Rosalyn, not her real name, didn’t know what to do with three boxes of spaghetti that she just tossed into her shopping basket. She didn’t want them—she certainly didn’t need them—but never mind, she had to buy them. And the spaghetti boxes weren’t the only unwanted items she picked up in the grocery store that day during the first year of the COVID-19 pandemic. When she even tried to grab one item, it was thrown into her cart.
“Everything my hand touched I had to buy,” she said. “I didn’t feel I had a choice. There was too great a chance that I had somehow contaminated the item, and then it would hurt another unsuspecting customer who bought it.” So she left the store with a bulging load of shopping bags—and a lot of guilt, too. “Once I had bought so much, I worried there wouldn’t be enough food left for other people.”
According to the National Institute of Mental Health, Rosalyn is among the 2.3% of Americans diagnosed with obsessive compulsive disorder (or OCD). OCD can be caused by an excessive amount of activity in the amygdala (a structure that is walnut-sized at the bottom of the brain and which processes fear, danger, and the fight or flight response). The disorder can manifest as compulsive, repetitive behaviors; an anxiety about getting ill or spreading germs; or an excessive sense of responsibility, and an intense fear of causing risk to others, as in Rosalyn’s case. A 2008 study that was published in the Journal in 2008 found that 25% to 25% of Americans suffer from obsessive-compulsive behaviors at least occasionally. Nature.
OCD patients have found their life difficult since the pandemic. Recent research has shown that OCD symptoms are getting worse for some people since the pandemic. New diagnoses have also increased. More and more people are turning up in doctors’ offices with new cases of the condition. “Studies have consistently shown that people without OCD have scored higher on our OCD assessments than they did before the pandemic,” says Guzick. “They are exhibiting more OCD-like behaviors and reporting more intrusive fears characteristic of OCD.”
It’s no wonder: A global pandemic is a perfect breeding ground for anxiety. OCD can be described as a disorder of doubt. It wasAre the knobs on your doors contaminated? It wasWhat if I don’t turn on the stove? What did I say to the doctor when she said my freckle is real? JustWhat is a freckle? You can see a freckle?
“OCD thrives on intolerance of uncertainty and a perceived need to prevent harm, especially as it relates to contamination, so it is no surprise that it has been a difficult time for people struggling with the disorder,” says Andrew Guzick, a clinical psychologist at the Baylor College of Medicine. In October 2021, he published his meta-analysis. Current Psychology ReportsAccording to a study, 32% of OCD sufferers experienced worsening symptoms in the wake of the pandemic.
OCD can be triggered by context. It is more severe when there are high levels of stress or personal trauma. When the situation becomes less stressful, it will improve. Since COVID-19 first emerged, a flurry of research in addition to Guzick’s has been conducted looking at the exacerbation of symptoms in people with the condition, and the findings have been troubling. The September 2020 study was published in the International Journal of Environmental Research and Public HealthFor example, the study of more than 6000 people suffering from OCD found that half of them reported an increase in their OCD symptoms, or the onset of new OCD symptoms, since the beginning of the pandemic, which ran from late 2019 to the end March 2020. In November 2021, a meta-analysis of 21 papers was published. Neuroscience & Behavioral ReviewsThe pandemic caused an increase in OCD symptoms for up to 65%, according to the study. Another 2020 study was published in BMC PsychiatryOctember was devoted to young people aged 7-21. Nearly 45% reported a worsening in OCD symptoms after the pandemic.
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For people suffering with OCD involving contamination, the pandemic has been something of a validation—a “told-you-so” to all of the people who had scolded them that their compulsive need to wash their hands and socially distance before the pandemic was excessive and unhealthy. “Welcome to My world!” memes have popped up all over the internet from OCD sufferers as the population at large began to adopt exactly the same precautionary habits they had long practiced. But that kind of satisfaction is short-lived—and comes with a long-term price.
“There are some folks who are saying, ‘I’m actually having an amelioration of symptoms, or I feel validated in my concerns,’” says Michael Wheaton, assistant professor of psychology at Barnard College, and the lead author of a June 2021 study in the Journal of Anxiety DisordersIt was found that 72% people suffering from OCD experienced worsening symptoms after the outbreak of the pandemic.
People without OCD react to the pandemic-era guidelines in a different way than those with OCD. In the age COVID-19, washing your hands for just 20 seconds may be a common habit. However, people suffering from OCD often respond to pandemic-era guidelines by repeatedly washing their hands for more than 20 minutes. It’s that kind of overreaction that clinicians are worried is becoming too prevalent.
“For somebody with contamination issues, we would talk to them about hand washing upon entry of the home, but no other hand washing once you’re in the confines of your home. We tell them we’re going to operate by CDC [the U.S. Centers for Disease Control and Prevention], not OCD,” says clinical psychologist Anthony Pinto, program director of the Northwell Health OCD Center on the campus of Long Island Jewish Medical Center. Pinto also suggests that those with OCD “practice touching [potentially contaminated] objects in the home after washing.” Re-exposing patients to perceived dangers like picking up mail or unwashed groceries and then resisting the urge to decontaminate—a treatment approach known as exposure and response prevention (ERP)—was a pillar of all OCD treatment long before the pandemic.
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ERP during the pandemic era was problematic because it wasn’t clear if exposure was dangerous. We used to open doors using our elbows and push shopping carts while our sleeves were down. In those early days, COVID-19 was still a new concept. Even now—especially with the rise of Omicron—no psychologist treating an OCD patient would recommend wading unmasked and untested into crowds of people whose viral status is unknown, just to toughen a patient’s psyche against the anxiety caused by OCD.
What’s more, ERP is traditionally meant to be practiced in the supportive presence of a clinician—a context that isn’t necessarily comfortable or even available for many during the pandemic. ERP specialists have learned to adapt; Zoom and other platforms and telehealth sessions have grown in popularity over the last two years. Many exercises can now be completed virtually, just as easily on-screen. If a patient is afraid to sit on their bed after being outside, for example, “we can work with that patient online to go outside and then come back in and sit on their bed, then lay on the bed with their street clothes on,” says Pinto. “This is really geared towards experiential learning—having the patient ride through that uncomfortable experience.”
Things get trickier for people with the responsibility form of OCD—the fear not of putting themselves in danger, but of harming others—like Charles. Charles, not his real name, used to hear every three-year old son’s sniffles to alert him to go to the doctor to get another COVID-19 test. This involved a painful deep-nose probe. Charles advocated for home tests but his wife refused. When the boy didn’t get tested, Charles suffered inwardly.
“I, predictably, imagine doomsday scenarios whereby we wipe out his entire nursery school because we were cavalier about minor cold symptoms,” he says.
OCD can be exacerbated by stress, in whatever form that it may take. The more anxious someone is, the more they will seek comfort from their rituals. “We see in students who have OCD, when it comes time for final exam period, they’re stressed and sometimes OCD symptoms get worse,” says Wheaton. “They have developed this habitual response that when I’m anxious and stressed out, I turn to compulsions, because it’s sort of a learned behavior to give me a sense of control.”
Although the pandemic is likely to end in the final, OCD sufferers may need to continue their anxiety and preventive measures. “The driving force in OCD is the amygdala’s distress signal; it’s not driven by new information from society,” Phillipson says. To undo two years worth of contamination validation can take time. Pinto is concerned that OCD sufferers will not be able to let go of their old habits and continue to adhere to the pandemic. “Those individuals were going to have a hard time adapting or trying to return to some normal activity because they want some assurance of 100% safety,” he says. “The only way to have that assurance would be to remain shut down.”
For some people, however, the trial by viral fire has actually been instructive, forcing them to deal with their OCD in ways they hadn’t before. “The COVID era has exacerbated my OCD symptoms, but it’s also been something of an opportunity,” says Charles. “I have a long history with cognitive behavioral therapy, and there has certainly been no shortage of chances to sharpen those skills. The added stress has also led me to seek out a psychiatrist and a prescription for medication, which has been a big help as well.”
“But in the end,” he adds with a rueful laugh, “would I do it all again? Hell no.”