OCD: Treatment for Contamination Fears

OCD: Treatment for Contamination Fears

Before discussing currently accepted treatments for contamination obssessive-compulsive (OC) disorder, let’s cover treatments that should be avoided (but unfortunately are still used by some providers).

These treatments may be helpful for other problems, but the weight of evidence suggests that for contamination OC (and other forms of OCD), these should be avoided.

  • Systematic desensitization: The functional component of this treatment involves relaxation in association with feared images and objects. Although this approach is of some value for other anxiety conditions, it is not advisable for contamination OC. One of the clearest reasons is that most people receiving this treatment find they cannot engage in relaxation exercises when they are ‘in the moment’ of their contamination fears. If this portion fails, then the whole treatment falls apart and the only thing left is frustration.
  • Cognitive Disputations: Some have found that directly challenging ‘faulty beliefs’ associated with different conditions are valuable. However, many others feel that this approach is demeaning, where one is locked in a verbal battle with the treatment provider. Cognitive therapy is widely used for contamination OC, but proper use involves a style that is entirely tailored to OC, and it is unlike the format of cognitive disputation. This is discussed later in this article. Also, see the article Cognitive Behavior Therapy for Obsessive-Compulsive Disorder.
  • Analysis: Some still adhere to the idea that contamination OC is best described as a problem associated with a breakdown of intrapsychic processes, and only through lengthy analysis does one resolve this difficulty. Unfortunately, this fails on two accounts. First, there is limited symptom focus, so one entering treatment typically remains symptomatic for some time, often with no relief in sight. The other problem is worse. Analysis fosters some doubt about past associations and the relations with current problems. For some problems this may be effective, but in contamination OC, where there is already considerable doubting, this actually creates a worsening of symptoms. Analysts have actually known that their form of therapy is of no value to people with OCD for many years. In 1965 (just prior to the initiation of programs of research using behavior therapy for OCD), the British Journal of Psychiatry declared that “traditional efforts to treat OCD are a complete failure and should you encounter a patient with this condition, tell them gently that nothing can be done.” Since there have been no appreciable advances in psychoanalytic theory for OCD since that time, the same statement holds true for this therapeutic approach when applied to OCD.
  • Thought stopping: This approach takes the form of keeping a rubber band on one’s wrist and every time an urge arises to wash, the person is instructed to snap the rubber band. The goal is ultimately for one to be able to remove the rubber band, and instead state ‘stop’ to themselves as a means of alleviating the thought and preventing the ritual. This actually creates a worsening of symptoms. In fact, there has been much research to show that this is a harmful way of proceeding for people with OC, as well as for people without OC.

Given this list of treatments that should be avoided, let me describe treatment that has been accepted as more effective. There are basically five distinct steps involved that therapists repeat in cycles until there is symptom relief.

  1. Construct a hierarchy of fears: Here, the therapist and client collaborate over what things are least feared, to those most feared. For example, one may find it possible to carry a napkin that has touched the floor, but cannot bear the thought of directly touching the floor without washing. This can be applied to other feared items (such as public doorknobs, toilet seats, subway straphandles, etc.).
  2. Self-monitoring: Maintaining a record of frequency of hand washing (by keeping a log, or self-monitoring sheet) individuals often experience some reduction of symptoms. As treatment progresses (by inclusion of exposure with response prevention), self-monitoring can be extended to successful completion of behavioral exercises. The value of this stems from the ability to objectively evaluate progress over time. Further, in discussing weekly progress, it is then possible to recall more accurately how and under what circumstances improvement took place. For example, someone may do very well the first three days following a session, and then struggle a bit just before the next session. Without the objective data, someone could say they ‘are doing terribly.’ However, that is not entirely true. Instead, there was some variation in success, as noted in the self-monitoring forms.
  3. Exposure with response prevention: Once a hierarchy of fears has been established, the therapist and client ‘climb the hierarchy’ by exposure to low items on the list. The important portion associated with this approach involves not washing after the activity. As part of this experience, it is important to introduce items that are contaminated into the individuals’ contamination free zones. That is, the most effective treatment involves ‘spreading’ the contamination, which (a) prevents keeping track of what is dirty or clean and (b) promotes more rapid treatment response. An additional feature of this spreading of the contaminant prevents ‘contrast effects.’ This may be most painful by individuals establishing strong safe zones in close proximity to contaminated zones.
  4. Re-Exposure: Once the person actually washes (which therapists acknowledge is completely necessary for hygiene, of course), it is most important for the person to engage in re-expose to a feared contaminant. This is sometimes the most difficult thing to do in therapy, but also fosters rapid treatment gains. The rationale behind this involves fostering a sense that one can never be completely clean, and that contaminants are pervasive. It also addresses the concern over intolerance of uncertainty. That is, one can be clean yet still be contaminated.
  5. Contractual matters: A final important aspect. Treatment, and progress through the hierarchy, is akin to a contractual agreement. However, in actual practice, people encounter feared items that are not part of the contract. We would encourage washing after contact with these items, but immediate re-exposure to contracted items. For example, it may be contracted that exposure takes place with doorknobs, but not for the bathroom doorknob (yet). If contact is made with the bathroom doorknob, wash but immediately touch a different doorknob.

What is the rational behind this treatment? This form of treatment has emerged from a rich theoretical tradition in psychology that is now referred to as cognitive-behavior therapy. This form of treatment is described on this site.

Treatment Rationale for Contamination OC

The most frequently cited reason for engaging in treatment activities of the sort described here is to achieve habituation. I have described habituation to others as sand in the shoe after going to the beach. At first, you notice a few grains between the toes, and it is quite irritating. But if you don’t do anything about the sand, after a short while it is forgotten. Exposure therapy works in a similar manner. At the beginning, the anxiety associated with the activity is distressing, but diminishes after a short while.

The hierarchy provides a pace chart for treatment. If one moves up the hierarchy too quickly, then the client will not only struggle with treatment, but may get worse. If we refer to the shoe example, a little sand is typically tolerated. However, if there was a great deal of sand in the shoe, it has to be dealt with. In fact, if you leave a large mass of sand in the shoe, blisters could develop and result in intolerable pain. This is the situation if someone climbs the hierarchy too fast.

Sometimes, people refer to exposure as an effort to ‘bend the pole.’ That is, at the point of entering therapy, clients with contamination OC are at one end of the normal curve for washing. Treatment suggests moving to the other side of the normal curve for a short while, in an effort for people to get to the middle (average washing). This is important, because sometimes in therapy, people are asked to do things that sound ridiculous. For example, as part of treatment I have demonstrated to clients that I can touch my tongue to the bottom of my shoe, or am capable or touching various items in a bathroom then go enjoy a bag of popcorn. Yes, this is extreme, but demonstrating that this is possible illustrates the possibility of doing exercises like this (one day, not the first day) as part of bending the pole to the other extreme.

Cognitive Therapy

Cognitive therapy for OCD has evolved significantly over the past several years. One significant change involves going from level of ‘disputation’ to instead relying on a collaborative approach in which client and therapist explore ways to ‘re-appraise’ functional ideas regarding contamination. For example, people with contamination OC who are concerned with harming others might feel that they are responsible for many things, and appraise most situations as ones over which they can exercise control.

One goal of therapy, then, is to assist in altering appraisals such as these. Other appraisals may involve perfectionism, probabilitistic thinking, and assigning over-importance to thoughts. Perfectionism is a concern that one has to engage in many (or all) activities perfectly, with washing being part of that framework. Probabilistic thinking is that assigning of probabilities to the likelihood of thoughts will turn into events.

Over-importance of thoughts is a more recent construction that involves a belief that having a thought is the functional equivalent of the associated action. So if you think you are dirty, then you are more likely to be dirty. Cognitive therapy can be successfully utilized as an adjunct to behavioral treatment described before (hierarchy/exposure/re-exposure). In fact, some have suggested that although cognitive therapy may not appreciably increase treatment effectiveness, people are able to stick to the demands of behavior therapy more when cognitive therapy is used as well.

Special impediments to successful treatment outcome

There are several things that can create difficulties with treatment outcome for people with contamination OC. One of them involves the role assigned to the therapist during the course of treatment. Given the description of treatment to this point, it is clear that it is important for people to demonstrate, through potentially anxiety-producing exercises, that contamination can be tolerated.

However, in some instances, by virtue of the therapist being present during exposure, the client assigns responsibility to the therapist. This ensures that should illness befall either the client or others around, then it is the therapists’ fault since the therapist was present when the exercise was being conducted (whether it be touching a napkin to the floor, or coming into contact with items in public restrooms).

This is a difficult problem to overcome, and I would like to emphasize that it is not done intentionally. This is frequently a natural reaction to fear and anxiety. The best way to overcome this problem is by successfully completing assignments designed to reproduce the therapy experience outside the office (without the therapist present). Although this forms an important part of therapy anyway, it is particularly crucial in cases such as these.

Another important problem that can occur in contamination OC (as in other forms of OCD) is the presence of overvalued ideas. This has been shown to be associated with poorer treatment outcome, and at this point, it is not entirely clear how to best deal with the problem. Overvalued ideas are characterized as falling on a continuum from frank acknowledgement that the idea is not rational but the urges are compelling, to an inability to identify the idea as irrational. For example, if one with contamination OC felt genuinely that only by washing 36 times would all the contaminants be washed away, and that anything less would result in illness, then that person would have high overvalued ideas.

When overvalued ideas are high, they have been described as two sides of a double-edged sword. One side of the sword represents rational thought, and the other side irrational thought. As is the case of a sword, one can quickly switch from one side to the other. People with high overvalued ideas regarding the necessity of washing usually require more time in treatment, and the prognosis is not typically as positive. This does not mean that there is no hope, simply that treatment may need to be more intensive or for a greater duration, or both.

Finally, sometimes individuals simply cannot effectively engage in treatment related exercises. This problem manifests itself frequently when the fear associated with engaging in behavioral exercises is too high to be tolerated. When this happens, the onus is placed more upon the therapist to develop exercises that can be completed. Creativity is the key here. I’ve highlighted this as a number of previous clients of mine complained that prior therapists were unwilling to work with them as they could not do the assignments. When this happens, it is not surprising that the client feels defeated and demoralized. My suggestion, however, is that if the therapist is unwilling to determine methods that are ‘do-able,’ then perhaps that is not a good match in treatment anyway.

Maintaining Treatment Gains

Although many sufferers recover from contamination OC, it is widely acknowledged that special attention must be paid to matters related to staying recovered. Although at the end of treatment many behavioral exercises no longer produce anxiety, it is important for people recovering from contamination OC to continue to engage in activities that were previously anxiety producing. The way that one can justify the ongoing self-therapy approach is to consider this like any of their other health maintaining activities. Just as some engage regularly in physical exercise to remain physically healthy, it is likewise important for those with contamination OC to engage in mental and behavioral exercises to remain mentally healthy. If physical exercise is a metaphor that doesn’t appeal to you, then consider it like brushing your teeth. Here, regular behavioral exercises serve to ‘brush your brain.’

Some Concluding Thoughts…

Contamination OC can be disabling, and sufferers struggle mightily with symptoms that are frequently tormenting and painful. Further, our knowledge of how to best treat contamination OC is still developing so that therapy may be either faster, more thorough, or capable of helping those for whom treatment fail. Yet there is treatment available, and the results are often encouraging. Some recent research has suggested that when therapy is conducted in this manner, approximately 80% of participants are capable of experiencing symptom relief.

Why OCD Treatment Has to Change After the COVID-19 Pandemic

My therapist stands up, walks over to the bookshelf in his office, and picks up two red apples that are sitting on one of the shelves. The apples look out of place next to his personal library of psychology books, collection of fidget toys and various decorations.

He grabs two plastic knives from the same shelf and hands me a knife. He hands me one of the apples. Silently, he then sits on the floor, cross-legged, and waits for me to join him.

I am reluctant I know what is coming.

I finally take a seat on the floor, cross-legged as well. I can feel the carpet beneath my legs as I hold the apple in my left hand and the plastic knife in my right.

My therapist begins to cut into his apple. He cuts it flawlessly into slices, an impressive feat since we are using plastic knives and just cutting the apples in our laps without the use of a table or other hard surface.

A few seconds later (though these seconds feel like days), I begin to slice my apple as well. I am not as talented at this freestyle cutting as he is. My slices are jagged and uneven.

My therapist then places an apple slice on the floor and rolls it around. He makes sure each side of the apple slice touches the carpet multiple times as he rolls it over and over. I am cringing on the inside. But I know what I must do next.

I slowly place my apple slice on the floor. I roll it over once, then twice, then a third time. I pick it up and look at it, disgusted. I can’t help but think of all the germs that are on that floor, embedded in the carpet, and now on my apple slice.

My therapist picks up his apple slice and holds it near his mouth. I know he is waiting for me to do the same.

In another short period of seconds that felt like days, I begin to raise my apple slice to my mouth as well. I stare at it, examining it as if I could physically see all the germs that now tarnish it. Sometimes, I expect that I actually will see the germs but, of course, I never do.

My therapist and I are there, stuck in what can only be described as an excruciating time vortex, preparing to eat apple slices off the floor. We stare at each other for a few seconds. He can sense my hesitation, my disgust, my anxiety . Alternatively, I can sense his support, encouragement and faith in me. We share these feelings without ever saying a word.

I look down at my apple slice and then raise my gaze again to meet my therapist’s eyes. He waits for me, patiently.

With our eyes still locked, I move my apple slice closer to my lips. He mirrors me, doing the same.

And then we both take a bite.

Exposure and response prevention therapy, or ERP, has long been considered the gold-standard treatment for obsessive-compulsive disorder (OCD) . ERP is in the family of cognitive behavioral therapy, or CBT. ERP often looks a lot like what I just described above a trained therapist encourages their clients to face their fears head-on and then refrain from engaging in any sort of compulsive or compensatory acts. This particular “exposure” I described is based on my irrational and debilitating fear of germs, contamination, and illness. Over the course of many months, my therapist and I worked through a series of exposures in which I was intentionally confronted with a feared situation (germs) and encouraged to face these fears head-on (as I did when I ate the apple slice off the floor). Over time, ERP retrains the mind, and the feared stimulus becomes less and less threatening. The idea is that ERP serves as a bit of an “overcorrection” — in other words, eating apple slices off the floor in my therapist’s office for a couple of months ultimately allowed me to be able to eat out at restaurants without having a full-blown anxiety attack if I didn’t have my hand sanitizer with me.

To paint an even more graphic picture for you, eating apple slices off the floor was not the most harrowing exposure I did to try to combat my fear of germs. Over a series of months, my therapist and I rubbed apple slices on public restroom sinks, doorknobs, elevator buttons and the backs of toilet tanks. Each time, I shook my head, said I could not do this, and stared at the apple slice waiting for the germs to appear. I thought if the germs appeared, or if I felt them in my hand (which I sometimes believed I did), I could say, “Look! I was right!”

But the germs never appeared. My therapist was always patient, yet always unwavering. He never forced me to do anything, but encouraged me nonetheless. And, eventually, I (almost) always ate the apple slice.

As you may have surmised by now, these events took place months ago. I have not seen my therapist in-person for quite some time now, and I do not know when we will physically meet again. Treatment of OCD has entered uncharted territory due to the threat of the coronavirus (COVD-19) it is no longer expected, advisable or safe for clinicians to conduct ERP in the way I described above. The “illogical” fears of many people living with OCD have suddenly become logical people without OCD are engaging in cleaning and sanitizing behaviors that go well beyond the “normal standard” prior to the pandemic. For those of us with OCD — the fears we have spent months (and years) trying to untangle and strip of power have suddenly become quite real, with no foreseeable end in sight.

I have the unique experience of being both a person with OCD and a therapist myself. I wonder how clinicians like myself (and my own therapist) will have to adapt and change the way we treat OCD going forward. The “gold-standard treatment” is not so gold anymore. The way we treat this disorder will have to be reflective of the times we are living in.

Understandably, not much research has been done yet with regard to OCD treatment in the midst of a global pandemic. But some researchers, clinicians and other professionals have begun to devise a new and improved discourse for treatment of this disorder, given the circumstances.

According to Fineberg et al. (2020), clinicians should give consideration to the use of medication for the treatment of OCD during this time. Specifically, “based on the risks associated with exposure and response prevention (ERP) in the pandemic … pharmacotherapy should be the first option for adults and children with OCD with contamination, washing or cleaning symptoms during the COVID-19 pandemic.” ERP as it has been done traditionally (as I described above) is no longer safe for either the client or the therapist. Therefore, medication (when prescribed by a doctor and taken with compliance) might be a helpful option for clients with OCD to consider and discuss with their treatment team. In particular, the use of selective serotonin reuptake inhibitors (SSRIs) has evidence of success in alleviating the symptoms of this disorder.

Additionally, Fineberg et al. (2020) offer suggestions from a cognitive-behavioral perspective regarding how to adjust one’s ERP treatment plan during this time. Fineberg et al. (2020) recognize that it may “be difficult to disentangle OCD -related cleaning and checking compulsions from rational COVID-19 -related safety behaviors.” Therefore, the authors “recommend significantly tailoring CBT to take into account the CDC guidance.” Clients with OCD should no longer be expected to stop washing their hands completely, even if this was part of their exposure plan prior to the pandemic. Instead, Fineberg et al. (2020) suggest, the therapist should focus on supporting their clients and “trying to prevent them from deteriorating.” The authors suggest using activity scheduling and behavioral activation with clients to combat the unfortunate reality that “obsessions often expand to fill a vacuum of time.” With too much time on their hands and fewer in-person exposure opportunities (as well as the looming threat of a global pandemic), clients with OCD can be more prone to increased obsessional thoughts and compulsive acts.

Treatment providers who see clients diagnosed with OCD are currently facing a unique and unprecedented predicament. My therapist often helped me realize that my fears around germs were irrational, or at least not as bad as the catastrophic scenario my brain had concocted. Now, however, he has his own fears around contamination and illness related to the pandemic. He has to take care of himself and his loved ones. It would be unsafe and inadvisable for us to continue engaging in ERP the way we had been doing it for many months.

The way we treat OCD has to change there is simply no way around it. Treatment protocols will have to be adjusted for the foreseeable future, and possibly forever. I am curious to see how this pandemic and its aftermath impacts both my treatment and that of my clients. We have no choice but to use the information at our disposal from both OCD experts and public health officials to make the most educated decisions moving forward. Only time will tell how COVID-19 influences OCD symptoms, diagnosis, and treatment in the long term. But I believe we can say with certainty at this point that I will not be eating apples off the floor of my therapist’s office again for quite some time.

Struggling with anxiety or OCD due to COVID-19? Check out the following articles from our community:

Exposure Therapy to Provoke Disgust and Fear Responding in OCD Patients

Obsessive-compulsive disorder (OCD) is characterized by obsessions, i.e., intrusive negative thoughts that often produce anxiety. Most people with OCD cope with these thoughts through a series of rituals/behaviors called compulsions (Broderick, Grisham, & Weidemann 2013). There are several different types of OCD. One of the most common types features contamination-based fears and manifests itself as the rigid fear of infection, disease, or pollution from people or objects the individual believes are soiled or dirty (Broderick et al., 2013). Broderick and fellow researchers (2013) highlight recent research that has indicated the contamination-fear related OCD may be distinguishable from other strains of OCD on varying levels, most interestingly to the researchers in abnormalities related to the emotion of disgust (Broderick et al., 2013 Woody & Teachman, 2000).

Role of Disgust in Contamination-Based OCD

Because OCD has typically been characterized as one of anxiety, driven by an “abnormal fear experience” Broderick et al. (2013, p.27) are particularly interested in the role of disgust as it relates to contamination-fear OCD. The researchers note that further research into the particularities of the role of disgust could be critical in improving treatment for contamination-fear OCD. The current standard of treatment for OCD is exposure-based behavioral therapy however, a significant portion of patients with OCD do not respond well to treatment (Fisher & Wells, 2005). This may be because “self-report findings suggest that disgust is particularly resistant to extinction relative to fear” (Broderick et al., 2013, p. 29 Mason & Richardson, 2010). Thus, it is critical for the advancement of OCD treatment options to further explore the distinctions between standard fear-based OCD and contamination-fear OCD, which is more associated with disgust than with fear.

Reactions During Disgust Experiences

The investigators designed a study to contribute to this canon of literature by determining the normative disgust experience for both populations with high and low contamination fears and examining how the disgust experience is influenced by exposure (Broderick et al., 2013). This study examined change, both physiological and self-reported, over time and exposure of 12-14 minutes. Participants were drawn from the freshman class at a university in Wales and screened for contamination fears. Those with the highest and lowest reports were invited to participate in the study. Participants were hooked up to ECG machines so heart rate could be measured during the session. Then images from two distinct disgust-related categories, body waste and blood injury, were shown. These pictures were shown over four block sessions.

Expose Contamination-Fear OCD Patients to Body Waste Images

The results of the study indicated significant differences between the two image types: “Body waste images elicited a stronger self-report of disgust than blood injury while blood injury images elicited a stronger self-report of fear than [did] body waste” (Broderick et al., 2013, p. 34). The researchers note the implications of this finding for clinicians seeking to elicit either fear or disgust in patients during exposure therapy. They further concluded that body waste images were perhaps more useful stimuli to use with contamination-fear OCD patients because they elicited a greater degree of disgust than fear (Broderick et al., 2013). Also, consistent with the researchers’ initial hypothesis, the participants with high contamination fears experienced greater overall levels of disgust and fear than their counterparts. Thus, elevated disgust response during disgust provocation may be helpful in differentiating contamination-fearing OCD from other types of OCD. Interestingly, a significant difference was not observed with respect to changes in heart rate after exposure. Thus, the researchers concluded it may be the case that “high contamination fears are associated with elevated subjective, but not cardiovascular, disgust response” (Broderick et al., 2013, p. 35). The researchers are careful to highlight that individuals struggling with contamination-based OCD are not without fear moreover, that the emotional experiences and motivators of fear and disgust are separate and distinct from one another.

Broderick, J., Grisham, J., & Weidemann, G. (2013). Disgust and fear responding in contamination-based obsessive-compulsive disorder during pictorial exposure. Behavior Therapy, 44(1), 27-38.

Fisher, P., & Wells, A. (2005). How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis. Behavior Research and Therapy, 43(12), 1543-1558.

Mason, E., & Richardson, R. (2010). Looking beyond fear: The extinction of other emotions implicated in anxiety disorders. Journal of Anxiety Disorders, 24(1), 63-70.

Woody, S., & Teachman, B. (2000). Intersection of disgust and fear: Normative and pathological views. Clinical Psychology: Science and Practice, 7(3), 291-311.

What Are Contamination Fears?

Contamination fears may be triggered by things in the physical world such as touching a doorknob in a bathroom.

  • Dirt, dust or grime
  • Sticky or oily substances that can cling to the skin and spread to other objects with touch
  • Chemicals like household cleansers, preservatives in food and pesticides
  • Environmental toxins like asbestos, lead paint, mold and radiation
  • Human secretions such as blood, saliva, feces, urine, semen or sweat
  • Animals, especially those that lick, shed, crawl or bite
  • Crowds or densely populated places

Contamination fears can also occur on a mental level, plaguing the mind with repellent thoughts. This is called mental contamination. It affects about 44 percent of people with OCD according to research in the Journal of Obsessive-Compulsive and Related Disorders. 2

  • Feeling harmed or irreversibly changed by exposure to the wrong ideas
  • Feeling like you might lose your sense of self or transform into a different person
  • Feeling like seeing a particular sign or stimulus might force you to do an unwanted behavior, like commit a crime
  • Feeling like another person has made you “feel like dirt” with critical or negative comments
  • Feeling invaded by impure or unclean thoughts, such as sexual or religious imagery
  • Fears of ill omens or bad luck

These types of OCD are fear-based. Fears can be addressed through types of therapy like Cognitive Behavioral Therapy (CBT). A form of CBT called exposure and response prevention gradually exposes clients to the sources of their fears in a safe, supported way. This lets them learn to control their anxiety, negative thoughts, and worries and to begin to interact with themselves and the world without fear. CBT is just one of many positive and encouraging forms of treatment for OCD.

You or your loved one can find health, healing, and relief. You don’t have to work through this alone. At Black Bear Lodge, we offer specialized therapies to help you regain control over your life. Call us at 706-914-2327 today to learn more about what we have to offer.

1 McCay, Dean. “OCD: Symptoms of Contamination.” Psych Central. 17 Jul. 2016.

2 Coughtrey, Anna, et al. “Mental Contamination in Obsessive-Compulsive Disorder.” Journal of Obsessive-Compulsive and Related Disorders. Oct. 2012.

(p. 55) A Cognitive Theory of Contamination Fears and Compulsive Washing

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The main premise of cognitive theories of anxiety is that disorders develop when a person misappraises the significance of external or internal threats to his or her health or well-being. The probability and/or seriousness of the threats are grossly overestimated and the person feels under current threat. Fears of contamination, and the associated compulsions, persist until the misappraisals are removed or reduced. Feelings of contamination can be generated and maintained by cognitions. Mental contamination is caused by a violation which then generates disturbing cognitions in the form of images, memories, and thoughts of the violation and violator. The most common causal experiences are degradation, humiliation, sexual assault, painful criticism, and betrayal. The concept of mental contamination is coherent and measureable and provides a platform for cognitive therapy.

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Modifying Treatment for OCD Patients During COVID-19

ERP remains the most efficacious intervention for OCD, regardless of whether a pandemic is currently ongoing.

Psychologists using exposure and response prevention therapy (ERP) to treat patients with obsessive-compulsive disorder (OCD) may need to adapt therapy to address contamination fears during coronavirus disease 2019 (COVID-19), and do so in a way that does not jeopardize patient care, progress, or physical health.

In a case report published in the Journal of Anxiety Disorders, the authors considered how psychologists treated OCD patients early in the AIDS epidemic when less was known about how the disease spread, as well as client-specific infection risks.

Then and now, psychologists have a duty to provide science-informed treatment while following public health guidelines. Providers can modify ERP — the most effective OCD intervention for patients with contamination-related OCD — to include video visits and/or pharmacotherapy. “Therapies should focus on maintaining, rather than improving, a patient’s current OCD symptoms,” the authors noted.

However, the process of facing triggers that pose risk should be adjusted to follow public health guidelines. Pausing treatment is not recommended. Patients who do not have contamination symptoms can receive their usual treatment, keeping CDC and WHO guidelines in mind. A medication-only approach is not recommended, the authors stated.

The case study profiled a patient with a 14-year contamination fear history. When businesses shut down at the beginning of the pandemic, her anxiety increased. After a one-month break, the patient continued treatment using video. During this time, she performed “safe” tasks such as walking outside without a mask when no people were around. Her COVID-19-related fears lessened after seven visits, at which time she and the psychologist focused on other fears.

“While ERP must be modified accordingly to accepted public health guidelines,” the authors conclude, “we caution against modifying therapies in a way that may jeopardize the efficacy of patient care or progress.”

(p. 1) Contamination Fears

PRINTED FROM OXFORD CLINICAL PSYCHOLOGY ONLINE ( © Oxford University Press, 2021. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Clinical Psychology Online for personal use (for details see Privacy Policy and Legal Notice).

Intense fears of contamination feature prominently in the serious psychological disorder OCD. Roughly half of the patients afflicted by the disorder engage in compulsive washing/cleaning. The driving force which compels them to wash/clean compulsively is their need to prevent the perceived harmful consequences of being contaminated. There are four broad classes of fear-provoking contaminants: dirt/pollution, germs/disease, dangerous substances such as pesticides, and mental pollution. The fears are complex, powerful, dominating, disturbing, and exceedingly difficult to control. Major features of clinical contamination are: rapid acquisition, non-degradability, contagiousness, and asymmetry.

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Managing OCD and related disorders during the COVID-19 Pandemic

For those living with OCD (obsessive-compulsive disorder) and related disorders, times of high stress and anxiety can lead to changing or worsening symptoms. To help manage these growing concerns during the COVID-19 pandemic, we recommend the following:

Set a Safety Plan

With the help of your therapist or support group, including friends and family, create a basic safety plan for maintaining personal hygiene and decreased social contact. Once this is done, try not to add more to it. Recommendations from trusted health organizations including the CDC and WHO include the following:

  • Wash your hands for 20 seconds with soap and water after being in a public place, before eating, or after blowing your nose, coughing or sneezing. Use hand sanitizer with 60% alcohol when soap and water are not available. Avoid excessive hand washing which may injure your skin and strip the barrier that protects against infection.
  • Disinfect frequently touched surfaces daily including doorknobs, light switches, phones and countertops. Do this once or twice a day and always think about whether you truly need to clean this surface.
  • Cover coughs and sneezes with a tissue or use the inside of your elbow.
  • Avoid close contact with others (keep about 6 feet) and stay home as much as possible

If you struggle with contamination fears, this safety plan may help relieve some anxiety over how extensive your routine for protecting against COVID-19 truly needs to be. If you would like to do more than this or you find yourself repeatedly adding more to this list, pick a person who can help you decide what are rational safety measures for you to follow.

If you struggle with perfectionism or fears of harming others, remember that no one expects you to be able to protect yourself or others “perfectly” and that there is no way you can. Lean on your support system to help navigate the uncertainty and sometimes lack of specific guidelines that could create room for your OCD behaviors and worries to take over.

Allow Room for Change

The protective measures we are taking against COVID-19 are our new normal but they are only temporary, and at some point, we will return to our normal lives. Until then, we have to be open to change. For those undergoing or seeking in-person services, including exposure and response prevention (ERP) therapy, talk to your health provider about how your treatment plan might change.

Given the need for social isolation to limit the transmission of COVID-19, talk to your health provider about temporarily transitioning your therapy to a video teleconferencing service. Research has found that ERP therapy can be effectively provided via video teleconferencing for children and adults with OCD. Not all therapists can provide these services, however, and not all health insurances will cover it. Check in with your therapist and health insurance to discuss your options. You may have to temporarily see a different therapist if your current one does not offer teletherapy. Many state Medicaid and Medicare plans cover teletherapy while private insurance coverage varies from state to state, and by insurance plan.

Therapy Goals

The protective measures we are asking everyone to follow might not fall in line with your current goals for treatment, especially if you suffer from contamination fears. Look to your therapist for guidance in creating a new baseline. It may feel like a setback, but remember this change is temporary, and with support you will be able to get back on track. If you are not currently seeking treatment, consider reaching out to a provider than can help prepare you in case worsening or changing of OCD symptoms occur.

Practice Self Care

Remember to be kind to yourself and to those around you. This isn’t easy. Make time for mental rest, relaxation and physical activity to help keep your mind and body busy.

The Connection Between OCD and Childhood Trauma

Many studies have solidified the link between OCD and childhood trauma. A theory proposed by psychologist Stanley Rachman suggests that people are more likely to experience obsessions when they are exposed to stressful situations. The theory also suggests that these thoughts are triggered by external cues. And when it comes to compulsions, Rachman believed that they occur when a person believes they have a responsibility to prevent unwanted events. In the case of childhood trauma, a person might respond with compulsions that they believe will prevent these events.

Other research shows that traumatic events primarily cause psychological symptoms like “repeated and unwanted re-experiencing of the event, hyperarousal, emotional numbing, and avoidance of stimuli (including thoughts) which could serve as reminders for the event.” While most people will experience these symptoms at some point in their lives, they typically fade away after a few months. But many experience them for years after the traumatic event. Some experts believe that these people could be living with OCD or PTSD.

And it makes sense: Looking at cognitive-behavioral models of PTSD reveals many similarities to similar models of OCD. Recent research even suggests that these disorders exist on the same continuum. Although studies continue to shed light on the causes and effects of this disorder, many therapists are unsure of how to approach people with childhood trauma and OCD. For this reason, a comprehensive treatment program is often necessary.

Begin Your Recovery Journey.

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

Obsessive-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.

Watch the video: Ιδεοψυχαναγκαστική διαταραχή. Η πρακτική, θεραπευτική αντιμετώπιση των έμμονων ιδεών (January 2022).