Obsessive-compulsive disorder, contamination subtype
Contamination OCD with 4-hour daily ritual time; reassurance-seeking from family; minimal insight at intake.
Presenting concern
Y-BOCS at intake: 28 (severe). Contamination obsessions focused on bodily fluids. Compulsions: showering 90 minutes daily, hand-washing to bleeding, avoidance of public transit and shared bathrooms, reassurance from mother ~30x/day. Quit job 6 months prior.
History
Symptoms onset at 16, escalating over 5 years. Brief CBT at 18 that didn't include ERP — gains lost. Family accommodation extensive (mother handles 'contaminated' items).
- Severe Y-BOCS
- High family accommodation
- Low initial motivation (came at family's insistence)
- Functional impairment (unemployed)
- Bright, articulate when not in obsession
- Family willing to participate in family-based ERP
- No comorbid depression at intake (will need to monitor)
- Past therapy experience even if incomplete
Conceptualization across modalities
Intrusive thought of contamination triggers anxiety; compulsion (washing, avoidance, reassurance) provides short-term relief, which negatively reinforces the cycle and prevents disconfirmation of the feared outcome. Family accommodation removes natural opportunities for habituation/inhibitory learning.
- Build motivation via psychoeducation on the OCD cycle
- Construct exposure hierarchy collaboratively
- Begin graded exposure with response prevention
- Coach family on reducing accommodation systematically
OCD has narrowed his life via experiential avoidance of contamination-related sensation. Values (independence, romantic relationship, work) are not being lived. ACT framing makes exposure not just symptom reduction but a values-led act.
- Values clarification — what is OCD costing him?
- Defusion from intrusive thoughts
- Willingness as the alternative to compulsion
- Committed action toward valued life domains
Treatment plan
Engage (1–3)
Psychoed, motivation, family meeting, hierarchy construction.
Begin ERP (4–12)
Graded exposure, response prevention, family accommodation reduction.
Generalize (13–20)
Out-of-office exposures, return-to-work planning.
Maintenance (21+)
Self-directed ERP, relapse prevention.
Y-BOCS dropped from 28 to 14 by session 20. Returned to part-time work at month 5. Mother required her own brief consultation to sustain the accommodation reduction.