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The COVID-19 pandemic has presented a challenge for treating people with OCD and it could be postulated that those with OCD fearing contamination might be more affected in current circumstances. Although there have been some studies already published, results have been heterogeneous and conflicting; possibly because of different populations or geographical locations examined.
In this preliminary study we aim to identify the impact of the pandemic on the severity of OCD, as measured by Y-BOCS scores. To our knowledge, it is the first UK study of this kind and the only study that examines change in Y-BOCS scores over such a long time period.
Patients were identified from national OCD unit referral databases at Springfield Hospital. Referrals from March 2019–March 2020 were examined and patients included if they had a diagnosis of OCD, were accepted by the service following initial assessment and sufficient data were available. This preliminary study focused only on Y-BOCS to assess clinician-rated severity of OCD. Y-BOCS scores were compared from different time periods correlating to the progression of COVID-19. ‘Pre-pandemic’ score was taken from Jan–Dec 2019 or, if not available, from Jan–23 March 2020 (prior to UK lockdown). ‘Pandemic’ score was taken as the most recent rating from April 2020 onwards.
21 patients were included. All treated as outpatients (although 9 had undergone previous inpatient treatment during the time period above). 81% showed improvement in Y-BOCS score between pre-pandemic and pandemic time periods, with an overall mean decrease in Y-BOCS of 10.3.
Overall, this study indicates that severity of OCD decreased during the pandemic compared to pre-pandemic. It may be that patients found it easier to access remote appointments, or perhaps the pandemic environment of being encouraged to stay at home and limiting unnecessary contact may have allowed limited opportunity for exposure. It might be that the pandemic provided a reason for patients to be avoidant of potential contamination thereby leading to a perceived rather than real improvement in Y-BOCS scores.
Identification of specific contributing factors is beyond the scope of this preliminary study, however it will be important to conduct further research with a larger sample size that incorporates post-lockdown and post-pandemic scores to ascertain whether trends seen here are in fact maintained when normal social contact resumes.
Obsessional slowness in OCD is a rare phenomenon on which there is minimal published literature. This is a particularly severe and atypical case of early onset OCD with extreme obsessional slowness and mutism. To the best of our knowledge, there have been no reports of similar severity published in this age group. This report seeks to provide discussion of important organic causes that may need to be considered as well as information on treatment approach.
An 18-year-old male was admitted to the National OCD Unit, Springfield Hospital with a history of autism and normal development until the age of 14, after which symptoms of OCD with fear of contamination emerged, followed by progressive motor slowness and mutism.
Due to the severity of OCD and self-neglect he had two previous admissions to CAMHS wards and required a course of ECT to treat catatonic symptoms age 17.
Pharmacological treatment has included Aripiprazole 5 mg and Fluoxetine 60 mg, which the patient was taking at admission. The latter was subsequently switched to Sertraline 250 mg and Aripiprazole increased. As it was hypothesized that his obsessional slowness stemmed from severe levels of anxiety, Buspirone was also added.
Therapy has been intensive, although communication difficulties have made targeting specific fears challenging as the exact nature of the intrusive thoughts remains unclear.
Following combined neurology and neuropsychiatry review, the patient spent four weeks in a general hospital for further investigation as it was initially felt an organic cause was likely. Initial differentials included Juvenile Onset Parkinson's or Wilson's disease. Both were subsequently ruled out and despite multiple investigations, no obvious organic cause was found. A markedly abnormal FDG PET scan showed findings usually seen in advanced dementia, but not necessarily clinically correlating to his current presentation.
The OCD unit have continued to provide intensive input and tailored treatment programme, encouraging actions against any rules he has in place. Prompting and pacing, verbal exercises and regular stretching exercises due to stooped posture which he attributed to needing to obey certain rules have been used.
It is important for clinicians to be aware of obsessional slowness in OCD and this report highlights a particularly rare and severe example in a young adult who has been difficult to treat. Organic causes may need to be considered and MDT approach to treatment is essential.
Neuropsychological, neuroimaging, and genetic studies have demonstrated the biological underpinnings of attention deficits hyperactivity disorder (ADHD). These studies have correlated deficits in executive functioning, response inhibition and planning with specific regions of the brain. The multimodal treatment study (MTA) study randomized participants to intensive behavioral therapy, pharmacotherapy with systematically delivered methylphenidate, a combination of the two, or standard community care. The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameters for ADHD published in 2007 combine short- and long-term empirical evidence with expert opinion from pediatric mental health researchers and clinicians. A meta-analysis of atomoxetine and stimulant studies revealed a robust effect size for atomoxetine and the stimulants, both of which are currently approved by the food and drug administration (FDA) for the treatment of ADHD. In the interim, appropriate diagnosis, informed prescribing, clinical monitoring, and collaborative treatment planning can all help to optimize outcomes in ADHD management.
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