Many people with obsessive-compulsive disorder (OCD) suffer from having a comorbid condition that adds another level of challenge to their treatment and recovery. While the most common comorbid disorder of OCD is depression, with others including; attention deficit hyperactivity disorder (ADHD); body dysmorphic disorder (BDD); panic disorder (PD); autistic spectrum disorder (ASD); eating disorders (ED); and post-traumatic stress disorder (PTSD). Additionally, obsessive-compulsive personality disorder (OCPD) and borderline personality disorder (BPD) or traits are often comorbid with OCD.
What is OCD?
OCD consists of obsessive thoughts that are intrusive and recurring and can create unwanted images that trigger anxiety or negative emotions even though there is no evidence of anything wrong or bad happening in the moment. The prevalence of OCD is about 2% of the world population. Physical OCD symptoms include compulsions (or rituals) which are any mental or physical attempts to reduce anxiety or negative emotions. Some people can become stuck performing rituals until they achieve a “just right” feeling (such as Just Right OCD) or until the high-stress level begins to subside.
People with OCD understand that their obsessions aren’t rational and that their behaviors do not accomplish their intended purpose. However, they may still engage in them to reduce unwanted feelings. For example, someone with intrusive thoughts about a loved one being harmed may engage in reassuring mental rituals such as, “Nothing bad will happen to my children today,” creating a positive image of the person. Physical rituals may involve calling or texting them to ensure everything is okay, tapping an object a certain amount on a lucky number, or sitting home until the loved one returns.
Common obsessive thoughts of OCD consist of:
- Aggressive/harming/safety (Harm OCD)
- Contamination (Contamination OCD)
- Scrupulosity/moral perfectionism (Scrupulosity OCD)
- Sexual orientation obsessions (not homophobia, but rather about the uncertainty)
- Relationship OCD (Relationship OCD)
- Not-just-right-experiences (no particular obsession but a sense of incompletion that causes repetitive behaviors or being stuck in place until the “right” feeling is achieved)
- Symmetry/exactness (Symmetry OCD)
- Superstitious obsessions (such as special significance to numbers, colors, dates, words, and cultural practices that need to be performed flawlessly)
What is Comorbidity & How Does It Relate to OCD?
Comorbid disorders occur when an individual has at least two mental health disorders. Comorbid disorders may exist independently or interact with each other, enhancing the complications of the other. For example, someone with OCD may also have ADHD. Someone with comorbid OCD and depression may experience improvement in mood when the OCD symptoms are under better control since they interact with each other. Most OCD and comorbid disorders are often related to each other.
Studies have shown that 90% of patients with OCD meet the criteria for at least one other psychiatric diagnosis in their lifetime.1 The most common comorbid mental health diagnoses are other anxiety disorders (76%), including panic disorder, social phobia, specific phobias, and posttraumatic stress disorder. Other common comorbidities include mood disorders (63%), particularly major depressive disorder (41%); impulse control disorders (56%); and substance use disorders (39%).2
OCD & Depression
Between 12-68% of people with OCD reported having major depressive episodes 3. Some people with OCD may have depression symptoms that are secondary to OCD and are often resolved with effective treatment.
Those with OCD that are also depressed may experience the following:
- Persistent low moods
- Lose interest in activities (Anhedonia)
- Disconnection from friends and family
- Feeling worthless
- Feelings of hopelessness
- May have thoughts about self-harm or suicidal ideation
OCD and depression require a differential diagnosis due to similarities observed in both disorders. Obsessive fears and behaviors may result in physical or social isolation to prevent causing harm or any actions that will put a loved one in harm’s way. Such isolation can lead to depression due to being cut off from meaningful relationships, work, or leisure activities that provide pleasure.
Exposure and response prevention (ERP) is the gold standard evidence-based treatment for OCD. It consists of confronting triggers of obsessive thoughts and finding alternatives to performing physical or mental rituals to reduce or avoid anxiety.
Those with OCD can manage their depressive symptoms by using techniques such as:
- Behavioral activation
- Physical activity
- Having a structured schedule
- A consistent sleep schedule
- Actively maintaining social and family relationships
Almost all disorders will benefit from self-compassion therapy which is reframing negative and critical self-talk into how someone would talk to a good friend going through the same difficulty.
Medication for depression and OCD coincidentally use selective serotonin reuptake inhibitors (SSRIs) as their first-line medications prescribed for both disorders.
Common SSRIs are:
- Citalopram (Celexa)*
- Escitalopram (Lexapro)*
- Fluoxetine (Prozac)*
- Paroxetine (Paxil, Pexeva)*
- Sertraline (Zoloft)*
*These medications have a black box warning, the most severe kind of warning from the FDA for the risk of suicidal thoughts and behaviors in certain people. You should talk with your doctor about these risks before starting this medication.
Augmenting medications that can enhance the effect of the SSRIs are:
- BuSpar (Buspirone)
- Risperdal (risperidone)
- Zyprexa (olanzapine)
- Abilify (aripiprazole)
OCD & ADHD
OCD and ADHD are distinct but also comorbid disorders that can share similar symptoms, behaviors, and treatment outcomes. Research reveals abnormal activity in the same brain regions for each condition. OCD is associated with increased activity in frontal and striatal regions, while ADHD is associated with decreased activity in similar areas.
Symptoms of ADHD include:
- Difficulty focusing
- Short attention span
- Persistent repetition of words or actions
Similarities between OCD and ADHD include symptoms such as:
- Distracted by stimuli in the environment
- Interference with school or work performance
Treatment for ADHD will usually combine ERP with cognitive behavioral therapy (CBT) to:
- Identify and reframe cognitive distortions
- Break up tasks into small steps
- Create simple organizational systems
- Strategize for successfully making plans
Medication treatment for ADHD and comorbid OCD can be complex since the stimulants prescribed for treating ADHD often cause the OCD to get worse.
Common ADHD medications are:
- Adderall XR (amphetamine)
- Concerta (methylphenidate)
- Dexedrine (amphetamine)
- Evekeo (amphetamine)
- Focalin XR (dexmethylphenidate)
- Quillivant XR (methylphenidate)
- Ritalin (methylphenidate)
- Strattera (atomoxetine hydrochloride)
*These medications have a black box warning, the most severe kind of warning from the FDA for risk of medication misuse or abuse.
OCD & Anxiety Disorders
Within the anxiety disorders section of the diagnostic and statistical manual of mental disorders (DSM-5), conditions to be considered a type of anxiety include:3
- Obsessive-Compulsive Disorder (OCD)
- Panic Disorder
- Generalized Anxiety Disorder
- Post-Traumatic Stress Disorder (PTSD)
With OCD considered a type of anxiety, it can present itself with other anxiety disorders, increasing the intensity of anxiety symptoms.
OCD & Panic Disorder
Most people have experienced a situational panic attack in their lifetime. Panic disorder (PD) occurs when the physiological system is overtaken by intense fear leading to anticipatory anxiety about suddenly having the next episode, leading them to plan their daily routine to avoid it. People may initially experience a panic attack as coming from “out of the blue,” but when they are caused by pervasive anticipatory and catastrophic thinking, it becomes a disorder.
Many people with panic attacks experience symptoms such as:
- Shortness of breath
- Chest tightness
- Dry mouth
- Tingling sensations
- Feeling disoriented
Common to OCD and PD is experiencing acute anxiety in situations without evidence of a threat. People report panic attacks to occur suddenly, much like people with OCD experiencing sudden obsessive triggers. Both disorders compel reassurance or “coping” behaviors to ensure things are safe and can result in avoidance of triggering situations. The prevalence of PD is 2–25% of the population 4
Typically, panic episodes will occur from catastrophic OCD thoughts about what could happen, such as:
- Fear of losing control
- Fear of having medical or other kinds of emergency
- Fear of being alone without access to help
- A general sense of doom.
Psychological treatment for both OCD and panic attacks is exposure and response prevention. Accepting those symptoms of obsessive thoughts may be part of everyday life, rather than fighting them, takes power away from the fear and paradoxically reduces their occurrence. Diaphragmatic breathwork and using mindfulness to focus on your five senses are highly effective in treating panic symptoms but should not be used in place of ERP for OCD. The medications prescribed for OCD and PA consist of the same SSRIs for depression.
OCD & Generalized Anxiety Disorder (GAD)
We all worry about real-life uncertainties, but about 1–34.6% of the population suffers from a legitimate Generalized Anxiety Disorder.5 Further anxiety disorders such as GAD, panic disorder (with and without agoraphobia), and specific phobias are found in 5 -35% of people with OCD.6.
Those with GAD and OCD may worry more than usual over important life factors such as:
- Family and friend relationships
The symptoms of each anxiety disorder vary in significant ways. However, they all make patients feel extremely nervous and worried. Patients may even know their worries are illogical or disproportionate, but they cannot stop the negative thoughts without treatment.
OCD & Post-Traumatic Stress Disorder (PTSD)
Everyone will have their way of experiencing traumatic events. In some people, it lays dormant, while for others, it overtakes their ability to function or cope with everyday tasks. It has been reported that 30-82% of people who have experienced trauma also have OCD, and 30% of those with primary OCD have had trauma in their lives.7
The common symptoms of OCD and PTSD include:
- Intrusive thoughts (such as OCD and Sexually Intrusive Thoughts)
- Avoiding specific triggers (such as reminders of trauma or obsessions)
- Anxiety and disgust when confronted with triggers
Both disorders can develop as the result of a traumatic event. While OCD and PTSD have significant differences, people who experience trauma may be more likely to develop OCD than their peers, making this common.
Teaching healthy coping skills targeting cognitive distortions works well in treating PTSD and OCD and includes:
- Acceptance of uncertainty about the future
- Taking control over the present moment which the person has control
When designing a treatment plan for comorbid OCD and PTSD, appropriate exposure therapy (or exposure therapy for OCD) should focus on obsessive fear and not trigger the trauma so the person can benefit from treatment rather than be retraumatized. For example, sexual abuse may cause excessive showering, hand washing, or cleaning behaviors to wash away the emotional effects of the trauma. In this case, too much focus on exposure to not being clean may trigger traumatic responses.
OCD & Eating Disorders
OCD & Anorexia
Anorexia nervosa is an obsession with the perception that the person’s body is too fat. Between 15-18% of people with an eating disorder had comorbid OCD, with anorexia accounting for the higher end of the scale.8
Anorexia will usually lead to ritualistic behaviors similar to OCD, such as:
- Calorie counting
- Excessive exercising
- Food restriction
- Ritualistic eating behaviors
- Excessive checking weight on a scale
OCD is commonly known for having dysfunctional eating behaviors that can often lead to misdiagnosis of anorexia. People with OCD may use restricting foods as a punishment for sexual, violent, or religious obsessions. Or they may have problems eating because they fear that others may have contaminated the food they ingest. These obsessions may lead to compulsive rituals around how the food is ordered on the plate, cut, and in what order it is eaten.
The common themes between the two disorders are rigid thinking and rules, hyper-awareness of details, and a need for control.
OCD & Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is an obsessive preoccupation with an imagined defect of one’s appearance. It does not include body image concerns but details about a perceived imperfection that causes extreme distress. Due to excessive up-close mirror-checking episodes, sufferers may develop a distorted image of the particular appearance concern and assume others also will become focused on that detail.
The common factors of OCD and BDD are:
- Obsessive preoccupation with the triggering stimuli
- Checking behaviors (such as body checking)
- Reassurance-seeking from others
- Social avoidance can lead to isolation
- Problems with social and vocational functioning
OCD & Obsessive-Compulsive Personality Disorder (OCPD)
Diagnosing Obsessive-Compulsive Personality Disorder (OCPD) during an active OCD episode is difficult since many overlapping traits exist. Once a specific OCD trigger is under better control, the personality traits will be more evident since they persist after OCD treatment. The prevalence of comorbid OCD and OCPD ranges from 9-27%.9
The criteria for an OCPD diagnosis are:
- Preoccupation or fixation with details, rules, schedules, organization, and excessive thoroughness with list making
- Excessive need for an order
- Perfectionism that interferes with the completion of the task
- Undue and detailed attention to work tasks and productivity
- Difficulty designating tasks to others because they won’t be completed to the person’s satisfaction
- Disconnection from participating in leisure and social activities
Common obsessions and compulsions of both disorders are:
- Need for control (or control issues)
- Need for order
- Attention to detail
- Fear of making mistakes
- Trouble asking for help
- Problems with decision-making
- Checking (seen most in Checking OCD)
- Information hoarding
- Difficulty engaging in leisure activities
While exposure and response prevention is highly effective for getting OCD symptoms under control, therapy for OCPD is a longer-term intervention since obsessive traits are experienced as part of one’s character. The major problem with OCPD is the effect it has on others. A person with OCPD should start to consider therapy when the controlling nature of their personality interferes with their lives and others and when they are ready to commit to change.
Risk factors for Developing OCD or Comorbid Disorders
It is unclear what determines someone with OCD to develop a comorbid disorder. Still, these co-occurring conditions all seem to affect the same brain region, have similar neurochemical activity, and may have a shared genetic component.
Other risk factors considered to have a role in OCD comorbidity are:
- Higher severity of symptoms
- Negative consequences of daily life
- Early onset of a disorder
- Social isolation
- Childhood emotional neglect or physical abuse
- Trauma history
- Perinatal events (such as a damaging event after birth)
- Genetic predisposition for OCD
- Medical problems
- Stressful life events
Other findings reveal that:10
- More people went through treatment for OCD and trauma than for other comorbidities.
- The highest success rate came from those in treatment for OCD and depression.
- Initial decreases in OCD symptoms during intensive exposure and response prevention treatment tended to be followed by intensification of trauma-related intrusive thoughts, PTSD flashbacks, and nightmares.
Quality of Life Living With Comorbid OCD
Comorbid conditions can significantly compromise the quality of life for those suffering from untreated OCD and other disorders. Still, with hard work and effective treatment, people can restore it to healthy functioning. Participating in regular psychotherapy sessions is crucial to maintain recovery and support when life stressors arise.
The best lifestyle changes someone can adopt to manage a dual diagnosis of OCD are:
- Having a regular wake-up and bedtime routine (see Sleeps Impact On Mental Health)
- Staying gainfully busy with vocational, social, and leisure activities
- Learn and practice stress management strategies
- Learn and practice assertiveness skills through assertiveness training for effective communication and reduce people-pleasing behaviors
- Engage in regular physical activity (see Mental Health Benefits for Mental Health)
- Keep a healthy diet
How to Find Help for OCD and Comorbid Disorders
Fortunately, similar cognitive and behavioral techniques and medications are consistently recommended for treating OCD and the mentioned comorbid conditions. General talk or psychotherapy will not sufficiently target the brain “glitch” that ERP and behavioral strategies accomplish. Other helpful augmenting therapies that can be beneficial include developing self-compassion and acceptance and commitment therapy (ACT).
Most experienced cognitive behavioral therapists who conduct ERP will be familiar with the different issues and interventions required for successful treatment. Those interested in therapy can find a therapist using an online therapist directory and review their experience with OCD, trauma, eating disorders, and mood disorders to see if they are right for you. Additionally, you can find online psychiatrists who can help provide you with medication treatment to support your recovery through therapy better.
OCD and comorbid disorders are challenging to have but are very treatable. Finding the right therapist and psychiatrist is key to ensuring the best quality of care. Developing a list of questions to ask your providers will help you to know how to manage your symptoms appropriately. So don’t be shy to ask what experience your mental health professional has had with treating your OCD comorbid disorder and what to expect from the treatment you will receive from them. Fortunately, virtual therapy has provided broader access to providers, making appropriate care available to anyone who needs it!
For Further Reading
- Mental Health America
- National Alliance on Mental Health
- The International Obsessive Compulsive Foundation
- Association for Behavioral and Cognitive Therapies
- Obsessive Compulsive Disorder: Elements, History, Treatment, and Research by Leslie J. Shapiro
- Getting Control: Overcoming Your Obsessions and Compulsions by Lee Baer
- When Once Is Not Enough: Help for Obsessive-Compulsives by Gail Steketee
- The Perfectionist’s Handbook: Take Risks, Invite Criticism, and Make the Most of Your Mistakes by Jeff Szymanski
- The Self-Compassion Workbook for OCD: Lean into Your Fear, Manage Difficult Emotions, and Focus On Recovery by Kimberley Quinlan
- The OCD Stories: Podcast Series
- Podcast/Blog – Therapy & Counseling for OCD & Eating Disorders
- OCD RECOVERY on Apple Podcasts
- 30 Best Obsessive-Compulsive Disorder (OCD) Podcasts You Must Follow in 2023
- 2-Minute Neuroscience: Obsessive-Compulsive Disorder (OCD)
- GGOC: App for OCD Relief