OCD: Common Compulsions

In my last post about OCD, I discussed reasons why people do rituals. This time, I’ll identify specific rituals that are common in obsessive-compulsive disorder (OCD) characterized by a fear of germs, contamination, diseases, and other health-related ills.

OCD: Hand-washing Rituals/Compulsions

Hand-washing is a very common ritual and typically involves prolonged and frequent hand-washing behaviors. These washing behaviors may involve a particular sequence, order, or rhythm. Some individuals count while washing or wash in multiples of particular numbers. If these washes are interrupted, the individual may feel the need to repeat the entire sequence to make sure that the wash has been performed “properly.” Although people with OCD may think that their washing rituals are primarily for hygienic reasons, the true function of washing rituals is to reduce feelings of distress, anxiety, doubt, and vulnerability.

The frequency and intensity of these washes and the use of abrasives or antibacterial soap often results in dry, reddened, or cracked skin. In some cases, washing causes bleeding, scarring, or other skin damage. Washing continues until the person feels less anxious about their particular OCD feared outcome.

OCD: Showering Rituals/Compulsions

Similarly, individuals with health-related OCD may take long, frequent showers. Showers are often taken using scalding hot water. If bathing, some individuals elect to literally boil their bath water in order to reach antiseptic temperatures. Showers may be taken routinely after certain events, such as after having a bowel movement. Others wash upon returning home in order to maintain a distinction between “clean zones” (the house) and “dirty zones” (the outside world).

Like the hand-washing behaviors described above, showering often follows a particular sequence or order. Shower routines frequently develop around the idea of not cross-contaminating body parts. In addition to following a specific sequence, individuals may wash certain body parts multiple times (e.g., genitals). Others will entirely avoid direct contact with certain body parts for fear of contamination (e.g., genitals, feet, anus). After showering the individual may exhibit rituals that involve drying body parts in a particular order. Others will allow their bodies to “drip dry” or “air dry” so that their bath towels don’t “spread contamination.” Some individuals dry their bodies excessively using hair dryers in order to remove residual moisture that they fear may be hospitable to the growth of germs or bacteria.

Obsessive-compulsive disorder (OCD) is a disease characterized by contradictions.

Elaborate rituals may be used when cleaning bathroom surfaces, like sinks, toilets, and shower stalls; in order to reduce perceived health risks. However, other individuals avoid cleaning entirely in order to minimize contact with germs, bacteria, mold, or mildew. This seeming paradox can be confusing for friends and family members who assume that all people with OCD clean excessively. This is not the case. Both over-cleaning and under-cleaning serve the function of avoiding potential danger. Messiness, dirtiness, or poor hygiene can reflect an extremely powerful avoidant process.

OCD: Toileting Rituals/Compulsions

Due to the fear of urine, feces, semen, or other bodily secretions, toileting behaviors can be especially distressing for individuals with health-related OCD. Individuals may use large amounts of toilet paper and will often wipe excessively, resulting in bleeding and skin abrasions. Because these behaviors may be repeated multiple times per day, it is often difficult for the skin in these areas to heal. Some individuals also make use of antiseptic cleansers that further damage or distress tissue. Other individuals make use of gloves or other skin barriers while toileting. In efforts to avoid inhaling feces or urine, some individuals hold their breaths or wear face masks while using the restroom, particularly when flushing the toilet.

Although unrelated to contamination fears, some individuals experience the sensation that they have not emptied their bladders or sphincters fully. They may strain or injure themselves in efforts to void completely. These types of symptoms may also be associated with the misuse of laxatives, fiber supplements, and diuretics. These symptoms typically do not reflect a fear of germs but rather may be signs of sensorimotor OCD.

Other common rituals & avoidance behaviors include:

• Wiping off hands frequently using paper towels, antibacterial wipes, or Kleenex.
• Excessive use of hand sanitizers containing rubbing alcohol or other antibacterial agents.
• Excessive use of disinfectants and cleansers.
• Using fresh bath towels and washcloths for every shower (not reusing).
• Cleaning the body with harsh chemicals.
• Compulsions involving ritualistic or excessive tooth brushing (brushing each tooth surface multiple times, reapplying tooth paste, spitting excessively while brushing, counting, and other rhythmic movements).
• Rituals involving shaving (shaving the same area of the skin many times, continually checking the skin for smoothness, reapplying shaving cream, using multiple razors, checking for shaving symmetry).
• Changing clothes upon entering/leaving the household. Asking other family members to participate in these rituals.
• Throwing away any clothing that gets stained or soiled without attempting to launder it.
• Laundering clothes using multiple through wash cycles.
• Not picking up items that have fallen on the ground.
• Wearing only shoes that have velcro fasteners (to avoid touching laces that have come in contact with the ground).
• Sanitizing dishes using multiple wash cycles.
• Boiling cooking utensils.
• Avoiding moving air (through air ducts), etc., that might transmit pathogens (mold, dust, germs).
• Not flushing the toilet.
• Not sitting on the toilet (sometimes even within one’s own home).
• Excessive use of Lysol and other cleansers on household objects.
• Over-cooking foods to kill pathogens.
• Avoiding “dangerous” foods like meats, poultry, or eggs.
• Exclusive use of paper towels rather than cloth towels.
• Using gloves, paper towels, or other skin barriers to avoid touching objects directly with bare skin.
• Avoiding physical contact with other people (hand-shaking, hugs, intimacy).
• Avoiding contact with children and animals.
• Using elbows, fingernails, or other indirect means to open doors or flip lightswitches.
• Holding one’s breath to avoid airborne contaminants.
• Avoiding people who mention or exhibit any symptoms of physical illness (coughing, sneezing, looking flushed, clearing throat).
• Avoiding sitting in public or having meals in public.

Collectively, these behaviors are intended to neutralize, avoid, or remove pathogens that might otherwise infect oneself or others.

OCD: Other Avoidance Behaviors

Individuals with contamination-related OCD often avoid contact with “dirty” objects or things that other people might have touched. These things include toilets, public restrooms, doorknobs, railings, or the ground. They may avoid busy public places, such as malls, subways, trains, buses, hospitals, doctor’s offices, schools, and daycare facilities.

The above reflects only a sampling of the possible compulsions related to dirt, germs, or other contaminants. Join me next time when I talk about health-related rituals that don’t involve cleaning, washing, or disinfecting.

Questions? Comments? What are your health-related rituals? Share below…

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