Why can’t I sleep when I feel dirty? What a therapist says

Are you unable to relax if you don’t feel clean? Do you get into bed and immediately assess how dirty you are? Do you take lots of showers, or change your sheets, even if they’ve recently been washed? 

Any of these could be a sign that you’re experiencing a theme of obsessive-compulsive disorder (OCD) called contamination OCD. Of course, it’s not automatically disordered to like being clean before going to bed. But if cleanliness feels like a high-stakes matter—something you have to achieve—or if nothing you do makes you feel clean enough to sleep, it could be something that warrants help, says April Kilduff, MA, LPCC, LCPC, LMHC, a therapist and clinical trainer at NOCD.

What is Contamination OCD?

OCD is a mental health condition that consists of persistent, unwanted intrusive thoughts, images, urges, sensations, or feelings (or obsessions). Intrusive thoughts are ego-dystonic, meaning they don’t align with your values, morals, or beliefs. Everyone experiences intrusive thoughts, but if you have OCD, you’re unable to dismiss them as being out-of-alignment with who you are, and instead, you take them extremely seriously.

These obsessions can cause extreme distress, causing you to perform mental or physical actions (compulsions) to try to relieve your discomfort. 

In this case, you may have intrusive thoughts and compulsions around feeling “dirty” or “contaminated.” You may worry about spreading or contracting germs, or feel intolerant to the idea of being contaminated. 

“For some people, the core issue with contamination OCD isn’t actually fear, but disgust. You might think, ‘I’m going to get contaminated, and that’s just gross,’” Kilduff explains.

OCD always interferes with things that we value. For example, perhaps you like to travel, but the fear or disgust of feeling dirty prevents you from getting on planes, or staying in hotels. Or maybe you enjoy sleeping at your partner’s house sometimes, but being unsure of when they last washed their sheets or took a shower is too distressing. 

What are some signs that I have Contamination OCD?

Here are some examples of what intrusive thoughts with contamination OCD can sound like: 

• What if there are germs all over my bed that are making me ‘dirty’?
• What if I never stop feeling ‘contaminated’?
• What if when I shook that person’s hands, their germs seeped into my skin? Should I shower again?
• What if I contract HIV from using a public restroom?
• I brushed up against someone’s sweaty arm at the concert. I should wash my arms again to make sure nothing gets onto my bedsheets.
• What if I can never get clean ‘enough’?
• What if I feel this disgusting forever?
• What if my sheets will never be clean enough? Maybe I should stock up on new sheets?

Some commonly seen compulsions that ensue include:

• Excessive hand washing or showering. This is a highly common compulsion among those with contamination OCD. You might wash your hands dozens or more times per day. You may feel like you need to wash them “just right”, and if it doesn’t feel “just right”, you start the process again. Similarly, you might feel the need to shower multiple times per day.
• Excessive wiping down/cleaning of surfaces and items. This occurs when you worry about what germs or contaminants you’ve brought into, or already exist in, your home. This might look like washing your sheets every single day or even washing them again if you get into bed and they don’t feel “right”.
• Doing excessive online research. For example, maybe you research the “best” kind of soap to get your body as clean as possible, or the best kind of detergent for your sheets. You might try to understand the “dangers” or “dirtiness” of every possible surface, like public toilet seats or handrails, in order to prevent making contact with them in the future (and ultimately prevent feeling “dirty”). 
• Mental review. This happens when you comb through past situations and memories to look for evidence that your intrusive thoughts are or are not true. For example, before you get into bed at night, you might look back through your day and ask yourself, Did I touch anything at my doctor’s office? Did I shower ‘good enough’ earlier? Did I make my bed as soon as I got up to make sure no ‘contaminants’ from the air got on my sheets? 
• Rumination. This looks like turning a thought over and over in your mind, hoping for new information that will prove or disprove your intrusive thoughts. You might spend hours asking yourself the same questions and turning over the same pieces of “evidence.” For example, you may lie down at night and ruminate on the feeling of being dirty, thinking, I feel so dirty. Why do I feel so dirty? What can I do?
• Avoidance. This occurs when you avoid the people, places, and situations that trigger your intrusive thoughts. For example, if you are triggered by leaving the house and being introduced to possible “contaminants”, you may start to avoid leaving the house. 

These are commonly seen compulsions, but it’s important to know that compulsions, as well as intrusive thoughts, can be as unique as each individual who engages in them. At their root, compulsions are any behavior, internal or external, done with the hope of getting rid of intrusive thoughts, seeking certainty, and relieving distress. 

And unfortunately, compulsions bring only temporary relief, as they ultimately feed the obsessive-compulsive cycle. They reinforce the idea that your intrusive thoughts are astronomical threats that you must “solve” or protect yourself against. Therefore, one can never do enough compulsions to get rid of intrusive thoughts. 

“The more we respond [to intrusive thoughts], the more it teaches our brains that we better do compulsions or we’re not going to feel better. Compulsions reinforce this feedback loop that ‘if I’m having worry and doubt, I need to do a compulsion.’ And unfortunately, no one has ever done enough compulsions to satisfy OCD,” Kilduff says.

OCD can be daunting, but the good news is that it has a highly effective, evidence-based treatment.

When is it time to get help?

The key words for knowing that it’s time to seek help for any mental health condition are impairment and distress. How is this feeling of being “dirty” getting in the way of what you value? How is your state of mind—chaotic? Frantic? Stressed? How is your quality of life being impacted? 

Note that “impairment” does not only indicate a loss of external functioning. You may still go to work or school and complete your typical daily tasks, but if you’re spending an hour or more on compulsions every day, canceling plans because you’re too worried about feeling “dirty”, or having intense feelings of distress, those are forms of impairment, too. 

“[OCD] can be very taxing on you from a cognitive perspective. Something that OCD is good at is making people feel ashamed and guilty, and that’s a lot to carry around. And when people feel the pressure to look like everything is fine, that just adds to the weight of those heavy feelings. We can never really know what’s going on internally, and there can be a lot going on internally,” Kilduff says.

How can you get help?

No matter the theme of OCD, all are treated with exposure and response-prevention (ERP) therapy. ERP works by gradually, with guidance from your therapist, exposing you to your fears and giving you tools to not engage in compulsions before, during, or after the exposures. 

“You break the grip of OCD by learning to break compulsions,” says Kilduff.

While you’ll never be forced to do anything you don’t want to do, your therapist will encourage you to leave your comfort zone. When you leave your comfort zone, you empower yourself to live a life that isn’t ruled by OCD. 

Exposures will be tailored to your unique experience of contamination OCD, but examples could include: 

• Reading a story in which someone is unable to shower
• Writing a worst case scenario, such as, “I get in bed and feel dirty in bed, then…” and re-reading it back to yourself
• Allowing people to enter your home without taking their shoes off
• Sitting on your bed with “outside clothes” on
• Washing your hands just once when you get home
• Going to a place that you used to enjoy but now can’t help but feel “dirty” in, such as a bar
• Shaking someone’s hand (and not showering when you get home because of it)

Naturally, ERP can be hard work. There’s a spike in anxiety that occurs as you grow accustomed to facing your fears. This “spike” is strategic, though. It’s what teaches you how to sit with discomfort and stop seeing it as dangerous. 

The longer you spend resisting compulsions, the more you will realize that you can, in fact, tolerate uncertainty and discomfort without “doing something” about it. You will learn that your intrusive thoughts aren’t threats. 

If the feeling of being “dirty” is impacting your sleep and overall quality of life, hopefully you are comforted by the fact that there are trained professionals who know how to help you. Ultimately, there is nothing more empowering than conquering your fears and realizing that you and your values are stronger than them.