Impact of COVID-19 on People With Obsessive-Compulsive Disorder

The COVID-19 pandemic has been difficult for most everyone, but especially for individuals with mental health problems (1). A particularly vulnerable population consists of individuals with obsessive-compulsive disorder (OCD), a debilitating psychiatric condition that runs a chronic course without appropriate intervention. Obsessive-compulsive symptoms are heterogeneous in nature and generally fall into the following dimensions: contamination and/or cleaning, symmetry and/or ordering, unacceptable or taboo thoughts (i.e., sexual or aggressive obsessions), and doubting and/or checking. Although established interventions exist, including cognitive-behavioral therapy with exposure and response prevention (ERP) and serotonin reuptake inhibitor medications, access to treatment remains an issue, and COVID-19 further complicates treatment availability and engagement. This column describes some of the ways that COVID-19 has affected individuals with OCD, as well as their treatment.

Impact of the COVID-19 Pandemic on OCD Symptoms

There is a history of public health crises affecting OCD onset and symptom severity. The HIV/AIDS epidemic is a good example; uncertainty about the nature of and transmission of HIV early in the epidemic provoked contamination fears among individuals with OCD or vulnerability to anxiety. Similarly, the COVID-19 pandemic has been associated with new onset OCD, as well as worsening of symptom severity for those with existing OCD. For example, as there have been widespread calls for increased personal hygiene and lack of clarity about the scope and impact of COVID-19, onset and worsening of OCD symptoms have been reported (2–6), along with relapse among individuals whose symptoms were previously stable (7, 8). In addition to being motivated by fear of catching COVID-19, factors such as increased stress and social isolation and reduced ability to use coping strategies (e.g., exercise) have contributed to escalating symptoms for many.

New-onset COVID-19–specific obsessions and compulsions have occurred with regularity. Similar to other OCD symptoms in terms of content and function (i.e., to prevent negative outcomes), these symptoms are typically motivated to “prevent” contracting or spreading COVID-19 to others and manifest as contamination concerns (i.e., fears of self or loved ones getting sick) or as harm obsessions (i.e., may inadvertently harm others by spreading COVID-19). The challenge many clinicians have faced is to evaluate behaviors reflecting real-world concerns versus obsessive-compulsive symptoms; the key factor in differentiating these involves assessing behaviors that are in excess of recommended guidelines (9). Additional factors to consider involve the patient’s medical history or unique risk factors (i.e., is there logic behind more excessive behaviors), fixity of beliefs, and willingness to accept new information in adapting the behavioral response. For example, after learning that it was unnecessary to clean items before coming into the home, could the person easily stop this once-recommended behavior? Nonetheless, the uncertainty associated with COVID-19 has posed a significant challenge for individuals with OCD in balancing the fear of contracting the virus with the real-world risk.

Impact of the COVID-19 Pandemic on Therapy

An unforeseen benefit associated with the COVID-19 pandemic has been the uptake of telemedicine. This format has addressed a number of treatment barriers, including travel, accessing rural and underserved areas, reducing certain treatment costs, and addressing the need for child care. Furthermore, there are other benefits, such as being able to engage others more easily into treatment (e.g., parents or significant others) or provide treatment directly into the home. Some evidence (10) suggests that treatment outcomes have continued on a positive course when transitioning to telehealth. However, for those in treatment at the start of the pandemic, outcomes may have plateaued or returned to baseline levels, particularly for adults versus children, those with medical risk factors, and those under financial duress (9). On the clinician side, no-show and cancelation rates have decreased (11), and treatment may be more potent for some when applied directly into the natural environment. On the other hand, telehealth interventions may be less accessible for those lacking tech-savviness or possessing certain clinical characteristics (e.g., limited insight, certain comorbid conditions).

Despite the progress in telepsychiatry, there have been challenges as well. ERP is an impressively effective intervention for OCD, involving gradual, systematic exposure to distress-provoking triggers, with ritual and/or avoidance abstinence in order to learn that feared outcomes do not take place and/or that the patient can cope with distress. Throughout the COVID-19 pandemic, but particularly at the onset, when information about the virus was less clear, it has been important to implement ERP with an understanding of “usual risk.” This simply indicates that ERP should be provided in a manner in which providers and patients adhere to established safety guidelines (i.e., from the Centers for Disease Control and Prevention) that are in line with usual risk (7). Exposure therapy does not involve people being exposed to extraordinary risk, but rather to ordinary risk. Thus, certain considerations (e.g., use of personal protective equipment during in-person exposures) may be included, but the intervention’s core components remain fundamentally the same. However, at the pandemic’s onset, some clinicians struggled with applying “usual risk” guidelines in treatment application, resulting in a less robust intervention approach. Fortunately, this has normalized as clinicians have integrated this framework into practice.

Impact of the COVID-19 Pandemic on Neuromodulation

Although safety protocols and vaccine availability have begun to reopen access to neuromodulation treatment, the pandemic was initially associated with challenges to providing neuromodulatory interventions. For example, deep transcranial magnetic stimulation treatment, which requires daily in-person treatment sessions typically in an enclosed room, was often postponed prior to wide-spread vaccine availability. Deep brain stimulation procedures were delayed during the beginning of the pandemic, because of their elective status, before safety protocols were implemented. Challenges for in-person programming have persisted secondary to difficulty traveling.

Impact of Vaccination on OCD Symptoms

The impact of vaccination on OCD symptoms remains unclear. Anecdotally, for some patients, vaccination has reduced symptoms, particularly for symptoms related to fear of COVID-19 contamination, because the risk has been reduced and the person is able to engage effectively in adaptive coping. For others, however, this added protection has not been related to reduced symptomology, perhaps because the symptoms are unrelated to COVID-19 or because the uncertainty that drives many OCD symptoms has not been eliminated. Further research on the impact of vaccination on individuals with obsessive-compulsive disorder is needed.

Conclusions

This column highlights the impact of the COVID-19 pandemic on individuals with OCD. For many patients, symptoms have worsened and/or taken on characteristics associated with COVID-19 concerns (e.g., fear of contracting the virus), and many who have previously been stable have experienced increased symptoms. Although there have been some benefits in terms of uptake of teletherapy ERP sessions, treatment outcomes may have been affected for people with OCD at the pandemic’s onset before leveling off and returning to expected outcomes. Clinicians would be well advised to closely monitor symptoms of their patients with OCD and to potentially increase the intensity of treatment as needed. Fortunately, evidence-based interventions have been successfully adapted for use during the pandemic.