Contamination OCD in the age of coronavirus

[cara susanna]

Hey all,

Any suggestions for working with individuals who have contamination OCD (and behaviors like cleaning, handwashing, etc) within the context of coronavirus? Right now I'm focusing on differentiating between CDC guidelines vs. safety behaviors and doing informal exposure work that is still within the limits of health recommendations. Would love more thoughts, though, especially because I admit that this is not my clinical specialty.

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[Fan_of_Meehl]

Hey all,

Any suggestions for working with individuals who have contamination OCD (and behaviors like cleaning, handwashing, etc) within the context of coronavirus? Right now I'm focusing on differentiating between CDC guidelines vs. safety behaviors and doing informal exposure work that is still within the limits of health recommendations. Would love more thoughts, though, especially because I admit that this is not my clinical specialty.

First thoughts...prescriptive approaches to in vivo exposure + response/ritual prevention just got a helluva lot riskier from a medicolegal risk perspective. Hell, the parameters that they're putting out regarding 'social distancing' are a moving target and you could probably find different parameters put out by various agencies regarding handwashing protocols/frequency. Strong therapeutic relationship, documented informed consent with details of exposure plan and risks/benefits, input from medically-trained team members? I'd be sorely tempted to consider delaying ERP implementation until we have more solid knowledge about mortality, transmission/infection rates, best practices, etc. but that's just me. Leveraging the therapeutic relationship to come up with 'boundaries' or upper-limits of appropriate handwashing/cleaning behavior (e.g., anything causing skin degradation or other tissue damage is unnecessary) would seem appropriate. Helping patients self-monitor and be able to do some cognitive restructuring to help with intrusive obsessions would seem wise. I think the folks who do cognitive therapy for OCD (Paul Salkovskis? Some other folks from UK) get good outcomes if I remember correctly.

 

[cara susanna]

First thoughts...prescriptive approaches to in vivo exposure + response/ritual prevention just got a helluva lot riskier from a medicolegal risk perspective. Hell, the parameters that they're putting out regarding 'social distancing' are a moving target and you could probably find different parameters put out by various agencies regarding handwashing protocols/frequency. Strong therapeutic relationship, documented informed consent with details of exposure plan and risks/benefits, input from medically-trained team members? I'd be sorely tempted to consider delaying ERP implementation until we have more solid knowledge about mortality, transmission/infection rates, best practices, etc. but that's just me. Leveraging the therapeutic relationship to come up with 'boundaries' or upper-limits of appropriate handwashing/cleaning behavior (e.g., anything causing skin degradation or other tissue damage is unnecessary) would seem appropriate. Helping patients self-monitor and be able to do some cognitive restructuring to help with intrusive obsessions would seem wise. I think the folks who do cognitive therapy for OCD (Paul Salkovskis? Some other folks from UK) get good outcomes if I remember correctly.

I had the exact same thoughts about risk! As I mentioned, right now I'm doing informal in vivo work around decreasing behaviors that are excessive to the point of skin damage. Definitely would NOT go full ERP right now. I also am advising to err on the side of public health.

 

[Fan_of_Meehl]

I had the exact same thoughts about risk! As I mentioned, right now I'm doing informal in vivo work around decreasing behaviors that are excessive to the point of skin damage. Definitely would NOT go full ERP right now. I also am advising to err on the side of public health.

Although almost everyone would agree that EX/RP is--all else being equal--the psychotherapeutic treatment of choice for OCD, in current circumstances, approaches that emphasize cognitive techniques over behavioral/exposure techniques should probably be considered reasonable alternatives. The following reference (a review article by Edna Foa) seems to indicate that cognitive therapy for OCD is a viable and empirically supported option.

Foa, E.B. (2010). Cognitive-Behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 199-207.

 

[Therapist4Chnge]

Great question. I actually thought about it the other day, but I thankfully settled on "This is why I don't see therapy cases!"

That said, I'm still going to review this with my counselor to ensure we are nice and conservative with how we instruct patients in regard to their behavior changes and risk w. Coronavirus. What a mess.

 

[futureapppsy2]

You could always use ACT to teach distress tolerance around the intrusive thoughts.

 

[nessa34]

I don't think it's necessary to completely abandon ERP, though I agree that patient safety would mean limiting intentional exposures for the time being. Instead, see the current circumstances as one big naturalistic exposure. Limiting cleaning to CDC guidelines (e.g., handwashing for only 20 seconds and after certain activities only), accepting that cleaning & sanitizing will not guarantee that one will not get coronavirus - and tolerating that distress w/o engaging in compulsions to 'feel sure', limiting reassurance seeking from others and excessive researching about how to clean to prevent coronavirus and other safety behaviors, etc.

OCD is OCD regardless of external circumstances- with contamination OCD, patients generally want to feel 100% sure they are not contaminating themselves or others, and even with the increased cleaning & sanitizing that is currently recommended, they (and everyone else) can never achieve that. Also, a lot of validation that this is going to be a really triggering time given what they are struggling with and so working on building in acceptance, distress tolerance, coping, pleasurable activities, etc.

 

[IWillSurvive]

IOCDF is a great resource and community. They have a page on COVID-19 and are hosting town halls in case you haven't run across this organization yet. Resources for the OCD and related disorders community during the COVID-19 outbreak

 

[IWillSurvive]

IOCDF is a great resource and community. They have a page on COVID-19 and are hosting town halls in case you haven't run across this organization yet. Resources for the OCD and related disorders community during the COVID-19 outbreak

They are actually doing a webinar to answer questions about treating OCD during COVID-19 as we speak:

 

[bcliff]

I've had similar thoughts about panic/agoraphobia -- Not necessarily right now, but I wonder if we'll see a spike in panic/agoraphobia cases down the road as folks are encouraged to resume normal life after having been isolated for an extended period of time.

 

[cara susanna]

I've had similar thoughts about panic/agoraphobia -- Not necessarily right now, but I wonder if we'll see a spike in panic/agoraphobia cases down the road as folks are encouraged to resume normal life after having been isolated for an extended period of time.

I believe that was found in China already. Well, anecdotally, I don't know about any formal statistics.

 

[thebalmofhurtminds]

I've had similar thoughts about panic/agoraphobia -- Not necessarily right now, but I wonder if we'll see a spike in panic/agoraphobia cases down the road as folks are encouraged to resume normal life after having been isolated for an extended period of time.

I was thinking that too. A lot of reinforcers for anxious thoughts/behaviors related to social/outside activity right now. Can't imagine that'll just disappear once shelter in place is lifted.

 

[clausewitz2]

I was thinking that too. A lot of reinforcers for anxious thoughts/behaviors related to social/outside activity right now. Can't imagine that'll just disappear once shelter in place is lifted.

Anecedatally the one person I am working with right now with really classic panic disorder is finding this whole thing motivating to actually put effort into evidence-based treatment. Turns out when you can't leave the house and start having your panic attacks at home as well the futility of avoidance is an easier sell.

 

[clausewitz2]

They are actually doing a webinar to answer questions about treating OCD during COVID-19 as we speak:

I heard Jon Grayson in another interview said that until this pandemic he had not washed his hands since 1979, so it is definitely shaking things up a bit.

Metacognitive Therapy for OCD talks about Exposure and Ritual Commission, i.e. performing rituals while deliberately focusing on the intrusive thought. Idea is to break the association between ritual performance and any kind of distraction or relief. Medicolegally it certainly seems a safer approach to anything that might impinge on current COVID-19 guidelines.

 

[deleted343839]

I heard Jon Grayson in another interview said that until this pandemic he had not washed his hands since 1979

Wow, that's a whole other kind of pathology.

 

[clausewitz2]

Wow, that's a whole other kind of pathology.

Some of the more well-known ERP people have...interesting habits. Steven Phillipson for instance apparently makes a point of verbally wishing that his spouse gets cancer or that his children die in a car accident every day.

 

[Fan_of_Meehl]

Wow, that's a whole other kind of pathology.

LOL, I watched that Youtube conversation too and I took this more as a bit of hyperbole. I mean, if he got oil or dirt or something on his hands I assume that he did not lick them clean. I also found them a bit--I dunno--almost 'religious' in their insistence that cognitive approaches (or emphasis) shouldn't even be considered an option (despite apparent support in the literature for the basic efficacy of the approach). I thought it a bit 'straw man' like to say that they would not consider a cognitive emphasis to treatment because 'you can't talk people out of their obsessions.' I don't consider cognitive therapy to be aptly described as an attempt to argue with people or 'talk them out' of anything (with REBT being a possible exception depending on how it is practice). I have also noticed--as a practitioner of cognitive therapy and cognitive processing therapy--that cognitive change in session can lead to spontaneous behavioral change (and 'exposure') outside session by patients. To 'poo poo' the work of people like Paul Salkovskis and David Clark as somehow 'bunk' also smacks a bit of arguing from a 'method of authority' or 'begging the question' as well. I trained at an anxiety disorders research and treatment site way back in the 90s and believe in the primary efficacy of exposure and behaviorally oriented approaches with anxiety disorders. It's just that in the present context I would think clinical flexibility may be called for (or at least considered seriously) and the 'pros-cons' weighed.

 

[futureapppsy2]

Wow, that's a whole other kind of pathology.

Yikes. There's a middle ground between watching your hands to the point of tissue damage and distress and ignoring the very real, very important science on hand hygiene. Neither is aspirational or healthy.

 

[deleted343839]

Yikes. There's a middle ground between watching your hands to the point of tissue damage and distress and ignoring the very real, very important science on hand hygiene. Neither is aspirational or healthy.

I mean, hopefully it's a joke. I didn't see the interview so I don't have the context. But I'm reminded of the anecdotes about Steve Jobs insisting that his odd vegan diets prevented him from having body odor and hence he did not need to bathe regularly or use deodorant, to the horror of his co-workers who knew otherwise.

 

[clausewitz2]

I mean, hopefully it's a joke. I didn't see the interview so I don't have the context. But I'm reminded of the anecdotes about Steve Jobs insisting that his odd vegan diets prevented him from having body odor and hence he did not need to bathe regularly or use deodorant, to the horror of his co-workers who knew otherwise.

In context he said he did this because he wasn't prepared to ask his clients to do anything he wouldn't do himself. Which is laudable and all, but d*mn.

LOL, I watched that Youtube conversation too and I took this more as a bit of hyperbole. I mean, if he got oil or dirt or something on his hands I assume that he did not lick them clean. I also found them a bit--I dunno--almost 'religious' in their insistence that cognitive approaches (or emphasis) shouldn't even be considered an option (despite apparent support in the literature for the basic efficacy of the approach). I thought it a bit 'straw man' like to say that they would not consider a cognitive emphasis to treatment because 'you can't talk people out of their obsessions.' I don't consider cognitive therapy to be aptly described as an attempt to argue with people or 'talk them out' of anything (with REBT being a possible exception depending on how it is practice). I have also noticed--as a practitioner of cognitive therapy and cognitive processing therapy--that cognitive change in session can lead to spontaneous behavioral change (and 'exposure') outside session by patients. To 'poo poo' the work of people like Paul Salkovskis and David Clark as somehow 'bunk' also smacks a bit of arguing from a 'method of authority' or 'begging the question' as well. I trained at an anxiety disorders research and treatment site way back in the 90s and believe in the primary efficacy of exposure and behaviorally oriented approaches with anxiety disorders. It's just that in the present context I would think clinical flexibility may be called for (or at least considered seriously) and the 'pros-cons' weighed.

There is definitely a religious aspect to how people talk about ERP sometimes in the OCD treatment world (cause, y'know, no other therapeutic modality had ever been treated that way). Charitably I think it comes from the fact that some persons diagnosed with OCD are going to take Socratic questioning or knowledge of explicit distortions or whatever properly cognitive technique and ritualize it. I am sure that this does not mean those approaches are not effective most of the time but I am guessing if you have that happen a couple times you might end up in a very dogmatic place.

 

[PsyDr]

In context he said he did this because he wasn't prepared to ask his clients to do anything he wouldn't do himself. Which is laudable and all, but d*mn.



There is definitely a religious aspect to how people talk about ERP sometimes in the OCD treatment world (cause, y'know, no other therapeutic modality had ever been treated that way). Charitably I think it comes from the fact that some persons diagnosed with OCD are going to take Socratic questioning or knowledge of explicit distortions or whatever properly cognitive technique and ritualize it. I am sure that this does not mean those approaches are not effective most of the time but I am guessing if you have that happen a couple times you might end up in a very dogmatic place.

subjectively, I would encourage providers to separate the content from the process. In the neurological patient, the content of the perseveration is largely ignored while the process is treated. The psych patient isn’t so different.