The impact of the COVID-19 pandemic on those with OCDs

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The impact of the COVID-19 pandemic on those with OCDs

Post by trader32176 »

The impact of the COVID-19 pandemic on those with OCDs

11/19/20 ... -OCDs.aspx

Researchers from the University Medical Centre Hamburg-Eppendorf and University Hospital, Munich in Germany, have reported their findings on the course of obsessive-compulsive disorders (OCDs) during the coronavirus disease 2019 (COVID-19) pandemic. Their study, titled “Obsessive-compulsive disorder during COVID-19: Turning a problem into an opportunity?,” was published in the latest issue of the Journal of Anxiety Disorders.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of COVID-19, has infected a large proportion of the global population, with over 56.42 million cases confirmed worldwide. SARS-CoV-2 is a highly infectious virus that spreads via aerosols and airborne droplets from the mouth and nose. These microbe-laden droplets may also contaminate surfaces. Recent research suggests that the viral microbes landing on surfaces can survive on them for up to 72 hours, increasing the risk of surface (or fomite) transmission. Hand hygiene and mask-wearing are therefore among the primary preventative measures used to curb the spread of SARS-CoV-2.

The study’s authors state that these measures are particularly affecting those with obsessive-compulsive disorder (OCD) around sanitation and cleanliness. Those with washing compulsions have been particularly affected, they write. At present, however, there is little empirical evidence regarding how those with washing compulsions are fairing during the ongoing pandemic.

Mental health problems associated with the pandemic

The researchers point out that several mental health problems have been exacerbated by the pandemic and its associated public health measures. Social isolation measures and the economic downturn has also led to the flaring up of pre-existing mental health problems among many.

To study how COVID-19 has affected those with OCDs, the team used the diathesis-stress model to explain the “development and maintenance” of mental health problems among those susceptible to it. The team explains that those at risk suffer from additional contributing factors such as “low resilience, fewer social contacts, and reduced psychiatric care.” Problems aggravated by the pandemic include depression and anxiety disorders as well as associated behavioral problems such as substance abuse disorders, eating disorders and OCD, the team wrote.

Obsessive-compulsive disorder

A common form of OCD, called “contamination-related OCD (C-OCD),” and those with washing compulsions are often among the worst affected during a pandemic. The researchers explain that compulsions of washing and “ritualized washing behaviors,” have been considered to be part of the “new normal.” These behaviors have been advocated by health bodies such as the World Health Organization (WHO).

Fear of not having enough cleaning products has also led to a stockpiling of soaps, sanitizers, disinfectants, toilet papers and other hygiene products. This has been seen not only among those with OCD but also among others as well.

Guidelines and recommendations

According to the consensus statement from the International College of Obsessive Compulsive Spectrum Disorders and the Obsessive-Compulsive Research Network of the European College of Neuropsychopharmacology, patients with OCD need help adapting to the pandemic even with a pause in treatment to allow, “exposure and response prevention (ERP).” The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has also recommended ERP as an effective and recommended treatment for OCD.

The researchers write that what was perceived earlier as exaggerated could be the “new normal” and this may help reduce the stigma. They write, “people with OCD (particularly those with washing compulsions) may also experience relief due to reduced stigmatization or other factors. Some patients may (paradoxically) even experience a sense of competence as a result of their functional beliefs and use of adaptive coping strategies.”

Study design

For this study, a total of 394 persons diagnosed with OCD were included. Of these, 223 had washing compulsions. Persons aged 18 to 80 years were included. Participant recruitment was between March 23rd and May 18th, 2020. During this period, Germany was under a nationwide lockdown.

An assessment of OCD severity was made using the German version of the Obsessive-Compulsive Inventory-Revised (OCI-R). The severity of depression was assessed using the German version of the Patient Health Questionnaire (PHQ-9).

The participant took an online survey with a new set of questions developed by the researchers. Some of the questions were regarding changes in the participants’ OCD symptoms and reasons the participants attributed to this change.

Some participant responses included “reduced mobility, reduced availability of cleaning products, economic factors, lack of availability of doctors/therapist, interpersonal conflicts.” The team of researchers also assessed the beliefs and experiences of the participants of the COVID-19 pandemic.


The study results showed that most people with OCD were negatively affected by the COVID-19 pandemic. These were most pronounced among “washers,” and the most common cause of worsening symptoms included reduced mobility and interpersonal conflicts.

Overall results were:

At the start of the study, the OCD severity was moderate to severe among participants, with a mean score of 27 on the OCI-R. The average depression severity score was 12.41 on the PHQ-9, indicating that depression levels among the participants were largely moderate.
An increase in OCD symptoms was reported by 71.8 percent
This worsening was more significant among “washers” compared to “non-washers.”
Some patients, however, experienced a decrease in symptoms (6.5 percent), and some saw no change in symptoms (21.7 percent).
Dysfunctional beliefs regarding the pandemic were mainly hygiene-related, and these were more prevalent in “washers” than in “non-washers”. These also led to a rise in OCI-R scores and an increase in OCD symptoms overall.
“Washers” were also were more confident in their rituals and adaptability and provided other people with advice to prevent the spread of SARS-CoV-2 infection. A total of 22.4 percent offered advice to others.
Washers were, unfortunately, more likely to receive poor feedback from the people they provided with advice regarding infection prevention through hygiene. Overall, feedback in response to hygiene advice was 39.7 percent positive and 24.7 percent negative as per the participant survey.

Conclusions and implications

The researchers found that most participants with OCD were negatively affected by the COVID-19 pandemic, and this was more prominent among “washers” than in “non-washers”.

They called for rapid and specific interventions against OCD to prevent long-term and long-lasting implications of this pandemic-induced aggravation of symptoms among those with OCD.
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Re: The impact of the COVID-19 pandemic on those with OCDs

Post by trader32176 »

Cognitive Dysfunction in Obsessive-Compulsive Disorder

published 7/16/16 ... 016-0720-3


Obsessive-compulsive disorder (OCD) is a mental disorder featuring obsessions (intrusive thoughts) and compulsions (repetitive behaviors performed in the context of rigid rituals). There is strong evidence for a neurobiological basis of this disorder, involving limbic cortical regions and related basal ganglion areas. However, more research is needed to lift the veil on the precise nature of that involvement and the way it drives the clinical expression of OCD. Altered cognitive functions may underlie the symptoms and thus draw a link between the clinical expression of the disorder and its neurobiological etiology. Our extensive review demonstrates that OCD patients do present a broad range of neuropsychological dysfunctions across all cognitive domains (memory, attention, flexibility, inhibition, verbal fluency, planning, decision-making), but some methodological issues temper this observation. Thus, future research should have a more integrative approach to cognitive functioning, gathering contributions of both experimental psychology and more fundamental neurosciences.
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Re: The impact of the COVID-19 pandemic on those with OCDs

Post by trader32176 »

Exploring the neurobiology of OCD: clinical implications

published March 2, 2020


Obsessive-compulsive disorder (OCD) is a common neuropsychiatric condition, affecting 1-2% of the population globally. Despite considerable heterogeneity in the precise symptoms experienced across different patients (e.g., some patients are preoccupied with worries of contamination, whereas others obsess about symmetry), there is growing realization that common neurobiological processes may contribute to vulnerability towards OCD and its persistence. OCD is regarded as the archetypal disorder of compulsivity (i.e. a tendency towards repetitive habitual actions that a person feels a need to perform, with these tendencies having untoward functional consequences, such as detracting from overall life goals, or quality of life). Although the optimal definition of compulsivity likely depends upon perspective and context1, within this broad clinical framework, disorders of compulsivity include OCD and related disorders such as hoarding disorder, body dysmorphic disorder, trichotillomania, skin picking disorder, and Tourette’s2. Here we focus on recent advances in understanding the neurobiology of OCD, and the clinical implications of such knowledge viewed in the context of prevailing disease models.

Brain circuitry in OCD

Case vignette: Claire, a 21 year-old student, reports a five-year history of moderately severe OCD, mainly relating to taboo sexual thoughts and the repeated need to confess. Claire signs up for a research study exploring the neurobiology of OCD, in which she undertakes a clinical assessment, cognitive tests, and a structural brain scan. At the end of the session, Claire asks whether her brain scan can be used to help confirm that she has OCD. She says she has read on the Internet about research that can accurately diagnose OCD using brain scans. She asks if she can have a picture of her brain to see the changes that happen in OCD.

Structural and functional changes within the brain have long been implicated in the pathophysiology of OCD. Cortical and sub-cortical brain regions comprise a series of functionally relatively segregated circuits, that may play different roles in thoughts and behaviors3. Neuroimaging work in OCD has commonly identified structural and functional abnormalities, most typically involving the orbitofrontal cortices and basal ganglia (caudate nucleus), known as the ‘orbitofrontal circuit’ (for recent reviews see 4–6). These findings support the classical model that OCD can be considered a disorder of maladaptive habit circuitry7, a model that has gained traction and evolved into more recent conceptualizations focusing on habit8,9 and loss of top-down control by cortically-mediated inhibitory mechanisms (referred to as ‘disinhibition’)10.

In recent years, it has become apparent that OCD involves changes across a broad range of fronto-striatal loop circuits11, though abnormalities of the orbitofrontal cortices and basal ganglia have commonly been reported. OCD has typically been associated with grey matter volume increases in sub-cortical structures (such as the putamen and globus pallidus), and with grey matter reductions in the cortex (especially ventral and dorsal medial cortex, and inferior frontal cortex)12. In terms of measures of cortical thickness (a proxy for the number of neurons in a particular brain region), more widespread reductions have been typically observed, including not only in the frontal but also in the parietal and temporal parts of the brain. Another common finding reported in OCD has been reduced fractional anisotropy (a measure of fiber density, axonal diameter, and myelination in white matter) in anterior midline tracts (including parts of the corpus callosum and cingulate bundle)12. Collectively, these neuroimaging data suggest OCD is associated distributed changes across anatomically disparate brain structures, both in terms of grey matter and white matter tracts.

One approach used more recently to explore brain structure in OCD has been to pool structural neuroimaging scans from many diverse group case-control studies, a technique referred to as ‘mega-analysis’. This approach has found that OCD is associated with smaller hippocampal volumes and larger pallidum volumes, versus controls, but failed to find any significant differences in the caudate or putamen13. Furthermore, OCD was associated with decreased cortical thickness in various frontal, parietal, and temporal cortical regions, versus controls14. These mega-analytic results highlight the existence of structural brain abnormalities outside of the classic orbitofrontal loop circuit.

We can also think of the neurobiological underpinnings of OCD in terms of function of distributed brain networks, whether in the so-called resting state, or during cognitive tasks. Indeed, a meta-analysis of available resting state functional connectivity neuroimaging studies in OCD identified hypo-connectivity within and across some circuits; with dysconnectivity (no particular direction of connectivity changes) in other circuits15.

Cognitive neuroimaging studies in OCD have typically focused on domains previously found to be impaired in the disorder, such as motor inhibitory control, cognitive flexibility, and executive planning. Imaging can be used to assess neurobiological underpinnings of cognitive task performance in two ways: firstly, by measuring activation in particular brain regions; and secondly, by examining functional connectivity or ‘coupling’ between such brain regions. In a meta-analysis of functional neuroimaging studies using inhibitory control tasks, patients with OCD versus controls exhibited under-activation in several brain areas (rostral and ventral anterior cingulate cortices, bilateral thalamus/caudate, right anterior insula/frontal operculum, supramarginal gyus, and orbitofrontal cortex)16.

In terms of functional connectivity, there are recent findings from case-control studies. One study found that OCD patients and their clinically asymptomatic first-degree relatives had reduced functional connectivity between anterior and posterior cortical regions during a motor inhibition task (the stop-signal task)17 (Figure 1). In another study, this time focusing on connectivity between cortex and sub-cortical regions, reduced resting state functional connectivity between the ventrolateral prefrontal cortex and dorsal caudate nucleus was linked with worse cognitive flexibility in OCD compared to controls18. Elsewhere, on a neuroimaging executive planning task, dysconnectivity was identified between cortex and basal ganglia (putamen) in both OCD patients and their clinically asymptomatic first-degree relatives, versus controls with no known family history of OCD19. Because some of these brain changes extend to first-degree family members, they may represent vulnerability markers for OCD.

Collectively, what take home messages can be gleaned from the above? The imaging evidence to date suggests that OCD is associated with distributed, subtle, structural and functional brain changes involving not only the orbito-frontal loop but also other circuits. This information, including awareness of what the literature does and does not demonstrate, can be helpful when asked questions from patients, such as in the case of Claire in the vignette above. To address Claire’s question as to whether her brain scan would “show” OCD, we would explain that although brain changes have been reported when comparing groups of people with OCD to groups of people without OCD, these are ‘average’ differences and are very subtle. They cannot be seen ‘by eye’ on a person’s brain scan.

To address Claire’s other question, as to whether OCD can be diagnosed using a brain scan, the answer is no: there is no appropriately validated algorithm that can be used to diagnose OCD based on a brain scan. There have been studies using a technique called ‘multivariate pattern analysis’ to build predictive models that are capable of classifying scans (e.g. into OCD or control groups)20; however, one cannot conclude from this that these algorithms would generalize to OCD at large, or to other research or clinical settings. For example, smaller studies can result in model ‘over-fit’ – a statistical issue whereby a model can apparently give astoundingly high accuracy; but this just reflects statistical fallacy and results would not generalize. Also, in one of the largest classifier studies to date, using pooled mega-analysis data and high-quality methodology, machine learning classifiers based on neuroimaging measures were found to be poor and no better than chance at identifying OCD when applied to an independent set of data21. There were more promising results when such techniques were applied to a subset of the data, albeit some caution is needed due to the negative overall findings in the primary analysis.

Have advances in the neurobiology of OCD affected treatments?

Case vignette: Joseph is a 28 year-old man with a ten-year history of severe OCD, with contamination obsessions and washing compulsions, extensive procrastination, and repetitive list-making/doodling. He has received appropriate treatment trials with various serotonin reuptake inhibitors, including augmentation strategies using other agents (such as low dose antipsychotic medication, and n-acetyl cysteine), and extensive cognitive behavioral therapy (CBT) using exposure response prevention (ERP). His OCD symptoms remain severe; he is incapacitated by his illness and is not able to leave the house often, work, or socialize. Following approval by an ethics board, and careful discussion of the benefits and risks, Joseph underwent a neurosurgical procedure to implant electrodes targeting the nucleus accumbens. Approximately 6 months following Deep Brain Stimulation (DBS), and continuation of pharmacotherapy and CBT, Joseph reported a significant improvement in OCD symptoms, and he was able to work again and socialize. Three years post-surgery, his symptoms remained much improved with continuation of DBS treatment.

Given the changes across distributed brain circuits described previously, an interesting question is to what extent neurobiological knowledge of OCD has changed treatment approaches for patients. Current first-line, evidence-based treatments for OCD include serotonin reuptake inhibitor medications and/or CBT with ERP. In a recent systematic review and network meta-analysis22 serotonin reuptake inhibitors showed superiority over placebo in treating adult OCD; and all the examined psychological therapies had greater efficacy than drug placebo in adult OCD. These first-line treatments for OCD have been used for >30 years and have not practically been influenced or altered by neurobiological research into OCD.

However, imaging has yielded insights into brain mechanisms by which treatments may improve OCD. There are quite a few studies now that have found that structural and functional brain changes associated with OCD symptoms normalize to some extent with successful medication treatment. Such partial normalization also occurs with psychotherapy in OCD, as revealed in a recent systematic review of the literature23. At the same time, as noted in this review and others, there are some caveats – such as often small sample sizes, lack of suitable control conditions/groups, etc. Overall, successful treatment with medication or psychotherapy does seem to normalize at least some of the brain changes associated with OCD. This leads to the question of whether imaging could be used to direct or predict treatment response. As with diagnosing OCD at the individual patient level using a brain scan, there is no evidence that treatment can be usefully predicted at the individual subject level. Again, studies suggest that algorithms to predict treatment response using baseline scans can be built, including to predict response to psychotherapy24, but these approaches have yet to be shown to generalize or be useful at the individual subject level in clinical practice.

As indicated by the case vignette of Joseph above, DBS, or other ablative techniques such as gamma ventral capsulotomy25 are sometimes used in the most extreme cases of treatment-resistant OCD. These neurosurgical interventions, however, do not help everyone and when successful, may result only in reduction of OCD symptoms, not remission. This has led research into improving these interventions on the individual level based on more detailed neurobiological understanding of OCD. For example, one recent study used a clinical assessment and symptomatic provocation during functional MRI to enhance electrode placement for DBS in a small sample of patients26.

Concluding remarks

Substantive advances have been made in understanding the neurobiology of OCD. We have seen that OCD is often associated with structural brain changes implicating not only the classic orbitofrontal circuit but other regions too – including relative reductions in cortical thickness across multiple regions, which may contribute to the clinical picture of disinhibition and a loss of ‘top-down control’ governing basal-ganglia driven habitual response patterns. Functional imaging has revealed hypo-activation during tasks of inhibitory control, as well as (typically) reduced functional connectivity between key brain regions, during these and other types of cognitive tasks. While some OCD related brain changes appear to normalize with successful treatment, cognitive and neural changes have also been identified in first-degree relatives of OCD patients without symptoms. This indicates that some feature may be vulnerability markers, whereas others may reflect symptoms.

Longitudinal research is needed to better delineate vulnerability versus chronicity markers in OCD, and to translate these research findings into meaningful changes in daily clinical practice. To date, first line treatments for OCD are essentially unchanged for >30 years. Neurobiological advances are useful as they can help clinicians and patients understand the illness and how treatments work when they successfully improve symptoms. With time, the hope is that predictive algorithms could be developed and validated in order to help refine diagnosis and treatment prediction at the individual patient level; but this remains a hope rather than a present day reality.
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Re: The impact of the COVID-19 pandemic on those with OCDs

Post by trader32176 »

Pandemic-related selective increase in obsessive-compulsive symptoms in UK study

12/11/20 ... study.aspx

COVID-19 has now been around for almost a year and has caused enormous stress among the developed nations of the Western world. A devastating new study shows how a large-scale wave of increased obsessive-compulsive (OC) symptoms affected public behavior, such as seeking information about the pandemic and following government guidelines. This could predict long-term sustained disruptions of mental health as an unexpected sequel to the pandemic.

This study was published in the pre-print server medRxiv*.

Stress and Psychiatric Symptoms

All life events associated with significant stress cause an upsurge of ill mental health. The COVID-19 pandemic was no exception. It ushered in an era of disrupted finances, social interactions, and health. Predictably, all psychiatric symptoms increased over the first wave of the pandemic. This includes symptoms in already diagnosed patients with anxiety, depression, bipolar disease, schizophrenia, and obsessive-compulsive disorders (OCD).

Members of the general public also showed a significant increase in symptoms of anxiety and depression. However, in typical situations, once the individual adapts to the situation, such symptoms return to the baseline. This is mediated by the re-appraisal of the situation and the evolution of coping strategies.

OCD is a mental condition that is selectively cultivated by pandemic conditions because the campaign to contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread pivots around the need to prevent and remove contamination by cleaning. This pervasive fear of an invisible foe which spreads by contamination and is combated by cleaning and other non-pharmaceutical interventions (NPIs), including face mask use and social distancing, caters to OCD behavior.

“These news coverages and governmental guidelines may thus give validity to OCD-symptomatic behavior, potentially intensifying or triggering them.”

This may lead to a wave of OC symptoms in the general public as well, as more attention is paid to the area of contamination and cleaning.

Study Details

To assess this risk, the researchers carried out a longitudinal study on the impact of COVID-19 on OC, anxiety, and depression. They followed psychiatric scores in these three areas for several months from May to August 2020. They also observed any correlations between OC symptoms, information-seeking about COVID-19, and the following government guidelines.

The first data collection was from April 24, 2020, to May 7, 2020, the peak of the first wave. Here, standardized questionnaires were used to record the three types of symptoms among 416 participants, and information-seeking behavior, along with their use of news and social media. They also had a mental ability test.

This assessment was repeated at the second time point, between July 15 and August 15, 2020, with an additional assessment of how well they followed COVID-19 guidelines. At this time, the largest relaxation of pandemic restrictions had just occurred, and thus the effects of a significant change in the environment could also be measured. At this point, there were 304 participants.

The researchers used self-administered questionnaires to measure OC (Padua Inventory-Washington State University Revision (PI-WSUR)), with anxiety and depression (Hospital Anxiety and Depression Scale (HADS)). They also asked about the average use of news and social media pre-pandemic. At the second assessment, they asked also how far the respondents observed pandemic-related recommendations by the authorities.

Initial Rise in Psychiatric Scores

The investigators found that all psychiatric scores were initially elevated, some components of the PI-WSUR being scored at OCD level. With the HADS, too, about half and 40%, respectively, met the cut-off for anxiety and depression, respectively.

The corresponding population-level rates for the latter conditions before the pandemic, in one of the largest studies, was around 20% for both, showing high symptoms scores during the first wave of COVID-19.

Selective Increase in OC Symptoms in Later Phase

Over time, however, only the OC symptoms showed a further rise, even when items related to contamination and cleaning were excluded from the analysis. Thus, normal adaptation did not occur concerning OC symptoms during the lockdown, but instead, they continued to rise. Curiously, anxiety, and depression showed the expected drop, due to adaptation.

Increased Adherence to Guidelines

The third area of investigation was the role of these symptoms in causing pandemic-related behavior, especially since people with high OC symptoms were seen to be engaged in increased information-seeking behavior. They found that most of such behavior in respondents occurred at the beginning of the lockdown, and was due to the lack of knowledge about the pandemic.

The researchers also looked at the link between information seeking and psychiatric symptoms. They found that OC symptoms were related to a higher expression of this behavior at both early and late time points. The same was also true of anxiety scores but to a smaller extent. This was true even after adjusting for age, gender, and social media use unrelated to the pandemic.

What are the Implications?

When analyzed using all the psychiatric symptoms as potential predictors for information-seeking behavior, the only consistent association was found to be with OC symptoms. The association with anxiety disappeared in this analysis. Thus, although information-seeking decreased over time, the reverse was observed in connection with OC symptoms. This favors the role of OC symptoms as the main reason for pandemic-related information seeking.

Again, the increase in information seeking related to OC symptoms was found to result in the increased tendency to adhere to government COVID-19 guidelines even after the relaxation of restrictions. Both these behaviors were independently predictive of the tendency to follow these guidelines.

The benefit to society from such OC symptoms is obvious, with respect to viral containment, though they do impose a burden of care on the individual. On the other hand, the rise and prolonged duration of such symptoms suggest the need to put policies in place to follow up on individuals with a high risk of developing OCD. Interventions are necessary to prevent and treat the condition before long-term mental ill-health sets in.

Our findings highlight that OC symptoms are disproportionally affected by the pandemic by documenting their selective increase throughout the pandemic for the first time, which may result in serious adverse long-term consequences.”

*Important Notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:

Loosen, A. M. et al. (2020). Current Testing-Isolation Policies Effectively Prevent Campus Transmission of COVID-19. medRxiv preprint. doi: ... 20245803v1
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