The Way of the Future
by Jordan Levy, Ph.D.
What is Contamination OC?
Perhaps the most famous depiction of Contamination OC is represented in the portrayal of Howard Hughes in The Aviator. This movie chronicles the struggle Howard Hughes encounters with the threat of germs throughout his life. He carries his own soap, he will only drink milk that is fresh and unopened, and he is unwilling to hand someone a towel in the bathroom so as not to undo his washed hands. His symptoms worsen and his efforts to avoid contaminants become increasingly impairing, culminating with him living in complete isolation, compulsively repeating the phrase “the way of the future.”
We live in a culture obsessed with cleanliness. We are encouraged to wash or sanitize our hands often, not eat food that touches the floor (unless of course it has only been on the floor for less than five seconds), and to construct a mountain of toilet paper covering toilet seats when going to the bathroom. The comedian George Carlin discussed the ridiculousness of this culture, pointing out that in order to avoid infection, prison inmates receive an alcohol swab prior to being given a lethal injection. Many of us abide by cultural norms such as putting toilet paper on the toilet seat, but these norms represent helpful hints rather than stern rules. Unlike Howard Hughes, most individuals would not be overwrought with anxiety if they forgot to place toilet paper on the toilet seat or if they enjoyed lunch without washing their hands. Most people are not overly concerned on a daily basis with the threat of becoming sick or dying from germs, disease, or any harm-causing agent we encounter in our world. We all know people who describe themselves as “a little OCD” and who may wash their hands one or two more times than most. This article is NOT intended for the casual hand washer. This article is about Contamination OC and is aimed toward those who respond to germs, dirt, bacteria or diseases with immense anxiety similar to how one would react to a blaring alarm in a nuclear reactor site. This article is intended to serve as an informative guide to Contamination OC.
OCD can be parsed into three main branches: Purely obsessional (Pure-O), Responsibility OC, and the classic obsessive-compulsive. This article will discuss Contamination OC, a hallmark subset of the classic obsessive-compulsive. Contamination OC is defined as a persistent fear that one will contract and/or transfer germs, sickness, or any subjectively determined “unacceptable” substance. Contamination OC is not a minor concern of being dirty or washing one’s hands a few more times than others. Contamination OC is an avalanche of fear that one will contract germs, an illness, or any contaminant that will harm oneself or a loved one. This is followed by an intense yearning to allay this fear often via hand washing or through use of a sanitizing agent. Unsavory items such as toilet seats, subway platforms, raw chicken or muddy shoes represent a freight train of fear to someone suffering with Contamination OC. It is common for someone suffering with this form of OCD to spend many hours per day washing hands until they bleed, meticulously scrubbing bathroom tiles, or repeatedly washing and drying clothing to ensure they are free of dirt, germs or other contaminants.
How is it similar and different from Pure-O and Responsibility O-C?
What separates Contamination OC from other forms of OCD is that compulsive rituals are typically overt and observable. Rather than mental rumination, temporary anxiety reduction is achieved through a tangible process of compulsively cleaning, washing and/or checking for contaminants. While many consider this form of OCD to be the “hand washing OCD,” it is much more complex and painful than is often presupposed. Individuals with Pure-O or Responsibility O-C often quip, “I wish I had that hand washing OCD instead of worrying all day about killing someone or being a child molester.” While hand washing is often a critical compulsion that maintains this disorder, the fear that underlies this form of OCD is equally torturous and substantial as in other forms of OCD.
While some individuals living with Contamination OC engage in compulsive behavior as a response to an overwhelming feeling of threat from a contaminant, others perform undoing responses as a consequence of feeling “icky.” Often times sufferers experience an unwillingness to have “icky feelings” which they report they can actually feel on their skin. If someone with the “ick” were to touch a subway pole they may report feeling a substance on their finger tips until they were able to wash their hands (thus removing the “ick.”) It is not unusual for an individual describing a need to rid themselves of the “ick” to also possess perfectionistic tendencies.
Just Right versus Number of Times
Many people with this form of OCD report having a specific routine they engage in to decontaminate. They may shower in a specific way, put on/take off clothing in a certain order or wash hands one way. The amount of time one spends compulsively decontaminating varies from person to person. Some people will wash hands, clean a room etc. for a predetermined length of time. For example, someone may say, “Every time I return from home I wash my hands for two hours and then I feel clean again.” Others may engage in the same compulsive hand washing but for a predetermined number of times (12 times instead of two hours). When length of time or number of times is not an important variable, seeking a “just right” feeling becomes the end point. Decontaminating until it “feels right” takes the form of hand washing, toilet scrubbing, etc. until the sufferer feels that the identified threat has been sufficiently thwarted.
Many people living with various forms of OCD report some experience with contamination fears early in life. This is not to suggest that every child who washes their hands more than other children will inevitably develop OCD later in life. Many times this concern either subsides or becomes the predecessor for another spike theme later in life. For the Contamination OC sufferer, there is usually the proverbial writing on the wall when looking back at earlier life. At this time, it is impossible to predict who will develop OCD and who will not. A child with Contamination OC typically does not recognize that their behavior is problematic until adolescence or early adulthood. They develop habits or routines to maintain cleanliness and view themselves as being in control. If left untreated, the cycle of obsessive thoughts and relief-seeking behavior worsens into adolescence and adulthood. For example, an individual may begin by washing hands completely upon returning from work; however this can develop into a ritual of removing outside clothes upon entrance into the home followed by a long, hot shower followed by a thorough cleaning of the house. The terrorizing threat of becoming contaminated can become an all-encompassing task that feels like it must be attended to immediately.
Depression: Many sufferers with Contamination OC experience a sense of hopelessness and helplessness as they begin treatment. They have let OCD win so many battles and feel it is impossible to learn how to break out of this cycle. Symptom management often appears to be an insurmountable undertaking. Enjoyable activities have been replaced with incessant compulsive behaviors which furthers the depression.
Panic: Continuous unwanted thoughts involving the presence of contaminants and relief-seeking efforts to reduce associated discomfort can yield a plethora of emotional outcomes including feeling that one is in a state of panic. There is an overwhelming sense that this cycle can never and will never be broken. In this scenario, panic often takes the form of racing heart, dizziness, a fear of losing contact with reality or difficulty breathing.
Interpersonal difficulty: Contamination OC affects those closest to the sufferer. The need to feel free and clear from germs, diseases, or other contaminants takes center stage. Marriages, friendships, and family relationships can be ravaged. A conversation with a spouse is torpedoed by thoughts of whether or not a ritual was completed. Sexual relations may be impaired as sexual intercourse is deemed “too dirty” or bedroom behavior must be altered to suit the needs of the OCD demon. When OCD becomes the priority, everyone suffers.
Career impairment: In addition to the devastating effects OCD has on loved ones, irreparable damage can be done to the career of someone with Contamination OC. One man was forced to shut down his in-home practice as he could not stand the thought of anyone entering his home and believed he could not concentrate on anything besides the preoccupation with contamination. A minimal level of effort and presence is required to maintain employment. This is not always a choice that one is willing to commit to while in the throes of this disorder.
Monetary concerns: Individuals with Contamination OC often discard contaminated items in their home including but not limited to clothing, washing machines, food, sofas, shoes or even the entire home. Replacing these items can be an endless and costly process. Additionally, sufferers with Contamination OC may possess several sets of clothing; the contaminated clothing to be worn outside and a separate “clean” set of clothing is purchased for wear inside the home. Sometimes items are worn only once then quickly discarded, leading to the re-purchasing of a replacement item. Continually discarding clothing that has been contaminated or moving into a new “cleaner” home can have devastating monetary consequences.
As with other forms of OCD, exposure and response prevention (EX/RP) represents the most effective Cognitive-Behavioral treatment for Contamination OC. As stated in other articles, it is not the number of unwanted thoughts (spikes) that maintains the disorder. It is relief-seeking ritualistic behaviors which maintain this disorder. Effective treatment is based on the ability to increase tolerance of anxiety-provoking thoughts and situations without relenting to compulsive actions. A common misconception is that aggressive treatment will help sufferers get over or move past OCD. EX/RP emphasizes learning to manage symptoms through the utilization of a step-wise progressive treatment plan. For example, someone who believes they will contract germs from touching a toilet seat will first be encouraged to touch the doorknob to the bathroom without engaging in the relief-seeking behavior of hand washing. Repeated confrontation to feared items or situations will allow for new learning to take place. The automatic link between a thought and the anxiety it provokes can be broken if one allows for the anxiety to subside on its own. Successful exposures are based on the idea of letting the thoughts and feelings be there and not trying to forcibly push them away via hand washing.
When engaging in exposures, a common trap that sufferers fall into, is doing the exposures for the express purpose of symptom relief. Instead of saying, “I can live with this anxiety,” one says, “If I can sit with this gross feeling on my hands for five minutes then I get to wash my hands!” The whole idea is to learn to gain a sense of comfort and control with anxiety by rendering the anxiety-provoking thoughts irrelevant. With this in mind it is important to tell oneself statements in the spirit of, “Maybe I am going to get the Flu from touching this subway pole,” or “I better call my lawyer to draw up my will now that I touched that!”
The above article is intended to serve as a brief description of Contamination OC and not as a substitute for treatment. If you feel that you can relate to many of the ideas discussed in this article, you may be experiencing Contamination OC. It is recommended that the treatment principles discussed in this article be attempted under the care of a qualified mental health professional.
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