Why some with OCD are doing worse, some are doing better, and many are struggling in ways you might not have considered.
I’ve seen a lot of commentary lately about how people with obsessive-compulsive disorder (OCD) are coping with the COVID-19/Coronavirus pandemic. Some have made jokes about this being the world OCD sufferers have been waiting for, referencing the fact that some people with OCD suffer from health anxiety obsessions and catastrophic fears of contamination. But this is clearly not an educated perspective on OCD, a mental health disorder which manifests in countless obsessive themes and subthemes. Though many people with OCD do have obsessions related to contamination concerns, many of the OCD sufferers I treat struggle with intrusive thoughts about morality, violence, religion, or sexuality.
Contamination Means Many Things
For those who have what I would identify as contamination OCD, many of them do not actually have health anxiety or a pronounced fear of germs, but an exaggerated fear or disgust with bodily fluids, chemicals, or environmental contaminants. Even within that subtype, many of these sufferers are not afraid of contracting illness as much as they are afraid of violating social hygiene norms, harming others through negligence, being overwhelmed by disgust or shame, or failing to follow self-imposed rules about washing and avoidance that have nothing to do with actually being clean.
Some of my clients who compulsively wash their hands have found themselves actually reducing ritualistic washing in the midst of the COVID-19 crisis. How can this be? One reason is that compulsive handwashers are often highly aware that their behavior is excessive. Contrary to public perception and media portrayal, people with contamination OCD do not delight in washing and keeping everything clean. When they wash, they are often doing so out of desperation or a belief that they are not capable of tolerating the uncertainty over whether or not to wash. In this pressurized and anxious state, a handwash can be furious and chaotic or hyper-specific and ritualistic, and in both manifestations there is likely to be significant psychological inflexibility. What this means is that any errors in or doubts about the washing are likely to result in repetition and prolonged efforts to get it “right” before being able to stop and move on to the next task. In short, shame about washing increases compulsive washing. In the face of a scientifically mandated and culturally accepted increase in washing, this shame is reduced and so are the rituals. A 20-second handwash that’s culturally endorsed, even if unnecessary, can be more easily stopped at 20 seconds.
Many people, of course, are also having difficulty containing or navigating the frequency of their washes. This likely has to do with difficulty making moral judgments about when hands should be washed without it being explicitly laid out. For example, we all should know by now that part of appropriate social distancing, indeed our civic duty in the face of this crisis, includes washing the hands “frequently”. But if you’re anything like me, you touch your phone within five seconds of any handwash. Further, we are instructed to avoid touching the face to avoid giving the virus an opportunity to get in our eyes, nose, or mouth. But if you’re anything like me, you touch your face all the time. I can’t have an original idea without touching my face. My face is the equivalent of the touch screen on my iPad – if someone asks me for information, I touch my face to get the answer for some reason. So some people with OCD are surely having a hard time working with this word “frequency” and this word “avoid” because it appears to be without concrete limits.
Obsessing About the Virus Means Many Things
By and large, however, I have not seen a significant increase in OCD symptoms or anxiety in the people I treat, not about the virus itself anyway. The OCD-driven inquiries are more like this:
- What if I touched something and didn’t realize it and this gets someone sick?
- What if I think about the virus too much and this causes it to be more deadly somehow?
- What if I have thoughts about wanting people to get sick or die?
- What if I’m having the wrong emotional reaction to the crisis and this means I’m a bad person?
- What if I feel relieved to have something different to obsess over and this means I’m callous?
The morally scrupulous OCD sufferer may find themselves over-monitoring their emotional reactions to the crisis, testing, reviewing, checking, and analyzing whether they are feeling the “right” things. Just like a person with relationship-themed obsessions may get stuck on whether they are feeling the right thing towards their partner, many OCD sufferers place enormous pressure to feel the “right” thing about an event. This pandemic is tragic, but make no mistake, what’s happening is also exciting, absurd, intellectually curious and, literally, novel. Most of us are comfortable with a variety of emotions occupying the same space, but many people with OCD suffer tremendous guilt over it and cause themselves hours a day of mental anguish.
Yet, perhaps ironically, many with OCD find a sort of relief in something bigger than their obsessions taking place. The presence of a crisis often means two things: no responsibility for the cause and little uncertainty how to respond. I am at my most relaxed when the pilot tells me we have turbulence headed our way. The pilot is in charge and my job is to stay seated. It’s when it’s not clear what my role is or what the right thing to do is that I most often fall apart.
The television show of life is not ending, but it is apparently going through an especially dark season. Every show has one. This cynical sense that the series won’t get renewed for another season can also press some OCD buttons. Those with obsessions about sexual orientation, gender identity, relationship quality, existential and religious obsessions may all feel an increase in pressure to figure it all out. OCD says you need to know you’re living an “authentic” life (whatever that means, I have no idea), and these days it may be saying you need to wrap it up already and get certain before it’s too late.
I only have three recommendations to OCD sufferers who are either spiked or strangely settled by the COVID-19 pandemic:
- COVID-19 has not changed the status of mental rituals. They remain pointless. Continue to practice noting when you’re ruminating and abandoning it for the present moment, whatever is in front of you.
- Do what the CDC and WHO tell you to do. Don’t do more than you’ve been told just to prove you’ve done enough. If you are not sure you’ve done enough, you’ve done enough.
- Many have said to limit your news intake to a few trusted sources. While I agree that compulsive checking and compulsive research should be avoided, I think you need to make this choice based on your personality. Not all people with OCD are the same. Some can derive strength and comfort from staying on top of their knowledge base and learning to distinguish between helpful information and conspiracy theories. Ask yourself what is nourishing and let self-compassion be the guide.
Only Part of the Game Has Changed
Instrumental in developing mastery over OCD is cultivating a healthy sense of skepticism of harm narratives and a loving embrace of the uncertain. This often means learning to be more impulsive, less careful, and more intentionally joyous of the present moment. Treatment for the disorder is the development of these skills. But COVID-19 has temporarily changed a few rules of this game, asking us to trust what we’re being told and be as certain as we can about social distancing. Social distancing will undoubtedly save hundreds of thousands of lives in the U.S.
So if I have one recommendation for the resilient and courageous OCD sufferers during this significant moment in history, it is to change the rules of this game only. Following the recommended guidelines does not mean mentally reviewing how well you followed them, engaging in self-punishment or self-criticism for your doubts and fears, excessive checking and reassurance-seeking, or over-washing and over-cleaning until it feels right. Accept all feelings about COVID-19, not just the ones you’d want others to know, and do the best you can to prove to the OCD that you can pivot to a change in one part of this war without sacrificing your mastery in the other parts. This is a new challenge, but you’re good at facing challenges.
For more info on this crisis and OCD, go to: iocdf.org/covid19
Jon Hershfield, MFTDirector, The Center for OCD and AnxietySpecialties:Anxiety Disorders, Cognitive Behavioral Therapy, Obsessive-Compulsive Disorder (OCD)