Obsessive‐compulsive disorder (OCD) is characterized by unwanted and distressing thoughts, images or urges (obsessions) and repetitive behaviors or mental acts that aim to decrease the resulting distress or according to rigid rules (compulsions; APA, 2013). Different studies suggest OCD to affect up to 3.1% of the general population and to be associated with substantial disability and decreased quality of life (Fontenelle, Mendlowicz, & Versiani, 2006; Ruscio, Stein, Chiu, & Kessler, 2010). One of the main clusters of symptoms of OCD involves fear of contamination and washing compulsions (Stein et al., 2019). Individuals with OCD and fear of contamination may spend hours worrying about the possibility of contacting an infections illness, avoiding potential contaminants (such as not touching certain surfaces or decreasing social contacts), and/or engaging in compulsive washing behaviors of different sorts (such as taking excessively long showers or spending hours washing or disinfecting hands, and not rarely, harming their skin). Often, these behaviors have a very ritualistic character and are not difficult to diagnose by a mental health professional, as individuals feel the need to follow a specific sequence of actions which may need to be repeated a certain number of times, such as washing first the fingers, then the space between the fingers, then the wrists, hands, and so forth.

Given the recent coronavirus disease (COVID‐19) pandemia declared by the World Health Organization, the unprecedented contagiousness and uncontrollability of an infectious illness in modern times, the enormous preoccupations of the general public (which has been exposed to often scary news through the media) and the explicit recommendations by the health authorities on how to deal with its potential threats (including washing hands frequent and avoiding physical contact with other people and specific surfaces), which often overlap in “appearance” with OCD symptoms, it is important for mental health professionals to think about the potential impact of COVID‐19 in their practice. In this regard, we believe that the implications of the COVID‐19 for the field of OCD and related disorders to be particularly relevant. First, there might be an increased number of individuals affected by OCD and fear of COVID‐19 infection in the next few months or even years. Whether this will be restricted to individuals “at risk” for OCD that would be unlikely to develop OCD if not exposed to such infectious threat, is an important question to ask. Second, one needs to reflect on the diagnostic threshold for OCD, that is, if an excessive washing behavior is endorsed by health agencies, should we reconsider how we should diagnose OCD? Can we rely on a specific diagnostic feature other then time, distress, or impairment (APA, 2013)?

Third, it is important to reflect upon the impact of the COVID‐19 pandemic on existing OCD cases, which may change their phenotype and the focus of their main preoccupations. For instance, individuals with OCD that used to fear contamination with human immunodeficiency virus or tuberculosis may now be worried about the coronavirus in addition to having greater hand washing compounded by increased avoidance. By extension, individuals with OCD who are afraid of having an illness (i.e., those with somatic obsessions), rather than being contaminated, may now dread having an undiagnosed coronavirus infection, while others may now fear contaminating others by spreading COVID. In addition, this threatening environment may facilitate the recurrence of symptoms in remitted patients with OCD.

Fourth, it has become apparent that recommendations of OCD experts on how to treat fear of contamination (e.g. exposure and response prevention) may clash with health agency advices being advertised everywhere. For instance, to deal with the COVID‐19 threat, the CDC site (CDC, 2020) now recommends the population: to “clean and disinfect frequently touched surfaces daily”; “if soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol; and “cover all surfaces of hands and rub them together until they feel dry.” These endorsements may have a huge impact on patients with OCD. Note that, while we understand these measures, dealing with these recommendations on the daily clinical practice will be challenging.

Therefore, a relevant question involves how mental health professionals should adjust their discourse to their patients with fear of contamination during this specific period of coronavirus dissemination. Exposure to excessive fears of getting an infection while preventing hand washing is the leading treatment for OCD with contamination and washing compulsions (Abramowitz, Blakey, Reuman, & Buchholz, 2018). However, how can we determine how much washing is enough during the COVID‐19 pandemic surge? While the answer might be within ourselves (as we should not ask patients to do unreasonable things that we would not be willing to personally do), this can be obviously tricky, and it is likely that a number of ambiguous situations will emerge in clinical practice.

A recent consensus paper by the International College of Obsessive‐Compulsive Spectrum Disorders recommended pharmacotherapy as the first option for OCD patients with contamination fears and washing compulsions during the pandemia. (Fineberg et al., 2020) It further indicated that, for safety reasons, in vivo cognitive‐behavioral therapy with exposure and response prevention (ERP) may need to be substituted by imaginal exposure. (Fineberg et al., 2020) By the same token, we also feel that the pandemia provides increased room for testing the role of ERP delivered thought new technologies, such as virtual reality (Ferreri et al., 2019). Given the importance given to pharmacotherapy, another topic of concern is drug interactions of experimental drugs for COVID‐19 and medications prescribed for patients with OCD. A search on one database of drug interactions of experimental agents used in the treatment of COVID‐19 (University_of_Liverpool_Drug_Interactions_Group, 2020) suggests that atazavir, lopinavir/ritonavir, and cloroquine/hidroxicloroquine all seem to have potential for drug interactions with SRIs and antipsychotics (particularly quetiapine and pimozide), the most widely used drugs for OCD.

One could argue that the inevitability of a coronavirus infection, estimated to affect up to 70% of the globe, could work as some sort of massive flooding, leading to decreases, rather than increases in OCD symptom severity. This is unlikely though, as there are many other alternative “themes” for people with OCD to worry about. Finally, despite these potential stressors to individuals with OCD or “at risk” to developing OCD, could COVID‐19 outbreak also be an opportunity to show to our patients the adaptive and protective factor that means having OCD? Do people with OCD and fear of contamination will be less frequently infected and contribute, with social distance or avoidance behaviors, to diminish the spread of the virus due to the specific features of their phenotypic expression? By putting these facts in the context of an evolutionary perspective (Feygin, Swain, & Leckman, 2006), we can contribute to diminish stigma associated with the disorder and explain the nature of some OCD symptoms as behaviors that can be adaptive in certain periods of history when we do not have more effective ways to combat an infection.

In conclusion, given the unparalleled contagiousness of the coronavirus, maybe we will need to reframe our orientation to our OCD patients with predominant fear of contamination and washing rituals to explain the rationale of anti‐OCD treatments to current and future individuals with OCD.

强迫症 (OCD) 的特征是不想要的和令人痛苦的想法、图像或冲动（强迫观念）以及旨在减少由此产生的痛苦或根据严格的规则的重复行为或心理行为（强迫症；APA，  2013 年）。不同的研究表明，强迫症会影响高达 3.1% 的普通人群，并与严重的残疾和生活质量下降有关（Fontenelle、Mendlowicz 和 Versiani，  2006 年；Ruscio、Stein、Chiu 和 Kessler，  2010 年）。强迫症的主要症状之一涉及对污染和洗涤强迫的恐惧（Stein 等人，  2019）。患有强迫症和害怕污染的人可能会花费数小时担心接触感染疾病的可能性，避免潜在的污染物（例如不接触某些表面或减少社交接触）和/或从事不同类型的强迫性洗涤行为（例如淋浴时间过长或花费数小时洗手或消毒双手，而且经常会伤害他们的皮肤）。通常，这些行为具有非常仪式化的特征，并且不难由心理健康专业人员诊断，因为个人觉得需要遵循可能需要重复一定次数的特定动作顺序，例如先清洗手指，然后是手指之间的空间，然后是手腕、手等等。

鉴于最近世界卫生组织宣布的冠状病毒病 (COVID‐19) 大流行，现代传染病前所未有的传染性和不可控性，公众的巨大关注（通过媒体经常接触到可怕的新闻） ) 以及卫生当局关于如何处理其潜在威胁的明确建议（包括经常洗手和避免与他人和特定表面的身体接触），这些建议通常在“外观”上与强迫症症状重叠，这对于精神卫生专业人员考虑 COVID-19 在其实践中的潜在影响。在这方面，我们认为 COVID-19 对强迫症和相关疾病领域的影响特别重要。第一的，在接下来的几个月甚至几年内，可能会有更多的人受到强迫症的影响并担心感染 COVID-19。这是否将仅限于那些如果不暴露于这种传染性威胁就不太可能发展成强迫症的强迫症“有风险”的个人，这是一个重要的问题。其次，需要反思强迫症的诊断阈值，即如果过度洗涤行为得到卫生机构的认可，我们是否应该重新考虑应该如何诊断强迫症？除了时间、痛苦或损伤（APA、是一个重要的问题。其次，需要反思强迫症的诊断阈值，即如果过度洗涤行为得到卫生机构的认可，我们是否应该重新考虑应该如何诊断强迫症？除了时间、痛苦或损伤（APA、是一个重要的问题。其次，需要反思强迫症的诊断阈值，即如果过度洗涤行为得到卫生机构的认可，我们是否应该重新考虑应该如何诊断强迫症？除了时间、痛苦或损伤（APA、 2013 )?

第三，重要的是要反思 COVID-19 大流行对现有强迫症病例的影响，这可能会改变他们的表型和他们主要关注的焦点。例如，曾经害怕被人类免疫缺陷病毒或肺结核污染的强迫症患者现在可能会担心冠状病毒，除了更多的洗手和更多的避免。通过扩展，那些害怕生病（即那些有躯体强迫症的人）而不是被污染的强迫症患者现在可能害怕感染未确诊的冠状病毒，而其他人现在可能害怕通过传播 COVID 来污染他人。此外，这种具有威胁性的环境可能会促进缓解的强迫症患者症状的复发。

第四，很明显，强迫症专家关于如何治疗对污染的恐惧（例如暴露和反应预防）的建议可能与到处宣传的卫生机构建议发生冲突。例如，为了应对 COVID-19 威胁，CDC 网站 (CDC,  2020 ) 现在建议人们：“每天清洁和消毒经常接触的表面”；“如果没有现成的肥皂和水，请使用酒精含量至少为 60% 的洗手液；并“覆盖手的所有表面并将它们擦在一起直到它们感觉干燥。” 这些认可可能会对强迫症患者产生巨大影响。请注意，虽然我们了解这些措施，但在日常临床实践中处理这些建议将具有挑战性。

因此，一个相关的问题涉及在冠状病毒传播的特定时期，精神卫生专业人员应如何调整他们对担心被污染的患者的话语。在防止洗手的同时过度担心感染是强迫症的主要治疗方法，包括污染和洗涤强迫症（Abramowitz、Blakey、Reuman 和 Buchholz，  2018 年）。但是，我们如何确定在 COVID-19 大流行期间洗多少衣服才足够？虽然答案可能在我们自己身上（因为我们不应该要求患者做我们个人不愿意做的不合理的事情），但这显然很棘手，并且很可能会在临床实践中出现一些模棱两可的情况.

国际强迫症谱系障碍学会最近的一份共识文件推荐药物治疗作为在大流行期间有污染恐惧和洗涤强迫的强迫症患者的首选。(Fineberg et al.,  2020 ) 它进一步表明，出于安全原因，具有暴露和反应预防 (ERP) 的体内认知行为疗法可能需要被想象暴露替代。（Fineberg 等人，  2020 年）同样，我们也认为大流行为测试 ERP 提供的思想新技术（例如虚拟现实）的作用提供了更大的空间（Ferreri 等人，  2019 年））。鉴于药物治疗的重要性，另一个值得关注的话题是 COVID-19 实验药物与强迫症患者处方药物之间的药物相互作用。搜索用于治疗 COVID-19 的实验药物的药物相互作用数据库（University_of_Liverpool_Drug_Interactions_Group，  2020 年）表明，阿扎韦、洛匹那韦/利托那韦和氯喹/羟氯喹似乎都可能与 SRI 和抗精神病药物发生药物相互作用（尤其是喹硫平和匹莫齐特），最广泛使用的强迫症药物。

有人可能会争辩说，估计会影响全球 70% 的冠状病毒感染的必然性，可能会像某种大规模洪水一样起作用，导致强迫症症状严重程度减少，而不是增加。但这不太可能，因为强迫症患者还有许多其他替代“主题”需要担心。最后，尽管对患有强迫症或“有发展成强迫症的风险”的个体有这些潜在的压力，但 COVID-19 的爆发是否也可以成为向我们的患者展示强迫症的适应性和保护性因素的机会？患有强迫症和害怕污染的人是否会较少受到感染和贡献，有社交距离或回避行为，由于其表型表达的特定特征而减少病毒的传播？通过将这些事实置于进化观点的背景下（Feygin、Swain 和 Leckman， 2006 年），我们可以帮助减少与该疾病相关的耻辱感，并将某些强迫症症状的性质解释为在我们没有更有效的方法来对抗感染的某些历史时期可以适应的行为。

总之，鉴于冠状病毒具有无与伦比的传染性，也许我们需要重新定位我们对强迫症患者的定位，这些患者主要担心污染和清洗习惯，以向当前和未来的强迫症患者解释抗强迫症治疗的基本原理。