Compulsive Washing Research Articles

It's the Feeling Inside My Head: A Qualitative Analysis of Mental Contamination in Obsessive-Compulsive Disorder

It was recently proposed that feelings of dirtiness and pollution can arise in the absence of physical contact with a contaminant. At present, there is limited data regarding the qualitative features of this construct of "mental contamination", although it is hypothesized to be particularly relevant to Obsessive Compulsive Disorder (OCD), where compulsive washing in response to contamination fear is a common symptom presentation (Rachman, 2006). The aim of this research was to explore the qualitative features of mental contamination in 20 people with contamination-based OCD, using a semi-structured interview. All participants reported times when they had felt dirty or contaminated in the absence of physical contact with a dirty or dangerous object. Mental contamination generated diffuse feelings of internal dirtiness not localized to the hands, which evoked urges to wash (100% participants), neutralize (80% participants) and avoid (85% participants). In support of the theory outlined by Rachman (2006), mental contamination was found to take a number of forms, be primarily associated with a human source, generate internal dirtiness and cause emotional distress and urge to wash. The clinical implications of these findings are discussed and ideas for future research are proposed.

Termination of washing compulsions: A problem of internal reference criteria or ‘not just right’ experience?

Recent research suggests that obsessive–compulsive washers are more likely than individuals without washing compulsions to use conscious, internal reference criteria when deciding when to terminate compulsions ( Wahl, Salkovskis, & Cotter, 2008). An alternative view is that they possess tendencies towards non-cognitive, automatic ‘not just right’ experiences (NJREs) that influence compulsion duration. The current study sought to investigate the latter explanation using valid behavioral tasks. Non-clinical participants ( N = 133) completed self-report measures, immersed their hands in a dirt mixture, and afterwards were allowed to wash their hands. Additionally, a subset of participants completed an in vivo assessment of NJRE using a pile of clutter. Total number and intensity of NJREs were predictive of hand-washing duration. Additionally, affective response to the clutter was uniquely predictive of hand-washing duration when controlling for pre-wash anxiety. These results suggest that internal reference criteria as well as NJREs may influence compulsive washing, though the former may be a consequence of the latter.

Guilt and Compulsive Washing: Experimental Tests of Interrelationships

Recent evidence suggests a potentially important relationship between guilt and compulsive washing. The present studies sought to clarify this relationship. In Study 1, we examined whether washing reduced guilt. Following guilt induction, 132 non-clinical participants were randomized to one of three conditions: hand-wiping, straightening of clutter, or a control task. Contrary to predictions, analyses indicated no differences between conditions in post-task guilt. Moderator analyses indicated that among those in the straightening task, higher ordering symptoms were associated with greater increases in guilt. Study 2 examined whether guilt increased washing behavior. Sixty-one non-clinical participants were randomized to either a guilt induction or neutral condition. Afterwards, participants were timed as they cleansed their hands. Individuals in the guilt induction condition washed significantly longer than those in the neutral condition. These findings suggest that hand-washing does not lead to unique reductions in guilt, but guilt may prolong hand-washing behavior. Theoretical and clinical implications are discussed.

The Mediating Roles of Disgust Sensitivity and Danger Expectancy in Relation to Hand Washing Behaviour

Recent interest in the role of vulnerability factors in obsessional washing has suggested that disgust sensitivity, danger expectancy and health anxiety may be of interest. This study explores the differential impact of these factors on both behavioural and cognitive measures of washing behaviour and is based on a replication of the Jones and Menzies (1997) experiment, during which participants immersed their hands in a noxious compound while rating themselves on a range of measures: the time they subsequently took to wash their hands was measured and danger expectancies were found to be the best predictor of this. The present study added measures of disgust sensitivity and health anxiety to this experimental methodology while removing factors they found to be of little import to compulsive washing. Thirty non-clinical participants took part. Results confirmed that disgust sensitivity was related to the behavioural measure of washing time, but that this relationship was almost entirely mediated by the danger expectancy concerning judgements of severity of consequent disease. However, a different pattern emerged when the outcome measure was questionnaire based: danger expectancy was not at all related to this. Disgust sensitivity mediated the relationship between health anxiety and scores on a questionnaire measure of washing compulsions. Interestingly, these scores were not related to the behavioural measure of washing time. The implications of these relationships to the further development of subtypes of Obsessive Compulsive Disorder (OCD) are discussed.

Danger Ideation Reduction Therapy for Obsessive–Compulsive Checking: Preliminary Findings

Danger Ideation Reduction Therapy (DIRT) is a cognitive treatment package developed in the mid-1990s to treat obsessive–compulsive (OC) washing. DIRT is solely directed at decreasing threat expectancies and does not involve direct or indirect exposure. The effectiveness of the DIRT package for OC washers has been examined, and to date a number of publications, including two randomised controlled trials, support its efficacy. Recently, the DIRT package was modified to treat people with the OC checking subtype. In the current study, three adult OC checkers received DIRT in 12 to 14 individual 1-hr sessions conducted by a clinical psychologist. At posttreatment, substantial and clinically significant reductions in scores on a range of standardized outcome measures of obsessive–compulsive disorder symptom severity were apparent for all three participants. Crucially, these improvements were maintained at 4-month follow-up. Although further research is clearly warranted, these preliminary findings suggest that DIRT for checkers may prove as effective as DIRT for OC washers.

Nonclinical Obsessive-Compulsive Symptoms and Executive Functions in Schizophrenia

Nonclinical Obsessive-Compulsive Symptoms and Executive Functions in Schizophrenia

DIRT—danger ideation reduction therapy for obsessive–compulsive washers: a comprehensive guide to treatment

AbstractDanger ideation reduction therapy (DIRT) for obsessive compulsive disorder (OCD) is a new intervention focusing on providing corrective information, and is the subject of a new comprehensive guide to treatment for compulsive washing. The components of DIRT are well presented in this manual‐based treatment and the documentation includes dialogues, filmed interviews with workers in dangerous occupations, and fact sheets to persuade the client to exchange beliefs about danger for beliefs about safety. The book is well organized and user friendly. Clinical trials have shown DIRT to be an effective treatment. Although DIRT as a stand alone therapy seems to offer some advantages over conventional CBT, it may function currently more as an adjunct to help cognitive restructuring. DIRT certainly encourages us to rethink some assumptions about the use of corrective information in treating OCD. Copyright © 2009 John Wiley & Sons, Ltd.Key Practitioner Message:• Danger ideation therapy is principally a cognitive approach.• Corrective information may help in the treatment of OCD for washing.• The application of DIRT in other types of OCD and symbolic contamination remains uncertain.

Are obsessive‐compulsive disorders and personality disorders sufficiently considered in occupational dermatoses? A discussion based on three case reports

Hand dermatitis is relatively common in the general population. Among work-related diseases, it is the most common form of occupational skin disease. Irritant hand dermatitis is the most frequent type. Besides wet work and direct contact to irritating occupational substances frequent hand washing can damage the barrier function of the skin facilitating the manifestation of hand dermatitis that frequently occurs chronically. According to own observations the role of obsessive-compulsive washing as part of an anxiety disorder or personality disorders may not be considered sufficiently. A possible pathogenetic relation between hand dermatitis and psychogenic disorders is discussed in a 22-year old physician's assistant, a 50-year old male nurse working in intensive care, and a 54-year old cleaner. All three patients complained about feelings of revulsion, fear of contamination and a high frequency of hand washing. These cases may encourage dermatologists to consider psychological aspects of hand dermatitis e.g. obsessive compulsive washing, overcome their inhibitions and consider these aspects in an integrated way when planning patient's therapy.

False memory and obsessive-compulsive symptoms

The memory deficit hypothesis has been used to explain the maintenance of repetitive behavior in individuals with obsessive-compulsive disorder, yet the majority of studies focusing on verbal memory show mixed results. These studies primarily evaluated memory accuracy via the inclusion or omission of previously encountered material, as opposed to false recognition (i.e., the inclusion of erroneous material). We evaluated false memories and memory processes in individuals with obsessive-compulsive washing symptoms (OC), individuals matched on depression and anxiety without OC symptoms (D/A), and in nonanxious individuals (NAC). Twenty-eight OC, 28 D/A, and 29 NAC individuals read OC-threat relevant, positive, and neutral scenarios and then performed a recognition test. Erroneous recognition of words associated to encoded, but not previously viewed, scenarios were classified as false memories. To evaluate processes underlying memory, participants completed a modified remember/know task to examine whether the OC individuals differed from the other individuals in recollective clarity for false memories of OC-relevant (e.g., germs), positive (e.g., lottery), and neutral (e.g., bread) material. The OC individuals used "know" more than the D/A and NAC individuals for false memories of threat. For veridical memories, the OC individuals used "know" more than the NAC, but not, D/A individuals. The greater reliance on "know" (i.e., feelings of familiarity) in general and false threat memories in particular in individuals with OC symptoms may add to feelings of uncertainty for threat-relevant material, which may contribute to compulsive behavior.

Eating disorders and obsessive–compulsive disorder: A dimensional approach to purported relations

The purpose of this research was to investigate the specificity of purported relations between symptoms of eating disorders (ED) and obsessive–compulsive disorder (OCD). Whereas most research has focused on diagnostic comorbidity or between-groups analyses, this study took a dimensional approach to investigate specific relations among symptoms of anorexia, bulimia, and OCD, as well as panic, depression, and general distress in a student sample ( N = 465). Results were that all symptoms showed significant zero-order correlations, including all ED–OCD pairings. After removing general distress variance, however, none of three OCD scales significantly predicted anorexia; only compulsive washing among OCD scales significantly predicted bulimia. Hierarchical multiple regression demonstrated that panic and depression out-performed OCD in predicting bulimia symptoms. Overall, symptoms of ED and OCD did not show unique relations at the level of core dimensions of each construct. A possible link between bulimia and compulsive washing is worth further study.

A Case of Late-Onset Obsessive Compulsive Disorder Developing Frontotemporal Lobar Degeneration

A Case of Late-Onset Obsessive Compulsive Disorder Developing Frontotemporal Lobar Degeneration

An exploration of the relationship between mental pollution and OCD symptoms

Rachman [(1994). Pollution of the mind. Behaviour Research and Therapy, 32, 311–314] theorized that a subtype of compulsive washing exists which has its compulsions triggered by feelings of internal dirtiness, or ‘mental pollution’. Since this construct was proposed, few empirical studies have examined it in relation to obsessive–compulsive contamination fear. This study represents a validation of the Mental Pollution Questionnaire (MPQ), which was developed for the measurement of mental pollution. Psychometric data were obtained from two studies using non-clinical samples. The final version of the MPQ consisted of eight items and two subscales related to washing and ideation. Higher mental pollution scores were associated with greater obsessions, contamination, and washing symptoms. In addition, MPQ scores were positively associated with inflated responsibility beliefs and thought–action fusion. Lastly, a third study found that both MPQ subscales predicted OC symptoms after controlling for general distress, trait guilt, and disgust sensitivity. Potential uses of the MPQ as a clinical and research instrument are discussed.

‘I wash until it feels right’: The phenomenology of stopping criteria in obsessive–compulsive washing

Recent elaborations of cognitive behavioral theory in OCD suggest that difficulties in deciding when to stop a compulsive action may be related to the use of counter-productive termination criteria by obsessional patients [Salkovskis, P. M. (1999). Understanding and treating obsessive–compulsive disorder. Behaviour Research and Therapy, 37, s29–s52]. Such criteria are characterized by their subjective nature, i.e. a primarily internal reference point (e.g. ‘just right’ feelings), and are conceptualized as the “top level” of a general strategy involving elevated evidence requirements. Thirty-eight obsessional washers, 41 obsessionals with other problems and 43 healthy controls were interviewed about and rated two situations varying in the degree of urgency to wash; they also washed their hands in a behavioral test. Washers reported using subjective criteria more frequently and rated them as more important for the termination of the washes than the other groups in questionnaire, interview and laboratory data. Both obsessional groups considered more criteria before stopping than the healthy controls, suggesting that using multiple criteria is a general strategy. The data are consistent with the predictions of the elaborated cognitive-behavioral model of OCD. They indicate that the use of subjective criteria and elevated evidence requirements is affected by the perceived significance of the situation in a similar way for obsessional and non-obsessional individuals.

The Superiority of Danger Ideation Reduction Therapy (DIRT) Over Exposure and Response Prevention (ERP) in Treating Compulsive Washing

AbstractThe present study involved the random allocation of 22 obsessive-compulsive (OC) washer/cleaners to one of two treatment conditions: Danger Ideation Reduction Therapy (DIRT), or Exposure and Response Prevention (ERP). Participants received 12 1-hour individual clinical sessions and were assessed at pretreatment, posttreatment and at a 6-month follow-up with a battery of 17 measures assessing core obsessive-compulsive disorder (OCD) symptomatology, depression, stress, general anxiety, disease expectancy and perceived responsibility. DIRT subjects experienced significantly greater before to after-treatment reductions in symptomatology on six outcome measures. On 10 of the remaining 11 measures, posttreatment mean scores were lower in the DIRT condition than in the ERP condition, though differences between groups failed to reach significance. Of note, on 3 of the 17 measures, DIRT subjects experienced significantly greater posttreatment to follow-up symptom reduction. Finally, and most importantly, symptom change (regardless of treatment condition) was shown to significantly correlate with change in threat or disease expectancy across the trial. No relationships were found between improvements in perceived responsibility and any of the dependent variables. The findings suggest that DIRT and ERP may be working by reducing specific beliefs in threat; the former treatment being more effective in producing such change than the latter.

Danger Ideation Reduction Therapy (DIRT) for Atypical Obsessive—Compulsive Disorder: A Case Study

AbstractThis paper describes the application of danger ideation reduction therapy (DIRT) to a case of atypical obsessive—compulsive disorder (OCD) with prominent magical ideation. Treatment consisted of eight weekly sessions. It was cognitive in nature, did not include any exposure or response prevention, and was aimed solely at reducing threat expectancy. The treatment components were adapted from the original DIRT package for compulsive washing, and comprised attentional focusing, corrective information, cognitive restructuring and the probability of catastrophe estimation task. At posttreatment, the subject demonstrated normal functioning on all assessment measures, and met Jacobson and Truax's criteria for ‘recovery’ on the MOCI, OCI-R, DASS depression scale and DASS stress scale. The findings provide preliminary support for the effectiveness of DIRT in individuals with atypical OCD symptoms characterised by magical ideation. Implications of these findings are discussed.

The importance of importance in OCD memory research

Investigations of memory and associated phenomena in obsessive-compulsive disorder (OCD) can advance our understanding of this often debilitating problem. Theoretical models predict both the presence and absence of memory biases in favour of threat-relevant information in association with anxiety disorders generally, and with OCD specifically. Two previous experiments (one involving compulsive washing and another involving compulsive checking) that demonstrated such a memory bias are reviewed in the context of the existing literature. Additionally, a new experiment failing to demonstrate such a bias (in association with compulsive ordering and arranging) is presented. The results are discussed in terms of cognitive-behavioural and information processing approaches to understanding OCD. It is argued that experiments which utilize stimuli that are low in ecological validity are unlikely to detect explicit memory biases in OCD. As such, experimental paradigms that are perceived as particularly significant, relevant and important to participants with OCD are encouraged.

The importance of importance in OCD memory research

Investigations of memory and associated phenomena in obsessive-compulsive disorder (OCD) can advance our understanding of this often debilitating problem. Theoretical models predict both the presence and absence of memory biases in favour of threat-relevant information in association with anxiety disorders generally, and with OCD specifically. Two previous experiments (one involving compulsive washing and another involving compulsive checking) that demonstrated such a memory bias are reviewed in the context of the existing literature. Additionally, a new experiment failing to demonstrate such a bias (in association with compulsive ordering and arranging) is presented. The results are discussed in terms of cognitive-behavioural and information processing approaches to understanding OCD. It is argued that experiments which utilize stimuli that are low in ecological validity are unlikely to detect explicit memory biases in OCD. As such, experimental paradigms that are perceived as particularly significant, relevant and important to participants with OCD are encouraged.

Association between Protestant religiosity and obsessive-compulsive symptoms and cognitions.

There is evidence that religion and other cultural influences are associated with the presentation of obsessive-compulsive symptoms, as well as beliefs and assumptions presumed to underlie the development and maintenance of these symptoms. We sought to further examine the relationship between Protestant religiosity and (1) various symptoms of obsessive-compulsive disorder (OCD) (e.g., checking, washing) and (2) OCD-related cognitions. Using self-report questionnaires, we compared differences in these OCD-related phenomena between highly religious Protestants, moderately religious Protestants, and atheist/agnostic participants drawn from an undergraduate sample. Highly religious versus moderately religious Protestants reported greater obsessional symptoms, compulsive washing, and beliefs about the importance of thoughts. Additionally, the highly religious evinced more obsessional symptoms, compulsive washing, intolerance for uncertainty, need to control thoughts, beliefs about the importance of thoughts, and inflated responsibility, compared to atheists/agnostics. Results are discussed in terms of the relationship between religion and OCD symptoms in the context of the cognitive-behavioral conceptualization of OCD.

Subjektives Gefühls- und Körpererleben bei Wasch- und Kontrollzwangshandlungen

Subjective Emotional and Physical Experience during Compulsive Washing and Checking Background: Contrary to its general acceptance, empirical evidence for the anxiety reduction hypothesis for compulsions has so far been insufficient. Furthermore, a number of arguments question its validity. For the development and maintenance of compulsive washing and checking – the two most important subgroups of obsessive- compulsive disorder – anxiety reduction could be of differential importance. Patients and Methods: The present study examined whether compulsive behavior also serves to intensify positively valent emotions apart from reducing negatively valent emotions and physical arousal and, moreover, whether positive reinforcement is dominating in compulsive checking in comparison to compulsive washing. Results: The study shows that compulsions are experienced as both reducing negative affectivity and intensifying positive affectivity, accompanied by a subjective physiological deactivation. Compulsive washing and checking do not differ herein. On the level of single emotions and physical sensations, significant changes of intensity could be shown for anxiety, relief, satisfaction, tension, inner agitation, and relaxation. The experience of disgust represents a particularly discriminating characteristic between washing and checking. Conclusion: The results suggests that the anxiety reduction hypothesis should also encompass the aspect of a possible ‘double reinforcement’ of compulsions.

Danger Ideation Reduction Therapy (DIRT) for treatment-resistant compulsive washing

Five intractable cases of obsessive–compulsive disorder were treated with the Danger Ideation Reduction Therapy (DIRT) program. All five cases: (1) had displayed excessive washing/cleaning behaviour for at least 10 years; (2) had failed to respond to a minimum of two separate, 12-week drug trials with serotonergic agents; (3) failed to respond to at least 15 sessions of exposure and response prevention at the beginning of the present trial, and; (4) satisfied the DSM—IV criteria for OCD with Poor Insight. DIRT was conducted in 14, weekly, individual sessions or until, in the judgement of the treating clinician: (1) clinically significant gains were apparent with minimal symptomatology remaining, and (2) clients displayed a sound grasp of the cognitive model underpinning DIRT procedures. At post-treatment, substantial reductions in scores on the Padua Inventory (PI), Maudsley Obsessional–Compulsive Inventory (MOCI), Beck Depression Inventory—II (BDI—II) and two global rating scales were apparent for four of the five subjects. These improvements were maintained at 4-to-6 month follow-up, with four of the five cases meeting Jacobson and Truax's (1991) criteria for ‘recovery’ on the MOCI and the PI by this assessment stage. While one subject remained non-responsive, the present findings suggest that DIRT may be a viable option for treatment-resistant cases of compulsive washing. The theoretical implications of the findings are discussed.