Can a patient have a diagnosis of both anxiety and Obsessive-Compulsive Disorder (OCD)?

Can a Patient Have Both Anxiety and OCD?

Yes, a patient can absolutely have both an anxiety disorder and OCD as separate, comorbid diagnoses—in fact, anxiety disorders are the most common comorbid conditions with OCD, occurring in approximately 90% of individuals with lifetime OCD. 1

Understanding the Comorbidity

High Rates of Co-occurrence

• Anxiety disorders represent the most frequent comorbid psychiatric conditions in patients with OCD, with epidemiological data from the National Comorbidity Survey Replication showing that 90% of individuals with lifetime OCD met diagnostic criteria for another psychiatric disorder, most commonly anxiety disorders. 1
• In the majority of cases (79.2%), OCD began after the comorbid anxiety disorder, suggesting that anxiety disorders often precede OCD development. 1

Diagnostic Criteria Allow for Multiple Diagnoses

• The DSM-5 diagnostic criteria for OCD explicitly state that the diagnosis should only be excluded if "the disturbance is not better explained by the symptoms of another mental disorder." 1
• This means that if a patient has distinct OCD symptoms (obsessions/compulsions taking >1 hour per day or causing significant distress) and separate anxiety disorder symptoms (such as generalized worry in GAD, social fears in social anxiety disorder, or panic attacks in panic disorder), both diagnoses are appropriate. 1

Key Diagnostic Distinctions

When to Diagnose Both Conditions

You should diagnose both OCD and an anxiety disorder when:

• The obsessions and compulsions are distinct from the anxiety symptoms (e.g., contamination obsessions with washing compulsions in OCD, plus excessive worry about multiple life domains in generalized anxiety disorder). 1
• Each condition causes independent functional impairment and meets full diagnostic criteria on its own. 1
• The OCD symptoms are not simply excessive worries as seen in generalized anxiety disorder—OCD obsessions are intrusive, ego-dystonic thoughts that the patient attempts to neutralize with compulsions. 1

Common Pitfalls to Avoid

• Do not confuse generalized anxiety disorder's excessive worries with OCD obsessions—GAD worries are typically about realistic life circumstances, while OCD obsessions are often unrealistic, intrusive thoughts about contamination, harm, symmetry, or forbidden thoughts. 1
• Carefully assess whether anxiety symptoms are secondary to OCD (e.g., anxiety only occurs when prevented from performing compulsions) versus representing a separate anxiety disorder. 1
• Use structured assessment tools like the Yale-Brown Obsessive Compulsive Scale (Y-BOCS score ≥14 for obsessions alone or ≥28 for combined symptoms indicates clinically significant OCD) to quantify OCD severity separately from anxiety measures. 1, 2

Treatment Implications

When Both Diagnoses Are Present

• SSRIs are first-line pharmacotherapy for both OCD and most anxiety disorders, making them particularly useful in comorbid presentations—sertraline is FDA-approved for OCD, panic disorder, PTSD, and social anxiety disorder. 1, 3
• Cognitive Behavioral Therapy with Exposure and Response Prevention (ERP) remains the gold standard for OCD, even in the presence of comorbid anxiety disorders. 1
• Address comorbid conditions in treatment planning—the presence of comorbid anxiety disorders may require integrated treatment approaches, though ERP for OCD should not be delayed. 1
• Comorbid depression is also common (occurring alongside anxiety disorders and OCD) and may interfere with therapeutic progress, requiring concurrent treatment. 1, 4

Specific Comorbid Presentations

• Social Anxiety Disorder with OCD: When a patient has both marked fear of social scrutiny (social anxiety) and separate obsessions/compulsions, both diagnoses apply—treatment includes ERP for OCD and exposure therapy for social anxiety, with sertraline as first-line medication. 2
• Illness Anxiety Disorder with OCD: These conditions frequently co-occur but represent distinct disorders with different symptom profiles—careful functional analysis distinguishes health-focused obsessions (OCD) from pervasive illness preoccupation (illness anxiety). 5, 6

Clinical Assessment Approach

To determine if both diagnoses apply, systematically assess:

• Whether obsessions are truly intrusive and ego-dystonic (unwanted, causing marked distress) versus realistic worries about life circumstances. 1, 7
• Whether compulsions are present as repetitive behaviors or mental acts aimed at reducing anxiety from obsessions (>1 hour per day or causing significant impairment). 1
• Whether anxiety symptoms exist independently of OCD symptoms and cause separate functional impairment. 1
• The temporal relationship between symptom onset—did anxiety symptoms precede OCD, or did they emerge simultaneously? 1