How to manage obsessive-compulsive disorder (OCD) under COVID-19


Comprehensive Psychiatry (2020), j.comppsych.2020.152174

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 Neuro psychopharmacology

Comprehensive Psychiatry (2020), j.comppsych.2020.152174

How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician’s guide –

A working group of clinical experts from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive Research Network of the European College of Neuro psychopharmacology (OCRN) have produced this consensus statement with the aim of delivering pragmatic guidance at the earliest opportunity to clinicians for managing this complex challenge.

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.

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

2. Careful history taking
Confirm the diagnosis of OCD, paying particular attention to other obsessive compulsive
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 msome 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.


Provide psycho education 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 trusted sources to avoid myths, rumours and misinformation. You may wish to refer the patient to the relevant health education websites of the WHO ( topics/ coronavirus#tab=tab1), the Centres for Disease Control and Prevention (CDC) ( sanitizer.html), or the Centre for Health Security, Johns Hopkins University ( 19/index.html). Hand washing videos may be helpful to guide patients about what is appropriate and discourage unnecessary excess.

For example, the National Health Service ( and CDC videos recommend hand washing for 20 seconds; thus, anything beyond this is likely to be compulsive and excessive.



If OCD symptoms are the main problem:

I. Review medication status as a priority

II. Review and risk assess the CBT plan

III. Deepbrainstimulation(DBS)

IV. Socialandoccupationalcare

V. Carer support

I. Review medication status as a priority

Based on the risks associated with exposure and response prevention (ERP) in the pandemic, and uncertainty as to which of the two evidence-based treatments, pharmacotherapy or cognitive behaviour therapy (CBT), represents the most efficacious first line treatment modality11.

Pharmacotherapy should be the first option for adults and children with OCD with contamination, washing or cleaning symptoms during the COVID-19 pandemic.

• • • •

Most patients should receive an SSRI, or if not responsive, another SSRI and as a third choice clomipramine (for which an ECG may be required in certain patient groups)

Dosage- If the patient is on a suboptimal dose, consider increasing it, paying attention to any contraindications

SSRI-resistance – Consider low dose of adjunctive antipsychotic (aripiprazole, risperidone, quetiapine, olanzapine), especially if a tic is present

Adherence ensure the patient is able to obtain an adequate supply and is taking the treatment regularly.
Manage sleep disturbance when present, as healthy sleep contributes to immune function and enhances anxiety management.

II. Review and risk assess the CBT plan

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 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 symptoms12. Indeed, activity scheduling can be particularly useful as a form of CBT at this time.

For clinicians working in specialist centres, other less evidence-based forms of CBT not involving ERP, such as imagine exposure or danger ideation reduction therapy, could potentially be offered for patients with contamination – related OCD, even when their concern is COVID.

This should be considered on a case-by-case basis and only done if the patient has good insight, is willing, and is stable enough to do so. It would need to be made clear that the efficacy of this form of treatment is not as well established and it should not be viewed as a substitute for in vivo ERP when post pandemic restrictions are lifted.

For those patients whose exposures are not contamination related, many ERP treatment plans could be continued (e.g. addressing urge to check, obsessive thoughts of harm, symmetry/order obsessions), especially those that can be done at home, and as long as they are within CDC recommended precautions such as maintaining physical distancing.

Once again it is important to remember that even if the OCD does not focus on contamination fears, the physical distancing can increase symptoms of anxiety and depression. ERP increases distress and can also temporarily increase depression and so the patient’s mental state must be monitored carefully.

Keeping people calm and reducing the risk of depression using supportive techniques is an essential element of care. Nevertheless, the clinician should still try to find ways to help the patient foster resilience towards obsessional thinking and compulsive acts. Thus, extreme behaviours should be discouraged along with mental compulsions. Avoidance and accommodation should be assessed carefully to determine whether it is proportional to the current situation and addressed carefully to prevent backsliding.

We suggest therapists should regularly check e.g. by phone or digitally, those OCD patients likely to engage in particularly harmful decontamination rituals or behaviours. The use of video calls with the patients should be recommended, where possible.

The added benefit of video calling is that it helps the therapist perform a visual risk evaluation, which is especially valuable for patients living alone, to determine the condition of the patient’s hands, presence of food in the fridge or cupboard, etc.

Identify and discourage high-risk obsessive-compulsive behaviours, such as washing in boiling (very hot) water or bleach, or total fasting. On the contrary, encourage eating and drinking to maintain health.

III. Deep brain stimulation (DBS)

For this small group with extremely severe, treatment resistant illness, a moderate increase of psychological distress or OCD symptoms may be expected during the pandemic, but this does not mean that DBS is not working.

We recommend delaying the implantation of electrodes in those OCD patients waiting for DBS until the outbreak is over. In those who have electrodes implanted, a worsening of OCD symptoms may be experienced if the battery stops working.

Such patients should be encouraged to check with their treating clinician in case the power has simply been turned off, or if there is a real need for battery 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.

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. Help the isolated patient to overcome loneliness and build stability by increasing communication with friends, family members and loved ones.

In the case of those with a poor social network, telephone helplines such as those run by OCD charities are particularly useful, especially if managed by qualified trained professionals. Also encourage patients and family members to keep weight under control e.g. by creating new places for sports in the home and including physical activity in their home routine.

Exercise can be additionally helpful for some patients coping with the mental effects of the pandemic. Aerobic exercise has in some studies been shown to have positive effects for those with depression, anxiety 14,15 and OCD16.

Where there is ability to go out for aerobic exercise once a day then a brisk walk or run can be useful.

Gyms and yoga studios centre’s are fuelling the drive to stay active by offering online exercise classes, some free of charge, or extending trial periods for at-home workouts.

V. Carer support

Remember that family members and caregivers of patients with OCD are also at increased risk of developing stress related disorders owing to the worsening of patients’ symptoms and may need additional support in their own right.

Parents of children with OCD are likely to require even more coaching and support than before, especially as relationships may be impacted in unpredictable ways by the fact that parents and children are spending so much time together.

Consider that parents are burdened differently under COVID-19, especially single parents who may be heavily burdened or those with little living space, especially if children are becoming irritable or aggressive (as is often the case for children with OCD if their behaviours are not accommodated).

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.

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.


International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive Research Network (OCRN)
of the European College of Neuro psychopharmacology

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