An adult female presented with more than 20 years h/o contamination OCD characterized by distress, anxiety, fear and irritability coupled with nausea feelings for contamination in toilets. She keeps her bathroom spotless which is a cause of concern because of time consumed in cleaning and issues with husband and children regarding maintenance of cleanliness. She would ensure clean toilets. Due to the concern over cleanliness, she finds it extremely difficult to use public toilets or toilets of other houses. She would hold herself from using others' toilets as far as possible. She uses specs. While using others' toilets she would either remove specs or would not switch on the lights to avoid noticing any spots, site of hairs, shit and wet soaps. Also, she would try to distract herself from the mental images of contamination or try to eliminate those images from awareness.
In her teen age, she had to use extremely dirty public toilet which precipitated her problem. Also she was in NCC and did a course in mountaineering where she got exposed to dirty places. Quick Cognitive Drill Assessment revealed following fear structure (imagined feared consequences)
1. She would not be able to eat.
2. Hairs could come into food items
3. The mental images of shit would dominate her mind and she would not get rid of them
4. She would feel nausea.
She was given psycho-education that she has been avoiding the contaminated objects of surface structure. She never worked on underlying fear structure. The fear structure is responsible for continuation of her problems. If she works on the underlying fear structure then the contaminated objects will cease to elicit the problematic reactions.
Cognitive Drill Therapy was applied on her and she was asked to form mental images of shit and repeatedly verbalize feared consequences in past or present time reference. Initially she felt visibly anxious, defensive, hesitant and tried to avoid mental images of contamination. The drill continued with pauses for 30-90 seconds as and when the SUDs were medium to high. After 20 minutes of the application of Cognitive Drill her reactions significantly subsided to imaginal and verbal exposure. She was then taken to others toilet as a behavioral test. She did not feel anxious however, because of the fear of anxiety activation she took 2-3 minutes to come near the gate of the toilet. She was not forced into this exposure. She felt comfortable to stand near the gate of the toilet.
After one hour of this application she comfortably took her lunch even when the bathroom door was open within her vision. It was recommended to her that she should continue practicing the drill and it is likely to reduce her OCD significantly.
A young adult was having contamination OCD for several years. He has being receiving regular treatment. But his contamination OCD was still persisting. He would feel severe distress when exposed to dirty objects. It was noticed that he was having more discomfort particularly in wet contaminated objects and the places where white ants were present.
Beneath this surface structure he was having fear of “inhalation of germs”. For processing of his fear of germs; I asked him to do drill in imagination and at verbal level for the germs. He was required to imagine wet contaminated objects and verbalize “germs inhale kar chukka hun”; “germs inhale kar chukka hun”; “germs inhale kar chukka hun” (I have inhaled germs).
When he felt comfortable with imaginary drill, I exposed him to wet contaminated objects and places of white ant in real. He demonstrated severe discomfort to this exposure characterized by itching sensations in the body and perceptible body tremors. I told him that he need not touch these wet contaminated objects. He need to just keep his palm over it and keep on verbalizing “germs inhale kar chukka hun”; “germs inhale kar chukka hun”; “germs inhale kar chukka hun”. Because of severe discomfort, I had to give extended pauses in between. I also prescribed the same exposure to him as homework. He performed this drill at his home also. Within a few days of this exposure and drill; he is now having negligible discomfort to wet contaminated objects and places of white ants.
A young girl reported a phobia and disgust for spiders. Following objects/situations of fear were identified:
She had typical body-mind reactions of fears characterized by accelerated heart beat, rapid breathing, startle reaction, dilated pupil, goose bumps, nausea and so on. The safety behavior was quite prominent. She would either run away/withdraw from the place or remove the spider with a long stick. The thoughts of underlying danger perception were as follows:
1. If it falls on my body I would become unconscious
2. Spider would crawl on my body
Following cognitive drill was formulated and practiced for 15 minutes:
1. Spider has fallen over my body, I have become unconscious
2. Spider is crawling over my body
She performed above drill in imagination. Then she was taken to a point where a spider was visible on the ceiling. She performed drill by seeing the spider on ceiling. Then she was shown images of spider. Again the drill was practiced during exposure to images. Having done this, she was asked for daring by hitting the spider on ceiling with a tiny object. She threw the object on spider and stood below that so that if spider falls, it would fall over her body. The rise and falls in body-mind reactions were observed in during drill and daring. Within minutes, she could overcome the body-mind reactions by continued drill.
A young girl reported phobia of monkeys. She had following danger perception that monkey could attack on her and she may die. She was prescribed following drill “monkey has attacked me”. Within a few minutes she was able to overcome severe body-mind reactions to a normal level. She needed drill dilution because she was having very high distress when drill was initiated. She continued the drill and overcame her fears and body-mind reactions. Then she was shown images of money which were apparently dangerous. She could drill and minutely inspect the images with no discomfort. Instead, the entire topic of monkey became the point of amusement.
At times, drill can act very fast specifically in cases of phobia. The only thing is that we need to identify the thoughts of danger perception and drill those thoughts by imagining the objects of phobia or real-time exposure to the objects/situations of phobia.
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