Everything You Need to Know About Contamination OCD
There may be no illness more self-diagnosed than obsessive compulsive disorder. In fact, it’s commonplace to hear people exclaim that they’re “so OCD” because they prefer a tidy house or they wash their hands before sitting down at the dinner table. Yet, in reality, OCD is not frequently encountered: it’s found in 1 in 40 adults (2.3% of the population) and 1 in 100 children.
OCD is not a disease that simply bothers sufferers; it is a disease that tortures them. The preference for an organized sock drawer or a living room free of dog hair doesn’t mean you have OCD. And, as anyone with OCD will tell you, you don’t want it to.
OCD, in a Nutshell
In textbook terms, OCD is a mental illness that causes the sufferer to get stuck in cycles of obsessions and compulsions. Obsessions present as unwanted images, thoughts, ideas, or urges that cause overwhelming anxiety and terrors. Compulsions are behaviors adopted to help decrease the distress.
One of the most well-known examples of the obsession/compulsion partnership is the compulsive hand washer. The sufferer has a thought that their hands are contaminated (this is the obsession) and so they wash their hands over and over in an attempt to make their hands feel clean (this is the compulsion).
OCD is never really satisfied by the compulsion – the handwasher might feel momentary relief, but their hands often feel dirty again a few minutes later. Thus, begins a cycle that is truly vicious. OCD feels like a game of Whack-a-Mole; knock down one obsession and the next one pops right up.
The Concept of Intrusive Thoughts
While intrusive thoughts are indeed a hallmark of OCD, it’s not only those with the disorder who have them. Everyone experiences upsetting images or unwanted ideas from time to time. The difference between the OCD sufferer and someone else is that the sufferer takes these intrusions seriously. The person without OCD casts them aside as the nonsense they are.
Think of it in terms of email. Spam filters automatically filter out the junk mail, relegating chain letters and pyramid schemes to forgotten folders where they’re never seen. In the OCD brain, the spam filter is broken; the intrusive thoughts land in the main inbox, potent, powerful, and demanding attention.
OCD sufferers take their intrusive thoughts so seriously that these thoughts interfere with their lives, consuming their time, affecting their relationships, and interfering with their ability to focus on more important activities.
Even so, most people with OCD recognize on some level that they’re acting irrationally – the sufferer who washes their hands for twenty minutes at a time often knows that it’s probably unnecessary. Yet OCD is a disease that flourishes on uncertainty; What if? could serve as its tagline.
What if your hands are covered in asbestos? What if not washing thoroughly enough gives you HIV? What if you hug your child and contaminate them with an illness?
It’s this What if? that feeds the cycle.
The Specifics of Contamination OCD
Of all the flavors of OCD, contamination gets the most press. It’s so present in pop culture and everyday misconceptions that it’s not unusual to find people who believe that contamination OCD is the only type of OCD. But not everyone who has OCD has contamination fears. Some studies suggest that contamination obsessions and compulsions are present in 25% of sufferers; other studies suggest that number is closer to 50%.
Either way, contamination is one of the most common types of OCD, which is likely why it’s talked about as much as it is. That doesn’t mean that it’s understood. As previously mentioned, many people erroneously assume they have OCD because they’re particular about their belongings, zealous about hygiene, or, perhaps, even a little anal-retentive in their desires. But people with contamination OCD don’t mop the floors compulsively or wash their hair multiple times a day because of personal preference; they do it because of extreme anxiety.
Contamination OCD, like all types, doesn’t look the same for everyone. And it tends to adapt and change. As painful as it is to pay OCD any type of compliment, it is creative; it always introduces innovative and original ways to worry those afflicted. In some aspects, it feels as though there are no limits to its imagination – in contamination OCD, it tells the sufferer that all sorts of things are tainted – doorknobs, public transportation, bathrooms, elevators, sidewalks, clothes, other people. It can make the sufferer believe that their cat is radioactive or that their dog is covered in toxins. It can make them believe that their beer at the local pub is filled with bleach or that they’ll contract HIV if they use an outhouse. It can make them shower multiple times a day, for hours at a time.
Common Contamination Obsessions
While OCD may contaminate anything and everything in the mind of those who have it, there are areas where it tends to latch on. Overall, some of the most common contamination obsessions include a fear of:
- HIV (or AIDS) and other communicable diseases
- Viruses and bacteria
- Cancer and other terminal illness (the sufferer may fear that eating an apple that hasn’t been washed will expose them to carcinogens)
- Bodily fluids (such as urine, feces, spit, or blood)
- Environmental contaminants (such as asbestos, lead, and radiation)
- Household cleaners (such as acetone, bleach, and ammonia)
- Dirt or mud
- Other people, believing they are somehow contaminated
- Pets, birds, and other animals
- Broken glass
- Wood chips
The contamination fears aren’t limited to the individual. In other words, the sufferer may be afraid of contamination for themselves but they may also be afraid of germs or disease infecting their loved ones. Often, they’re afraid of both.
Contamination OCD isn’t rooted in logic either. While someone with contamination fears would certainly fear HIV if they had a real-life exposure (coming into contact with someone else’s blood, for instance), their brain takes it further and they even fear contracting OCD from activities which involve zero risk (such as using a handrail on an escalator or washing their face in a communal sink).
Contamination OCD may involve “magical thinking,” a process in which the sufferer believes something has happened or will happen simply because they thought of it or talked about it. They may believe that saying the word “cancer” will cause their grandma to get a tumor or they may believe that wearing a red shirt will give them hepatitis. They may believe that looking at a picture of a sick person will give them whatever disease that person is fighting. They may believe that picturing a chemical spill on their kitchen floor will contaminate the floor in real life. They may believe that reading a book about bats will infect them with rabies.
Common Contamination Compulsions
To manage the obsessions, the sufferers perform compulsions, rituals designed to relieve their felt anxiety. These are time-consuming and repetitive. Engaging in the same ritual once or twice is never enough; OCD demands more.
Compulsions, like obsessions, are unique to the individual. But there are routines most commonly engaged in. These include:
- Excessive hand washing
- Excessive or lengthy showers
- Excessive disinfecting and sterilizing
- Frequent use of hand sanitizer or rubbing alcohol
- Using paper towels instead of bath towels (as they can be thrown away after use)
- Avoiding places (such as public restrooms)
- Avoiding touching things (such as doorknobs)
- Changing clothes frequently
- Throwing things away unnecessarily
- Pouring bleach on the hands or body
- Using chemical-free cleaning supplies
- Asking others for reassurance that they haven’t been contaminated or infected with anything
- Checking on others to make sure they haven’t been contaminated or infected with anything
- Avoiding others in fear that the sufferer will contaminate them
- Marking off areas of the home that are off-limits
- Creating a “clean” world (that is kept sterile) and a “dirty” world (where everything is presumably contaminated) and making sure these worlds never overlap
- Saying or thinking about words, positive affirmations, or prayers to cancel out the negative thought
- Clapping, snapping, or performing another action to cancel out the negative thought
- Getting tested frequently for STDs (including HIV)
What Causes Contamination OCD?
No one’s entirely sure what causes contamination OCD (or any type of OCD, for that matter). Researchers do have an idea, however, and they’re also aware of what doesn’t cause it.
Scientific studies show that people with OCD have brains that don’t function normally. Instead, the communication is compromised in the front parts of the brain (such as the orbitofrontal cortex and the anterior cingulate cortex) as well as the deeper parts of the brain (the striatum and thalamus). But neurotransmitters play a role too: OCD sufferers may have low levels of serotonin and dopamine, and high levels of glutamate.
Even with the above knowledge, doctors still can’t name the exact culprit behind OCD, at least not in the way they can pinpoint the culprit of many other illnesses (smoking causes lung cancer or red meat causes heart disease, for instance). They believe, instead, that OCD results from a combination of several factors, including genetics, environment, neurobiology, and cognition.
The genetic link has long been explored because of OCD’s tendency to run in families; around 1 in four people who have OCD have an immediate family member who has it. In twins, OCD is more likely to affect both siblings if they’re identical rather than fraternal. And studies have found that some people with OCD have mutations on their serotonin transporter gene (hSERT), further emphasizing the role that heredity plays.
But while genetics may lay the foundation, it is perhaps behavior that keeps OCD going. Some doctors believe that compulsions are a result of behavioral conditioning, responses learned by the sufferer as a way to manage anxiety.
Most OCD sufferers possess dysfunctional beliefs as a rule; this is to say they put credence in thoughts that are ridiculous, meaningless, and ego-dystonic.
According to the Obsessive-Compulsive Cognitions Working Group, there are six types of dysfunctional beliefs that plague the OCD mind. These include:
- Possessing an overinflated sense of responsibility: OCD sufferers believe that they are responsible for preventing negative outcomes that not only affect them but others. This belief doesn’t come from a place of self-importance or from a desire to play the role of the superhero. Rather, it comes from a place of fear.
In contamination OCD, this belief may manifest as the suffer cleaning door knobs around their office, fearing their coworkers will contract an illness if they don’t.
- Placing importance on thoughts that are meaningless: This is sometimes known as “thought-action fusion” and involves the idea that a bad thought will cause something bad to happen in real life.
In contamination OCD, this belief may manifest as scrubbing kitchen tiles because the sufferer imagined that they were covered in blood.
- Seeking control of thoughts: While no one has control over their thoughts, people with OCD believe that they should. This inevitably leads the sufferer to seek control through things like thought stopping, which only tends to make OCD worse. Go ahead and try it out: tell yourself not to imagine a pink elephant in a tutu sitting next to you. What’s the first thing that comes to mind? Probably a pachyderm ready for its recital.
In contamination OCD, this belief may manifest as the sufferer trying to stop images of bodily fluids on their toothbrush or the thought that not washing their hands after opening the mail will give them cancer.
- Overestimating the threat: Not only do OCD sufferers pay attention to their intrusive thoughts (unlike non-sufferers as previously mentioned), they overestimate the thought’s foundational threat.
In contamination OCD, a sufferer who believes they’ve been exposed to germs because they touched a magazine overestimates the threat of those germs. They don’t fear getting a common cold or a respiratory virus; they fear getting AIDS or hepatitis or Ebola.
Likewise, OCD sufferers inflate the actual risk of legitimate dangers. For example, radiation is a well-known carcinogen and diagnostic radiation is limited in patients because of this. But, although it’s a risk, it’s an exceptionally low risk: it’s estimated that 1 out of every 2000 CT scans will cause a fatal cancer (or .05%). To the OCD sufferer, that .05% percent evolves from a possibility to a probability and eventually a sure thing.
- Striving for perfectionism: Though perfectionism is common in OCD sufferers, it’s not exclusive to this illness; you can be a perfectionist without having OCD. In OCD, however, it comes up frequently, as sufferers possess the belief that they’re not allowed to make mistakes and anything less than perfect is unacceptable.
In contamination OCD, this belief may manifest in the need to clean a house immaculately. Dust on the windowsill, smudges on the television screen, or crumbs on the kitchen floor may lead the OCD sufferer to believe that something bad is about to happen.
- Possessing an inability to tolerate uncertainty: OCD sufferers feel as though they “have to know,” which makes dealing with uncertainty a challenge. Sometimes referred to as “the doubting disease,” OCD sufferers work to neutralize this doubt, desiring absolute proof that a negative event won’t occur.
In contamination OCD, this belief may manifest as cleaning something over and over again, until the sufferer feels as though the item is 100% clean (and, thus, 100% safe).
Factors that May Lead to OCD’s Onset
OCD is not as common in childhood as it is in adults, not even in those who are predisposed to it because of genetics. But a child without OCD doesn’t mean they’ll grow up without it. It’s rather common for OCD to rear its ugly head during two periods of life, between the ages of eight and 12 and between late adolescence and early adulthood. However, it’s possible for symptoms to first appear at any age.
Some people who are diagnosed with OCD as adults look back on their childhood and realize that they had OCD then as well. OCD often worsens with time, especially without treatment.
Even with all this, no one is sure of OCD’s exact trigger. While it can appear in times of transition (even when those transitions are happy ones like marriage or the birth of a child), traumatic events might trigger it too.
Brain injuries, for instance, can lead to onset; so can strep. In the latter, children appear to develop OCD seemingly overnight. It’s believed that this condition, called Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS), isn’t technically OCD but instead causes OCD-like symptoms in those who possess a genetic predisposition.
What Doesn’t Cause Contamination OCD?
As science works to learn exactly why some people get OCD when others don’t, researchers believe they already have a good grasp on the non-guilty parties.
Parenting, especially in the area of toilet training, was once blamed for OCD, with a domineering or controlling style singled out. Doctors now believe that parents don’t play a role in OCD’s development (outside of their genetics, anyway).
Stress doesn’t cause OCD either. In the sufferer who already has OCD, stress typically makes it worse, but it won’t cause it to develop in the unaffected.
Families belong in the same category as stress: they don’t cause OCD but they might make it worse. This is because family members tend to accommodate and enable the person with OCD, offering reassurance, checking for them, or engaging in rituals and routines that decrease the sufferer’s anxiety. While moms, dads, brothers, and sisters do this to help, it ultimately worsens the disorder, feeding the proverbial monster and allowing it to grow.
Family members who shame, criticize, or fail to empathize with the OCD suffer will, likewise, make things harder. It’s recommended that families go through training, therapy, or take part in support groups to learn better how to become an ally.
Growing up in a disorganized or poorly kept home doesn’t cause OCD, either. It may lead a person to keep their house immaculate once they reach adulthood. Yet this is done out of dislike for disorder and not because you have a disorder.
Misconceptions About Contamination OCD
Society, as a whole, tends to harbor misconceptions of mental illness. And OCD, specifically, is often painted in minimizing light, cast-off as a minor inconvenience or a funny personality quirk. But those who have OCD, their families, and the therapists who help them aren’t laughing. They see OCD for the struggle it is.
Perhaps this is the biggest misconception: OCD is a minor mental illness or something that subtly irks the sufferer. In truth, people with OCD are so consumed by their obsessions and compulsions that this disorder ruins their lives. Unfortunately, suicide is not uncommon.
In contamination OCD, more focused misconceptions exist as well. These include:
- Everyone who has OCD has contamination obsessions: Contamination OCD may be the most common type of OCD, but people have obsessions and compulsions about all sorts of things (really, anything). Because OCD is an illness that tends to involve shame and secrecy on the part of the sufferer, it’s difficult to say exactly how common it is or how frequently the different types present.
Some people have OCD with obsessions and compulsions that have nothing to do with dirt, illness, or toxins. While contamination sufferers may wash their hands hundreds of times a day, those with other types of OCD may hardly ever wash their hands. This isn’t to say they’re going around licking petri dishes, put they’re not made anxious by germs, either.
- Contamination OCD means you’re neat and organized: The common utterance of “I’m so OCD” is often made by people who prefer to keep their houses, cars, and office spaces neat and organized. But OCD has nothing to do with desire; people who clean because of contamination OCD aren’t sweeping the tile over and over because they like their house a specific way; they’re doing it because they think something terrible will happen if they don’t. In essence, it’s about controlling anxiety, not dirt.
- People with OCD enjoy tidying up: In adding to the above, this couldn’t be further from the truth. OCD is not enjoyable for the sufferer. While they may find relief through cleaning, they never find pleasure.
- OCD means you’re uptight and particular: It’s commonly believed that people with OCD are uptight, particular, and rigid. This is such a popular belief that “OCD” has nearly become synonymous with “fussy” when used in everyday language. But someone who color-coordinates their sweaters or alphabetizes their soup cans because they like things in order isn’t suffering from OCD (though they may be anal-retentive).
Part of the reason for this misconception is that an OCD sufferer may react negatively to having their belongings moved or to someone using their shower. Yet their reaction is the result of anxiety and not because of personal preference.
- It’s obvious when someone has OCD: OCD isn’t always obvious. Conversely, many people go to great lengths to hide their obsessions and compulsions out of embarrassment or fear of being viewed as crazy. And they exhibit great creativity in their secrecy.
A subset of OCD sufferers experience obsessions without visible compulsions. This form, Pure-O, largely involves compulsions that are performed inside the sufferer’s head (the compulsion may be counting, saying a mental prayer, or thinking a positive thought to neutralize a negative one).
- People with OCD can just think of other things: OCD is marked by intrusive thoughts, thoughts that pop into the head uninvited. The sufferer can’t control their arrival and trying to stop them tends to make OCD worse. Sufferers, instead, must learn to accept them (which is always much easier said than done).
- OCD sufferers think they’re rational: One of the unique features of OCD is that sufferers typically know that their thoughts are irrational. But they’re not certain and it’s this gray area of doubt where OCD flourishes.
The logical side of an OCD sufferer may be 99% sure that their intrusive thoughts are nonsense but 1% of them remains unsure. And it’s this 1% that feels as though it carries the most weight.
- OCD is just a phase: OCD is a chronic illness that tends to get worse as time goes on if it’s left untreated. Even with treatment, those who have it experience plateaus and valleys where it’s sometimes more severe than others.
Treatment for Contamination OCD
Overall, the most common treatments used for contamination OCD include:
CBT with ERP: The gold standard of OCD treatment is cognitive behavioral therapy (CBT), specifically exposure and response prevention (ERP). During this treatment, patients are asked to expose themselves to a distressing thought and then avoid performing their compulsion.
For instance, the sufferer may be instructed to touch a doorknob and then refrain from washing their hands afterwards. They’ll also be encouraged to refrain from seeking reassurance (such as asking their spouse if there was blood on the doorknob). They’re asked to sit in their anxiety and, in doing so, they come to learn that nothing bad happened simply because they touched the doorknob.
It seems like an easy solution but refraining from performing their compulsions causes severe anxiety in the sufferer. That’s why ERP exercises work better when they’re done gradually, with the sufferer first exposed to situations that are more tolerable. As treatment progresses, ERPs get harder and harder. But they become easier eventually, assuming the sufferer can stick with them.
Along the way, people with OCD are taught to accept uncertainty and accept that contamination is everywhere; it’s impossible to sterilize the world.
Medication: About 70% of people with OCD respond to medication, yet this comes with a caveat. Unlike other diseases where you take a pill and fix the issue, medication in OCD doesn’t act as a cure; it doesn’t eliminate the intrusive thoughts entirely (at least not usually). But it does reduce the severity of those thoughts, making it easier to perform ERP exercises. And that’s a vital piece of the puzzle: medication alone doesn’t do enough; it must be coupled with exposure and response prevention.
Even when medication is an effective ally, it takes a while to find the right type. Part of this is because individuals respond differently to drugs and part of it is because virtually all meds come with side effects, ranging from the minor and inconvenient to the severe and life-threatening.
OCD sufferers with preexisting conditions may be at particular risk of medication-induced complications. A sufferer with heart disease, for instance, may be advised not to take any medication that increases blood pressure or causes arrhythmias. Finding the right prescription involves weighing the reward with the risk.
The prescribing doctor must consider preexisting medications as well and only prescribe drugs that aren’t contraindicated with what their patient is already taking.
Age is a concern too, as the risk of suicide in children, teens, and young adults is amplified with some antidepressants. This is especially true when the medication is new or the dosage changes.
With all the above, there are common drugs that serve as the proverbial OCD starter kit. In general, the main medications used are Serotonin Specific Reuptake Inhibitors (SSRIs), a class of antidepressants that work to increase serotonin in the brain. Drugs in this category include:
Anafranil (or Clomipramine) is used too, though it’s not an SSRI but a tricyclic antidepressant.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs closely related to SSRIs) work by enhancing both serotonin and norepinephrine in the brain and may also be used as a front-line treatment.
In recent years, the use of off-label medications has become increasingly accepted. These are medications not approved for OCD but those that have been found helpful through both research and anecdotal reports.
One of these is Ultram (Tramadol), a narcotic used for pain management. Because it has an SSRI-like influence on the brain, it’s sometimes prescribed for OCD as well as depression.
Many people with OCD have accidentally happened upon its beneficial tendencies; they’ve been prescribed Ultram for back pain or menstrual cramps only to find that it was especially good at controlling their OCD.
Other off-label medications used (as either a standalone med or as a supplement med) include:
Off-label meds are particularly useful in people who are ultra-rapid metabolizers. Ultra-rapid metabolizers possess genetic variations that cause them to essentially chew up the drugs inside their body before those drugs take effect. This mutation also makes side effects more potent in the meds that play on the mutated gene.
On the flipside, ultra-rapid metabolizers may metabolize some drugs more efficiently. While they don’t respond fully to many SSRIs, they have a higher response to certain meds with metabolites.
It’s not common to be an ultra-rapid metabolizer (it’s a mutation that appears in only about 5-8% of the population). But any OCD sufferers who have tried med after med to no avail might consider finding out their status.
They (or anyone else) can find out what kind of metabolizer they are through a simple genetic study that’s often covered by insurance. This info is incredibly useful in finding the most effective pharmaceuticals in treating OCD and treating illness in general.
ACT Therapy: While ERP remains the treatment of choice for many, Acceptance and Commitment Therapy (ACT) has quietly made a name for itself in the world of OCD (and other mental illness). This treatment focuses on accepting intrusive thoughts and feelings rather than reacting to them. The ACT patient is taught to view their thoughts as simply thoughts, sometimes using clever imagery (such as imagining the thought flashing across a television screen).
It feels counterintuitive at first, but it plays on the ol’ “face your fears” phenomenon. It cultivates psychological flexibility, mindfulness, self-compassion, and nonjudgmental acceptance. Sufferers, above all, are told to view their thoughts as dispassionately as possible, almost as if the thoughts aren’t even theirs.
For example, in contamination OCD, the sufferer may have an intrusive thought that tells them they’ll get rabies if they sleep outside. Instead of challenging the thought, the sufferer is instructed to state, “I’m simply having a thought that sleeping outside will give me rabies.” By labeling it in this manner, the sufferer is able to detach from it, ultimately not reacting at all.
OCD is an imp in the mind and one that wants to bother its sufferers; once someone stops reacting to it, it practically sulks off and pouts, fading away in the process. Its needs for attention is why ACT serves as a logical line of treatment. Still, ACT is new and it’s recommended that it’s used in conjunction with ERP or mindfulness.
Lifestyle: Though it’s extremely challenging to control OCD without professional assistance, maintaining a healthy lifestyle that limits general life stress also limits OCD.
It’s recommended that OCD sufferers:
- Eat well
- Exercise regularly
- Engage in mindfulness, meditation, or yoga
- Limit coffee (as tragic as this may feel)
- Work with a therapist weekly
- Seek out support groups
- Maintain social relationships
- Limit consumption of alcohol
TMS: A novel form of treatment is Transcranial Magnetic Stimulation (TMS). This is commonly used for treatment of depression, but more and more providers are using it to treat OCD as well. It may prove especially important to those who haven’t experienced relief from more traditional routes.
TMS isn’t brain surgery; it’s a non-invasive procedure that uses a magnetic field to regulate the deep areas of the brain associated with OCD.
It’s intensive to begin with daily treatment for a period of several weeks. A maintenance program is recommended as follow up.
Finding an OCD Therapist
While OCD is a heartbreaking illness, it’s also one that can be defeated. And that’s where a therapist comes in.
But – like in so many aspects of OCD – finding a good therapist isn’t as easy as it sounds. Many clinicians treating OCD are untrained or unqualified; others grossly misunderstand the illness and recommend treatment that worsens it rather than helps. Some have even left patients traumatized.
That means sufferers must choose wisely.
The best thing they can do is to look for someone who specializes in OCD; general knowledge of it is not enough. Ideally, treating practitioners should have completed intensive OCD-programs and classes.
The International OCD Foundation’s directory of providers is a great place to start.