Researchers from the University Medical Centre Hamburg-Eppendorf and University Hospital, Munich in Germany, have reported their findings on the course of obsessive-compulsive disorders (OCDs) during the coronavirus disease 2019 (COVID-19) pandemic. Their study, titled “Obsessive-compulsive disorder during COVID-19: Turning a problem into an opportunity?,” was published in the latest issue of the Journal of Anxiety Disorders.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of COVID-19, has infected a large proportion of the global population, with over 56.42 million cases confirmed worldwide. SARS-CoV-2 is a highly infectious virus that spreads via aerosols and airborne droplets from the mouth and nose. These microbe-laden droplets may also contaminate surfaces. Recent research suggests that the viral microbes landing on surfaces can survive on them for up to 72 hours, increasing the risk of surface (or fomite) transmission. Hand hygiene and mask-wearing are therefore among the primary preventative measures used to curb the spread of SARS-CoV-2.
The study’s authors state that these measures are particularly affecting those with obsessive-compulsive disorder (OCD) around sanitation and cleanliness. Those with washing compulsions have been particularly affected, they write. At present, however, there is little empirical evidence regarding how those with washing compulsions are fairing during the ongoing pandemic.
Mental health problems associated with the pandemic
The researchers point out that several mental health problems have been exacerbated by the pandemic and its associated public health measures. Social isolation measures and the economic downturn has also led to the flaring up of pre-existing mental health problems among many.
To study how COVID-19 has affected those with OCDs, the team used the diathesis-stress model to explain the “development and maintenance” of mental health problems among those susceptible to it. The team explains that those at risk suffer from additional contributing factors such as “low resilience, fewer social contacts, and reduced psychiatric care.” Problems aggravated by the pandemic include depression and anxiety disorders as well as associated behavioral problems such as substance abuse disorders, eating disorders and OCD, the team wrote.
A common form of OCD, called “contamination-related OCD (C-OCD),” and those with washing compulsions are often among the worst affected during a pandemic. The researchers explain that compulsions of washing and “ritualized washing behaviors,” have been considered to be part of the “new normal.” These behaviors have been advocated by health bodies such as the World Health Organization (WHO).
Fear of not having enough cleaning products has also led to a stockpiling of soaps, sanitizers, disinfectants, toilet papers and other hygiene products. This has been seen not only among those with OCD but also among others as well.
Guidelines and recommendations
According to the consensus statement from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive Research Network of the European College of Neuropsychopharmacology, patients with OCD need help adapting to the pandemic even with a pause in treatment to allow, “exposure and response prevention (ERP).” The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has also recommended ERP as an effective and recommended treatment for OCD.
The researchers write that what was perceived earlier as exaggerated could be the “new normal” and this may help reduce the stigma. They write, “people with OCD (particularly those with washing compulsions) may also experience relief due to reduced stigmatization or other factors. Some patients may (paradoxically) even experience a sense of competence as a result of their functional beliefs and use of adaptive coping strategies.”
For this study, a total of 394 persons diagnosed with OCD were included. Of these, 223 had washing compulsions. Persons aged 18 to 80 years were included. Participant recruitment was between March 23rd and May 18th, 2020. During this period, Germany was under a nationwide lockdown.
An assessment of OCD severity was made using the German version of the Obsessive-Compulsive Inventory-Revised (OCI-R). The severity of depression was assessed using the German version of the Patient Health Questionnaire (PHQ-9).
The participant took an online survey with a new set of questions developed by the researchers. Some of the questions were regarding changes in the participants’ OCD symptoms and reasons the participants attributed to this change.
Some participant responses included “reduced mobility, reduced availability of cleaning products, economic factors, lack of availability of doctors/therapist, interpersonal conflicts.” The team of researchers also assessed the beliefs and experiences of the participants of the COVID-19 pandemic.
The study results showed that most people with OCD were negatively affected by the COVID-19 pandemic. These were most pronounced among “washers,” and the most common cause of worsening symptoms included reduced mobility and interpersonal conflicts.
Overall results were:
- At the start of the study, the OCD severity was moderate to severe among participants, with a mean score of 27 on the OCI-R. The average depression severity score was 12.41 on the PHQ-9, indicating that depression levels among the participants were largely moderate.
- An increase in OCD symptoms was reported by 71.8 percent
- This worsening was more significant among “washers” compared to “non-washers.”
- Some patients, however, experienced a decrease in symptoms (6.5 percent), and some saw no change in symptoms (21.7 percent).
- Dysfunctional beliefs regarding the pandemic were mainly hygiene-related, and these were more prevalent in “washers” than in “non-washers”. These also led to a rise in OCI-R scores and an increase in OCD symptoms overall.
- “Washers” were also were more confident in their rituals and adaptability and provided other people with advice to prevent the spread of SARS-CoV-2 infection. A total of 22.4 percent offered advice to others.
- Washers were, unfortunately, more likely to receive poor feedback from the people they provided with advice regarding infection prevention through hygiene. Overall, feedback in response to hygiene advice was 39.7 percent positive and 24.7 percent negative as per the participant survey.
Conclusions and implications
The researchers found that most participants with OCD were negatively affected by the COVID-19 pandemic, and this was more prominent among “washers” than in “non-washers”.
They called for rapid and specific interventions against OCD to prevent long-term and long-lasting implications of this pandemic-induced aggravation of symptoms among those with OCD.