The Interplay Between Obsessive-Compulsive Disorder and Delayed Sleep Phase Disorder: Why Specialized Training Matters

LaToya is a 23-year-old student at the University of Alabama at Birmingham (UAB) with contamination OCD (meaning that she has obsessive thoughts about becoming contaminated by dirt or germs) and a longstanding pattern of going to bed at 3:00 a.m. and waking around noon. Her nighttime rituals, including excessive showering and cleaning, consume hours. She struggles to attend her classes despite trying to schedule them as late in the day as possible. Sometimes she is sleepy during class, even in evening classes. LaToya is also having difficulty concentrating in class and finds herself irritable when walking around campus.  LaToya has OCD and Delayed Phase Sleep Disorder. Friends and family tell her to just go to bed earlier, but this seems impossible. If she tries to fall asleep earlier she is wide awake and extremely distressed by the urge to complete her cleaning rituals.

Obsessive-Compulsive Disorder (OCD) is a chronic and often debilitating mental health condition that affects millions worldwide. Characterized by intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions), OCD interferes significantly with daily life. Simultaneously, Delayed Sleep Phase Disorder (DSPD) is a circadian rhythm sleep-wake disorder where individuals struggle to fall asleep until very late at night and find it difficult to wake up at socially conventional times.  This is not just a preference for staying up; it is a biologically encoded rhythm.  The co-occurrence of these two conditions is not only common but also clinically significant.

Sleep disturbances in individuals living with OCD are well-documented with roughly half of all people with OCD reporting concerns (Patterson et al., 2013). This high comorbidity raises critical concerns for treatment efficacy, daily functioning, and long-term outcomes. Individuals with OCD are more likely to have delayed circadian rhythms and insomnia symptoms compared to healthy controls (Cox et al., 2022).  Understanding the interplay between OCD and DSPD (and sometimes Insomnia) is essential for both clinicians and patients, particularly when engaging in evidence-based treatments like Exposure and Response Prevention (ERP), the gold standard for OCD treatment. This blog explores the bidirectional influence between OCD and DSPD, the implications for ERP therapy, and why therapists must be proficient in both OCD treatment and Behavioral Sleep Medicine (BSM).

Understanding OCD and DSPD: Definitions and Core Features

Obsessive-Compulsive Disorder (OCD)

OCD involves persistent, distressing intrusive thoughts, images, or urges that lead to compulsive behaviors intended to neutralize the anxiety or prevent feared outcomes. These compulsions can include checking, washing, counting, or repeating actions or mental rituals. OCD is heterogeneous, with many subtypes such as contamination fears, harm obsessions, symmetry obsessions, and intrusive taboo thoughts.

Delayed Sleep Phase Disorder (DSPD)

DSPD is characterized by a significant delay in the circadian phase of the major sleep episode. Individuals with DSPD typically do not feel sleepy until late at night and find it difficult to wake up in the morning. This condition is not simply a preference for late nights but a biological misalignment between the individual’s internal clock and external societal demands.  Specific measurement of a sleep hormone, melatonin, in patients with OCD showed a later release of this chemical compared to patients without OCD.  Individuals who attempt to sleep a more “regular” schedule, say 11 p.m. to 6am often feel less rested as they are not obtaining sleep that is “chemically right” for their biology. DSPD is distinct from insomnia, which is characterized by difficulty falling asleep and staying asleep at any time. However, DSPD can lead to insomnia when individuals try to force themselves to go to bed earlier than their biology will allow, which may lead to the bed becoming associated with wakefulness and frustration.

The 40% Overlap: What the Research Shows

Recent research suggests that as many as 2 in 5 individuals diagnosed with OCD also exhibit symptoms consistent with Delayed Sleep Phase Disorder (Coles et al., 2020; Cox et al., 2022). The reasons behind this 40% overlap include shared genetic vulnerabilities, altered arousal systems, and maladaptive behavioral patterns common to both disorders. Individuals who do not meet full criteria for DPSD, may still notice an impact on their sleep timing. Of note, many teens experience a shift in their circadian rhythm during this developmental period.  It may be especially important to consider adapting ERP for this phase delay in teens with OCD.

How Sleep Impacts Symptoms

The compulsive rituals and cognitive arousal associated with OCD often intensify at night, either due to a lack of distraction or because individuals delay bedtime while engaging in compulsions. This nocturnal activity exacerbates delayed sleep onset, further disrupting circadian rhythms. Additionally, the chronic sleep deprivation and circadian misalignment caused by DSPD can impair cognitive functioning and emotional regulation, worsening OCD symptoms. For some individuals with OCD and DSPD, insomnia may also be present and worsen symptoms and daytime functioning

How DSPD Disrupts Exposure and Response Prevention (ERP)

Exposure and Response Prevention (ERP) is a frontline cognitive-behavioral therapy for OCD that involves gradually exposing patients to feared stimuli while preventing the engagement in compulsive behaviors. Success in ERP relies heavily on consistency, mental stamina, and emotional resilience—factors strongly influenced by sleep quality and circadian alignment.

Sleep Deprivation Undermines ERP

1. Cognitive Impairment: Sleep deprivation impairs executive functions such as attention, working memory, and inhibitory learning, which is key for effective treatment.

2. Emotional Dysregulation: Poor sleep amplifies negative affect and emotional reactivity, potentially making it more difficult for patients to complete exposures.

3. Reduced Motivation and Engagement: Fatigue from circadian misalignment makes it more difficult for patients to attend therapy, complete homework assignments, and stay consistent with exposures.

Circadian Misalignment Complicates Scheduling

Because individuals with DSPD often do not awaken until mid-to-late morning, scheduling therapy sessions becomes challenging. ERP often involves practicing exposures throughout the day in real-world settings. However, if a person wakes at noon and feels functional only in the evening, opportunities for daytime exposures become limited.

Nighttime Rituals Reinforce DSPD

Compulsions such as checking locks or engaging in lengthy mental rituals often become more frequent or prolonged at night.  This behavior both delays sleep and reinforces the misaligned circadian pattern. Executive functioning skills are often lower at night, making it more difficult for individuals to inhibit behavior. Over time, the cycle of late-night compulsions and delayed sleep becomes self-reinforcing.

DSPD and OCD Loops:

* OCD symptoms, especially evening rituals and nighttime obsessions, delay sleep onset.

* Sleep deprivation and circadian misalignment heighten anxiety, reduce coping capacity, and exacerbate OCD symptoms.

* The exacerbated OCD leads to more rituals, which again delay sleep, and so the vicious cycle continues.

This loop can make both conditions more resistant to treatment if addressed in isolation. The International OCD Foundation notes that many individuals with OCD wait an average of 14-17 years to receive proper diagnosis and treatment. Attempting to treat OCD without correcting the circadian rhythm results in suboptimal ERP outcomes, leading individuals to feel even more hopeless about ever recovering from OCD. Likewise, addressing DSPD without modifying compulsive behaviors that delay sleep yields limited improvement.

Why Specialized Training Matters: OCD + Behavioral Sleep Medicine

Treating comorbid OCD and DSPD is not as simple as combining ERP with basic sleep hygiene. Instead, it requires a nuanced understanding of both OCD treatment and circadian rhythm science. Here’s why dual training is essential:

Tailoring ERP to Circadian Patterns

Clinicians trained in Behavioral Sleep Medicine (BSM) and Exposure Plus Response Prevention (like those at Upward) can adjust ERP schedules to fit the patient’s biological rhythm. This can include progressively shifting sleep and exposure timing if the patient wants to shift their sleep. For example, a therapist might initially conduct ERP in the late afternoon or evening when the patient is most alert, then gradually adjust the schedule. Additionally, the presence of insomnia symptoms has been found to mediate the relation between OCD and DSPD.  Understanding the mechanisms within these concurrent sleep disorders and how to apply interventions is key.

Treating DSPD with Evidence-Based Tools

Specialists in BSM may use tools commonly found in insomnia sleep treatments, but it is more than just sleep hygiene or even Cognitive Behavioral Therapy for Insomnia.  Delayed phase sleep disorder is a specific sleep disorder that requires unique interventions. Chronotherapy techniques such as melatonin timing, specialized timing of bright light therapy, and consistent wake times to stabilize circadian rhythm.

These tools must be carefully integrated into OCD treatment or sequenced so that the patient is not overwhelmed by simultaneous behavior changes.  Concurrent or sequencing treatments can also be based on patient preferences.

Therapists with expertise in both domains can help patients understand the mutual reinforcement between OCD and DSPD, which fosters motivation and compliance with integrated treatment protocols.

Best Practices for Clinicians

1. Screen for DSPD in OCD Patients: Ask about bedtimes, wake times, and daytime sleepiness. Use tools like sleep diaries or actigraphy.

2. Coordinate ERP and Circadian Interventions: Consider treatment sequencing based on patient preferences and the bidirectional relation between the disorders.

3. Use Chronotherapy Cautiously: Always time melatonin and light exposure based on circadian science.

4. Educate Patients: Explain the interplay so patients buy into a dual-modality treatment plan.

5. Advocate for Interdisciplinary Collaboration:  If you're not trained in BSM, consider referring to a colleague who is, or co-manage the case. Collaboration with a physician trained in sleep medicine can help with care coordination as well.

Best Practices for Clients

1. Let your clinician know about your natural sleep/wake schedule. When do you have the most energy during the day? What is your preferred sleep/wake schedule if you can choose exactly what feels best?
2. Ask for appointment times that fit your needs. If you know you need afternoon or evening appointment times to benefit the most from treatment, speak up! If your clinician cannot provide times that work for you, ask if they can recommend a colleague. Research shows that telehealth appointments are just as effective as in-person appointments, so consider telehealth to reduce time spent traveling to a clinic.
3. Look for clinicians with training in both OCD and Behavioral Sleep Medicine. Good resources are the International OCD Foundation and the Society of Behavioral Sleep Medicine. If your clinician is not dually trained, are they willing to consult with a colleague?

The Future: Bridging the Gap Between OCD and Sleep Medicine

There is a pressing need for more clinicians to pursue dual training in OCD and Behavioral Sleep Medicine. Currently, the number of therapists competent in both areas is limited, creating barriers to effective care. Clinical training programs should consider integrated tracks, and professional organizations must advocate for cross-disciplinary certifications.