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Cleanliness Rules Germaphobes' Lives

Germaphobes are obsessed with sanitation and feel compelled to clean
excessively, but they're really suffering from obsessive-compulsive
disorder.
By Leanna Skarnulis
WebMD Feature
Reviewed By Brunilda Nazario, MD
In the Monk TV series, gentle detective Adrian Monk works the grimy streets of
San Francisco but is so driven by a fear of germs that he must scrub his hands
after shaking hands with someone. Monk has been called the "poster boy" for
obsessive-compulsive disorder (OCD). In fact, in an informal survey conducted
by the Obsessive-Compulsive Foundation, OCD patients said they liked the
character, who triumphs even when his condition interferes with his ability to do
his work.
Monk is a "germaphobe," the popular name for people who become obsessed
with germs and dirt and feel compelled to act out rituals of washing and
cleaning. Real people with this condition include the late Howard Hughes and
Saddam Hussein, who reportedly often ordered visitors to strip and wash with
antibacterial soap.
True germaphobes have OCD, which can take various forms. For example, some
people with OCD are "checkers." They're obsessed with a fear of losing control
of aggressive urges, and their anxiety can be relieved only by checking
something, such as whether a burner on the stove has been turned off.
Hoarding, counting, and praying are some other manifestations of the disease.
People often have multiple forms of OCD.
What Causes the Compulsion to Wash?
OCD is believed to be caused by an abnormality in the brain's circuitry. Brain
scans show brain activity is different in people with OCD. There's probably a
genetic component as well, especially when OCD begins in childhood. One-third
to one-half of adults with OCD say their illness started in childhood or
adolescence.
Why someone with the disease is compelled to wash, as opposed to check or
count or hoard, isn't known. What's true with all types of OCD is that a
compulsion is acted out to relieve anxiety produced by an obsessive, intrusive
thought. For example, a woman accidentally cuts herself, washes the wound,

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puts antibacterial ointment on it, and bandages it. That should be that, but an
anxious feeling and thought intrude: what if microscopic germs remain? She
knows it's irrational, but she's compelled to wash the cut again in order to relieve
the anxiety. She may have to repeat the act over and over.
When Is Cleanliness a Problem?
Every office has its neat freak. Maybe it's the woman who cleans her cubicle
every morning and keeps everything arranged just so. Is she just a perfectionist
or is she driven by OCD? It can be hard to tell at first because OCD is a secretive
illness, says Mary Guardino. She is the executive director of Freedom From Fear,
the national mental illness advocacy organization she founded in Staten Island,
N.Y., in 1984. "When you first meet her, you notice how nice and organized and
clean everything is. But she may be hiding her rituals. If she heard a co-worker
got the flu, she'd fear she might have touched something that person handled,
so she'll sneak into the bathroom to wash."
Guardino says a clinician looks for these signs of OCD:
The obsession with contamination is gradually taking over the person's life
and actions.
The individual engages in ritual cleaning or washing at least one hour a
day.
Acting out the rituals is done to relieve anxiety.
The person knows the obsession with germs is foolish but feels compelled
to wash or clean over and over.
"People who have OCD really don't want to be that way," Guardino tells WebMD.
On the other hand, people who have obsessive-compulsive personality disorder
(OCPD), which is less serious than OCD, pride themselves on being neat freaks.
Felix Unger, of The Odd Couple, for example. "It didn't bother Felix that he ran
around with a paper towel and Windex. It bothered Oscar. Also Felix probably
didn't clean a surface over and over. He thought his behavior was appropriate
because he needed to have things perfect. He didn't want to change."
Treatment With Medication and Therapy
The most effective treatment combines medication, usually one of several
antidepressants, and a form of cognitive behavioral therapy called "response
prevention" or "exposure and response therapy."
"The object of response prevention therapy is to delay implementation of the
ritual," says Guardino, whose expertise and advocacy grew out of her own
25-year battle with anxiety and depression. "The longer you delay it, you will get
slowly over time a decrease in the anxiety to enact the ritual."
For example, the therapist might tell a patient that after washing her hands once,
she must wait 15 minutes before washing them again. Gradually the length of
time is increased until the patient can wash just once without feeling compelled
to wash again. Successful treatment produces a change in brain activity and, for
most patients, at least partial remission of the disease.
The Role of Family Members
Families often make the mistake of enabling loved ones with OCD. "A man who
sees his wife cleaning the house three or four hours a day may at first think he's

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got the world's greatest wife," says Guardino. "But over time he sees her energy
level go down, she's irritable, and there's something bizarre about her cleaning.
So he reads about OCD on WebMD and gets her into treatment."
Family members can play an important role in carrying out response prevention
treatment prescribed by a therapist. "After dinner, the wife jumps up to clear the
table and get the bleach, but the husband tells her, 'Sit down for half an hour,
we're listening to Mozart,'" says Guardino. "In the morning he says, 'I'm throwing
my pajamas on the floor and I want them there when I get home tonight."
Do Germaphobes Know Something Others Don't?
You might think you could get expert advice about SARS or flu or another
infectious disease from a germaphobe. You'd probably be wrong. Guardino tells
WebMD germaphobes act on irrational fears, not on knowledge.
In fact, cleaning rituals may increase their risk for infection. "They use a lot of
bleach, and most spend at least half an hour in the shower, so their skin is dry
and cracked," she says.
She adds that people who study germs obsessively typically have a form of
hypochondria, not OCD. "They spend all their time seeking information. The
washers are too busy acting out their rituals to seek information."
It's true that hand washing is the single most important thing you can do to
prevent catching an infectious disease, including colds, flu, hepatitis A,
meningitis, and infectious diarrhea, according to the CDC. But that's not license
to scrub hands raw. CDC guidelines recommend washing:
Before and after you prepare food
Before you eat
After you use the bathroom
After handling animals or animal waste
After coughing or sneezing
When your hands are dirty
More frequently if someone in your home is sick
To wash properly:
Wet your hands and apply liquid or clean bar soap. Place bar soap on a
soap dish that allows it to drain.
Rub your hands together vigorously, scrubbing all surfaces for 15 to 20
seconds. That's about how long it takes to hum "Happy Birthday" twice.
Rinse well and dry your hands. In a public restroom, use the air dryer or
paper towels.
In the absence of soap and water, use alcohol-based disposable hand
wipes or gel sanitizers.
Resources
Guardino recommends several self-help books: The OCD Workbook: Your Guide
to Breaking Free from Obsessive-Compulsive Disorder, by Bruce M. Hyman,
PhD; Stop Obsessing! How to Overcome Your Obsessions and Compulsions, by
Edna B. Foa, PhD, and Reid Wilson, PhD; Everything In Its Place: My Trials and
Triumphs With Obsessive Compulsive Disorder, by Marc Summers and Eric
Hollander, MD; and OCD Casebook: Obsessive Compulsive Disorder, by John H.

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Greist and James W. Jefferson.

In addition, the Freedom From Fear web site has a directory of mental health
professionals that can be searched by ZIP code. "We only list people who will
give the first consultation free," says Guardino. "We know a free consultation will
increase the probability that people will get into the mental health system."
Published July 12, 2004.
SOURCES: CDC. Mary Guardino, executive director, Freedom From Fear, Staten
Island, N.Y. Obsessive-Compulsive Foundation.
Last Editorial Review: 4/26/2005

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