John's arms are so dry his skin has turned white and powdery. His scrubbed blond hair, devoid of oil, stands straight up like dead grass. His face is red and chapped and clean as a whistle. But still John must wash.
For fear of getting dirty or contaminated, John will not touch most things in his house. He sits in only a couple of chairs carefully covered with sheets and towels and uses tissues to open doors and turn on lights. At night he showers for hours at a time. He says he goes through 15 bars of soap and six boxes of tissues a week.
John, 60, has been diagnosed as having obsessive-compulsive disorder, a relatively rare psychological illness in which a person has an obsessive, recurring thought that compels some action.
Until recently, the disease was considered quite rare, but recent statistics suggest that about 1% of the population may be afflicted with obsessive-compulsive disorder, about as many people as are afflicted with schizophrenia.
"The key feature of the disease is the internal struggle," said Tom Insel, a psychiatrist at the National Institute of Mental Health who has extensively studied obsessive-compulsive disorder. "Sufferers describe their illness as a battle between the impulse to do something and the struggle to stop it."
Feeling of Contamination
John's obsession is that he is dirty, and that many of the things in his world are contaminated in some vague way. The obsession produces a compulsion to wash, and to avoid touching "contaminated" things like doorknobs, light switches, or anything that has come into contact with the floor.
John, a West Los Angeles contractor, led a normal life until four years ago. Then he began noticing changes. He had always enjoyed going to the race track, spending an occasional day watching the horses and betting a few dollars. But he began to feel dirty at the track and before leaving, he felt compelled to scrub himself, to wash his wallet and to carefully wipe the steering wheel of his car. He knew it made no sense; he just had to do it.
In a couple of months, his cleanliness obsession had pervaded every aspect of his life. He quit going out, and lost interest in just about everything--except washing.
By late in the summer of 1985, John and his wife, Evelyn, were in a panic. "He was taking hours-long showers, keeping me up all night. He was also swearing and yelling at himself all the time. He was entirely out of control," she recalled.
"I had reached the end of my rope," Evelyn said. "I even called a lawyer about getting a divorce, but he said we would have to sell the house and I didn't want to do that."
Instead, she called a local crisis center, which referred John and Evelyn to UCLA's Neuropsychiatric Institute, where John began seeing Dr. Lewis Baxter, a psychiatrist with considerable experience treating obsessive compulsives.
Baxter says John's symptoms are typical of contamination obsession, one of a number of manifestations of obsessive-compulsive disorder. Other forms of the disease include compulsive checking or counting, recurring and uncontrollable intrusive thoughts, and primary obsessional slowness.
Compelled to Recheck
A compulsive checker is someone who becomes concerned about something and then must check it over and over. For example, the checker might wonder if he left the stove on, and then be compelled to check it not once but dozens of times.
Someone suffering from intrusive thoughts will think about something violent or catastrophic, and then be unable to rid himself of those thoughts, sometimes for days.
An obsessive compulsive with primary obsessional slowness ritualizes normal behaviors to such an extent that brushing his teeth or hair can take up to six hours a day. Baxter describes, for example, one patient who was near starvation because his eating rituals were so complicated he took all day to eat and still was getting insufficient calories.
Baxter says that obsessive compulsives know their behavior is highly abnormal, but are unable to control it. "It is among the most devastating diseases," Baxter said. "These people are acutely aware they are ill, and they are consumed with guilt."
Until recently, the disease has not received much attention in the United States. "It's a kind of disorder that hasn't really captured the American imagination," said psychiatrist Tom Insel of the National Institute of Mental Health. "It just doesn't have the sexiness of anorexia nervosa or panic disorder, both of which are far less common."
Some experts in treating obsessive compulsive disorder have reported excellent results using behavior modification to treat patients. The therapy has two components--exposure and response prevention.