For adults
Contamination OCD
Contamination OCD is the version most people picture when they hear the word OCD, and it is often misunderstood. It is not always about germs, it is not a liking for cleanliness, and it tends to spread rules across a whole household.
What people with contamination OCD are afraid of
For some people the fear is of illness, such as catching a serious disease from a door handle. For others it is about responsibility, and the thought is “what if I spread it and someone else gets ill because of me?” Some fear chemicals, such as bleach getting into food. In some cases there is no clear feared outcome, only an intense sense of disgust and of being dirty that will not settle until they have washed in a particular way.
In practice it looks like washing hands dozens of times a day, long showers that follow a fixed order, clothes changed on coming into the house, a home divided into clean and dirty zones, and avoiding public toilets, bins, handrails and shaking hands. Sore or cracked skin from washing is common, and your GP or pharmacist can advise on treating it. Children often show it through long bathroom visits or needing a parent to wash things for them, as described on the page on OCD in children and teenagers.
Mental contamination
Some people feel contaminated without having touched anything. A woman whose former partner treated her badly feels dirty whenever she drives past his street, and showers when she gets home. The psychologist Stanley Rachman called this mental contamination. Its source is a person, a memory, an image or a thought, so washing does not reach it, and people often wash more and feel no cleaner. In a study of 177 people with obsessive-compulsive symptoms, 46 per cent described experiencing it, and around one in ten had mental contamination without the usual fear of touching dirty things (Coughtrey and colleagues, 2012). Practising with door handles will not reach a fear whose source is the memory of a person, so treatment is tailored to it.
Rules that spread to the family
Over months the whole household can adopt rules. Partners undress in the hallway, shoes stay outside, visitors are discouraged, and family members do the bins or the laundry so that the person with OCD does not have to. It is done out of kindness, and it keeps the OCD going, because every rule that is followed confirms that the danger was real. In treatment we agree which rules to drop and in what order, and I can help you explain the changes to the people you live with.
Why washing makes the next wash more likely
Washing brings relief within seconds, and the relief teaches the brain that washing was necessary. Each wash therefore makes the next one more likely and lowers the threshold for what counts as contaminated, so the door handle becomes the whole door and then anything the post has touched. Avoidance works in the same way, because never touching the bin means never finding out that you can manage the feeling. Many people also wash until it feels right rather than until their hands are clean, which is why a wash can go on for a long time. Disgust may ease more slowly than fear during exposure, so progress with disgust-based contamination can feel slower at first even when it is happening.
- Trigger: A door handle in a public toilet
- Obsession: What if it’s on me and I make someone ill?
- Feeling: Disgust, anxiety, a feeling of being dirty
- Compulsion: Washing your hands, again, until it feels right
- Relief, for now: Clean for a moment, then the next touch
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: Other people’s phones, your own front door, shopping trolleys, cash and cards.
Where treatment steps in. You touch what you have been avoiding, in steps you choose, and delay or drop the wash. You learn that you can handle the feeling and the uncertainty without washing.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
How I treat contamination OCD
The treatment is exposure and response prevention (ERP), a form of CBT. We map what feels contaminated, every wash and avoidance, and every rule other people follow. Then you touch what you have been avoiding and delay or drop the wash, starting with a step you have chosen and feel able to manage. Anxiety or disgust rises and often eases without the wash, and the practice counts even when it does not. The main thing you learn is that you can handle the feeling and the uncertainty without washing, and noticing that the feared illness did not follow comes second to that. The steps become easier with practice, and online sessions let us practise in the kitchen and bathroom where the rules apply.
Examples of practice, from early steps to later ones
- Touching the front door handle and then your clothes, and not washing for an agreed period.
- Touching the lid of the kitchen bin, then the worktop, and carrying on with your evening.
- Using a public toilet, washing once for about 20 seconds, and leaving.
- For mental contamination, looking at a photo of the person or driving down the street associated with them, without showering afterwards.
What ordinary hygiene looks like at the end
The goal is washing the way most people do. The NHS advises washing your hands for about 20 seconds after using the toilet or changing a nappy, before and after handling raw food, before eating, after blowing your nose, sneezing or coughing, when treating a cut, and after touching animals. Beyond that, ordinary life includes a daily shower of a few minutes and a house cleaned on a regular routine rather than in response to a feeling. During an outbreak of vomiting or diarrhoea at home, the ordinary extra precautions apply and then stop.
After COVID
During the pandemic the OCD’s rules and the government’s were hard to tell apart, and some people’s symptoms grew worse and have not come back down. The practical test is to compare your washing with current public health advice rather than the advice of 2020. If you are doing considerably more than that, and it is driven by fear and costing you time, skin or places you used to go, it is worth treating.
What is not known
Contamination OCD is one of the most studied forms of OCD, and ERP is the psychological treatment NICE recommends for it. Less is known about mental contamination, where the research is newer and treatment trials are few.
Sources
- Coughtrey, A. E., Shafran, R., Knibbs, D., & Rachman, S. J. (2012). Mental contamination in obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 244-250. sciencedirect.com (opens in a new tab)
- NHS. How to wash your hands. nhs.uk (opens in a new tab)
- National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline CG31 (2005; an update is in development). nice.org.uk/guidance/cg31 (opens in a new tab)
Sources for the course-length figures
- National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113 (2011; checked 2020). nice.org.uk/guidance/cg113 (opens in a new tab)
- National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. Clinical guideline CG159 (2013). nice.org.uk/guidance/cg159 (opens in a new tab)
- National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline CG31 (2005; an update is in development). nice.org.uk/guidance/cg31 (opens in a new tab)
- Pediatric OCD Treatment Study (POTS) Team. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder. JAMA, 292(16), 1969-1976. doi.org (opens in a new tab)
- Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child and Adolescent Psychiatry, 59(3), 362-372. doi.org (opens in a new tab)
Common questions
Is it contamination OCD or am I just very clean?
Plenty of people like a clean house and wash their hands often. The difference is in what drives it and what it costs. In contamination OCD the washing is driven by fear or disgust rather than preference, it takes up a lot of time, the skin is often sore or cracked, and rules about what is clean and dirty have started to control where you go, who you see and what the family is allowed to do. If you would stop if you could, and cannot, that points towards OCD.
Will treatment make me unhygienic?
No. The aim at the end of treatment is ordinary hygiene, the same as most people around you. During treatment some practice goes further than everyday life, such as touching a floor and then carrying on without washing, because practising beyond the target makes the target easier to keep to. These steps are chosen with you and they are temporary.
How long does treatment take?
There is no fixed number. Published guidance gives an idea: NICE describes 12 to 15 weekly sessions for generalised anxiety and 7 to 14 hours in total for panic disorder (CG113), up to 14 sessions for social anxiety (CG159), and more than 10 hours of therapist time for OCD with a moderate impact on daily life (CG31); the largest US trials used 14 sessions for childhood OCD (Pediatric OCD Treatment Study, 2004) and 12 parent sessions for SPACE (Lebowitz and colleagues, 2020). I give you an estimate by the end of the first session, and sometimes further assessment is needed before I can. A long history, or a household with many rules, can mean a longer course.
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