Fear of Contamination
Contamination obsessions are the most frequent type of obsessions, accounting for 25% of all OCD symptoms. In fact, the desire for cleanliness or some type of purity is the motivation in most rituals. Contamination OCD is identified by the fear of coming into contact with either real or magical things viewed as harmful. This may include anxiety about germs, body fluids, toxic chemicals, animals or just a sticky feeling. This anxiety may be associated with a concrete fear of being personally at risk or exposing others to risk. Rituals may include not just cleaning or washing, but also avoidance, checking or reassurance seeking.
Treatment for Contamination OCD starts with an initial appointment during which I get details about the symptoms and history, administer the Yale-Brown Obsessive-Compulsive Scale (YBOCS), confirm the diagnosis of OCD and note the presence of other diagnoses. At the conclusion of the first appointment, I will make treatment recommendations and assign the first homework. For example, this may be asking the client to tally hand-washes or write down what triggers them. This sets the expectation of having to work between appointments and is a measure of the likelihood that the client will comply with future assignments.
The second appointment is focused on developing a hierarchy for Exposure with Response Prevention (ERP). I will have reviewed the data from the YBOCS and outlined a hierarchy. I will use that, along with the data from the homework, to ask the client details about their obsessions and compulsions. I describe a series of scenarios and ask the client to rate how much anxiety the exposure would create for them. During the second appointment, I also educate the client about ERP. I stress that ERP produces more robust and lasting benefits than medication and that research shows that therapist-assisted exposure is more effective than self-help. Finally, I inform the client that cleaning rituals have been found to negatively affect response to the medications commonly prescribed to treat OCD, and that clients with cleaning and checking rituals tend to respond best to ERP.
At the end of the second appointment I ask the client to choose their first ERP exercise. Though clients can get the same gain whether they confront the most distressing situations from the start of therapy or confront less the distressing items first, I have my clients start with the easiest of tasks. This is another test of compliance and can create some early success which can be very motivating. The client’s expectations of success, motivation and compliance influence outcome so it’s important that they know that the severity of their OCD and the type of their rituals do not predict outcome. They must also know that prolonged continuous exposure is more beneficial than interrupted exposure and, that though the exposures can be gradual, the ritual prevention must be complete.
If a client struggles with the ERP, I may have them choose an easier exposure. If they cannot stop the ritual, I may let them either delay, shorten or somehow change the ritual. These modifications lessen the Subjective Units of Distress (SUDS) and increase the likelihood of success. I do not encourage self-reassurance, reminding them that our goal is not for them to “learn” or be convinced that it’s okay to be exposed to various contaminants, our goal is for them to gain resilience by tolerating more and more anxiety.
In some instances I will allow a client to use a mental exercise to diminish the intensity of their anxiety. I teach them a four step cognitive method in which they define the worry as just OCD, devalue how real it feels, disengage from any further mental involvement and then distract themselves until their anxiety diminishes.
Cognitive therapy focuses on the belief domain most relevant to contamination OCD: Thought-Action Fusion. This is a belief that thoughts are equivalent to actions or that just thinking about something increases the chance it will occur. I urge clients to test that theory. There is a lot of perfectionism among clients with OCD, so I also challenge the beliefs that “perfect” really exists and that certainty is equated with absence of anxiety. Finally, I challenge the client’s efforts to alleviate the anxiety that there is a chance they are contaminated by seeking a guarantee about cleanliness via their rituals. I reframe their choice as being between taking a chance that they may be contaminated versus the guarantee of continuing to be controlled by OCD if they continue to engage in their rituals.