Having Obsessive-Compulsive Disorder (OCD) in the Age of Covid
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Wash your hands for at least 20 seconds at frequent intervals throughout the day. Wear a mask indoors. Practice social distancing and avoid large crowds.
We have all heard this advice many times over the past two years. These preventive practices represent a change in our habits for most of us, but this is not true for everyone. People with obsessive-compulsive disorder (OCD) might have engaged in these and similar behaviors for years.
How does a pandemic affect people who are already unusually anxious about germs and potential dangers? Can the pandemic contribute to the development of OCD in people who never had it before? What can health care providers do to help? And what can we learn from people with OCD about coping with uncertainties?
What is Obsessive-Compulsive Disorder (OCD)?
Obsessive-compulsive disorder (OCD) combines the experience of obsessions, or intrusive, anxiety-producing thoughts, and compulsions, or repetitive behaviors intended to reduce anxiety.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association in 2013, stipulates that the obsessions and compulsions must be time-consuming, taking up at least one hour per day, or cause significant distress and impairment of normal daily functioning.
Obsessions and compulsions can take many forms. Among the most common obsessions are worries about contamination, disturbing sexual thoughts, concern about blurting out obscenities, excessive orderliness or symmetry, fear of losing something important, or fear of harm befalling others.
Compulsions often consist of excessive or ritualistic handwashing, brushing of teeth, showering, or toileting; frequent ordering or arranging objects; the repeated cleaning of household objects; checking locks, switches, and appliances; constantly seeking approval or reassurance; and counting.
In some cases, the obsessions and compulsions seem logically connected. For example, a person with contamination obsessions might wash their hands hundreds of times per day. In other cases, the obsessions and compulsions seem completely detached from one another.
Like many psychological disorders, OCD lies along a continuum with typical behavior rather than being qualitatively different. An example of a qualitatively different behavior would be the presence of hallucinations in schizophrenia. We don’t have rules stating that a few hallucinations are normal but having them for more than an hour a day means you might have a psychological disorder. Having one hallucination, assuming no drug use, is reason enough for concern.
In conditions like OCD, however, we must figure out where to draw the line. When do obsessions and compulsions warrant a diagnosis? The DSM is helpful in this regard by stipulating a metric for spending too much time on obsessions and compulsions (one hour or more) and the usual wording about causing clinically significant impairment. Using these guidelines, professionals should be able to diagnose the right people.
The origins of OCD remain murky. These behaviors likely represent an exaggeration of very normal behaviors that reach deep into our evolutionary past. The hunter-gatherers who failed to check their perimeter for threats before going to sleep probably didn’t survive to number among our ancestors. Avoiding contamination was key to health. We even see evidence of OCD-like behaviors in other animals, such as the excessive licking and grooming to the point of injury that plagues some dogs (Overall & Dunham 2012).
In keeping with an evolutionary background, there is some evidence that genetics can play a role in developing OCD. As is the case in many psychological disorders, stress by itself is unlikely to initiate OCD, but stress can make OCD symptoms worse. In other cases, an illness or injury seems to precede the onset of symptoms.
Regardless of the cause, the resulting behaviors and their brain correlates are relatively well documented. OCD is accompanied by widespread differences in brain volume and connectivity (Moreira et al. 2017). Disruptions in the activity of circuits involving the basal ganglia are commonly observed. The basal ganglia are a collection of structures near the middle of the brain that are involved with the selection of voluntary movements. Given the fact that compulsions represent a poor selection of voluntary movement, the participation of the basal ganglia in OCD makes sense. The abnormal activity of the basal ganglia associated with OCD can normalize in response to the medications or cognitive-behavioral therapy (CBT) used to treat the disorder.
Interactions Between OCD and Covid
The responses of people with OCD to the Covid pandemic are diverse. Not all have contamination obsessions, which are logically the most likely to be impacted by a pandemic. Even among people with contamination obsessions, not all of these involve germs or Covid in particular. Nonetheless, the stress of the pandemic might have a general effect of worsening symptoms among those with OCD.
People with contamination obsessions are advised to work with their therapists to develop a set of behaviors that is “okay” based on expert advice for dealing with Covid and to agree to not add to it. People with perfectionism problems need reminding that completely protecting ourselves from Covid is simply not possible. We can only do so much. People who obsess about harming others might struggle with the idea that they can be asymptomatic, yet still infect others. People with OCD are encouraged to contact their therapists if any new symptoms occur or if existing symptoms worsen.
There are actually some advantages of the pandemic for people with OCD. Some report that it is comforting to be able to tell others, “Now you know what it’s like.” Experiencing fear of Covid and engaging in preventive strategies might make the public more empathic toward people with OCD. Other people with OCD appreciate the lesser expectations for leaving the house or socializing with others. Those who can work at home might experience an anxiety reduction. The fears raised in many people by Covid might not be deemed significant to those accustomed to worrying about even larger things. People with OCD are possibly more familiar with feelings of dread and uncertainty and are better prepared to cope.
On the downside, high levels of anxiety and stress can initiate a type of tunnel vision in some people with OCD. This might lead to an excessive focus on one aspect of preventive advice shared by experts at the expense of the larger picture. It becomes difficult to judge behavior within its context, such as the difference between wearing a mask indoors in the company of many strangers versus outdoors during a solitary hike. Seeing others fail to adhere to preventive advice, such as mask-wearing or social distancing, might provoke a highly anxious state.
Another potential problem for those with OCD is the constant stream of news and social media messages about the pandemic. News outlets care quite a bit about their ratings and subscriptions and are well-aware that human beings pay far more attention to negative stimuli than to positive stimuli—they respond by feeding the public a steady diet of negative content. People who consume larger amounts of news, even from reputable sources, report more negative moods and depression than those with more modest consumption of news content.
Layering this relentless negativity on top of the symptoms of OCD might be overwhelming. Professionals often advise their patients and clients to limit their news consumption.
Treating OCD During Covid
How are professionals approaching treating their clients and patients with OCD during the pandemic?
In many cases, it is business as usual. OCD is typically treated with medication, usually anti-depressants, and/or a type of cognitive-behavioral therapy that combines exposure and response prevention.
Due to Covid restrictions, many professionals rely on telehealth to interact with clients and patients. Although some practitioners believe it is more difficult to conduct therapy remotely, others disagree. Using video calls, the patient or client can be physically in the space where their exposure naturally occurs, making treatment more ecologically valid than treatment sessions in a therapist’s office. The additional benefits of avoiding anxiety associated with leaving the home to go to the therapist’s office can help clients and patients relax and focus on the therapy process itself.
Helping people with OCD distinguish between appropriate and inappropriate responses is necessary with or without Covid. For example, therapists set clear boundaries regarding the circumstances calling for handwashing. However, an open and transparent discussion of the role of news about Covid in stimulating compulsive behaviors is not a bad idea.
Outreach and education efforts by therapists, educators, and advocacy groups are necessary for helping people with previously undiagnosed OCD recognize when treatment is appropriate. In some respects, the pandemic is assisting in this process by raising awareness of OCD.
Advice from the OCD Community
Many people with OCD feel that they have something valuable to offer the rest of us coping with a pandemic. The International OCD Foundation has offered some friendly advice from which all of us can benefit.
- Don’t try to wish away your anxiety.
Anxiety is unquestionably unpleasant, but like pain, it has its role in our ability to survive and thrive. Anxiety is defined as the anticipation of danger, as opposed to fear, which is a response to a clearly present danger right in front of you. You will feel anxiety as a park ranger reports that signs of bear activity have been seen on the trail you plan to hike, but actually seeing a bear on the trail in front of you will produce fear. Many of our experiences with anxiety are normal and natural. Thinking of anxiety as “bad” or unhealthy and suppressing it adds more stress to an already stressful situation.
Covid is undeniably scary. Recognizing that a pandemic is likely to make most people anxious helps normalize the anxiety we are feeling. Isolation is reduced by recognizing that you are not the only person feeling this way. - Remind yourself that you can handle uncertainty and that you already do so regularly.
Life is not nearly as predictable as we like to believe. Things happen. We all have years of experience in handling uncertainty. The uncertainties raised by a pandemic might feel new, but they are nonetheless uncertainties with some similarity to the ones we have already managed in the past. Reminding ourselves of past successes in handling life’s curveballs can give us the confidence to go forward. - Realize that we aren’t always in control.
Psychologists distinguish between two types of loci of control (“locus” means place). A person with an internal locus of control believes that outcomes reflect personal factors like talent and hard work. A student with an internal locus of control will attribute an A on a difficult exam to being smart and studying hard. A person with an external locus of control believes that outcomes are more likely a result of chance, luck, or being in the right place at the right time. A student with an external locus of control will attribute the A on the exam to “lucky guesses” or that they happened to study the right material.
Neither extreme is, of course, completely true in most cases. Outcomes are usually the result of interactions between our personal characteristics and just a bit of chaos. As the old saying goes, “chance favors the prepared.”
Even if it’s slightly unrealistic, people who maintain an internal locus of control generally enjoy better resilience to stress and greater well-being. Even when you’re feeling completely out of control, such as when you are diagnosed with a serious disease like cancer, you can still reduce stress by exerting control in the form of informing yourself about available treatments. If you lose your job, the simple act of reasserting your control and agency by updating your LinkedIn resume can reduce stress. When we take action, even in small steps, a chaotic, helpless situation becomes more manageable.
Because we have much experience like this, it is tempting to exert control to reduce anxiety associated with Covid. Some efforts are reasonable, such as getting vaccinated or practicing social distancing. But the temptation to believe that all aspects of the pandemic can be managed this way can lead to unrealistic and anxiety-provoking lines of thought. Coming to peace with the reality of a bit of chaos can be reassuring. - Be self-compassionate.
Self-compassion is never a bad idea, but it can be particularly helpful when we’re in a situation that brings out strong, negative emotions. Instead of berating yourself for feeling negative emotions and anxiety, treat yourself with respect and self-kindness.
The Covid pandemic is unprecedented in many ways, but human beings have managed to find strength and resilience in the face of many challenges. Whether we do or do not have OCD, we can learn and support one another.
References:
American Psychiatric Association (APA; 2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Moreira, P., Marques, P., Soriano-Mas, C., Magalhães, R., Sousa, N., Soares, J. M., & Morgano, P. (2017). The neural correlates of obsessive-compulsive disorder: a multimodal perspective. Translational Psychiatry, 7, e1224. https://doi.org/10.1038/tp.2017.189
Overall, K. L., & Dunham, A. E. (2002). Clinical features and outcome in dogs and
cats with obsessive-compulsive disorder: 126 cases (1989–2000), Journal of the American Veterinary Medical Association, 221(10), 1445-1452.
Laura Freberg, PhD
Writer & Contributing ExpertLaura Freberg serves as professor of psychology at Cal Poly, San Luis Obispo, where she teaches introductory psychology and behavioral neuroscience.
Dr. Freberg is the author or co-author of several textbooks, including Discovering Psychology: The Science of Mind, Discovering Behavioral Neuroscience, Applied Behavioral Neuroscience, and Research Methods in Psychological Science. She served as President of the Western Psychological Association (WPA) in 2018-2019.