Caring for Patients with OCD in a Pandemic

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.

When a mass trauma or disaster hit, mental health clinicians often focus on encouraging resilience. In the middle of the COVID-19 pandemic, however, interventions that maintain calm, build community, and sustain hope may take priority, according to a working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Research Network of the European College of Neuropsychopharmacology.

While the COVID-19 pandemic has tested everyone, “[p]erhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD),” say the group members, who include clinicians from Stanford University, University of California, and VAHCS in Palo Alto. “Paradoxically, they are ‘experts by experience’ in attempting to avert dangers through enacting compulsive behaviors.”

Consequently, coronavirus may become all these patients think about. Some who have contamination-related OCD may express doubts about the rationality of their therapies, while other  patients have told their clinicians they were “right all along.” Moreover, people with OCD can be inflexible at “unlearning” danger responses and are thus conditioned to prolonged virus-induced distress and anxiety.

In response to the emerging crisis and growing calls from patients and clinicians, the working group produced a consensus statement with the aim of delivering “pragmatic guidance” for the treatment of OCD under COVID-19 conditions. Their report covers the issues they judged currently most relevant for clinicians.

Stipulating that the best available treatments for most patients are likely to include evidence-based pharmacotherapy and modifying or pausing cognitive behavioral therapy (CBT) in conjunction with enhanced supportive therapies, the panel also recommends:

• Using telemedicine, including telephone or video calls, but be aware of the patient’s circumstances: For some, poverty makes it hard to stay home. Regularly check on patients who are likely to engage in particularly harmful decontamination rituals or behaviors. The added benefit of video calling is that it helps the therapist perform a visual risk evaluation—which is especially valuable for patients living alone—to determine the condition of the patient's hands, presence of food in the fridge or cupboard, etc.
• Taking a careful history, clarifying the extent to which the symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of the OCD. Don’t assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19.
• Assessing suicide risk. Factors such as a recent increase in OCD severity, experiencing a family member found positive for COVID-19, or finding the effects of quarantine or isolation distressing have anecdotally been shown to raise suicide risk.
• Providing balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Patients need to understand that this health crisis may persist for some time, and they will need to manage their stress levels over that time (eg, by putting into play long-term routines of mindfulness techniques, exercise and structure).
• Inquiring about Internet usage and news consumption. Some patients spend hours a day watching television and online media sources, which may significantly exacerbate OCD and anxiety symptoms. Offer a balanced approach (eg, individuals should not spend more than a half-hour in the morning and at night to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest trusted sources to avoid myths, rumors and misinformation.
• Identifying and discouraging high-risk obsessive-compulsive behaviors, such as washing in water that is too hot or bleach, or total fasting. Some patients, as a result of doubt or uncertainty about whether food in the house is contaminated, respond by throwing everything away and consequently have little or nothing to eat. Encourage eating and drinking to maintain health.

Keeping people calm and reducing the risk of depression using supportive techniques are an essential element of care. Nevertheless, the group says, clinicians should still try to find ways to help patients foster resilience towards obsessional thinking and compulsive acts.

“We are aware this guidance marks a change in practice for many clinicians treating OCD,” they note. “Temporarily modifying or pausing in vivo CBT with ERP [exposure response prevention] for contamination-related OCD, … is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed.”

Understanding the impact of a pandemic like COVID-19 on patients with mental health disorders can provide important insights into the environmental determinants, the panel says. They urge research-active groups to investigate the effects of such changes on health outcomes—as well as exploring ways to address the expected rise in incidence of OCD once the pandemic is over.