Tales from the Couch

Seeing the patient from psychiatry’s perspective

A Dirty Little Secret

Some things are best left unexplored.

Mrs. Clark came to see me because of a problem beginning one year earlier. An attractive woman of 45, she’d noticed some white amidst her head of black hair. She’d decided to color her hair jet black.

On the day she treated her hair, she got some dye on her hands. No matter how often she washed them, she felt she couldn’t cleanse her hands. After many attempts, she grew frustrated and frightened. Over the next weeks and months, her worries about contamination spread. She repeatedly washed and re-washed the family’s laundry, but was convinced the clothing still wasn’t clean enough.  She began scrubbing floors and vacuuming frenetically, always imagining dirt, no matter how thorough she’d been.

Her “filth phobia” expanded. She felt she was unclean, and showered so frequently her skin became dry and flaky. She began using latex gloves to attend to bodily functions such as toileting. She refused to touch money, believing it was “dirty.” This obsession with filth limited her ability to shop for the family’s food; she avoided public transportation, fearing she would contract an infectious disease; and her husband had to drive her everywhere.

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Mrs. Clark’s life became increasingly constricted by fear of “filth.” Her husband grew frantic, realizing her life was spinning out of control.

It was clear: the onset of Mrs. Clark’s obsession with dirt and contamination had repressed psychodynamic underpinnings. I was certain a deeply-buried, unacceptable idea about something in her past had threatened to surface: perhaps angry, sexual feelings, or some other unacceptable “dirty little secret.” She reminded me of patients described by Freud and the early Viennese psychoanalysts at the turn of the 20th century.

However, I knew she was not a candidate for deeply probing psychotherapy. That could very well unleash a full-blown decompensation. She would need something to help her negotiate the obsessive symptoms completely dominating her life.

Some years earlier, the new generation of anti-depressants had come on the market. They were known to be quite effective in treating depression, and were eventually approved by the FDA for phobias and obsessive-compulsive disorders. 

I prescribed medication for Mrs. Clark. After about 6 weeks, her symptoms improved dramatically. She stopped using latex gloves for toileting; no longer cleaned her house obsessively; was showering only once a day; was able to go shopping; and took public transportation, no longer fearing contamination.

I followed up with Mrs. Clark on a less frequent basis, lowering her dose of medication at intervals, intending to wean her off it completely.

Eventually, she was phobia-free, off medication, and her obsession about dirt had resolved. She achieved symptomatic relief, which had been the goal. The medication had done its job. 

It could have been dangerous to “unearth” the “dirty little secret” she’d kept from herself.

Mark Rubinstein, M.D., is a former professor of psychiatry at Cornell. His most recent book is the novel Mad Dog House.

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