Obsessive-compulsive disorder during the COVID-19 pandemic

The new coronavirus outbreak was characterized as a pandemic by the World Health Organization in March 2020. Although the frequency of mental disorders is expected to increase during pandemics,¹ the peculiarities of the COVID-19 pandemic can directly impact the clinical course of obsessive compulsive-disorder (OCD), a condition that affects approximately 3% of the general population.² OCD is characterized by the presence of obsessions (which are unwanted and unpleasant thoughts, images, or urges) and/or compulsions (repetitive behaviors or mental rituals aimed at reducing the distress provoked by obsessions).³ Cleanliness, contamination, and fear of contracting a disease, which are topics of concern for patients with OCD, have now become a central theme of news and social media. Thus, we would like to elaborate on some possible implications of the COVID-19 pandemic for both diagnosis and clinical decision making about OCD.

1. According to the current biopsychosocial model of psychiatric disorders, socio-cultural, biological, and psychological factors interact synergistically to determine the onset of different disorders. These factors include the patient’s beliefs and behaviors, which may be influenced by historical and environmental changes.⁴ Diagnostic classification systems, including the DSM-5 and ICD-11, include the core symptoms of disorders, as well as the level of distress experienced by patients and the impact of symptoms on functioning. Frequent handwashing, which was previously considered excessive and one of the most common symptoms of OCD, have now been normalized. Currently, considering time-consuming cleaning rituals as a single symptom seems insufficient to diagnose OCD. In such cases, clinical reasoning should counterbalance the degree of protection these rituals produce with their level of interference in functioning. Such reasoning is required to confirm an OCD diagnosis or consider treatment changes for those already on medication or in cognitive-behavioral therapy.

2. Patients may experience a worsening of OCD symptoms in different dimensions, including, but not limited to, contamination/cleaning, aggression, and hoarding dimensions. Patients who had never presented such symptoms may experience their onset in the context of this major environmental change. Higher levels of avoidant behavior are also expected. Moreover, OCD patients can experience a worsening of depression and anxiety symptoms during major life events, among which the current pandemic should be included.¹

3. Exposure and ritual prevention, a key behavioral technique in OCD treatment,⁵ should be carefully tailored during this period. Recommending unrestricted exposure to feared stimuli may prove imprudent. Psychological strategies for treating OCD should consider the well-being and safety of patients. Pharmacological strategies should be guided by the best evidence-based recommendations.⁵

4. Protection recommendations (e.g. hand washing) can reinforce the irrational beliefs of patients with OCD and poor insight. Therefore, engagement in exposure and ritual prevention activities may be lower, which could impact the long-term prognosis for OCD.

Although the above considerations should be considered speculative, they are based on clinical experience and previous scientific research. Predictions regarding the outcome of OCD in response to stressful situations should be confirmed by longitudinal studies.

References

• ¹
  Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020 Apr 13. doi: https://10.1056/NEJMp2008017 Online ahead of print.
  » https://10.1056/NEJMp2008017
• ²
  Fontenelle LF, Mendlowicz MV, Versiani M. The descriptive epidemiology of obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30:327-37.
• ³
  Shavitt RG, de Mathis MA, Oki F, Ferrao YA, Fontenelle LF, Torres AR, et al. Phenomenology of OCD: lessons from a large multicenter study and implications for ICD-11. J Psychiatr Res. 2014;57:141-8.
• ⁴
  Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137:535-44.
• ⁵
  Stein DJ, Costa DL, Lochner C, Miguel EC, Reddy YC, Shavitt RG, et al. Obsessive-compulsive disorder. Nat Rev Dis Primers. 2019;5:52.

Publication Dates

• Publication in this collection
  22 June 2020
• Date of issue
  Jan-Feb 2021

History

• Received
  30 May 2020
• Accepted
  2 June 2020