Obsessive-Compulsive Symptoms in the General Population Under Stressful Conditions: Lessons Learned from the COVID-19 Pandemic

1. Introduction

There is now a large amount of evidence that during COVID-19 pandemic, mental health in the general public worsened [1,2,3]. In a recent study conducted by the COvid Mental hEalth Trial (COMET) network [1] 20,720 participants were recruited and completed a survey. Among them, 12.4% of respondents (N= 2,555) reported severe or extremely severe levels of depressive symptoms, 17.6% (N= 3,627) of anxiety symptoms and 41.6% (N = 8,619) reported to feel at least moderately stressed by the situation. The authors found evidence that, while physical isolation and lockdown represent essential public health measures to contain the spread of the COVID-19 pandemic, they are a serious threat for mental health and well-being of the general population; therefore, as an integral part of COVID-19 response, mental health needs should be addressed. Moreover, as mental problems increased, a significant reduction in referrals and self-presentation to community mental health services was reported in Italy [4], with loneliness [5] and bad eating habits [6] being among the most common contributors to mental health issues. A significant psychopathological load associated with COVID-19 was present in healthcare professionals: Sani and colleagues (2022) [7] found that, compared to the rest of the population, healthcare professionals showed a considerably greater risk for mental health disorders [7]. As previously considered, wellbeing and mental health in the general population during COVID-19 pandemic worsened: a meta-review of prevalence including eighteen different meta-analyses found the prevalence of mental health problems to range from 20 to 36% in the general public, with insomnia and stress being the most common issues, 32.34% (CI: 25.65–39.84) and 36% (CI: 29.31–43.54), respectively [8]. The reasons for the negative impact of the pandemic on mental health might be several, but it is possible that the psychological issues could be a consequence of general stressful environmental triggers, rather than the pandemic and fear of COVID-19 itself. Therefore, it is important to keep trying to investigate the specific psychiatric symptoms in the general public and the possible risk factors behind them, in order to be more knowledgeable and ready to face future critical and stressful events, catastrophes and even possible future pandemics [9].

In this current study, we focus on a specific type of symptomatology during the COVID-19 pandemic in the general public: obsessive compulsive symptoms. Obsessive-compulsive disorder (OCD) is a chronic and debilitating condition characterized by a combination of recurrent obsessional thoughts and time-consuming compulsive rituals, often resistant to treatments [10]. OCD is responsible for a significant disability burden globally [11], has a detrimental effect on the quality of life of the individuals affected [12] and can even lead to suicide [13,14]. Studies report 12-month prevalence estimates of 0.7–3.0% in adults and 0.25–0.30% in children [15,16]. A substantial proportion of the population - estimated at 21% and 28% in the studies by Ruscio et al. (2010) [15] and Fineberg et al. (2013) [17] - report subthreshold obsessive-compulsive symptoms. It is anticipated that individuals with these disorders would have difficulty adjusting to new environments and would struggle during stressful events [18,19]. Obsessive-compulsive symptoms have been a significant concern during the COVID-19 pandemic, with various studies highlighting the impact of the pandemic on individuals with obsessive-compulsive disorder (OCD) [20,21,22,23]. Research indicates that during the early stages of the pandemic, obsessive-compulsive symptoms worsened, particularly for subjects with contamination-related OCD [20]. The prevalence of obsessive-compulsive symptoms (OCS) throughout this period was investigated by several studies because of the similarity between the contagion-containing measures (such as physical separation, hand washing, mask use, and quarantine) and obsessive-compulsive phenomenology (e.g., contamination worries and frequent washing and/or checking). A systematic review and meta-analysis of 35 studies [24] found that clinically significant obsessive-compulsive symptoms (OCS) were common among the general population during the pandemic: their prevalence was as high as 22% (studies=19). Specifically, the prevalence of OCS was 36% in pregnant women, 22% in COVID-19 cases, 21% in undergraduate students and 5% and healthcare professionals. However, the heterogeneity in the results was high, given the use of different scales, each with a different cut-off. OC symptoms increased significantly during the pandemic not only in individuals with a history of the disorder, but also in the ones without such diagnosis [21]. Furthermore, the fear, uncertainty and stress associated with the spread of COVID-19 have not only been linked to the exacerbation of obsessive-compulsive symptoms [25,26], but also associated with the onset of new ones [26]. The impact of the pandemic on obsessive-compulsive symptoms has been observed across different populations, including medical students [27], young adults [28], children and adolescents [29,30,55], and individuals with preexisting mental disorders [31]. The increased frequency of contamination obsessions and cleaning compulsions has been a common theme during the pandemic, with limited exposure to COVID-related news potentially serving as a protective factor against symptom deterioration [31]. Moreover, subjects suffering from OCD may encounter significant difficulty in giving up behaviors that they previously believed were essential for safeguarding against COVID-19 infection [19,32,33]. The study conducted by Fineberg et al. (2021) [19] is the sole published research examining the mental health challenges faced by the general population in response to the relaxation of lockdown measures in the UK. This study took place between July and November 2020, coinciding with the initial phase of easing restrictions. Therefore, the COVID-19 pandemic has had a significant effect on individuals with obsessive-compulsive symptoms, leading to the exacerbation of pre-existing symptoms and/or the possible onset of new ones. The fear, insecurity, and uncertainty surrounding the pandemic have contributed to the worsening of obsessive-compulsive behaviors, highlighting the need for continued monitoring and support for individuals with OCD during traumatic events such as this one. The COVID-19 pandemic could be adopted as an example or paradigm of a general stressful trigger, affecting the entire population, and possibly eliciting, inducing or exacerbating obsessive compulsive symptoms [34,35,36]. It would be therefore pivotal to know the types and frequencies of OC symptoms in the general public during this period, the possible incidence of new cases of OCD and finally the predictors for this specific symptomatology. The predictors could be particularly important for future prevention of the exacerbation or new onset of obsessive compulsive symptoms under traumatic situations and in the context of public stress and trigger factors.

2. Materials and Methods

The COvid Mental hEalth Trial (COMET) is a nationwide trial organized by the University of Campania "Luigi Vanvitelli" in collaboration with nine other university sites: Università Politecnica delle Marche, University of Ferrara, University of Milan Bicocca, University of Milan "Statale," University of Perugia, University of Pisa, Sapienza University of Rome, "Catholic" University of Rome, and University of Trieste. The National Institute of Health in Rome's Center for Behavioral Sciences and Mental Health has supported the dissemination and implementation of the project, in accordance with the clinical guidelines produced by the National Institute of Health, to manage the effects of the COVID-19 pandemic. The COMET study was designed as an observational study that aimed to gather data from a representative sample of the Italian general population. The study used a snowball sampling approach for recruitment. The whole research procedure may be found in another study [37] and this current study stems from a sub-analysis of the original study sample [37].

Demographic information, such as gender, age, geographical location, employment status, and education, as well as clinical information, such as history of physical or mental disorders and use of illegal substances, have been collected. The Obsessive-Compulsive Inventory - Revised version (OCI-R) [38] was used to detect obsessive compulsive symptomatology; a total score on the OCI-R equal to or greater than 21 indicates clinically significant OCD symptoms. The OCI-R is available in an Italian version with defined normative scores [54]. Other validated and reliable questionnaires included in the study are: DASS-21 (Depressive Anxiety and Stress Scale-21) [39]; Impact of Event Scale-short version (IES) [40]; UCLA scale-short version to evaluate levels of perceived loneliness [41]; Suicidal Ideation Attributes Scale (SIDAS) [42]; Severity of Acute Stress Symptoms Adult scale (SASS) [43]; General Health Questionnaire-12 items version (GHQ) [44]; Coping Orientation to Problems Experienced Inventory-short version (brief-COPE) [45].

This research has been done in compliance with universally recognized norms of ethical conduct, in alignment with the Declaration of Helsinki and local legislation. The participants granted their written informed permission to participate in this research. The research has received approval from the Ethical Review Board of the University of Campania "L. Vanvitelli" (Protocol number: 0007593/i). Informed consent was obtained from all subjects involved in the study.

Quantitative analysis of data was conducted by using statistical methods. An analysis of descriptive statistics provided a description of the socio-demographic of the overall sample. ANOVA and T-tests for independent samples have been used for continuous variables and chi-square test was conducted for categorical variables to assess differences between groups (different levels of obsessive compulsive symptomologies). Scores on the OCI-R total and the relative subscales indicating specific OC dimensions were compared between our sample and the Italian norms [54]. Moreover, the prevalence of clinically significant obsessive-compulsive symptoms, both for the total OCI-R (a score equal to or greater than 21) and for the OCI-R subscales was estimated [38]. The sample has been subdivided into four different subgroups in order to explore the impact of the pandemic on obsessive compulsive symptoms in specific populations: individuals affected by COVID-19, healthcare staff, individuals with mental health disorders (persistent and self-declared) and subjects in quarantine. A multivariate linear regression model, controlled for independent variables such as age, gender, education, occupational status, civil status, other coping strategies, level of social supports, having a COVID-19 infection, geographical region, time to exposure to the pandemic, was conducted to determine potential predictors of significant OCD symptomatology. The multiple imputation technique has been used to address missing data. Analyses of the data was performed using JASP (Version 0.16.3) [46], a freely available statistical program created by the University of Amsterdam (JASP Team, 2022) and STATA, version 15 [47]. For all analyses, the level of statistical significance was set at p < 0.05.

3. Results

A total sample of N=20,720 took part in the survey. N=2332 individuals had a score equal to or higher than 21 on the OCI-R (11.3%) (indicating the presence of clinically relevant obsessive compulsive symptoms) [38]. The sociodemographic characteristics of the sample are summarized in Table 1.

The mean OCI-R total score in the entire sample was 10.7 (SD: 8.2). The total score and the scores on the different dimensions of the OCI-R were significantly greater than the Italian normative values (apart from checking and hoarding dimensions, see Table 2). Therefore, in our large population sample, behaviours such as washing, ordering, obsessing and mental neutralizing were significantly more severe compared to normative values.

We then explored the OCI-R scores in the four different subgroups in order to investigate the impact of the pandemic on obsessive compulsive symptoms in these specific and at risk populations: individuals affected by COVID-19 (representing a cluster with particular physical and psychological stress), healthcare staff (a cohort under work-related stress), individuals with pre-existing and self-declared mental health disorders (a vulnerable group), and individuals in quarantine (subjects under psychological stress) (Table 3).

The most affected group in terms of OCI-R severity was the one composed of individuals with mental disorders; these subjects showed higher scores on all of the items of the OCI-R compared to the normative values. Both groups of individuals affected by COVID-19 and in quarantine had greater score on the OCI-R than the norms, pointing out the impact of stressful events on obsessive-compulsive symptomatology; these two groups had higher severity on all items of the OCI-R apart from the checking dimension, compared to the norms. Healthcare staff had higher scores on the total OCI-R and on the washing dimension only.

We found that N=2332 individuals had a score higher than or equal to 21 on the OCI-R (11.3%), which is considered as significant for indicating the presence of clinically relevant obsessive compulsive symptoms) [38] (Table 4). Such a great percentage implies that around one out of ten individuals from the general public could have experienced clinically relevant obsessive compulsive symptoms during the pandemic. Individuals with a previous mental disorder had higher rates of clinically significant OC symptoms compared to the three other groups. The frequencies of washing and hoarding dimensions were higher in the individuals with a previous mental disorder and in individuals affected by COVID-19 (Table 4).

We then compared patients having a OCI-R score greater than or equal to 21 to the ones having a score below 21, and observed that the former group had more depressive, anxious and stress symptoms than the latter. Also, patients with an OCI-R ≥ 21 scored higher in the GHQ score, in the UCLA and in the SASS scale. No difference was detected in the scores on the SIDAS measuring attitude toward suicide and the Impact of Event Scale—short version, measuring acute and chronic post traumatic stress disorders (Table 5).

Given that we showed a higher severity of OCI-R scores and higher frequency of clinically significant symptoms in individuals with a previous mental disorder, we conducted another analysis by excluding this specific group. We still obtained a significant number of subjects with OCI-R total score greater than or equal to 21: N=2024, representing 10.3% of the overall sample. The subsample of people scoring ≥ 21 at OCI-R in individuals without pre-existing mental disorders was analyzed through multivariate regression analyses to identify possible factors associated with incident OC symptoms (Table 6) and found the following independent variables associated with the new onset of OC symptoms: being in one of the most COVID-19 affected and severely hit Italian regions, an age range from 24 to 54 years, increased levels of perceived loneliness (as measured by the UCLA), female gender and conspicuous use of substance.

4. Discussion

Our findings suggest that obsessive compulsive symptoms were more frequent and more severe in the general population during a critical event such as the COVID-19 pandemic. In particular, people with previous mental disorders showed higher rates of clinically significant OC symptoms and higher OCI-R scores and they should be paid particular attention to during a stressful situation of this kind. Healthcare professional group had higher scores on the washing dimension compared to the norms; a possible explanation of this could be an overresponse to professional guidelines, that could hypothetically develop as compulsive behaviour if conducted excessively (i.e., the continuous repetition of washing behaviours in the workplace might acquire a compulsive nature). This finding is in line with results from previous studies [52,53].

A significant percentage of our large population sample (11.3%) exhibited clinically relevant symptoms. If we consider the frequency of the specific dimensions of the OCI-R, individuals with previous mental disorders had higher frequencies in all symptom dimensions than the three other groups. Compared to the individuals without clinically significant symptoms (OCI-R < 21), individuals with an OCI-R greater than or equal to 21 had more depressive, anxious and stress symptoms, experienced more loneliness, had a worse general mental health, and more severe symptoms of acute stress. Given the highest chance for people with previous mental disorders to have greater scores on the OCI-R and possibly to have full-blown OCD, we performed another analysis by excluding the individuals with a history of mental disorders (N=1,133) from the total sample (N=20,720), obtaining a new sample of N=19,587. Intriguingly, even after excluding the subjects known to have a previous mental disorder, the percentage of individuals experiencing significant OC symptomatology remained high (10.3%). This last finding could point out to a possible substantial incidence of new cases of OCD having developed during the pandemic (as high as one out of ten individuals in our sample) and is in line with previous results [19,32]. Then, we tried to answer the question about who is most at risk of developing obsessive compulsive symptoms (excluding individuals with a previous mental disorder) during a critical and stressful event such as the COVID-19 pandemic. We found that living in one of the most COVID-19 affected and severely hit Italian regions, being an adult in working age (24-54 years), being a female, being lonely and a significant use of substance were all independent risk factors. It is important to understand the impact of the pandemic on OC symptoms in the general public because such a traumatic and critical event could happen again in the future and we can use the COVID-19 pandemic as a paradigm of a stressful environmental trigger [9]. Being a female in working age, living in a highly stressful environment such as one of the most affected and severely hit by the pandemic Italian regions, having higher levels of loneliness, and using substances to cope with the stress, is the profile who could be mostly at risk of emerging obsessive compulsive symptoms. These factors could be seen as red flags for the members of the public that are most at risk, under traumatic situations and in the context of general public stress and trigger factors, to develop an OC symptomology; possible preventive strategies could be adopted accordingly [48,49,50].

5. Limitations

First, the snowball sampling methodology could have led to a selection bias, with only the individuals who were interested in the psychological consequences of the pandemic willing to participate [51]. Second, the cross-sectional nature of the study does not allow us to infer any causal relationship between our study variables. Third, we have identified individuals with mental disorders by asking a direct question about the presence of a pre-existent mental disorder, without any further clinical evaluation or use of diagnostic interviews. The same limitation applies to the selection of the COVID-19+ group, which was, again, done by self-declaration. Lastly, since we were only able to recruit individuals who were at least 18 years old, our sample cannot be said to be completely representative of young people.

6. Conclusions

This paper aimed at characterizing the obsessive-compulsive symptoms in the italian general population during the critical event of COVID-19 pandemic, with the intent to go beyond the mere cross-sectional picture and look at the possible new incidence of clinically significant obsessive compulsive symptoms and the associated risk factors. By excluding individuals with a history of mental disorders, we could hypothesise that the subjects scoring higher than or equal to 21 on the OCI-R represented new occurrence of obsessive compulsive symptoms in the general public. We were then able to point out specific red flags or risk factors that were linked with this new onset. Our sample was large and representative of the Italian general population during the time of the pandemic. In conclusion, we can say that obsessive compulsive symptoms should be looked at in the general public, especially in who is most at risk and could be identified by using the risk factors we found, during traumatic events such as a pandemic.