The other side of COVID-19: Impact on obsessive compulsive disorder (OCD) and hoarding

The world has been in the grip of a new and evolving threat for the last three months. This new year marked the beginning of the Corona virus disease 2019 (COVID-19), caused by the novel coronavirus SARS-CoV-2 which took a little more than a month to turn into a pandemic. Initiated at the Wuhan province of China, this highly contagious illness spread fast to affect more than 1.7 million globally and claiming the lives of around one lakh till date (World Health Organization Situation Report as on 12 April 2020). Borders have been shut down internationally, economies slashed, and billions of people quarantined or isolated at their own homes. As the global health agencies struggle to find a solution for containment, the major strategies recommended by the World Health Organization (WHO) and Center for Disease Control and Prevention (CDC) are social distancing, hand and respiratory hygiene. The demand for sanitizers, soaps and gloves have sky-rocketed all over as hand washing is considered to be one of the safest precautions against the infection. Every single media source is stressing on the importance of hygienic measures, washing and prevention of contamination. While apparently it seems the easiest to follow, what about those who already have their doubts with hygiene and the compulsive need to stay clean: patients with obsessive compulsive disorder (OCD). Out of the many psycho-social implications that the COVID-19 pandemic has brought forth including panic, health anxiety, mass hysteria and loneliness of isolation: the prominence of obsessive-compulsive symptoms has largely been neglected, while we can only assume how much distress it causes to those affected. Worldwide there have been reports of increased symptoms, distress and concern about this illness. Sadly, lack of sensitization to this mental health issue among public health workers adds to the problem statement.

The burden of OCD is worrisome. Even before COVID-19 struck the world, it had a lifetime prevalence of 2–3 percent. Anxiety disorders (panic disorder, generalized anxiety disorder, phobias, panic attacks) form the commonest comorbidity of 70 percent and depressive disorders around 30 percent (American Psychiatric Association, 2013). Of the multiple symptom domains, obsessions of contamination and compulsive hand washing are amongst the commonest. Also, it has been seen that though these domains respond well to pharmacotherapy and psychotherapy, it tends to relapse in case of stress due to external or environmental cues (Cordiero et al., 2015). The increase in symptoms might not be immediate, but might take days to months to fully manifest. Various prevalent factors during the present pandemic, can play a role in worsening the symptoms of those already affected:

• 1The increased demand for hand washing and the minimum time duration recommended for it.
• 2The importance for ‘proper’ hand-washing steps as per recommendations: can add to a ritualistic pattern.
• 3The need to keep the hands clean every time a person comes from outside or there is a suspected exposure: cognitive 'justification' of same rather than considering it to be a problem.
• 4The prompting of family to ensure strict hygienic measures and vice versa.
• 5The constant loading of information from various media sources about possibility of the virus to stay active on various inanimate surfaces, hence adding to the thoughts of contamination.
• 6Increased ruminations and repeated washing (or even bathing), can be ‘normalized’ at the face of a pandemic response as an exaggerated precautionary measure
• 7Stocking of masks, soaps, sanitizers, disinfectants that can lead to hoarding and panic shopping.

In this context, it is also vital to consider Hoarding disorder, which is a part of the broader Obsessive Compulsive (OC) Spectrum in DSM-V. It can be highly comorbid with OCD but also has been considered as a distinct phenotype in many individuals. Though, most of the earlier research has focused exclusively on hoarding disorder as a sub-type of OCD, it is now thought to be a distinct disorder with a significant lifetime prevalence of 2–5 percent. Also, apart from hoarding items of little use, it has also been shown that need-based hoarding can increase both in OCD and hoarding disorder. The above-mentioned issues apply in a similar way to people who hoard, and their anxiety can increase subsequent to quarantine and nation-wide lockdown in response to the COVID-19 threat. This also applies to medications used for symptomatic treatment of flu like analgesics, anti-inflammatory and anti-viral drugs. This can lead to shortage of supplies, agitation in the public and patients with genuine needs being deprived of them. Subsequent anxiety might lead to obsessive use of medications like hydroxychloroquine (HCQ), which has recently emerged in guidelines for COVID-19. However, without adequate supervision and precautions, it can be potentially cardio-toxic and even life-threatening for certain individuals. Since COVID-19 was declared as a pandemic by WHO with strict emphasis on washing and disinfection, various media sources have focused on the distress of patients with OCD, increased reporting to the hospitals and first-person accounts of their difficulties. They reported increase of patients with OC symptoms in out-patient departments all across countries like China, United States, United Kingdom, Italy and India but scientific literature on the statistics are yet to be established (www.time.com)

Pandemics are not just biological or medical phenomena. They have immense psycho-social implications and affect society at a large. It is well-established that people with pre-existing mental disorders are more prone for relapses, defaulting on medications, stress, stigma, poor self-care and suicidality during pandemics. It also contributes to ‘medical mistrust’, paranoia, depression that can be compounded by isolation and physical distancing from interpersonal relationships (Duan and Zhu, 2020). OCD varies in insight and cases with delusional symptoms might be at a greater risk for decompensation. In previous outbreaks like Severe Acute Respiratory Syndrome (SARS), Middle East respiratory syndrome (MERS) and Influenza, the exacerbation of OCD has been well-documented especially within 6–12 months after ceasing of the outbreak. Whenever the strategies against an infection involve 'repititive behaviors;, it carries the risk of increasing obsessional disorders. It might not be evident in the active phase of the outbreak due to under-detection, disruption of medical services and alternate public health priorities (Mak et al., 2009). Especially during the active phase of a pandemic, mental health needs might not be on the publci health forefront leading to worsening of symptoms and late diagnoses. Many patients of OCD might have insight but are hesitant to seek help either due to stigma or lack of understanding related to what is 'excess' behaviour in terms of washing and bathing. However, with increasing number of countries affected with passing days of isolation, managing mental disorders has been emerging as a necessity to stabilize quality of lives.

The number of OCD patients relapsing in India are increasing at various set-ups, though it is still personal and anecdotal data from most clinicians. We hope to systematically analyze it in the coming days to have a better understanding of the relapses. Also, non-essential medical services are suspended at many places as an attempt to contain the outbreak. This can further lead to lack of follow-ups and prescription refills, discontinuation of psychotherapy, and lack of availability of online psychotherapy at many set-ups. Though tele-psychiatric practices are increasing, the use and accessibility in many areas are limited. Even clinicians continue to have their own challenges and reservations about tele-consultations. Especially in developing countries like India, where OC symptoms are also considered to be culture-bound and religion-laden in certain areas, it is difficult to sensitize people and their families to what is ‘excessive’ washing in a context where everyone is panicking to follow the precautionary instructions. However, awareness is the need of the hour. Psychoeducation of the patients and families, debunking misinformation about the pandemic, facilitating tele-consults and online psychotherapy, using the psychiatric social work support to follow-up on severe and treatment resistant patients, ensuring drug compliance are necessary steps to help people who are in need. It is vital to explain to them the context and circumstances of washing and make them realize what is ‘out of proportion’. Similarly, any unnecessary hoarding needs to be minimized. Uncontrolled obsessions and compulsions can lead to dermatological conditions, chronic stress, insomnia and high risk for suicide. More so, when the overall panic and fear of a pandemic is looming large. Lack of inhibitory control in OCD can run into a vicious loop thus bringing in a chronic sense of vulnerability to the infection, hence increased thought of contamination and increased washing. Both the psychiatrists and allied specialties need to be sensitized to this. We need to be prepared for the likely surge of such cases, especially in the next 3-6 months. Primary health-care workers at various sites need to be trained to identify OC complaints and the necessary referrals. The pandemic will eventually die down, but the increased frequency and intensity of this disturbing mental disorder will be an unfortunate aftermath for many months to come.

Declaration of Competing Interest

None.