The perceived long-term impact of COVID-19 on OCD symptomology

Abstract

A pandemic outbreak can lead to excessive, maladaptive levels of anxiety, particularly among individuals who already suffer from obsessive-compulsive disorder (OCD). The Coronavirus Disease 2019 (COVID-19) provided a novel opportunity to examine the possibility that individuals with OCD, compared to those without OCD, might experience greater distress from this common stressor. The present study examined the lasting effects of COVID-19 in the year after the outbreak. Additionally, there is limited research regarding the stability of OCD dimensions; therefore, this study examined whether the COVID-19 pandemic impacted the stability of OCD dimensions. One hundred and forty-three adults who reported they had been diagnosed with OCD and ninety-eight adults without OCD, completed an online survey assessing the impact the COVID-19 pandemic had on symptoms of OCD in the year after the initial outbreak. The OCD group showed greater concern about the pandemic and greater concern about future pandemics compared to the comparison group. In addition, COVID-19 related distress differentially related to OCD symptoms dimensions, showing the strongest association with the contamination dimension. Lastly, results showed that many individuals reported that their OCD dimension shifted to obsessions about COVID-19 from their pre-existing OCD dimension.

1. The perceived impact of COVID-19 on OCD symptomology

Obsessive-compulsive disorder (OCD) is a disorder that involves intrusive and unwanted thoughts (obsessions), that are alleviated by ritualistic overt behaviors or mental acts known as compulsions (APA, 2013). OCD is heterogeneous, in that there are many different dimensions that individuals can experience including contamination, responsibility for harm, symmetry, and unacceptable thoughts. The COVID-19 pandemic, a once in a century event that has negatively impacted people worldwide, provided a unique opportunity to further examine how negative life events might affect existing OCD. The COVID-19 pandemic has direct links to some of the obsessions found in individuals with OCD, specifically those who fit into the contamination OCD and responsibility for harm dimensions might be more relevant to the pandemic given that such individuals might be constantly worried that they could become infected by a contagion (Wheaton et al., 2021).

1.1. OCD and stress vulnerability

Fluctuations in OCD severity has been linked to stress, as multiple studies indicate that stressful life events can affect OCD symptomology (Briggs & Price, 2009; Hazra, Mukhopadhyay, & Sarkhel, 2015; Sarkhel et al., 2011). However, not all stressful life events cause increased OCD severity. Therefore, it is important to examine whether the COVID-19 pandemic is a type of stressful event that would negatively impact individuals with OCD more than it has impacted people without OCD. This is particularly important given research showing that healthy individuals, without previous mental health diagnoses, were detrimentally impaired in work, family, and social life as a result of the COVID-19 pandemic (Gallagher et al., 2020). Research on the COVID-19 pandemic has also found that individuals who received a diagnosis of COVID-19, lost a loved one to the virus, and had previous anxiety and depression were more at risk for developing immense fear of the pandemic and having their mental health adversely impacted (Gallagher et al., 2020). Research done prior to the pandemic has shown that those with OCD may experience difficulties above and beyond the norm as a result of these individuals struggling with intolerance of uncertainty (Tolin et al., 2003).

Several recent studies examined how individuals with OCD have been impacted by the COVID-19 pandemic. Small sample sizes and limited generalizability have produced mixed results, with some studies showing that OCD symptoms in general worsened due to the COVID-19 pandemic (Benatti et al., 2020; Davide et al., 2020), whereas others indicate less effect (Chakraborty & Karmakar, 2020). Importantly most of these studies assessed the immediate effects of COVID-19 on individuals with OCD (i.e., shortly after the onset of COVID-19), but as the pandemic has continued, it is important to study the lasting effects of COVID-19 on those with OCD (e.g., 1-year following the initial outbreak).

In addition, most studies have examined how COVID-19 has affected individuals with OCD as a whole; however, very few studies have looked at whether various dimensions of OCD are more greatly impacted by the COVID-19 pandemic. One study found that worsening OCD symptoms during COVID-19 was more strongly linked to contamination and responsibility for harm symptoms than taboo thoughts and symmetry symptoms (Wheaton et al., 2021). The authors suggested these two OCD dimensions have a direct relationship to the COVID-19 virus. First, individuals with contamination OCD are frequently preoccupied with becoming infected with a contagion and as a result compulsively wash their hands or take other safety mechanisms to protect themselves such as wearing a face mask or gloves. For individuals with predominant symptoms in this OCD dimension, the COVID-19 pandemic seems to be exactly what they are fearful of (e.g., contracting a deadly virus) and some individuals with this dimension remarked that their worst fear had come true (Demaria et al., 2022). Similarly, individuals with symptoms in the responsibility for harm dimension typically fear causing harm to others. At the start of the pandemic there were frequent media messages that it is everyone's responsibility to curb the spread of the virus. Given that many individuals infected with the COVID-19 virus were asymptomatic, it was difficult to know whether one needed to quarantine. For this reason, it is thought that individuals with responsibility for harm OCD were more severely impacted by the COVID-19 pandemic as they took the responsibility of ensuring not to spread the virus, out of fear that someone else may catch it (Dennis et al., 2021). Further research and clarification on how individuals with different dimensions of OCD are impacted differently by the COVID-19 pandemic is warranted as OCD in general may not be the factor that determines whether the pandemic exacerbates one's OCD, but it may be the specific dimension that impacts one's impairment and functioning.

1.2. Stress and OCD stability

Given that OCD is a heterogeneous disorder and dimensional in nature (Kühne et al., 2020), some individuals with OCD only have symptoms corresponding to one dimension of OCD while others have symptoms across multiple dimensions (Cromer et al., 2007). Research on OCD dimension stability is scarce. Stressful events can incite a change in one's mental health symptoms (Palinkas & Wong, 2020) yet, there has been very little research on whether life stress is related to changes in one's OCD dimension. Rettew et al. (1992) found that among children and adolescents, OCD dimensions can change over time meaning that individuals may develop new obsessions. In comparison, the majority of research on the stability of OCD dimensions done with adults generally find that, although symptom severity and specific content may fluctuate within the OCD dimensions (i.e., someone with contamination fears transitioning from fearing contracting AIDS to fearing contracting another illness such as herpes), the symptom dimension remains quite stable overtime (Fullana et al., 2009; Mataix-Cols et al., 2005). This means that it would be less common for patients to shift from one OCD dimension to an entirely new one (i.e., a patient with symptoms in the symmetry dimension shifting to experience symptoms from the contamination dimension). However, previous studies did not assess whether OCD symptoms may shift dimensions after a significant stressful life event versus simply shifting over time.

1.3. The present study

The present study attempts to advance our understanding of the perceived effects of the COVID-19 pandemic on individuals with OCD. First, we examined how OCD might act as a vulnerability factor in terms of responses to the COVID-19 pandemic. There are inconsistent findings regarding whether individuals with OCD versus individuals without OCD react more adversely to negative life events. One possibility is that OCD-related stress-vulnerability varies across the type of negative events. The COVID-19 pandemic provides a novel opportunity to examine OCD-related stress vulnerability given that the pandemic has many relevant themes to what individuals with OCD experience (e.g., possibility of contamination). Thus, the first aim of the study sought to compare those with OCD to those without a diagnosis of OCD to examine differences in responses to the COVID-19 pandemic one year from the initial start of the pandemic. It was hypothesized that individuals with OCD would have more impairment in work, family, and social life, be more concerned of the COVID-19 pandemic, and show more concern of future pandemics relative to individuals without an OCD diagnosis while adjusting for gender, age, ethnicity, race, general depression, anxiety, and death of a loved one from COVID-19.

Secondly, the study aimed to understand how different dimensions of OCD are differently impacted by the COVID-19 pandemic a year after it began. We hypothesized that among individuals with OCD, contamination OCD and responsibility for harm OCD would be most strongly linked to COVID-19 concern, functional impairment by OCD, and report worsening OCD symptoms. Most of the literature on OCD and COVID-19 focus on how individuals with the broader classification of OCD were impacted by the pandemic; however, very few studies investigated how each dimension of OCD was impacted.

Finally, this study had an exploratory aim of understanding how a global life stressor such as COVID-19 impacts the stability of the OCD symptom dimensions. Research is lacking regarding whether individual's OCD symptoms shift from one dimension to another dimension throughout life. Some limited studies suggest that OCD dimensions remain quite stable. However, these studies did not assess whether symptoms change dimensions after stressful life events. Because there is no other literature on past pandemics or global stressors that have lasted a substantial period, this study sought to examine this novel aim. We hypothesized that OCD symptoms can shift to a new dimension a year after the start of the pandemic given the gravity of the stressor. Specifically, we expected that individuals who did not have contamination/washing symptoms prior to COVID-19 might experience new obsessions and compulsions related to COVID-19, reflecting an OCD dimension shift.

2. Methods

2.1. Participants and procedures

Participants included 143 adults who reported that they had been diagnosed with OCD and 98 adults without OCD. Participants from the OCD sample were recruited via an electronic advertisement on the International OCD Foundation's website (https://iocdf.org). The participants from the control group were recruited from an electronic flyer on Amazon's Mechanical Turk (Mturk), a marketplace where individuals are compensated for completing surveys. Data was collected from April 15th until July 2nd, 2021.

Individuals in the OCD group were eligible to participate if they (a) reported that they had a prior diagnosis of OCD by a mental health professional, (b) lived in North America, and (c) were fluent in English. Participants in the comparison group were eligible to participate if they (a) did not have a diagnosis of OCD, (b) lived in North America, and (c) were fluent in English. Once participants completed the eligibility screener, they were prompted to either complete the survey or told they did not qualify for the study. Participants in the OCD group completed the survey in exchange for an entry into a raffle for a $100 Amazon gift card. Participants in the control group were compensated $1.00 for completing the survey. Once they completed the study, participants were excluded if they incorrectly answered the attention check questions (N = 12) or if they were in the comparison group and had an elevated score, indicating OCD, on the Dimensional Obsessive Compulsive Scale (DOCS; N = 16 (Abramowitz et al., 2010);). Individuals in the OCD group were excluded if they completed the DOCS and did not score in the range of someone having a diagnosis of OCD (N = 12) or failed the attention checks (N = 3). Both groups of participants completed the study measures online using Qualtrics, an online survey development tool. The study was reviewed and approved by the Institutional Review Board at Fairleigh Dickinson University.

2.2. Measures

Demographic and background variables. The survey included questions about age, race/ethnicity, and gender. In addition, participants answered whether they had gotten sick with the COVID-19 virus and if they had lost a loved one to the virus.

Obsessive-compulsive symptoms. Participants completed the Dimensional Obsessive- Compulsive Scale (DOCS (Abramowitz et al., 2010);). The DOCS is a 20-item self-report inventory of OCD symptom severity (with higher scores indicating more severe symptoms). The DOCS includes subscales assessing four empirically supported OCD symptom dimensions: contamination/washing, responsibility for harm, symmetry, and unacceptable “taboo” thoughts. For each dimension, five items (scored 0–4, with 0 = “none at all” to 4 = “8 h or more each day”) assess the following parameters of severity: (a) time occupied by obsessions and compulsions, (b) avoidance, (c) distress, (d) functional impairment, and (e) difficulty disregarding the obsessions and refraining from compulsions. Scale scores were created by summing total responses for each OCD dimension. All five subscales demonstrated good reliability: contamination ($\alpha =.93)$, responsibility for harm ($\alpha =.95)$, unacceptable thoughts ($\alpha =.94)$, and symmetry ($\alpha =.95)$. Three items from the OCD Symptomology Scale were also given to the OCD sample. This scale was developed for the purpose of the current study. These questions assessed whether one's OCD dimension shifted (e.g., experienced contamination/washing symptoms that were not experienced before), whether their OCD changed in intensity, and whether the COVID-19 pandemic became a new obsession ($\alpha =.50)$.

Depression and anxiety symptoms. Participants completed the anxiety and depression sections of the Depression Anxiety Stress Scale-21 (DASS-21 (Antony et al., 1998);). The DASS-21 is a self-report inventory that is frequently utilized in research studies to assess distress and mood symptoms (see appendix for items). Each item is rated on a 0–4 sale (0 = “did not apply to me at all” and 4 = “applied to me very much or most of the time”). Higher scores indicated greater severity. The DASS-21 subscales have been found to have good reliability and construct validity (Antony et al., 1998). Scale scores were created by summing responses across the relevant items; reliability was good for both scales: anxiety ($\alpha =.92)$, and depression ($\alpha =.92)$.

Covid-related distress. Participants competed the COVID -19 Concern Scale (CNS). The CNS is a 11-item questionnaire that was developed for the present study by adapting a self-report inventory designed to assess anxiety about the H1N1 influenza (Wheaton et al., 2012). Participants responded to items using a 5-point scale (1 = “Not At all” to 5 = “Very Much”) regarding concern about COVID-19 and its variants, concern that vaccines will not be effective, concern of becoming severely ill from COVID-19 and its variants, and behavioral changes in response to COVID-19 (e.g., travel plans, handwashing, masks). A composite score was created by summing the responses. The CNS demonstrated good internal consistency ($\alpha =.93)$.

Impairment Scale. To assess how COVID-19 has impacted individuals’ impairment in functioning, three questions were developed for the study. Participants were asked to what extent they have been impacted in school or work, social life, and in family or home responsibilities on a 5-point response scale (1 = Not at All to 5 = Extremely). A scale score was created by summing responses across the items; this scale had good reliability ($=.85)$.

2.3. Data analysis

Multiple regressions were used to examine whether OCD status was predictive of the COVID Concern Scale and Impairment Scale. In all analyses, gender, age, race, ethnicity, anxiety, depression, getting sick with COVID-19 and losing a loved one to COVID-19 were entered as covariates. Age and gender were controlled for because previous research has found that there are gender differences in individuals with OCD. Specifically, females have a later age of onset of OCD than males (Castle et al., 1995). Further, previous research has found that there are differences in OCD symptoms and beliefs across ethnic groups (Wheaton et al., 2013). Anxiety and depression are both comorbid in many individuals with OCD and for this reason it was important anxiety and depression were covariates in the analyses (Crino & Andrews, 1996). Lastly, there is research showing that individuals who lost a loved one to COVID or those who contract the virus themselves have greater probability of experiencing psychological distress (Boyraz & Legros, 2020). To examine how OCD dimensions were related to COVID-19 concern, impairment, and worsening of OCD, bivariate correlations were first examined. Further, linear regressions were used for the second aim to examine the unique effects of the OCD dimensions after controlling for each other as well as demographic and control variables. For the third exploratory aim, percentages were used to ascertain whether individuals with OCD reported that their OCD symptoms shifted across dimensions, worsened, and whether the COVID-19 pandemic became an obsession.

3. Results

3.1. Descriptive statistics

Demographic information for the final sample (N = 241) is presented in Table 1 . Of the OCD sample, 55.2% identified as female, 73.4% identified as white or European American, 55.2% of the sample were currently single, and 58.7% were currently employed full time. Most of the OCD sample had not contracted COVID-19 at the time of data collection (81.8%) and 78.3% of the sample did not lose a loved one to the virus. For the comparison group, 51.5% of the sample identified as male, 88.9% identified as white or European American, 72.7% were employed full time, and 52.5% identified as single and never married. Of the comparison group, 91.9% did not get COVID-19 or have a loved one pass away from the virus. Table 1 displays the means and standard deviations of the CNS, DOCS, DASS-21 (depression and anxiety), and impairment by COVID-19 broken up by diagnostic category.

Table 1.

Mean and standard deviations of symptom measures.

	OCD Participants (n = 143)	Control Participants (n = 98)	Statistical difference values
COVID-19 Concern Scale	27.6 (9.4)	13.5 (9.0)	t = -11.64***
Total Score on DOCS	40.3 (11.9)	6.54 (5.6)	t = -26.16***
Impairment by COVID-19	6.8 (2.3)	2.5 (2.5)	t = -13.47***
Contamination on DOCS	10.3 (4.0)	2.49 (2.5)	t = -17.16***
Responsibility for Harm on DOCS	10.6 (3.4)	1.39 (2.0)	t = -24.10***
Unacceptable Thoughts on DOCS	10.2 (3.7)	1.64 (2.1)	t = -20.72***
Symmetry on DOCS	9.13 (4.4)	1.02 (1.9)	t = -17.17***
Depression Symptoms	8.47(4.4)	3.14 (4.5)	t = -9.15***
Anxiety Symptoms	9.91 (4.4)	1.64 (2.7)	t = 16.58***

Independent samples t-tests were used to test whether significant differences existed between the two groups on continuous variables. Categorical variables were tested via chi square tests. Race was dichotomized into white/non-white categories due to small cell sizes. There were significant differences in age, race, ethnicity, getting COVID-19, and losing a loved one to the virus (Table 2 ). These demographic variables were retained as covariates in all subsequent analyses.

Hypothesis 1

Differences in COVID-19 Concern between OCD and Non-OCD Individuals

Table 3 shows the results of the regression predicting concerns about COVID-19 from the OCD grouping variable and relevant control variables. It was hypothesized that participants with OCD will exhibit greater concern about the COVID-19 pandemic and will show more concern about future pandemics as measured via the COVID-19 Concern Scale and experience more impairment due to the COVID-19 pandemic compared to those without OCD. The model predicting COVID concern explained 40.9% of the variance and was significant, F(9,231) = 17.79, p < .001. Individuals with OCD and those with higher levels of anxiety were more concerned by the COVID-19 pandemic. A second regression examined impairment level. The model explained 45.7% of the variance and the model was significant, F (9,230) = 21.49, p < .001. It was found that diagnostic group, specifically those in the OCD group, and those identifying as Hispanic had significantly greater impairment due to the COVID-19 pandemic.

Hypothesis 2

Impact of COVID-19 on Specific OCD Dimensions

It was predicted that among individuals with OCD, those with higher scores on the contamination subscale and responsibility subscale of the DOCS would report that they experienced worsening of their OCD, would show impairment in social, work, and family life, and be more concerned about COVID-19. Correlations are presented in Table 4 . Results showed that those with higher scores on the contamination dimension of the DOCS had significantly higher scores on the CNS and reported that their OCD had worsened. However, there was not a statistically significant association between impairment by COVID-19. Furthermore, individuals with higher scores on the responsibility for harm scale of the DOCS also reported significantly higher scores on the CNS and reported that their OCD had worsened. However, responsibility for harm symptoms were not associated with impairment by COVID-19 or fear of future pandemics. Similarly, higher severity of unacceptable thoughts OCD and higher scores on the CNS showed a statistically significant elevation in believing that their OCD had worsened because of the pandemic. There were no significant associations with symmetry OCD symptoms.

Table 2.

Demographic characteristics and descriptive statistics.

	OCD Participants (n = 143)	Control Participants (n = 98)	Statistical difference values
Mean age in years (SD)	28.0 (7.7)	38.6 (12.7)	t = 8.04, p < .001**
Gender			X2(2, 241) = 2.1, p = .36
Male	63	51
Female	79	47
Other	1	0
Race (N)			X2(1, 241) = 9.8, p = .002**
White	105	88
Non-White	38	10
Ethnicity (N)			X2(1, 241) = 36.8, p < .001**
Hispanic/Latino	57	5
Not Hispanic/Not Latino	86	93
Employment Status (N)			X2(6, 241) = 12.1, p = .061
Student	24	13
Unemployed	9	6
Employed Full Time	84	72
Employed Part Time	17	4
On Disability	2	0
Homemaker	5	1
Retired	2	3
Marital Status (N)			X2(2, 241) = .557, p = .76
Single (Never Married)	79	52
Married/Living with Partner	57	39
Divorced/Separated	7	7
Widowed	0	0
Sick with COVID-19 (N)			X2(3241) = 8.0, p = .047*
No	117	91
Yes, Mild Symptoms	18	7
Yes, Severe Symptoms	5	0
Yes, Hospitalized	3	0
Death of Loved One from COVID			X2(1, 241) = 9.3, p = .002**
No	112	91
Yes	31	7

Table 3.

Diagnostic group predicting impairment and COVID-19 concern.

Predictors	B	SE	Beta	p
Impairment
Diagnostic Group	2.2512	0.493		<0.001**
Age	−0.001	0.015	−0.004	0.941
Gender	−0.118	0.297	−0.020	0.691
Race	−0.577	0.385		0.135
Ethnicity	0.781	0.379	2.062	0.040*
Becoming Sick with COVID	0.118	0.319	0.020	0.711
Losing a Loved One to COVID	0.422	0.444	0.051	0.2343
Depression	0.064	0.045	0.107	0.159
Anxiety	0.100	0.052	0.182	0.054
COVID-19 Concern Scale (CNS)
Diagnostic Group	8.987	1.938		<0.001**
Age	0.019	0.059	0.018	0.752
Gender	0.190	1.166	0.008	0.871
Race	−2.255	1.514		0.138
Ethnicity	0.300	1.486		0.840
Becoming Sick with COVID	−0.716	1.253	−0.032	0.568
Losing a Loved One to COVID	−0.222	1.745	−0.007	0.899
Depression	0.099	0.176	0.044	0.574
Anxiety	0.539	0.202	0.260	0.008*

Table 4.

Correlations among survey items in the OCD group.

	CNS	DOCS-Contam	DOC-RH	DOCS-Thoughts	DOCS-Symm	DASS-Depres	DASS-Anxiety
CNS	–	.45**	.24**	.18*	.15	.20*	.25**
Impairment by COVID-19	−.036	−.051	.045	−.018	−.107	.017	.12
OCD Worsening	.134	.19*	.26**	.24**	.04	.134	.13

Note. CNS=COVID-19 Concern Scale; DOCS = Dimensional Obsessive Compulsive Scale.

RH=Responsibility for Harm; Thoughts = Taboo thoughts; Symm = Symmetry Concerns.

DASS = Depression Anxiety Stress Scales.

Next, three regressions examined if any OCD dimension uniquely predicted COVID-19 concern, COVID-19 impairment, and worsening of OCD (See Table 5 ). The first regression tested whether OCD dimension uniquely predicted COVID-19 Concern. The model explained 28.1% of the variance and the model was significant, F(12,130) = 4.235, p < .001. It was found that higher levels of contamination OCD were uniquely related to COVID-19 concern.

Table 5.

OCD dimension predicting COVID concern, anxiety, impairment, and worsening of OCD.

Predictors	B	SE	Beta	p
COVID-19 Concern Scale
Contamination OCD	1.107	0.223	0.481	<0.001**
Responsibility for Harm OCD	0.004	0.269	0.001	0.989
Unacceptable Thoughts OCD	−0.012	0.246	−0.005	0.960
Symmetry OCD	−0.229	0.197	−0.107	0.249
Depression	0.064	0.245	0.030	0.794
Anxiety	0.388	0.230	0.182	0.094
Age	0.085	0.095	0.070	0.369
Gender	−0.448	1.420	−0.025	0.753
Race	−2.591	1.669		0.123
Ethnicity	−1.276	1.536		0.408
Becoming Sick with COVID	−0.042	1.298	−0.003	0.974
Losing a Loved One to COVID	−1.917	1.892	−0.085	0.313
COVID-19 Impairment
Contamination OCD	0.293	0.049	0.513	<0.001**
Responsibility for Harm OCD	−0.009	0.059	−0.001	0.987
Unacceptable Thoughts OCD	0.091	0.054	0.148	0.095
Symmetry OCD	0.031	0.044	0.058	0.483
Depression	0.048	0.054	0.091	0.371
Anxiety	−0.002	0.051	−0.003	0.973
Age	0.009	0.021	0.031	0.652
Gender	−0.135	0.312	−0.030	0.665
Race	−0.278	0.367		0.451
Ethnicity	0.325	0.338		0.337
Becoming Sick with COVID	−0.023	0.285	−0.006	0.937
Losing a Loved One to COVID	−0.207	0.416	−0.037	0.619
Worsening of OCD Symptoms
Contamination OCD	0.044	0.023	0.196	0.060
Responsibility for Harm OCD	0.035	0.028	0.134	0.207
Unacceptable Thoughts OCD	0.033	0.025	0.135	0.202
Symmetry OCD	−0.026	0.020	−0.127	0.203
Depression	0.002	0.025	0.001	0.992
Anxiety	0.013	0.024	0.065	0.573
Age	−0.016	0.010	−0.137	0.102
Gender	0.014	0.147	0.008	0.923
Race	0.277	0.173		0.110
Ethnicity	−0334	0.159		0.037*
Becoming Sick with COVID	−0.002	0.134	−0.002	0.986
Losing a Loved One to COVID	0.032	0.196	0.015	0.868

A second regression predicted COVID-19 impairment in work, family, and social life by OCD dimension and control variables. The model explained 43.7% of the variance and the model was significant F (12,129) = 8.344, p < .001. It was found that the only unique predictor was contamination OCD symptoms.

A final regression examined self-reported worsening of OCD due to COVID-19. The results of the regression indicated that the model accounted for 18.2% of the variance and that the model was significant, F (12,130) = 2.406, p = .008. However, no individual OCD dimension emerged as an individual predictor but identifying with Hispanic ethnicity was a unique predictor of OCD worsening.

Hypothesis 3

Symptom Dimension Stability

The third hypothesis was to explore whether participants would experience a shift to experience symptoms in a new OCD dimension due to the COVID-19 pandemic. Self-report measures showed that 73.4% of the OCD sample reported that their OCD dimension shifted because of the COVID-19 pandemic. Results indicated that 61.5% of the OCD sample reported that their specific OCD concerns were not as distressing as their current concerns about the COVID-19 pandemic and 51.7% of the sample believed that the COVID-19 pandemic was a current OCD obsession of theirs. In addition, 63.7% of the OCD sample reported that their OCD symptoms worsened during the pandemic. See Table 6 for the results of the survey questions and for the questions presented to the participants.

Table 6.

OCD symptoms during the COVID-19 pandemic.

Variable	N	%
Since the outbreak of COVID-19, has the severity of your OCD symptoms changed?
OCD Symptoms have gotten a lot better	2	1.40
OCD Symptoms have gotten a little better	8	5.59
OCD Symptoms are about the same	42	29.4
OCD Symptoms have gotten a little worse	59	41.3
OCD Symptoms have gotten a lot worse	32	22.4
Which is true for you?
OCD dimension remained the same	38	26.6
OCD dimension shifted	105	73.4
Which is true for you?
OCD concerns are less distressing than current concern about COVID-19	88	61.5
OCD concerns remain primary even if concerned about COVID-19	55	38.5
Has COVID-19 become part of your current OCD concerns?
Any concerns about COVID-19 are separate from OCD	15	10.5
Concern about COVID-19 was an obsession of mine only during the initial stages of pandemic (March–June 2020)	54	37.8
Concern about COVID-19 has become an OCD obsession of mine and remains part of my OCD	74	51.7

4. Discussion

The current study examined the impact of the COVID-19 pandemic on individuals with OCD. Further, this study investigated whether the OCD dimension influences how individuals responded to the COVID-19 pandemic. Lastly, this study assessed how a global life stressor can impact OCD dimension stability.

The first aim examined differences in how those with OCD responded to the COVID-19 pandemic compared to those without a diagnosis of OCD. As hypothesized, individuals with OCD reported significantly more concern about the COVID-19 pandemic relative to those without OCD. Specifically, those with OCD reported higher levels of fear about the virus, reported feeling more threatened by the pandemic, and reported that work, family responsibilities, and social life were all impacted by the COVID-19 pandemic. Given that there has been a robust literature of research even prior to the current pandemic that those with OCD have trouble coping with uncertainty (Tolin et al., 2003), it is perhaps not surprising that those with OCD reported significantly more fear and impairment as a result of the COVID-19 pandemic due to the pandemic being filled with layers of uncertainty (Koffman et al., 2020). A qualitative study found five overarching themes for how individuals with OCD have been impacted by the COVID-19 pandemic. One theme was the amount of uncertainty at the start of the COVID-19 pandemic, which caused feelings of loss of control, anxiety, hopelessness, and depression (Tandt et al., 2022). Feelings of loss of control and uncertainty were prevalent in many individuals at the start of the pandemic; however, this is worse in those with OCD as beliefs of losing control can worsen OCD (Carr, 1974; Han et al., 2018, 2021; McLaren & Crowe, 2003).

The second aim was to examine whether specific symptom dimensions of OCD were impacted to a greater degree by the COVID-19 pandemic. The hypothesis was that those with contamination and responsibility for harm dimensions as measured via the DOCS would be more strongly linked to COVID related distress than other symptom dimensions (symmetry or unacceptable/taboo dimensions on the DOCS). The rationale for this hypothesis was that those with contamination OCD may be preoccupied with becoming infected by the COVID-19 virus (Rachman, 2004). Furthermore, many individuals with responsibility for harm are preoccupied with causing harm or illness to others (Foa et al., 2001). For this reason, it was hypothesized that these individuals would experience the COVID-19 pandemic with greater distress as they may become preoccupied with spreading the virus to others (Shafran et al., 2020). As predicted, severity of symptoms in the contamination dimension were linked with greater concern about the virus and higher levels of impairment due to COVID-19 one year after the beginning of the pandemic. Similarly, severity of responsibility for harm symptoms was linked to higher levels of concern regarding COVID-19 and self-reported worsening of OCD. Contrary to the hypothesis, severity of responsibility for harm symptoms was not linked to reported severity of impairment from the pandemic.

For those with unacceptable thoughts and symmetry dimensions of OCD, it was hypothesized that they would not be as impacted by the COVID-19 pandemic relative to those with other OCD dimensions. Bivariate correlations indicated that individuals with higher scores on unacceptable thoughts believed that their OCD had worsened. This result may indicate that most dimensions of OCD have been negatively impacted by the pandemic, but some forms more significantly than others (Wheaton et al., 2021). It is possible that any stressful life event could lead to a generalized increase in OCD severity (Kracker Imthon et al., 2020). However, when assessing unique predictors, it was found that only higher scores on the contamination subscale were linked to COVID-19 concern and impairment by the pandemic, which is to be expected given the fears associated with this dimension.

The third exploratory aim examined the stability of one's perceived primary OCD dimension. Consistent with the study hypothesis, most individuals reported that their OCD had shifted to a new topic: COVID-19. Of these individuals, most stated that their pre-existing OCD dimension was currently less distressing compared to their current concern of the COVID-19 pandemic. These results may preliminarily suggest that a global life stressor may have the capability of shifting an individual's main OCD dimension. Research on the stability of one's OCD dimension has been quite sparse and most of the limited research on this topic studied one's symptom stability with the passage of time alone. This is the first study of its kind to examine the stability of one's OCD theme after a global stressor has occurred (Fullana et al., 2009; Rettew et al., 1992). These results may not be surprising given the magnitude of stress this global pandemic has caused (Bareeqa et al., 2021). However, these results only suggest that during the first year of the COVID-19 pandemic, when the study was administered, individuals with OCD were reportedly preoccupied with obsessions regarding the COVID-19 pandemic in place of their usual dimension. It is possible that as the uncertainty of the COVID-19 pandemic diminishes and vaccinations and treatments become widely available that those with OCD will shift back to have symptoms in the dimension they had before the COVID-19 pandemic (Pan et al., 2021).

Importantly, there were significant demographic differences in group demographics between the OCD non-OCD group that warrant discussion. The non-OCD group was significantly older than the OCD group. Although age was a covariate in each analysis given the significant difference between the two groups, there are nonetheless implications to be considered. First, research has shown that those of older age were more at risk for severe illness from the virus (Cucinotta & Vanelli, 2020). Although the non-OCD group was significantly older, the majority of the participants were not classified as elderly. Instead, the average age of this group was in the mid-thirties while the OCD group was in the mid-twenties. As a result, those in the non-OCD group may have more responsibilities such as more likely to have a family and perhaps more likely to have a job. Both raising a family and working outside the home were stressful life factors that research has shown contributed to anxiety levels during the COVID-19 pandemic (Mariani et al., 2020). In addition, life stressors in your mid 20s are related to navigating adulthood which may also contribute to stress levels (LeBlanc et al., 2020). Further, there was a statistically significant difference in ethnicity and race between the two groups. The OCD group had significantly higher number of individuals who identify as Hispanic and Non-White. There has been a robust body of research demonstrating that minority groups were disproportionately negatively affected by the COVID-19 pandemic. As a result, it may be that even without a diagnosis of OCD that these individuals experienced more impairment and exacerbation in their mental health difficulties (Katikireddi et al., 2021). Similarly, the OCD group had significantly more individuals who became sick with COVID-19 and lost a loved one to the virus. Therefore, it is also likely that this group of individuals, regardless of their OCD diagnosis, may have been more negatively impacted by the pandemic (Koçak et al., 2021). In this study, an individual's ethnicity, regardless of diagnostic group, was a significant predictor of greater impairment from the COVID-19 pandemic. Those who identify as Hispanic, compared to their non-Hispanic counterparts, reported greater impairment in work, family, and social life. Past research suggests that those individuals who identify as Hispanic are the ones who provided critical aid to individuals at increased risk for severe illness from COVID-19 and that those who identify as Hispanic were at increased risk for anxiety and depression during the COVID-19 pandemic, quite likely due to the type of work environments (Czeisler et al., 2020).

4.1. Clinical implications

The findings of this study are particularly relevant to those with a diagnosis of OCD or who experience OCD symptoms. The results shed light on how those with OCD are impacted by the COVID-19 pandemic and what clinicians who treat OCD might expect to see as new variants of the COVID-19 virus (or other viruses) emerge. These results may also be relevant in informing how those with OCD might respond to future global stressors.

Clinicians treating patients with OCD may need to be even more vigilant regarding how their patients are coping with the COVID-19 pandemic as current results indicated that these individuals are impacted more severely than those without OCD, even as the pandemic continues. Perhaps, some of these individuals will need augmented treatments such as an increase in session frequency or medication changes. In addition, clinical attention ought to be given to individuals with OCD who identify as Hispanic. Given our findings, those who identify as Hispanic were significantly more likely to report that their OCD had worsened. Not only were those who have a diagnosis of OCD and identify as Hispanic at greater risk for reporting that their OCD had worsened, but also those who identify as Hispanic, regardless of an OCD diagnosis, reported that they were more impaired in work, family, and social life due to the pandemic.

Given the current findings that OCD symptoms can shift, specifically shifting one's obsessions toward the global stressor, it is important that clinicians are assessing for whether obsessions and compulsions have surfaced surrounding the specific global stressor such as the COVID-19 pandemic, regardless of what symptom dimension of OCD the patient initially presents with. Clinicians may want to assess changes in dimensions repeatedly over time to assess not only OCD severity but also whether new symptoms are emerging. If clinicians continually assess whether the global life stressor has become a part of one's OCD, it is hypothesized that the patient's obsessions will be able to be treated as research has shown the sooner one begins therapy for OCD the better the prognosis (Poyraz et al., 2015).

4.2. Limitations

There are several important limitations of this study. First, this study was conducted online and utilized only self-report measures. Self-reports of the severity of one's OCD, how the COVID-19 pandemic has impacted their OCD symptomology, and how they have coped with the COVID-19 pandemic are subjective and prone to participant bias. Participant bias can occur in this situation as there is no objective test or measure to retroactively say how one fared during a specific time. Although this study is prone to participant bias, the study had a comparison group without OCD and large sample size to mitigate participant bias effects. Despite this study having the potential for participant bias, this is an important research question to address as it can inform future longitudinal studies. Additionally, although each participant completed the DOCS which is a reliable and valid questionnaire that has been widely used for OCD diagnosis in other studies (Abramowitz et al., 2010), the study design did not allow for a structured interview to ensure a proper diagnosis of OCD. For this reason, it is possible that some participants do not meet full criteria for a diagnosis of OCD. Furthermore, participants were not screened for other mental health disorders, which raises the possibility that participants may have been experiencing other disorders such as general anxiety disorders or depression. As noted, only self-report measures were used in the current study, and so the distinction between obsessing and worrying is not able to be completely ascertained. It is possible that those with OCD who reported that COVID-19 became an obsession of theirs simply meant that they were overly worried about the pandemic. For this reason, the third aim is exploratory and the results indicating that dimension stability seems to have the capability to shift to a new dimension needs to be further explored.

Given the recruitment strategy employed for this study, there could be a potential for selection bias. For instance, those with OCD who had COVID-19 related distress may have preferentially participated in this study as it was directly related to their concerns. Individuals who had no distress from the pandemic may have been more likely to opt out of the study. A further limitation is that three out of the five scales used for this study were created for the purpose of the current study and had not been empirically validated. Of note, all scales, including the ones developed for this study, all had good internal consistency.

This study was conducted about a year after the start of the pandemic. Because of the swift and evolving nature of the COVID-19 pandemic, these results cannot be generalized to different time periods of the pandemic. For instance, vaccinations and greater access to treatments have become available after the study had been conducted. Results may have been different once individuals had some semblance of relief following vaccination.

Lastly, the current study did not collect any qualitative information or personal examples of how the COVID-19 pandemic impacted each individual, in what way their OCD worsened, and their future concerns about the pandemic. This study also did not collect qualitative data on the specific dimension content prior to the COVID-19 pandemic and personal accounts of how the content of their OCD obsessions shifted when COVID-19 became a concern. Further, no data surrounding previous or current treatment was gathered. Such information could shed light on the specifics of how the COVID-19 pandemic impacted those with OCD and whether some individuals with OCD were coping better with the pandemic as a result of utilizing coping behaviors, such as being involved in therapy.

4.3. Future directions

Future research should be conducted to expand the findings from the current study. First, the current study only assessed stability of OCD symptom dimensions one year after the start of the COVID-19 pandemic. It is important that future research assesses whether preoccupation with the COVID-19 pandemic continues to be more distressing than the individual's original OCD dimension or whether one's original dimension re-emerged as the most distressing aspect of their OCD. In addition, it would be useful for future research to understand which, if any, dimensions of OCD tend to be stable both overtime and with an added stressful life event. Further, future research should not only assess how quantitatively individuals were impacted by the COVID-19 pandemic, but also should assess it qualitatively. For example, it would be useful for future studies to assess whether COVID-19 incited fear, stress, distress, anxiety, or impairment. Based on quantitative data alone, it is difficult to get a sense of these different constructs.

Given that the current study did not assess how treatment impacted symptom outcomes, it is important that future studies continue to explore this. A prior study found that most individuals who were in mental health treatment for their OCD did not have worsening of their illness when COVID-19 emerged (Sharma et al., 2021). Further, this study found that even those with contamination OCD seemed resilient to their OCD symptoms worsening (Sharma et al., 2021). It would be beneficial for future research to continue to examine how treatment impacts one's resilience to direct mental health impacts from the COVID-19 pandemic.

Additionally, this study should be repeated to assess the impact of the COVID-19 pandemic on individuals after they have received vaccinations to protect themselves from the COVID-19 virus. Future research should continue to assess how those with OCD are coping after the evolving nature of the COVID-19 pandemic. Additionally, researchers should assess whether those with OCD are more or less hesitant to receive vaccines compared to individuals without a diagnosis of OCD. This research could also allow for understanding whether individuals with OCD who are vaccinated show a decrease in impairment from the COVID-19 pandemic compared to those with OCD who are unvaccinated.

4.4. Summary and conclusions

The results of this study support the hypothesis that those with OCD have been markedly more impaired by the COVID-19 pandemic compared to those without this diagnosis. Further, different dimensions of OCD are associated with varying fears related to the COVID-19 pandemic. This study demonstrated that one's symptoms have the potential to shift to a new dimension as a result of a global life stressor. These results have clinical importance for both clinicians and those with a diagnosis of OCD. Future research should continue to assess how those with OCD have adapted to life after many of the original restrictions related to COVID-19 have been removed.

Authorship statement

All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication.

Declaration of competing interest

Given their role as an Editorial Board Member, Michael Wheaton, Ph.D., had no involvement in the peer-review of this article and had no access to information regarding its peer-review. All other authors have declared no conflict of interest.

Data availability

Data will be made available on request.