This article discusses two types of Contamination OCD. As discussed below, some contamination cases may reflect aspects of both types.
Type 1
In the first type, the person is afraid of contamination because they are afraid that the contamination could cause something else bad to happen that could have permanent emotional consequences. An example of this would be someone who is afraid that if something accidentally touches a certain chemical or germ this could cause someone to get sick, which could lead to a permanent feeling of guilt, separation, etc.
Type 2
In the other type, the person isn’t afraid that the contamination could cause something else bad to happen. Rather, they are afraid of the feeling of contamination itself. More specifically, they are afraid that if they don’t keep track of the contamination and keep it from spreading, then everything could become contaminated, and thus the feeling of contamination would become inescapable.
These two different cases require different approaches to ERP:
ERP for Type 1
In a case where a person is afraid of contamination causing something bad to happen, ERP focuses on taking risks by eliminating avoidance and compulsion, and by contaminating things on purpose. For example, depending on what they are afraid of, they might touch the floor and lick their finger, or touch a doorknob and then touch a plate in the cabinet. In this type of case, you can start with easier exposures and then progress to harder ones. Compulsive rumination could play a significant role in this case, but only as much as it could play a significant role in most OCD cases.
ERP for Type 2
In a case where the person is afraid of the feeling of contamination becoming inescapable, ERP looks different. This type of Contamination OCD is driven by a specific form of compulsive rumination: keeping track of the contamination. Keeping track of the contamination actually generates the feeling of contamination that the person is trying to escape. Thus, as long as the person continues to keep track of what’s contaminated, they will continue to feel just as contaminated, and exposures thus won’t accomplish anything. Therefore, Response Prevention of compulsive rumination is the crux of the intervention, and must also be the starting point.
The exposure exercises for this type of case look different as well. The person isn’t afraid of something becoming contaminated, as long as they remain aware of what is contaminated. Thus the exposure exercises discussed above don’t really make sense. Instead, the exposure would be to contaminate everything, or to otherwise lose track of what is contaminated. I prefer the former because it helps a person to completely resign themselves to everything being contaminated and to let go of keeping track (which makes the feeling of contamination go away).
As stated, some cases reflect aspects of both paradigms. For example, someone might be afraid of losing track of the contamination, as in Type 2, resulting in a consequence that goes beyond the feeling of contamination itself, as in Type 1 (e.g., being unable to function and therefore failing). Similarly, someone who is afraid of a practical consequence of contamination, as in Type 1, might also generate a feeling of contamination by trying to keep track of what is contaminated, as in Type 2.
To avoid missing the nuances of these in-between cases, it can be helpful to consider the following two questions when conceptualizing a case:
- Is the person afraid of a consequence of contamination; the feeling of contamination becoming inescapable; or a consequence of the feeling becoming inescapable.
- What is the role of compulsive rumination — specifically, keeping track of contamination — in the case?
As the above illustrates, jumping into contamination exposures without a clear case conceptualization has the potential to miss the mark. I hope this article contributes to clearer case conceptualizations, and that this in turn leads to more exact interventions, and to better treatment outcomes for individuals suffering from this form of OCD.