Your body is one interconnected system. And when it comes to your health, some diseases or conditions seem to “go together.” This is called comorbidity: as the Centers for Disease Control and Prevention (CDC) defines it, a comorbidity is “when a person has more than one disease or condition at the same time.” This occurs across the health spectrum. For example, common comorbidities of obesity are hypertension, type 2 diabetes, and non-alcoholic fatty liver disease, according to StatPearls.
The same can be said of mental health conditions, such as obsessive-compulsive disorder (OCD). It’s common that if you have OCD, you also have another psychiatric illness or neurodevelopmental disorder. In fact, in a pooled sample of more than 15,000 people with OCD, 69% had comorbidity, with men being more likely to have one than women, according to a systematic review and meta-analysis in Frontiers in Psychiatry in 2021.
In this article, we’ll learn about the comorbid conditions most commonly associated with OCD, how treatment is affected, and where to find the right help.
What conditions are most commonly comorbid with OCD?
The large Frontiers in Psychiatry study identified several common comorbidities, including:
- Major depressive disorder
- Generalized anxiety disorder
- Neurodevelopmental disorders (such as attention deficit hyperactivity disorder).
- Obsessive-compulsive related disorders (such as body dysmorphic disorder or trichotillomania, also called hair-pulling disorder)
Of those above, April Kilduff, MA, LCPC, LMHC, licensed therapist and clinical trainer at NOCD, most often sees anxiety and depression related to a client’s OCD. “It’s rare that I see someone with only OCD; there is also often a comorbid condition present.” Here’s a little more in-depth info about both anxiety and depression as they’re involved in OCD:
Anxiety
About 7 million adults in the U.S. have generalized anxiety disorder, with women having twice the risk of men, says the Anxiety & Depression Association of America (ADAA). According to the Association, some of the symptoms of anxiety are:
- Feeling nervous, irritable, or on edge
- Having a sense of impending danger, panic, or doom
- Increased heart and breathing rate, sweating, or trembling
- Weakness and fatigue
- Difficulty sleeping
OCD often involves being in a highly anxious state. Obsessions—the “O” in OCD—are unwanted thoughts, images, feelings, sensations, or urges that cause distress, while compulsions are the repetitive and ritualistic mental or physical behaviors done to neutralize the distress caused by the obsession. Very often, distress from obsessions comes in the form of anxiety, and because that anxiety feels so uncomfortable, you’re triggered to perform compulsions, which will bring temporary relief to that anxiety.
With all this anxiety swirling around in OCD, you can also develop an anxiety disorder, while on the other hand, having an anxiety disorder may also predispose you to developing OCD.
In fact, anxiety is such a prevalent experience in OCD that OCD was historically categorized as an anxiety disorder. OCD is now diagnosed in its own class called Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Depression
Some research suggests that depression is the most common comorbidity of OCD. Depression affects 264 million people in the world, and it’s the leading cause of disability in the United States among adolescents and young adults, according to the ADAA. Symptoms of the widespread condition include:
- Overwhelming feeling of sadness
- Loss of interest and pleasure in usual activities
- Appetite changes
- Too much or too little sleep
- Fatigue
- Feelings of worthlessness or excessive guilt
- Thoughts of death and suicidal ideation
- Brain fog
Depression may be associated with OCD in a couple of ways.
Namely, you can have primary or secondary depression. Primary depression means that depression developed first, and it is possible for OCD to show up in addition to depression. One study found that about half of people with major depressive disorder had at least one obsessive-compulsive symptom, and 14% had more than four of these symptoms. And the worse the OCD symptoms in depression, the more difficult it was to go into remission for depression. The researchers explain that these OCD symptoms are underrecognized and undertreated in those who have OCD.
Kilduff says that secondary depression with OCD is even more common. That’s when you develop OCD first; then, due to the distress, impairment, and potential isolation of OCD, you develop depression. What’s more, there may be some common brain differences associated with both depression and OCD, research notes, which could also help explain, in part, why the two conditions so often occur together.
Body-focused repetitive behaviors (BFRBs)
BFRBs are considered OCD-related disorders, such as:
- Trichotillomania (hair pulling)
- Excoriation (skin picking)
“I’ve seen clients with both BFRBs and OCD, which makes sense because they’re considered to belong to the same group of disorders, and they share commonalities,” says Kilduff. Each of the above disorders will have their own set of symptoms, but in general they are defined as “any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails,” according to The TLC Foundation, an organization that supports the 5% of the population who have BFRBs. The sensations of picking or pulling helps people with BFRBs self-regulate and some may enjoy the behaviors themselves, though they can lead to severe health issues, the Foundation explains.
Post-traumatic stress disorder (PTSD)
PTSD is a mental health disorder that can occur if you’ve experienced or witnessed a traumatic event, according to the American Psychiatric Association. It can happen as a response to war, natural disasters, accidents, and assault. If you have PTSD, you may experience the following symptoms, which must be present for more than a month and cause distress in your life:
- Intrusive triggers in the form of memories, dreams, or flashbacks of the trauma
- Avoiding things that you fear may trigger memories surrounding the event
- Changes in cognition and mood
- Irritability, anger, recklessness, or being easily startled
OCD and PTSD are often linked. Why? OCD is an opportunistic disorder. “It’s easy for OCD to take trauma and exploit it in ways that are painful. OCD is always looking for the hot buttons it can push and what you care about—and then scare people around those things,” says Kilduff.
How does having more than one diagnosis affect treatment?
First before jumping into treatment, be fully assessed for comorbid conditions. “Proper diagnosis is crucial. It’s important that someone understands what’s happening with them—and for us to help normalize it,” says Kilduff. It’s common for OCD to be mistaken for anxiety, for example, or for OCD symptoms in people with other conditions not to be addressed at all.
“Once you know the diagnoses, you can start to look at the gold-standard treatment for those conditions,” says Kilduff. “There is not a one-size-fits-all here. You want to make sure you’re getting the right treatment for the right things, which will net the most benefit out of therapy and increase the chance that you can move into recovery,” she says.
Here’s a couple examples of how that might play out in real scenarios.
First, let’s consider that you have OCD and then have developed depression because your quality of life has diminished so much due to the cycle of obsessions and compulsions. Here, your clinician would focus on treating the OCD because that is the cause of the depression. The optimistic news here, says Kilduff, is that “once you treat OCD, depression naturally lifts. You don’t need extra or parallel treatment.” This does not mean that OCD treatment will be easy—it will take work—but if this describes your current struggles, you can take comfort in knowing that one form of treatment can help you recover in multiple ways.
What about primary depression? “If primary depression is untreated, quite possibly you won’t have the energy to do the gold-standard treatment for OCD,” called exposure and response prevention, or ERP. So, you might see a therapist for depression treatment to build necessary skills, or be assessed for medication in order to allow you to open up to the treatment you need for your OCD.
A final situation: you have PTSD. Let’s say one of your symptoms is dissociation or flashbacks. This can complicate the use of ERP because using ERP first might actually trigger dissociations or flashbacks, says Kilduff, which would cause unnecessary distress and compromise OCD treatment. In that case, a clinician might suggest focusing on PTSD treatment first and then moving onto OCD.
How to approach treatment for OCD and other conditions
Regardless of your comorbidities, you must be treated for OCD. “We know for sure that if you leave OCD untreated, it will only grow and create more encompassing, complex, and involved compulsions,” says Kilduff.
It’s possible that you could work with two types of therapists during treatment, depending on your needs. For example, you might see a therapist for cognitive-behavioral therapy (CBT) for depression, says Kilduff. And both of your clinicians should be okay with that. “We want you to get help,” they say. Make sure you’re open with both clinicians, which will allow them to coordinate your care. “This setup can be beneficial as long as both parties understand how we’re approaching certain things so we’re not giving conflicting information,” Kilduff adds.
For example, if you are seeing a therapist, certain coping strategies learned in talk therapy could actually be detrimental to OCD by creating new compulsions, such as reassurance-seeking. If your care is coordinated, both therapists can connect to make sure that you’re being supported and given the tools needed for recovery.
In addition, in some instances, medications may be recommended. Some of these medications, such as SSRIs, are used for multiple psychiatric disorders, like depression, anxiety, and OCD. To learn if you are a good candidate for medication, Kilduff recommends connecting with a psychiatrist. Your primary care provider may be able to prescribe these, but if a psychiatrist is available to you, they are the ones who are specialized in psychiatric medications.
Where to access treatment for OCD and co-occurring conditions
OCD and comorbid conditions don’t go away on their own–you need the right tools to manage them. The good news: you can now access affordable, convenient, and evidence-based treatment for all these comorbidities—depression, anxiety, BFRBs, and PTSD—with NOCD Therapy, along with ERP therapy for OCD.
When comorbid conditions are left untreated, they can reduce the effectiveness of your OCD treatment. This is why NOCD has consistently expanded our care to provide truly holistic, effective care for the OCD community.
If you’re interested in learning more about accessing treatment for OCD, along with its most common and severe comorbidities, I encourage you to learn more about NOCD’s accessible, effective approach to care for people with OCD.