Exposure and Response Prevention (EXRP) is the most widely accepted, evidence-based treatment for the symptoms of Obsessive-Compulsive Disorder (OCD). For OCD patients with contamination concerns, this likely involves foregoing handwashing, extreme cleaning, and other sanitation procedures as part of treatment. The long-term benefits of the treatment are significant, and well worth the negligible risk due to actual infection/contamination the patient may encounter in normal times.
But these are not normal times, and recent Centers for Disease Control (CDC) guidelines prescribe a baseline of handwashing and sanitation measures to combat the spread of the COVID-19 virus that may exceed the usual efforts of the typical, physically healthy, non-OCD individual. The new CDC guidelines are forcing clinicians and patients to reconsider and redefine acceptable risks. To help clinicians and patients work through the new normal, the International OCD Foundation has suggested some commonsense guidelines for selecting safe exposure exercises.
First, the IOCDF recommends we adjust the baseline of acceptable risk to the CDC guidelines. For individuals with OCD, compulsive thoughts dictate behavior far outside baseline during normal times, and this will be true for many during the pandemic restrictions as well. Washing, cleaning, sanitizing, and avoidance of perceived contamination is likely to increase, as are anxiety levels related to infection and contamination. Thus, constructing exposures that regard the CDC guidelines as the target response level will still be an “exposure level” task for individuals who may feel compelled to wash and clean much, much more than that.
The IOCDF also recommends setting clear limits so that expected is not left ambiguous and to consider the context in which the patient lives and works as those limits are negotiated. For example, instead of leaving it with a vague, “clean hands often,” instruct patients when, where, and how long to wash according to their circumstances. The guideline may be different depending on where they work, with whom they work, whether they live alone or with others, and whether they have contact with the public. EXRP therapists are accustomed to tailoring exposure guidelines to individual, contextual factors, and this will become particularly important during this more vulnerable time.
Though contamination/infection obsessions are most obvious concern, patients may experience increased challenges in other areas as well. For example, the “need to know” or find out more about the pandemic is probably familiar to everyone affected, but for individuals with OCD, the seemingly constructive behavior of seeking out more information can consume countless hours, with indiscriminate reading of both legitimate and questionable news sources, internet searches, and frequent checking behaviors like temperature taking and symptom monitoring. Specific and reasonable limits and guidelines will help patients stay on track and avoid giving in to compulsions. Scrupulosity concerns may cause a patient to struggle and perseverate, unable to make reasonable judgements about necessary versus unnecessary travel, social distance, and self-isolation. These circumstances will require individualized consideration of contextual factors to maintain treatment as well as physical safety for both patients and the public.
The IOCDF has posted several helpful resources for patients and providers, including more detailed treatment recommendations and other topics relevant to the COVID-19 virus and OCD on their webpage.