In this series on Contamination OCD, I will attempt to break down the symptoms and treatment for obsessive fear of contamination from three common triggers.
Part One: Blood
Traditionally germs have been the focus of attention when it comes to contamination obsessions, with the emphasis on health anxiety and fears of getting ill or causing others to get ill. While that is a common and important area of attention for those interested in understanding OCD, the obsession with bodily fluids may warrant more attention. In this first installment, I will be focusing on blood, how fear associated with blood often presents in OCD, and how cognitive behavioral therapy (CBT) can be used to treat it.
Blood isn’t dangerous
Blood is a liquid in the body that delivers oxygen and nutrients to cells and carries away waste from those cells. Inside the body, very cool stuff indeed. Outside of the body, it is gross (for many people anyway). This disgust may be an evolutionary necessity. After all, if you are seeing blood outside of the body, it usually means something is wrong. There has been some kind of accident, an act of violence, or a sickness that brought the blood out of its home in the body and into your presence. A long time ago, it was probably a good idea to get far away from it before it attracted saber-toothed tigers (or vampires). So despite there being nothing inherently dangerous about blood, somewhere in our genetic database is probably an urge to avoid being in its presence. The internal voice that says “ewww” is also saying “run away.” Normally this would not pose much of a problem, unless you felt you needed certainty that you were far enough away. Enter OCD stage right.
Obsessive compulsive disorder is a mental health issue in which the person suffering from it experiences unwanted intrusive thoughts and engages in repeated behaviors aimed at getting certainty that the thoughts won’t come true. In blood obsessions, it typically presents as:
- Fear of contracting a disease from casual contact with blood
- Fear of being irresponsible in terms of allowing self or others to become contaminated by blood
- Fear of being overwhelmed with disgust about blood
Compulsions typically include:
- Excessive avoidance of situations or environments where blood may be present (i.e. hospitals)
- Avoidance of intimacy and sexual behavior for fear of catching or spreading blood-borne diseases
- Excessive avoidance of sharp objects, band-aids, or anything that could be perceived as causing or having come in contact with exposed blood
- Excessive washing to ensure there is no blood on the skin or clothes
- Excessive cleaning of items feared to have come in contact with blood (i.e. bottom of shoes)
- Avoidance of people associated (accurately or inaccurately) with blood contact or blood-related illnesses (i.e. doctors, hairdressers, homeless people, gay people)
- Avoidance of contact with people in general (i.e. avoiding handshakes in case someone has a cut on their finger)
- Avoidance of things that could be confused with blood (red paint, etc.)
- Checking, reassurance seeking, or analysis of items that may or may not be blood (i.e. a red mark on a wall)
- Checking for blood or for cuts in the skin (on self or others)
- Reassurance seeking online (or elsewhere) regarding blood-borne illnesses and how they are contracted
- Reassurance seeking from others that they have not come in contact with blood
- Mental rituals, such as mentally retracing what could have touched what or mentally repeating reassuring statements
- Scrutinizing the behavior of dentists, doctors or any other professionals who may be exposed to blood (yours or others)
Rituals in blood fears can become extreme rather quickly. I have known clients to burn their clothes, spend hours showering, hours checking their body for cuts, abandon groceries in the parking lot of the supermarket, abandon entire locations (including their own home) for fear of blood contamination. It spirals out of control pretty easily, with each new avoidance sending the message to the brain that death was narrowly escaped, prompting further, more indirect reasons for avoidance. People who have an obsessive fear of blood contamination often focus as much on the fear of spreading harm to a loved one as on being contaminated themselves. The chain of thought typically goes something like this:
“I must be certain that I did not get any blood on me. If I am not certain, then I may have gotten some blood on me and it may give me a terrible disease. If I get this disease, I may give it to my child (or partner or other loved one). If they get the disease, they will resent me for ruining their life and I will live in terrible shame knowing it was all my fault. People will also think I did something pretty awful to get the disease in the first place and that is the only story that will ever be told about me.”
The OCD makes a pretty strong case for doing compulsions. Wouldn’t you wash your hands just one more time to keep a family member from dying a horrible death and blaming you for it? Just to be sure? The problem, however, is that compulsions fail to guarantee success. What’s worse, compulsions simultaneously provide temporary relief from unwanted thoughts and feelings. This removal of the unwanted becomes something the brain naturally gravitates toward more and more through a process called negative reinforcement. Further, washing just sends the message to the brain that getting stuff off your hands is an important thing to focus on. It’s an inconvenient behavior, so it must be important, right? So the urge to do compulsions continues to go up over time while the obsessive fear of blood never abates (and actually worsens over the same period of time).
Among the more common manifestations of blood-focused OCD, is an obsession with human immunodeficiency virus (HIV). HIV is the boogeyman of health anxiety. It is the virus that causes AIDS, it is incurable (as of this writing), and it is loaded with all kinds of stigma and misconceptions. The virus is actually pretty fascinating. It is relatively weak in that everything pretty much kills it quickly (heat, cold, air, water, saliva) but if it can make it from one person’s blood to another, it has a slight chance of binding to one of that person’s blood cells. Once attached, it reprograms the cell to start attacking other cells and creating copies of itself that set out to attack even more and so on and so forth. The process depletes the immune system, resulting a a gradual deterioration of health, the final stages of which is called Acquired Immune Deficiency Syndrome (AIDS).
What is most interesting about the obsessive fear of HIV is that for all the handwashing and avoiding, HIV is not an environmental contaminant.
Free reassurance, come and get it:
- There are no documented cases of contracting HIV through environmental contact (i.e. touching infected blood)
- There are essentially only two ways to get HIV – the use of shared hypodermic needles in which blood from one person is literally extracted and put into the bloodstream of another person, and unprotected sex with an infected person in which semen or vaginal secretions are essentially pushed into the bloodstream of another person through tears in the skin of the mouth, vagina, anus, or penis (other ways of contracting it include transmission from pregnant mother to fetus and transfusions of infected blood [which is no longer an issue due to testing standards])
- Blood pours out, not in. What this means is that when you have a cut on your arm, for example, the blood is pushed out of the cut pushing whatever might have fallen onto the cut away from the opening. It is not a suction cup pulling contaminants into the body. So having something get on a cut is not the threat your OCD is telling you it is.
OK, a reality check is all well and good, but if the OCD is in high gear, reality is no substitute for certainty and certainty doesn’t exist. What this means is that nobody wants to be the cautionary tale or the first person made famous by getting a terrible disease from casual contact with blood. In the end, only acceptance of some level of uncertainty will allow the OCD to be diminished. How do we develop a capacity for uncertainty tolerance when the OCD makes it seem impossible? The answer is a combination of cognitive and behavioral treatment strategies that together define cognitive behavioral therapy (CBT).
Cognitive strategies for blood related fears
For most people with contamination OCD there are two central distorted beliefs that drive all the others. One is that a person should or must know at all times whether or not they are safe from a blood-borne illness. Since it is not possible to know anything at all times, it is unreasonable to set a rigid guideline that involves a requirement to know such a thing. Another is that the feeling of disgust, the state of “gross” is somehow dangerous; that the experience is so unacceptable that it should not be tolerated or that the experience itself is an indicator of impending harm. Disgust is a feeling, and like all feelings, it cannot be relied upon for factual information about danger. In addition to emotional reasoning, black-and-white thinking and magnifying can play an important role as well. The idea that all blood is dangerous because some blood can carry a virus makes resisting compulsions that much harder. Challenging distorted beliefs and ideas about blood can help reduce the reliance on compulsions, so long as these challenges are not used as a ritualized form of a reassurance.
Behavioral treatment for blood related fears
The most effective treatment for any form of OCD is exposure with response prevention (ERP). The problem with OCD is the cyclical nature of obsessions and compulsions. Obsessions trigger discomfort, compulsions temporarily relieve discomfort, and the awareness of this relief triggers further sensitivity to the unwanted thoughts and greater urges to engage in more compulsions. To break the cycle, the OCD sufferer has to remove the only removable element. You can’t just not think something. If I say don’t think about blood, it will have the same effect as me saying not to think about a tap-dancing giraffe! But you can just not do something. You can resist washing in the presence of a blood-related thought. (You can also presumably resist putting tap shoes on a giraffe.) It just requires an ability to cope with the associated discomfort.
Exposure with response prevention works by bringing up the unwanted thought (through exposure to triggers) and practicing resisting the compulsive response. Over time, through a process called habituation, this practice of resisting compulsions becomes more automatic and the brain is forced to release its association between the thoughts and the responses that make them seem so important. This involves a gradual process of identifying with your therapist what your triggers and compulsions are, then working to overcome each one from the easiest up to the hardest. Concurrent with exposures that may involve touching triggering items, interacting with triggering people, or visiting triggering locations, the person working to overcome their fear would work on resisting washing, reassurance seeking, checking, and other neutralizing rituals.
Mindfulness for blood-related fears
Mindfulness is the practice of observing what is going on inside in the present without judgment or analysis. Employing mindfulness skills can be an integral part of revealing distorted thinking and compulsive urges. When a person comes in contact with something they feel is contaminated, they have an opportunity to stop and take a look at what is going on inside. Mindfulness practice would entail noticing the feeling of contamination and allowing it to be there, as a feeling, without making compulsive attempt to eliminate it. Similarly, if a thought about blood is present in the mind, mindfulness enables you to see it for what it is, a thought about blood. By observing and allowing, you are weakening the glue that binds unwanted thoughts to compulsive urges.
Life is dangerous
Life is dangerous… and funny and interesting and beautiful. But when OCD puts all the focus on “dangerous,” all of life’s other qualities become obscured. It is true that we should be well-informed about our health and take precautions to reduce the likelihood of harm from preventable illnesses. It is also true that at some point, we draw a line in the sand and we say, enough. People don’t get Hepatitis C from hugging. It’s not a thing. But OCD makes it difficult to draw that line. It says there is no line at which you could accept a tragedy befalling you.
If the OCD demands certainty and certainty is unavailable, then why would I certainly avoid sharing a needle but not certainly avoid hugging a person who looks like they might have once shared a needle? If I am going to avoid unprotected sex, then what about sleeping in a hotel room where someone might have had unprotected sex? If OCD won’t let you draw the line with rational thinking, then how are you supposed to choose to ever draw the line? There is no easy answer, but there are clues. A major clue is how much of your life you are willing to sacrifice for your fear. People fear blood because they associate it with being sick, contagious, unlovable, incapable of being around others, ashamed and rejected from society. Yet OCD creates the same problem. It asks you to sacrifice all the same things. Are you willing to sacrifice time with your family because you’re stuck in the shower? Are you willing to sacrifice being social because you might encounter a triggering person? What about shaking hands when you meet someone? What about sex? What about a simple walk in the park where you might brush up against a sharp plant… or step on a discarded band-aid? If the concern of getting a blood-borne illness is about being isolated from the people you love, incapable of enjoying relationships, work, daily life, then why let OCD create that very same environment with avoidance and other compulsions? With the right treatment for your OCD, you can reclaim the funny, the interesting, and the beautiful parts of life while mastering your discomfort with the dangerous.
In the next installment, I will go over another area of contamination OCD that many find difficult to talk about, yet many OCD sufferers struggle with – fear of contact with semen. It is what it is.