Impact of COVID‐19 pandemic on patients with obsessive compulsive and related disorders—Psychodermatological perspectives

Dear Editor,

Since health crisis by novel corona virus has spread globally in pandemic proportion within a short span of time, health authorities have stepped up the public awareness campaign of preventive measures like social distancing and hand hygiene to a maximum level. Many countries have made it mandatory by law. Though there is no doubt that these measures are the best things to break the disease transmission chain, it has made the life of patients with obsessive compulsive and related disorders (OCRDs) and their therapists difficult equally. ¹

The burden of OCRD in dermatology patients is considerably high. Of the many domains of OCDR symptoms, obsessions of contamination and compulsive hand washing are among the commonest. Many such patients present to dermatology out patient departments with hand eczema and psychodermatologists may be the primary health care provider to these patients. COVID‐19 crisis has the potential to exacerbate the symptom while they may get unprecedented moral support from the family and society for the same. It has been noted that, though this symptom respond well to combination of pharmacotherapy and psychotherapy, relapse is imminent if subjected to stress due to external or environmental cues. ² The importance of hand hygiene in destroying virus gives a cognitive justification to the patients. Nonpracticality of commonly employed cognitive behavioral therapy (CBT) method exposure and response prevention (ERP) makes things more difficult. At this juncture, we suggest psychodermatologists to follow the guideline by Fineberg et al in a case to case basis. ³ A compassionate calming approach should be maintained and a proper history should be taken. Suicidal risk assessment is vital and proper referral should be made if vulnerability is detected. Psychoeducation with balanced information about the known risks and impact of COVID‐19 on physical and mental health should be provided. A balanced routine should be advised to maximize social and occupational care and some restrictions can be put regarding watching media which exacerbate anxiety. Importance of family support to OCD patients is most crucial in the current situation. They should be counseled properly to extend their support “judiciously,” to distract the patient from gloomy thoughts of infection and to create joyous family space. The use of CBT with ERP can be modified or paused with balance in benefits and risks assessment. Pharmacotherapy with selective serotonin re‐uptake inhibitors at optimal dose can be considered as the first line therapy for OCD during the pandemic. Addition of a low dose antipsychotic can be considered in resistant cases. Trained clinicians can offer other less evidence‐based forms of CBT not involving ERP, such as imaginal exposure or danger ideation reduction therapy, which will be less risky during the pandemic.

We should remember that other conditions in OCRD, as defined by diagnostic and statistical manual of mental disorders 5, such as trichotillomania, psychogenic excoriation, and onychophagia can also be aggravated proportionately to the stress level. ⁴ Moreover the information about skin manifestations of COVID‐19 infection has become popular among public and we are witnessing an increased anxious enquiries regarding the same from our patients. ⁵ Perniosis lesions are being mistaken for reported “Covid toe” by many. This can cause significant obsession and hypochondriasis (which has been recently endorsed as a OCRD in the World Health Organization ICD‐11), which further illustrates the role of psychodermatologists during the pandemic. ⁶

CONFLICT OF INTEREST

The authors declare no potential conflict of interests.