Non-washing rituals in Contamination OCD

Although contamination-related OCD and washing rituals often go hand-in-hand, many rituals in this domain do not actually involve cleaning or disinfecting. Reassurance seeking is a subtle ritual that involves asking questions or seeking out information regarding the prevention, transmission, incubation, and symptoms of various diseases.

Although contamination OCD and washing rituals often go hand-in-hand, many rituals in this domain do not actually involve cleaning or disinfecting. These more subtle rituals are often based around reassurance seeking behaviors that become ingrained in everyday habit. In the context of exposure and response prevention (ERP), reassurance seeking OCD rituals are just as important to address as washing rituals. If you resist washing rituals but continue to engage in reassurance seeking rituals, your recovery will eventually stall (or perhaps never get started at all).

Do you believe that knowledge is power?
Do you aspire to optimum health?
Do you believe that an ounce of prevention is worth a pound of cure?

If so, you may be vulnerable to reassurance seeking rituals.

Information-Seeking vs. Reassurance Seeking

Reassurance seeking rituals involve mentally preparing for potential threats. These compulsions are often based around behaviors such as asking questions or looking up information about disease prevention, transmission, incubation, or symptoms.

Because reassurance seeking rituals are subtle, they might easily slip past you. You might be thinking, “These behaviors are not rituals. They’re simply responsible behaviors.”

Fortunately, not all information-seeking is compulsive. When I worked at the St. Louis Behavioral Medicine Institute (SLBMI), Alec Pollard discussed the differences between information-seeking and reassurance seeking. Because information-seeking behaviors are used to become informed, they involve asking questions one time (only) to obtain needed information. Information-seekers understand the limits of knowledge and ask answerable questions, accept uncertain answers (when appropriate), and use information obtained to draw conclusions. Decisions tend to be quick and result in some type of behavior change or action.

In contrast, reassurance seeking behaviors are attempts to reduce OCD doubt and uncertainty, as well as anxiety. As such, reassurance seekers often ask the same question multiple times in slightly different ways. Many sources are consulted, and often the same source is consulted multiple times to increase understanding and reduce potential miscommunication. Reassurance seekers often worry that they haven’t understood the answer properly, and they frequently ask for answer repetition or clarification.

Reassurance seekers often ask unanswerable questions or questions that their conversation partners cannot (or are not qualified to) answer (e.g., “Do you think I’m going to get sick?” or in the case of scrupulosity, “Do you think I’m going to hell?”). They often know the answer they want to get in advance of asking the question and have a difficult time tolerating uncertain or ambiguous answers. Upon obtaining an answer, conclusions are typically deferred in hopes of understanding the issue more thoroughly later. Alternatively, action may be stalled in hopes that better or more accurate information might emerge in the future. As such, the decision making process is often time-consuming, stressful, frustrating, and non-productive. Moreover, the decision making process may be stopped and started multiple times due to OCD-related indecision.

Information seeking and reassurance seeking are not wholly separable, and it’s more accurate to think about them existing on a continuum rather than as separate processes. For exposure and response prevention (ERP) to be most effective, reassurance seeking rituals must be discontinued entirely. Developing appropriate response prevention guidelines that describe acceptable information search behaviors is necessary. These guidelines often impose time limits on information search, restrict information sources, and constrain the number of times information can be reviewed.

Reassurance Seeking Rituals in OCD

One of the most common reassurance seeking rituals involves compulsively searching for health-related information online. Although sources of information may vary in their level of scientific credibility (e.g., the CDC website vs. an online forum), credible information sources are just as vulnerable to rituals as those lacking in credibility.

Other individuals compulsively search for information about their medications. These individuals worry that the only “safe” way to proceed is to find the best medication and to be aware of every possible medication side effect. Hypervigilance for potential medication side effects often results in body scanning rituals that increase one’s sensitivity to normal bodily fluctuations. This then becomes a self-fulfilling prophecy. Because these individuals internally check their bodies for potential medication side effects, they become primed to notice “dangerous” or unwanted sensations. This decreases medication tolerability and leads many individuals to prematurely discontinue helpful medications.

OCD: Common Reassurance Seeking Rituals
  • Using Google, Bing, or other search engines compulsively to obtain disease-related information.
  • Compulsively searching online for possible medication side effects and counter-indications.
  • Reviewing the same information multiple times and/or from multiple sources.
  • Re-reading books, articles, or websites that focus on disease or health-related topics.
  • Body scanning rituals (internally checking for aches, pains, nausea, fatigue, or other unwanted symptoms).
  • Closely monitoring body temperature and/or avoiding extremes in temperature.
  • Taking excessive vitamins and/or supplements in efforts to prevent illness.
  • Compulsive mirror checks (checking skin color/temperature, checking for growths/moles, or checking to see if one looks “healthy” and “rested”).
  • Compulsively monitoring vitals (e.g., blood pressure, temperature, heartrate).
  • Asking or checking with others about their grooming habits and/or hygiene (e.g., how often they shower or how they bathe, etc.).
  • Engaging in excessive exercise or fitness routines in order to prevent disease.
  • Asking reassurance seeking questions that begin with… “Do you think it’s okay if I…?”
  • Asking reassurance seeking questions that begin with… “Is it normal to…?”
  • Adopting non-applicable healthcare guidelines (e.g., following hand-washing guidelines developed for surgeons).
  • Over-cooking food or avoiding certain types of foods because they might be dangerous.
  • Adopting restrictive diets based around eating only healthy foods (i.e, “orthorexia nervosa”).
  • Obtaining excessive inoculations against disease (or alternatively, forgoing all vaccinations).
  • Scheduling excessive doctor’s visits, procedures, or consultations (or alternatively, avoiding all doctor’s appointments).
  • Compulsively searching for the perfect provider before beginning treatment in order to avoid making a mistake, benefiting sub-optimally from treatment, or wasting time/money.
  • Making excessive phone calls to family members when confronted with potentially “dangerous” situations.
  • Tracking, monitoring, and inspecting bowel movements and other bodily secretions.
  • Asking other people to repeat themselves or write things down in order to prevent miscommunication.

Of course, most often individuals with health-related OCD engage in reassurance seeking rituals in combination with washing and cleaning compulsions. It is also very common to engage in mental rituals, such as trying to control your thoughts.

As I discussed in a previous post, the true purpose of rituals is to escape from an unwanted feeling. This escape may be superficially based around the idea of washing off germs or viruses, but it’s actually a more generalized process. Relief comes not so much from actually removing germs, but more from the perception that you successfully averted an unwanted outcome. Because many individuals with OCD experience a heightened sense of responsibility and a greater fear of potential regret or possible mistakes, they feel compelled to take excessive precautions in situations they perceive as risky.

OCD demands that you seek more certainty and safety. It tells you that you must do everything within your power to live responsibly and avoid risks. It whispers that you can never know enough, prepare enough, or have enough information. OCD also says that acting on insufficient information is dangerous and irresponsible. It says that you might make a mistake that will have permanent consequences. You might get sick and die, or you might cause someone else to get sick. OCD cautions you to never do things that you might regret someday.

The truth is that we can never have 100% certainty about anything.

No matter how many times you wash or how thoroughly you clean, you can never be 100% sure that you’re “safe”. Moreover, the more you listen to OCD and let it establish the parameters of your behavior, the more your symptoms will worsen.

The sooner you recognize that your rituals serve emotional rather than hygienic functions, the sooner your recovery begins.

Questions? Comments? How do you resist your reassurance seeking rituals? Share below…