Obsessive-Compulsive Disorder During the COVID-19 Pandemic Process: A Narrative Review

This study aimed to review all empirical contributions published between March 2020 and June 2022, addressing the impact of the COVID-19 pandemic on obsessive-compulsive disorder in adults. We searched the literature in PubMed, Google Scholar, and Web of Science. A total of 543 articles were scanned and 73 full-text articles were identified. Reviews, comments, letters to the editor, and case reports (except case series) were excluded. It was determined that 42 articles met the inclusion criteria, 6 studies involving only children and adolescents were excluded, and 36 were decided on their suitability for our study. The analysis determined that COVID-19 had an impact on obsessive-compulsive disorder. Characteristics such as liability for harm and unacceptable thoughts influenced the symptoms as well as contamination and washing. Some studies showed an increase in the severity of obsessive-compulsive symptoms, while some reported no worsening but improvement with treatment and follow-up. While some reported variations in outcomes related to sociodemographic characteristics and subtypes, some focused on the risk of suicide. There were also studies conducted on special groups such as pregnant women or healthcare workers. The results were controversial. While available data contain more information on worsening obsessive-compulsive disorder symptoms, data on the status of patients under treatment were scarce. There were not enough studies evaluating follow-up results. Influencing factors such as sociodemographic characteristics, subtypes, comorbid conditions, treatment, and support did not seem to have been adequately addressed.


Introduction
After the World Health Organization declared the coronavirus (COVID-19) outbreak a pandemic in March 20201 dramatic measures were taken, such as quarantining cities with thousands of people to limit the spread of the virus.The effect of measures such as social distance, selfisolation, and quarantine on vulnerable individuals with mental health problems has been an important research topic for scientists.
An important issue of mental health that may be affected by the pandemic is obsessive-compulsive symptoms.Obsessive-compulsive disorder (OCD) symptoms are characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed to reduce the anxiety of the obsessions. 2 Its prevalence in the general population is 2%-3%. 3e common contact of OCD symptoms with epidemic measures is contamination concerns and washing/cleaning compulsions. 4There is a significant overlap between conta minat ion/ w ashin g symptoms of OCD and recommended public health recommendations (hand washing, using face masks, wiping around, etc.) to prevent the spread of COVID-19. 5Other OCD themes include obsessions about COVID-19 (intrusive thoughts about the growing number of COVID-19 cases), hoarding (over-supply of food and other needs), and controlling (exaggerated and repetitive monitoring of the news about coronavirus) behaviors. 6e health risk and anxiety of the COVID-19 pandemic may have a special impact on individuals susceptible to OCD, by both worsening the existing symptoms and accelerating new symptoms. 6However, the fear of contamination provides preventive behaviors for COVID-19, 7 and in a way, OCD symptoms also play a protective role. 8 OCD, concerns about COVID-19 may be considered to have responsibility for being infected or having undetected symptoms, as well as infecting and harming someone else. 6Another impact of the pandemic on OCD symptoms is that people with OCD may tend to attach personal meaning to viruses and microbes.As these features involve rituals such as increased handwashing, they can lead to prolonged distress and anxiety during the COVID-19 outbreak. 9For individuals with OCD, the pandemic can also be a process of providing exposure and response prevention therapy. 10,11e aim of our review was to explore the latest literature on the effect of the COVID-19 pandemic on OCD patients and identify the limitations.Particularly, we wanted to assess whether OCD symptoms were worsening and which issues of OCD were particularly affected.Our main purpose was to analyze and synthesize all published empirical studies from March 2020 to June 2022 that had identified the impact of COVID-19 pandemic on OCD.

Research Question
The aim of the present narrative review was to evaluate existing contributions by researching the impact of coronavirus pandemic on OCD in adults and highlighting their limitations.We especially wanted to verify if there had been a worsening of OCD symptoms and which OCD subtypes were mostly affected.Our main objective was to analyze all studies from March 2020 to June 2022 concerning OCD and the coronavirus pandemic focusing on clinical populations of adults and analyze the current literature.We suggest that research on OCD in times of pandemics is important because the effect of such a global situation might be continued and a pandemic might be repeated.

Methods
We analyzed all studies from March 2020 to June 2022 concerning OCD and the coronavirus pandemic focusing on clinical populations of adults.The aim of this review was to evaluate existing contributions by researching the impact of coronavirus pandemic on OCD in adults.We included original studies investigating the impact of the COVID-19 pandemic on OCD and obtained information from studies focusing on different countries.

Eligibility Criteria
The studies with the following criteria were included: peer-reviewed academic journals published between March 2020 and June 2022; a clinical sample of OCD in an adult population and empirical study on the impact of the COVID-19 pandemic; cross-sectional or longitudinal study design; and accessible abstracts and articles with full texts.
Studies with the following criteria were excluded: not making an original contribution (e.g., review, comment, case report, or letter to the editor).Typology of treatment, presence of comorbidity, publication status, and language and nationality of the contributor were not exclusion criteria.

Search Strategy
A total of 543 articles were scanned and 73 fulltext articles were identified.Reviews, comments, letters to the editor, and case reports (except case series) were excluded.It was determined that 42 articles met the inclusion criteria, 6 studies involving only children and adolescents were excluded, and 36 were decided on their suitability for our study (Figure 1).

Results
The characteristics of reviewed articles are illustrated in Table 1.

Study Characteristics
The studies showed 6 different research designs: 26 cross-sectional studies, 2 also included qualitative assessments, 4 case-control studies, 1 description, 6 longitudinal studies, and 1 with case series reporting.Research designs are illustrated in Table 1.
36,45 In 1 study, data were obtained from the opinion of clinicians. 25 Coclusion criteria are illustrated in Table 1.
As of February-March 2020, studies were conducted in many countries during the first curfew period and in the following periods.One study compared the results from 2019 with other data collected during the first quarantine (January-May 2020). 35

Sample Characteristics
In general, the sample groups evaluated in the studies were diverse in terms of gender, age, and comorbidity.Studies included both small and larger-scale trials (Table 1).
Two studies had 2 samples of groups with and without a diagnosis of OCD. 28,46In 2 studies conducted on pregnant women, the status of pregnant and non-pregnant women was compared. 42nother study was a comparison between health workers working in the COVID-19 service and in different services. 43In addition, Jelinek et al 20 evaluated 2 OCD subsamples, washers, and non-washers to compare compulsions during the COVID-19 pandemic.There was only 1 study evaluating OCD-related disorders such as hoarding disorder (HD) and skin-picking disorder (SPD). 19Tandt et al 40 study was the only study that evaluated the status of families as well as OCD patients. 40Obsessive-compulsive disorder patients were the participants who were with different comorbidities such as anxiety disorder, 18,22,23,26,30,46 or mixt anxiety disorder and depressive disorder. 17,24,27,28,31,33,41,43In some studies, comorbid diagnoses were excluded. 19,40n other studies, psychiatric comorbidity was not specified. 21,25,29,39,41,45,47

Main Points
• People with obsessive-compulsive disorder (OCD) were vulnerable to the psychological effect of the COVID-19 pandemic and many studies have been conducted on this subject.
• Studies reported more information on worsening OCD symptoms.
• Studies evaluating follow-up and treatment results were few.
• There is a need for the development of the studies.More studies are essential to capitalize on more appropriate and early interventions and to understand how variables exacerbate OC symptoms in the OCD population.
anxiety about COVID-19 as a separate problem.Obsessive-compulsive disorder symptoms have been found to be associated with contamination and liability for harm.Davide et al 35 evaluated the status of OCD patients during pandemic process who were in remission and those who were not in remission before the pandemic, and it was found that there was a significant increase in OCD symptoms and more worsening in those who were in remission before the pandemic.Tukel et al 44 reported that OC symptom severity worsened in 60% of OCD patients during the pandemic.
Two studies by Khosravani et al 36,37 specifically found that all symptom dimensions of OCD were affected during the COVID-19 pandemic, not only contamination obsessions but also responsibility for harm and reported that situations such as responsibility for harm, stress response to trauma, and unacceptable intrusive thoughts were effective in the increasing risk of suicide.
In 3 longitudinal studies that conducted treatment follow-up studies, 39,41,45 improvement in OCD symptoms was reported in OCD patients followed up with acceptance and commitment therapy (ACT) and exposure response prevention (ERP) therapies.No significant symptomatic exacerbation was reported in the study in which the results of regular follow-ups of 2 months and 6 months with cognitive behavioral therapy (CBT), ERP, and pharmacological treatment were shared 41 and in which pharmacological treatments were followed. 45In the study, in which clinicians' opinions were evaluated and the results of follow-up with ERP were reported, 25 the clinicians showed that the symptoms of 38% of their patients worsened during the pandemic and the symptoms did not change although 47% participated in ERP.
The study that evaluated the early and longterm effects of COVID-19 on OCD patients demonstrated that depressive, anxiety, and OCD symptoms worsened during early COVID-19 and the negative effect continued at 1-year follow-up. 24In 1 study, the coping attitudes of OCD patients were evaluated; positive reframing, acceptance, and humor were lower, while the results on instrumental support and religion were better in OCD group. 46The OCD group showed higher rates of denial and selfblame, and cognitive coping and spiritual coping were statistically significant.While the control group mostly used cognitive strategies, the OCD group mostly used emotional strategies.Study of Tandt et al 40 also included families of patients and showed that the COVID-19 crisis increased OCD symptoms of almost all patients, decreased their ability to use coping strategies, and they needed increased family support.The pandemic had strained patients' social and family lives and had led to withdrawal from face-to-face therapy, leaving many to feel less supported.The importance of including family support in the therapy process was emphasized.

Obsessive-Compulsive Symptoms of the General Population During the Pandemic Process
The study by Zheng et al 13 investigating the prevalence of OCD in an urban population in China showed the OCD prevalence as 17.96%.Aggression and contagion obsessions and compulsions to clean, check, and repeat were evident.Two studies found increased prevalence of OCD during COVID-19 pandemic among the general population. 32,33Another study that was conducted to examine the prevalence of OCD symptoms in pregnant women found the prevalence as 7.12% of participants, more than twice as high as rates of peripartum OCD reported prior to the pandemic. 34 Samuels et al' s study 15  April 2020 Depression and anxiety symptoms were higher in the OCD group.Positive reframing, acceptance, and humor were higher in the control group.The OCD group showed better results on instrumental support and religion.The OCD group showed higher rates of denial and self-blame, and cognitive coping and spiritual coping were statistically significant.While the control group mostly used cognitive strategies, the OCD group mostly used emotional strategies.
Cox et al, USA 47 Evaluating whether insomnia before COVID-19 would be a predictor for OCD symptoms Cross-sectional study N = 369 Undetermined Undetermined

Face to face interview
April 2020 There was a small increase in OCD symptoms after the pandemic compared to pre-COVID-19.Having a pre-pandemic insomnia symptom resulted in a small increase in OCD symptoms in the post-COVID era.

Table 1. Analysis of the Studies (Continued)
increased at the beginning of the pandemic and then decreased, and was especially found to be associated with OC symptoms.In a study that evaluated intrusive thoughts about COVID-19 and OCD in individuals without OCD, 18 OCD and COVID-19 intrusive of those with high OCD symptoms were at a similar rate as those with low OCD symptoms.Severity of OCD symptoms was significantly correlated with the frequency of COVID intrusions and the amount of their distress.In the study, in which OCD subtypes (OCD-related disorders) were mentioned, an increase in subtypes such as HD, SPD, hair picking disorder, decreased quality of life, and increased disability rate were reported.In 2 studies conducted by Jelinek et al 20,21 on the general population, worsening of OCD symptoms was reported.
In the study by Taher et al 22 in which OCD prevalence, related factors, and correlations were evaluated among medical students, 57% were evaluated as normal, while 43% as probable OCD requiring further evaluation.About 70% had accompanying psychiatric symptoms, anxiety, and stress.Unpleasant thoughts were the most common symptoms in 51.8%.The study by Yassa et al. 42 on pregnant women showed more OCD and less anxiety symptoms compared to non-pregnant women.State anxiety levels did not differ between the trimesters.In a study conducted on healthcare professionals in Turkey, 43 healthcare professionals working in COVID-19 services showed a significant increase in OCD, depression, and anxiety symptoms compared to healthcare professionals working in other services.There was only 1 study that evaluated the pre-pandemic period and compared the period before and after the pandemic and evaluated whether insomnia before COVID-19 would be a predictor for OCD symptoms. 47Having insomnia symptoms before the pandemic showed a small increase in OCD symptoms in the COVID-19 period.In the study by Al-Shatanawi et al. 26 which evaluated self-reported obsessions for COVID-19 preventive measures among medical students, 6.8% of participants reported obsessions related to preventive measures against COVID-19, and 93.2% (n = 1308) showed that they had no obsessions. 26In a study evaluating the prevalence of OCD symptoms during the pandemic process, screening was conducted among university students in 3 different periods.In questionnaire 1, 11.3% of the participants were identified as probable OCD.In surveys 2 and 3, 3.6% and 3.5% of respondents had scores indicating probable OCD, respectively. 30In another study, the prevalence of OCD symptoms increased at a significantly higher rate than reported pre-pandemic rates for the sample population. 31e Course of Symptoms Associated with the Contamination There were few studies specifically evaluating OCD symptoms associated with contamination.Wheaton et al 12 and Davide et al 35 reported that an increase in OCD symptoms was evident in symptoms related to contamination.The prevalence study by Zheng et al 13 reported that aggression and contagion obsessions and compulsions to clean, check, and repeat were prominent.The study by Khosravani et al 36 reported an increase in all OCD symptoms and an increase in both conta minat ion-r elate d symptoms and obsessions such as responsibility for harm, symmetry, and unacceptable thoughts. Anther study reported an increase in symptoms related to contamination by 64.7% and symptoms related to harm by 56.2%.38 The study comparing washers and non-washers reported that OCD symptoms increased more in washers.20 In the study evaluating medical students, the contamination and washing subscales were found to be lowscored.22 In the study conducted on pregnant women, an increase in OCD symptoms and anxiety was reported and symptom subtype was not specified, but no correlation was found between anxiety and hygiene-cleaning subscales.42 There was also a study reporting that contamination symptoms increase anxiety, but it did not specifically report an increase in contamination symptoms.27 There were 6 studies reporting an increase in contamination, washing, and cleaning in particular.12,13,15,20,35,36 One study reported improvement with ACT and ERP therapies, suggesting that the pandemic process may be an opportunity to achieve overexposure and treatment goals.39 Another study reported that complying with washing and hygiene rules within the scope of COVID-19 measures did not increase washing compulsions. 45Factors Associated with Obsessive Compulsive Symptoms Studies that found the increased OC symptoms of people with OCD to be associated with COVID-19 anxiety, 12,18,23,26,29,40,43 as well as studies that reported increased obsessive symptoms, especially related to the responsibility to do harm, were also present.14,27,36,37 In a study reporting that responsibility to harm was an important cause of the increase in OCD symptoms, 37 it has been reported that responsibility to harm and unacceptable thoughts, as well as OCD severity, stress response to COVID-19, traumatic stress reactions, control compulsions, comorbid depression, and anxiety affect suicidal ideation.Another study reporting an increased risk of suicide reported that deterioration in obsessive symptoms was also associated with internet control for reassurance, the need for family support, and sleep disturbances.15 A study reported that symptomatic worsening was more common during the COVID-19 pandemic process in those who reported that they were in remission before quarantine, 35 and another study that evaluated the pandemic process reported that sleep disorder before the pandemic had little effect on OCD.47 In the prevalence study conducted on the pregnant women, younger maternal age, income loss, and suspected SARS-CoV-2 infection were all associated with higher OC symptoms.34 The study that investigated how the pandemic has affected OCD patients found that COVID-19 obsession levels were correlated with anxiety severity.44 In a prevalence study conducted on the general population, 13 being single, being a student, family history of OCD and other mental disorders, comorbid psychiatric comorbidity, and prolonged sleep latency were risk factors for OCD.
In another prevalence study, 31 higher OCD symptoms were evaluated to be associated with higher stress.
Generalized anxiety disorder (GAD), and major depressive disorder (MDD).In a study investigating the prevalence of OCD among medical students, 22 the presence of other psychological symptoms such as anxiety, depression, sleep disorders, eating disorders, and stress was significantly associated with probable OCD.In a study investigating the prevalence of OCD among university students, 30 fear intensity was found to be positively associated with probable OCD rate and mean total scores for Yale-Brown Obsession Compulsion Scale (Y-BOCS), with a higher probability of OCD in non-medical fields.
In a study evaluating the coping strategies of OCD patients during the pandemic, 46 it was reported that some positive strategies and maladaptive strategies differ in their use.In the OCD group, comorbidity influenced greater use of inappropriate strategies (denial, substance abuse, and self-blame).The subtype of obses sions -comp ulsio ns was not effective in their use.Anxiety and depression symptom severity was associated with more maladaptive behaviors.
A study evaluating the early and long-term effects of the pandemic on OCD patients demonstrated that female gender, concern about COVID-19, and baseline OCD level and exacerbation of OCD symptoms were risk factors, while optimism was a factor of mental toughness which is protective against increase of OCD both in early period and follow-up. 24In another study, 28 the OCD group scored higher in perceived anxiety and depression levels, experienced suicidal thoughts more often, and experienced more frequent changes in perceived eating and sleep patterns.In a case-control study in pregnant women, an increase in OCD symptoms but a decrease in anxiety symptoms was reported in pregnant women, and it was stated that this situation may be related to the use of coping strategies. 42 the study conducted by Hojgaard 14 , a group of 29.4% reported that they accepted their obsessive thoughts more during the pandemic process.
The study evaluating healthcare workers stated that the increase in OCD symptoms of healthcare workers working in the COVID-19-positive service was associated with COVID-19 anxiety. 43

Treatment Characteristics
Besides several studies showing an increase in OC symptoms in adults despite the possibility of psych ophar macol ogica l treatment and psychotherapy (CBT and/or ERP), 12,24,25,28,35,36,37 there was also 1 study reporting that drug compliance was higher in patients with OC deterioration. 38Improvement was reported in OCD patients in the follow-up study by Kuckertz et al 24 with ACT-ERP therapies and by Carmi et al. 41 with CBT, ERP, and pharmacological treatment.
In the study by Chackraborty et al. 45 exacerbation was reported in only 5-6 of 84 patients, and they were those who could not take their medications because they could not go to the pharmacy.In the study by Storch et al 41 in which the ERP results of OCD patients during the pandemic were evaluated, it was stated that ERP progression was weak.In Alonso et al's study, 28 all participants were on pharmacological therapy, 25.1% of patients required a change in pharmacological therapy during the first months of the pandemic, and all except 2 were given increasing doses of selective serotonin reuptake inhibitors (SSRI) or clomipramine (n = 16), antipsychotic doses (n = 3), or received increased or added doses of benzodiazepines.

Discussion
This study aimed to analyze and review the studies investigating the impact of the COVID-19 pandemic on OC symptoms in adults.The COVID-19 pandemic may cause worsening of pre-existing psychiatric illnesses.Especially, recent research has indicated that COVID-19 may have an impact particularly on people with OCD.It has been observed that COVID-19 is an important source of stress for individuals with OCD. 12,16,37In the early stages of the pandemic, OC symptoms increased both in those with OCD and in the general population. 13,15,20,33,34,39t can be thought that warnings about the coronavirus and reminders for hygiene have exacerbated obsessive concerns about contamination. 14,20,35The results showed that people with OCD had high concerns on the spread of pandemic diseases, including COVID-19.COVID-19 had become an important problem, especially in those with contamination obsessions and those with OCD who had more fear of COVID-19. 15,23,35,44ny studies had found a worsening of the symptom dimensions of OC symptoms, especially among patients with contamination symptoms. 12,13,15,20,35However, besides the contamination symptoms, responsibility for harm and unacceptable thoughts were among the deteriorated OC symptom dimensions. 36,37nly a few studies had examined OCD subtypes. 19,36,37,39There were also contradictory results showing that the pandemic had no impact on some fields of OCD. 45,46Because the complex nature and heterogeneity of OCD is known, variable responses to the COVID-19 outbreak may also be considered normal.Anxiety about COVID-19 was a part of OCD for some, while it is a separate issue for others.Although some OCD groups experienced high anxiety about COVID-19, a great majority reported that their primary problem was preexisting OCD concerns, while few reported COVID-19 as their main concerns. 15,18,28garding OCD symptom dimensions, participants' self-reports suggested that worsening of OC symptoms was more strongly associated with symptoms of contamination and responsibility for harm than with intrusive thoughts or symmetry symptoms. 12,36These results were in line with past research demonstrating contamination concerns about past pandemics. 48terestingly, there were several studies showing a rise in OC symptom severity in adults despite the possibility of psych ophar macol ogica l treatment and psychotherapy. 12,24,25,28,35,36,37However, 3 different studies highlighted that the impact of COVID-19 on OCD patients was only minimal, and symptoms even showed improvement. 39,41,45ne of these studies noted that pandemic may be an opportunity for exposure. 39 is important to underline that providing treatment can affect outcomes of the OC symptoms because in most studies, the method of treatment was uncertain or only some reported receiving treatment.Briefly, data about the method and course of treatment were uncertain and heterogeneous.
Regarding the measures used in data collection, studies preferred quantitative measures with psychometric properties and/or qualitative tools such as questionnaires.Y-BOCS had been used frequently, considering that it was the gold standard to measure the severity of OCD symptoms. 49Regarding self-report measures, the OCI-R was used. 50Most of the articles we analyzed preferred online methods such as phone interviews and online surveys to comply with COVID-19 precautions.
Heterogeneity of measurements may affect results; a face-to-face interview conducted by researchers may be more certain than phone interviews or self-report questionnaires.In addition, studies did not specify whether the participants had COVID-19.Obsessive-compulsive disorder patients affected by COVID-19 can be expected to experience worsening of their symptoms.
While responses have been variable, significant mental health problems appear for many adults with OCD because COVID-19 has an effect on worsening symptoms and complex therapy for many.Further studies are needed to identify the mental health burden of COVID-19 on OCD patients.In times of quarantine and social distancing, increasing accessibility to treatment and ensuring treatment delivery in a safe and effective way will be important at this unprecedented time.
Although studies reporting worsened OCD symptoms were significant, data on treatment results were scarce.Follow-up studies were few and factors such as sociodemographic characteristics, subtypes, comorbid conditions, treatment, and family support seem to have not been adequately studied.More studies are essential to understand how variables exacerbate OC symptoms in the OCD population.

Conclusion
Results were conflicting.Although studies reported more information on worsening OCD symptoms, data on treatment were scarce.Studies evaluating follow-up results were few.Factors such as sociodemographic characteristics, subtypes, comorbid conditions, treatment, and support seem to have not been adequately studied.
Our results indicate the need for the development of the studies and seem important for clinicians and the scientific community in terms of shedding light on the impact of the COVID-19 pandemic on OCD, a psychiatric disorder that causes significant impairments of functionality.This information is essential to capitalize on more appropriate and early interventions and to understand how variables exacerbate OC symptoms in the OCD population.

Table 1 .
Analysis of the Studies (Continued)

Table 1 .
Analysis of the Studies (Continued)

Table 1 .
Analysis of the Studies (Continued)