In the realm of anxiety, OCD, and PTSD recovery, selecting the right therapeutic approach is crucial for effective treatment. PTSD and OCD commonly co-occur, and while each diagnosis has distinct symptoms, both include high levels of anxiety. While the exact causes of OCD vary and are thought to involve a complex interplay of genetics, life events, and biological factors, OCD can emerge for the first time after a traumatic event.

Two distinct methodologies are utilized when treating anxiety stemming from either OCD or PTSD. Each therapeutic framework serves different purposes, and understanding when to apply them can significantly impact treatment effectiveness.

Grounding techniques are emphasized early in trauma treatment, as part of evidence-based therapies like EMDR.

Grounding refers to a set of techniques used to help individuals reconnect with the present moment. These techniques aim to provide a sense of safety and stability by anchoring individuals in their immediate surroundings and current sensory experiences.

Grounding is pivotal in trauma therapy because PTSD can disrupt brain function, particularly the prefrontal cortex (PFC). The PFC, responsible for higher-level cognitive functions such as decision-making and emotional regulation, can become less active or “go offline” during PTSD episodes.

In contrast, exposure and response prevention (ERP) therapy methods are utilized to treat OCD.

While relaxation and grounding skills can be beneficial for both treatment of PTSD and overall mental wellness, they are counterproductive to ERP goals when used in direct response to intrusive thoughts caused by OCD.

ERP focuses on progressively increasing one’s tolerance to intrusive thoughts by allowing two brain to occur: habituation and inhibitory learning.

ERP involves exposing oneself to anxiety producing situations without compulsive intervention and instead, allowing the passage of time to do its job.

When individuals respond to intrusive thoughts associated with OCD by urgently applying a grounding skill, the brain receives the message that “this thought is important and I have to do something about it!” Urgent and repetitive grounding skill application interrupts the neural restructuring process that is necessarily to treat OCD effectively.

Treatment complexities arise when both OCD and PTSD are present, necessitating careful consideration of which methods to employ and when.

Navigating these treatment decisions is not an exact science, and addressing both conditions simultaneously requires flexibility and adaptations based on evolving symptoms over the course of treatment.

The first step in treating these diagnoses is determining which symptoms are primarily driving the anxiety.

Anxiety symptoms related to PTSD often have a clearer connection to details of the traumatic event, and the symptoms tend to “make sense” as part of a larger narrative.

On the other hand, OCD symptoms may not be “logical” in the traditional sense. (Disclaimer: a newer model for OCD called I-CBT would postulate that OCD symptoms/obsessional doubts are not random and have a story that developed relative to dysfunctional reasoning. When I say that the symptoms are not logical when comparing PTSD to OCD, I mean that they are not always as intuitive without further therapeutic work to uncover).

Below, we will compare three symptoms of anxiety that can occur in both PTSD and OCD, but will distinguish how these symptoms present differently:

Common anxiety symptoms associated with PTSD include:

Intrusive Memories: Recurrent, distressing memories of traumatic events, often in the form of flashbacks or nightmares. These memories can feel as if they are happening again and can lead to dissociation to occur.

Avoidance: Avoiding people, places, activities, or situations that remind the individual of the traumatic events.

Hyperarousal: Persistent feelings of heightened alertness, anxiety, or being easily startled. This can lead to difficulty concentrating, irritability, insomnia, or hypervigilance.

Anxiety symptoms related to an OCD diagnosis may have a more irrational quality to them:

Intrusive Thoughts: Unwanted, distressing thoughts, images, or impulses that repeatedly enter a person’s mind. These thoughts are typically disturbing; may be completely unrelated to events happening in the present moment; and go against the individual’s values or beliefs.

Avoidance: Avoidance behaviors are intended to reduce anxiety caused by obsessive thoughts. These behaviors are often ritualistic and repetitive. Avoidance behaviors can provide temporary relief but typically reinforce the cycle of obsessions and compulsions in OCD.

Hyperarousal: The hyperarousal associated with OCD symptoms is related to thoughts (obsessions), as opposed to trauma hyperarousal which is thought to originate in the body (the premise of the book “The Body Keeps the Score” by Bessel Van Der Kolk).

After carefully evaluating the anxiety symptoms described above and assessing whether they are more closely related to OCD or PTSD, therapists should make an informed decision on where to begin treatment – either addressing trauma first or focusing on OCD symptoms.

The is debate so to whether or not PTSD therapies like EMDR can be applied to OCD treatment. It is important to note that EMDR is not an evidenced-based treatment for OCD. While EMDR’s exposure principle overlaps with ERP and can potentially aid in symptom reduction, the exposure component alone in EMDR does not address the most important part of OCD treatment – response prevention.

The response prevention aspect of ERP involves strengthening one’s ability to experience an OCD trigger without engaging in compulsions. There is also an emphasis on strategies such postponing, undoing, or resisting compulsive actions. Without expert training in this part of treatment, a client may struggle to sustain long-term progress.

Other aspects unique to OCD treatment that are not included in EMDR include intensive education on OCD and brain processes; real-world exposures, as opposed to solely imaginal; and involving loved ones in treatment to minimize accommodation and reassurance-seeking behaviors.

Ideally, finding a therapist specializing in both OCD and PTSD is optimal.

Consider consulting both an EMDR and ERP therapist who can collaborate on a treatment plan. Enlisting help from both providers who can work together in your treatment is ideal; both of these diagnoses are complex and require advanced training to treat.

In conclusion, navigating the complex interplay of OCD and PTSD requires careful consideration of tailored therapeutic approaches that address the unique manifestations of each condition.

Pursuing coordinated treatment plans and leveraging complimentary evidenced-based therapies can optimize outcomes for individuals facing these overlapping challenges. By prioritizing flexibility in treatment goals, therapists and individuals can collaboratively work towards achieving meaningful and sustainable recovery.

No spam, just a good old fashioned monthly blog. Enter your email for writings about anxiety and other mental health topics to be delivered right to your inbox.

Barb Shepard is a Licensed Mental Health Counselor and OCD and Anxiety Specialist in Syracuse, New York. Any content on my website or blog is a not substitute for therapy and is for educational purposes only. I cannot provide tailored therapeutic advice unless you are a therapy client. Reading this blog or listening to audio content does not constitute a therapeutic relationship. If you are seeking therapy, visit psychologytoday.com. If you are in crisis, dial 911 or visit your local emergency room.