The OCD Cycle

We live in a society that collectively has difficulty tolerating anxiety and accepting ambiguity. Anxiety is an emotion that is associated with a lot of negative connotations and generally leads us to quickly seek out solutions to escape the discomfort. For some people, anxiety becomes connected to everyday, seemingly neutral things such as other people, social situations, doorknobs, dogs, physical sensations, and emotions. The actions taken in attempts to evade anxiety are called safety behaviors (or within OCD, they are called compulsions). These behaviors are enacted with the hopes of decreasing distress. Unfortunately, the relief acquired from engaging in safety behaviors is only temporary. Some common safety behaviors include avoiding anxious triggers, seeking reassurance, researching, using substances, washing, counting, etc. Since these behaviors actually do work (but only in the short-term), people continue to use them. Unfortunately, continuing to rely on safety behaviors causes individuals to become trapped in the anxiety cycle and prevents them from learning that their fear was either unfounded or tolerable. Ironically, these safety behaviors and compulsions only preserve the fear in the long run. Simultaneously, reliance on safety behaviors prevents growth and learning, which can severely restrict quality of life. The thoughts, situations, emotions, or body sensations that create the anxiety might be different within each presentation of OCD, but the cycle that maintains anxiety generally has low variability from person to person. Please see our previous blog entry – Understanding the Cycle of Anxiety – for further information.

What is Contamination OCD?

Contamination OCD is perhaps the most well-known subtype of OCD. It is characterized by the presence of obsessions pertaining to concerns of coming into contact with contaminants. Contaminants are generally thought of as being physical, such as germs or animals, but contaminants can also be of a less concrete variety, such as bad luck. Exposure to contaminants provokes a significant amount of distress/anxiety and/or disgust and results in the individual seeking ways (via compulsions) to sterilize the contamination or neutralize their contact with the contaminant. The decontamination methods enacted in such situations are excessive and typically time-consuming. In addition to compulsions, the individual may have elaborate methods or rules (otherwise known as rituals) for either avoiding or preventing contamination from happening, or counteracting contamination once it has occurred. The obsessions and compulsions present in OCD are excessive, cause a great deal of emotional upset, and have the potential to impair the person’s functioning in important life areas, such as work/school, hygiene behaviors, relationships, etc.

Common Obsessions in Contamination OCD

Common obsessions include (but are not limited to):

• Getting sick
• Getting others sick and other themes of over-responsibility
• Being contaminated
• Having contaminated belongings
• Bringing contamination into one’s home (particularly one’s bedroom, kitchen, and bathroom)
• Feeling dirty or disgusting
• Taking on negative personality traits of a triggering person

Commonly identified contaminants the context of Contamination OCD include (but are not limited to):

• Dirt
• Germs
• Animals
• Insects
• Bodily excretions and fluids (urine, feces, vomit, sweat, tears, mucus, blood, semen, saliva)
• Bacteria and viruses
• Raw or spoiled foods
• Plants
• Chemicals
• Cleaning products
• Radioactivity
• Sticky substances
• High traffic areas
• Floors/ground
• Push buttons
• Remotes
• Stair railings
• Doorknobs
• Elevators
• Public restrooms
• Carts at stores
• Waiting rooms
• Doctors’ offices/hospitals
• People with illnesses or disabilities
• Places where something dangerous or stressful took place
• Negative personality traits

Common Compulsions in Contamination OCD

Common compulsions/rituals/safety behaviors include (but are not limited to):

• Avoidance
• Reassurance seeking
• Using barriers to open doors/cabinets/drawers
• Refusing to sit down where others have sat
• Refusing to touch things that others have touched
• Not going to the restroom for as long as possible and/or limiting consumption of foods and liquids so as to have to use restroom less often
• Elaborate cleaning/sterilizing/decontaminating rituals
• Having others complete tasks that have a risk of contamination
• Excessive washing and rewashing hands/body/hair
• Changing clothes
• Having “clean” places in the home that others are allowed to touch/access
• Retracing steps (mentally and/or physically) to determine whether or not a contaminated item or surface was touched
• Keeping distance from a contaminated item, place, or person
• Refraining from engaging in certain hygiene activities (blowing nose, flossing, wearing contacts, etc.)
• Not eating hand-held foods
• Having silverware, dishes, glasses, etc. that are not to be used by others
• Taking longer routes so as to avoid passing locations that are perceived as contaminated
• Avoiding doctor and dental appointments
• Avoiding physical and other forms of contact (electronic, shared items, etc.) with others

Treatment of Contamination OCD

The gold-standard treatment for Contamination OCD is Exposure and Response Prevention (ERP). ERP is an evidence-based treatment, which means that there is a significant amount of research, empirical studies, and data that consistently demonstrate the efficacy of employing an ERP treatment protocol to successfully ameliorate the symptoms of OCD. In the context of Contamination OCD, the goals of treatment are to both reduce distress associated with triggering stimuli and situations and to decrease functional impairments in daily living and significant areas of life. Through ERP, individuals engage in exposure to their fears in order to help them to learn that the perceived risk is not as high as their OCD leads them to believe. ERP facilitates opportunities to challenge worries and to differentiate between anxious predictions and the actual outcomes of encountering feared stimuli and situations. Another goal of ERP is to increase the individual’s ability to tolerate the uncertainty, discomfort, and doubt that their OCD creates. Please see our previous blog entry — What is Exposure and Response Prevention (ERP) – for more information about this treatment.

Exposures can include anything that provokes anxiety and/or uncertainty related to contamination concerns. Examples of exposures that may be conducted in the context of ERP treatment for Contamination OCD include: standing in close proximity to triggering stimuli, making brief contact with triggering stimuli and refraining from engaging in compulsions, making extended contact with triggering stimuli and refraining from engaging in compulsions, contaminating one’s personal belongings (phone, keys, wallet, purse), home, and bedroom, interacting with animals, spending time outdoors/gardening, preparing food, using a public restroom, etc. In addition to participating in exposure work with triggering stimuli, treatment must also include Response Prevention, which involves eliminating compulsions and deconstructing rituals. Examples of Response Prevention include: reduction of hand washing rituals and bathing rituals (less time, water, and soap), decreased frequency/thoroughness of cleaning at home, decreased frequency/thoroughness of washing of bedding and clothes, no longer having spaces at home that are designated as “clean,” sharing items with others (tv remote, serving utensils, hygiene products), etc. Engaging in ERP treatment helps individuals to learn new ways to respond to stressful situations and, after engaging in repetitious practice, they will likely experience a reduction in anxiety and/or learn that they are able to tolerate the stress and uncertainty while still engaging in enjoyable and meaningful activities.

ERP treatment for Contamination OCD almost always requires participation from others who live with the patient (parents, siblings, spouse, roommate), since these individuals have typically adjusted their behaviors and routines at home to accommodate OCD. These individuals have an instrumental role to play in the treatment process and they will learn to provide constructive support to the patient. In a stepwise fashion, family members will resume their typical household patterns/routine. They will be coached to provide less reassurance as well as to supply less hygiene and cleaning products. Involving support persons in treatment is essential to help them distinguish the difference between helping their loved one and helping OCD. The former version of help means that they will be assisting their loved one in approaching and challenging his/her OCD, whereas the latter version of help means that they will be accommodating OCD’s demands (this enables OCD to become stronger and their loved one to remain stuck in the anxiety cycle). Incorporating the participation of family members into the treatment process will help them learn how to extricate themselves from requests for “help” that are allowing the patient to continue to avoid engaging with triggering stimuli.

Although ERP is the first-line treatment for Contamination OCD, Acceptance and Commitment Therapy (ACT) can often serve as a beneficial adjunct. Within ACT, individuals are introduced to the concepts of mindfulness and acceptance, which aid them in being present with their anxious thoughts without trying to change them or engage in compulsions. Interventions focusing on increasing acceptance of uncertainty and doubt are necessary to supplement ERP work in the treatment of Contamination OCD. Such interventions often overlap with Response Prevention work and may include refraining from retracing steps (both physically and mentally), refraining from seeking reassurance, refraining from engaging in online researching, refraining from asking others about their hygiene and/or cleaning practices, etc. In the context of ACT, acceptance is making space for the thoughts and worries to be present without feeling the need to react or respond to them. Struggling against anxious or worrisome thoughts is likely to exacerbate anxious feeling and create more emotional suffering. Using ACT-based strategies, individuals are better able to differentiate their thoughts and values from their OCD and identify if the behaviors they are engaging in provide them joy and pleasure (which is the goal), or if they are behaving in response to anxiety and uncertainty stemming from their OCD. They are able to learn to be aware of their thoughts and fears while not paying undue attention to and/or over-engaging with them. The goal is to learn to live life and participate in activities that are important, even if the thoughts are present. Thus, ACT is employed to increase psychological flexibility and reduce the cognitive rigidity seen in OCD. ACT aims to help people to defuse from their obsessive/intrusive thoughts and maintain a present-focused awareness. This awareness will enable them to engage in the activities taking place in the moment, rather than retreating into obsessive worries. Outside of therapy, individuals with Contamination OCD can also benefit from medication.

Need help or support?

If you or a loved one are struggling with OCD or any other mental health concerns, know that you are not alone. If you are a parent or a caregiver and are seeking additional information about these diagnoses and how you can best support your child, our office provides parent training with the SPACE program. Please see our November 2021 Newsletter for more information on SPACE.

For these or any other mental health concerns, please contact The OCD and Anxiety Center at (630) 522-3124 or info@theocdandanxietycenter.com. We have offices in Oak Brook and Orland Park that specialize in helping individuals overcome anxiety disorder, Obsessive-Compulsive Disorder, and other co-occurring mental health conditions. We provide telehealth services that are available in Illinois, Indiana, and Iowa.

At The OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, etc.). We will work closely with you to create an individualized treatment plan and discuss the appropriate frequency of appointments (once a week or more, if needed). We look forward to working with you!

Click here for more information on OCD Treatment.

Dr. Ashley Butterfield is a licensed psychologist at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in Cognitive Behavioral Therapy and Exposure and Response Prevention Therapy for anxiety, OCD, and anxiety-related disorders. She is comfortable working with children and adults and is able to provide treatment both in the office and outside of the office, wherever anxiety happens.