Compulsive Washing, Contamination Fears: It’s Not Just About Anxiety

By Dean McKay, Ph.D.
September 26, 2017



obsessive-compulsive disorderObsessive-compulsive disorder (OCD) has been portrayed in the popular media as primarily a problem of checking or washing.

The lay public has accepted OCD as one many people claim, in an ad hoc way, to have given the virtuous qualities associated with it, such as fastidiousness, cleanliness or being well organized. Unfortunately, when individuals actually suffer from this condition, these qualities could not be further from the truth. No one would want to claim they have OCD if they were cognizant of the full range of symptoms.

Most people with OCD suffer greatly and experience incredible emotional pain. Their families struggle with how to best help them.OCD is a severe and debilitating psychological condition affecting 1 percent to 3 percent of the population. The World Health Organization ranks it among the top 10 disabling conditions. Research suggests it is comprised of subtypes that generally fall in the following categories: symmetry obsessions with symmetry compulsions; obsessions (such as aggressive, sexual, religious or somatic concerns), checking compulsions and contamination obsessions and cleaning compulsions.

Epidemiology research suggests that approximately half of all OCD sufferers report contamination fears associated with washing rituals. Therefore, if you treat individuals with OCD, there is a very high likelihood that the sufferer will have this variant of the disorder.Many practitioners are aware that the treatment with the greatest level of scientific support for OCD is exposure with response prevention (ERP), which is a component of a broader program of cognitive-behavior therapy (CBT).

ERP is said to work through a process of teaching clients that experiencing situations that are avoided do not result in the consequences that they are expecting. In the case of treating individuals with contamination fears and washing rituals, here are a few helpful tips:

Exposure is not harmful

Many therapists are reluctant to practice exposure therapy. The concerns typically involve fears (by the therapist) that the client will drop out, get worse or that the practice will increase the risk of litigation.

Research has shown that dropout among individuals with OCD is comparably high regardless of intervention employed but that ERP is of the highest likelihood in producing good outcome and that clients rarely worsen with its application.

There are no documented cases of litigation to therapists that came about solely due to the application of exposure therapy. This is particularly true in contamination fear with washing rituals, which is one of the most readily treated of the subtypes of OCD.

Emotional reaction to exposure is not always fear

The stereotype of OCD sufferers with washing rituals is that they are fearful of contracting an illness. Research over the past 15 years suggests that at least as much of the avoidance in contamination fear is due to much higher disgust reactivity. Many therapists are less familiar with disgust, so here are a few important points to know about this understudied emotion.

Disgust is a transmittable emotion

Certain substances and objects lead to disgust reactions. Among the most disgusting things we can encounter are certain body products (i.e., feces, urine, mucus), rotting food and certain types of insects (i.e., spiders) or animals (i.e., rodents). However, experimental findings have shown that disgust operates based on two principles. The first is called the Law of Contagion.

This principle operates when an otherwise neutral object comes in contact with a disgusting object, transferring disgust onto that neutral object. For example, if a clean pen came in contact with mucus, the pen would acquire the disgusting properties. In the case of OCD with washing rituals, the problem is compounded. If that pen were to come in contact with another object such as a cell phone, now the cell phone is also contaminated.

This contagion problem can persist across objects multiple times over.

The second principle is a bit less relevant in OCD, called the Law of Similarity. This is when an object that is neutral, but is shaped like a disgusting object leads to a disgust reaction. For example, if one were to serve soup in a bowl shaped like a miniature toilet, this would be evocative of disgust.

Disgust can be treated with exposure

It may require a bit more intestinal fortitude for the therapist, but ERP for washing rituals where disgust is evoked can still be effective. Be aware that it may take a bit longer than exposure in other circumstances.

When conducting ERP and the primary emotion is fear, there is a consequence that the client is concerned about, but which will not come to pass with the exposure exercise. So the learning is that there is nothing to fear. With disgust, there is typically no consequence except the client offering statements such as “it feels yucky” or “this looks gross.”

These are reactions that are slower to respond to treatment, since it is more a matter of simply getting accustomed to the emotional experience and not recognition of reduced risk. It may be necessary to schedule more frequent sessions in order to ensure a good outcome, such as two or three sessions a week, or longer duration sessions (i.e., up to 90 minutes).

Exposure with response prevention is widely sought out among OCD sufferers. Online forums and professional organizations that have consumer-oriented materials (such as the International Obsessive Compulsive Foundation or the Anxiety and Depression Association of America) have promoted ERP as an empirically supported approach.

As a result providers are often asked to deliver this treatment. In doing so, awareness of the full range of typical emotional reactions that might be provoked is essential for producing better outcomes for clients.

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Dean McKay, Ph.D., ABPP, is professor of psychology at Fordham University. He is past president (2013-2014) of the Association for Behavioral and Cognitive Therapies and president-elect of the Society for a Science of Clinical Psychology. His email address is mckay@fordham.edu

 

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