult to confront in one whole step, it is approached more gradually. Some patients can only touch something that has touched a feared substance or object, and only later do they go on to touch directly what is feared. Family and friends are taught to not participate in rituals and to not give reassurance or answers to the same questions.No one is ever forced to do anything, nor is anything sprung on them by surprise. It takes persistence and hard work, but through steady week-by-week work, the disorder is chipped away until recovery is eventually reached.
Because OCD is biochemical in origin, medicine can often be of great help as well. I believe it should be regarded as a tool to assist in doing behavioral therapy. Both treatments together are often more effective than either one alone. The main family of medicines used to treat OCD is known as SSRIs (Serotonin Specific Reuptake Inhibitors). Basically they enhance the activity of serotonin, the brain chemical implicated in this disorder. Members of this drug family include Lexapro, Prozac, Celexa, Paxil, Luvox, and Zoloft.
If you suffer from this, or any other type of OC disorder, my suggestion is that you seek help. OCD is chronic. This means that there is no cure. There is recovery though, and many have achieved it. With the right treatment, you can hope to live a normal productive life and go on to fully realize your own real potential.