Eric Storch, PhD, Vice Chair Department of Psychiatry at Baylor College of Medicine, talks about those suffering with OCD amid the COVID-19 pandemic.
For a person who has existing OCD and went through many of these handwashing rituals, germaphobia, how has COVID-19 impacted the approach they have?
Storch: As you may know OCD is made up of multiple different subtypes. Contamination is one of the more common types that a lot of people recognize as core to OCD. But there are also several other types. One of them involves experiencing unwanted intrusive upsetting thoughts that can involve things like harming other people even though you do not want to or unwanted fears that you could do something sexually inappropriate or something that’s morally or religiously against your values. These are common symptom subtypes. There is also a sizable group of folks with a need for things to be exactly right or perfect that often results in repetition-type compulsions that frequently come into play. Now COVID-19 has hit all those. So, for folks with contamination symptoms, many have reported an increase in those symptoms of the fear of contracting COVID-19 or some other potential contaminated factor or potentially passing it onto someone they love. Likewise, with folks who have more intrusive thoughts about inadvertently and unwillingly harming other people, COVID-19 has also grabbed a hold of that. We have seen folks who have a fear that they could pass on COVID-19. Now beyond this there is the stress of dealing with a pandemic that has challenged all of us to have to cope with stress in ways that are different from the usual ways that we have managed. That stress along with more objective things like economic stressors, not being able to see family or friends, has made it exceedingly difficult for people with OCD as well as people with other behavioral health problems.
It is almost like if you could flip flop it and say that people who normally don’t have OCD might now understand that compulsion to hand wash or harm other people.
Storch: There’s some talk that there may be a possibility of increased rates of OCD over time. One of the factors that is critical to keep in mind is that OCD is all about the excess, unwanted over-the-top impairing rituals that are motivated by different obsessions. For someone who’s hand sanitizing frequently or washing their hands consistent with public health guidelines, it is not at all OCD. That is having your behavior reflect increased risk currently. Now if our guidelines are at one point and we have a person whose behaviors are way in excess of these guidelines, then this is where we want to target those types of symptoms. But if someone just increased their behavior in frequency to be consistent with those guidelines, that’s just being very responsive and responsible to guidance by our public health officials.
So, let us look at it this way. When I take a walk, I take hand sanitizer with me. I must consciously think about spraying that hand sanitizer after I touch the gate. How does that contrast with people who have internalized OCD to the point that they do not even think about it?
Storch: The way that you describe it there is a very conscious behavioral choice here that is not motivated by anxiety or distress. It reflects the behaviors that objectively we need to do to remain safe. In the case of someone with OCD we see this distress-motivated element that is driving the behavior to excess. It is common that for some folks it becomes automatic in nature. So, in those cases we want to try to slow down the cycle, look and understand what the function of the behavior is which allows us to really target it. One of the ways that we can get at that is by looking at things like what happens if you are not able to do it or if you have to delay hand sanitizing or washing hands? What are the levels of avoidance that come into play? And then that urge to engage in the behavior. On top of all those things we want to get a sense of impairment. Are these the behaviors that someone without OCD would be doing? Ultimately, I think one of the questions is what happens when the risk begins to subside? Do we see behaviors remain at this level or do we see that risk further go down or be dragged along with it? I do think for some folks what we are going to see is that this level of handwashing, sanitizing and avoidance behaviors maintains over time. There is that question of what will happen as time moves on and we see that objective levels of risk have been reduced.
What triggers or causes OCD?
Storch: OCD is it a mental health condition that is characterized by obsessions and compulsions that go together. The obsessions are unwanted upsetting thoughts or images the person has that they really want to get rid of. The compulsions include behaviors which can be things that you see or even things that are occurring in the mind with the aim of reducing the distress and the chance for the feared outcome to happen. Now as I mentioned earlier, there are several different examples of OCD. One of the more common types involves these unwanted thoughts of doing something that is completely against who you are. For example, someone that I worked with had these thoughts that as they picked up a child that maybe they grabbed their private parts. They found these thoughts to be so upsetting and completely inconsistent with who they were. But every time they were around the child, they kept wondering did they touch them? Did they do something inappropriate? So, they would stay away from kids even though this was the type of person that you would want to babysit your own children. Now another example involves these fears of contaminants or contamination concerns. So, this could be being around things that you worry could make you sick or could make other people that you care about sick. Someone I recently worked with was afraid that maybe they had contracted COVID-19 but were asymptomatic and would be responsible for any sort of negative outcome happening to them. Now in that person’s case, they were washing their hands and hand sanitizing to excessive amounts to the point where their hands were bleeding because of their dryness and cracked nature. One of the things they also did was avoid doing a lot of things such as just go outside for a walk. So, they kept themselves homebound but with the whole idea of preventing other people from having a negative outcome and getting ill.
They kept themselves housebound because they didn’t want to contaminate somebody else, not that they didn’t want to get contaminated.
Storch: For many people with OCD there is this keen moral sense where there’s concern that their behavior can negatively impact someone else. At the same time one of the ways of preventing that negative outcome could be through behavioral rituals that you see and can almost quantify. But in other ways it involves avoiding and shutting one’s life down to prevent that feared outcome from taking place.
That moral compulsion component of it which is incredibly interesting. Does that tie in for a lot of them with social anxiety?
Storch: Social anxiety involves this significant element of behavioral avoidance. If you are worried about the scrutiny of others and the negative evaluation of others, if you stay away from others then you are more successful at keeping those fears at bay. The problem is it is not a long-term path to living a fulfilling life and achieving all the goals that one might have. When the interventions that we do with both OCD and social anxiety have individuals directly confront those fears in a gradual but systematic manner learning the outcomes that they predict to happen are not the outcomes that are actually taking place.
Could you delve into the moral aspect a little more? I have always thought that they are wanting to protect themselves but what I am hearing from you is that it is much larger.
Storch: Certainly, for many people there is this concern of a negative outcome happening to themself but also to the people they love or people within the community. So, for many folks that level of distress is so intense that it motivates them to engage in these kinds of erroneous behaviors whether it be ritualistic or avoidance to prevent that feared outcome from taking place. I think one of the keys is the meaning that is made by individuals in terms of who they would be if they did do these behaviors. For example, someone that harmed someone else or touched someone else inappropriately for many people with OCD the thought of that is worse than anything else. So, they will go to great lengths, including being distressed and negatively impacting their life, for those feared outcomes not to take place.
So, they have lost control of some greater measure of their life. The smaller attempt to gain control is that what they are going after as well as the moral?
Storch: There’s this aspect of the world that is truly relevant when we think about people with OCD. That is the idea of being able to tolerate uncertainty. Right now, it’s obviously a very uncertain time and I think some people are able to tolerate the fact that we just don’t know what the answers are going to be the next day, next week, next month. But for others that is a difficult proposition. With OCD one of the core elements at play is this difficulty in tolerating things that we do not know. For a vast array of symptoms that people experience, that is one of the underlying mechanisms. So, if we step back for a minute, what we can recognize is that everyone has intrusive thoughts. The presence of intrusive thoughts does not equate to having OCD because most people have this thought and it just passes by. They do not make sense of it or make meaning of it. And they do not think of it again. But someone with OCD grabs onto that thought and at the end of the day so many things that happen in our lives we cannot be certain. So, as you drive home from work, you think that you are going to get home safely but you really do not know that. And as you let your teenager go out for a bike ride, you assume they are going to come back but you do not know if that is going to happen. Now most of us are OK with these things because we think about our life experiences, the experiences of others and the rules of the world. We can come up with some reasonable degree of certainty that makes us not sweat those things too much. I think in OCD what happens is that element of uncertainty comes in and it always lingers and there is this kind of moral compass that directs many folks to think they cannot live with uncertainty. So, they must achieve some element of control over this to prevent that awful thing from happening. And that is where the rituals come into play to start having some piece of control within this whole equation so that thing that makes that person deathly afraid is brought at bay and they have some semblance of control. The problem with any sort of ritual is that it is temporary. It does not stick for a while, so it keeps coming back. Then the more you feed that monster the more likely it is to come back again and in an even bigger and more significant form.
Do you have advice for people who have OCD? Is it a good thing for them to talk about it and share it with others so that others might understand?
Storch: The answer is going to be individual. For some people bringing this out and talking about it and helping others understand it is an incredible thing. It reduces the stigma. It brings some element of support and understanding, and it helps them help others interface with them. Others may not feel as comfortable. And that is fine. Within this nightmare of COVID-19 I think one of the things that has been a positive is that we’ve really begun to appreciate the notion of telemedicine and that’s helped us improve access to care that maybe wasn’t there beforehand. For example, the last two weeks in my clinic I have had five people come in virtually who lived over three hours away. For these individuals it would have been very difficult to drive in for that session and then come back on a regular basis and now we’re able to expand our reach and more effectively help those in need.
So, a summary on someone who has OCD and lives amid this time of COVID-19. Is the OCD then escalating, remaining the same or diminishing?
Storch: That’s the million-dollar question. We are doing a research study where we are hoping to answer this exact question. Clinically what I have seen is most people with OCD are managing just like everyone else. There is a subjective level of stress that is above all of us. But their OCD is their OCD and it is continuing forward and progressing in treatment as we would expect. There is a small group of people who seem to be doing a lot better. When we talked earlier about individuals with social phobia as one example they do not have to go out as much, so the triggers are not there as frequently. So that is a bit more comfortable. Alternatively, people who have intrusive thoughts, for example, one individual that I saw was describing that because he’s not going out as frequently he’s not seeing people which would bring about those intrusive thoughts of hurting someone else. So, there is a minority of folks that may be doing well. Another person that I have worked with is a schoolteacher and we were talking about how they don’t have to wake up at 7:00 or 6:00 in the morning to go to school so they’re enjoying sleeping in and having an extended day virtually. Now while about two thirds of the folks with whom we work with in our clinic have not experienced stress related to COVID-19 much differently than anyone else, there are a group of individuals where this really has been a noticeably clear trigger. While some of them may have more of a dominant contamination focus to their symptoms, others have the full array of OCD symptoms. I think sometimes the kind of exacerbation of symptoms is due to COVID-19 directly interacting with that individual’s OCD. I think sometimes this is simply due to the stressors that are going on all around us in terms of not being able to connect with friends, loved ones, economic stressors, doing the things that you really enjoy doing so it’s a little bit less specific to OCD and more to the COVID-19 situation.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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If you would like more information, please contact:
Homa Shalchi
Baylor College of Medicine
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