Some patients with anxiety and OCD have a counterintuitive reaction to the Coronavirus
I have noticed something in my clinic that I find to be an interesting phenomenon.
While discussing the Coronavirus pandemic with my patients with anxiety and OCD, specifically contamination-type OCD, I’ve noticed many have been able to maintain a surprising level of calm throughout the chaos.
As someone who also lives with OCD, many of my peers are surprised at how calm I have been throughout this ordeal. I have developed some hypotheses as to what is going on in the rare cases that match what I am describing.
1) Feelings of validation:
Usually people with OCD are painfully aware that their fears are irrational. It is quite invalidating to have feelings on the inside that do not match up with one’s current circumstances.
However, in the case of a clear and present danger, many of these fears are no longer irrational and vague and there is no longer the cognitive dissonance (inconsistent thoughts or beliefs relating to attitudes and behavior) that causes many people to suffer. The observation of no change in, or in fact decreased anxiety in a subset of contamination-type OCD seems counterintuitive.
According to neuroscientist and clinical professor of psychiatry, Dr. Heather Berlin, “One possible explanation for this phenomenon is that patients with OCD and anxiety disorders have already been experiencing high levels of anxiety for a prolonged period of time so they may have habituated to it so it does not get worse. Cognitive neuroscience studies have shown that people with OCD have increased insula activation compared to controls and experience heightened levels of disgust. When their feelings of disgust and contamination fears are invalidated this might frustrate them and increase their anxiety. For example, they may question why they are having these exaggerated worries and extreme behaviors and become frustrated that they cannot modulate them. But now that there is a real external threat (i.e. COVID-19), their behaviors and thoughts may feel less abnormal and more accepted by society.”
According to Dr. David Bresler, a psychiatrist in West LA, "If a bear is chasing you in the woods, your body releases a flood of anxiety-producing chemicals that make you run faster, think clearer and perform better. If those same chemicals get released when you're sitting on your couch without a clear target to focus on, it creates a terrifying and helpless feeling, and your brain begins "looking" for something to blame the anxiety on (obsessions) and some way to fix them (compulsions). But when a clear external target becomes available, often those with unfocused anxiety suddenly have the opportunity to experience the positive benefits of the anxious chemicals their bodies have been releasing all along”
Author, Shahida Arabi, notes this fact with trauma survivors as well stating, “As trauma survivors we are always on alert for the danger to come. We’ve been preparing for it our whole lives. So while we are obviously horrified by this, there is definitely a lot of caution and grief given the devastating losses around the world, now that there is a tangible danger that has arrived, our survival skills are kicking in and we feel more prepared than most emotionally.”
Similarly, some of my patients with depressive symptoms and OCD have reported that they are feeling relieved that they don’t have to be “living their best lives.” In fact, similar to the validation point from above, they feel as though they don’t need to be happier thus eliminating that dissonance as well.
2) These new recommendations are already automatic:
Many of the people with contamination-type OCD have been over practicing the hygiene steps that are recommended for years and it is automatic. I’ve heard some patients report that they have been “on it for years” and the rest of us are “just catching up.”
One person with contamination OCD reports, “I’m actually doing okay, I've surprised myself. I've decided to let the rest of the town do whatever. Just sticking to my usual ways of wiping stuff down with bleach cleaner and washing hands. I have to buy groceries week to week so I did that. I'm not going to panic. Just going to stay home more.”
One mother reported, “The world has now caught up with those with cleaning obsessions. My daughter says she now feels everyone knows what it's like. What everyone else is doing now, she's been doing forever.”
According to Dr. Berlin, "Finally, people are now taking precautions against contamination which many patients with contamination-type OCD may have wished they would have taken in the past. This will likely decrease their anxiety related to a fear of contamination (even though the risk of actually getting a dangerous virus is higher) as more people are now being increasingly cautious.”
In addition, “People with OCD do not need to significantly change their behaviors in response to COVID-19 compared with the precautions they were already taking. However, people without OCD have had to make major adjustments in their behaviors to prevent the spread of the virus, which may have increased their anxiety.”
3) Relinquishing an urgent need for control:
Some of what keeps OCD going is a persistent need for control despite the fact that the idea of control is truly an illusion. An illusion that people with OCD hold tight to.
One patient reported, “I felt really worried and scared the past few days up until now: I was freaking out because I had no control and I shat myself like five times one day because I was so stressed out, but I realized that I have no control and no matter how I feel it won’t influence what will happen. So, I can either feel stress and continue to shit myself while nothing changes or accept the circumstances and try to stay calm and look on the bright side while nothing changes.”
One patient claimed that now that this situation is so out of her control, she feels she can relinquish some of that control that has been causing her such anxiety for her entire life. She reports that the anxiety was worst when the need for control was internal and “now that it is external, [she] can let it go.”
4) Just fitting in:
Some people who have been using Purell and washing their hands excessively have been ashamed of this abnormal behavior and hiding it from the public and now they no longer feel the need to hide.
According to a teen with OCD, “I’ve been a germaphobe my whole life. I wash my hands all the time and worry if they’re clean enough. I walk around feeling anxious every day. I almost never leave the house. Now, everyone is me!” According to his mother, “For the first time in a long time, his world is the norm…and it feels good to him to belong. It’s not that he wishes this situation on anyone; it’s just good to feel like he knows how to live in the world the rest of us now find ourselves in. He summed it up to us, as he shared his perspective, “Welcome to my world!”
Further, according to Shahida Arabi, “[Now] other people are feeling in a similar way as we do on a daily basis which cuts through the alienation that we often feel and offers some validation for a reality we live in every day, though we wouldn’t wish it on anyone. We are all in this together."
It is important to remember that only a subsection of the people that have OCD have responded to COVID-19 in the counterintuitive ways described here. Many other people with OCD have increased intrusive thoughts related to COVID-19, which may compound their other symptoms (e.g. compulsions) as well as secondary depression at a time when they may have less access to their regular treatment.
In fact, one psychologist, Dr. Joe Schippa of Westchester, NY reports, “My OCD folks have more obsessive thoughts, need more reassurance, and have escalated their hygienic compulsions...I have one person who can barely leave her home now. This pandemic is only helpful insofar as it has created another opportunity for exposure.”
In sum, according to Dr. Berlin, “People with OCD will likely continue to have over-activation in parts of their prefrontal cortex. And the uncertainty about the virus, the real external threat, and their need to try to maintain control over fairly uncontrollable circumstances may cause their anxiety to increase. However, in a subset of patients, their anxiety levels may stay the same or even decrease because they feel validated. They are also now being flooded/exposed to their worst fears, and they may have already habituated to heightened levels of anxiety, contamination fears, and preventative/compensatory behaviors. ”
Although we are reporting observations in a very small sample, it is an important piece of information that I have not only seen in my own practice, but have read about on OCD blogs, as well as heard echoed from colleagues.
The power of normalization and validation is invaluable to mental well-being. As Arabi so eloquently puts it, “It shouldn’t take a global pandemic or collective trauma for people to develop empathy for others or see their perspective. May there be a collective healing on all levels ahead for everyone.”