By Drs. Angela Smith & Emily Anderson McLean OCD Institute // Houston
Response to Wall Street Journal Opinion by Elias Aboujaoude, M.D., on March 31, 2020
As Clinical Psychologists specializing in the treatment of Obsessive Compulsive Disorder and anxiety disorders, we have witnessed the unique challenges experienced by individuals with these disorders in recent weeks. While some of the adjustments resulting from the current pandemic are fairly universal, individuals with OCD and other anxiety-based disorders face unique challenges, and these challenges will continue in the future when restrictions around physical distancing begin to lift.
As mental health professionals, this is one of the burdens we have felt for our own patients and the millions of others with unique struggles at this time. Thus, we were surprised by the tone and opinion offered by Dr. Elias Aboujaoude in a WSJ opinion piece entitled, We All Need OCD Now, published on March 31, 2020. Here, Dr. Aboujaoude provides an evolutionary explanation for OCD–that high levels of anxiety have been maintained over the course of human history because they are adaptive and that the compulsive behaviors of those with contamination-related OCD are preferable at this time. [As an aside, while this is an explanation for the universal human experience of anxiety, it does not adequately explain the development of OCD, which affects about 1 in 40 individuals]. Our concern is that these statements, made by a psychiatrist specializing in the treatment of OCD, nonetheless, are insensitive to, and minimize the struggle of, the millions of people with this disorder. Here, we offer another perspective on OCD and the Coronavirus/COVID-19 pandemic.
Notably, COVID-19 is a real threat that warrants significant modifications for everyone, whereas individuals with contamination OCD typically engage in rituals or avoidance related to perceived threats (or to real threats, but responses are disproportionate). Regarding specific CDC recommendations, individuals with contamination OCD may follow the guidelines regarding handwashing, for example, but for many of these individuals, this duration may feel insufficient, and thus, they may wash much longer than the 20-second recommendation. Alternatively, they may be able to limit the handwash to 20- seconds, but feel incomplete afterwards and thereby experience significant anxiety that is highly distressing or that interferes with daily living. Individuals without contamination OCD likely engage in a 20-second hand wash and move on afterwards, with limited to no anxiety. There is a dramatic difference not only in anxiety level, but also in functionality. For those with contamination-related OCD the struggle to return to “normal” once the crisis has ended will be more difficult than it is for most. As noted, It is likely that many of these individuals already had extensive washing, cleaning, and distancing practices that have been exacerbated by the newly developed recommendations by the CDC. Indeed, CDC-recommended practices may continue to be implemented by many long after the threat of this contagion has passed and certainly those who have engaged in excessive washing, cleaning, and avoidance of contagions for months and years will struggle with this adjustment. In the past few weeks, we have heard the same concern repeated, “Once this is over, how will I get back to ”normal “? These individuals who have tirelessly engaged in Exposure and Response Prevention (ERP, the Gold Standard in OCD treatment) are reflecting on the challenging nature of treatment with concern (even dread) about the work that lies ahead. This is not only so for individuals with OCD, but also for those with panic disorder, social anxiety, and health-based anxiety; they too will face a greater burden related to the adjustment to being out in the world again. It is crucial that we understand that there are people who will struggle more than we might and that we have empathy for those who will endure these hardships.
During this difficult, unprecedented time in modern history, articles and opinions addressing mental health can be extremely helpful. However, the tenor of the opinion in the WSJ piece seems misplaced. Now is the time for increased dissemination of thoughtful content that serves the broader public, promotes understanding of the impact of current circumstances on those with mental health disorders, or both. Following the recommendations of the medical community is, undeniably, critical to overcoming the spread of this virus; however, equating the recommendations with compulsive behavior and portraying compulsions as something to strive for minimizes the significant distress and impact on functioning experienced by those with OCD. Mental health professionals and advocates for OCD have worked to overcome misconceptions about this disorder, including such misguided statements as something being “so OCD.” Surely, an opinion offered by a professional from the OCD community in a publication as widely distributed as the Wall Street Journal undermines this cause.
For the millions of people in the United States and around the world who have an anxiety-based disorder, including OCD, this is a time to consider flexibility. Circumstances have changed drastically in recent weeks and months. Interactions that were once normal (shaking hands, giving hugs, standing in close proximity to people) are now unsafe, in that they can exacerbate the spread of this deadly virus. Research scientists are working tirelessly on curative and preventative measures, but for the time being, physical distance and washing/sanitizing are the best efforts to stop the spread. We must flex, we must adjust to the changing circumstances. When the recommendations once again change, we will be flexible once again. To be flexible is to change our behavior as our circumstances change; not to follow rules rigidly, but to adapt as the world around us changes. Unfortunately, being flexible is extremely difficult for those with OCD and other anxiety disorders, so this will be a challenging task. Certainly as therapists who treat OCD, we are now washing our hands, sanitizing, avoiding physical contact with people more than we ever have before. Do these behaviors look similar to those we have treated for years? Yes, they do. But this is what the current context prescribes. It will be difficult to flex back once this time has passed, particularly for those individuals with contamination OCD, and there is a community of providers who understand the affliction and are there to help with the process.
We understand that COVID-19 necessitates that everyone engage in dramatic changes in behavior, following current CDC recommendations. If we all do so on a consistent basis, we may be able to slow the spread of this deadly disease. We hope that our response to the WSJ piece helps people to understand that OCD being considered adaptive in the current context is misguided and invalidating for those with OCD. We could all benefit from recognizing the unique struggles individuals with OCD face in the midst of our current pandemic, and will continue to face long after we can resume some sense of normalcy, and especially as our sense of normalcy will likely be changed forever. Our hope is that people recognize that we do not “need OCD” in the midst of this crisis, because OCD symptoms are debilitating for those who struggle with this disorder. Instead we would be better served to develop a sense of empathy for those who struggle with mental health concerns in the midst of a world crisis and not minimize their struggles.
Drs. Smith and Anderson are Clinical Psychologists, practicing at the McLean OCD Institute, Houston.