OCD Comorbidity: Anxiety, Depression, ADHD, & More

What Is OCD?

Obsessive compulsive disorder (OCD) consists of obsessive thoughts that are intrusive and recurring and can create unwanted images that trigger anxiety or negative emotions even when there is no evidence of anything wrong or bad happening in the moment. 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 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 number of times, or sitting home until the loved one returns.

Common obsessive thoughts of OCD consist of:

• Fear of harming themself or others (Harm OCD)
• Fear of contaminating themself or others (Contamination OCD)
• Having to be morally or religiously perfect (Scrupulosity OCD)
• Checking that they don’t have same-sex attraction (HOCD)
• Fearing that they’re in the wrong relationship (Relationship OCD)
• A sense of incompletion that causes repetitive behaviors or being stuck in place until the “right” feeling is achieved (Just right OCD)
• 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 someone has at least two mental health disorders. For example, someone with OCD may also have ADHD. Comorbid disorders may exist independently or interact with each other, enhancing the complications of the other. 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 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 anxiety, specific phobias, and post-traumatic stress disorder.

Other common comorbidities include:²

• Mood disorders (63%), particularly major depressive disorder (41%)
• Impulse control disorders like ADHD (56%)
• Substance use disorders (39%)

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.

Treatment for Comorbid OCD & Depression

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 involves 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 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:

• Distractibility
• Hyperactivity
• Impulsivity
• Difficulty focusing
• Forgetfulness
• Short attention span
• Fidgeting
• Irritability
• Anger
• Anxiety
• Boredom
• Excitement
• Persistent repetition of words or actions
• Absent-mindedness

Similarities between OCD and ADHD include symptoms such as:

• Distracted by stimuli in the environment
• Inattention
• Interference with school or work performance
• Anxiety

Treatment for Comorbid ADHD & OCD

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)

Anxiety disorders such as GAD, panic disorder, and specific phobias are found in 5 -35% of people with OCD.⁶ 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 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
• Dizziness
• Dry mouth
• Sweating
• Tingling sensations
• Nausea
• Shaking
• Feeling disoriented

Common to both OCD and panic disorder 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.

Treatment for OCD & Panic Attacks

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 diagnosable case of generalized anxiety disorder.⁵

Those with GAD and OCD may worry more than usual over important life factors such as:

• Finances
• Work
• Health
• Family and friend relationships

People with generalized anxiety 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 a common comorbidity.

Treatment for Comorbid PTSD & OCD

When designing a treatment plan for comorbid OCD and PTSD, appropriate exposure therapy 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.

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
• Mindfulness

OCD & Eating Disorders

OCD can co-occur with eating disorders, most commonly anorexia and body dysmorphia. Between 15-18% of people with an eating disorder had comorbid OCD, with anorexia accounting for the higher end of the scale.⁸

OCD & Anorexia

Anorexia nervosa involves an obsessions that someone’s body is too large, and therefore the person severely limits their food intake in dangerous ways. The common themes between the two disorders are rigid thinking and rules, hyper-awareness of details, and a need for control.

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

Anorexia Misdiagnosis in Those With OCD

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.

OCD & Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is an obsessive preoccupation with an imagined defect of one’s appearance. It involves 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 of their body.

The common factors of OCD and BDD are:

• Obsessive preoccupation with the triggering stimuli
• Repeated 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 will 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:

• Feeling that things are not just right or incomplete
• Rigidity
• Need for control
• Need for order
• Attention to detail
• Fear of making mistakes
• Trouble asking for help
• Problems with decision-making
• Repeating
• Information hoarding
• Difficulty engaging in leisure activities

Treatment for Comorbid OCPD & OCD

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 & 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 include:

• Higher severity of symptoms
• 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 include:

• Having a regular wake-up and bedtime routine
• Staying gainfully busy with vocational, social, and leisure activities
• Learning and practicing stress management strategies
• Learning and practicing assertiveness skills through assertiveness training for effective communication and to reduce people-pleasing behaviors
• Engaging in regular physical activity
• Keeping a healthy diet

How to Find Help for OCD & Comorbid Disorders

Fortunately, similar cognitive and behavioral techniques and medications are consistently recommended for treating OCD and common comorbid conditions. General talk therapy 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, like acceptance and commitment therapy (ACT).

Most experienced therapists who conduct ERP will be familiar with the different issues and interventions required for successful treatment. Those interested in therapy can explore finding 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 use online psychiatrist services to find a psychiatrist who can help provide you with medication treatment to support your recovery through therapy better without leaving your home.

Final Thoughts

OCD and comorbid disorders are challenging to have but are typically 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!