Comorbidities: A History of Mental Health Conditions
Some coexisting mental health conditions, known as comorbidities, can contribute to the severity of OCD symptoms. Individuals with OCD often concurrently struggle with other types of mental health conditions, and these comorbidities could contribute to worsening OCD.
Up to 60–80% of patients with OCD experience a depressive episode in their lifetime, and at least one-third of patients with OCD have a concurrent major depressive disorder at the time of evaluation (Pallanti et al., 2011).
Other comorbid conditions that can add to the severity of OCD symptoms include other anxiety disorders, such as PTSD, social anxiety disorder and health anxiety, eating disorders, attention deficit hyperactivity disorder (ADHD), and substance abuse disorders.
If these comorbidities are left unattended, they can be worsened by increased anxiety and distress and potentially cause OCD behaviors to exacerbate.
Compulsions
Compulsions are actions that people with Obsessive-Compulsive Disorder (OCD) perform to reduce anxiety or prevent feared outcomes related to their obsessive thoughts.
These actions can be visible, like washing hands repeatedly, or mental, like silently repeating a prayer. People with OCD often feel compelled to do these actions in a very specific, ritualized way.
Giving into the compulsions will typically make OCD worse by fueling the vicious cycle of obsessions and compulsions.
While doing a compulsion may initially provide relief and feel like the only way to ease your anxiety, the more compulsions you do, the more OCD will want from you.
And, the longer you remain in the cycle, the more momentum and strength it gains, making it even more difficult to break the cycle, which will repeat itself if you resist the obsessions and give in to the compulsions.
Compulsions prevent learning that the feared outcome wouldn’t happen without the ritual. They also prevent anxiety from naturally fading on its own.
Avoidance
When struggling with OCD, many people will avoid situations they deem triggering to gain control over the anxiety.
For example, they might think, “If I don’t leave my home, I will not get contaminated.” While this might relieve anxiety in the short term, it will only reinforce the OCD in the long term.
If they can’t avoid a feared situation entirely, they may try more subtle avoidance, like wearing gloves to not directly touch things, using their sleeve to open doors, keeping their distance, or having someone else do certain tasks for them.
Over time, more and more things can start to seem connected to their obsessive fears, so they avoid an increasing number of triggers. While these avoidance strategies are understandable, they prevent the person from learning that their feared outcomes likely wouldn’t occur even without avoidance.
Avoidance also takes a lot of time and effort, allowing OCD to intrude more into their lives. So even though it provides some short-term relief, avoidance makes OCD worse in the long run by maintaining the negative beliefs underlying the disorder.
Avoidance gives the power to the OCD and does not allow people to face and overcome triggering situations.
Hypervigilance
People with OCD are constantly on the lookout for things that might trigger their obsessive thoughts, signs that their feared outcomes have happened or will happen, and hints that their compulsive rituals haven’t successfully prevented harm.
This hypervigilance can focus on their own thoughts and bodily sensations or on things in their external environment.
For example:
- Someone afraid of contamination might mentally track everything a “contaminated” object like their purse has touched so they can avoid or clean those spots. Or they might constantly scan the ground for contaminants like blood or feces to avoid.
- Someone with an obsession with symmetry or exactness may track the movements of others in their home so they can fix objects that have been moved out of place.
- Someone with violent or sexual thoughts may monitor their own thoughts for any recurrence of the upsetting ideas, or check the news for signs their feared outcomes have happened.
- Someone afraid of illness may frequently check their body for signs and symptoms.
Ironically, avoiding triggers requires being hypervigilant about those triggers in the first place. Hypervigilance is not always captured on standard OCD symptom checklists, but it’s an important sign of how severe and disruptive the disorder is.
Like avoidance, hypervigilance makes sense as an OCD coping strategy, but backfires in the long run.
Constantly scanning for danger means the person notices the tiniest signs of potential threat, but might miss information showing that the situation is actually safe.
Frequent checking also leads to doubt and undermines confidence in one’s own perceptions – if you check repeatedly, you stop trusting that you’ll notice if something is wrong the first time. Hypervigilance feeds the OCD cycle and makes it difficult to let go of obsessive fears.
Reassurance
When we worry or feel anxious, we can often look to others to reassure us. We might ask, “Are you sure I am a good person?” or “Are my hands clean?” or “Did you sanitize the light switch?” to make us feel better and ease our doubts. However, this habit only fuels the OCD by reinforcing their original fears and feeding into the OCD cycle.
It might make you feel better in the moment, but constant reassurance does not allow your brain to learn to tolerate discomfort.
In the long term, reassurance-seeking prevents you from disconfirming your fears and only contributes to the maintenance of OCD symptoms. Instead, you must practice sitting with short-term discomfort to see long-term success.
Uncertainties
Uncertainty about future events can exacerbate OCD, as an intense need marks this disorder for certainty, control, and perfection.
When faced with unpredictable situations or unknown outcomes in the future, individuals with OCD may react with heightened feelings of anxiety, an overthinking process characterized by repetitive, unrealistic worry.
This anxiety entails a continuous loop of negative thoughts about future events circulating in the mind.
This might include worrying about a future event, thinking of all the worst-case scenarios, replaying a past scenario, predicting how something will play out, or planning something to every last detail.
Stressful Life Events
Stressful life events, such as unemployment, relationship issues, death of a loved one, birth of a child, or financial problems, can provoke stress and intensify our OCD symptoms.
While the symptoms of OCD will range in severity and duration from person to person, they could increase during particularly stressful times, making the condition more difficult to manage.
Like with most other anxiety disorders, periods of high stress can bring out symptoms because as you start to feel overwhelmed, you resort to the unhelpful coping mechanisms you have learned (such as avoidance or compulsions).
This can lead to a return, or a worsening, of OCD symptoms.
Isolation
Isolation from friends, family, and loved ones is common for anyone struggling with mental health challenges. For people with OCD, their preoccupation of their intrusive thoughts and compulsions can make social events seem like a chore.
Over time, this isolation can cause sufferers to feel quite lonely. Anxiety and other OCD symptoms seem to feel the strongest when the person is alone and left with nothing to do but overthink.
While socializing might seem daunting and tiresome, isolation could feed and grow the OCD.
Junk Food
“Junk” foods, such as foods high in processed ingredients, sugars, fats, oils, and sodium, could exacerbate your OCD symptoms.
A poor diet can put excess stress on the body, such as fluctuating blood sugar levels, impairing higher cognitive functioning, or causing neuro-inflammation.
By avoiding highly processed and gluten-based foods, people with OCD can slow their obsessions and compulsive behaviors.
Inadequate or Poor Sleep
It is common for individuals with OCD to have difficulty falling and staying asleep due to racing thoughts, nightmares, worries, rumination, intrusive thoughts, and urges.
Severe OCD symptoms are proven to be associated with greater sleep disturbance, and the more severe the OCD, the more severe the sleep disruption.
Not getting enough sleep will impact your health and well-being, and consequently, it can worsen your OCD symptoms.
If the body’s internal clock is altered, then your mind’s perception of control and the ability to ward off compulsions may be too. A poor night’s sleep could significantly affect the next day by making OCD symptoms more severe.
OCD Coping Strategies
Symptoms of OCD can be managed with proper treatment and coping skills. The International OCD Foundation suggests that 70% of people with OCD will benefit from treatment with Exposure Response Prevention (ERP), medication, or a combination.
Additionally, becoming more aware of your triggers and learning how better manage your intrusive thoughts by not giving in to your compulsions can also lessen the anxiety associated with OCD.
Instead of focusing on blocking your thoughts and thinking of ways to prevent your OCD, try channeling your energy into other activities or relationships.
People who suffer from OCD tend to struggle with perfectionism. Striving always to be the best in life can sometimes become an obsession, feeding your OCD. It is important to remember that perfection does not exist and that being perfect does not always correlate with progress.
There are several treatment options and coping strategies to manage your OCD symptoms and prevent them from progressing further.
You can control your stress levels by engaging in activities that elevate your mood or help manage your stress. These might include yoga, working out, meditating, and journaling.
Cognitive-Behavioral Therapy (CBT)
One therapy often used to treat OCD is cognitive-behavior therapy, using an intervention called Exposure Response Prevention (ERP).
Exposure and response prevention is a sub-type of CBT considered the first-line psychotherapy for OCD (Hezel & Simpson, 2019).
ERP involves deliberately exposing oneself to intrusive thoughts, objects, and situations that make you anxious and then preventing yourself from engaging in compulsive actions in reaction to these thoughts.
The hope is that you will learn that no harm will follow even if you refrain from compulsive behaviors and eventually become less sensitive to the things that once caused you great anxiety.
When doing ERP, your therapist will help you decrease your anxiety by identifying the thought patterns distorting your view of reality and leading to these obsessive thoughts.
This is followed by learning how to gradually reduce the frequency of compulsions while sitting with those intrusive/ obsessive thoughts.
The goal of CBT in the context of OCD is to uncover the underlying fear driving the intrusive thoughts, reassess these misguided beliefs, and restructure these thoughts in productive ways.
When undertaking CBT, it is customary to initially experience greater anxiety than you did before you started therapy (Mancebo, 2011).
Dialectical Behavior Therapy (DBT)
Dialectical behavior therapy is a form of cognitive behavioral therapy focusing on mindfulness, acceptance, emotion regulation, interpersonal effectiveness, and distress tolerance.
“Dialectical” means combining opposite ideas and finding comfort in contradiction.
DBT is a skill-based treatment that focuses on helping people accept their realities while helping them learn to change their unhelpful behaviors.
With DBT, your thoughts and behaviors are not categorized as good or bad, but instead, they are accepted for what they are.
This step of acceptance and non-judgment is often necessary before people are ready to make measurable changes.
Deep Brain Stimulation (DBS)
Deep Brain Stimulation is an investigational approach for people with more severe OCD symptoms that do not improve with traditional medications or psychotherapy.
DBS is an investigational surgical treatment that uses electrical impulses to target specific brain areas contributing to your symptoms.
The goal of DBS in treating OCD is to alleviate the disorder’s symptoms by modulating the activity of certain brain circuits believed to be involved in its pathology.
DBS involves the surgical implantation of a neurostimulator device (similar to a heart pacemaker), which delivers electrical impulses to specific brain areas.
For OCD, the most commonly targeted areas are the parts of the brain involved in regulating mood and behavior, such as the ventral capsule/ventral striatum (VC/VS), the anterior limb of the internal capsule (ALIC), and other regions associated with the cortico-striato-thalamo-cortical (CSTC) circuit.
The precise mechanisms by which DBS works are not entirely understood. However, it is thought to help normalize the abnormal neural activity seen in OCD, potentially reducing the frequency and intensity of obsessions and compulsions.
Exercise
Exercise can be another beneficial tool to help manage OCD symptoms. Exercise is a natural reducer of stress and anxiety because when your body is active, your body releases endorphins that decrease tension, lift your mood, and reduce discomfort.
For example, one study by Dr. Ana Abrantes of Butler Hospital in Rhode Island found that 30% of participants who added exercise to their OCD treatment regimen reported decreased depression, anxiety, and OCD symptoms.
Although physical activity is not a substitute for therapy, and the effects may only be temporary, adding exercise to your daily routine can lead to an overall decrease in your OCD-related anxiety.
Mindfulness
Mindfulness meditation can be an effective way to manage OCD thoughts or urges and the distress that comes with them.
While sitting with your obsessive thoughts might be overwhelming, meditation can help you relax, slow down your busy thoughts, and learn to be more present in the moment.
We learn to be more mindful of where our thoughts go by focusing on our breath, a mantra, or specific imagery. Mindfulness can be done effectively in conjunction with a form of CBT.
Medication
Certain psychiatric medications, specifically selective serotonin reuptake inhibitors (SSRIs), may manage control the obsessions and compulsions of OCD.
Several different SSRIs have been approved by the U.S. Food and Drug Administration (FDA) to treat OCD, including Clomipramine (Anafranil), Fluoxetine (Prozac), Paroxetine (Paxil, Pexeva), Escitalopram (Lexapro), and Sertraline (Zoloft).
While medication therapy can be effective, it is essential to be aware of the side effects and understand that it might take time for patients to identify what medication is the most effective for them.
The best treatment for OCD is a combination of CBT and SSRIs, especially if OCD symptoms are severe.
Does OCD Go Away?
OCD is a chronic mental health condition that does not typically go away on its own without treatment. However, with appropriate treatment and management strategies, many individuals with OCD can experience significant improvement in their symptoms and lead fulfilling lives.
The goal of treatment for OCD is to reduce the frequency and intensity of obsessive thoughts and compulsive behaviors and enhance the overall quality of life.
FAQs
Does anxiety make OCD worse?
Yes, periods of high anxiety and stress can bring out OCD symptoms. As we start to feel overwhelmed and anxious, we tend to turn to the coping mechanisms we have learned and rely on our compulsions to ease our stress.
When we are in states of heightened anxiety, we have less strength to sit with our OCD thoughts, which can lead to a return or worsening of OCD symptoms.
Can smoking or drinking make OCD worse?
While drinking or smoking might provide short-lived relief from your OCD symptoms, these habits could worsen your symptoms and create more distress in the long run.
In some instances, smoking and drinking are the compulsions used to relieve an individual’s obsessions, so by giving in to these compulsions, you are just fueling the OCD cycle.
Some people who were not experiencing OCD symptoms before drinking report a return of OCD symptoms after drinking
Does social media make OCD worse?
Notably, aspects of social media and OCD can be pretty similar. While social media can be a precious resource for individuals with OCD and other mental disorders, social media usage as a coping strategy could contribute to reinforcing OCD symptoms.
The internet can be an escape and a source of community for some, but for others, it is just another place for OCD to emerge.
Why is my OCD worse at night?
Bedtime is the loneliest part of the day, and OCD symptoms could emerge more easily when we are less occupied. When you are alone with your obsessions, this can make them feel more real and powerful.
At night when your mind is meant to be quiet, anxious thoughts could linger and grab control of your mind.
Obsessive thoughts can keep victims of OCD up all night, and one compulsion can disrupt an entire night’s sleep.
Additionally, research has shown a link between OCD and insomnia – people with OCD are more likely to have insomnia than the rest of the population.
Does OCD get progressively worse as we age?
OCD is typically diagnosed between the ages of 8 and 12 or between the late teenage years and early adulthood, but the condition varies in severity throughout one’s life. The average age of onset is 19, with 25% of cases occurring by age 14.
OCD symptoms are known to intensify and worsen as we age. The symptoms tend to come on gradually early in life and become more challenging to manage over time.
However, it is essential to note that OCD does not necessarily get worse for everyone. Most people who experience mild-to-moderate symptoms of OCD will learn to manage their obsessive thought patterns and compulsive actions.
But when left untreated, the symptoms could worsen over the years and even become unmanageable with a triggering life event.
Because there are many subtypes of OCD, such as checking OCD, counting OCD, or
cleaning OCD, and many different ways the condition can show up in a person’s life, people typically experience their OCD differently throughout their lifetime.
Sources
Brierley, M. E. E., Thompson, E. M., Albertella, L., & Fontenelle, L. F. (2021). Lifestyle interventions in the treatment of Obsessive-Compulsive and Related Disorders: A systematic review. Psychosomatic medicine, 83(8), 817-833.
Brown, R. A., Abrantes, A. M., Strong, D. R., Mancebo, M. C., Menard, J., Rasmussen, S. A., & Greenberg, B. D. (2007). A pilot study of moderate-intensity aerobic exercise for obsessive compulsive disorder. The Journal of nervous and mental disease, 195(6), 514-520.
Cox, R. C., Parmar, A. M., & Olatunji, B. O. (2020). Sleep in obsessive-compulsive and related disorders: a selective review and synthesis. Current Opinion in Psychology, 34, 23-26.
Gillan, C. M., Morein-Zamir, S., Urcelay, G. P., Sule, A., Voon, V., Apergis-Schoute, A. M., … & Robbins, T. W. (2014). Enhanced avoidance habits in obsessive-compulsive disorder. Biological psychiatry, 75(8), 631-638.
Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian journal of psychiatry, 61(Suppl 1), S85.
Morgado, P., Freitas, D., Bessa, J. M., Sousa, N., & Cerqueira, J. J. (2013). Perceived stress in obsessive–compulsive disorder is related with obsessive but not compulsive symptoms. Frontiers in psychiatry, 4, 21.
Raines, A. M., Vidaurri, D. N., Portero, A. K., & Schmidt, N. B. (2017). Associations between rumination and obsessive-compulsive symptom dimensions. Personality and Individual Differences, 113, 63-67.
Wheaton, M. G., Gershkovich, M., Gallagher, T., Foa, E. B., & Simpson, H. B. (2018). Behavioral avoidance predicts treatment outcome with exposure and response prevention for obsessive–compulsive disorder. Depression and anxiety, 35(3), 256-263.
