Impact of COVID-19 on Patients with Obsessive Compulsive Disorder: A Review
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International Journal of Science and Healthcare Research
Vol.5; Issue: 3; July-Sept. 2020
Website: ijshr.com
Review Article ISSN: 2455-7587
Impact of COVID-19 on Patients with Obsessive
Compulsive Disorder: A Review
Sakshi Bhardwaj1, Abhinav Bhardwaj2, Ravi Parkash3
1
Senior Resident, Dept. of Psychiatry, Maharishi Markandeshwar Institute of Medical Sciences and Research
2
Senior Resident, Dept. of Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research
3
Senior Resident, Dept. of Psychiatry, Pt. B.D. Sharma PGIMS Rohtak
Corresponding Author: Ravi Parkash
ABSTRACT case on 30th January 2020. [1] Countries
have taken extreme steps to reduce the
The unpredictability and uncertainty of the transmission of corona virus such as total or
COVID-19 pandemic, lockdowns, social partial lock down with social distancing,
distancing, quarantine, isolation and the quarantine, and isolation. [2] The pandemic
forthcoming economic breakdown can increase
has increased the burden of psychiatric
the risk of mental health problems. This review
assesses the effect of corona pandemic on OCD illnesses among the population either due to
patients. Various studies suggest that OCD emergence of de novo symptoms or due to
affect up to 3.1% of the population and is loss to follow up of patients and inability to
associated with substantial disability and take medications. Among the individuals
decreased quality of life. One of the main with mental illnesses of various types, OCD
symptoms of OCD involves fear of is the one which is directly affected by the
contamination and washing compulsions. worsening outbreak of COVID-19. The
Recent pandemic declared by WHO has put peak in anxiety about the virus has
certain recommendations to tackle this viral exacerbated the existing obsessive fears of
illness such as hand hygiene, sanitization, contamination and harmful compulsive
avoiding contact with people and surfaces which
actions in some people with OCD. [3] Print,
overlaps with OCD symptoms. People with pre-
existing OCD are prone to relapses, the fear of electronic and social media are flooded with
transmitting COVID-19, distress and suicidal advisories issued by governments and other
ideas. Despite the nature of their conditions, national & international agencies. The
these people must adhere to routine processes, celebrities, public figures, governments
such as washing hands, wearing masks and bodies dealing with health-related affairs are
gloves, and sanitizing hands. So, it is important advising people to wash hands repeatedly,
for mental health professionals to identify the patients of OCD may find it difficult to
high risk individuals who are at risk of getting resist. [4] The role of media in exacerbating
OCD or to identify triggering factors in already the symptoms of OCD is supported by few
diagnosed OCD. studies. [5] Prestia et al. carried out a study
to evaluate the changes in OCD symptoms
Keywords: Obsessive compulsive disorder,
pandemic, COVID 19 before and after quarantine in a group of
patients who were on psychiatry treatment
INTRODUCTION of OCD (DSM 5 criteria) during the last 6
The first case of corona virus disease months. A significant increase was seen in
2019 (COVID-19) emerged in Wuhan, severity of obsession and compulsion
China in December 2019. It spread symptoms on Yales Brown Obsessive
throughout the world within less than three Compulsive Scale (YBOCS). [6] In an
months. India recorded its first COVID-19 another study by Ismail et al. in 598 Turkish
International Journal of Science and Healthcare Research (www.ijshr.com) 581
Vol.5; Issue: 3; July-September 2020Sakshi Bhardwaj et. al. Impact of COVID-19 on patients with obsessive compulsive disorder: a review
adolescents, the relationship between fear of prevalence rate of sub threshold OCD up to
COVID-19 and OCD was analyzed and 12.6%. Community studies of OCD have
found the role of emotional reactivity, reported a slight female predominance.
experiential avoidance and depression- OCD is highly comorbid with other
anxiety in this relationship. Experiential psychiatric illnesses, most commonly
avoidance strategies such as distraction, depression and anxiety disorders, high risk
inhibition, denial or suppression were used for suicidal behavior and high rates of
to control negative experiences. [7] Hisato et substance and alcohol use disorders. [10]
al. investigated the acute impact of the
COVID-19 pandemic on the changes of Effect of COVID 19 pandemic on OCD
severity or symptomatology of OCD patients
symptoms in 60 full or partial remitted OCD Obsessive-compulsive disorder
patients who were treated for more than 3 (OCD) is characterized by obsessions
years in OCD clinic who directly visited the (recurrent and persistent thoughts that are
clinic from April 7 to May 2, 2020 in experienced as intrusive and inappropriate,
emergency in Japan. Their OCD symptoms causing marked anxiety) and repetitive
were reassessed at the time when they came compulsions (repetitive behaviors or mental
to clinic in the emergency. The results acts carried out in response to an obsession
showed that those subjects with OCD and are aimed at preventing or reducing
symptoms badly affected by COVID-19 anxiety). These symptoms of OCD often
were significantly more likely to have interfere with a person’s normal routine,
higher trait anxiety, depressive status, occupation, or social activities and
higher prevalence of generalized anxiety relationships. Individuals those who are
disorder and contamination/washing already suffering with OCD specifically
symptoms specifically associated with virus contamination or hypochondriacal type of
respiratory infection such as Influenza worries or having perfectionistic type of
infections at the assessment before the personality might be more vulnerable to this
spread of COVID-19. [8] pandemic
World Health Organization (WHO)
METHOD OF CONDUCTING REVIEW and Centers for Disease Control and
Articles that assessed the impact of Prevention (CDC) recommended the social
COVID 19 pandemic on OCD patients were distancing and hand hygiene as the major
identified through searches of the PubMed, strategies recommended for control of
EMBASE, and Google Scholar databases spread of COVID 19 infection. This has led
for articles published in English between to an increase in the demand for sanitizers,
January 2020 and August 2020. The search soaps and gloves. Every media source is
combined the terms obsessions, stressing on the importance of hygienic
compulsions, challenges faced due to measures, washing hands and prevention of
COVID 19 pandemic etc. Additional articles contamination. It has led to the increased
were identified by a manual search of the stress in the patients of preexisting OCD
reference lists of the identified articles and due to doubts with hygiene and the
recent review articles. compulsive need to stay clean. OCD
individuals with fear of contamination may
Prevalence of OCD in general population spend hours worrying about the possibility
According to the World Health of contacting an infections illness, avoiding
Organization, OCD is the sixth most potential contaminants such as not touching
disabling psychiatric disorder. The lifetime certain surfaces or decreasing social
prevalence of OCD is 2.3% according to contacts, or engaging in compulsive
National Comorbidity Survey Replication washing behaviors of different sorts such as
reports. [9] A few studies reported taking excessively long showers or spending
International Journal of Science and Healthcare Research (www.ijshr.com) 582
Vol.5; Issue: 3; July-September 2020Sakshi Bhardwaj et. al. Impact of COVID-19 on patients with obsessive compulsive disorder: a review
hours washing or disinfecting hands. [8] The prompting of family to ensure strict
Need for certainty can lead to excessive, hygienic measures and vice versa.
intense, and repeated reassurance seeking. The constant loading of information
Inconsistencies between the sources of from various media sources about
information can lead to further information- possibility of the virus to stay active on
seeking from a range of resources, some of various inanimate surfaces, hence
which are likely to be more accurate than adding to the thoughts of contamination.
others. [11] High levels of fear of COVID- Increased ruminations and repeated
19 may cause irrational and unclear washing (or even bathing), can be
thoughts. Apart from the panic, health ‘normalized’ at the face of a pandemic
anxiety, mass hysteria and loneliness of response as an exaggerated
isolation created due to COVID pandemic, precautionary measure.
the prominence of obsessive-compulsive Stocking of masks, soaps, sanitizers,
symptoms has largely been neglected. disinfectants that can lead to hoarding
Worldwide there have been reports of and panic shopping.
increased symptoms, distress and concern Hoarding disorder is considered as a
about this illness. [12] The pandemic can act part of Obsessive Compulsive (OC)
as a triggering factor for underlying OC Spectrum in DSM 5. Apart from hoarding
spectrum disorders in a genetically prone items of little use, need-based hoarding can
person, shift the balance from ‘normal’ increase both in OCD and hoarding
obsessions to a pathological OC pattern, or disorder. This also includes medications
can worsen an already existing OC disorder. used for symptomatic treatment of flu like
analgesics, anti-inflammatory and anti-viral
The presentations of symptoms in OCD drugs. This can lead to shortage of supplies,
in the pandemic agitation in the public and patients with
The various presentations of genuine needs being deprived of them.
symptoms can be as follow- Subsequent anxiety might lead to obsessive
1. New onset of symptoms of OCD related use of medications like hydroxychloroquine
to fears of COVID-19 (HCQ), which is recently mentioned in the
2. Current worsening in the severity of guidelines for COVID-19. It can be cardio-
OCD in patients who have been on toxic and even life-threatening for certain
follow-up for OCD individuals who are taking medications
3. Relapse in those who previously without adequate supervision.
responded/remitted with treatment Due to these reasons mentioned
4. Factors affecting the worsening of OCD above, early identification and proper
following the COVID-19 pandemic treatment by a qualified psychiatrist and
team is the key in management.
Reasons why OCD patients are at most
risk Pharmacological management of OCD
The reasons why OCD patients are during COVID Pandemic
more prone due to COVID pandemic are as
Confirm Diagnosis - Identify whether
follow-
the current symptoms are an aggravated
The increased demand for hand washing response to recent stressful events or the
The importance for ‘proper’ hand- worsening of obsessive-compulsive
washing steps as per recommendations symptoms.
can add to a ritualistic pattern. Comorbid conditions - Identify the
The need to keep the hands clean every presence of comorbid conditions such as
time a person comes from outside or anxiety disorder, depression, bipolar
there is a suspected exposure can add to disorder, or posttraumatic stress disorder
the distress cognitively. (PTSD), or any other medical condition
International Journal of Science and Healthcare Research (www.ijshr.com) 583
Vol.5; Issue: 3; July-September 2020Sakshi Bhardwaj et. al. Impact of COVID-19 on patients with obsessive compulsive disorder: a review
which may influence or interfere in the health crisis can persist for some time,
treatment of OCD. and they need to manage their stress
Pharmacological treatment levels over time (e.g., long-term routines
- SSRI (Drug of Choice) of mindfulness techniques, and
- Another SSRI if no response to first exercise).
SSRI Cognitive behavioral therapy (CBT) is
- Clomipramine as third choice considered as a first-line intervention for
Adequate dosing - Gradually increase OCD. In ERP, people are being exposed
the suboptimal dose, pay attention to to things that trigger their OCD, so those
contraindications and adverse effects. with contamination fears may be asked
Adjuncts - Low-dose antipsychotics can to touch things in public places, then
be used as an adjuncts (eg, risperidone, resist washing their hands which would
olanzapine, aripiprazole, quetiapine,) if counter public health recommendations
the response is inadequate or if tics are in COVID pandemic and can be
present. dangerous to the patient. In vivo
Adherence - Ensure patient is taking exposure should be paused and ERP
medications in adequate dose and interventions should be modified
regularly. Involve family/caregivers if according to individual case. For
adherence is in question. patients whose exposure is unrelated to
Assess suicidal risk- Some patients, contamination, ERP treatment plans can
including those with severe obsessions, be continued. Balancing the risk of a
comorbid depression, bipolar disorder, patient contracting COVID-19 during
impulse control disorders, substance use ERP with the potential benefit of ERP
disorders, personality disorders and on reducing obsessive-compulsive
eating disorders may be at increased symptoms should be central to treatment
risk. Additional COVID-related factors planning, considering both the latest
may potentially increase the suicide risk information and guidelines about the
such as recent increase in OCD severity, pandemic with the degree of impairment
family member found positive for and distress caused by OCD. [13]
COVID-19 or finding the effects of Activity scheduling and structuring the
quarantine or isolation distressing. day to include physical activity,
Telemedicine - include telephone, enjoyable activities, practices that
WhatsApp, text messages, email or enhance sleep, and mindfulness. Patients
video calls. Use teleconsultation under quarantine or staying at home
services as per telepsychiatry guidelines. under restrictions are at great risk of
circadian rhythm disruption which can
Non - pharmacological management of increase anxiety and worsen OCD
OCD during COVID Pandemic symptoms while regular circadian
Psychoeducation - Give information rhythms and regular physical activity
about the risks and impact of COVID-19 will help in reducing anxiety.
on physical and mental health. This Support to caregiver: family members
includes the difficulties in managing the and caregivers of patients with OCD are
uncertainty associated with the virus but at increased risk of developing stress
it might be challenging for some people related disorders due to the worsening of
with OCD, hypochondriasis or anxiety. patients’ symptoms and may need
Highlight the need for physical additional support. Parents are
distancing (staying at home except for encouraged to engage in joyful activities
essential tasks like grocery shopping), with their child.
with special precautions for the elderly.
Patients need to understand that this
International Journal of Science and Healthcare Research (www.ijshr.com) 584
Vol.5; Issue: 3; July-September 2020Sakshi Bhardwaj et. al. Impact of COVID-19 on patients with obsessive compulsive disorder: a review
Other measures to deal with OCD during obsessions and compulsions can lead to
pandemic dermatological conditions, chronic
Balanced information-Tell the patients stress, insomnia and high risk for
about the known risks and impact of suicide.
COVID-19 on their symptoms and clear Training of Primary health-care
their myths and doubts if any. For workers at various sites need to be done
example, patients who have washed to identify OC complaints and the
their hands for hours and bleached or necessary referrals.
even boiled their hands. Limit media use- Patients are asked to
Clear myths-Some patients with OCD check news once a day for a maximum
thinks whether it is safe to touch a of five minutes, or watch the evening
newspaper or if they can catch the virus news once a week, or decide not to
if they go outside, even if no one is check news at all.
around. Some wonder if they should Practice self-compassion - Tell the
'quarantine' a package or wear gloves to patient that it is normal to be anxious
bed. It will be helpful to show them the about the coronavirus. COVID-19
public health guidance of the WHO or worries many people, including those
CDC advising that 20 seconds of hand who don't have OCD. Encourage
washing is adequate. patients to be vigilant if they experience
Check source of information-Some of an increase in OCD symptoms. Remind
the sources of information about them that it’s not their fault and to do
COVID-19 are not factually correct and what they can to keep their compulsions
that people get incorrect information in check without trying to be perfect.
from watching these news all day and Follow advice from heath care
being bombarded with information professionals and follow guidelines for
which makes their symptoms a thousand social distancing.
time worse. Therefore, patients should Take time to do things you enjoy such
be advised to limit news to half an hour as contact with family and friends, listen
twice daily. to music, read good books, get some
Empathetic attitude towards patients- fresh air, sing or dance, watch TV and
Clinicians should listen to patients’ movies that make you happy, and take
symptoms and complaints every opportunity to relax.
empathetically and should follow a
compassionate, calming and culturally CONCLUSION
sensitive approach to inform all Providing accurate and personalised
interventions. Empathy from close information on relevant risks can prevent
friends and family is helpful. the development or exacerbation of mental
Psychoeducation of the patients and health problems. It is important that
families, debunking misinformation clinicians and policymakers should be
about the pandemic, using the aware of the potential increased risk of
psychiatric social work support to relapse among those with an underlying
follow-up on severe and treatment OCD diagnosis during infectious disease
resistant patients, ensuring drug pandemics and proactive efforts are needed
compliance are necessary steps to help to support this vulnerable population. As
people who are in need. It is vital to mental health professionals (MHPs), we
explain to them the context and need to assess and educate all patients of
circumstances of washing and make anxiety disorders and OCD visiting us in
them realize what is ‘out of proportion’. outpatient services. Providing alternative
Similarly, any unnecessary hoarding channels of care like telephonic helplines
needs to be minimized. Uncontrolled and online consultations might also help.
International Journal of Science and Healthcare Research (www.ijshr.com) 585
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