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The impact of coronavirus (COVID‐19) in the diagnosis and treatment of obsessive‐compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by unwanted and distressing thoughts, images or urges (obsessions) and repetitive behaviors or mental acts that aim to decrease the resulting distress or according to rigid rules (compulsions) (APA, 2013). Different studies suggest OCD to affect up to 3.1 % of the general population and to be associated with substantial disability and decreased quality of life (Fontenelle, Mendlowicz, & Versiani, 2006; Ruscio, Stein, Chiu, & Kessler, 2010). This article is protected by copyright. All rights reserved.

Obsessive-compulsive disorder (OCD) is characterized by unwanted and distressing thoughts, images or urges (obsessions) and repetitive behaviors or mental acts that aim to decrease the resulting distress or according to rigid rules (compulsions;APA, 2013). Different studies suggest OCD to affect up to 3.1% of the general population and to be associated with substantial disability and decreased quality of life (Fontenelle, Mendlowicz, & Versiani, 2006;Ruscio, Stein, Chiu, & Kessler, 2010). One of the main clusters of symptoms of OCD involves fear of contamination and washing compulsions (Stein et al., 2019). Individuals with OCD and fear of contamination may spend hours worrying about the possibility of contacting an infections illness, avoiding potential contaminants (such as not touching certain surfaces or decreasing social contacts), and/or engaging in compulsive washing behaviors of different sorts (such as taking excessively long showers or spending hours washing or disinfecting hands, and not rarely, harming their skin). Often, these behaviors have a very ritualistic character and are not difficult to diagnose by a mental health professional, as individuals feel the need to follow a specific sequence of actions which may need to be repeated a certain number of times, such as washing first the fingers, then the space between the fingers, then the wrists, hands, and so forth.
Given the recent coronavirus disease (COVID-19) pandemia declared by the World Health Organization, the unprecedented contagiousness and uncontrollability of an infectious illness in modern times, the enormous preoccupations of the general public (which has been exposed to often scary news through the media) and the explicit recommendations by the health authorities on how to deal with its potential threats (including washing hands frequent and avoiding physical contact with other people and specific surfaces), which often overlap in "appearance" with OCD symptoms, it is important for mental health professionals to think about the potential impact of COVID-19 in their practice. In this regard, we believe that the implications of the COVID-19 for the field of OCD and related disorders to be particularly relevant. First, there might be an increased number of individuals affected by OCD and fear of COVID-19 infection in the next few months or even years. Whether this will be restricted to individuals "at risk" for OCD that would be unlikely to develop OCD if not exposed to such infectious threat, is an important question to ask. Second, one needs to reflect on the diagnostic threshold for OCD, that is, if an excessive washing behavior is endorsed by health agencies, should we reconsider how we should diagnose OCD? Can we rely on a specific diagnostic feature other then time, distress, or impairment (APA, 2013)?
Third, it is important to reflect upon the impact of the COVID-19 pandemic on existing OCD cases, which may change their phenotype and the focus of their main preoccupations. For instance, individuals with OCD that used to fear contamination with human immunodeficiency virus or tuberculosis may now be worried about the coronavirus in addition to having greater hand washing compounded by increased avoidance. By extension, individuals with OCD who are afraid of having an illness (i.e., those with somatic obsessions), rather than being contaminated, may now dread having an undiagnosed coronavirus infection, while others may now fear contaminating others by spreading COVID. In addition, this threatening environment may facilitate the recurrence of symptoms in remitted patients with OCD.
Fourth, it has become apparent that recommendations of OCD experts on how to treat fear of contamination (e.g. exposure and response prevention) may clash with health agency advices being advertised everywhere. For instance, to deal with the COVID-19 threat, the CDC site (CDC, 2020) now recommends the population: to "clean and disinfect frequently touched surfaces daily"; "if soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol; and "cover all surfaces of hands and rub them together until they feel dry." These endorsements may have a huge impact on patients with OCD. Note that, while we understand these measures, dealing with these recommendations on the daily clinical practice will be challenging.
Therefore, a relevant question involves how mental health professionals should adjust their discourse to their patients with fear of contamination during this specific period of coronavirus dissemination. Exposure to excessive fears of getting an infection while preventing hand washing is the leading treatment for OCD with contamination and washing compulsions (Abramowitz, Blakey, Reuman, & Buchholz, 2018). However, how can we determine how much washing is enough during the COVID-19 pandemic surge?
While the answer might be within ourselves (as we should not ask patients to do unreasonable things that we would not be willing to personally do), this can be obviously tricky, and it is likely that a number of ambiguous situations will emerge in clinical practice.
A recent consensus paper by the International College of Obsessive-Compulsive Spectrum Disorders recommended pharmacotherapy as the first option for OCD patients with contamination fears and washing compulsions during the pandemia. (Fineberg et al., 2020) It further indicated that, for safety reasons, in vivo cognitive-behavioral therapy with exposure and response prevention (ERP) may need to be substituted by imaginal exposure. (Fineberg et al., 2020) By the same token, we also feel that the pandemia provides increased room for testing the role of ERP delivered thought new technologies, such as virtual reality (Ferreri et al., 2019). Given the importance given to pharmacotherapy, another topic of concern is drug interactions of experimental drugs for COVID-19 and medications prescribed for patients with OCD. A search on one database of drug interactions of experimental agents used in the treatment of COVID-19 (University_of_Liverpool_Drug_Interactions_ Group, 2020) suggests that atazavir, lopinavir/ritonavir, and cloroquine/ hidroxicloroquine all seem to have potential for drug interactions with SRIs and antipsychotics (particularly quetiapine and pimozide), the most widely used drugs for OCD.
One could argue that the inevitability of a coronavirus infection, estimated to affect up to 70% of the globe, could work as some sort of massive flooding, leading to decreases, rather than increases in OCD symptom severity. This is unlikely though, as there are many other alternative "themes" for people with OCD to worry about. Finally, despite these potential stressors to individuals with OCD or "at risk" to developing OCD, could COVID-19 outbreak also be an opportunity to show to our patients the adaptive and protective factor that means having OCD? Do people with OCD and fear of contamination will be less frequently infected and contribute, with social distance or avoidance behaviors, to diminish the spread of the virus due to the specific features of their phenotypic expression? By putting these facts in the context of an evolutionary perspective (Feygin, Swain, & Leckman, 2006), we can contribute to diminish stigma associated with the disorder and explain the nature of some OCD symptoms as behaviors that can be adaptive in certain periods of history when we do not have more effective ways to combat an infection.
In conclusion, given the unparalleled contagiousness of the coronavirus, maybe we will need to reframe our orientation to our OCD patients with predominant fear of contamination and washing rituals to explain the rationale of anti-OCD treatments to current and future individuals with OCD.