Impact of <scp>COVID</scp>‐19 on obsessive–compulsive disorder patients

Abstract

The COVID-19 pandemic has led to a significant elevation of psychological distress in the general population, with reports of moderate to severe increases in anxiety, depression, and stress.1 Obsessive–compulsive disorder (OCD) patients might be especially vulnerable to increased psychological distress,2-4 as many aspects of the COVID-19 crisis focus on uncertainty and cleanliness, which are core symptoms of many OCD patients.3 Alternatively, individuals with OCD tend to direct their attention toward their inner mental thoughts5 and thus might be less affected by external events. Similarly, OCD symptoms tend to be specific and subjective5 and thus the existence of a new virus would not necessarily increase the fear of contamination. Furthermore, quarantine may instead lead to patients feeling more protected from harm or that their concerns surrounding cleanliness or preventing harm are ‘justified,’ which might consequently provide them with some relief. Therefore, we assessed OCD symptom change in response to COVID-19 during the period of quarantine in Israel. Sixty-five participants who reported being diagnosed with OCD by a licensed psychiatrist completed an online survey consisting of the Depression Anxiety Stress Scale – 21 (DASS-21)6 and questions regarding their OCD. This study was approved by the Ethics Committee of the Faculty of Social Sciences of the Hebrew University of Jerusalem and was completed between 29 March and 20 April 2020, during a period of mandated quarantine in Israel, which began on 17 March and ended on 19 April. The period of mandated quarantine was accompanied by strict guidelines allowing individuals to leave their residence only for buying food, medical treatment, and essential work. Participants indicated whether they experienced symptoms relating to five common categories of OCD symptoms: contamination, moral concern, harm avoidance, concerns about symmetry and exactness, and checking.7, 8 For each endorsed category, participants reported the duration of their OCD, rated the severity of their symptoms, and indicated the degree of change in their symptoms in the past 2 weeks (on a scale from 1 [Significantly worsened] to 5 [Significantly improved]). Results indicated that participants were evenly distributed in reporting improvement (n = 21), worsening (n = 21), or no change (n = 23) in symptom severity. Of those reporting change, over 70% reported mild change (16 improved, 14 worsened) and less than 30% reported a significant change (5 improved, 7 worsened). There were no differences in symptom severity nor in symptom categories among the people reporting improved, worsened, or no change in symptom severity over the past 2 weeks (Fig. 1). Univariate analyses of variance indicated that compared to participants reporting improvement or no change in symptom severity, participants reporting worsening of symptoms in the past 2 weeks reported higher anxiety (DASS-21-A), F(2, 62) = 115.52, P < 0.001, ηp2 = 0.79, and stress (DASS-21-S), F(2, 62) = 34.49, P < 0.001, ηp2 = 0.53, but not depression (DASS-21-D), F(2, 62) = 0.21, P = 0.81. There were no differences across participants who reported improved, worsened, or no change in symptom severity in age, proportion of men and women, mean symptom severity, mean onset of earliest symptom, medication status, or psychotherapy status (Fig. 1). A binary logistic regression analysis was carried out to predict reports of (at least one) symptom worsening over the past 2 weeks. Type of symptom, current symptom severity, medication status, psychotherapy status, symptom onset, sex, age, and DASS subscales were entered as predictors. Results indicated that only the DASS-21-A and the DASS-21-S were significant predictors (βDASS-A = 34.164, P < 0.001; βDASS-S = 21.338, P < 0.001). Similar results were obtained for a binary logistic regression analysis to predict reports of at least one symptom improving (βDASS-A = −4.4121, P < 0.05; βDASS-S = −3.147, P = 0.076). After the outbreak of the COVID-19 crisis, some researchers suggested that the pandemic might have a greater detrimental effect on symptom severity of people with OCD.2-4 The current data indicate that, contrary to some expectations,2-4 most OCD patients have either been unaffected by the COVID-19 crisis or have even experienced symptomatic improvement. Perhaps this improvement was driven by the quarantine, which might lead to a reduction in the need for several compulsive behaviors (e.g., cleaning, checking). The category of OCD symptoms did not predict symptom change, surprisingly, including contamination and harm avoidance. Patients who experienced symptomatic worsening reported more feelings of anxiety and stress. Although causality cannot be unequivocally inferred from the present findings, this suggests that anxiety and stress may predict one's reaction to the COVID-19 crisis. The current study sheds light on the immediate effect of quarantine on OCD patients. However, it is worth noting that the results are limited by their reliance on self-report. Furthermore, future studies should also collect data regarding participants' potential comorbidities, and regarding the long-term effects of quarantine as the effects of the pandemic on OCD symptoms may change depending on the length of the quarantine and the crisis. It has been recently suggested that psychosocial interventions during pandemic crises should be evaluated in patients with mental illness to support the application of effective coping strategies.9 Results from the current study suggest that patients' reactions to the pandemic are heterogeneous and that OCD symptoms may be less sensitive to some environmental changes than expected. Therefore, therapeutic efforts for OCD patients should be tailored to the specific and individual needs of each patient, their symptoms, and their reaction to the pandemic crises. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.