Staying home and washing our hands more often is recommended to combat the spread of COVID-19. Is refusing to touch something someone else has touched a compulsion or an appropriate safety measure right now? At what point do fears of contracting illness become an obsession?
Health professionals diagnose obsessive-compulsive disorder (OCD) when the amount of distress is excessive and impacts a person’s ability to function. The pandemic presents some unique challenges in the recognition and treatment of OCD.
Fears of contamination, which may seem protective, are not the only symptoms patients with OCD are suffering from right now. Obsessions may include forbidden thoughts of a sexual or violent nature, religious preoccupations, or a need for symmetry.
The treatment of choice for OCD is a kind of cognitive behavior therapy (CBT) called exposure and response prevention (ERP) and medication. ERP consists of gradual exposures to triggers while keeping the person from performing their compulsion and managing any thoughts related to the experience.
Here are three recently published studies that review current needs and future directions for OCD treatment:
1. ERP during a pandemic
A recent clinical review discussed the challenges of treating patients with OCD via telehealth during COVID-19. About half of patients with OCD have some contamination fears, so ERP would generally involve leaving the house and not washing excessively. Clinicians must weigh the ethics of continuing this type of exposure work during a pandemic against the risk of exposure to COVID-19.
There are unique risks for patients with chronic health conditions that affect their immunity, but therapists can't limit tasks so much that the session is no longer useful. ERP is the most effective treatment for OCD and can continue safely via telehealth.
Exposures should proceed following the Center for Disease Control (CDC) guidelines in more open, less populated areas. Clinicians can also shift focus to symptoms less tied to contamination fears.
2. Predicting response to ERP
A study performed at the University of Michigan examined whether brain activity is associated with treatment response to exposure-based CBT.
Eighty-seven patients with OCD were randomly assigned to receive 12 weeks of CBT or a control intervention called stress management therapy. Before treatment, researchers conducted functional MRI (fMRI) brain scans while patients performed a series of tasks. They completed the symptom severity scale Yale-Brown Obsessive Compulsive Scale (Y-BOCS) throughout treatment.
The patients with the most significant response to CBT showed more activation in several brain areas before starting treatment. The active regions are associated with cognitive control and reward processing. These data suggest that brain scans could identify biomarkers to personalize treatment in OCD.
3. Effects of cannabis
A paper by Washington State University researchers is getting a lot of attention given medical marijuana use. There is very little data regarding cannabis use in patients with OCD, and what does exists suggests that cannabis may even exacerbate the condition.
Eighty-seven subjects rated logged their symptom severity into the Strainprint app for 31 months. After smoking cannabis, they reported use reduced compulsions by 60 percent, unwanted thoughts by 49 percent, and anxiety by 52 percent. Cannabis strains with higher concentrations of cannabidiol (CBD) were associated with more considerable reductions in compulsions.
The study did not follow an experimental design as there was no control group, and participants self-identified as having OCD. Improvement in symptom ratings decreased with time, suggesting little long-term benefit.
Don’t give up ERP, the most effective treatment for OCD, because it’s more complicated during the pandemic. In the future, treatment providers may be able to use fMRI to predict which patients are most likely to respond to ERP. Cannabis may provide temporary relief to some OCD patients, but more structured studies are needed.