Psychiatry Research 293 (2020) 113363

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Exacerbation of obsessive compulsive disorder symptoms in children and T

adolescents during COVID-19 pandemic
⁎
Yaşar Tanir a, , Ali Karayagmurlua, İlyas Kayaa, Tuba Bilbay Kaynara, Gaye Türkmena,
Büşra Nur Dambasana, Yavuz Meralb, Murat Coşkun a
a
Istanbul University, Istanbul Medical Faculty, Child and Adolescent Psychiatry Department, 34116 İstanbul, Turkiye
b
İstanbul University-Cerrahpaşa Medical Faculty Child and Adolescent Psychiatry Department

A B S T R A C T

Objective: To investigate the effects of COVID-19 pandemic and related home

confinement on symptom profile, symptom severity and exacerbation of obsessive compulsive disorder (OCD) symptoms and related factors among young subjects
with OCD.
Method: Young subjects who have been followed up with a primary diagnosis of OCD in a university hospital were reached by telephone or online programs to assess
symptom profile, symptom severity and exacerbation during pandemic. Children's Yale-Brown Obsessive Compulsive (CY-BOCS) and Clinical Global Impression-
Severity (CGI-S) Scales were used to rate symptom profile and severity before pandemic and during pandemic periods.
Results: There was a significant increase in the frequency of contamination obsessions (p=0.008) and cleaning/washing compulsions (p=0.039) during pandemic
period. CY-BOCS obsessions (p<0.001), compulsions subscales (p<0.001) and total scores (p<0.001), and CGI-S scores (p<0.001) during pandemic period were
statistically higher than before pandemic period. There was a significant relationship between the change in CY-BOCS scores with talking/searching in the social
environment about COVID-19, daily preoccupation about COVID-19, duration of OCD diagnosis and diagnosis of COVID-19 in someone familiar.
Conclusions: Young subjects with OCD may develop additional symptoms and worsen already existing symptoms of OCD during COVID-19 pandemic.

1. Introduction study reported that children isolated or quarantined during pandemic

outbreaks were more likely to develop acute stress disorder, adjustment
The world is struggling with the threat of the coronavirus (COVID- disorder, and grief (Sprang and Silman, 2013). In a review of the psy-
19) outbreak caused by the newly developed and evolving virus SARS- chological effects and consequences of restraint and quarantine as a
CoV-2. This infectious disease, which originated in the Wuhan province result of the COVID-19 pandemic, most studies reported negative psy-
of China, spread rapidly to affect more than 7 million people world- chological effects, such as post-traumatic stress symptoms, confusion,
wide; approximately 406,000 people have died so far (World Health and anger (Brooks et al., 2020b). Pandemics have serious psychological
Organization, 2020). In Turkey, the first cases of COVID-19 were re- and social effects along with their biological effects. Those with mental
ported on March 11, 2020. As of June 9, 2020, 172,000 cases and 4,729 health problems are especially sensitive to these negative effects and
deaths had been reported (Republic of Turkey Ministry of Health, are prone to worsen because of a pandemic (Davide et al., 2020;
2020). Training in schools stopped on March 16, 2020, in Turkey, and Özdin and Bayrak Özdin, 2020). Although studies are increasingly fo-
on April 3, 2020, curfews for children and adolescents were imposed cusing on the mental health effects of pandemics on adult patients
and home quarantine began (Republic of Turkey Ministry of Interior, (Gao et al., 2020; Wang et al., 2020), relatively few studies focus on the
2020). effects of pandemics on children and adolescents (Chen et al., 2020).
It is thought that the quarantine environment may contribute to Chen et al. demonstrated that COVID-19 influenced symptoms of
stress in children and adolescents due the deterioration of daily rou- mental disorders, including OCD, fear, hypochondria, depression, and
tines, restrictions to social lives, the inability to attend school, and the neurasthenia, in college students (Chen et al., 2020).
uncertainty of the disease (Brooks et al., 2020a; Brooks et al., 2020b). Obsessive–compulsive disorder (OCD) is a chronic disorder char-
Prolonged lockdown has been shown to have negative effects on the acterized by recurrent obsessions and compulsions which affects about
mental health of children and adolescents and can induce stress, an- 0.5%–3% of children and adolescents (American Psychiatric
xiety, and depression (Chen et al., 2020; Wang et al., 2020). Another Association, 2013; Heyman et al., 2003). The most common OCD

⁎
Corresponding author.
E-mail address: yasar.tanir@istanbul.edu.tr (Y. Tanir).

https://doi.org/10.1016/j.psychres.2020.113363
Received 10 June 2020; Received in revised form 25 July 2020; Accepted 2 August 2020
Available online 03 August 2020
0165-1781/ © 2020 Elsevier B.V. All rights reserved.
Y. Tanir, et al. Psychiatry Research 293 (2020) 113363

symptoms are an obsession with contamination and the compulsion to Table 1

clean (Bloch et al., 2008; Stein et al., 2019). Davide et al. stated that Clinical and Sociodemographic Characteristics of the Subjects
during the COVID-19 pandemic, there was a significant increase in the Variable N(%)/Mean(SD)
severity of obsession and compulsion in adult cases with OCD
(Davide et al., 2020). Since the strategies that combat infectious dis- Age (years) 13.62 ± 2.72
Gender
eases contain repetitive behaviors by nature, these strategies can
Male 34 (55.7)
worsen OCD (Banerjee, 2020). OCD symptoms may worsen due to ad- Female 27 (44.3)
ditional emphasis on self-hygiene in the current health advice for pre- Mean duration of father education (years) 9.3 ± 3.83
venting COVID-19 contamination. Although there are case reports of Mean duration of mother education (years) 8.55 ± 3.58
adult patients with worsening OCD symptoms during the COVID-19 Family income
Below minimum wage 10 (16.4)
pandemic (Kumar and Somani, 2020; French and Lyne, 2020), the ef-
Above minimum wage 51 (83.6)
fects of the COVID-19 pandemic on OCD symptomatology, symptom Current OCD diagnosis in parent(s) 14 (22.9)
severity and exacerbation, and other related factors have not been COVID-19 diagnosis in someone familiar 30 (49.2)
studied in young populations. Information source about COVID-19
TV 52 (85.2)
This study investigates the effects of the COVID-19 pandemic and
Talking/searching in the social environment 39 (63.9)
related home confinement on symptom profiles and the possible ex- Internet 39 (63.9)
acerbation of OCD symptoms among young subjects who have been Social media 30 (49.2)
diagnosed with OCD in the Istanbul Medical Faculty, Istanbul Daily preoccupation about COVID-19 (hours/day) 1.59 ± 1.29
University, child and adolescent psychiatry department. We expected Duration of OCD diagnosis (years) 2.19 ± 1.78
Treatment status
that a significant portion of subjects would show symptomatic exacer-
Only Selective Serotonin Reuptake Inhibitors (SSRIs) 27 (44.3)
bation during the pandemic and the lockdown period compared to the SSRIs + aripiprazole or risperidone 20 (32.8)
period before the pandemic. We also aimed to investigate possible re- Cognitive behavioral therapy (CBT) 1 (1.6)
lated factors if symptomatic exacerbation was present. CBT+SSRIs 6 (9.8)
No current treatment 7 (11.4)

2. Methods
pandemic conditions. Inter-rater reliability was high for CY-BOCS
2.1. Eligibility criteria and procedure
scores [K:0.973 and K:0.975 (95%-confidence interval, 0.82-1)] before
and during the pandemic (McHugh, 2012). The study was approved by
This study was conducted in the child and adolescent psychiatry
the ethical committee of Istanbul Medical Faculty (No: 29624016-
department of the Istanbul Medical Faculty, Istanbul University.
050.99-961).
Participants for this study included subjects aged 6–18 years who had
diagnosed with OCD. Either experienced child psychiatrists or child
2.2. Measures
psychiatry residents under the supervision of faculty members in the
department diagnosed OCD in these subjects. Ninety subjects were
2.2.1. Sociodemographic form
identified according to their medical records as candidates for inclusion
The researchers filled out the sociodemographic information form
in the study, and 61 subjects met eligibility criteria and were included
with the subjects and the subjects' parents. The form consisted of
in the study. Thus, 29 subjects were excluded from the study, either
questions related to sociodemographic characteristics such as age,
because they lacked a Children's Yale-Brown Obsessive Compulsive
gender, the education level of parents in years, and familial income.
Scale (CY-BOCS) score from before the pandemic period (n=11), be-
The survey also addressed the COVID-19 pandemic, with questions
cause they could not be reached (n=10), or because they did not
addressing points such as a current OCD diagnoses in either parent, a
consent to participating in the study (n=8). Eligibility criteria included
COVID-19 diagnoses in someone familiar, sources of information about
the following: a) an OCD diagnosis according to DSM-5 criteria; b)
COVID-19, and any daily preoccupations concerning COVID-19.
Scores from the Clinical Global Impression (CGI-S) scale and CY-BOCS
scores from before the pandemic; c) no diagnoses of autism or schizo-
phrenia spectrum disorders, intellectual disabilities, or substance use 2.2.2. Clinical Global Impression–Severity Scale (CGI-S)
disorders; and d) verbal informed consent and assent to participate in The Clinical Global Impression (CGI) measures symptoms and has
the study. Of the study participants, 53 subjects continued medicated three sub-scales: Severity (CGI-S), Improvement (CGI-I), and Efficacy
treatment and seven subjects completed their medicated treatment (CGI-E). In the present study, the CGI-S scale, which ranges from 1 to 7,
during the pandemic (See Table 1 for additional information on pa- with 1 = normal or not at all ill while 7 = extremely ill, was used to
tients' treatments). Subjects who underwent cognitive behavioral measure the symptom severity (Busner, 2007).
therapy (i.e., exposure-response prevention) before the pandemic dis-
continued their therapy during the pandemic. Remission status was 2.2.3. Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
defined as a CY-BOCS score ≤12 (Mataix-Cols et al., 2016), and 55.7% CY-BOCS is a semi-structured clinician-rated measure consisting of
(n=34) of individuals comprising the sample had demonstrated re- 10 items rated on a 5-point Likert scale. Separate scores are computed
mission before the pandemic. for obsessions and compulsions, and a total severity score is determined
Due to home confinement for this age group, participants and their by summing all 10 items (Scahill et al., 1997). The CY-BOCS possesses
parents were interviewed via telephone or online programs from April adequate internal consistency and convergent and discriminant validity
20 to April 30, 2020, to collect data for the study. Parents and subjects (Storch et al., 2004). The psychometric properties of the Turkish ver-
were first informed about the details of the study, then several points of sion of the CY-BOCS have been previously established (Yucelen et al.,
sociodemographic information were gathered. Then subjects were as- 2006).
sessed for their during-pandemic condition (lasting 6 weeks, starting
from March 11, 2020, when the first COVID-19 case was reported in 2.3. Statistical analyses
Turkey) using the CY-BOCS and the CGI-S scale to assess symptom
profiles and rate OCD severity. CY-BOCS and CGI scores from the six All analyses were carried out using SPSS Statistics, version 21.
months prior to the first confirmed case of COVID-19 in Turkey (i.e., Percentage, arithmetic mean, and standard deviation were used as de-
September 2019 to March 2020) were considered participants' pre- scriptive data. The distribution of data was assessed using the

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Y. Tanir, et al. Psychiatry Research 293 (2020) 113363

Kolmogorov–Smirnov test. The Wilcoxon test was used for non-nor- before quarantine; of these, 19 patients (31.1%) returned to clinically
mally distributed data. McNemar's test was used for categorical vari- significant levels of OCD during the pandemic (CY-BOCS total score
ables that did not fit the normal distribution. Cohen's Kappa coefficient >16). The Wilcoxon test analysis revealed that CY-BOCS obsessions (z:
was used to measure the inter-rater agreement for qualitative (numeric) −4.726, p<0.001), compulsions subscales (z: −4.348, p<0.001), and
items for CY-BOCS scores both before and during the pandemic total scores (z: −4.695, p<0.001) were statistically higher during the
(McHugh, 2012). Probability (p) values <0.05 were regarded as sta- pandemic compared to before the pandemic (Table 2).
tistically significant (two-tailed test). Factors related to CY-BOCS scores The Wilcoxon test of CGI-S scores during and before the pandemic
were evaluated by linear logistic regression analysis. The variables with revealed that CGI-S scores for contamination obsessions during the
p-value <0.05 are included in the analysis. pandemic (2.78 ± 1.37) were statistically higher than those before the
pandemic (2.22 ± 1.03) (z: −4.339, p<0.001). For cleaning compul-
sions, CGI-S scores during the pandemic (2.75 ± 1.42) were also sta-
3. Results tistically higher than those from before the pandemic (2.18 ± 1.07) (z:
−4.196, p<0.001). Regarding total OCD symptom severity, CGI-S
The study included 61 subjects with their primary diagnoses as scores during the pandemic (3.55 ± 0.99) were also statistically higher
OCD. The sample consisted of 34 males (55.7%) and 27 females than before the pandemic (2.91 ± 0.75) (z: −4.196, p<0.001).
(44.3%) (13.62 ± 2.72 years). The duration of participants' OCD di- A multiple linear regression model was used to identify factors that
agnoses (i.e., the time since an initial diagnosis) was 2.19 ± 1.78 years. affected CY-BOCS scores. A significant relation was found between the
Sources of information about the COVID-19 pandemic included change in CY-BOCS scores and the model. In the analysis, there was a
watching TV (85.2%), following news from the internet (63.9%), significant correlation between changes in CY-BOCS scores and talking/
talking/searching in the social environment about COVID-19 (63.9%), searching in the social environment about COVID-19 (B=3.728
and using social media (49.2%). Daily preoccupation about the COVID- CI:0.654; 6.802, p=0.018), daily preoccupation with COVID-19
19 pandemic (including TV/internet/social media exposure and (B=1.656 CI: 0.510; 2.801, p=0.005), duration of OCD diagnosis
talking/searching in the social environment) was 1.59 ± 1.29 hours per (B=0.947 CI: 0.136; 1.758, p=0.023), and the diagnosis of COVID-19
day. The clinical and sociodemographic characteristics of subjects are in someone familiar (B=3.872 CI: 0.927; 6.817, p=0.011). The mul-
summarized in Table 1. tiple linear regression analysis that identified the factors that predicted
More than half of the subjects (n=33; 54.09%) reported an increase changes in CY-BOCS scores is summarized in Table 3.
in symptom severity according to both the CY-BOCS and CGI-S scales,
with 22 subjects (36.06%) having at least a 30% increase in total CY-
BOCS scores during the pandemic period. Contamination obsessions 4. Discussion
and cleaning/washing compulsions were the most frequent OCD
symptoms both before and during the pandemic. There was a sig- This study evaluated OCD symptom profiles, changes to symptom
nificant increase in the frequency of contamination obsessions severity, and other related factors from both during and before the
(p=0.008) and cleaning/washing compulsions (p=0.039) during the COVID-19 pandemic in young subjects who had been diagnosed with
pandemic (Table 2). While there was no change in symptom severity in OCD in a university hospital's child and adolescent psychiatry clinic.
21 subjects (34.4%), seven subjects (11.4%) reported a decrease in CY- Important findings were obtained in our study—the severity of OCD
BOCS scores (changing from 1 to 7 scores with a mean of 2.4). Thirty- symptoms increased during the pandemic in more than half of the study
four patients (55.7%) were remitters of obsessive-compulsive symptoms subjects. Studies have shown that contamination obsessions and com-
pulsive handwashing are among the most common OCD symptoms
Table 2 (Bloch and Storch, 2015; Coskun et al., 2012; Coskun and
Types and severity of OCD symptoms during and before pandemic. Zoroglu, 2009; Stein et al., 2019). Little research has concerned adult
subjects who report exacerbated OCD symptoms during the COVID-19
Variable During Pandemic Before Pandemic p-value
pandemic usually presented through the worsening of contamination
Type of obsessions, N (%) obsessions and cleaning/washing compulsions (Davide et al., 2020;
Contamination 48 (78.6) 40 (65.6) 0.008a French and Lyne, 2020; Kumar and Somani, 2020). In their very recent
Aggressive 11(18) 10 (16.4) 1a
study, Davide et al. reported that a significant increase in obsession and
Sexual 13 (21.3) 13 (21.3) 1a
Hoarding/saving 7 (11.5) 7 (11.5) 1a compulsion severity emerged, and both the remission status of OCD
Religious 25 (41) 24 (39.3) 1 symptoms and having contamination symptoms before the quarantine
Magical thinking 12 (19.7) 12 (19.7) 1a were significantly associated with greater worsening of OCD symptoms
Somatic 12 (19.7) 6 (9.8) 0.109a during quarantine (Davide et al., 2020). It has been reported that hand
Type of compulsions, N
washing during pandemic is considered to be one of the safest measures
(%)
Cleaning/washing 46 (75.4) 38 (62.3) 0.039a against infection, and since these hygienic measures are emphasized in
Checking 27 (44.3) 30 (49.2) 0.375a media sources, it has worsened the symptoms of patients with OCD who
Repeating 18 (29.5) 17 (27.9) 1a
Counting 13 (21.3) 14 (23) 1a
Table 3
Ordering/arranging 15 (24.6) 14 (23) 1a
Multiple linear regression analysis for predictors of change in YBOCS scores
Hoarding/collecting 8 (13.1) 7 (11.5) 1a
Superstition 10 (16.4) 10 (16.4) 1a Variables OR 95.0% CI for OR p-value
CY-BOCS Scores Lower Upper
mean ± SD (min-
max) Talking/searching in the social 3.728 0.654 6.802 0.018
Obsession 9.72 ± 3.67 (5-18) 7.18 ± 2.66 (5-15) <0.001b environment about COVID-19 *
Compulsion 9.27 ± 3.47 (5-17) 7.06 ± 2.51 (5-14) <0.001b Daily preoccupation about COVID-19 1.656 0.510 2.801 0.005
Total 19.0 ± 6.89 (10- 14.24 ± 5.05 (10- <0.001b Duration of OCD diagnosis 0.947 0.136 1.758 0.023
35) 28) Diagnosis of COVID-19 in someone 3.872 0.927 6.817 0.011
familiar *
Notes:
a
McNemar test, Notes: R=0.675. R2=0.455; p<0.001. Bold data, p<0.05 (significance).
b
Wilcoxon test, Bold data, p<0.05 (significance). CI;Confidence Interval. Standard Error: SE. OR: Odds Ratio;
⁎
CY-BOCS: Children's Yale-Brown Obsessive Compulsive Scale reference, absence (0) presence (1)

3
Y. Tanir, et al. Psychiatry Research 293 (2020) 113363

have concerns about contamination, hygiene, and cleanliness prevent the worsening of OCD symptoms in young subjects.
(Banerjee, 2020; French and Lyne, 2020). Of the four basic dimensions Furthermore, this study has several limitations that should be noted.
of OCD, the contamination and cleaning-washing dimensions in parti- First, this was a cross-sectional study conducted during the pandemic
cular were reported to be associated with exaggerated threat and in- and may not reflect long-term effects of the COVID-19 pandemic on
flated responsibility (Wheaton et al., 2010). Intensive expression of young people with OCD. In addition, subjects were assessed by tele-
health problems related to COVID-19 and measures to be taken, as phone or via online interviews due to home confinement for this age
presented in the media and in social life, may increase the perceptions group. Finally, the worsening of OCD symptoms may be a natural
of threat and responsibility in people with OCD. In addition, cleaning course of an individual's disorder, which may or may not be attributable
compulsions frequently seen in patients with a fear of contamination to COVID-19. Further studies with larger samples, more structured in-
are directly related to behaviors such as the use of washing and pro- terviews, and long-term follow-ups are needed on this subject.
tective equipment due to the outbreak of COVID-19 (Banerjee, 2020).
Contamination obsessions and cleaning compulsions were found to be Author disclosure
the most common symptoms both before and during the pandemic in
the current study. In addition, as expected, there was a significant in- The authors transfer all copyright ownership of the manuscript
crease in the frequency of these symptoms, which means that more entitled "Exacerbation of Obsessive Compulsive Disorder Symptoms in
subjects developed contamination and cleaning/washing symptoms Children and Adolescents During COVID-19 Pandemic" to the
during the pandemic among our sample. This finding is consistent with Psychiatric Research Journal. The authors warrant that the article is
previous reports regarding adult subjects. However, to date, the re- original, is not for consideration by another journal, has not been
searchers were unable to find any study or report that considered the previously published, and has been prepared according to the manu-
effects of the COVID-19 pandemic on children and adolescents with script rules. The authors warrant that they have no conflict of interests
OCD. in general or in connection with the submitted article and no financial
In our study, CY-BOCS ratings of obsessions and compulsions, plus relationships with any pharmaceutical company.
overall CY-BOCS scores as well as CGI-S scores, showed statistically
significant increase during the COVID-19 pandemic, with more than Declaration of Competing Interest
one-third of the subjects having an increase of at least 30% in total CY-
BOCS scores. In addition, more than half of the subjects identified as None.
remitters before the pandemic relapsed with clinically significant
symptoms. Importantly, there was a significant relationship between CRediT authorship contribution statement
the changes in CY-BOCS scores with talking/searching in the social
environment about COVID-19, daily preoccupation with COVID-19, the Yaşar Tanir: Conceptualization, Funding acquisition, Formal ana-
duration of OCD diagnosis, and the diagnosis of COVID-19 in someone lysis, Writing - original draft, Writing - review & editing. Ali
familiar to patients. Some of these findings are consistent with the Karayagmurlu: Conceptualization, Funding acquisition, Formal ana-
limited literature regarding adult subjects who reported exposure in lysis, Writing - original draft. İlyas Kaya: Conceptualization. Tuba
social environments and media as important factors for the exacerba- Bilbay Kaynar: Funding acquisition, Formal analysis. Gaye Türkmen:
tion of OCD symptoms (Banerjee, 2020; Kumar and Somani, 2020; Funding acquisition, Formal analysis. Büşra Nur Dambasan: Funding
French and Lyne, 2020). Our study confirms that these findings also acquisition, Formal analysis. Yavuz Meral: Funding acquisition,
apply to young subjects with OCD. However, in contrast to the available Formal analysis. Murat Coşkun: Conceptualization, Writing - original
literature, we also found that the duration of a subject's OCD diagnosis draft, Writing - review & editing.
and a COVID-19 diagnosis in someone familiar were both associated
with an increase in OCD symptom severity during the pandemic. The References
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