Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Are OCD symptoms a trauma response?

By Grant Stoddard

Jul 17, 20238 min read minute read

Reviewed byPatrick McGrath, PhD

Since it was first recognized as a distinct condition in the 19th Century, mental health professionals have learned a lot about Obsessive Compulsive Disorder (OCD). We’ve learned that it’s a serious, sometimes debilitating, mental health disorder that doesn’t tend to get better without treatment. We’ve come to understand that non-specialized therapy is often ineffective at treating OCD and can even make symptoms much worse. We now recognize that, no matter how often people say that “we’re all a little OCD,” only around 1 or 2% of us meet its specific diagnostic criteria. 

What we can’t say with certainty is what causes OCD. Instead, we’ll say that it results from a combination of genetic, environmental, and psychological factors, which is really just a fancy way of saying, “We don’t have the exact answer yet.”

This article is a small part of a bigger quest to better answer what causes OCD. Specifically, we’ll be looking at whether or not OCD can be a ”trauma response” and, if so, the possible implications on how it’s diagnosed, treated, and recovered from. 

OCD: a primer

To understand the potential link between OCD symptoms and trauma, we must first step back briefly and define the condition’s core features. 

OCD involves random, recurring, distressing thoughts that sufferers find difficult to dismiss the way people without the condition do. Instead, they engage with these thoughts and seek meaning in them. These thoughts then become obsessions, and to reduce or relieve the anxiety they cause, people with OCD perform repetitive and often ritualistic behaviors or mental acts called compulsions. These compulsions tend to reduce anxiety for a short while, but only end up reinforcing this sequence, often called the “OCD cycle.” 

The diagnostic criteria for OCD include the presence of obsessions and compulsions that take up more than an hour a day, cause distress, and impair everyday functioning. OCD is distinct from other anxiety disorders, often focusing on specific themes. The most well-known are contamination, symmetry, and perfectionism, but many people’s obsessions can be violent, sexual, and even pedophilic. It’s these more taboo OCD subtypes that are most often misdiagnosed by physicians and mental healthcare professionals who have limited familiarity with OCD. This misidentification is one of the key reasons why, on average, nearly 13 years on average can pass before someone gets a proper diagnosis and treatment.

So now that we have a sense of what OCD is, let’s get back to the question posed at the top of this page: Can the symptoms of OCD be a response to trauma? 

OCD as a trauma response

“Some people can be genetically predisposed to developing OCD, and are simply more prone to experiencing it at some point,” says Monique Williamson, LMFT, a therapist at NOCD. “However, some people’s OCD might stem from their own experiences. Let’s say a member had a difficult home life growing up and would get in significant trouble and would be harmed for not cleaning the house. This can become an unhealthy need to clean that they carry long afterward, even growing into Contamination OCD. Around 20% of the people I work with have a trauma background. So, drawing from my personal experience of treating it, I would say that it’s very common for people’s OCD to relate closely to traumatic life events or backgrounds.”  

Williamson’s experience is backed up by clinical literature. Studies that investigate the relation between OCD and post-traumatic stress disorder (PTSD) and found that the conditions co-occur between 19% and 31% of the time. Other studies have found that  54% of people diagnosed with OCD have experienced one or more traumatic life events, and somewhere between 30% to 82% of those diagnosed with OCD have a trauma history. Put simply, OCD can indeed be related to trauma for a significant portion of the estimated 8.5 million  people in the US who are living with the disorder. 

Williamson explains that while irrational fears generally typify OCD, trauma can make fears related to past events feel far more plausible and threatening. The plausibility of certain fears, even extraordinarily unlikely ones, feels like it’s “proven” by the fact that something similar has already happened.  

For some people, OCD symptoms can emerge as a direct response to a specific traumatic event, such as physical or sexual abuse, a natural disaster, or a car accident. The distress caused by the traumatic experience can trigger obsessions and lead to the development of compulsive behaviors to cope with the anxiety and fear associated with the trauma. In other cases, chronic exposure to stressful situations, such as ongoing bullying, an abusive relationship, or living in a high-stress environment, can contribute to the manifestation or exacerbation of OCD symptoms. The persistent stress and anxiety resulting from these situations can trigger intrusive thoughts and increase the frequency and intensity of compulsive behaviors.

“In either case, someone with OCD can strongly assert that they’re not being irrational,” says Williamson. “Like, ‘I need to make sure these things are done because bad things are likely to happen if I don’t.’ This makes OCD feel necessary, which can make treatment more challenging for people with trauma backgrounds.” 

Even when a history of trauma poses a roadblock for treatment, trauma-related OCD remains highly treatable. The gold-standard treatment for OCD is a specially created technique called exposure and response prevention therapy (ERP), and it can accommodate the challenges created by trauma.

Exposure and response prevention therapy (ERP) 

The main idea behind ERP is to expose people to their fears or triggers—the things that cause their distressing obsessions—and then help them resist the urge to engage in their usual compulsive behaviors or rituals.

The therapy works gradually and systematically. First, the therapist and therapy member work collaboratively to identify their specific obsessions. They then use this catalog to create a list of situations or things that trigger these obsessions, ranked by the relative distress they cause.

Once the triggers are identified, the next step is doing the exposures. The person is gradually exposed to these triggers, starting with those that cause less anxiety and progressing to more challenging ones. This exposure can be done by imagination, through pictures, or, in some cases, by facing real-life situations or physical sensations.

Here’s the important part: during the exposure, the therapist helps the person resist the urge to perform their usual compulsive behaviors. This is known as response prevention. It means they learn to live with the anxiety, discomfort, and uncertainty that comes from their obsessions, without resorting to their rituals or repetitive behaviors.

Over time, with repeated exposures and the practice of resisting the urge to perform the compulsions, people with OCD learn that their anxiety reduces on its own without needing to engage in the rituals. They gain a sense of control and confidence in managing their obsessions without relying on their compulsions.

Research has shown that ERP is highly effective in reducing OCD symptoms. Many people experience significant improvements in their symptoms and overall quality of life. It helps them break free from the cycle of obsessions and compulsions that can be disruptive and distressing, allowing them to live life on their own terms—not OCD’s.

Treating OCD related to trauma with ERP can present several challenges due to the complex nature of trauma and its interaction with OCD. Some of the common challenges specially-trained ERP therapists consider include: 

Emotional distress: Trauma-related OCD often involves intense emotional distress, and exposure to trauma-related triggers during ERP can evoke strong emotions and anxiety. This emotional intensity can make it more challenging for individuals to engage in exposure exercises and resist the urge to engage in compulsions. Trained therapists need to provide a supportive and safe environment for individuals to process these emotions effectively.

Trauma triggers during exposure: “Exposure exercises in ERP may run the risk of inadvertently triggering trauma-related memories or sensations,” explains Williamson. “Especially if the trauma is fresh or hasn’t previously been addressed in a therapeutic setting.” This can lead to heightened anxiety or emotional flooding, potentially hindering treatment progress. Therapists who specialize in treating OCD with ERP are prepared to address these triggers and have strategies in place to help people manage and process trauma-related emotions and memories.

Overlapping symptoms: Trauma-related OCD often co-occurs with post-traumatic stress disorder (PTSD) or other anxiety disorders. The overlapping symptoms can complicate the treatment process, as exposure exercises in ERP may trigger OCD-related anxiety and PTSD symptoms. It requires careful assessment and targeted interventions to address both OCD and trauma-related symptoms effectively.

Safety behaviors and rituals linked to trauma: People with trauma-related OCD may develop safety behaviors or rituals specifically related to their traumatic experiences. These safety behaviors provide a sense of control and comfort, making it challenging to resist engaging in them during ERP. Addressing these trauma-related safety behaviors and rituals becomes essential to treatment, as they can reinforce compulsive avoidance and hinder progress.

Therapeutic rapport and trust: Building a solid therapeutic alliance and trust between the therapist and the member is crucial for successful OCD treatment. However, trauma-related OCD can involve deeply personal and sensitive topics, making it more challenging to establish rapport and trust. Specialty-trained therapists are attuned to a person’s unique needs, provide a safe and non-judgmental space, and can adapt the treatment approach accordingly.

Although it may be initially challenging and anxiety-provoking—especially for those with trauma-related OCD—by working collaboratively with a therapist trained in ERP, you can develop increased confidence in your ability to tolerate distress and resist compulsions. Through this process, you’ll likely experience significant improvements in your overall well-being and regain control of your life as a growing number of people have. 

Getting help 

If you think you might have OCD and want to learn how it’s treated with ERP, schedule a free 15-minute call with the NOCD Care team to learn more about how we can help you. 

All of our therapists specialize in OCD and receive ERP-specific training, and many are also specialty-trained in providing Prolonged Exposure therapy (PE) for people struggling with both OCD and PTSD—it’s a highly effective, evidence-based approach to treating PTSD that shares some similarities with ERP.

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