This article is written by Dr Ben Harkin. Department of Psychology, Manchester Metropolitan University.
“Within weeks, the compulsions I had spent years trying to overcome were becoming public health advice” (1). This quote, from Charlie, a 21-year-old patient with Obsessive-Compulsive Disorder (OCD), indicates how the COVID-19 pandemic and associated health messages are exacerbating traits of this disorder. As a cognitive researcher, I am familiar with the cognitive mechanisms associated with OCD, and I will outline those that are likely triggered under the pressures of the present pandemic. Specifically, we will look at repeated exposure, ecological validity, ambiguity of contamination fears, inflated personal responsibility, repeated checking, and isolation/avoidance. I will use recent quotes of OCD patients on the pandemic, and show how cognitive research explains the exacerbation in their symptoms.
The repeated exposure of COVID-19 has increased the triggers related to OCD in the general population. For example, recent analysis of text messages to an online crisis centre reported that 80% who typed, “virus” reported feeling “anxious”; the use of the words “cleaning” had doubled; and “symptom, fever, and cough” were among the top 10 words (2). This suggests, that even in those who may not be categorised as suffering from clinical OCD, the constant presence of public health messages on the TV, radio, and social media is increasing anxiety, contamination related thoughts and behaviours across a range of people with subclinical to clinical OCD. Indeed, a recent study by the Office for National Statistics on COVID and its social impacts, reported that ~50% of adults are presently experiencing high levels of anxiety (3). In combination, with this chronic exposure, we also observe that these messages are specific to the symptoms of a large majority of those with contamination-specific OCD, in cognitive circles we refer to this as ecological validity. In that, in cognitive research we expect that OC symptoms are easily and acutely triggered when stimuli are specific to the symptoms of the sufferer (4), as depicted in Figure 1. As observed in the recollections of this OCD patient, when they were 11 years old, with respect to 2009 swine flu: “Around the time of the [swine flu] outbreak an authority figure told me that I wasn’t washing my hands properly. That, combined with the messages of health professionals, sparked an obsession with germs.” (5).
Indeed, a core feature of viruses, germs, and diseases, particularly for someone with OCD, is the inherent ambiguity of contamination fears. In that, someone with OC-traits will ruminate on the fact you cannot see a virus, so how do you know if a virus is on your hands or not. They will observe that while ‘they say’ we should clean our hands for 20 seconds, many with OCD will start to think “40 seconds or eve 4 minutes has to be better” but then immediately after washing for that extended time will think: “How can I be sure!?”. This sets up the often-observed pathological loop between obsessional contamination fears and compulsive handwashing (8).
Figure 1. Specific instructions from the UK Government on handwashing to stop the spread of COVID-19. Consider how this taps into contamination obsessions and/or handwashing compulsions in someone with OC-traits.
The present public health messages of “Stay Home, Protect the NHS, Save Lives” and “Washing your Hands Could Be a Matter of Life and Death” taps into another sinister feature of OCD known as inflated personal responsibility (9). In that, those with OCD are sensitive to taking on the responsibility of others, catastrophic events that they are not involved in, and of course the outcomes of the COVID-19 pandemic. This can leave the OCD sufferer in a torturous double bind, where not only do they live in constant fear of getting the virus they are petrified of giving it someone else. As written by this OCD patient: “My fear was less of catching the disease and more of spreading it to others, weighed down with guilt … of not performing your social duty – it’s crushingly exhausting” (5). In turn, this can lead to repeated checking, a core symptom in up to ~80% of those with OCD (6). A curious feature of checking is that while its aim is to increase certainty, reduce ambiguity and anxiety, empirical evidence shows that it actually causes the opposite: It paradoxically increases the urge to check, associated anxiety, and reduces confidence in memory and memory accuracy (7). This in turn serves to increase the likelihood of subsequent checking, setting up the deleterious cycle of checking, doubt, poorer memory, and checking again, and again: “Quickly, I was washing my hands more than 50 times a day, probably stretching into triple figures on the worst occasions” (5).
Isolation is a simple outcome of the “Stay at Home” message; while this is a perfectly sensible social distancing measure, it forces the OCD sufferer to stay in the place that research indicates their symptoms are most prevalent – at home! (10). Then, when they leave their home, they are encouraged to wear a mask and keep 2 meters apart. While this may be enough to alleviate initially contamination fears in those with OCD-traits, as we have seen with respect to ambiguity, those with OCD may start to ruminate on instances when they were, perhaps, not 2 metres apart, leading to thoughts such as “Was that person contaminated, will I infect my family when I get home?” This may lead to complete avoidance of others, refusal to leave the house, anxiety at the thought to leaving the house, yet at the same time trapped in their house where they are most likely to experience their symptoms. So not only is the OCD sufferer controlled by the health measures of the current pandemic, they are likely controlled by the key cognitive features discussed above.
While this paints a potentially dark outlook for the person with OCD traits, all of the main OCD groups have identified it as an area for concern and have advised individuals on how to counteract an escalation in their symptoms (e.g., see OCD Action: https://www.ocdaction.org.uk/articles/covid-19). Consider Charlie, the OCD patient whom we opened this article with, they learned to challenge and overcome their pandemic triggered thoughts: “If I’m in any doubt, I ask myself what the function of carrying out a behaviour is – is it genuinely to reduce the spread of passing on the virus, or is it to quell my anxious thoughts?” (1).
- De Putter, L. M., Van Yper, L., & Koster, E. H. (2017). Obsessions and compulsions in the lab: A meta-analysis of procedures to induce symptoms of obsessive-compulsive disorder. Clinical Psychology Review, 52, 137-147. doi: 10.1016/j.cpr.2017.01.001
- Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Molecular Psychiatry, 15(1), 53. http://dx.doi.org/10.1038/mp.2008.94
- Harkin, B., & Kessler, K. (2011a). The role of working memory in compulsive checking and OCD: A systematic classification of 58 experimental findings. Clinical Psychology Review, 31(6), 1004-1021. doi: 10.1016/j.cpr.2011.06.004.
- Lopatka, C., & Rachman, S. (1995). Perceived responsibility and compulsive checking: an experimental analysis. Behaviour Research Therapy, 33(6), 673-684. doi: 10.1016/0005-7967(94)00089-3
- Rachman, S. (2002). A cognitive theory of compulsive checking. Behaviour Research Therapy, 40(6), 625-639.