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Compulsive washing in the absence of phobic and illness anxiety
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Pergamon
Behav. Res. Ther. Vol. 34, No. 4, pp. 361-362, 1996 Copyright © 1996 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0005-7967/96 $15.00 + 0.00
0005-7967(95)00079-8
Compulsive washing in the absence of phobic and illness anxiety FRANK TALLIS Charter Nightingale Hospital, 11-19 Lisson Grove, London N W I 6SH, U.K.
(Received 21 August 1995) Summary--A new typology of washing compulsions has been proposed: those that arise from a sense of dirtiness, those that arise from a sense of mental pollution, and finally, those that arise from a fear of illness. A case series is reported suggesting that a further class of washing behaviour can be described attributable to the personality trait of perfectionism.
INTRODUCTION Washing and checking have long been recognised as the most common manifestations of obsessive compulsive disorder; however, it is most probably checking that has received the greatest attention in recent years. This is perhaps because contamination fears and subsequent washing appear to correspond very closely to the two factor behavioural account of the acquisition and maintenance of simple phobias (Mowrer, 1947). Individuals with contamination fears have relatively well defined triggers, report high levels of anxiety after provocation, and reliable anxiety reduction after washing has been completed. Checkers on the other hand have less well defined triggers, often report discomfort (rather than anxiety), and frequently experience increasing levels of discomfort as checking is repeated (Rachman & Hodgson, 1980). It is not surprising, therefore, that the seemingly more complex phenomenon of checking has received more academic attention than washing, which conforms more readily to the existing behavioural model. Notwithstanding the success of the 'phobic' model, it may be the case that, with respect to washing, clinical psychology has prematurely abandoned more extensive study. This contention is supported by Rachman (1994), who suggests that washing compulsions are of three types; those that arise from a sense of dirtiness, those that arise from a sense of mental pollution, and finally, those that arise from a fear of illness. The purpose of the present case series is to suggest that a further class of washing behaviour can be described, namely, washing attributable to the personality trait of perfectionism. These patients have distinct features which discriminate them from those described by Rachman (1994), although there is clearly some overlap. All cases met DSM-IV criteria for OCD. Moreover, all showed perfectionist tendencies in other areas of general life functioning. CASE A The S was a 23-yr-old man with excessive washing compulsions. Feared contaminants were mostly human and animal bodily products and rubbish of any kind. The S also felt uncomfortable using public transport and walking in public access areas (parks). His concern was that vagrants may have 'contaminated' seats or objects that he might then touch. In addition to contamination fears, the S also exhibited some order and symmetry rituals. The S experienced only slight anxiety on exposure to contaminants, providing he could wash before returning home. His principal concern was that valued possessions (e.g. CDs, musical instruments) would be contaminated, and therefore be in less than perfect condition. He did not believe that contamination would result in an illness and was not worried that he might contaminate others. CASE B The S was a 32-yr-old man with excessive washing compulsions. Feared contaminants were exclusively greasy substances of any kind, but most notably butter and margarine. In addition to contamination fears, the S also exhibited some order and symmetry rituals. A history of number rituals was also reported (e.g. touching objects four times etc.) although these had remitted spontaneously. The S experienced only slight anxiety on exposure to contaminants, providing he could wash before touching certain objects. Indeed, he frequently ate fatty foods and was happy to cook using butter and margarine. His principal concern was that valued possessions, especially his golfing clothes and equipment, would be contaminated. As with Case A, the S felt that it was essential that valued objects be maintained in pristine condition. He did not believe that contamination would result in an illness and was not worried that he might contaminate others. CASE C The S was a 28-yr-old woman with excessive washing compulsions, She once maintained washing for 12 hr without interruption. She avoided a wide range of contaminants, but most notably those associated with animal and human bodily products. In addition to the above the S exhibited pronounced order and symmetry rituals, and modest levels of checking behaviour. The S experienced moderate levels of anxiety under provocation conditions, providing she could wash immediately. She did not believe that contamination would result in an illness and was not worried that she might contaminate others. Her principal concern was that she would not be able to complete a perfect wash. The S recognised that, without supervision, she would continue washing more or less indefinitely. Subsequently, she often avoided washing altogether, preferring to feel 'dirty' rather than to engage in the exhausting pursuit of perfect ablution. 361
362
SHORTER COMMUNICATIONS DISCUSSION
The above cases share some notable common features. All failed to exhibit the slightest concern with respect to contamination resulting in illness to themselves or others. Moreover, all were relatively comfortable with the idea of being dirty. They were not, therefore, phobic of contaminants as is conventionally observed in OCD. Finally, in all cases, excessive washing was employed to preserve the perceived perfect condition of valued possessions (Cases A and B), or achieve a perfect state of cleanliness. The co-morbidity of symmetry and order rituals in all cases suggests that the personality trait of perfectionism had also resulted in the manifestation of other more clearly trait-related obsessional behaviour. It has been suggested that a refined typology of washing phenomena will inform the preferred treatment modality employed (Rachman, 1994). For example, patients with a fear of illness might benefit more from a combination of cognitive and behavioural (exposure) strategies, whereas those with a relatively straightforward fear of dirt will benefit more from exposure per se. Given that a cornerstone of cognitive therapy is the modification of perfectionist beliefs (Burns, 1980) it would be expected that a predominantly cognitive intervention would be highly recommended with the patients described above. Interestingly, the response to cognitive therapy was relatively poor. For example, by using cumulative probability technique (van Oppen & Arntz, 1994) it was possible to demonstrate to Case B, that under some feared conditions, the chance of contaminating his golf clubs with butter was approximately 1 in 10,000,000. Moreover, he readily admitted that the idea of owning pristine golfing equipment was senseless, in so far as during the course of a game of golf, his own bodily secretions and contact with soil and grass was inevitable. Furthermore, a microscopic amount of grease on his clubs would neither decrease the value or utility of his equipment. Finally, the knowledge that his clubs were contaminated with grease would have little or no effect on his performance. In spite of these standard cognitive manoeuvres, he was still eager to wash after everyday activities such as eating, as he remained uncomfortable with the idea that his golf clubs could be 'contaminated'. Yet more perplexing for a predominantly cognitive model, is the fact that none of the cases could describe specific learning experiences (with accompanying belief formation) that would account for their obsessional features. With respect to treatment, the most effective intervention for all cases was purely behavioural i.e. exposure and response prevention (Rachman & Hodgon, 1980). This was superior to both cognitive therapy and serotonergic medication (e.g. Anafranil or Prozac) which had exclusively antidepressant effects. However, it should be noted that treatment gains were modest. Cases A and C received intensive inpatient treatment with considerable outpatient follow up. Both continued to report significant avoidance behaviour. Case B received extensive outpatient care. Although he was able to inhibit his compulsive washing more or less successfully he continued to experience significant discomfort after contact with greasy substances. There can be little doubt that the clinical lexicon as applied to OCD has been vastly elaborated in recent years. Concepts such as inflated responsibility, thought suppression, thought-action fusion, and the role of guilt avoidance have gained considerable currency (el. Tallis, 1995); however, many of these advances appear to be more relevant with respect to obsessional phenomena such as intrusive cognition, checking behaviour, re-tracing, and superstitious rituals, than compulsive washing. It is a testimony to the efficacy of traditional behaviour therapy that washing has been somewhat neglected from a theoretical point of view for the past 20 years. Nevertheless, as Rachman's novel typology suggests, it might be time to reconsider washing behaviour. As is so often the case with OCD, a seemingly straightforward phenomena may prove more complex on closer study. REFERENCES
Burns, D. (1980). Feeling Good: The New Mood Therapy. Baltimore, MD: Penguin Books. Mowrer, O. H. (1947). On the dual nature of learning--a reinterpretation of 'conditioning' and "problem solving'. Harvard Educational Review, 17, 102-148. Rachman, S. (1994). Pollution of the mind. Behaviour, Research and Therapy, 32, 311 314. Rachman, S. & Hodgson, R. (1980). Obsessions and Compulsions, Englewood Cliffs, NJ: Prentice-Hall. TaUis, F. (1995). Obsessive Compulsive Disorder: A Cognitive and Neuropsychological Perspective. New York: Wiley. van Oppen, P. & Arntz, A. (1994). Cognitive therapy for obsessive compulsive disorder. Behaviour Research and Therapy, 32, 79-87.
Pergamon
Behav. Res. Ther. Vol. 34, No. 4, pp. 361-362, 1996 Copyright © 1996 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0005-7967/96 $15.00 + 0.00
0005-7967(95)00079-8
Compulsive washing in the absence of phobic and illness anxiety FRANK TALLIS Charter Nightingale Hospital, 11-19 Lisson Grove, London N W I 6SH, U.K.
(Received 21 August 1995) Summary--A new typology of washing compulsions has been proposed: those that arise from a sense of dirtiness, those that arise from a sense of mental pollution, and finally, those that arise from a fear of illness. A case series is reported suggesting that a further class of washing behaviour can be described attributable to the personality trait of perfectionism.
INTRODUCTION Washing and checking have long been recognised as the most common manifestations of obsessive compulsive disorder; however, it is most probably checking that has received the greatest attention in recent years. This is perhaps because contamination fears and subsequent washing appear to correspond very closely to the two factor behavioural account of the acquisition and maintenance of simple phobias (Mowrer, 1947). Individuals with contamination fears have relatively well defined triggers, report high levels of anxiety after provocation, and reliable anxiety reduction after washing has been completed. Checkers on the other hand have less well defined triggers, often report discomfort (rather than anxiety), and frequently experience increasing levels of discomfort as checking is repeated (Rachman & Hodgson, 1980). It is not surprising, therefore, that the seemingly more complex phenomenon of checking has received more academic attention than washing, which conforms more readily to the existing behavioural model. Notwithstanding the success of the 'phobic' model, it may be the case that, with respect to washing, clinical psychology has prematurely abandoned more extensive study. This contention is supported by Rachman (1994), who suggests that washing compulsions are of three types; those that arise from a sense of dirtiness, those that arise from a sense of mental pollution, and finally, those that arise from a fear of illness. The purpose of the present case series is to suggest that a further class of washing behaviour can be described, namely, washing attributable to the personality trait of perfectionism. These patients have distinct features which discriminate them from those described by Rachman (1994), although there is clearly some overlap. All cases met DSM-IV criteria for OCD. Moreover, all showed perfectionist tendencies in other areas of general life functioning. CASE A The S was a 23-yr-old man with excessive washing compulsions. Feared contaminants were mostly human and animal bodily products and rubbish of any kind. The S also felt uncomfortable using public transport and walking in public access areas (parks). His concern was that vagrants may have 'contaminated' seats or objects that he might then touch. In addition to contamination fears, the S also exhibited some order and symmetry rituals. The S experienced only slight anxiety on exposure to contaminants, providing he could wash before returning home. His principal concern was that valued possessions (e.g. CDs, musical instruments) would be contaminated, and therefore be in less than perfect condition. He did not believe that contamination would result in an illness and was not worried that he might contaminate others. CASE B The S was a 32-yr-old man with excessive washing compulsions. Feared contaminants were exclusively greasy substances of any kind, but most notably butter and margarine. In addition to contamination fears, the S also exhibited some order and symmetry rituals. A history of number rituals was also reported (e.g. touching objects four times etc.) although these had remitted spontaneously. The S experienced only slight anxiety on exposure to contaminants, providing he could wash before touching certain objects. Indeed, he frequently ate fatty foods and was happy to cook using butter and margarine. His principal concern was that valued possessions, especially his golfing clothes and equipment, would be contaminated. As with Case A, the S felt that it was essential that valued objects be maintained in pristine condition. He did not believe that contamination would result in an illness and was not worried that he might contaminate others. CASE C The S was a 28-yr-old woman with excessive washing compulsions, She once maintained washing for 12 hr without interruption. She avoided a wide range of contaminants, but most notably those associated with animal and human bodily products. In addition to the above the S exhibited pronounced order and symmetry rituals, and modest levels of checking behaviour. The S experienced moderate levels of anxiety under provocation conditions, providing she could wash immediately. She did not believe that contamination would result in an illness and was not worried that she might contaminate others. Her principal concern was that she would not be able to complete a perfect wash. The S recognised that, without supervision, she would continue washing more or less indefinitely. Subsequently, she often avoided washing altogether, preferring to feel 'dirty' rather than to engage in the exhausting pursuit of perfect ablution. 361
362
SHORTER COMMUNICATIONS DISCUSSION
The above cases share some notable common features. All failed to exhibit the slightest concern with respect to contamination resulting in illness to themselves or others. Moreover, all were relatively comfortable with the idea of being dirty. They were not, therefore, phobic of contaminants as is conventionally observed in OCD. Finally, in all cases, excessive washing was employed to preserve the perceived perfect condition of valued possessions (Cases A and B), or achieve a perfect state of cleanliness. The co-morbidity of symmetry and order rituals in all cases suggests that the personality trait of perfectionism had also resulted in the manifestation of other more clearly trait-related obsessional behaviour. It has been suggested that a refined typology of washing phenomena will inform the preferred treatment modality employed (Rachman, 1994). For example, patients with a fear of illness might benefit more from a combination of cognitive and behavioural (exposure) strategies, whereas those with a relatively straightforward fear of dirt will benefit more from exposure per se. Given that a cornerstone of cognitive therapy is the modification of perfectionist beliefs (Burns, 1980) it would be expected that a predominantly cognitive intervention would be highly recommended with the patients described above. Interestingly, the response to cognitive therapy was relatively poor. For example, by using cumulative probability technique (van Oppen & Arntz, 1994) it was possible to demonstrate to Case B, that under some feared conditions, the chance of contaminating his golf clubs with butter was approximately 1 in 10,000,000. Moreover, he readily admitted that the idea of owning pristine golfing equipment was senseless, in so far as during the course of a game of golf, his own bodily secretions and contact with soil and grass was inevitable. Furthermore, a microscopic amount of grease on his clubs would neither decrease the value or utility of his equipment. Finally, the knowledge that his clubs were contaminated with grease would have little or no effect on his performance. In spite of these standard cognitive manoeuvres, he was still eager to wash after everyday activities such as eating, as he remained uncomfortable with the idea that his golf clubs could be 'contaminated'. Yet more perplexing for a predominantly cognitive model, is the fact that none of the cases could describe specific learning experiences (with accompanying belief formation) that would account for their obsessional features. With respect to treatment, the most effective intervention for all cases was purely behavioural i.e. exposure and response prevention (Rachman & Hodgon, 1980). This was superior to both cognitive therapy and serotonergic medication (e.g. Anafranil or Prozac) which had exclusively antidepressant effects. However, it should be noted that treatment gains were modest. Cases A and C received intensive inpatient treatment with considerable outpatient follow up. Both continued to report significant avoidance behaviour. Case B received extensive outpatient care. Although he was able to inhibit his compulsive washing more or less successfully he continued to experience significant discomfort after contact with greasy substances. There can be little doubt that the clinical lexicon as applied to OCD has been vastly elaborated in recent years. Concepts such as inflated responsibility, thought suppression, thought-action fusion, and the role of guilt avoidance have gained considerable currency (el. Tallis, 1995); however, many of these advances appear to be more relevant with respect to obsessional phenomena such as intrusive cognition, checking behaviour, re-tracing, and superstitious rituals, than compulsive washing. It is a testimony to the efficacy of traditional behaviour therapy that washing has been somewhat neglected from a theoretical point of view for the past 20 years. Nevertheless, as Rachman's novel typology suggests, it might be time to reconsider washing behaviour. As is so often the case with OCD, a seemingly straightforward phenomena may prove more complex on closer study. REFERENCES
Burns, D. (1980). Feeling Good: The New Mood Therapy. Baltimore, MD: Penguin Books. Mowrer, O. H. (1947). On the dual nature of learning--a reinterpretation of 'conditioning' and "problem solving'. Harvard Educational Review, 17, 102-148. Rachman, S. (1994). Pollution of the mind. Behaviour, Research and Therapy, 32, 311 314. Rachman, S. & Hodgson, R. (1980). Obsessions and Compulsions, Englewood Cliffs, NJ: Prentice-Hall. TaUis, F. (1995). Obsessive Compulsive Disorder: A Cognitive and Neuropsychological Perspective. New York: Wiley. van Oppen, P. & Arntz, A. (1994). Cognitive therapy for obsessive compulsive disorder. Behaviour Research and Therapy, 32, 79-87.