When it comes to our health, it’s not uncommon to have multiple conditions present together. For physical health, this might look like experiencing both diabetes and hypertension, or cardiovascular disease and strokes. For mental health, it might look like dealing with both depression and anxiety.
We call this phenomenon “co-occurring conditions,” comorbidities, or dual diagnoses, and it can occur with two conditions appearing simultaneously, or with one condition triggering another. If you live with obsessive-compulsive disorder (OCD), it’s common to also experience another mental health or neurodevelopmental condition—like anxiety, depression, post-traumatic stress disorder (PTSD), body-focused repetitive behaviors (BFRBs), or attention deficit hyperactivity disorder (ADHD).
While managing more than one condition at once may come with challenges, there are proven ways to learn how to manage all the symptoms you’re experiencing. Keep reading to learn about the co-occurring conditions most commonly associated with OCD, and how to navigate treatment options.
What is a co-occurring condition?
A co-occurring condition is when you’re dealing with two or more health conditions, even if symptoms for one of those conditions started first. You’ll usually have what’s called a primary (or principal) diagnosis, which is the condition that you’re specifically receiving care for. Your healthcare provider will view that primary diagnosis as their main focus, keeping the other co-occurring conditions in mind when determining a treatment plan. Your primary diagnosis can change depending on what type of healthcare professional you’re seeing.
Conditions that commonly co-occur with OCD
If you’re unfamiliar with OCD, it’s a chronic mental health condition defined by two main symptoms. Obsessions are repeated intrusive thoughts, sensations, images, feelings, or urges that cause anxiety or distress. Compulsions are repetitive behaviors or mental acts performed to neutralize the obsession, prevent something bad from happening, or try to reduce distress.
In a pooled sample of more than 15,000 people with OCD, 69% had co-occurring conditions, according to a systematic review and meta-analysis in Frontiers in Psychiatry. The most common were:
- Major depressive disorder
- Generalized anxiety disorder
- Neurodevelopmental disorders (such as ADHD)
- Obsessive-compulsive related disorders (such as body dysmorphic disorder or body-focused repetitive behaviors)
April Kilduff, MA, LCPC, LMHC, licensed therapist at NOCD, says of the conditions listed above, she most frequently treats anxiety and depression alongside OCD. “It’s rare that I see someone with only OCD; there is also often a co-occurring condition present.”
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Here’s a little more about the most commonly co-occurring conditions:
Anxiety
According to the Anxiety & Depression Association of America (ADAA), about 7 million adults in the U.S. have generalized anxiety disorder, and women are twice as likely as men to have an anxiety disorder. Symptoms of anxiety include:
- 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 obsessions often trigger anxiety. In response, people with OCD perform compulsions, in an attempt to relieve that anxiety. OCD can both trigger anxiety disorders, and anxiety disorders may predispose you to developing OCD.
Depression
Some research suggests that depression is the most common co-occurring condition with OCD. According to the ADAA, depression affects 264 million people in the world, and is the leading cause of disability in the United States among adolescents and young adults. Symptoms include:
- Overwhelming feelings 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
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. However, it’s even more common to develop depression after first experiencing OCD. OCD symptoms can cause significant distress and isolation—which may lead to depression.
Body-focused repetitive behaviors (BFRBs)
BFRBs are considered OCD-related disorders. These include:
- Trichotillomania (hair pulling)
- Excoriation (skin picking)
- Nail-biting
- Cheek-biting
Kilduff says both BFRBs and OCD often show up together and share similarities. While different BFRBs have unique symptoms, what ties them together is a constant, repetitive fixation with a body part.
Post-traumatic stress disorder (PTSD)
PTSD is a mental health condition that can occur if you’ve experienced or witnessed a traumatic event, which is a distressing and/or dangerous experience that causes physical, emotional, or psychological harm. Common PTSD symptoms include flashbacks, severe anxiety, nightmares related to the traumatic event.
“It’s easy for OCD to take trauma and exploit it in ways that are painful,” says Kilduff. “OCD is always looking for the hot buttons it can push and what you care about—and then scare people around those things.” This may cause you to develop obsessions and compulsions that are related to trauma you’ve experienced, like developing a fear of driving after a near-death car accident.
Attention deficit hyperactivity disorder (ADHD)
ADHD is a neurological condition that affects your brain and nervous system. It’s categorized by impulsivity, inattention, and/or hyperactivity. These symptoms can affect your day-to-day life, leading to:
- Difficulty remembering responsibilities
- Procrastination
- Poor time management, organization, or planning
- A constant need for stimulation or activity
- Picking an immediate reward without thinking about future rewards or consequences
OCD and ADHD both make it hard to focus and make interacting with others difficult, but those with OCD tend to avoid risk while those with ADHD are drawn toward it.
Treatment
OCD is most effectively treated with exposure and response prevention (ERP) therapy, a specialized form of cognitive behavioral therapy (CBT). An ERP therapist will gradually guide you through exposures and response prevention techniques that teach you how to address your fears head-on without engaging in compulsions. In time, you learn to sit with the discomfort that arises from obsessions instead of resorting to compulsions.
Before jumping into OCD treatment, it’s best to be fully assessed for co-occurring conditions. Depending on your needs, you may be able to work with two types of therapists in tandem. For example, you might see a therapist for depression on Mondays while you see an ERP specialist on Tuesdays and Thursdays. Be sure to discuss your treatment plan with both clinicians, so they can best coordinate 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, certain coping strategies taught in talk therapy can actually be detrimental to OCD recovery. If both therapists are in contact, they can make sure that you’re being given the right tools needed for recovery.
In some instances, medications may be recommended. Some of these medications, such as SSRIs, are used for multiple mental health conditions, like depression, anxiety, and OCD.
Treating OCD and depression
If your depression has developed as a result of OCD, your clinician would focus on treating your OCD first. According to Kilduff, “once you treat OCD, depression naturally lifts. You don’t always need extra or parallel treatment.”
If depression is your primary condition, you probably won’t have enough energy to dive right into OCD treatment. Instead, you might get assessed for medication, or see a therapist who specializes in behavioral activation (BA), a form of cognitive therapy that helps you gradually re-engage in meaningful activities that once brought you joy, like exercising or reading. Once you start to better manage your symptoms of depression, you’d be better able to embark on ERP therapy for OCD.
Treating OCD and PTSD
With PTSD, diving right into ERP might actually trigger dissociations or flashbacks, says Kilduff, which can compromise OCD treatment. Instead, your clinician might suggest focusing on a PTSD treatment called prolonged exposure (PE) therapy and then moving onto ERP.
PE works by teaching you to gradually and intentionally approach your trauma-related experiences and feelings. By learning to identify negative thoughts that emerge, and confront these painful memories in a controlled environment, you’ll be able to better cope with related feelings that arise outside of sessions.
Treating OCD and anxiety
While talk therapy can be used to treat anxiety disorders, it isn’t effective for OCD. The best path forward for co-occurring anxiety and OCD is ERP therapy, which can treat both conditions at once. Your ERP specialist will zero in on what type of anxiety you’re dealing with, and adjust your treatment plan accordingly. For instance, if you have social anxiety, your ERP sessions may focus on gradually exposing yourself to triggering social situations and learning to stop partaking in safety behaviors, like avoidance. In time, you’ll learn that these social scenarios are not as scary as your mind is telling you they will be.
Treating OCD and BFRBs
With a BFRB, it’s important to get assessed by a primary care physician or a dermatologist to address any bodily damage from the condition. After that, you can begin to address your mental health.
BFRBs are best treated with a form of cognitive behavioral therapy (CBT) called habit-reversal training (HRT). HRT involves gaining more awareness of BFRBs by tracking them, and replacing behaviors with competing responses, where you intentionally do a different action—like sitting on your hands—when you feel like you’re going to engage in an unwanted behavior. If your ERP therapist is trained in HRT, you can dedicate different sessions to working on your OCD with ERP and your BFRBs with HRT. If not, you may need to see two different therapists, but both therapies can be conducted during the same period of time.
Treating OCD and ADHD
Medication is usually the first-line of treatment with ADHD. If that doesn’t quell symptoms, general CBT may be used, as well as social skills training (SST), where you learn better problem-solving and decision-making approaches. This type of therapy would be separate from your ERP sessions. Like with some of the above conditions, you may choose to work with an ADHD specialist one day a week, while doing ERP therapy on other days.