Expert opinion in Obsessive-Compulsive Disorder: Could protective measures for COVID-19 contribute to the worsening of OCD symptoms?

The COVID-19 outbreak has placed considerable strain on the wellbeing of individuals across the world, and resources have been already put in place to assess the psycho-social aftermath of this pandemic. With strict hygiene measures and recommendations now constituting the norm, we wonder specifically about those individuals that were heavily concerned by contamination, germs and viruses in the pre-COVID era. Patients affected by obsessive–compulsive disorder (OCD), and specifically those of the contamination/washing subtype, might indeed be exceptionally vulnerable to an increase in symptom severity due to the current circumstances. Albeit only relating to the acute phase of this pandemic, evidence collected thus far offer valuable insights into whether this concern is substantiated. After reviewing some of the available results, we reason on the conclusions that we can currently draw, on the factors that might play a role in driving them and on those that might be worth focusing on as the pandemic is running its course.


Introduction
The advent of COVID-19 posed an unprecedented challenge to the way of living that we have grown to take for granted. The simple behaviors and actions that effortlessly and automatically distinguished our daily interactions with the surrounding environment started to present a threat to personal and societal survival. Our day-to-day reality is now turned into one advocating the need for physical distancing, the use of personal protective equipment, and the exhaustion of precautionary hygiene measures such as washing/disinfecting hands and object items. The fear of being a risk for oneself and others after touching a specific surface or being 1.5 m too close to another person, came as something new into the world of most. However, for a portion amounting to around 2-3% of the population worldwide [1], these thoughts have represented the norm long before the spread of COVID-19.
The excessive, intrusive worrying or fear of specific circumstances, associated with ritualistic behaviors consequently endorsed to prevent the dreaded event/situation or to reduce the elicited anxiety, are characteristics of obsessive-compulsive disorder (OCD). Albeit the content of obsessions and compulsions can vary considerably across affected individuals, recurrent themes have been identified, with contamination fear and washing/cleaning compulsions being among the most commonly experienced [2].
Pandemics and infectious diseases constitute exceptional circumstances that can render this group of individuals exceptionally vulnerable to an increase in symptom severity, potentially providing them with indisputable evidence that the world is indeed a dangerous place at the mercy of germs and viruses and that only proper, scrupulous hygiene practices prevent diseases of this form from spreading uncontrollably. As a matter of fact, previous outbreaks like Severe Acute Respiratory Syndrome (SARS), Middle East respiratory Syndrome (MERS) and Influenza have witnessed and documented an exacerbation of OCD [3].
Since the classification as a pandemic by the World Health Organization, resources have been trans-geographically put in place to account for the psycho-social aftermath of the COVID-19 outbreak on individuals affected by OCD. A discrete number of studies report various levels of symptoms aggravation already detectable during or following the first wave of the pandemic, ranging from 5% up to 70% among both adult [4][5][6][7][8][9] and children/adolescents [10,11] populations. Following the above-mentioned line of reasoning, special attention has been devoted to the contamination/washing subtype, and the link with a greater increase in symptom severity (compared to other obsessions and compulsions types) has been in more than one instance established [6,8]. When evaluating beliefs associated with COVID-19, washers agreed more with dysfunctional hygiene-related beliefs (along the lines of "Coronavirus is the result of people being very careless about hygiene") than non-washers, a factor that positively correlated with worsening of symptoms [6].
Alongside these results however, empirical evidence once more highlights how syllogistically reasoning on the relationship between occurrences is most often, at least partially, inadequate. For example, in a Danish sample of children and adolescents with OCD, contamination fear was not predictive of poorer outcome, but baseline aggressive/ sexual obsessions and compulsions were [10]. Or else, Chakraborty and Karmakar [5] surveyed only OCD patients with obsessions related to contamination, and compulsions related to hand washing or cleaning household items, yet reported that only 6% experienced a 5-10% increase in symptoms. Or again, Khosravani et al. [7] found a significant increase in symptoms common to all, but special to none, symptom dimensions, suggesting that general distress and anxiety rather than specific enforced COVID-19 recommendations might mediate worsening of symptoms, similar to what has been observed in other clinical and nonclinical populations.
Conversely, it is worth noting that a proportion of OCD patients so far maintained a stable symptom status or even experienced an improvement during the pandemic [9,12]. Identifying what makes people thrive on difficult circumstances is instrumental to help those who do not. Hence, we wonder, what lightens in some the increased burden that falls on others?
First, we do not underestimate the impact that the stigma associated with mental illness and consequent isolation from society normally has on individuals affected by this or other psychiatric disorders. In some sense, COVID-19 rendered feelings of impotence, uncertainty or fear universal. This might have given back to OCD patients a sense of belongingness, of being aligned again with the rhythms of the healthy society, potentially amplifying resilience and strengthening mental resources, as suggested already long ago [13]. Second, increased free time might provide the opportunity to obsessions and compulsions to thrive even more. In this regard, whether a patient is currently undergoing treatment might make a difference on clinical outcome. Remission status and having concluded the treatment course before the beginning of the pandemic has indeed been associated with more elevated symptom worsening in both adults [8] and children/adolescents [10]. Of note, therapeutic approaches have been challenged by the situation in a number of ways. At least for certain periods, they might have stopped altogether, with medical staff being deployed to emergency care and, even when in place, factors like increased stress from both patient and clinician sides, alongside logistic challenges, might have halted the expected progress. This was for example the experience of 137 US clinicians, reporting a worsening of symptoms in 38% of their patients, undergoing exposure and response prevention (ERP) treatment at that time [9]. Not only might traditional treatment approaches not be feasibly and effectively implementable during the pandemic, but also a recent consensus paper by the International College of Obsessive-Compulsive Spectrum Disorders explicitely advised ERP programmes to be paused for patients with contamination fear and washing compulsions [14], recommending pharmacological treatment as the first option. Distinguishing compulsive from mindful/responsible hand washing, or obsessive worrying from rational concern can be difficult not only for patients but for clinicians as well, rendering ERP strategies that are meaningful and robust, while being in line with governmental guidance, challenging to design and implement. Enhanced supportive therapies like social and occupational care and immediate access to psychological support might nonetheless be a key distinguishing element allowing a portion of patients to improve regardless of the pandemic. Lastly, we shall not neglect the role of subjectivity that the exclusive use of self-report questionnaires inevitably introduces, recognized as a limitation general to the majority of the studies conducted until now and herein reported.
Altogether, the evidence collected so far does not convincingly ascribe a crucial role to the specific COVID-19 recommendations in driving symptom worsening in patients affected by OCD, nor recognizes individuals of the contamination/washing subtype as being at exceptional risk in the current circumstances. The OCD population as a whole rather demonstrates an increased vulnerability that needs to be carefully addressed, yet without assuming that necessarily all patients will be negatively affected. However, our current understanding, together with the conclusions that we can draw, are limited cross-sectionally in time.
Only longitudinal studies will elucidate the long-term sequalae of the COVID-19 pandemic, which could still reveal an increase in OCD symptoms that are centred around the contamination theme. In this regard, we deem especially relevant to document, for example, a switch in main OCD phenotype, or the rise of new obsessions and compulsions related to germs and viruses. Given the history of previous epidemics, we acknowledge the need of extending this latter concern to the general population as well. Alarmingly high prevalence rates of post-traumatic stress disorder, depression and OCD have indeed been documented in severe SARS survivors up to four years after the spread of the disease [15]. For the current epidemic, some evidence has been collected already, pointing to an increase in obsessive-compulsive symptoms in populations of adults [16], students [17] and healthcare workers [18]. However, with hygiene precautionary measures and social restrictions still heavily enforced on the population, the still standing fine, blurry line separating adaptive from maladaptive responses makes it difficult to undertake any objective assessment. Yet, in light of the evidence at our disposal, we still regard a rise in OCD symptoms and/or diagnoses as a concrete risk, and we thus make it a priority to watchfully evaluate the mental wellbeing of individuals throughout what we can assume will still be a long course of this epidemic.