Germaphobes are obsessed with sanitation and feel compelled to clean excessively, but they're really suffering from obsessive-compulsive disorder.
By Leanna Skarnulis
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, 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 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.
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. 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.