STRONGER THAN DIRT

-OCD and Contamination-

 by Fred Penzel, Ph.D.

Recently, while going through some back issues of the OCF newsletter, it struck me that unless I was mistaken, there had never really been any special articles written about contamination problem. Perhaps it's because it is so well known. On the surface, it's not a very complicated subject dirt, germs, washing - what could be simpler? Actually, when examined more closely, contamination is quite a bit more complicated than that.

First of all, what we are really talking about breaks down into two parts: contamination obsessions and decontamination compulsions. Let us first examine the nature of obsessive contamination fears. Contamination isn't simply limited to dirt, germs, and viruses. It can also include:

• bodily excretions (urine, feces)
• bodily secretions (sweat, saliva, mucus, tears, etc.)
• blood
• semen
• garbage
• household chemicals
• radioactivity
• broken glass
• greasy or sticky substances
• people who appear unwell, shabby, or unclean
• spoiled food
• soap (really!)
• lead
• asbestos
• pets
• birds
• dead animals
• newsprint

This list is by no means complete. There are practically no limits to the things that could be contaminating. From my own experience, I would guess that the fear of certain illnesses is still

the leader. Many years ago, cancer was one of the more commonly feared illnesses. In the last decade or so, this seems to have been replaced by AIDS (see my previous OCF newsletter article, "OCD and AIDS When Epidemics Collide").

One particularly unusual aspect of contaminating substances is the extent to which tiny amounts of them are often believed to cover very large areas. Some sufferers believe that a minute quantity of a contaminant (such as blood or urine, for example), 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: 

• thoughts
• words
• 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
• colors
• 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 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 a bit 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 obvious 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
• simple avoidance of going to 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 occurred. Sufferers will also, at times, 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 functioning in this zone. This dirty world usually takes in most of the outside world, and can also include portions 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 function 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 very 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 for a long enough period of time, or a certain number of repetitions. 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 manipulate things that are supposed 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 "hyperresponsibility." 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 of simultaneously.

Having briefly covered this very complex topic, the next question would be, what can be done about problems such as these? To those of you familiar with OCD, the answer should be obvious behavioral therapy and possibly medication. Behavioral therapy would be in the form of Exposure and Response Prevention. 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, avoidinge 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 therefore serve no 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 conducted 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 repetitive questions. No one is ever forced to do anything, nor is anything sprung upon 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, medication can often be of great assistance 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 medications used to treat OCD are 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 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 potential as a human being.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disordes: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at
www.ocdbook.com