Are OCD and BPD related? Here’s what experts say

If you’re familiar with obsessive-compulsive disorder (OCD) and borderline personality disorder (BPD), you might be aware of some similarities that the conditions can share, at least on the surface: deeply-rooted doubts about oneself and one’s relationships, difficulty tolerating anxiety related to these fears, and lasting damage to relationships and self-esteem.

What explains the potential similarities between the two conditions, and are they related in any deeper way? We spoke with our in-house experts and analyzed for the best available research to learn more. 

What is OCD?

Obsessive-compulsive disorder is a mental health condition characterized by two main symptoms: obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, and urges that cause persistent distress. Compulsions are mental or physical actions performed in response to obsessions to get rid of this distress or to keep unwanted events from happening.

What is BPD?

In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DMS-V TR), personality disorders are defined as “enduring pattern[s] of inner experience and behavior” that conflict significantly with a person’s culture, cause distress, or lead to unhealthy outcomes. These conditions affect many aspects of life and tend to remain stable when left untreated, usually beginning in early childhood or adolescence. 

BPD is one of many personality disorders. It involves a range of symptoms, including:

• Fear of abandonment and efforts to avoid it
• Unstable interpersonal relationships
• Fragile sense of self or self-image
• Impulsivity
• Unstable mood or emotional reactions
• Overly intense anger

Can OCD and BPD be caused by the same things?

There is a wide range of factors that can contribute to the development of both OCD and BPD. With that said, there are, very generally, some common traits or circumstances that might increase the chances that one could develop either condition.

Genetics

Both OCD and BPD appear to be highly heritable. For example, one study found that identical twins generally have about double the risk of having OCD if the other twin has it, compared with non-identical twins. Similarly, one systematic review gave BPD a heritability estimate of 41%. This means that genes alone account for about 41% of why one person has BPD while another doesn’t.

Stress and trauma

Genes rarely work in isolation. Most of the time, environmental factors also contribute to mental health conditions. For example, stress and trauma can contribute to the development of both OCD and BPD. Studies have found that a history of childhood trauma is particularly common among individuals with BPD and that compared to other personality disorders, those with BPD experience childhood trauma more frequently.

Invalidating Environments

A lot of research has gone into the kind of environment or upbringing that can make people more likely to develop BPD. What they have discovered is that there is a strong link between BPD and emotional invalidation. This is when one’s environment, or their parents or caregivers, is dismissive of their emotions. For example, a crying child may be told, “You’re having a crying fit again? Why can’t you just pull yourself together?” Dr. Nicholas Farrell, Regional Clinical Director here at NOCD, explains that “This is how the seeds that are planted from genes might germinate into full-grown borderline personality disorder.”

While there’s no empirical evidence that this type of environment leads to or might exacerbate OCD, Dr. Farrell suggests that it could in theory. He states, “If an emotionally invalidating environment makes someone feel unable to trust and honor their emotional experiences, this can set them up later in life to second-guess their emotional experiences. So it feeds the doubt that often characterizes different forms of OCD and fosters a perceived inability to tolerate that doubt.”

Are people with OCD more likely to have BPD?

The few studies that have investigated the combination of OCD and BPD indicate that people with OCD are more likely to have BPD as well. For example, a recent study found that the prevalence of BPD among OCD patients has been estimated to be around 5%. This is more than three times the overall rate of BPD, which is around 1.4% of the general population. 

Can BPD make OCD worse?

Dr. Patrick McGrath, Chief Clinical Officer at NOCD, notes that BPD tends to have a pretty negative impact on many parts of a person’s life. But how exactly could it impact OCD? One study has investigated this question closely. Researchers found that one way BPD makes OCD worse is that it increases the chances of having other related conditions that are known to exacerbate the symptoms of OCD. For example, they found that people with both OCD and BPD are more likely to have symptoms of depression, panic disorder, specific phobias, skin-picking disorders, and more. 

They also found that people with both conditions were more likely to display more severe obsessions and compulsions overall, as well as experiencing particular OCD symptoms more often—specifically, a compulsive need to confess, seek reassurance, touch objects or others, and somatic checking (counting or fixating on physical feelings). 

Can BPD cause or exacerbate Relationship OCD?

Obsessive-compulsive disorder comes in many subtypes, which focus on particular themes or topics. One of those subtypes is called Relationship OCD (ROCD). This form of OCD is characterized by ongoing intrusive thoughts and compulsions related to one’s romantic or other close relationships.

BPD has the potential to make ROCD worse. The hallmark trait of borderline personality disorder is a very chaotic and unstable sense of self. Dr. Farrell explains: “You can imagine how, if your baseline is a volatile sense of yourself, that will bleed into ROCD. You’re probably more prone or vulnerable to intrusive doubt about whether anybody could ever want to stay if they really got to know you.”

It might make it worse in other less direct ways, too. For example, if one is more impulsive because of their BPD, they may prematurely decide to leave their relationship. “It’s common for folks with Relationship OCD to want to seek a sense of certainty or assurance” says Dr. Farrell. One of the ways that one might do that is to abruptly terminate a relationship. “I think the tendency to be impulsive would only loosen the trigger, so to speak, for people with ROCD to terminate a relationship or self-sabotage in smaller ways.” 

Another important factor is that people with BPD tend to idealize and devalue in abrupt succession. In other words, they may frequently switch from thinking their partner is perfect to hating them or never wanting to speak to them again. This can result in a more turbulent relationship, which can then lead to more intrusive thoughts and doubts. Dr. Farrell notes that “greater relationship turbulence will only worsen symptoms of relationship OCD. As a relationship becomes rockier from the idealization-devaluation cycle, you can probably expect more doubt and uncertainty, as well as more compulsive rumination and reassurance-seeking.”

Can people with BPD recover from OCD?

Yes: people with BPD can recover from OCD, but having BPD may make the process more difficult. 

Exposure and response-prevention (ERP) therapy is the gold standard for OCD. In this treatment, people with OCD trigger their obsessions and distress without relying on compulsions for short-term relief. Over time, this helps them learn to tolerate uncertainty and distress, decreases the frequency of obsessions, and reduces the level of stress caused by these intrusive experiences when they do occur.

As Dr. McGrath notes, the fact that ERP can be stressful might provoke the tendency to become intensely angry, which is common in BPD. “Someone with BPD and OCD could become very frustrated with a therapist for suggesting that they do ERP,” he says. “They may feel angry at the suggestion that they go through a potentially stressful process to alleviate their symptoms.” 

Dr. McGrath notes that people with BPD may also misperceive negative emotions, like anger or resentment, from their therapist. Recent experiments on emotional recognition in people with BPD suggest the same thing. For example, several studies have found that those with BPD are less accurate at identifying facial displays of anger and disgust, often sensing them when they aren’t there. 

To make ERP more effective for people with BPD, it’s best to combine the treatment with other forms of therapy that specifically target the symptoms of BPD. The most commonly recommended therapy for BPD is called dialectical behavior therapy (DBT), which has proven to be effective for conditions involving difficulty regulating negative emotions. In the case of BPD, people are taught how to manage interpersonal relationships, tolerate distress, and respond to their feelings in healthier and more productive ways. Other therapies for BPD include mentalization-based therapy, schema-focused therapy, and transference-focused therapy.

Medications may also help those with BPD manage their symptoms, which might make them more receptive to ERP. However, it’s important to note there are no medications approved by the US Food and Drug Administration (FDA) for BPD. Additionally, while selective serotonin reuptake inhibitors (SSRIs), like sertraline and fluoxetine, are commonly prescribed for OCD, there is limited evidence for their effectiveness for BPD, so psychiatrists typically utilize other medications, such as mood stabilizers like lithium and valproate, anticonvulsants like lamotrigine, and antipsychotics like risperidone or clozapine. 

All things considered, BPD can make ERP more challenging, but by combining different forms of therapy and utilizing medications when necessary, patients with OCD and BPD can find relief from their symptoms.