COVID Q&A: Obsessive Compulsive Disorder (OCD)

We spoke to Rachel Ginsberg, PhD, Assistant Director, Columbia University Clinic for Anxiety and Related Disorders (CUCARD) -Westchester and Assistant Professor of Medical Psychology (in Psychiatry) at Columbia University Irving Medical Center, about living with Obsessive Compulsive Disorder (OCD) during the OCVID-19 pandemic.

Columbia Psychiatry: All the talk about the coronavirus and germs must cause heightened reactions in those who suffer from OCD or germ phobias, or cause the beginnings of such disorders in those who never experienced them prior to the pandemic. What is OCD and how common is it?

Dr. Ginsberg: Obsessive-compulsive disorder (OCD) is a mental health condition that is characterized by obsessions, compulsions, or both. Obsessions are excessive and repetitive intrusive thoughts, images, or impulses that are distressing and increase anxiety, and often drive compulsions. Compulsions (which can be physical or mental) are ritualized behaviors aimed at neutralizing or quieting obsessions. According to the National Institute of Mental Health, OCD has a lifetime prevalence of 2.3%. 

Columbia Psychiatry: How can those who suffer from OCD or a fear of germs cope with the incessant talk about COVID-19 all around them?

Dr. Ginsberg: The key to effective coping is practicing balance and flexibility. Individuals with OCD have typically been taught to approach and not avoid their fears. Ideally, individuals who suffer from OCD would want to strike a balance between being open and willing to tolerate COVID-19-related talk without trying to escape, avoid, or suppress the information, while also finding ways to reduce overconsumption of conversation and news related to COVID. Individuals with OCD would benefit from practicing “making room” for tolerating COVID-related talk, while focusing on pursuing healthy coping strategies (e.g. daily exercise, spending time outdoors, engaging in good sleep habits) to ensure that they are engaged in daily activities in line with their personal goals and values. The main idea here is to balance a willingness to tolerate uncertainty, doubt, and discomfort, while at the same time practicing self-compassion and setting healthy limits so as not to obsess or dwell on COVID-19 discussion. It is best to focus more on staying connected and focus less on staying updated. This might mean learning to effectively shift the focus of conversation with friends and family members who may be alarmist to other topics of discussion that are more productive and conductive to healthy living.

Columbia Psychiatry: Could excessive cleaning and handwashing during the coronavirus pandemic lead to OCD or germ phobia?

Dr. Ginsberg: OCD or contamination fears are caused by a combination of factors, captured by the diathesis-stress model. Individuals who develop OCD have a genetic (biological or neurological) vulnerability to developing OCD, which is typically precipitated by environmental stressors. In individuals who have these biological vulnerabilities and obsessive-compulsive tendencies, behaviors such as excessive cleaning, handwashing, and avoidance can trigger these conditions. However, individuals who are not predisposed to OCD are unlikely to develop these lifelong conditions, and instead, will become less concerned with cleaning rituals as time goes on and normal routines resume. Our sensitivities to cleaning and handwashing have been explicitly heightened as safety precautions, but when “normal” and safe activities resume, those without predispositions to OCD will likely gradually return to standard handwashing/cleaning practices rather than maintaining fear-based rituals over time. In non-OCD sufferers, when the threat diminishes, the threat-based response will diminish. In OCD sufferers, when the threat diminishes, the threat-based response may persist or amplify. 

Columbia Psychiatry: How can you tell if you’re just careful about handwashing and cleaning versus if you have OCD? 

Dr. Ginsberg: Due to the convergence of contamination anxiety and the threat of COVID-19, the differences between being cautious versus having OCD can be hard to delineate; however, there are a few key and critical distinctions. For those who struggle with contamination fears, you want to make sure that you are following the CDC guidelines, but doing no more than what is “prescribed.” This might include disinfecting surfaces once per day for a few minutes if you received packages, washing your hands with soap for 20 seconds (and no more) after being in public, and engaging in social distancing, etc.

For those who feel compelled to do more and are unsure whether an activity seems reasonable or excessive, it is best to typically assume that these activities are excessive. It is important to remember that the goal is not to engage in cleaning or washing when you “feel” like you should or engage in these behaviors in order to “feel” clean. You want to try and focus more on the facts than the feelings.

Individuals with OCD might be more inclined to clean or handwash until they “feel clean” or “just right” and their fears or not-just-right sensations might persist despite engaging in cleaning or washing. Furthermore, individuals with OCD are more likely to experience perfectionism and the need for control, “magical thinking” and superstitious fears around handwashing and cleaning, such as fear of being contaminated or contracting COVID if they do not do something a certain way, or in a certain order.

In working with clients with OCD, I often refer to this problem as helpful thinking versus “extra” thinking, and challenge clients to go with their gut as to whether a thought or impulse seems excessive (i.e. stretched logic) or whether others would agree that it makes sense and fits the facts. You want to be thinking, “Is this a rational response or an emotional reaction?” This is similar to if a doctor prescribes 100mg of a medication to help with your pain. You don’t want to aggressively double the dose just because you feel pain or anxiety. The goal is to follow CDC guidelines and not push beyond them. OCD’s rules and recommendations are harsher than the CDC’s – choose to play by the latter’s rulebook.

It is also important to practice daily radical acceptance that no matter what precautions we take, or what rules we uphold, there is no “perfect” way to clean and there is always still a possibility of becoming ill; this can help disarm the urgency associated with excessive cleaning rituals, and help individuals shift their focus to healthier and more productive activities and surrender the illusion of control.

Columbia Psychiatry: Do you expect to see a surge of new OCD patients now that the general public has hand washing on their minds 24/7?

Dr. Ginsberg: The potential “surge” of OCD will most likely only affect those who were already biologically predisposed to OCD and/or obsessive-compulsive spectrum-related disorders, who are may be environmentally triggered by significant life stressors (e.g. social distancing, limited activities due to the shelter-in-place order, excessive idle time, unemployment/financial stressors, virtual learning, and family conflict). Even positive transitions (e.g. resuming social activities, returning to work, a delayed graduation), or “good stress” may precipitate OCD as well. Anecdotally, some individuals who I have worked with who struggled with contamination OCD in the past and completed treatment successfully are actually doing well (i.e. better than most) during these times since they have learned and practiced healthy ways to cope with their fears while engaging in realistic self-protective measures.  

Columbia Psychiatry: Are there any other types of OCD other than excessive handwashing and cleaning that may develop during the pandemic?

Dr. Ginsberg: Other types of OCD that can be triggered by this pandemic include somatic obsessions (concerns with illness or disease, such as headaches), sensory-focused symptoms (obsessing over sensations in the body or perceived feelings on the skin’s surface), feelings of overresponsibility and inappropriate guilt (e.g. related to spreading the illness), and harm OCD (e.g. fear that one will be responsible for something terrible happening, such as unknowingly causing others’ death). Additional OCD symptoms might include magical thinking, superstitious fears, fear of harm coming to self or others because of not being careful enough (fear of spreading germs if you were unknowingly COVID-positive or asymptomatic), and religious obsessions or excessive fear of right vs. wrong. Moreover, OCD symptoms may include needing to know or remember information related to updated guidelines, and related excessive information gathering and checking. In addition to handwashing and cleaning, compulsions that might present or worsen could include mental reviewing (of where you have been, how far you stood from someone else, what you might have touched), needing to tell/ask/confess to others, superstitious behaviors, and health-related compulsions (e.g. asking for excessive reassurance from doctors about health symptoms).

Obsessions and compulsions that one experiences at this time may vary significantly from person to person and may not necessarily relate in an obvious way to the virus. For example, an individual might have distressing fears that if they see the number “7” they will contract the illness unless they quickly see an even number, while another person might avoid a certain color that they feel is a bad omen for illness. Since anxiety is high in many people at this time, it may also trigger or exacerbate unrelated OCD themes. If one experiences new or worsening symptoms of OCD, it is best to try and begin treatment with a trained mental health professional, since the sooner you can work on challenging these symptoms, the less entrenched obsessive-compulsive behaviors become and the better able you are to cope effectively with anxiety and uncertainty. Though it is not quite a vaccine, EX/RP treatment can be an exceptionally helpful way of preventing or reducing unnecessary suffering and significantly improving quality of life in those with OCD.

It is important that individuals with OCD adhere to safety recommendations by the Center for Disease Control and Prevention (CDC). However, individuals with OCD should do their best to avoid compulsions such as reassurance seeking, checking, mental reviewing, and limit information-seeking (i.e. watching/reading the news for no more than an hour per day and reducing the channels of information). This balance will help to untangle excessive OCD-related behaviors from helpful self-protective behaviors and improve daily living and healthy coping.