Acute impact of COVID‐19 pandemic on phenomenological features in fully or partially remitted patients with obsessive–compulsive disorder

Recent researches and observations have indicated that during the COVID‐19 pandemic, a number of people have exhibited stress‐ or anxiety‐related psychopathological features, including fear of becoming infected, fear of coming into contact with possibly contaminated objects or surfaces, fear of foreigners, fear of the socioeconomic consequences of the pandemic, compulsive hand‐washing, checking and reassurance‐seeking associated with possible pandemic‐related threats, and traumatic stress symptoms about COVID‐19 infection (e.g., nightmares, intrusive thoughts). ¹ Fear and panic about COVID‐19 can also cause an increased risk of developing mental health problems, such as depression. ² Moreover, the high levels of fear of COVID‐19 may cause irrational and unclear thoughts. In contamination‐based obsessive–compulsive disorder (OCD) especially, overestimation of threat may include health‐anxiety‐based symptoms, such as obsessions with becoming ill or contaminating others. ³

Additionally, the explicit recommendations by the health authorities on ways to deal with COVID‐19’s potential threats (including washing hands frequently and avoiding physical contact with other people and specific surfaces) often overlap in ‘appearance’ with OCD symptoms. ⁴ Indeed, OCD individuals with fear of contamination may spend hours worrying about the possibility of contacting an infectious illness, avoiding potential contaminants (such as not touching certain surfaces or decreasing social contacts), and/or engaging in compulsive washing behaviors of different sorts (such as taking excessively long showers or spending hours washing or disinfecting hands). ² , ⁴ Thus, in such a situation, OCD patients, especially those with contamination/washing compulsions, may be most sensitive and vulnerable to COVID‐19 fears and at risk of deterioration or recurrence of OCD symptoms. ⁴ The possibility has been suggested that OCD patients may change their symptomatic phenotype and the focus of their main preoccupations, or may add obsessions or worries about COVID‐19 in addition to having greater hand‐washing compounded by increased avoidance. ⁴

To clarify the issues, we preliminarily investigated the acute impact of the COVID‐19 pandemic on the changes of OCD severity or symptomatology in 60 fully or partially remitted OCD patients (mean age = 41.5 years [SD = 7.9 years]; sex ratio (M/F), 25/35) consecutively treated for more than 3 years in our OCD clinic. All participants: met the DSM‐5 criteria for OCD; had directly visited our clinic from 7 April to 2 May 2020 in the state of emergency in Japan; and provided us with informed consent to participate in this study. Of the subjects, 24 (40%) had fully remitted (FR) OCD (total score on Yale–Brown Obsessive–Compulsive Scale [Y‐BOCS] < 8) and 36 subjects (60%) were assessed as partially remitted (PR; 9 < Y‐BOCS < 15), ⁵ and their principle OCD symptoms were categorized according to the symptom dimension typology, ⁶ such as contamination/washing (n = 29), aggressive/checking (n = 20), and symmetry/repeating and ordering (n = 11), at the latest assessment before the spread of COVID‐19 (before December 2019). Their OCD symptoms were reassessed at the time when they came to our clinic in the state of emergency as described above.

The mean (SD) Y‐BOCS total scores before and after the spread of COVID‐19 were, respectively, 5.5 (1.4) and 5.7 (1.5) in the FR group and 12.2 (2.2) and 13.0 (2.3) in the PR group. Only four participants (one in the FR group and three in the PR group; 6.7%) exhibited additional or renewed OCD symptoms associated with COVID‐19, such as contamination obsessions or washing compulsions, and no subjects exhibited the symptom transition of their principle symptoms. In addition, six of the participants (10%) experienced the deterioration of the symptom severity of OCD as assessed by increase of Y‐BOCS total score > 3, especially the ‘time spent performing compulsions’ score rather than the ‘time occupied by obsessive thoughts’ score on the Y‐BOCS without any significant differences in the prevalence between the FR (8.3%) and PR (11.1%) groups. All six subjects with deteriorated OCD, except for one assessed as predominantly having symmetry/repeating and ordering symptoms, had principle OCD symptoms associated with contamination/washing. Finally, those subjects with OCD symptoms badly affected by COVID‐19 were significantly more likely to have higher trait anxiety, depressive status, higher prevalence of generalized anxiety disorder, and contamination/washing symptoms specifically associated with virus respiratory infection, such as influenza infections, at the assessment before the spread of COVID‐19.

In this preliminary study, there were some crucial limitations, such as sample bias (only including subjects who had visited our clinic in the state of emergency), cross‐sectional assessment, and low number of subjects. Moreover, determining the diagnostic threshold for OCD along with severity of OCD symptoms especially associated with contamination/washing symptoms should be substantially affected by the attention in the media, because excessive washing behaviors for more than 30 s has been recommended and endorsed by Japanese health agencies.

Nevertheless, at least in the acute phase along with fully or partially remitted samples, there may be some acute impact on the phenomenological features and severity of OCD. These findings seem consistent with the long‐term stability of OCD symptom dimensions ⁷ and also seem to support the possible inflexibility of symptoms, specifically biological bases of the long‐term enduring symptom structure. ⁸ Further studies are needed to prospectively clarify the longer‐term effect of fear or anxiety regarding COVID‐19 on the onset or deterioration of OCD symptoms in a larger number of subjects, including the general population.

Disclosure statement

The authors have no conflicts of interest to declare.