Obsessive-compulsive disorder (OCD) is a psychopathological condition that, due to its clinical expression, can condition life in a very important way. Since it is also a condition of chronic course, it is possible that at some point in its evolution it may concur with other disturbances of the psychic sphere that may overshadow the prognosis.
In fact, most studies addressing the issue stress that having OCD is a risk factor for comorbidities of many different kinds. This circumstance becomes a therapeutic challenge of enormous magnitude for the psychologist who deals with it, and an emotional feat for the patient who faces it.
Comorbidity” is understood as the presence of two or more disorders in a single individual and moment, so that the result of their concomitance becomes much more than the simple sum of them. It is, therefore, a unique journey for each patient, since it also interacts with those personality traits that are specific to him.
This article will address some of the mental health problems that can arise throughout the lives of people with OCD (the comorbidities of OCD) although it is essential to emphasize that their appearance is not mandatory. We will only talk about an increase in risk, that is, an additional element of vulnerability.
Obsessive-Compulsive Disorder (OCD) is a clinical picture characterized by the presence of intrusive thoughts followed by ritual acts with a clear functional relationship , aimed at reducing the discomfort generated by the former. With the passage of time, the bond between them tends to become stronger, so that thinking and acting enter a cycle from which it is not easy to escape.
Most often the person is aware that their “problem” is irrational or disproportionate , but there are cases in which such an assessment may not be present, especially when dealing with children or adults with poor introspection.
There are effective treatments for it, both psychological (exposure to mental content, cognitive restructuring and so on) and pharmacological (especially with serotonin reuptake inhibitor and tricyclic antidepressants). If an adequate programme is not articulated, the evolution tends to be progressive and insidiously diminishes the quality of life of those who suffer from it. Moreover, it is a mental health problem that very often occurs with other disorders, as we will see in the following.
Comorbidities of OCD
As we saw earlier, OCD is a condition of enormous clinical relevance for the person who suffers it, with a great capacity to condition the development of his or her daily life. Furthermore, the possibility has been documented that a series of secondary mental problems may also appear , complicating their expression and treatment . This phenomenon (known as comorbidity) involves interactions between the problems referred to, from which derive combinations charged with a profound idiosyncrasy. In the text we will deal with some of the most relevant ones.
1. Major depression
Mood disorders, and more specifically major depression, are perhaps one of the most common comorbidities in OCD. Both of them involve intrusive thoughts that generate intense discomfort , which is associated with the altered activity of structures located in the prefrontal region of the brain. When presented together they tend to affect each other, thus accentuating obsessive ideas and their overall impact. In other words, both OCD and depression itself become more severe.
Most commonly, sadness and the loss of the ability to experience pleasure emerge as an emotional response to the limitations imposed by OCD on the activities of daily life, since in severe cases it becomes an enormously invasive pathology. It has also been suggested that both entities are linked to alterations in the function of serotonin , a neurotransmitter that contributes to the maintenance of mood and that could explain its remarkable comorbidity. Up to two-thirds, approximately 66% of OCD subjects, will suffer from depression at some point in their lives.
It is known that the prevalence of depressive symptoms in these patients directly affects the presence of obsessive ideas, reduces therapeutic adherence and increases the risk of the intervention not being effective. For this reason, it is important to know the synergistic effects of this dual pathology, to articulate a therapeutic program in which the possible adverse contingencies are foreseen and to stimulate the motivation during the whole process.
2. Anxiety disorders
Another common comorbidities of OCD is with anxiety problems; and especially with social phobia (18%), panic disorder (12%), specific phobias (22%) and generalized anxiety (30%) . The presence of these, as with depression, is a special concern and requires the use of mixed therapeutic approaches, in which cognitive behavioural therapy must be present. In any case, the prevalence of these psychological problems is higher in patients with OCD than in the general population, from a statistical point of view.
One of the main causes is the overlap between the expression of OCD and anxiety. So much so that, just a few years ago, OCD itself was included in the category. Most often, of course, it is “confused” with generalized anxiety, since in both cases there would be concern about negative thoughts. However, they can be differentiated by the fact that in generalized anxiety the feared situations are more realistic (related to topics of ordinary life) and that rumination here acquires egosyntonic properties (it is understood as useful).
Panic disorder is also very common in people with OCD, which is associated with an autonomic (sympathetic nervous system) hyperactivity that is difficult to predict, and whose symptoms disrupt any attempt to develop life normally. Specific phobias, or irrational fears, are also common when exploring people with OCD. These are often associated with a wide range of pathogens (in the case of cleaning obsessions), and they should be distinguished from hypochondriacal fears of serious illness.
3. Obsessive-compulsive personality disorder
People with OCD are at greater risk of showing an obsessive-compulsive personality profile, that is, one based on perfectionism of such a magnitude that it hinders the normal development of everyday life. It can often be a pattern of thinking and behavior that was present before the onset of OCD itself, as a kind of breeding ground for it. The synergy of both would lead to the appearance of invasive mental contents that would aggravate the high level of self-demand, greatly accentuating behavioural and cognitive rigidity.
In general, it is known that subjects with an obsessive-compulsive personality who suffer from OCD show symptoms of greater intensity and scope, since their perfectionism is projected toward much more intense efforts to control the degree of invasiveness of the obsessions, which paradoxically ends up making them worse.
4. Bipolar disorder
The literature has described people with OCD as being at increased risk for bipolar disorder, although there are discrepancies at this end. While some authors don’t believe that the two disorders have anything in common, and attribute any possible similarities to particularities in acute episodes of OCD (mania-like compulsive behaviors), others stress that the risk of bipolarity for these patients is twice that of the general population .
It has been described that people with OCD who also have a bipolar disorder indicate a greater presence of obsessive ideas, and that their content adapts to the acute episode being experienced at any given time (depressive or manic). There is also evidence that those with this comorbidity report more obsessive thoughts (sexual, aggressive, etc.) and a greater number of suicide attempts, when compared to patients with OCD without bipolarity.
5. Psychotic disorders
In recent years, based on new empirical evidence, a label has been proposed to describe people living with both OCD and schizophrenia: schizo-obsession .
These are subjects whose psychosis differs greatly from that observed in patients without obsessive-compulsive symptoms; both in terms of clinical expression and response to pharmacological treatment or cognitive impairment profile, indicating that it could be an additional modality within the broad spectrum of schizophrenias. In fact, it is estimated that 12% of patients with schizophrenia also meet diagnostic criteria for OCD.
In these cases, OCD symptoms are seen in the context of the acute episodes of their psychosis, or even during their prodromals, and should be distinguished from each other. The fact is that are disorders that share a common neurological basis , which increases the likelihood that at some point the two will coexist. The shared structures would be the basal ganglia, thalamus, anterior cingulate and orbitofrontal/temporal cortexes.
6. Eating disorders
Certain eating disorders, such as anorexia or bulimia, may share some traits with OCD itself. The most important of these are perfectionism and the presence of ideas that repeatedly enter the mind, triggering reassurance behaviors.
In the case of eating disorders , it is thoughts associated with weight or shape, along with the constant check that you have not changed your size or that your body remains the same as it was last looked at. This is why both should be carefully distinguished during the diagnostic phase, in case the criteria of one and the other are met.
Cases of OCD have been documented in which an obsession with food contamination (or that food might be infested with a pathogen) has reached such a magnitude that it has precipitated a restriction of intake. It is in these cases that a thorough differential diagnosis is particularly important, since the treatment of these pathologies requires the articulation of very different procedures. In the event that they coexist at some point, it is very possible that purging behaviour or physical overexertion will increase .
7. Tic disorder
Tic disorder is an invasive condition characterized by the inevitable presence of simple/stereotyped motor behaviors, which arise in response to a perceived urge to move, which is only relieved at the moment of “execution. It is therefore very similar functionally to what happens in OCD, to the extent that manuals such as the DSM have chosen to include a subtype that reflects such a comorbidity. Thus, it is estimated that approximately half of the pediatric patients diagnosed with OCD show this type of motor aberration , especially among males whose problem began at a very early age (early in life).
Traditionally, children with OCD who also refer to one or more tics have been thought to be difficult to address, but the literature on the subject is inconclusive. While in some cases it is pointed out that children with OCD and tics have more recurrent thoughts with aggressive content, or that they are patients with a poor response to pharmacological and psychological treatment, in others there are no differential nuances that warrant greater severity. However, there is evidence that OCD with tics shows a more notorious family history pattern , so its genetic load could be greater.
8. Attention Deficit Hyperactivity Disorder (ADHD)
Studies on the comorbidity of these disorders show that 21% of children with OCD meet the diagnostic criteria for ADHD , a percentage that drops to 8.5% in adults with OCD. This data is curious, since these are conditions that affect the same region of the brain (the prefrontal cortex), but with very different patterns of activation: in one case by increase (OCD) and in the other by deficit (ADHD).
To explain this paradox it has been proposed that the excessive cognitive fluidity (mental intrusion) of OCD would generate a saturation of cognitive resources , which would translate into an impairment of the executive functions mediated by this area of the nervous system, and therefore with an attentional difficulty comparable to that of ADHD.
On the other hand, it is estimated that the reduction in prevalence that occurs between childhood and adulthood could be due to the fact that from the age of 25 onwards the prefrontal cortex is fully mature (as it is the last area of the brain to do so), and also to the fact that ADHD tends to “soften” as time goes by.
- Lochner, C., Fineberg N., Zohar, J., Van Ameringen, M., Juven-Wetzler, A., Altamura, A., Cuzen, N., Hollander, E. …Stein, D.. (2014). Comorbidity in obsessive-compulsive disorder (OCD): A report from the International College of Obsessive-Compulsive Spectrum Disorders. Comprehensive psychiatry, 55(7), 47-62.
- Pallanti, S., Grassi, G., Sarrecchia, E., Cantisani, A. and Pellegrini, M. (2011). Obsessive-Compulsive Disorder Comorbidity: Clinical Assessment and Therapeutic Implications. Frontiers in psychiatry / Frontiers Research Foundation, 2 (70), 70.