Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus COVID-

19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
 Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

Contents lists available at ScienceDirect

Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

The impact of the coronavirus pandemic on specific symptom dimensions

and severity in OCD: A comparison before and during COVID-19 in the
context of stress responses
Vahid Khosravani a, *, Frederick Aardema b, Seyed Mehdi Samimi Ardestani c,
Farangis Sharifi Bastan d
a
Behavioral Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b
Montreal Mental Health University Institute Research Center, University of Montreal, Department of Psychiatry and Addictology, 7331 Hochelaga Street, Montreal, QC,
H1N 3V2, Canada
c
Departments of Psychiatry, Behavioral Sciences Research Center, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
d
Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: The present study aimed to compare a group of patients with obsessive-compulsive disorder (OCD; N = 270)
Obsessive-compulsive symptom dimensions before and during COVID-19 on specific obsessive-compulsive (OC) symptom dimensions and symptom severity.
Severity In addition, the study aimed to evaluate the associations of COVID-19-related stress responses with change in OC
COVID-19
symptom dimensions and severity of symptoms as the result of the pandemic. Results showed that patients with
Stress responses to COVID-19
OCD had higher scores on all OC symptom dimensions and symptom severity during the pandemic as compared
to their scores from before the pandemic. Thus, the effect of COVID-19 is not limited to an increase in fears of
contamination alone, but occurs across other symptom dimensions, including responsibility for harm, unac­
ceptable thoughts, and symmetry. In addition, regression analyses indicated that COVID-19-related stress re­
sponses significantly predicted the observed increase in specific OC symptom dimensions and general severity,
after controlling for pre-COVID-19 scores of symptoms and severity. The increase of symptoms as the result of
COVID-19 might be best understood in the context of a non-specific stress-related response similar to the effects
observed in non-clinical and other clinical populations.

1. Introduction 2020).
A relatively large number of studies have reported that COVID-19
The coronavirus disease-2019(COVID-19) pandemic has affected has increased general symptom severity, as well as contamination-
mental health in patients with obsessive-compulsive disorder (OCD) related obsessions and compulsions (Abba-Aji et al., 2020; Davide
(Pan et al., 2021) and has raised specific concerns for those with OCD et al., 2020; Knowles & Olatunji, 2021), but no other
due to their tendency to respond to danger and uncertainty (Khosravani, obsessive-compulsive (OC) symptoms (Matsunaga, Mukai, & Yamanishi,
Asmundson, Taylor, Bastan, & Ardestani, 2021; Wheaton, Messner, & 2020; Tanir et al., 2020). One recent study reported no general increase
Marks, 2021). In particular, it has been suggested that hygienic rec­ in symptom severity among children and adolescents with a significant
ommendations in the context of the pandemic may intensify illness portion of the sample in treatment (Schwartz-Lifshitz et al., 2021).
severity, especially for those with obsessional fears of contamination Jelinek, Moritz, Miegel, and Voderholzer (2021) found that 72% of OCD
(Fineberg et al., 2020; Fontenelle & Miguel, 2020; Lee, 2020). Indeed, patients, especially those with washing symptoms experienced an
most authors anticipating the negative effects of the pandemic on exacerbation of OC symptoms as the result of the pandemic. Also,
symptoms have focused on patients whose obsessional concerns revolve Benatti et al. (2020) reported that COVID-19 is associated with the
around contamination (Chatterjee, Malathesh Barikar, & Mukherjee, clinical worsening of OCD severity, as well as the emergence of new
2020; Fontenelle & Miguel, 2020; Kumar & Somani, 2020; Rajkumar, obsessions and compulsions.

* Corresponding author.
E-mail address: vahid.psy@gmail.com (V. Khosravani).

https://doi.org/10.1016/j.jocrd.2021.100626
Received 17 September 2020; Received in revised form 22 January 2021; Accepted 22 January 2021
Available online 26 January 2021
2211-3649/© 2021 Elsevier Inc. All rights reserved.
V. Khosravani et al. Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

Despite the surge in research on the effect of COVID-19 on those with 270 patients with OCD with the following exclusion criteria: 1) sub­
OCD, there are limitations to studies carried out so far, and significant stance abuse, 2) mental disabilities, 3) psychotic disorders, 4) physical
gaps in knowledge remain. Some studies have primarily focused on (other than COVID-19) or neurological diseases, and 5) the presence of
treated or young patients with OCD (e.g., Davide et al., 2020; Matsunaga personality disorders. All diagnoses were performed by a clinical psy­
et al., 2020; Schwartz-Lifshitz et al., 2021; Tanir et al., 2020), while chologist according to the DSM-5 (American Psychiatric Association,
there is evidence that the effects of COVID-19 may be stronger in adults 2013) on the Structured Clinical Interview for DSM-5 Disorders,
with pre-existing or untreated mental illnesses (Ahmed et al., 2020; Research Version (SCID-5-RV; First, Williams, Karg, & Spitzer, 2014). In
Asmundson et al., 2020; Pieh, Budimir, & Probst, 2020; Sher, 2020). the pre-COVID-19 study, all participants previously met the diagnostic
Similarly, those with an untreated and/or current diagnosis of OCD may criteria of OCD according to the DSM-5. The Medical Ethics Committee
be especially likely to experience adverse effects (Nissen, Højgaard, & of Shahid Beheshti University of Medical Sciences approved the current
Thomsen, 2020). Another important limitation is that a significant study (IR.SBMU.RETECH.REC.1399.901) and all participants provided
number of studies did not directly compare OC symptoms during the informed consent.
pandemic with scores from before the pandemic (e.g., Abba-Aji et al.,
2020; Benatti et al., 2020; Davide et al., 2020; Jelinek et al., 2021). In 2.2. Procedure
addition, most studies have only focused on contamination-related fears,
while ignoring other important symptom dimensions of OCD (e.g., We had previously studied a group of patients with OCD (N = 764)
Abba-Aji et al., 2020; Benatti et al., 2020; Davide et al., 2020; Knowles & examining the psychometric properties of several OCD questionnaires
Olatunji, 2021; Matsunaga et al., 2020; Tanir et al., 2020). Hence, a before the outbreak of COVID-19. During the pandemic, we decided to
comprehensive examination of the effects of COVID-19 across multiple recall the same OCD group and re-examine them. The re-evaluation
symptom domains as well as the potential role of COVID-related stress in occurred between May and July 2020 during the first wave of COVID-
the exacerbation of symptoms of OCD is needed. 19 in Iran. The overall response rate was 35.3% (N = 270). Common
Stress responses and anxiety induced by the current pandemic may reasons for non-participation included a fear of being infected with
be an important underlying mechanism accounting for an exacerbation COVID-19 during face-to-face visits or not having the necessary tech­
of symptoms among those with OCD during the current pandemic. nology or skills to participate online or by phone. Clinical variables that
Stressful life events, as well as distress in general, have previously been had been examined in the pre-COVID-19 study were re-evaluated during
shown to be associated with the exacerbation of OC symptoms (Adams the pandemic, including measures of OC symptom dimensions and OCD
et al., 2018; Imthon et al., 2020; Khosravani, Bastan, Ardestani, & severity that were previously administered. In addition, we evaluated
Amirinezhad, 2020; Khosravani, Ardestani, Mohammadpanah, & stress reactions resulting from COVID-19 on the COVID-19 Stress Scale
Amirinezhad, 2020; Rosso, Albert, Asinari, Bogetto, & Maina, 2012). (Taylor et al., 2020a) during the pandemic. Among patients with OCD
COVID-19-related stress is significantly associated with OCD-like stress recalled to participate, two-hundred seventy patients participated in the
symptoms (Taylor et al., 2020a), intrusive thoughts (Lee, 2020; Mar­ study. Participants took part in the study online and by phone or
roquín, Vine, & Morgan, 2020), reassurance-seeking (Shafran, Cough­ in-person and completed the questionnaires.
trey, & Whittal, 2020), intolerance of uncertainty, OCD symptoms,
health anxiety (Wheaton et al., 2021), anxiety symptoms, and avoidance 2.3. Self-report measures
behaviors (McKay, Yang, Elhai, & Asmundson, 2020; Nissen et al., 2020;
Seçer & Ulaş, 2020), especially in individuals with anxiety-related dis­ 2.3.1. The dimensional obsessive-compulsive scale (DOCS; Abramowitz
orders (Asmundson et al., 2020) and those with OCD (Khosravani et al., et al., 2020)
2021). Consequently, an increase in symptoms of OCD as the result of The DOCS is a scale to assess OC symptom dimensions including 1)
the current pandemic would be expected to be significantly predicted by contamination (5 items), 2) responsibility for harm (5 items), 3) unac­
what has recently been labeled as “COVID Stress Syndrome” (Khosra­ ceptable obsessional thoughts (5 items), 4) and symmetry (5 items). The
vani et al., 2021; Taylor et al., 2020c). DOCS has been validated in Iranian patients with OCD (Khosravani,
Abramowitz, Ardestani, Bastan, & Kamali, 2020). In the current study,
1.1. Aims and hypotheses of the present study Cronbach’s alphas for the total DOCS and its dimensions of contami­
nation, responsibility for harm, unacceptable obsessional thoughts, and
The aims of the present study were twofold. First, given the limita­ symmetry were 0.97, 0.93, 0.94, 0.94, and 0.97, respectively.
tions of previous studies, which have mainly focused on obsessional
fears of contamination in smaller sample sizes, younger patients, and 2.3.2. The Yale-Brown obsessive-compulsive scale (Y-BOCS; Goodman
without direct comparison between symptoms before and during the et al., 1989)
pandemic, we aimed to determine the effect of the current pandemic The Y-BOCS is a self-report scale to assess the two subscales of ob­
across symptom dimensions of OCD as well as general symptom severity sessions (5 items) and compulsions (5 items) to determine OCD severity.
in a large adult sample of OCD patients. Second, the current study aimed The scale has been validated in an Iranian sample (Esfahani, Motaghi­
to clarify the effects of COVID-related stress responses on OCD symp­ pour, Kamkari, Zahiredin, & Janbozorgi, 2012). In the current study,
toms. It was hypothesized that: 1) OCD patients experience an increase Cronbach’s alphas of the total Y-BOCS, and the subscales of obsessions
in symptoms across multiple symptom dimensions, not limited to fears and compulsions were equal to 0.97, 0.94, and 0.95, respectively.
of contamination alone; 2) those with OCD experience a general increase
in their severity of symptoms during the pandemic compared with their 2.3.3. The COVID-19 Stress Scale (CSS; Taylor et al., 2020a)
symptom severity before the pandemic, and; 3) the increase in symp­ The CSS has 36 items to assess stress reactions stemming from
toms and their general severity during the pandemic is significantly COVID-19 across sub-dimensions, including 1) danger and contamina­
predicted by COVID-related stress. tion; 2) socio-economic consequences; 3) xenophobia; 4) traumatic
stress, and; 5) compulsive checking. Items are rated on a 5-point Likert
2. Method scale scoring from 0 (never) to 4 (always/extremely). The scale has been
validated in an Iranian sample of patients with OCD (Khosravani et al.,
2.1. Participants 2021). In the present study, Cronbach’s alpha of the CSS was 0.95.

A group of treatment-seeking patients with a principal diagnosis of

OCD participated in the current study. The current study consisted of

2
V. Khosravani et al. Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

2.4. Statistical analysis for harm, unacceptable thoughts, and symmetry) and also general OCD
severity as measured by the YBOCS were significantly higher during
Paired t-tests were performed to investigate differences between the COVID-19 as compared to their scores from before the pandemic (all ps
scores before and during COVID-19 on OC symptom dimensions (DOCS) < 0.001) (Table 1).
and OCD severity (YBOCS). Hierarchical regression analyses were per­
formed to determine the role of COVID-19-related stress responses in
change in specific OCD symptom dimensions and general severity dur­ 3.3. Predicting change in OC symptom dimensions and general severity
ing COVID-19, by controlling for pre-COVID-19 scores of these symp­ based on COVID-19 stress responses during the pandemic
toms and general severity. In each regression model, the pre-COVID-19
score of each clinical symptom measure was entered in step 1. At step 2, The results of hierarchical regression analyses predicting symptom
the COVID-19 stress response as measured by the CSS total score was levels during the COVID-19 pandemic controlled for scores before the
entered as an independent variable. The dependent variable in each pandemic are represented in Table 2. Results showed that COVID-19
regression analysis consisted of the score of the relevant clinical symp­ stress responses as measured by the total score of the CSS was signifi­
tom measure during the pandemic (DOCS subscales and YBOCS). In cantly associated with the increase of all OC dimensions, including the
addition, to further disentangle the role of COVID-stress responses, hi­ DOCS subscales contamination (Adj R2 = 0.50), responsibility for harm
erarchical regression analyses were performed using the individual (Adj R2 = 0.56), unacceptable thoughts (Adj R2 = 0.50), and symmetry
subscales of the CSS in the prediction of change in symptoms due to (Adj R2 = 0.26), as well as OCD severity (Adj R2 = 0.46) (all ps < 0.001).
COVID-19. Kolmogorov-Smirnov test showed that the data were nor­ Table 3 shows the results of hierarchical regression analyses pre­
mally distributed. Data analysis was performed using SPSS-22 software dicting symptom dimensions and general severity during COVID-19
(IBM Corporation, Armonk, NY, USA). based on the individual subscales of the CSS (i.e., danger and contami­
nation, socio-economic consequences, xenophobia, traumatic stress, and
3. Results compulsive checking) entered as independent variables. After control­
ling for pre-COVID-19 scores of symptoms and general severity, all
3.1. Demographic and clinical characteristic of participants specific stress reactions as measured by the subscales of CSS offered
unique and contributed to the prediction of specific symptoms and
The sample consisted of 155 (57.4%) females and 115 (42.6%) males general OCD severity (p < 0.001), with the exception of xenophobic
with an average age of 36 (SD = 12.1; range = 17–67 years). The mean stress reactions (p > 0.05). Danger and contamination-related stress
education of the participants was 13.62 years (SD = 3.1). Among par­ reactions significantly predicted all specific OC symptom dimensions, as
ticipants, 41.5%, 51.8%, and 6.7% were single, married, and divorced, well as the general severity of symptoms. Except for symmetry,
respectively. The age of OCD onset and illness duration were 26.6 (SD =
8.55) and 9.6 (SD = 7.0) years, respectively. A substantial number of Table 2
patients had a comorbid disorder (N = 120; 44.4%), primarily consisting Predicting change in obsessive-compulsive symptom dimensions and OCD
of depressive and anxiety disorders. All participants were taking medi­ severity based on general COVID-19-related stress responses (CSS total score) a.
cation, and 30% of the total sample had previously received psycho­ Outcome variables Independent Adj R2 β t
logical treatment for their symptoms or received treatment during the (during COVID-19) variables R2 change
study, including cognitive-behavioral therapy (CBT). The mean score of Contamination 0.51
patients on COVID-19-related stress symptoms was 102.6 (SD = 23.1). Pre-COVID-19 0.01 0.02 0.50
contamination
COVID-19 stress 0.50 0.71 16.54b
responses
3.2. Differences between the scores of patients with OCD before and
Responsibility for 0.57
during COVID-19 harm
Pre-COVID-19 0.01 0.01 0.33
Table 1 shows the results of paired-tests comparing scores during the responsibility for
harm
COVID-19 pandemic with scores from before the pandemic. Results
COVID-19 stress 0.56 0.75 18.61b
showed that there were significant differences between the scores of responses
patients with OCD on symptoms and general severity before and during Unacceptable 0.51
COVID-19. The scores of patients with OCD on all OC symptom di­ thoughts
mensions as measured by the DOCS (i.e., contamination, responsibility Pre-COVID-19 0.01 0.01 0.25
unacceptable
thoughts
Table 1 COVID-19 stress 0.50 0.71 16.43b
Comparison of symptoms and severity before and during COVID-19 in a group of responses
patients with OCD (N = 270). Symmetry 0.27
Pre-COVID-19 0.01 0.06 1.10
Pre-COVID-19, During COVID-19, t symmetry
Mean ± S.D Mean ± S.D COVID-19 stress 0.26 0.53 10.05b
Total DOCS 38.4 ± 14.1 55.2 ± 14.2 13.5 responses
DOCS contamination 9.5 ± 4.0 14.4 ± 3.5 15.2 OCD severity 0.48
DOCS responsibility for harm 9.9 ± 4.4 14.0 ± 3.7 11.4 Pre-COVID-19 OCD 0.02 0.06 1.42
DOCS unacceptable thoughts 11.2 ± 3.9 14.3 ± 3.8 9.5 severity
DOCS symmetry 7.8 ± 4.5 12.4 ± 4.8 11.7 COVID-19 stress 0.46 0.69 15.44b
Total Y-BOCS 19.6 ± 9.1 28.7 ± 8.2 12.7 responses
Y-BOCS obsessions 10.5 ± 4.9 14.6 ± 4.1 10.6
Note.
Y-BOCS compulsions 9.1 ± 4.8 14.1 ± 4.2 13.6 a
There were two steps in each regression model: Step 1: The pre-COVID-19
Note. score of the outcome variable; Step 2: The total score of the CSS. Also, in
OCD = obsessive-compulsive disorder; COVID-19 = coronavirus disease 2019; these models, we represented the final step (step 2) for readability in the table.β
DOCS = dimensional obsessive-compulsive scale; Y-BOCS=Yale Brown = standardized coefficient; OCD = obsessive-compulsive disorder; COVID-19 =
obsessive-compulsive scale. coronavirus disease 2019; CSS=COVID Stress Scales.
b
All t values were significant (p < 0.001). p < 0.001.

3
V. Khosravani et al. Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

Table 3 uniquely predicted responsibility for harm.

Predicting change in obsessive-compulsive symptom dimensions and OCD
severity based on specific COVID-19 stress responses (CSS subscales) a. 4. Discussion
Outcome variables Independent Adj R2 β t
(during COVID-19) variables R2 change The current study aimed to compare the scores of a group of patients
Contamination 0.54 with OCD on OC symptom dimensions and OCD severity before and
Pre-COVID-19 0.01 0.03 0.72 during COVID-19. In addition, it aimed to evaluate changes in OC
contamination symptom dimensions and general severity based on COVID-19-related
CSS danger and 0.56 5.71b
stress reactions. It was hypothesized that COVID-19 is associated with
contamination
CSS socio-economic 0.04 0.71 an increase across all OC symptom dimensions and general severity. In
consequences addition, we expected COVID-19-related stress to significantly account
CSS xenophobia 0.08 0.92 for the change in these symptoms as the result of the pandemic. Results
CSS traumatic stress 0.17 2.52b
confirmed these hypotheses.
CSS compulsive 0.53 0.08 1.13
checking
Previous theoretical reports (e.g., Chatterjee et al., 2020; Fontenelle
Responsibility for 0.59 & Miguel, 2020; Kumar et al., 2020) and empirical studies (e.g.,
harm Abba-Aji et al., 2020; Benatti et al., 2020; Davide et al., 2020; Jelinek
Pre-COVID-19 0.01 0.01 0.28 et al., 2021; Knowles & Olatunji, 2021; Matsunaga et al., 2020; Tanir
responsibility for
et al., 2020) have highlighted a specific link between COVID-19 and
harm
CSS danger and 0.39 4.16b contamination symptoms. The present empirical study showed that
contamination COVID-19 is also linked to an increase in all OC symptom dimensions,
CSS socio-economic 0.03 0.44 including contamination, responsibility for harm, unacceptable
consequences
thoughts, and symmetry. In addition, as reported in previous studies
CSS xenophobia 0.01 0.17
CSS traumatic stress 0.16 2.86b
(Benatti et al., 2020; Tanir et al., 2020), the results of the present study
CSS compulsive 0.58 0.33 3.94b showed that the COVID-19 pandemic increased general OCD severity.
checking COVID-19 poses significant challenges for many that would be ex­
Unacceptable 0.52 pected to result in an increase in OC symptoms across different di­
thoughts
mensions. COVID-19 has been previously been noted to have negative
Pre-COVID-19 0.01 0.01 0.21
unacceptable effects on mental health due to increased levels of uncertainty and
thoughts unpredictability (Tull et al., 2020; Wheaton et al., 2021; Zandifar &
CSS danger and 0.37 3.62b Badrfam, 2020), distress, fear, anxiety (Elhai, Yang, McKay, &
contamination Asmundson, 2020; Mertens, Gerritsen, Duijndam, Salemink, & Engel­
CSS socio-economic 0.14 2.42b
consequences
hard, 2020), and health-related worries and concerns (Jungmann &
CSS xenophobia 0.08 0.88 Witthöft, 2020; Taylor, Landry, Paluszek, Rachor, & Asmundson,
CSS traumatic stress 0.33 3.67b 2020b). Indeed, when OC symptoms emerge in community individuals
CSS compulsive 0.51 0.03 0.48 due to the COVID-19 (Zheng, Xiao, Xie, Wang, & Wang, 2020), it is not
checking
surprising to find an increase in symptoms across multiple dimensions in
Symmetry 0.30
Pre-COVID-19 0.01 0.05 1.02 patients with OCD. In particular, as outlined earlier, COVID-related
symmetry stress and anxiety induced by the current pandemic may be an impor­
CSS danger and 0.40 3.29b tant underlying mechanism accounting for an exacerbation of symp­
contamination toms, including those with OCD.
CSS socio-economic 0.24 3.32b
consequences
The results of the present study supported the notion that the in­
CSS xenophobia 0.13 1.19 crease in symptoms and general severity observed among those with
CSS traumatic stress 0.06 0.52 OCD might primarily be due to stress induced by the current pandemic.
CSS compulsive 0.29 0.03 0.35 COVID-related stress responses explained a substantial amount of the
checking
variance of change in symptoms across all OC dimensions and general
OCD severity 0.49
Pre-COVID-19 OCD 0.02 0.06 1.41 OCD severity. In particular, stress reactions that revolved around danger
severity and contamination, traumatic stress, compulsive checking, and socio-
CSS danger and 0.36 3.48b economic concerns predicted a worsening of symptoms across multi­
contamination ple symptom dimensions and general OCD severity. While the present
CSS socio-economic 0.15 2.48b
consequences
study does not directly comment on whether those with OCD are more
CSS xenophobia 0.08 0.84 vulnerable to the negative effects of COVID-19 than other populations, it
CSS traumatic stress 0.29 3.12b highlights some of the potential mechanisms by which specific symp­
CSS compulsive 0.47 0.04 0.60 toms of OCD might be exacerbated as the result of the current pandemic.
checking
For example, excessive checking of news and events related to COVID-19
Note. might result in increased concerns about responsibility for harm and
a
There were two steps in each regression model: Step 1: The pre-COVID-19 checking behaviors (Shafran et al., 2020). Similarly, anger and pessi­
score of the outcome variable; Step 2: The subscales of the CSS. Also, in these mistic attitudes towards the future and aggressive symptoms might
models, we represented the final step (step 2) for readability in the table.β = result in an increase of symptoms revolving around immoral, sexual,
standardized coefficient; CSS=COVID Stress Scales; COVID-19 = coronavirus
suspicious, and violent themes or other OC symptoms during the
disease 2019; OCD = obsessive-compulsive disorder.
b COVID-19 pandemic in patients with OCD (Nissen et al., 2020).
p < 0.001.
Danger and contamination-related stress, which forms the core of
COVID-Stress Syndrome (Taylor et al., 2020c), predicted change in all
traumatic stress-related reactions predicted most specific OC symptoms symptom dimensions of OCD as well as change in general severity, as
and general severity. Socio-economic stress reactions significantly pre­
would be expected given that danger and contamination-related con­
dicted unacceptable thoughts, symmetry, and general OCD severity. cerns are highly prevalent in disorders with high levels of anxiety
Finally, compulsive checking-related stress reactions significantly and
(Asmundson et al., 2020), including those with OCD (Khosravani et al.,

4
V. Khosravani et al. Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

2021). It is worth noting, however, that perceptions of threat and Declaration of competing interest
danger, including exaggerated danger-related stress responses to
COVID-19, do not necessarily indicate a specific obsessional response, None declared.
which has been suggested to depend on more specific perceived
self-related vulnerabilities (Aardema, 2020; Aardema & Wong, 2020). Acknowledgements
Nonetheless, results support that these danger-related stress reactions
are associated with an increase in symptoms among those with OCD (Ji The authors would like to thank the Behavioral Sciences Research
et al., 2020; Nissen et al., 2020; Yassa et al., 2020), likely through similar Center, Shahid Beheshti University of Medical Sciences (SBUMS), Teh­
mechanisms by which symptoms may be exacerbated in non-clinical and ran, Iran for their support, cooperation, and assistance throughout the
other clinical populations (Montano & Acebes, 2020; Song, 2020; Taylor period of study.
et al., 2020a, 2020c).
References
4.1. Implications
Aardema, F. (2020). COVID-19, obsessive-compulsive disorder and invisible life forms
that threaten the self. Journal of Obsessive-Compulsive and Related Disorders, 26,
The present study has several important clinical implications. First, Article 100558. https://doi.org/10.1016/j.jocrd.2020.100558
the present study indicated that stress responses to the pandemic are Aardema, F., & Wong, S. F. (2020). Feared possible selves in cognitive-behavioral theory:
associated with an increase in all OC symptom dimensions and their An analysis of its historical and empirical context, and introduction of a working
model. Journal of Obsessive-Compulsive and Related Disorders, 24, Article 100479.
severity. Consequently, therapists should consider the effects of the
https://doi.org/10.1016/j.jocrd.2019.100479
pandemic on all OC symptom dimensions and adjust their treatment Abba-Aji, A., Li, D., Hrabok, M., Shalaby, R., Gusnowski, A., Vuong, W., et al. (2020).
plans accordingly (McKay, Minaya, & Storch, 2020; Sheu, McKay, & COVID-19 pandemic and mental health: Prevalence and correlates of new-onset
obsessive-compulsive symptoms in a Canadian province. JMIR Public Health and
Storch, 2020; Storch, Schneider, Guzick, McKay, & Goodman, 2020). In
Surveillance, 17(19), 6986. https://doi.org/10.2196/preprints.19648
particular, results suggest that reducing COVID-related stress may be Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C.,
particularly beneficial to reduce the negative impact of COVID-19 on Losardo, D., et al. (2010). Assessment of obsessive-compulsive symptom dimensions:
symptoms (Babore et al., 2020; Fullana, Hidalgo-Mazzei, Vieta, & Development and evaluation of the dimensional obsessive-compulsive scale.
Psychological Assessment, 22, 180–198. https://doi.org/10.1037/a0018260
Radua, 2020; Ye et al., 2020). In addition, therapists can provide online Adams, T. G., Kelmendi, B., Brake, C. A., Gruner, P., Badour, C. L., & Pittenger, C. (2018).
psychological therapy programs through CBT that are tailored to the The role of stress in the pathogenesis and maintenance of obsessive-compulsive
current pandemic, including relaxation, distress tolerance, acceptance, disorder. Chronic Stress, 2, Article 2470547018758043. https://doi.org/10.1177/
2470547018758043
and engagement in positive activities (Benhamou & Piedra, 2020). Ahmed, M. Z., Ahmed, O., Aibao, Z., Hanbin, S., Siyu, L., & Ahmad, A. (2020). Epidemic
of COVID-19 in China and associated psychological problems. Asian Journal of
Psychiatry, 51, Article 102092. https://doi.org/10.1016/j.ajp.2020.102092
4.2. Limitations American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders. Washington, DC: DSM-5 American Psychiatric Publishing.
Asmundson, G. J., Paluszek, M. M., Landry, C. A., Rachor, G. S., McKay, D., & Taylor, S.
This study has some limitations. First, results are limited by the use of
(2020). Do pre-existing anxiety-related and mood disorders differentially impact
self-report scales in the assessment of specific symptom dimensions, COVID-19 stress responses and coping? Journal of Anxiety Disorders, 74, Article
which might be subject to response bias. The distress induced by COVID- 102271. https://doi.org/10.1016/j.janxdis.2020.102271
19 may cause patients to exaggerate their symptoms. Alternatively, Babore, A., Lombardi, L., Viceconti, M. L., Pignataro, S., Marino, V., Crudele, M., et al.
(2020). Psychological effects of the COVID-2019 pandemic: Perceived stress and
patients may experience difficulty distinguishing between stress-related coping strategies among healthcare professionals. Psychiatry Research, 293, Article
reactions in response to COVID-19 and symptoms of OCD. Therefore, the 113366. https://doi.org/10.1016/j.psychres.2020.113366
use of clinical interviews may help further clarify the results of this Benatti, B., Albert, U., Maina, G., Fiorillo, A., Celebre, L., Girone, N., et al. (2020). What
happened to patients with obsessive compulsive disorder during the COVID-19
study, including the exact mechanisms by which symptoms of OCD pandemic? A multicentre report from tertiary clinics in northern Italy. Frontiers in
worsen through stress responses to the pandemic. Second, an important Psychiatry, 11, 720. https://orcid.org/10.3389/fpsyt.2020.00720.
point to consider is that the circumstances surrounding current Benhamou, K., & Piedra, A. (2020). CBT-informed interventions for essential workers
during the COVID-19 pandemic. Journal of Contemporary Psychotherapy, 50(4),
pandemic, including orders to stay at home, may cause patients with 275–283. https://doi.org/10.1007/s10879-020-09467-3
OCD not to seek treatment or follow-up meetings, which may play a role Chatterjee, S. S., Malathesh Barikar, C., & Mukherjee, A. (2020). Impact of COVID-19
in the exacerbation of symptoms. There is evidence that patients who are pandemic on pre-existing mental health problems. Asian Journal of Psychiatry, 51,
Article 102071. https://doi.org/10.1016/j.ajp.2020.102071
in-treatment do not fare worse during COVID-19 than the general public
Davide, P., Andrea, P., Martina, O., Andrea, E., Davide, D., & Mario, A. (2020). The
(Kuckertz et al., 2020). Results of the study may therefore not be impact of the COVID-19 pandemic on patients with OCD: Effects of contamination
generalizable to patients that are currently in treatment or those who symptoms and remission state before the quarantine in a preliminary naturalistic
study. Psychiatry Research, 291, Article 113213. https://doi.org/10.1016/j.
have previously been treated. Third, the effects of COVID-19 may be
psychres.2020.113213
temporary and should be re-examined after the pandemic has run its Elhai, J. D., Yang, H., McKay, D., & Asmundson, G. J. (2020). COVID-19 anxiety
course to determine if it has any lasting effect on symptoms of OCD. symptoms associated with problematic smartphone use severity in Chinese adults.
Journal of Affective Disorders, 274, 576–582. https://doi.org/10.1016/j.
jad.2020.05.080
Role of funding source Esfahani, S. R., Motaghipour, Y., Kamkari, K., Zahiredin, A., & Janbozorgi, M. (2012).
Reliability and validity of the Persian version of the Yale-Brown obsessive-
compulsive scale (Y-BOCS). Iranian Journal of Psychiatry and Clinical Psychology, 17,
This research has been supported by the Behavioral Sciences
297–303.
Research Center, Shahid Beheshti University of Medical Sciences Fineberg, N. A., Van Ameringen, M., Drummond, L., Hollander, E., Stein, D. J., Geller, D.,
(SBUMS) and approved by the Medical Ethics Committee of Shahid et al. (2020). How to manage obsessive-compulsive disorder (OCD) under COVID-19:
Beheshti University of Medical Sciences, Tehran, Iran. A clinician’s guide from the international college of obsessive compulsive spectrum
disorders (ICOCS) and the obsessive-compulsive research network (ocrn) of the
European college of neuropsychopharmacology. Comprehensive Psychiatry, 100,
Contributors Article 152174. https://doi.org/10.1016/j.comppsych.2020.152174
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2014). Structured clinical
Interview for DSM-5 disorders (SCID-5-RV), research version. Arlington, VA: American
The first author (methodology, data curation, formal analysis, Psychiatric Publishing.
writing - original draft, review, and editing). The second author (su­ Fontenelle, L. F., & Miguel, E. C. (2020). The impact of COVID-19 in the diagnosis and
pervision, methodology, writing - review and editing). The third author treatment of obsessive-compulsive disorder. Depression and Anxiety, 37, 510–511.
https://doi.org/10.1002/da.23037
(supervision, clinical diagnosis, review and editing). The fourth author Fullana, M. A., Hidalgo-Mazzei, D., Vieta, E., & Radua, J. (2020). Coping behaviors
(clinical diagnosis, data curation, formal analysis). associated with decreased anxiety and depressive symptoms during the COVID-19

5
V. Khosravani et al. Journal of Obsessive-Compulsive and Related Disorders 29 (2021) 100626

pandemic and lockdown. Journal of Affective Disorders, 275, 80–81. https://doi.org/ Pan, K. Y., Kok, A. A., Eikelenboom, M., Horsfall, M., Jörg, F., Luteijn, R. A., et al. (2021).
10.1016/j.jad.2020.06.027 The mental health impact of the COVID-19 pandemic on people with and without
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., depressive, anxiety, or obsessive-compulsive disorders: A longitudinal study of three
et al. (1989). The yale-Brown obsessive compulsive scale: I. Development, use, and Dutch case-control cohorts. The Lancet Psychiatry, 8(2), 121–129. https://doi.org/
reliability. Archives of General Psychiatry, 46, 1006–1011. https://doi.org/10.1001/ 10.1016/S2215-0366(20)30491-0
archpsyc.1989.01810110048007 Pieh, C., Budimir, S., & Probst, T. (2020). The effect of age, gender, income, work, and
IBM Corp. (2013). IBM statistics for windows. Armonk, NY: IBM Corp. physical activity on mental health during coronavirus disease (COVID-19) lockdown
Imthon, A. K., Caldart, C. A., do Rosário, M. C., Fontenelle, l. F., Miguel, E. C., & in Austria. Journal of Psychosomatic Research, 136, Article 110186. https://doi.org/
Ferrão, Y. A. (2020). Stressful life events and the clinical expression of obsessive- 10.1016/j.jpsychores.2020.110186
compulsive disorder (OCD): An exploratory study. Journal of Clinical Medicine, 9, Rajkumar, R. P. (2020). Contamination and infection: What the coronavirus pandemic
3371. https://doi.org/10.3390/jcm9103371 could reveal about the evolutionary origins of obsessive-compulsive disorder.
Jelinek, L., Moritz, S., Miegel, F., & Voderholzer, U. (2021). Obsessive-compulsive Psychiatry Research, 289, Article 113062. https://doi.org/10.1016/j.
disorder during COVID-19: Turning a problem into an opportunity? Journal of psychres.2020.113062
Anxiety Disorders, 77, Article 102329. https://doi.org/10.1016/j. Rosso, G., Albert, U., Asinari, G. F., Bogetto, F., & Maina, G. (2012). Stressful life events
janxdis.2020.102329 and obsessive–compulsive disorder: Clinical features and symptom dimensions.
Ji, G., Wei, W., Yue, K. C., Li, H., Shi, L. J., Ma, J. D., et al. (2020). Effects of the COVID- Psychiatry Research, 197, 259–264. https://doi.org/10.1016/j.psychres.2011.10.005
19 pandemic on obsessive-compulsive symptoms among university students: Schwartz-Lifshitz, M., Basel, D., Lang, C., Hertz, N., Dekel, I., Zohar, J., et al. (2021).
Prospective cohort survey study. Journal of Medical Internet Research, 22, Article Obsessive compulsive symptoms severity among children and adolescents during
e21915. https://doi.org/10.2196/21915 COVID-19 first wave in Israel. Journal of Obsessive-Compulsive and Related Disorder,
Jungmann, S. M., & Witthöft, M. (2020). Health anxiety, cyberchondria, and coping in 28, Article 100610. https://doi.org/10.1016/j.jocrd.2020.100610
the current COVID-19 pandemic: Which factors are related to coronavirus anxiety? Seçer, İ., & Ulaş, S. (2020). An investigation of the effect of COVID-19 on OCD in youth in
Journal of Anxiety Disorders, 73, Article 102239. https://doi.org/10.1016/j. the context of emotional reactivity, experiential avoidance, depression and anxiety.
janxdis.2020.102239 International Journal of Mental Health and Addiction, 1–14. https://doi.org/10.1007/
Khosravani, V., Abramowitz, J. S., Ardestani, S. M. S., Bastan, F. S., & Kamali, Z. (2020). s11469-020-00322-z
The Persian version of the dimensional obsessive-compulsive scale (P-DOCS): A Shafran, R., Coughtrey, A., & Whittal, M. (2020). Recognising and addressing the impact
psychometric evaluation. Journal of Obsessive-Compulsive and Related Disorders, 25, of COVID-19 on obsessive-compulsive disorder. The Lancet Psychiatry, 7, 570–572.
Article 100522. https://doi.org/10.1016/j.jocrd.2020.100522 https://doi.org/10.1016/s2215-0366(20)30222-4
Khosravani, V., Ardestani, S. M. S., Mohammadpanah, A., & Amirinezhad, A. (2020). The Sher, L. (2020). Individuals with untreated psychiatric disorders and suicide in the
Obsessive-Compulsive Inventory-Revised (OCI-R): Further psychometric COVID-19 era. Brazilian Journal of Psychiatry, 1–2. http://orcid.org/0000-0002-
examination and its adaptation to the DSM-5 in Iranian patients with obsessive- 7729-3222.
compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 26, Sheu, J. C., McKay, D., & Storch, E. A. (2020). COVID-19 and OCD: Potential impact of
Article 100547. https://doi.org/10.1016/j.jocrd.2020.100547 exposure and response prevention therapy. Journal of Anxiety Disorders, 76, Article
Khosravani, V., Asmundson, G. J. G., Taylor, S., Bastan, F. S., & Ardestani, S. M. S. 102314. https://doi.org/10.1016/j.janxdis.2020.102314
(2021). The Persian COVID Stress Scales (Persian-CSS) and COVID 19-related stress Song, M. (2020). Psychological stress responses to COVID-19 and adaptive strategies in
reactions among patients with obsessive-compulsive and anxiety disorders. Journal China. World Development, 136, Article 105107. https://doi.org/10.1016/j.
of Obsessive-Compulsive and Related Disorders, 28, Article 100615. https://doi.org/ worlddev.2020.105107
10.1016/j.jocrd.2020.100615 Storch, E. A., Schneider, S. C., Guzick, A., McKay, D., & Goodman, W. K. (2020). Impact
Khosravani, V., Bastan, F. S., Ardestani, S. M. S., & Amirinezhad, A. (2020). Psychometric of COVID-19 on exposure and response prevention for obsessive-compulsive
evaluation of the Vancouver Obsessional-Compulsive Inventory (VOCI) and its disorder: Present and post-pandemic considerations. Psychiatry Research, 292, Article
adaptation based on the DSM-5 in Iranian patients with obsessive-compulsive 113310. https://doi.org/10.1016/j.psychres.2020.113310
disorder. Journal of Obsessive-Compulsive and Related Disorders, 25, Article 100536. Tanir, Y., Karayagmurlu, A., İlyas, K. A. Y. A., Kaynar, T. B., Turkmen, G.,
https://doi.org/10.1016/j.jocrd.2020.100536 Dambasan, B. N., et al. (2020). Exacerbation of obsessive compulsive disorder
Knowles, K. A., & Olatunji, B. O. (2021). Anxiety and safety behavior usage during the symptoms in children and adolescents during COVID-19 pandemic: COVID-19 OCD
COVID-19 pandemic: The prospective role of contamination fear. Journal of Anxiety children. Psychiatry Research, 293, Article 113363. https://doi.org/10.1016/j.
Disorders, 77, Article 102323. https://doi.org/10.1016/j.janxdis.2020.102323 psychres.2020.113363
Kuckertz, J. M., Van Kirk, N., Alperovitz, D., Nota, J. A., Falkenstein, M. J., Schreck, M., Taylor, S., Landry, C., Paluszek, M., Fergus, T. A., McKay, D., & Asmundson, G. J. (2020).
et al. (2020). Ahead of the curve: Responses from patients in treatment for obsessive- Development and initial validation of the COVID stress scales. Journal of Anxiety
compulsive disorder to coronavirus disease 2019. Frontiers in Psychology, 11, Article Disorders, 72, Article 102232. https://doi.org/10.1016/j.janxdis.2020.102232
572153. https://doi.org/10.3389/fpsyg.2020.572153 Taylor, S., Landry, C. A., Paluszek, M. M., Fergus, T. A., McKay, D., & Asmundson, G. J.
Kumar, A., & Somani, A. (2020). Dealing with Corona virus anxiety and OCD. Asian (2020). COVID stress syndrome: Concept, structure, and correlates. Depression and
Journal of Psychiatry, 51, Article 102053. https://doi.org/10.1016/j. Anxiety, 37, 706–714. https://doi.org/10.1002/da.23071
ajp.2020.102053 Taylor, S., Landry, C. A., Paluszek, M. M., Rachor, G. S., & Asmundson, G. J. (2020).
Lee, S. A. (2020). How much “Thinking” about COVID-19 is clinically dysfunctional? Worry, avoidance, and coping during the COVID-19 pandemic: A comprehensive
Brain, Behavior, and Immunity, 87, 97–98. https://doi.org/10.1016/j. network analysis. Journal of Anxiety Disorders, 76, Article 102327. https://doi.org/
bbi.2020.04.067 10.1016/j.janxdis.2020.102327
Marroquín, B., Vine, V., & Morgan, R. (2020). Mental health during the COVID-19 Tull, M. T., Barbano, A. C., Scamaldo, K. M., Richmond, J. R., Edmonds, K. A., Rose, J. P.,
pandemic: Effects of stay-at-home policies, social distancing behavior, and social et al. (2020). The prospective influence of COVID-19 affective risk assessments and
resources. Psychiatry Research, 293, Article 113419. https://doi.org/10.1016/j. intolerance of uncertainty on later dimensions of health anxiety. Journal of Anxiety
psychres.2020.113419 Disorders, 75, Article 102290. https://doi.org/10.1016/j.janxdis.2020.102290
Matsunaga, H., Mukai, K., & Yamanishi, K. (2020). The acute impact of the pandemic of Wheaton, M. G., Messner, G. R., & Marks, J. B. (2021). Intolerance of uncertainty as a
COVID-19 on the phenomenological features in the full or partial remitted patients factor linking obsessive-compulsive symptoms, health anxiety and concerns about
with obsessive–compulsive disorder (OCD). Psychiatry and Clinical Neurosciences, the spread of the novel coronavirus (COVID-19) in the United States. Journal of
1–4. https://orcid.org/10.1111/pcn.13119. Obsessive-Compulsive and Related Disorders, 28, Article 100605. https://doi.org/
McKay, D., Minaya, C., & Storch, E. A. (2020). Conducting exposure and response 10.1016/j.jocrd.2020.100605
prevention treatment for contamination fears during COVID-19: The behavioral Yassa, M., Yassa, A., Yirmibeş, C., Birol, P., Ünlü, U. G., Tekin, A. B., et al. (2020).
immune system impact on clinician approaches to treatment. Journal of Anxiety Anxiety levels and obsessive compulsion symptoms of pregnant women during the
Disorders, 74, Article 102270. https://doi.org/10.1016/j.janxdis.2020.102270 COVID-19 pandemic. Turkish Journal of Obstetrics and Gynecology, 17, 155–160.
McKay, D., Yang, H., Elhai, J., & Asmundson, G. (2020). Anxiety regarding contracting https://doi.org/10.4274/tjod.galenos.2020.91455
COVID-19 related to interoceptive anxiety sensations: The moderating role of disgust Ye, Z., Yang, X., Zeng, C., Wang, Y., Shen, Z., Li, X., et al. (2020). Resilience, social
propensity and sensitivity. Journal of Anxiety Disorders, 73, Article 102233. https:// support, and coping as mediators between COVID-19-related stressful experiences
doi.org/10.1016/j.janxdis.2020.102233 and acute stress disorder among college students in China. Applied Psychology: Health
Mertens, G., Gerritsen, L., Duijndam, S., Salemink, E., & Engelhard, I. M. (2020). Fear of and Well-Being, 12(4), 1074–1094. https://doi.org/10.1111/aphw.12211
the coronavirus (COVID-19): Predictors in an online study conducted in March 2020. Zandifar, A., & Badrfam, R. (2020). Iranian mental health during the COVID-19
Journal of Anxiety Disorders, 74, Article 102258. https://doi.org/10.1016/j. epidemic. Asian Journal of Psychiatry, 51, Article 101990. https://doi.org/10.1016/j.
janxdis.2020.102258 ajp.2020.101990
Montano, R. L. T., & Acebes, K. M. L. (2020). Covid stress predicts depression, anxiety Zheng, Y., Xiao, L., Xie, Y., Wang, H., & Wang, G. (2020). Prevalence and characteristics
and stress symptoms of Filipino respondents. International Journal of Research in of obsessive-compulsive disorder among urban residents in wuhan during the stage
Business and Social Science, 9, 78–103. https://doi.org/10.20525/ijrbs.v9i4.773 of regular control of coronavirus disease-19 epidemic. Frontiers in Psychiatry, 11,
Nissen, J. B., Højgaard, D., & Thomsen, P. H. (2020). The immediate effect of COVID-19 1435. https://doi.org/10.3389/fpsyt.2020.594167
pandemic on children and adolescents with obsessive compulsive disorder. BMC
Psychiatry, 20, 511. https://orcid.org/0000-0003-4063-6866.