The Importance of Integrated Treatment for Co-occurring OCD and PTSD

John is a firefighter in Hoover, Alabama. He has struggled with symptoms of PTSD since responding to a motor vehicle accident call last year.  He experiences nightmares several times a week. He notices increased anxiety when calls related to car accidents come into the fire station. He has more difficulty driving and going to events with his family. His family describes him as irritable and distracted. He has been very focused on safety at home, at work, and when driving his vehicle. This started with a few safety checks and a more thorough walk-through of his home at bedtime. However, these rituals have been taking more time and effort over the last six months. He has recently told his best friend that he is having unwanted thoughts about his family being injured. He has not told anyone, but he sometimes has unwanted thoughts about harming his family. This has led him to counting backward from 300 each time these thoughts come up.  John’s friend encouraged him to seek care and said he may have OCD. Does John have PTSD, OCD, or both?

When navigating the complex landscape of mental health, individuals dealing with both Obsessive-Compulsive Disorder (OCD) and Post-Traumatic Stress Disorder (PTSD) often face unique challenges. These two conditions, while distinct, can intertwine in ways that exacerbate symptoms, making effective treatment more intricate. While both have effective treatments, the treatments are not interchangeable between disorders. Individuals with OCD often have symptoms up to 17 years before being diagnosed (Ziegler et al., 2021). Misdiagnosis is common.  OCD can be mistaken for a number of conditions, including Generalized Anxiety Disorder, depression, and PTSD. This is why it’s crucial to seek a therapist trained in both OCD and PTSD to ensure an integrated, comprehensive approach to recovery. Trauma-informed care principles are also vital in treating OCD in the absence of PTSD. Let’s examine the two illnesses, their core symptoms, what happens when the symptoms occur together, and what treatment options can help.

Understanding PTSD

PTSD is classified as a trauma- and stressor-related disorder (APA, 2022). In the DSM-5-TR, a trauma is defined as an exposure that causes actual threatened death, serious injury, or sexual violence. It can be something that an individual witnesses, experiences directly, or learns about happening to a close family member or friend. Roughly 70% of people are exposed to a trauma in their lifetime, but only about 7% are diagnosed with PTSD. It is caused by exposure to traumatic events that then lead to symptoms like nightmares, flashbacks, hypervigilance, changes in mood and thoughts, and avoidance.  These symptoms cause significant distress and/or impaired functioning in different domains.

Understanding OCD

OCD was previously classified as an anxiety disorder, but in the newest classification system, it was moved to a new category: Obsessive-Compulsive and Related Disorders (APA, 2022).  It is characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing distress. Obsessions are often inconsistent with the person’s values and sometimes include topics that are considered socially taboo. Compulsions are efforts to address, neutralize, or prevent the feared outcome associated with obsessions. These ritualistic behaviors do not always logically connect to the content of the obsessive thought. Significant time each day is spent managing symptoms which interfere with daytime functioning and cause distress.

Overlap and Directionality

Post-Traumatic Stress Disorder (PTSD) and Obsessive-Compulsive Disorder (OCD) are distinct mental health conditions. However, they share some overlapping symptoms which can complicate diagnosis and treatment. It is also possible for an individual to have both disorders simultaneously. This is estimated to occur in about 19% of cases in the community (Ruscio et al., 2010), with higher rates in intensive or residential settings (Gershuny et al., 2008). Let’s examine the key overlapping symptom categories, and how these can be differentiated or dynamic.

Intrusive Thoughts: Both PTSD and OCD involve distressing, intrusive thoughts. In PTSD, these thoughts cause the individual to re-experience the trauma in unwanted memories, thoughts, or emotions.  In OCD, intrusive thoughts usually manifest as persistent, unwanted obsessions that cause anxiety. These are focused on future feared outcomes. They can be trauma-related in the person with OCD (who also has a history of trauma exposure), but are not exclusively related to trauma.  For example, thoughts about the risk of danger to a loved one could be related to PTSD alone, OCD alone, or a dynamic interplay of the two disorders.

Avoidance Behaviors: Individuals with both disorders may engage in avoidance. In PTSD, this typically involves avoiding reminders of the trauma. This avoidance can be internal (e.g. unwanted trauma-related thoughts, memories, or emotions) or external avoidance (e.g. sights, sounds, smells that cue trauma reminders). In OCD, avoidance is often directed at situations that might trigger obsessive thoughts or compulsive behaviors. For example, avoidance of crowds might be related to contamination fears and worries about the resulting compulsion in OCD alone. Individuals with OCD may avoid, but this functions as an effort to control obsessions that would result in compulsions. The same stimuli of crowds could be related to safety concerns for self or others in PTSD alone. The avoidance behavior in someone with co-occurring PTSD/OCD could be related to avoidance of thoughts about the potential for harm to others in both disorders and a resulting compulsion for the OCD.

Anxiety and Distress: High levels of anxiety and emotional distress are common in both conditions, though the sources differ. PTSD-related anxiety often stems from trauma memories, whereas OCD-related anxiety is linked to obsessions and fears about potential outcomes. Again, these symptoms can overlap with the trauma memories initiating the distress and additional OCD fears being linked but distinct.

Hyperarousal or Heightened Vigilance: Both disorders may involve increased vigilance. In PTSD, this appears as hyperarousal symptoms like an exaggerated startle response. The brain is focused on finding and predicting threats related to trauma. The fight/ flight/freeze response is primed and ready to respond even to unhelpful cues. In OCD, heightened vigilance is related to monitoring for triggers of obsessions and compulsions.

Compulsive Behaviors or Rituals: While ritualistic behavior is a hallmark of OCD, individuals with PTSD may also develop ritual-like behaviors as coping mechanisms to manage trauma-related anxiety. This could include repeatedly checking doors or windows due to safety-related thoughts. There is an escape behavior developed where the safety behavior appears to prevent the feared outcome. However, continuing to perform the safety behavior perpetuates anxiety.  In OCD, the rituals are in direct response to obsessions and may not be related logically to the content.  For example, John counting backward to neutralize thoughts of harm to his family. When OCD and PTSD coexist, OCD rituals may serve a function of also reducing PTSD intrusion symptoms through avoidance.

Frequency and Directionality

The prevalence of PTSD is approximately 7% with higher rates in some groups such as combat veterans. OCD is less common and estimated to occur in 2-3% of the population. PTSD and OCD may co-occur in roughly 20-40% of cases (Brown et al., 2001; Fontenelle et al., 2012; Nacasch et al., 2011). Individuals with OCD have similar rates of trauma exposure as the general population, which is around 70%. Therefore, it is likely that individuals living with OCD have a history of trauma exposure.  Importantly, exposure alone does not result in a diagnosis of PTSD. Yet, exposure to trauma may carry some additional risk. Timing of exposure may be important as individuals with OCD report greater exposure to trauma in childhood compared to those without OCD (Lochner et al., 2002).  OCD symptoms severity has also been significantly associated with a history of traumatic events (Cromer et al., 2007). 

Investigations into potential directionality heavily favor the onset of OCD concurrent with PTSD or following PTSD.  The risk for OCD is 10x higher in people with PTSD (Ruscio et al., 2010). OCD being present before PTSD is estimated in only 25% of cases. Individuals who develop OCD after PTSD are usually older, and the content of their obsessions and compulsions may be more likely to have aggressive content, hoarding behaviors, or sexual/religious themes. Comorbid PTSD is associated with more severe OCD symptoms (Gomes de Araújo et al., 2018).  Exposure to trauma is unfortunately common, and trauma exposure alone does not guarantee a PTSD or OCD disorder will occur. However, this overlap in the two disorders suggests that there may be some shared etiology beyond trauma exposure.

Assessment and Diagnosis

Assessment for both disorders includes a clinical interview and validated clinician-administered and self-report assessments.  As the symptoms of these disorders can overlap, the assessor needs to consider symptoms’ overlap, what drives the symptom, what functions they serve, and the timing of symptom onset. DSM-5-TR diagnostic criteria caution against “counting” symptoms that are not better accounted for by another disorder.  However, symptoms that appear to be similar may have different functions under each disorder. Understanding the nuances is important for accurate diagnosis.

Evidence-based assessment of these disorders should include a detailed timeline assessment and a comprehensive review of the different functions of the symptoms.  There are specialized instruments available to assist with quantifying the overlapping symptoms and their dynamic interplay.  For example, the intrusive thoughts in OCD might be mistaken for PTSD intrusions or negative thoughts. Obsessions are future-focused thoughts that are not exclusively tied to trauma themes. Avoidance behaviors, common in PTSD, can mimic compulsions in OCD.  However, these behaviors are usually performed with less repetition and are not necessarily intended to neutralize obsessions. Many people living with PTSD and OCD endorse a link or overlap in symptoms (Wadsworth et al., 2023), and this is a primary reason that detailed assessment by a trained professional is key.  Diagnostic criteria usually emphasize that symptoms cannot “count” for one disorder if the symptom is better explained by another disorder.  However, in the dynamic interplay of PTSD and OCD symptoms that appear to overlap, likely have important nuances.

Effective Psychotherapy Treatment

Gold standard evidence-based interventions exist for both PTSD and OCD. The interventions do have some shared elements, but PTSD and OCD treatments are not interchangeable. If both disorders are present in the same person and causing distress and impairment, treatments for each disorder would usually be recommended.

OCD: Exposure Plus Response Prevention (ERP or ExRP; Foa et al., 2012) is the frontline treatment for OCD. This intervention is usually delivered weekly or more frequently for 17 to 25 sessions. It includes psychoeducation, the development of exposure, hierarchy, and between-session practice with in vivo and imaginal exposure.

PTSD: Prolonged Exposure Therapy for PTSD (PE; Foa et al., 2007) and Cognitive Processing Therapy (CPT; Resick et al., 2024) are front-line treatments for PTSD. These interventions are usually delivered weekly or more frequently for 8-15 sessions. Both can be effective in patients with co-occurring PTSD and OCD. In fact, Prolonged Exposure (PE) contains some of the same intervention elements as ExRP, including psychoeducation about trauma, in vivo, and imagined exposure. However, the content of the exposures primarily focuses on trauma-related memories, thoughts, and emotions. PE and ExRP are both exposure-based and share an underlying theory— Emotional Processing Theory (Foa & Kozak, 1986).

Treatment can be offered in three ways:

1) Sequencing: Individuals begin with one evidence-based protocol and complete this intervention before starting treatment for the other disorder.  Ordering of this treatment protocol can be based on which symptoms are most distressing or impairing during collaborative shared decision-making between the patient and therapist.

2) Parallel: A patient can enroll in both treatments simultaneously with usually two different therapists who communicate frequently to ensure continuity of care. This model may be more common in intensive outpatient or residential programs but can be done in the community.

3) Integrated: Treatment would be approached with PE and ExRP (Pinciotti et al., 2022) or CPT and ExRP (Van Kirk et al., 2018) protocols integrated. It can be conceptualized as a multichannel exposure treatment. This is an area of continued research and development for specialists trained in OCD and PTSD.

The Risks of Fragmented Treatment

The gold standard treatments for both disorders involve exposure, and many of the skills translate. ExRP for OCD encourages confronting feared situations without engaging in compulsions.  PTSD treatment might involve trauma-focused therapies like PE that address both traumatic memories (imaginal exposure) and in-real-life exposures (in vivo exposure).

Research has shown that people with specialization in either disorder often expressed confidence in their ability to treat both disorders. However, research into their practice has shown some common misperceptions that may impact efficacy and carry additional risk. The following concerns demonstrate why additional training for therapists in dual diagnosis and treatment is key:

· Misdiagnosis: Symptoms might be misattributed to one disorder or inappropriately attributed to both, delaying appropriate interventions. Assigning a single diagnosis when both are present may delay treatment or have iatrogenic effects. It is important to note that exposure to trauma is common, but exposure alone does not mean an individual has PTSD. Following DSM-5 diagnostic criteria is important, and additional attention needs to be paid to the function of the symptoms when trying to understand if it is PTSD-related, OCD-related, or serving both disorders, but in different ways.

· Increased Distress: Exposure techniques for one disorder might inadvertently reinforce symptoms of the other. When treatment is successful in improving one set of symptoms, the symptoms of the other disorder may increase (Van Kirk et al., 2018).  Individuals seeking OCD treatment who have comorbid PTSD may have attenuated effects in treatment (Gomes de Araújo et al., 2018). OCD can serve as a maladaptive, but protective function for PTSD symptoms. Blocking rituals in this case could flare PTSD.  Effective therapists will be prepared to address this within treatment.

· Contradictory Strategies: It would seem that a specialist trained in either disorder could treat both without additional training. However, people who have comorbid PTSD and OCD sometimes experience a dynamic interplay of the two illnesses, and approaching treatment from either a PTSD or OCD lens could unintentionally reinforce symptoms of the other disorder. When treated separately, therapeutic approaches might conflict. Techniques effective for PTSD, such as challenging thoughts, could be counterproductive for OCD, resulting in increased efforts at thought suppression. OCD symptoms can “latch-on” to skills used to target trauma symptoms and become rituals if not monitored and addressed.

Benefits of an Integrated Treatment Approach

A therapist trained in both OCD and PTSD can:

Provide Comprehensive Assessment: Understanding the full scope of both disorders and their timeline. A timeline interview and functional analysis are key to an accurate diagnosis.

Provide Personalized Treatment Plans: Considering sequencing of treatment, integrated treatment, or collaboration with other members of the treatment team. Combining ExRP with trauma-informed strategies while providing consistent support with a singular, trauma-informed approach.

Address Underlying Mechanisms: Integrated treatment can uncover how trauma influences OCD and how OCD impacts PTSD symptoms.

Provide Tailored Exposure Techniques: Therapists can adapt ExRP and trauma-focused therapies to complement each other, effectively reducing symptoms of both disorders. This reduces the need for sequencing treatment and moving to recovery more quickly. With integrated or collaborative treatment clients avoid the confusion of managing differing strategies from multiple providers. 

Help You Build Resilience: Focusing on evidence-based interventions that support both OCD and PTSD recovery.

Final Thoughts

Managing co-occurring OCD and PTSD is undeniably complex, but with the right therapeutic support, individuals can find relief and reclaim their lives. A therapist trained in both disorders offers nuanced, compassionate care that respects the interconnectedness of these conditions, paving the way for more effective, sustainable recovery.  At Upward Behavioral Health, we are committed to supporting individuals as they navigate the complexities of PTSD, OCD, and the dual diagnosis of PTSD and OCD . By understanding the interconnectedness of these experiences and utilizing evidence-based, dynamic treatment approaches, we can provide tailored therapeutic strategies that promote healing and growth.

To learn more about OCD and PTSD, here are trusted resources:

International OCD Foundation: https://iocdf.org

National Center for PTSD: https://www.ptsd.va.gov

If you or someone you know is struggling with these concerns, we encourage you to reach out to our practice for support.  We have clinicians with specialized training in PTSD, OCD, and co-occurring conditions.

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