Reviewed by Melinda (Santa) Gladden, LCSW
Research has shown that Post-Traumatic Stress Disorder (PTSD) and Obsessive-Compulsive Disorder (OCD) can co-occur in one person. Both conditions fall under anxiety disorders and are prevalent in people with a history of trauma. In some situations, the idea is that obsessive behaviors like repetitive cleaning may help deal with post-traumatic stress. In fact, studies have discovered that the severity of OCD in people is associated with the number of traumatic incidents they have witnessed or experienced.
The link between these disorders is still not evident, but some PTSD symptoms like hypervigilance can present themselves identically to OCD symptoms. Hypervigilance in PTSD can cause behaviors that are considered irrational because the person repeats a specific action repeatedly, like checking locked doors or looking out for danger, trying to alleviate their fears. These actions may reach the point where a medical professional would diagnose the person with OCD.
It is reasonable that someone who has experienced a fire incident may become preoccupied with the thought of forgetting the oven door and causing a fire, or someone whose house has been robbed may constantly stand up to check that all of their doors and windows are properly locked. However, it is vital to note when the symptoms become overreaching and signal PTSD or OCD.
It is estimated that around 4 to 22 percent of people with PTSD also have an OCD diagnosis. This estimate is higher than the current number of people with OCD in the population. Studies have shown a 30 percent chance that someone with PTSD will develop OCD within a year. The prevalent of the combination of the disorders have even birthed the term “post-traumatic obsessive-compulsive disorder.”
The treatment for OCD will probably vary if it co-occurs with PTSD, so you might need to mention a history of trauma to the mental health professional. The treatment will usually focus on managing the co-existing PTSD. Before looking at the relationship between PTSD and OCD, it is necessary to overview the two mental health disorders.
An Overview Of OCD
Obsessive-compulsive disorder, or OCD, is described as:
Recurring thoughts, impulses, or images that are inappropriate and intrusive – all of which may cause significant anxiety and distress;
Repetitive actions or compulsions (like excessive hand washing, hoarding, washing, checking, and constantly trying to arrange things) or mental rituals (like frequently praying, repeating phrases, or counting numbers in your head) that someone thinks they have to do to cope with obsessive thoughts. The often time-consuming actions are meant to reduce the stress caused by negative emotions or eliminate obsessive thoughts.
Obsession with attempts to reduce or remove anxiety and prevent the occurrence of some dreadful event or situation. People with OCD are consumed with the fear that something bad will happen if they do not follow the compulsions. OCD patients may hoard things and suffer anxiety at the idea of getting rid of items.
OCD can manifest in different forms. Some people are fixated on ordering things in a particular manner, while some may be gripped by the fear of hurting people they love. The fear of germs, illness, or contamination is common among OCD patients. You might get used to living with the condition if you have acknowledged the effects, but you can take steps to address the causes and manage the condition. Although the belief is that OCD is caused by different genetic and environmental factors, one possible factor that has been studied lately is childhood trauma.
To get a diagnosis of OCD, the person must experience intrusive and irrepressible obsession and compulsions over an hour. In addition, the obsessions and compulsions must result in significant distress and disrupt normal functions at school, work, or relationships.
An Overview Of PTSD
Post-traumatic stress disorder can start after experiencing or witnessing a traumatic event, a single unrelated incident, or more chronic and recurring traumatic incidents. Different forms of emotional disruptions and symptoms are linked with PTSD, which may lead to remarkable distress or dysfunction in the person’s ability to work, interact socially, and perform normal functions.
Examples of traumatic events that may cause PTSD to include physical or sexual abuse, car accident, losing a loved one, natural disasters, victimization, relationship issues like divorce. Someone dealing with PTSD may experience recurrent and disturbing thoughts related to the trauma and may relieve the experience through nightmares and throwbacks.
To get a diagnosis of PTSD, the person must have experienced trauma and dealt with the symptoms for at least 30 days. These symptoms may include negative thoughts, intense, recurrent memories, avoiding any reminder of the incident, and experiencing reactive symptoms, like angry outbursts and fidgeting.
Comorbid PTSD And OCD
In both PTSD and OCD, the person suffers intrusive thoughts and then indulge in counteracting actions to alleviate their anxiety from disturbing thoughts. With PTSD, the person will usually attempt to counter the negative thoughts by repressing them or exhibiting traits likes avoidance or isolation.
Intrusive thoughts in OCD or obsessions are indicated by speculative thoughts and excessive doubts about outcomes that provoke anxiety. For instance, someone with contamination OCD may is highly distressed by the uncertainly regarding if his or her hands are still contaminated, despite excessive washing. The intrusive thoughts of PTSD, on the other hand, comes from past trauma. In contrast to OCD obsessions, intrusive thoughts in PTSD often traces back to past trauma, like other PTSD-related intrusive symptoms like recurring nightmares or flashbacks.
Compulsions are the counteracting actions in OCD. Although compulsive behaviors like hoarding or order can give the person more sense of control, safety, and less anxiety in the short-term, these behaviors are eventually not adequate to compensate for the cause of anxiety. Sometimes, they may even worsen a person’s level of anxiety.
People with OCD that started after trauma exhibit a different set of symptoms, including severe self-mutilation symptoms, panic disorder with agoraphobia, depression, compulsive spending, and greater anxiety. However, these self-reported actions are not adequate for an official diagnosis.
There are research evidence and clinical observations in the mental health field to support the notion that comorbid disorders in patients are regular and not just coincidences. Most importantly, the incredibly high rate of comorbidity linked to PTSD indicates that the condition usually starts in the context of other mental health conditions such as depression.
A treatment option for patients with OCD is Exposure and Response Prevention Therapy (ERP). Essentially, ERP involves exposing patients to the source of their anxiety or fears. Through therapy, patients learn to limit the compulsive responses, adjust to the triggers, and manage the anxiety more adaptively. For patients with treatment-resistant OCD or a history of trauma, studies suggest that the intrusive thoughts of PTSD disrupt the effectiveness of the habituation process that forms part of ERP.
Research and case studies suggest a chance that for a few patients with comorbid PTSD and OCD, there could be a dynamic relationship between the symptoms of the two disorders, where treatments effective for alleviating OCD symptoms may inadvertently worsen PTSD symptoms and vice versa. Treatment that does not account for the interactions involved in comorbid PTSD and OCD diagnoses, like if a particular intrusive thought is more from the patient’s PTSD or OCD, may potentially lead to outcomes that suggest an illusion of recovery without actually being effective.
The back-and-forth between OCD and PTSD can develop if past traumatic incidents become evidence to back the overreaching idea that irrational and speculative obsessions are threatening. Coupled with the fact that patients now have enough proof for irrational fears, they are also getting a conscious and subconscious reminder of the event itself. The mental professional administering treatment knows that helping a patient adapt to an obsession that causes the trauma's intrusive memories is different if the obsession has nothing to do with the trauma. When PTSD symptoms present themselves in ERP treatment, the professional is tasked with helping the patient handle the emotional response and giving them a quick perception of safety.
Differentiating The Impact Of PTSD And OCD
Trauma exposure can cause recurrent and overblown negative thoughts. The trauma-related thoughts often threaten, query, or even alter certain perspectives and core beliefs related to the person’s perception of safety, self-esteem, and trust for others. In some cases, traumatized people have a higher sense of responsibility and a reduced sense of self-worth because of the negative thoughts.
Although OCD obsessions prompt fear and anxiety due to similar thoughts about safety or self-esteem, most people with OCD usually have reasonably good insight regarding their symptoms. For example, when a patient trembles at the idea of touching a dirty doorknob, the doctor may decide to dismiss the fear as irrational or unreal. Most patients will agree, even if they cannot dismiss their fear with the same ease. According to the DSM-5, only about 4 percent of patients with OCD have delusional beliefs or no insight. There is another suggestion that patients with OCD feel personally responsible for their obsessions, albeit overinflated. To some, thinking about performing the unthinkable action is the same as performing it. Others may feel it is up to them to perform a ritual that averts disaster over their loved ones. Unlike trauma-related thoughts, OCD obsessions are more likely to be related to a compulsion.
Instead of engaging in compulsions or rituals, people with PTSD may develop hypervigilance and avoidance symptoms. The compulsion and hypervigilance give them a sense of safety after completion and alleviates their anxiety. Sometimes, hypervigilance behavior may overlap with some compulsions, like checking behaviors. To other people, both hyperactive vigilant and compulsive actions are deemed as irrational, excessive, or ritualistic. However, the major difference is that hyperactive vigilant behaviors such as trauma-related thoughts come from trauma and serve the perceived purpose of averting the trauma from happening again, regardless of whether the threat is imminent or has passed.
Treating PTSD And OCD
When PTSD co-occurs with a condition like OCD, the situation assessment may vary in dynamic and complex ways that are impossible to capture with one line of secondary diagnosis. Considering the clinical effects of comorbidity on a patient’s healing, it is important to adopt new ways of assessing trauma. To ensure effective and proper care for patients, mental health professionals may establish relationships that produce information outside the confines of diagnostic criteria.
OCD is usually treated with exposure therapy, in which the person is subjected to their anxiety triggers and then stopped from indulging in the usual compulsion. However, with trauma-related OCD or comorbid OCD and PTSD, patients might require a different therapy type. Some professionals use cognitive-behavioral therapy (CBT) for trauma-related OCD. This form of therapy involves teaching patients how to redirect the intrusive thoughts resulting from a traumatic incident. Other forms of trauma-focused therapy that may help include Eye movement desensitization and reprocessing (EMDR) therapy and trauma-focused CBT.
Both PTSD and OCD are anxiety disorders and are treated with the same medications, but CBT for the two conditions is different. For trauma-related OCD, the treatment can be improved by including anti-PTSD techniques such as recalling the traumatic incident methodically in a safe environment until the emotional hold of the memories diminishes.
If you or a loved one is dealing with PTSD and OCD, you must visit a mental health professional for treatment. Ensure you mention any history of trauma to the therapy or psychologist since this may affect your treatment plan. Start by taking an assessment test for PTSD.