Technically a fear of germs could be classified as a type of specific phobia where the focus is germs, bacteria, contamination, or infection. Specific phobias (and other mental health conditions) are diagnosed using a specific set of criteria outlined in the Diagnostic and Statistical Manual of mental disorders, fifth edition.
It may be helpful to know, however, that in clinical settings this is rarely diagnosed. More often we see this fear of germs as a presentation of emetophobia, which is a specific phobia of vomit, or obsessive compulsive disorder (OCD).
A diagnosis of emetophobia might also be made when someone is fearful of germs. What makes emetophobia different from a specific phobia of germs is that the underlying fear is not the germs themselves, but that the germs will cause someone to be exposed to vomiting, either in themselves or someone else.
Fears of germs are also common in OCD. OCD is a disorder characterized by obsessions, which are unwanted thoughts, impulses or images that are distressing or disgusting, and compulsions,which are the thoughts or behaviors that are done in response to anxiety. These behaviors are often excessive and take up a lot of time or mental energy.
That means that even if you have a fear of germs, you may not be diagnosed with germaphobia. Regardless of which diagnosis makes the most sense, treatment will likely involve a form of exposure and response prevention (described below).
Remember that these fears are normal. Being aware of germs and handling contamination in a healthy way makes perfect sense. Rather than thinking about these fears as strange, think about them as falling on a continuum. For many medical conditions, the symptoms are either present or absent. With mental health, it’s a matter of degree, and what we often look for is distress and interference related to the symptoms.
What are common symptoms of germaphobia?
In addition to feeling nervous about coming into contact with germs, people with this fear might also experience the following symptoms:
- Frequent handwashing, several times in a row, for a long time, or in a specific way
- Using hand sanitizer after touching surfaces outside the home
- Using barriers like paper towels to touch door handles, faucets, steering wheels etc.
- Mental tracking of contaminated items
- Googling information about safety or symptoms
- Asking for reassurance from others that a behavior is safe
- Decontaminating/cleaning phone, glasses, clothing, shoes, wallet, or the home/car
- Avoidance of public places, especially grocery stores, playgrounds, restaurants, and public restrooms
- Avoidance of large social gatherings or family events
- Escaping and returning home if afraid of touching germs
The Cycle of Anxiety
No matter what the diagnosis, the cycle of anxiety about germs is the same. The cycle starts with a trigger. This could be touching a surface, learning that someone has been ill, hearing someone cough or sneeze, or any number of other triggers. The trigger is followed by thoughts like, “This is disgusting, I’m covered in germs, I’ll get sick, I’ll get other people sick.” These thoughts lead to feelings of anxiety, disgust, and apprehension. To cope with these uncomfortable feelings, certain behaviors are done to decrease the distress. This might be handwashing, cleaning or decontaminating, googling, asking for reassurance, or any of the other behaviors described above. These are sometimes called compulsions in OCD. These behaviors typically provide a short term sense of relief from anxiety, but the cycle inevitably starts all over again.
Why do people get stuck in the cycle?
The most important thing to understand about this process is that the behavioral responses or compulsions relieve a tremendous amount of discomfort. That’s called negative reinforcement. Humans and animals are wired to avoid discomfort and pain, in part because this kept humans alive in ancient times.
Behaviors can be either rewarded or punished. Behaviors that are rewarded will be increased, behaviors that are punished will be decreased. Because these behaviors remove a negative experience, they will be increased. That’s negative reinforcement, removing a negative. Think about the annoying sound your car makes when you don’t put on your seatbelt. When you buckle the seatbelt, a negative experience is removed, so you repeat it. So while the specific behavior may seem silly or unnecessary, it’s not actually about the behavior itself, it’s about the function, or what it does.
Examples of Fear of Germs
It might be helpful to get some examples of how this might look in real life. I created these examples (they’re not real people) but the fears and the behaviors are inspired by many people that I’ve worked with over the years.
Krystal is a 28-year-old married mother of two girls, a 6-year-old and 4-month-old baby. She works part time from home as an accountant. She experiences extreme anxiety and apprehension about the possibility that she, her partner, or her children will become sick and vomit. When she has these fears she experiences a racing heart, tightness in her chest, and an overwhelming feeling of dread. She also experiences a strong reaction of disgust.
She feels that she is walking on eggshells, constantly waiting to be triggered. Triggers include any signs of illness in her baby, her older daughter expressing that her stomach hurts or that she doesn’t feel well, traveling with her family, hearing of stomach bugs from other parents or the school nurse, or seeing what she thinks may be vomit, for example, a splatter near a garbage can.
Leaving the house, especially with her children, is also stressful and difficult. She avoids grocery stores, playgrounds, and public restrooms, which means she is not able to take her oldest daughter out to do developmentally appropriate things, like play with her friends or eat in restaurants. Situations where food is shared, for example outdoor picnics with buffet style food or family holidays, are also very difficult for her.
When she has to leave the house, she endures the experience with great distress and frequently uses barriers to avoid touching things and repeatedly washes or sanitizes her hands and her children’s hands. When returning home she goes immediately to the bathroom to wash her hands and her children’s hands. When she is with her husband, she often insists that he wash his hands or wash the children’s hands when she thinks they are contaminated. This often leads to arguments and tension, as he finds these requests unreasonable and excessive.
McKenzie is a 35-year-old married woman employed full time as a nurse in a large hospital. Her biggest fear is that she will bring germs or contaminants into her home that cause her wife or loved ones to become sick with a terrible illness and die.
She describes “crushing anxiety” and racing thoughts that she can “never, ever get away from.” One of her greatest fears is exposing her sister who has a disability to germs that might make her sick.
Triggers include returning home from being at work or in a public place, being around loved ones, bringing outside items inside the home (takeout food, packages, food from the grocery store), and nearly everything she comes into contact with at work.
Functioning at work is especially difficult for her. At the start of her shift she uses disinfecting wipes to wipe down her computer station, keyboard, mouse, and desk area. She repeats this several times per night. She sanitizes her hands before and after leaving each patient’s room but also several times between patient visits. She flushes her eyes at least once per night if she feels she may have been exposed to germs in the air. She also often seeks reassurance from fellow nurses, asking them over and over if they think she’s been exposed or will get sick. Many of them have become frustrated with this behavior and now seem to avoid her.
When McKenzie comes home from her shift at the hospital, she engages in extensive behaviors to prevent bringing germs into her home. She removes her shoes in a specific way outside the house, then proceeds directly to the bathroom where she removes her clothing, which she keeps separate from other clothes. She then showers in a specific way, washing her hair first so that the germs from her hair are removed first and don’t later contaminate the rest of her body. She washes her hands after washing every major body part and washes in a particular order. She must wash her entire body twice, once with a loofah and once with a cloth. Her showers take approximately one hour.
When she is unsure if something may have been contaminated, she often searches online. She also searches for signs and symptoms of illnesses she may have been exposed to at work, reading online articles and message board posts for hours.
Treatment for Fear of Germs
The treatment for emetophobia and OCD involve a specific form of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP). ERP has two parts.
The first part is exposure. Exposure involves helping a client identify behaviors that are difficult for them to do or that they have been avoiding entirely. This might include touching items in the grocery store, eating food at family gatherings, or using public restrooms. Then we put those things in order from easiest to most difficult. Clients begin with the easiest items and work their way up to the most difficult items.
The second part of the therapy is learning to prevent the response to discomfort (also sometimes known as a ritual or a compulsion). Examples here include hand washing or using sanitizer at unnecessary times, using barriers like a paper towel when using public restrooms, excessive cleaning, or mentally tracking where contaminated items have been and what they have touched. This is usually done by developing a list of response prevention guidelines.
The generally accepted response prevention guidelines for handwashing and sanitizer are after using the restroom or changing a diaper, before eating or preparing food, and since COVID-19, when returning home from being in public places.
(Read about using ERP to treat OCD here.)
What makes a compulsion a problematic behavior is how it functions. If it reduces the anxiety or distress, it’s probably a compulsion. Reducing ritualizing is just as important as the exposure part of therapy.
The goal of therapy is to help clients learn to sit with distress without relying on compulsions to escape discomfort. The pattern that keeps people stuck is having an intrusive thought, feeling distress, and doing a behavior to escape. The problem is that the behaviors are never enough. The relief they provide is temporary, and they have to be repeated or expanded or intensified to work to relieve anxiety. Giving up compulsions is the way to get out of these never ending loops.
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