key: cord-0885221-bbb4i2e3 authors: Fineberg, N. A.; Van Ameringen, M.; Drummond, L.; Hollander, E.; Stein, D. J.; Geller, D.; Walitza, S.; Pallanti, S.; Pellegrini, L.; Zohar, J.; Rodriguez, C. I.; Menchon, J. M.; Morgado, P.; Mpavaenda, D.; Fontenelle, L. F.; Feusner, J. D.; Grassi, G.; Lochner, C.; Veltman, D. J.; Sireau, N.; Carmi, L.; Adam, D.; Nicolini, H.; Dell'Osso, B. title: How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician's guide from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive Research Network (OCRN) of the European College of Neuropsychopharmacology date: 2020-04-12 journal: Compr Psychiatry DOI: 10.1016/j.comppsych.2020.152174 sha: 5aeb7864c91fad1bb0c38938264d548dbbc3c984 doc_id: 885221 cord_uid: bbb4i2e3 nan The rapid advance of the coronavirus COVID-19 pandemic has significantly increased mortality but also has demonstrated considerable potential to negatively impact mental health, including in the young 1, 2 . From a public mental health perspective, guidelines for responding to mass trauma and disaster emphasize the importance of focusing on resilience. In the immediate and ongoing response, consensus guidelines emphasize the importance of interventions that maintain calm, build community, and sustain hope 3, 4 . That said, it is important to provide appropriate attention to specific psychiatric conditions that may be initiated or exacerbated by disaster. Perhaps no group of individuals with mental illness is as directly affected by the worsening outbreak of COVID-19 as people living with obsessive-compulsive disorder (OCD). Paradoxically, they are 'experts by experience' in attempting to avert dangers through enacting compulsive behaviours. Chiefly, the spike in anxiety about the virus is fuelling existing obsessive fears of contamination in some people with OCD and further triggering harmful compulsive actions. For these people, coronavirus can become all they think about 5 . Indeed, some patients with contamination-related OCD are expressing doubts about the rationality of the therapies they have been pursuing. Several patients have told their clinicians they were "right all along", as now everybody looks like them. For others, COVID-19 is likely to cast a long shadow, as people of all ages with OCD are known to be particularly inflexible at 'unlearning' danger responses when they become obsolete 6, 7 and thereby conditioned to prolonged virus-induced distress and anxiety. In response to the emerging crisis and growing calls from patients and clinicians for guidance 5 The advice is largely based on empirical evidence, including the clinical experience gained from working in specialised OCD treatment-services before and during the pandemic. Our group of international experts includes a balanced representation of genders, including clinicians treating child, adolescent and adult patients, with additional contributions from individuals with lived experience of the disorder and early career scientists. Once agreement was reached on the key issues to be covered, in a series of online discussions, an initial draft was prepared and circulated iteratively among the authors and edits were sequentially incorporated. The final report covers the key issues judged by our group of experts to be of most relevance for clinicians for the treatment of OCD under COVID-19 conditions. Although preliminary, based on the 'precautionary principle' it was considered a priority to release guidance at the earliest opportunity, on the understanding that it may be updated as new information arises. The guidance to clinicians is as follows: 1. Take a compassionate calming approach. Use telemedicine including telephone or video calls. Be aware that the pandemic is affecting countries with different cultural environments and different available resources to deal with it. For example, in regions of Latin América and in Africa lack of water and access to the Internet, and poverty levels greater than 50 % make it hard to stay in at home, since there is no monetary support from the government to aid survival J o u r n a l P r e -p r o o f 2. Careful history taking. Confirm the diagnosis of OCD, paying particular attention to other obsessivecompulsive related disorders (OCRDs) including hypochondriasis (recently endorsed as an OCRD in the World Health Organisation (WHO) ICD-11) 8 , as these disorders are likely to be most affected by COVID-19. Clarify the extent to which the current symptoms represent a rational or exaggerated reaction to recent highly stressful events, or a worsening of obsessive-compulsive symptomatology. Establish the level of insight into the irrationality or excessiveness of the symptoms, and the presence or absence of tics, as these may influence the care plan. Note that many OCD patients may not experience exacerbation of their OCD. On the other hand, patients who have experienced contamination symptoms in the past may find that they re-experience contamination fears and cleaning or washing compulsions under the conditions of the pandemic. It is also important not to assume that every patient with contamination fears related to germs and illness will necessarily be excessively concerned about COVID-19. The focus of concerns in those with OCD is often idiosyncratic, and some individuals, for example, may have greater fears of a sexually transmitted disease or an antibiotic resistant infection. Many will, however, have significant exacerbation of contamination or illness concerns, or comorbid conditions that have worsened with stress (such as anxiety disorder, depression or bipolar disorder, or even posttraumatic stress disorder (as reported after the SARS epidemic) that may need to be managed separately in order to prevent decline in level of functioning. Indeed, OCD comorbidity can become particularly problematic, especially if patients have, or have previously shown, cleaning or washing symptoms. Where OCD and related disorder is not the principal diagnosis for clinical attention, please refer to other guidelines. In particular, note WHO ICD-11 guidelines regarding mental health and psychosocial considerations during the COVID-19 outbreak 8 . 3. Assess suicidal risk. Even though OCD has not been considered a disorder with high risk for suicide, recent studies have shown that some patients, particularly those with severe obsessions, comorbid depression, bipolar disorder, impulse control disorders, substance use disorders, personality and eating disorders may be at increased risk 9 . Additional COVID-related factors found anecdotally to potentially increase suicidal risk include a recent increase in OCD severity, experiencing a family member found positive for COVID-19 or finding the effects of quarantine or isolation distressing. For all patients with OCD, but particularly in such cases, consider actively evaluating the suicide ideation and risk through specific questions and instruments (e.g., the Columbia Suicide Severity Rating Scale 10 or similar) and hospitalize the patient if needed. 4 . Provide psychoeducation with balanced information about the known risks and impact of COVID-19 on physical and mental health. This includes the difficulties managing uncertainty associated with the virus, which almost everyone is experiencing right now but that might be particularly challenging for some people with OCD, hypochondriasis or anxiety. Highlight the need for physical distancing (staying home except for essential tasks like grocery shopping), with special precautions for the elderly. Patients need to understand that this health crisis may well persist for some time, and they need to manage their stress levels over time (e.g., by putting into play long-term routines of mindfulness techniques, exercise and structure). 5. Enquire about Internet usage and news consumption; some patients are spending hours a day watching television and online media sources, which may be significantly exacerbating their OCD and anxiety. Offer a balanced approach (e.g., individuals should not spend more than an hour a day [1/2 hour in the morning and a half-hour at night] to stay informed about the pandemic, to minimize the triggering of symptoms). Suggest J o u r n a l P r e -p r o o f trusted sources to avoid myths, rumors and misinformation. You may wish to refer the patient to the relevant health education websites of the WHO (https://www.who.int/health-topics/coronavirus#tab=tab_1), the Centers II. Review and risk assess the CBT plan; Considerations include whether it is feasible in the pandemic situation, and specifically whether it fits with government safety guidance. In many countries, psychotherapy services are being dramatically cut back as staff are redeployed to cover emergency care. Consider that it can be difficult to disentangle OCD-related cleaning and checking compulsions from rational COVID-19-related safety behaviours and to devise ERP strategies that are coherent and robust. Moreover, as COVID-19 is highly contagious, and patients can easily be confused by exposure exercises, particularly during the early stages of therapy or when practising exposure on their own at home, the risk of patients becoming seriously infected with the coronavirus could be increased. This risk becomes even more true for children whose knowledge base and judgment is not yet matured. We therefore recommend significantly tailoring CBT to take into account the CDC guidance (e.g., hand washing for 20 seconds with soap and water rather than ceasing hand washing completely). However for OCD patients with contamination fears and cleaning or washing compulsions, active and in vivo CBT with exposure and response prevention (ERP) will need to be sensibly adapted and may need to be paused. This specifically relates J o u r n a l P r e -p r o o f to active, in vivo exposure aimed at tackling contamination. Instead we suggest using therapist time to support patients and trying to prevent them from deteriorating, e.g. by encouraging them to restrain their compulsions as far as possible, rather than directed at actively treating contamination fears and concentrating on techniques such as behavioural activation and activity scheduling which can assist in preventing deterioration and help with depressive symptoms 12 . Indeed, activity scheduling can be particularly useful as a form of CBT at this time. Obsessions often expand to fill a vacuum of time and keeping busy is particularly important as a means of staying well. Patients can be asked to fill out an activity schedule diary in advance, making sure that they have a balance between activities which may give them a feeling of mastery as well as those for pleasure (see below) 13 . For clinicians working in specialist centres, other less evidence-based forms of CBT not involving ERP, such as imaginal exposure or danger ideation reduction therapy, could potentially be offered for patients with contaminationrelated OCD, even when their concern is COVID. replacement. If the latter, a balance between risks and benefits should be evaluated in each case and consideration given to whether the replacement procedure may be delayed to reduce the increased risk of being exposed to COVID-19 in hospital. IV. Social and occupational care; There is great value in activity scheduling and establishing a daily routine, even if stuck at home. Patients under quarantine or staying at home under national restrictions are at great risk of circadian rhythm disruption. Circadian rhythms disruption could increase anxiety and worsen OCD symptoms while regular circadian rhythms and regular physical activity are relevant in order to reduce anxiety or alarm levels and therefore achieve better control of OCD symptoms. Therefore it is recommended to respect a regular awakening time and bedtime every day and to regularly perform some physical activity in the morning especially in a bright room. Finally it is recommended to avoid late-night dinners so as not to affect sleep quality. Offer guidance regarding a rational amount of time spent listening to news as a distraction to occupational or preferred activities, provide acknowledgement of fear but also a balanced perspective on risk, address grief and loss of control and recommend hedonic activities especially those that involve children, such as baking, cooking, gardening, inventing a new game or watching a movie. Parents and children should be encouraged to maintain social contact with their environment via the Internet or phone for distraction and support. Rules for dealing with possible conflicts and tantrums should ideally be established in advance. Parents should not only focus on the problems connected with the current pandemic situation but be encouraged to engage in joyful activities with their child instead. Especially in a quarantine situation it is important to make clear that not all aspects of life are determined by the coronavirus or OCD. Staying hopeful and together seems one of the most important points (especially for parents, acting as role models for their children), and increased family togetherness may be a "silver lining" in the pandemic. We are aware this guidance marks a change in practice for many clinicians treating OCD. Temporarily modifying or pausing in vivo CBT with ERP for contamination-related OCD, which is an effective form of treatment often preferred by patients in normal times, is a difficult decision to make, but as with any treatment, the benefits and risks need to be balanced up and clear messages that take public health into account need to be given at this time of heightened risk of infection, to avoid confusion. On the other hand, many forms of CBT can be continued with modification for safety as needed. We believe that under COVID-19, stringent efforts should be made to provide effective care for individuals with OCD and that the best available treatments for most patients are likely to include providing evidence-based pharmacotherapy and modifying or pausing CBT in conjunction with enhanced supportive therapies including social and occupational care. Understanding the impact of a pandemic like COVID-19 on the expression of OCD in affected patients, and on the development of new cases of OCD, is likely to provide important insights into the environmental determinants of the disorder. We consequently urge research-active groups to engage in investigating the impact of such changes on health outcomes among their patients, as well as initiatives to explore the expected rise in incidence of OCD once the pandemic is over. DJV declares no conflict of interests. GG declares no conflict of interests. CL declares no conflict of interests. LC declares no conflict of interests. NS declares no conflict of interests. DA declares no conflict of interests. HN declares no conflict of interests. BD declares no conflict of interests. All authors were involved in drafting the manuscript and agreed to its publication. All authors read and approved their sections of the final version of the manuscript. World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak UK poll finds young people's mental health hit by coronavirus. The Guardian Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence Rolling updates on coronavirus disease (COVID-19) The hellish side of handwashing: how coronavirus is affecting people with OCD. The Guardian [Internet Neural basis of impaired safety signaling in Obsessive Compulsive Disorder Impaired cognitive plasticity and goal-directed control in adolescent obsessive-compulsive disorder Suicide attempts and suicidal ideation in patients with Obsessive-Compulsive Disorder: a systematic review and meta-analysis The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis Obsessive Compulsive Disorder: All You Want to Know about OCD for People Living with OCD, Carers, and Clinicians Exercise as a treatment for depression: A meta-analysis adjusting for publication bias Effects of exercise on anxiety and depression disorders: review of meta-analyses and neurobiological mechanisms Acute effects of aerobic exercise on negative affect and obsessions and compulsions in individuals with obsessive-compulsive disorder The authors wish to acknowledge the International College of Obsessive Compulsive Disorders