Impact of COVID-19 on exposure and response prevention for obsessive-compulsive disorder: Present and post-pandemic considerations.

Dear Dr. DeLisi,

Obsessive-compulsive disorder (OCD) is an impairing psychiatric condition characterized by presence of obsessions and/or compulsions (American Psychiatric Association, 2013). Patients present with symptoms spanning several dimensions, including contamination/cleaning, checking, taboo obsessions (i.e., sexual, aggressive content), and symmetry/repeating/ordering. The impact of the COVID-19 pandemic on those with OCD has been discussed related to symptom exacerbation, increased incidence of OCD cases, and with implications for assessment and treatment (e.g., Krompinger et al., 2020). However, there has been little attention on the impact of COVID-19 on during- and post-pandemic treatment of OCD.

The gold standard psychological treatment for adult and childhood OCD is exposure and response prevention (ERP). ERP involves gradual, systematic exposure to triggers that evoke obsessive-compulsive symptoms while the patient refrains from completing rituals or other avoidance behaviors. This approach involves exposure to triggers reflecting ‘ordinary’ levels of risk such as touching potentially ‘contaminated’ objects without washing hands, shaking hands with different people, or eating food off uncleaned surfaces. However, given the potential risk to previously acceptable exposure tasks, seasoned clinicians have shifted their exposure practice to reflect this new normal such as relying on imaginal exposure or exposure targeting rituals only in excess of public health agency recommendations.

There is potential risk to this effective intervention as a result of the pandemic. Research prior to the pandemic has shown that some clinicians hold negative attitudes towards exposure, which has no meaningful empirical support and translates to reduced use of this efficacious therapeutic technique (Farrell et al., 2013). The actual risk of ERP in the absence of a global pandemic, however, is very low, and is generally far exceeded by the potential benefits of this treatment; a recent survey of 256 experienced ERP therapists suggested that only one out of an estimated 17,415 patients participating in contamination-focused ERP experienced a significant negative consequence of ERP, and in this one case, the consequence was unlikely to be directly related to the contamination exposure (Schneider et al., 2020). Regardless, a substantial proportion of clinicians perceive this treatment to pose significant risks to patients, and it is unclear what the impact of COVID-19 may be on practice of ERP. Will those who have positive attitudes be less likely to utilize ERP even when COVID-19 health risks have subsided? Will those with negative attitudes be stauncher in their position? A concerning possibility is that ERP treatment post-COVID-19 is diluted by virtue of therapists not practicing exposure in a sufficiently robust fashion which is consistent with the actual level of environmental risk.

Considering the bioethical principles of beneficence and non-maleficence may provide guidance when clinicians are faced with decisions about implementing ERP when patients have severe, impairing contamination-related OCD. Balancing the risk of a patient contracting COVID-19 during ERP with the potential benefit of ERP on reducing obsessive-compulsive symptoms should be central to treatment planning, considering both the latest information and guidelines about the pandemic with the degree of impairment and distress caused by OCD. Once the pandemic is over, the benefit will theoretically far outweigh the risk, though avoidance patterns, safety behaviors, and concerns about germs that have been normalized and recommended during this unprecedented time may continue to linger and affect clinical decisions. Indeed, good treatment involves assisting the client to adopt social behavioral norms around personal hygiene. These norms may shift following the COVID-19 pandemic, and thus the goal of treatment remains unchanged.

Given that guidance is developing and often variable in content, it will be critical to provide guidelines established by expert ERP clinicians for how providers integrate realistic COVID-19 concerns into their ongoing practice, as well as that in the future. There is precedence for this. Early in the HIV/AIDS pandemic, ethical and practical guidelines were developed to responsibly conduct exposure for contamination fear (Bruce and Stevens, 1992). A similar process can be undertaken now in relation to COVID-19, with attention to local levels of COVID-19 risk. Because the future of the pandemic is unknown, continuous updates to these recommendations will likely be helpful. However, we highlight several ERP practice parameters for practicing clinicians and also direct the reader to Krompinger et al. (2020). First, exposures should target excessive behaviors/rituals stemming from obsessions and not adherence to public health guidelines. Second, clinicians are advised to continue to assess the function of ritualistic behavior and target symptoms that are driven by obsessional distress (Krompinger et al., 2020). Third, exposure tasks should target the patient's core symptoms, which are most often not centered around COVID-19. For example, a patient with fears of harming loved ones by stabbing them with a knife would have relatively unaltered ERP. In contrast, a person who is fearful of accidentally spreading COVID-19 if s/he was unknowingly asymptomatic would require more precise exposure tasks that balance therapeutic need with public health guidelines. Finally, while COVID-19 has elevated stress in most individuals with and without OCD, ERP should continue to build a core transdiagnostic skill in the patient in which s/he is encouraged to confront fear evoking triggers without unnecessary avoidance or rituals.

Just as public health officials’ guidelines for staying safe from COVID-19 have changed as the pandemic has evolved, it will be similarly important for ERP guidelines to reflect realistic safety concerns in conjunction with social behavioral norms that reflect the current state of COVID-19 and effective use of ERP. Once this pandemic does pass, it is our hope that guidelines such as these will be refined as circumstances evolve to promote continued effective and safe use of ERP.

Sincerely,

Disclosures

Dr. McKay, Dr. Guzick, and Dr. Schneider have nothing to disclose. Dr. Goodman reports grants from Brainsway, grants from Biohaven Pharmaceutics, grants from NIH, other from Medtronic, personal fees from Biohaven Pharmaceutics, personal fees from Neurocrine Biosciences, outside the submitted work; . Dr. Storch reports personal fees from Elsevier, personal fees from Wiley, personal fees from Springer, personal fees from American Psychological Association, personal fees from Jessica Kingsley, personal fees from Lawrence Erlbaum, personal fees from Oxford, grants from Greater Houston Community Foundation, grants from ReBuild Texas, grants from NIH, grants from Texas Higher Education Coordinating Board, personal fees from Levo Therapeutics, personal fees from International OCD Foundation.