OCD during COVID-19

OCD during COVID-19

Affecting approximately 1 in 100 individuals[1], obsessive compulsive disorder (OCD) is characterized by obsessions (intrusive thoughts, images, impulses, ideas, or doubts) and compulsions (behavioural/mental actions or avoidance aimed at reducing discomfort or preventing a bad outcome from happening). COVID-19 has added a new level of stress to daily living, increasing vulnerability for obsessional thinking, and the potential for depression.

OCD and fear of germs

There is a myth that those afflicted with OCD must have a fear dirt and germs. In fact, obsessions can focus on any subject matter, resulting in a sense of fear, dread, or disgust. There is much written about OCD on the Internet and on social media. OCD themes are often referred to with the following non-clinical labels: contamination OCD existential OCD, relationship OCD, checking OCD, harm OCD, and Pure-O. Obsessional themes can focus on anything that is contrary to an individual’s values. The gentlest person has graphic thoughts about forcing their grandmother’s hand into a meat grinder, the person who has always wanted to be a schoolteacher has sexual thoughts about children, and the person who prides themselves on being meticulous stats to doubt if they have missed something important and could henceforth be responsible for a grave outcome. The themes are endless, but they follow the same prescribed formula:

Obsession:

thought, image, impulse, idea, doubt

Physical compulsion

Mental compulsion

Avoidance of obsession

Reinforcement of obsession

Example: The front door might not be locked, and I’ll be responsible for a break-in

Checking and rechecking the door

Reviewing memory / rationalizing

Not leaving the house, or going too far

The only reason we were not robbed is that I spent 30 mins checking the door. So, I had better do the same next time.

 

For those with obsessions focussed on dirt and germs, the pandemic has led to a worsening in fear: “I knew it all along that it was dangerous to go to the grocery store!” Increased cleaning/washing and avoidance paradoxically leads to more (not less) obsessional thinking. For those with non-contamination themes of OCD, the pandemic may have worsened their symptoms just by adding to the individual’s daily stress.

A normal reaction to an abnormal situation

As psychologists we have begun to see a level of “COVID-fatigue” faced by many of our clients. The second wave of COVID and subsequent lockdown in Ontario corresponded with a rollercoaster of varying moods. More than ever, we have been normalizing the experience of having low mood and feelings of depression during this unprecedented time. It seems now to be somewhat of a normal reaction (feeling down and tired) to an abnormal situation (the pandemic).

With few exceptions, COVID-19 has affected us all negatively. In the extreme, some have suffered unimaginable loss: death of a loved one, job loss, homelessness, poverty etc. For others it has led to a change in “life as we know it”: an abrupt shift to remote learning, limited social connections, loss of work routine, inability to travel, uncertainty about the future etc. The pandemic is a major life stressor, and it can increase the risk for developing depression.

Feeling depressed vs. having “depression”

Feeling down or feeling depressed when faced with a life stressor is not unusual. It is important, however, to monitor for “major depressive disorder”, a technical term used to diagnose “depression”.  According to the Canadian Mental Health Foundation, approximately 8% of adults will experience depression in their lifetimes[2].

More than just feeling down or “blue”, a major depressive disorder lasts more than two weeks, and includes several different symptoms. To diagnose depression, an individual must be experiencing five or more symptoms during a 2-week period with at least one of the symptoms 1) depressed mood, or 2) loss of interest or pleasure. Other symptoms include:

  • Weight loss or gain
  • Trouble sleeping or sleeping too much
  • Moving slowly or being restless
  • Fatigue or loss of energy
  • Feelings of worthless or guilt
  • Difficulty concentrating or making decisions
  • Thoughts about death or suicide

Anyone experiencing suicidal thoughts should speak to their family doctor, reach out to another professional, or call a crisis phone line (see below).

OCD and depression

The global pandemic has led to unexpected changes in our lives. Experiencing change can be especially difficult for those who suffer from anxiety, and for those afflicted by OCD. It seems to be that when OCD recognizes worry/stress/anxiety/fear, it seizes the opportunity to make life worse for the individual. When obsessions increase in strength and frequency, and compulsions (or avoidance) worsen, feelings of hopelessness and depression can follow.

A recent study showed that depression is the most commonly occurring psychiatric disorder among those with OCD, affecting approximately 50% of these individuals.[3]  This same study found that the risk for depression increased if the individual with OCD had experienced a stressful life event during the preceding six months.[3] Dealing with a significant stressor (such as the pandemic) could be contributing to depression. When both OCD and depression are experienced together, treatment recommendations are determined on a case-by-case basis. Typically, OCD would be targeted first, in the hopes that the depression would indirectly remit. However, both conditions can be addressed simultaneously.

Treating OCD

OCD treatment always begins with a careful behavioural formulation. A trained expert catalogues the obsessions, maps out the reactions to these (i.e. compulsions, avoidance, selective attention), and examines the person’s beliefs about the obsessions themselves.  The current gold standard treatment for OCD is a type of cognitive-behaviour therapy (CBT) called exposure with response prevention (ERP). Medication is also considered an evidence-based treatment for OCD, and this may be prescribed instead of or in addition to ERP. When considering professional help, it is important to find an expert who has demonstrated experience and training in ERP, because other types of therapy (e.g. standard CBT, supportive counselling, hypnosis) can worsen the symptoms of OCD. The International OCD Foundation[4] provides a list of recognized OCD providers.

For those individuals with OCD who have started a course of ERP, the following tips are useful to remember when the going gets tough:

  • Engaging in compulsions makes the OCD worse over time
  • This anxiety is temporary and will subside
  • Trying to control anxiety with compulsions does not work
  • You can handle this and you know you will start to feel better soon
  • Remember how good you felt last time once the anxiety subsided
  • Keep pushing because it’s worth it to get your life back

Practicing ERP is effective at getting OCD under control. Once better managed, continued practice of ERP (without a therapist) provides some protective measure against worsening of the obsessions, and the development of new obsessions.

Treating Depression

Feeling down or depressed is experienced by most of us at some point. However, when the feelings become entrenched and last for more than two weeks, seeking professional can be considered. Currently, there are only two types of psychological treatment considered evidence-based for the treatment of depression: cognitive-behaviour therapy (CBT) and interpersonal psychotherapy (IPT). Medication has also been demonstrated through research to be an effective treatment for depression, and a combination of pharmacotherapy and psychotherapy can also be considered.

CBT for depression also starts with a careful assessment: examining negative thoughts, identifying core beliefs, and cataloging current daily activities. Once the individual’s situation is better understood, cognitive therapy is used to shift negative thoughts and beliefs, and targeted “behavioural activation” increases engagement in productive and pleasurable activities. When administered effectively, CBT can help individuals get well and stay well.

Building resilience

There are actions that we can all take to improve resilience, serving as some level of protection against stress and potentially depression. Ask yourself how much you are attending to the following areas:

  • Good quality sleep and rest
  • Relaxation
  • Physical activity
  • Fresh air and nature
  • Healthy eating
  • Social contact (virtual counts)
  • Creativity
  • Simplifying challenging tasks
  • Evaluating expectations
  • Practicing gratitude
  • Having purpose
  • Having fun

Start by setting some realistic goals for yourself. These strategies are especially recommended for anyone struggling with OCD and/or depression.

In summary

The global pandemic is a major life stressor that has worsened OCD for many, not just for those with obsessions about dirt and germs. When individuals with OCD are feeling more grounded and mentally strong, they are better able to disregard the obsessions and resist engaging in compulsions. When individuals are feeling worn down and vulnerable, they tend to fall back into their old patterns of engaging in their compulsions, inadvertently worsening the OCD, and increasing vulnerability for depression. During this era of COVID-19, it is important to keep up the fight against OCD, and to combat stress and feelings of depression by building resilience.

This article was written by: Joanna McBride, M.A., C.Psych., Director, Archways Centre for CBT

If you are in distress or need emotional support immediately, please call 1-833-456-4566 (Canadian Suicide Prevention and Support Line). If this is an emergency, please call 911.

[1] National Institute of Mental Health www.nimh.nih.gov

[2] Canadian Mental Health Association www.cmha.ca

[3] Altinas & Taskintuna (2015) Factors associated with depression in obsessive-compulsive disorder: a cross-sectional study. Noro Psikiyatr Ars. 52(4): 346-353

[4] International OCD Foundation www.iocdf.org

ABOUT AUTHOR

Joanna McBride

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