Contamination fears, germaphobia or mysophobia are all the same and all fall under the broader 
and complex diagnosis of Obsessive Compulsive Disorder. Fear of germs in its most severe form, can be very debilitating; literally isolating and keeping the victim from living any normalcy of life.
Obsessive compulsive hand washing is probably the most well know aspect of the disorder, but the avoidance and rituals are incredibly elaborate , and extremely time-consuming for the one who suffers this very disabling disease.
To the outsider, it can look just plain ridiculous, but then all OCD symptoms can appear that way. The degree of fearful avoidance of germs can even seem to take on delusional tones, but however irrational the thinking is, there is not any degree of perceptive distortion that one encounters such as in hallucinations or psychotic delusions.
However aware that their fears are indeed irrational, patients are unable to disregard the fears nor the anxiety. There remains a chronic preoccupation and doubt that perpetuates the avoidance and ritualised washings.
The hallmark symptoms are a chronic obsessional fear of contamination, persistent mental preoccupation of the feared germs, avoidance, compulsive ritualistic washing and cleaning, and intense distress, anxiety or panic associated with possible exposure to the feared contaminants. It is the elaborate avoidance regimes and washing rituals that weigh down the patient desperately trying to avoid whatever exposure that they are fearful.
As you well know, germs or bacteria, both good and bad are everywhere and mostly unavoidable for the most part. There are billions of them on our skin, orifices, in the air and in our guts. The good ones in our intestinal tract, enable us to produce vitamin B 12 and vitamin K , while assisting and promoting digestion of our food.
Without a properly balanced intestinal flora, we could be overridden with C difficile for example, and a host of other bacteria and yeasts that are kept in their place by our policing good intestinal bacterial flora. You may have read about replacing intestinal flora by probiotics and even stool infusions in order to heal victims plagued with chronic intestinal diseases.
Contamination patients may have singled out one particular virus or bacteria or just a host of them that they consider disgusting and dirty. The consuming worry about coming into contact with them precipitates avoidance routines that can look comical and completely unnecessary.
Often contamination fear patients will have concomitant panic disorder too, that can intensify heightened states of anxiety and avoidance, causing a paralysis in normal living. The following case is illustrative of the disabling nature of the illness that led to complete confinement.
The worst case that I ever had in my practice was a wonderful young woman, married, with a toddler to take care of. Her obsessional fears, anxiety and panic started after giving birth, when she was in her mid 20’s.
The early to mid 20’s by the way are often seen as the age when anxiety and panic disorders seem to start in most patients. The abrupt hormonal changes involved in post partum can also be a trigger in those genetically predisposed.
Although simple phobias are generally triggered by an earlier traumatic event involving the feared object, such as being bitten by a dog, OCD is much more seen running in families. Contamination fears are therefore an expression of OCD, rather than being precipitated by a previous germ “encounter”.
This patient had singled out a bacterial agent that to everyone else, but her, seemed extremely farfetched that she could ever be exposed. Her fear literally brought her life to a standstill, preventing her from being able to properly care for herself, and family.
By the time she was hospitalised, her existence was limited to the only “safe” place in her world, which was her bed. From her “perceived” safe harbor, she only reluctantly left to go to the bathroom, but this proved to be a real ordeal of avoidance rituals to avoid “exposure”.
Even a slight brush with any object, meant that she would have to spend hours in ritualistic washing, that often took 4 or 5 hours of soaping up and rinsing. She was unable to leave her home, and unable to cook or do household chores or appropriately care for her child that she adored.
If her child had been possibly “contaminated”, the child had to be washed and kept from being likewise “recontaminated,” which became increasingly more difficult to achieve. With her spouse and family at their wit’s end, she was brought in to be hospitalized against her will.
The most common physical sequelae seen in all contamination patients is contact dermatitis of hands, as some patients, not only wash 20 plus times a day, but use abrasive cleansers, such as ajax or even steel wool, which can cause disfiguring from residual scaring. These repetitive cleansings are perpetuated by chronic doubts that they may still be “unclean” which would produce much distress.
She also suffered from physical consequences of trying to avoid urinating, as navigating trips to the bathroom and remaining untouched proved arduous, therefore she would go hours on end with an over swollen bladder.
As a result, her bladder was weakened from chronic suppression of voiding. That in itself should demonstrate the tremendous power and control her obsessional fears had over her.
Anti anxiety medications were initiated along with a certain antidepressant that had anti obsessional and anti-panic properties. After the “fire” of anxiety was turned down a notch, psychotherapy was started to deal with the multitude of issues that by this time were present in her life.
After discharge, it was imperative that she start systematic desensitization therapy. This involves slowly exposing the patient to the feared agent with appropriately anxiety producing steps that they can handle and cooperate doing; hopefully replacing their fears with increments of successful “exposure” without consequences to them.
To do this without medication is cruelly painful to the patient and generally non productive. Additionally I do not believe in complete immersive therapy that tries to suddenly expose the patient to their feared object all at once for the same reason, as you risk going back to zero and losing their cooperation.
Before initiating this type of cognitive behavioral therapy, the therapist absolutely must have a strong therapeutic relationship with the patient, involving a lot of trust. Courage should be rewarded and reinforced as hopefully they will eventually initiate desensitization efforts on their own.
Medications used today are in the SSRI family, such Fluvoxamine, sold as Luvox and the oldie but goodie clomipramine, which is a serotonin-selective tricyclic medication sold as Anafranil. OCD is seen as a dysfunctional pathway of serotonin, which is one of our neurotransmitters.
After months of psychotherapy, conjoint and family therapy, progress was obtained to the degree she was able to drive again, cook and engage in household chores, though shopping for groceries was still very anxiety producing because of the primary belief she held about it being the local for possible contamination to the virus.
As in most mental illnesses there are varying degrees of severity, ranging from mild to severe as the above case illustrates. It is the degree of avoidance, mental preoccupation of the fears, and washings rituals that determine the severity.
Not all obsessional hand washing and avoidance of bacterial contamination is pathologic either. All health care practitioners must be extremely careful in office and hospital settings to avoid transmissions of viruses and bacterias from one patient to another.
Food preparation in home and restaurant settings should be vigilant in hygienic procedures. Multiple hand washings, and sometimes using gloves, along with strict observance of rules to avoid bacterial contamination of foods is imperative!
Common sense hygiene in all areas of one’s life is not pathologic, but excessive preoccupation with germs is. I have mild contamination fears myself, which actually were more pronounced during my late teens and twenties.
Growing bacteria in petri dishes in microbiology class only helped in reinforcing my fears, as well as working in a hospital setting, sometimes seeing patients extremely ill from physical pathogens.
Raising children, especially little boys, is wonderful systematic desensitization that occurs everyday, as well as having pets! Today, I do not like to touch the seats, bars and railings in the metro or buses, public doorknobs, nor facilities in public bathrooms, without scrupulous hand washings, but then again I think of that as normal hygienic practices everyone should do, as well as strict attention to cleanliness in preparing food.
My OCD quirkiness is, upon retiring home from using public transport, I do not sit in “my therapy” chair with the clothes I was wearing, and quickly change out of them, as in my mind they are “contaminated”.
My beloved doggies had more paw washings and baths than most I guess, and I do wash my hands more frequently than others, but otherwise have no other rituals.
OCD has a strong genetic trait, but contamination fears can be precipitated psychologically by incidents of sexual molestation or abuse, and I have seen this in my practice, but can be made worse in someone with a genetic tendency.
Obviously, it is an unconscious effort to rid oneself of the feelings of contamination and being “dirty” that all sexual abuse victims suffer. Treating the underlying abuse will often end up resolving or diminishing the contamination fears and rituals.
Preoccupation with germs that generally pose little threat may seem silly at best, but there are as I write, multiple mutations that are occurring, turning some treatable bacteria into dangerous ones that are non responsive to antibiotics. These superbugs are nothing to sneeze at either, and not the topic of this post, but worth mentioning as public germ consciousness has led to the overuse of disinfectants and hand sanitizers in addition to overexposure of antibiotics, either prescribed or in agricultural practices.
Contamination fears can cause widespread public panic as it did years ago, when certain diseases such as polio and plague were epidemic, and even recently with swine flu, cannot be considered a pathologic fear.
In closing, remember it is the excessive preoccupation with exposure to germs, with avoidance and washing rituals, without rational causes, that is pathologic, not common sense around hygiene and cleanliness.
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A recent Internet article delved into detailing how it is impossible to avoid germs. Washing machines and washed clothing have trace amounts of fecal matter (at least a tenth of a gram), flushed toilets spread trace amounts into the air contaminating bath rooms,. Avian flues are constantly mutating throughout the world. Per the FDA and other laboratories, salmonella, and other germs are easy spread within a six foot radius of the sink where meats/poultry are washed and around kitchen counters and kitchen utilities, towels, etc. And as mentioned, one cannot go out in public without exposure to a host of unknown germs. Floor carpeting is immensely contaminated with uncountable germs also. The reality is that even the most fervent of the OCD phobic can really escape exposure to germs. The latest laboratory tests demonstrate that “anti-bacterial” soaps are no more effective than “regular soaps”.
The Mears viruses and other drug resistant viruses are spreading throughout the hospitals and into the communities. In my recent visits and overnight stays at a hospital with one of my relatives, I frequently washed my hands because of the reports of the Mears viruses in the hospitals. However, somewhat rather oddly, the health of the human body is, in many ways, dependent on a host of foreign viruses in the lower tract of the intestines, and the development of the body’s natural resistance to germs and viruses . Viruses and germs are an inescapable part of existence in the real world; some are detrimental to health, some are critically necessary for health.
Howard Hughes, the industrialists, developed a phobia to germs after having caught an STD from his movie star wife (who caught it from her tennis pro), Hughes subsequently required any women in his presence to wear gloves. Hughes eventually succumbed to a drugged life that ended in his death. Then there is the bald headed game show host who is a germaphobic. The OCD germaphobic TV series detective Monk is an entertaining show in many ways. It just demonstrates that germaphobic people still have to find a way to functionally get through life or suffer dire consequences of it all. I can imagine how a woman, with her female anatomy, might be a little phobic about sitting in seats used by the general public. And it must be extremely difficult and taxing for a germaphobic to raise children, esp. boys; or to get through life comfortably without having anxieties about all of that.
It appears that exposure to a reasonable amount of germs and some viruses may be critically important for a person to develop a natural healthy resistance to infections. After all, vaccinations are merely the controlled injections of limited amounts of and forms of viruses in order for the body to develop a natural resistance to the virus. I’ve read that 90% of human DNA is actually “foreign viruses”. So, the OCD germaphobic merely has a distorted perspective of the reality of germs and the good aspects that some germs play in the biological functioning of our bodies.
It seems that a lot of people have some type of OCD behavior about various things; and most of that seems to be due to rather skewed perspectives and lack of rational understandings and thoughts about those matters. So how is yuor OCD now?
Thank you David for your wonderful in depth treatise on the impossibility of avoiding germs that are part and parcel of our everyday environment. That comprises the ludicrous nature of having contamination fears in the first place, as it really does not make much sense, unless in times of an overt epidemic sweeping our geographic territory.
But the origin of OCD is more neuro biological, as I pointed out, not a process of psychological reasoning, compensation, or defense mechanisms per sae, except in the incidences of earlier psychological abuse or trauma. Having said that, I do find obsessive compulsive cleanliness can be related to needing to reinstate a sense of order and structure that was otherwise deprived of in one’s childhood. As I said in the post, this “compensation” will be more prominently manifested in patients who have a family history of OCD.
Mers or Middle Eastern Respiratory virus is real and this mutated version of a corona virus that seems to have originated in Saudia Arabi is very dangerous. In the age of air travel, we can all be exposed. Another concern is whooping cough that has recently surfaced again, probably from a lack of consistent childhood vaccinations. There are indeed very dangerous viruses and bacteria lurking around, ready to attack those who are immune suppressed due to illness, extreme youth or old age.
Having a strong immune system, and decent hygienic practices is the best we can do. Again, the contamination fears patient may intellectually know this, but nevertheless be “compelled” towards avoidance and rituals. Dysfunctional neuronal pathways of serotonin, seemingly override the intellectual rational of OCD patients. That is why certain medications are effective in reducing the compulsive needs of avoidance and rituals. Psychotherapy hopefully can reinforce these gains and “prove” a sense of safety and well being, even when avoidance and cleansing rituals are abandoned.
Speaking of irrational reactions to things: In my wife’s recent trip to Hawaii with her sister, she experienced a rather unique “episode” during her flight from LA to Hawaii. June had a reserved aisle seat and her sister had the window seat. The passenger for the middle seat turned out to be a TREMENOUSLY overweight Hawaiian woman; my wife acquiesced to the Hawaiian woman’s request to change seats with June so she could have the aisle seat. The woman was so large that she could not lower the arm rest between them. June is a petite 5’ 2”, 106 pound woman.
During the flight, with the woman “overflowing” her seat into “June’s space”, June began to develop some type of “claustrophobic panic attack”; she said that it was unreal; but she just had a suffocating feeling and had to get out of her position. The enormous Hawaiian woman was so heavy that she literally could not get out of her aisle seat . . . that just made the situation even worse for June; she really began to panic. She would up STANDING in her seat and was prepared to LITERALLY climb over the passenger seats to “get out of there” to get some air. At this point June said that she didn’t care what it might look like or what anyone else thought of it; she just “had to get out of there”. Fortunately, the large Hawaiian woman was able to get out of her seat and June didn’t have to climb over the other seats . . . but she said she was on the verge of doing that.
June said that she KNEW that it was irrational; but at that point in time “rational” was “IMMATERIAL” to her; she just had the overwhelming compulsion that she “needed air and space” . . . Ha! (She has never had problems with claustrophobia in the past.) June said that she was suddenly afraid that she might have trouble flying in the future; but she managed to nervously complete the trip to Hawaii. (Then she was concerned whether she might have any type of similar episode on her flights going home.) I found her descriptions about it all to be a little humorous in some ways, which June wasn’t very appreciative of . . . Ha! She did “learn her lesson” of not giving up her aisle seats in the future and she should have insisted that the arm rest be dropped down or have the steward/stewardess seat the woman somewhere else.
The whole episode is a demonstration of how an intelligent and rational person can be overcome by an emotional compulsion . . . she was LITERALLY on the verge of climbing over the passenger seats when the large woman finally managed to get out of her seat . . . Ha! June said that at the time of the panic attack the only thing that mattered was being able to get out of the confining and seemingly oppressive situation . . . nothing else mattered to her. It has been my experience and observation in life that there can be a wide separation between intellect and emotions; ergo, sometimes intelligent people can act in irrational ways contrary to their intellect. It would appear to be the same for “germaphobics also.
It somewhat reminds me of Terry Thomas, the British comedian (the “gap tooth” character in the Chitty-Chitty Bang Bang movie). He developed a phobia about not being able to “walk through doorways” for some unexplainable reason(s). In an interview he said that it was especially a problem when he needed to go to the bathroom at night (sic. half asleep). He had to “trick himself’ by going through the door ways BACKWARDS. There just seems to be no accounting for the varied emotional/psychological problems that people develop. And it seems to me that a lot of people experience more of these problems as they become older.
What an unfortunate experience your wife had to endure! I would imagine the obese woman felt embarrassed by the resulting predicament. I hope June was able to sit elsewhere the rest of the flight. Feelings of panic can be so overwhelming that one feels a sense of “doom” if they are not able to escape the situation or place. For some, all it takes is one sensitizing event where the panic occurred, to cause an obsessional fear that if in the same situation, the panic will reoccur. Therefore avoidance behaviour sets in to avoid ever having those panicky feelings again. That is the classical evolution of obsessional fears and avoidance. People who are genetically predisposed, can develop the full blown spectrum.
OCD has nothing to do with intellect, as all compulsions done out of fear, and doubt are irrational. Fear will always override the rational mind in OCD sufferers.
Will write another post in the future, dealing with other manifestations of OCD that seem even more outrageous than contamination fears.
Your comment about the recent development/use of “stool infusions”: Recently, on NPR – National Public Radio, there was some type of health program in which they mentioned this procedure. There was an elederly woman in her mid eighties who had suffered from poor health for several decades. She claimed that after a “stool infusion” she was experiencing the best health and feelings, a lot more than anytime in the two previous decades. So, apparently the procedure is extremely helpful to some people who have deficiencies in critical “good bacteria/viruses”. However, I have also seen a lot of articles and news reports questioning the effective value of a lot of the “yougart” probiotic type foods that supposedly address these types of problems. And there are also a lot of “disputes” about the effective value of vitimin supplements, especially those that are not in a natural comoplex organic form that the human body can assimilate . . . purportedly 90% OR MORE of those “supplements” merely pass through the body without being absorbed by the body. So there is a multi-billion dollar industry that may be of negligible value.
I just picked up a book, “The Wisdom of Tuscany” by Ferenc Mate, Albatross Books, 2009, which is about the simplicity and “the Good Life” in the Tuscan life style. I do not see how they could possibly have any germaphobics in Tuscany . . . it is a rather basic and simple lifestyle
Tuscany is a beautiful place, but gastronomically and for their wines, I prefer the Piedmont area and the Liqurian coast. Unfortunately neuronal dysfunction can happen to those genetically predisposed even with simple and basic lifestyles. The book sounds wonderful. Enjoy!
Alas, the Tuscany life style has been greatly diminished by “prosperity”. After their wines became world famous, they have experienced a surge in tourism which has created prosperity. Once the Tuscans could afford automobiles, more mechanized farming equipment, refrigerators/freezers, etc., they walked through their community less often, and they did not need or depend on the help/assistance of their neighbors, and didn’t need or have the large communal meals together. This merely reflects the impact of “prosperity” and the lessening of dependence and associations amongst a village population. It reveals a somewhat dark social side of “prosperity”.
Thank you for your insight on the impact of prosperity in Tuscany. Perhaps it is applicable to other regional areas in Italy and in Europe who in the past had an enviable village atmosphere. The villages I do know in the south of France, still seem to congregate locals, hanging around in village cafes and to play les boules.