key: cord-0851590-ph35nh1j
authors: Fineberg, Naomi A.; Pellegrini, Luca; Burkauskas, Julius; Clarke, Aaron; Laws, Keith R.
title: Individual obsessive-compulsive traits are associated with poorer adjustment to the easing of COVID-19 restrictions
date: 2022-01-18
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2022.01.029
sha: 48abd6647fcf7dda7193e2a1cbd1dd8f3040d170
doc_id: 851590
cord_uid: ph35nh1j

BACKGROUND: As COVID-19 restrictions ease, the public are expected to relinquish previously enforced safety behaviors and resume a more normal lifestyle. Despite these aims, our recent survey of 438 adults from the general population, during a temporary release of lockdown in the United Kingdom (July–November 2020), showed that 25% of the public find re-adjustment problematic. This was especially the case in those with a history of mental disorder and obsessive-compulsive (OC) traits and symptoms, including rigidity as measured by a neurocognitive test of attentional flexibility. To aid in identifying those most at risk, we performed a secondary analysis on the data to determine which specific OC traits were related to specific aspects of behavioral adjustment. METHODS: Correlational and multiple regression analyses were performed to determine associations between the eight individual personality traits constituting DSM-5 Obsessive-Compulsive Personality Disorder (OCPD), as measured by the self-rated Compulsive Personality Assessment Scale (CPAS) and a range of self-rated Post-Pandemic Adjustment Questionnaire items. RESULTS: Three items on the Post-Pandemic Adjustment Questionnaire correlated with individual CPAS items: ‘General difficulties adjusting’ correlated with perfectionism, preoccupation with details, over-conscientiousness and need for control; ‘social avoidance’ correlated with perfectionism and preoccupation with details; and ‘disinfecting behaviors’ correlated with preoccupation with details and miserliness (Pearson's r - all p < .001). Intriguingly, none of the adjustment items correlated significantly with self-rated rigidity. CONCLUSIONS: Several OCPD traits predict post-pandemic adjustment difficulties, but perfectionism and preoccupation-with-details showed the most robust correlations. These traits constitute a platform for the development of new screening and interventional strategies aimed at restoring public mental health and wellbeing. Cognitive rigidity may be more reliably evaluated using an objective form of assessment.

1 Background 1 July 19 th, 2021 saw the lifting of legal enforcements concerning the majority of United 2 Kingdom restrictions mandated by the Government during the height of the COVID-19 3 pandemic (BBC, 2021) . Although unpredictable changes in levels of restriction and control are 4 still expected for the foreseeable future (The Guardian, A & B, 2021) , the UK public is 5 gradually being incentivized to return to the work-place, based on a need to reinstate vital 6 public services such as health and education, support the UK economy, and restore public 7 mental health and psychosocial wellbeing (Chadha, J., 2021) . Nevertheless, the ease with 8 which the public adjust to more normal behavior patterns, such as sharing closed spaces with 9 others on public transport or in the office environment, remains to be seen. 10 11 Converging evidence suggests that the COVID-19 pandemic has had a major negative impact 12 on overall public mental wellbeing (Knolle et al., 2021) . Population surveys have, for example, 13 identified moderate rates of adjustment reaction to the onset of the pandemic, ranging from 7 14 to 14% (Tian et al., 2020; McGinty et al., 2020; Liu et al., 2020) . The effect of the easing of 15 restrictions on mental health and wellbeing however has not been well studied. Lack of clarity 16 about the safety regulations has been cited as causing difficulties for the public, in terms of 17 adherence to the rules in the early stages of the pandemic and latterly in terms of adjusting to 18 their relaxation (The Guardian, B, 2021) . 19 20 Our recently published study (Fineberg et al., 2021) conducted between July and November 21 2020, as the first wave of easing of restrictions was implemented in the UK, is the only 22 published study to date investigating mental health difficulties experienced by the public in 23 response to the easing of lockdown restrictions. We surveyed a large adult UK population-24 based sample online, timed to coincide with changes in social-distancing rules (July-Sep 2020). 25

We obtained cross-sectional measures of the frequency and severity of adjustment difficulties 26 and associations with specific obsessive-compulsive (OC) traits and symptoms, finding that 27 one-in-four reported significant adjustment difficulties. 28 29 On mediation analysis, we showed that both OC symptoms (measured using the Compulsive Inventory Revised; OCI-R (Foa et al., 2002) ) and OC personality traits (measured 31 using the Compulsive Personality Assessment Scale; CPAS (Fineberg et al., 2007) ) acted as 32 indirect predictor variables of adjustment, though in different ways: OC symptoms 33 significantly predicted adjustment acting via depressive, anxious and stress symptoms 1 (measured through the Depressive, Anxiety, Stress Scale 21 (DASS-21) (Lovibond & 2 Lovibond, 1995) and via Covid-related anxiety (Covid Anxiety Scale (Chandu & Pachava, 3 2020)), whereas OC personality traits significantly predicted adjustment via depressive, 4 anxious and stress symptoms only. 5 6 'Poor-adjusters' also showed evidence of greater cognitive inflexibility on the intra-extra-7 dimensional set-shift task (Intra-Extra Dimensional Set Shift (IED) task: Robbins et al., 1998). 8 Moreover, higher than expected rates of OC symptomatology were found in study participants 9 with no prior history of mental disorder. Taken together, these findings expose mental health 10 inequalities among the public in terms of their ability to flexibly adapt and return to a more 11 normal lifestyle. While many members of the wider public are likely to be affected, those 12 whose psychiatric conditions (OC related) have been exacerbated by the pandemic and show 13 increased levels of rigidity, will struggle more than most as pandemic restrictions ease. 14 15

Several factors indicate that individuals with OC personality traits (cautious, rule-bound, 16 habitual, rigid), representing around 6% of the general population (Marincowitz et al., 2021; 17 Burkauskas & Fineberg, 2020), might be expected to find adjustment particularly difficult 18 during this transition phase, especially considering the ongoing uncertainty about the risk of 19 infection at an individual level. People with obsessive compulsive personality disorder (OCPD) 20 are defined by rigid and stubborn behaviours and show cognitive inflexibility on objective 21 neurocognitive testing (Fineberg et al., 2015) . Indeed, the disorder is characterized by a 22 pervasive preoccupation with orderliness, perfectionism and control of a degree that impairs 23 psychosocial functioning. As the official rules are relaxed, and members of the public start to 24 behave in more idiosyncratic ways, we might expect people with OCPD, who are likely to have 25 followed the rules conscientiously during the lockdown, would experience stress-related 26 symptoms. Indeed, based on the clinical experience of working in a UK NHS service treating 27 patients with OCPD, some of the authors (NF, LP) have come across several such patients 28 describing greater difficulty leaving home now the rules have been relaxed, owing to various 29 factors including disagreement with and rejection of the decision to change the rules and 30 uncertainty about how they and others should behave. 31 32 Diagnostic efficiency statistics (sensitivity, specificity, positive and negative predictive power) 33 suggest that four of the eight available DSM-5 OCPD traits, comprising perfectionism, 34 reluctance to delegate, preoccupation with details and rigidity may represent the most reliable 1 indicators of the disorder, though some debate remains (Haigler & Widiger, 2001; De Fruyt et 2 al., 2006; Fineberg et al 2007) . As OCPD as a construct is judged to be relatively stable across 3 the lifespan (Fineberg et al., 2007) , these traits carry the potential for predictive value, 4 compared to state makers such as OC symptoms. Considering our prior work, we hypothesized 5 that these core OCPD traits would be disproportionately associated with difficulties flexibly 6 re-adjusting. 7 8 Aims and Objectives 9

By identifying the specific OC traits most associated with adjustment difficulties among adult 10 members of the general public, we aimed to establish a platform for the development of new 11 screening and interventional strategies, as a step toward restoring public mental health and 12 wellbeing. including questionnaires about lifestyle, Covid-19 safety behaviors and OC traits was 24 completed by a broad spectrum of the general population aged 18 years or over, recruited via 25 advertisement on the Internet. The study ran from 16/07/2020 to 13/10/2020, during which 26 period pandemic restrictions were partially eased; schools, universities and high street shops 27 re-opened and people were allowed to travel and mix socially, albeit with some limitations. 28

Diverse groups were targeted including those living with anxiety and OCD, to facilitate 29 appropriate representation of minority and neglected groups disproportionately affected by the 30 pandemic. No reward was offered to participants. The survey gathered demographic and clinical details: age, gender, racial-ethnic group, 1 education level, occupation, living status, whether they (or family members) had contracted 2 Covid-19, whether someone close had died of COVID-related illness, the extent to which the 3 participants followed government guidelines for 5 We also obtained a subjective measure of the extent to which the person was experiencing 6 adjustment difficulties to the release of lockdown and lifting of restrictions, using the Post-7

Pandemic Adjustment Questionnaire -a series of seven likert-type statements (see Table 1 ). 8

The Post-Pandemic Adjustment Questionnaire is a 7-item self-rated tool developed by our 9 group specifically for this study as no other template for this purpose exists. The scale is first 10 described in the initial report of this study (Fineberg et al., 2021;  were defined as those who agreed or completely agreed with the Post-Pandemic Adjustment 2

Questionnaire statement "I am having great difficulty adjusting to the easing of the Covid-19 3 pandemic restrictions", while good-adjusters (n=219) were identified as those who disagreed 4 or completely disagreed with the same item. Ninety-five individuals endorsed 'neither agree 5 nor disagree' and were designated 'indeterminate-responders' and were excluded from the 6 comparative analysessee Table 2 below). 7 8 First, using two-tailed Student's t-test for continuous variables and Fisher's χ2 test for 9 categorical and nominal variables, we compared poor adjusters vs. good adjusters on the 10 measured socio-demographic characteristics and total scores on the CPAS. This comparative 11 analysis was conducted in order to investigate possible significant differences between the two 12 groups and identify those variables that might play a role in re-adjustment. 13 14 Next, Pearson correlation analysis was used to examine associations between individual CPAS 15 items with all the different items on the Post-Pandemic Adjustment Questionnaire. All 16 variables found to be statistically significant (p < .001) at this stage of analysis were then 17 included in a series of multiple regression analyses, performed to determine if the sum of the 18 specific CPAS items that were previously found to show a significant correlation in the Pearson 19 correlational analysis (independent variables or predictors), predicted adjustment problems 20 (dependent variables or outcomes) more precisely compared to the total score of the scale. We 21 examined scatterplots of residuals to check the assumptions of the regression analysis: 22 normality, linearity, and homoscedasticity. The variance inflation factor (all <1.2) and 23 tolerance statistic indicated no problem with multicollinearity. 24 25

Characteristics of the 438 participants are displayed in Table 2 . The majority of the participants 27 (n=325: 74%) were women; most were either employed (n=338; 77.2%) or studying (n=55; 28 12.6%). The mean age was 37 years (SD=14). Compared to good-adjusters, poor-adjusters 29 were younger (p<.01), had a higher degree of adherence to the government rules (p<.001) and 30 had higher CPAS total scores (p<.001). 31 32 J o u r n a l P r e -p r o o f 1 Pearson correlation analyses showed that several CPAS items correlated significantly with the 2 following specific items on the Post-Pandemic Adjustment Questionnaire: general difficulties 3 in adjustment; avoidance; disinfecting behaviors (Pearson's r, all p's < .001) (Table 3) . 4 5 General difficulties adjusting correlated (Pearson's r, all p's <.001) with perfectionism, 6 preoccupation with details, over-conscientiousness and need for control (CPAS items 2, 1, 4 7 and 5, respectively); social avoidance correlated with perfectionism and preoccupation with 8 details (CPAS 1 and 2); disinfecting behaviors correlated with preoccupation with details and 9 miserliness (CPAS items 2 and 7). 10 11 No significant correlation was found between any other CPAS items and any other measures 12 on the Post-Pandemic Adjustment Questionnaire. No significant correlation emerged between 13 adherence to government guidance and any CPAS items. 14 15 Table 3 about here  16   17 Multiple regression analyses (Table 4) showed how the models (adjusted β-weights and p-18 values) including only the scores of the specific CPAS items showing a significant correlation 19 on the Pearson analysis (independent variables) explained a significant amount of the variance 20 (R 2 ) and had a strong relationship (adjusted β-weights) with the adjustment problems. N.B. In 21 running these regression models, we controlled for age, as the only sociodemographic factor 22 statistically significantly differentiating between poor-adjusters and good adjusters in the initial 23 categorical analysis, and therefore as another potential factor affecting adjustment. 24 25 

Our findings describe the impact of individual OC traits on specific aspects of post-lockdown 29 adjustment. Our a priori hypothesis was validated in so far as three of the four core OCPD traits 30 were identified as risk factors for impaired adjustment. Of these, perfectionism and 31 preoccupation with details were the traits showing the strongest relationship with adjustment, 32 as they each significantly correlated with more than one item on the Post-Pandemic Adjustment 33 J o u r n a l P r e -p r o o f Questionnaire. Perfectionism was associated with general difficulties in adjustment and 1 avoidance, while preoccupation with details was related to avoidance and disinfecting 2 behaviors. Individuals with perfectionism might be expected to show difficulty tolerating the 3 relaxation of societal rules governing safety and continue to avoid social activities owing to the 4 ongoing uncertainty and the perceived incompleteness and inconsistency of the information 5 they have received about risks. In contrast, those with preoccupation with details, rules, lists 6 and so on, possibly reflecting poor "central coherence" (Gadelkarim et al., 2019) , might be 7 expected to value more and therefore hold onto, previously reinforced rules around safety-8 behaviours, such as washing and disinfecting. 9 10 Other OC traits bearing a relationship with one aspect of adjustment included over-11 conscientiousness and need for control, which were also associated with general adjustment 12 difficulties. Individuals with these traits might be expected to struggle as they feel a strong 13 sense of duty to act well and thoroughly; and are sensitized to and unduly distressed by any 14 inconsistency or inadequacy in the ways other people behave and over which, they are unable 15 to exert personal control. Interestingly, however, whereas we might have expected those with 16 conscientiousness or rule-bound traits to adhere more thoroughly to government guidance 17 during the pandemic, our analysis did not confirm this relationship. Therefore, whereas 18 adjustment was associated with rule-adherence across the whole study sample, adherence did 19 not appear to explain the specific relationship between OCPD and adjustment. The absence of 20 a relationship between OCPD and adherence to government guidance is to some extent a 21 counterintuitive finding, as it might be expected that perfectionist, detail-focused traits would 22 result in stricter adherence to statutory guidance, and thereby confer adaptive advantage in 23 terms of greater protection against infection during the pandemic itself. Our findings raise the 24 intriguing possibility that OCPD traits do not in fact confer such an advantage or an adaptive 25 profile for adherence to government guidance and COVID-19 rules. 26 27 Intriguingly, miserliness, a somewhat controversial diagnostic criterion for OCPD (Fineberg et 28 al., 2007) , was significantly associated with the maintenance of disinfecting behaviors. 29

Miserliness may represent an alternative and 'literal' behavioural marker of inflexible ways of 30 thinking and behaving, and therefore may be easily recognized and endorsed by participants 31 with rigid behavioural styles. However, unexpectedly, rigidity was not among those personality 32 traits associated with adjustment problems. This was unexpected, given that we (Fineberg et al 33 2021) had previously found that poor adjustment was linked to rigidity as assessed using an 34 J o u r n a l P r e -p r o o f objective cognitive task (IDED task, Robbins at al., 1995) . A failure in meta-cognition 1 associated with lack of personal insight into being rigid or stubborn has been reported in people 2 with OCPD (Oltmanns et al., 2005) . Therefore, one possibility is that people may have had 3 difficulty recognizing the trait of cognitive rigidity in themselves and underscored this item on 4 the self-rated version of the CPAS. Our results suggest that in future studies, rigidity might be 5 better assessed using either clinician-rated scales or objective cognitive tasks rather than self-6 assessment. 7 8 As around one quarter of the adult public are struggling to adjust (Fineberg et al., 2021), these 9

findings are likely to have public health implications. Our findings suggest that personality 10 traits play an important role in determining who will develop adjustment problems, regardless 11 of the degree of prior adherence to the safety rules. Greater awareness of the difficulties that 12 some sections of the public are experiencing in adjusting and the health inequalities 13 underpinning these difficulties is important, considering the expectation that many sections of 14 the public will have to return to in-person activities at some point (BDBF, 2021). These OCPD 15 traits may therefore constitute a platform for the development of new screening and 16 interventional strategies aimed at restoring public mental health and wellbeing as we recover 17 from this pandemic. Moreover, as lifelong traits, they are likely to carry predictive value for 18 adjustment in the case of future similar critical life events. 19 20 By recognizing and identifying those individuals most at risk, public and occupational health 21 policy may be adapted, and timely interventional strategies developed and adopted, e.g., 22

psychoeducation, guided self-help, reasonable workplace adjustments such as graduated return, 23 etc., before adjustment problems become chronic and entrenched. Employees routinely 24 undergo psychological assessment to detect traits of relevance to occupational performance. 25

As in-person working is re-established, employers could pay attention to the presence of these 26 specific OCPD traits to identify those employees likely to find it harder to re-adjust to previous 27 working habits, and who could therefore benefit from specific assistance and support. 28

However, it should be pointed out that OCPD has to date received relatively little research 29 attention and no evidence-based treatment exists. Therefore, this work also draws attention to 30 the need for new investigation of interventional strategies for OCPD (Marincowitz etl., 2021) . Admittedly, only a modest proportion of the variance in adjustment can be attributed to the 1 OCPD traitsaround 4-6%; however, this is contextualized by the fact that any variance can 2 be explained using so few items to predict very specific single item adjustment outcomes. 3

Indeed, while the amount of variance explained might on the face of it seem quite small, the 4 regression values correspond to Cohen's d values of somewhere between 0.40 to 0.50. In 5 considering the clinical importance of these effect sizes, it should be recognized that sometimes 6 even small effects can have significant implications. It may be, for example, that such an effect 7 accumulates with (or interacts with) other factors not yet tested. Moreover, it is thought likely 8 that the overall tendency to adjust well or not will be multifactorial and consist of many small 9 cognitive and behavioral 'nudges' (none necessarily large). This finding suggests that existing 10 OCD-like traits represent one such 'nudge'. Replication of this finding in another study would 11 be welcome. 12

Importantly, these traits are not likely to occur as a consequence of the Covid-19 pandemic, 13 but instead represent relatively stable, pre-existing risk factors and thus may not be readily or 14 immediately amenable to simple educational interventions in the opposite direction (e.g., by 15 governments and advisors offering health advice). 16

We nevertheless believe that it could be useful and feasible to screen for these OCPD traits 17 (though our study is not designed to address this point), as the CPAS scale consists only of 8 18 items and can be used as a self-rated instrument. For whom and in which contexts screening 19 should take place, is a very interesting question that would need careful consideration and to 20 be based on empirical evidence. For example, assessment for OCPD could possibly be readily 21 incorporated into occupational health assessment for those struggling to return to work. 22

Another limitation of our cross-sectional design is that we are unable to confirm the direction 23 of causality i.e., whether OCPD traits result in problems adjusting. Although OCPD as a 24 construct is thought to be reasonably stable across adulthood, there is also evidence that specific 25 traits may change over time (Nestadt et al., 2010) . It is therefore possible that the stress of the 26 pandemic and the current post-lockdown situation might have triggered or exacerbated OCPD 27 traits, that only became evident on testing afterward. 28 29

Of the wide range of OCPD traits predicting problems adjusting post-pandemic, perfectionism 31 and preoccupation with details showed the most robust correlations. These traits constitute a 32 platform for the development of new screening and interventional strategies aimed at restoring 1 public mental health and wellbeing. Cognitive rigidity may be more reliably evaluated using 2 an objective form of assessment. 3 Participants were asked to choose one of the following 5 alternative responses for each statement: Completely disagree, disagree, neither agree nor disagree, agree, completely agree. Scores on the responses were allocated from completely disagree = 1 to completely agree = 5). J o u r n a l P r e -p r o o f .14(.003) Note: Pearson's r (p); significance set at <0.001. 

Cohen's f² = 0

Cohen's f² = 0

Adjusted β-weights (and p-values) obtained by multiple regression analyses (enter method) computed for the association between CPAS and adjustment behaviors, while controlling for age

Wellcome Trust; she has accepted travel and/or hospitality expenses from the BAP, ECNP, RCPsych, CINP, International Forum of Mood and Anxiety Disorders, World Psychiatric Association, Indian Association for Biological Psychiatry, Sun; she has received payment from Taylor and Francis and Elsevier for editorial duties. In the past 3 years, she has accepted a paid speaking engagement in a webinar sponsored by Abbott. Previously, she has accepted paid speaking engagements in various industry supported symposia and has recruited patients for various industry-sponsored studies in the field of OCD treatment. She leads an NHS treatment service for OCD. She holds Board membership for various registered charities linked to OCD

The authors wish to acknowledge the International College of Obsessive-Compulsive Spectrum Disorders (www.ICOCS.org) and the European College of Neuropsychopharmacology (ECNP) Obsessive-Compulsive and Related Disorders Research Network (OCRN), who have contributed to the development of this article through network opportunities. This publication is based upon work from COST Action CA16207 European Network for Problematic Usage of the Internet, supported by COST (European Cooperation in Science and Technology), www.cost.eu.