The Connection Between OCD and Depression

Obsessive compulsive disorder (OCD) and depression are often comorbid, meaning that they occur together. This article takes a look at why the two are so closely tied and what can be done about it.

Content

The basics

What is OCD?

Obsessive compulsive disorder (OCD) is a mental illness categorized by obsessions and compulsions. Obsessions are distressing intrusive thoughts, and compulsions are repetitive or ritualistic actions carried out to ‘cope’ with these thoughts.

While we all experience intrusive thoughts, an individual with OCD attaches great significance to these thoughts and experiences a great deal of emotional distress in response to them. The compulsions they carry out attempt to alleviate their anxiety or to ‘prevent’ something bad happening as a result of their thoughts. Unfortunately, compulsions feed into the OCD cycle and perpetuate the problem.

OCD can take over an individual’s life. Obsessions can be extremely disturbing and make the person feel really bad about themselves. People with OCD often live in constant fear and experience high levels of anxiety. Compulsions often take up a great deal of time and can be very disruptive to the individual’s life.

What is depression?

Depression is a mood disorder causing very low mood and lack of energy, among other symptoms. This is more than just simply feeling a bit sad, but rather an all encompassing sadness which can cause the individual to feel hopeless, worthless, angry, distressed, fatigued and more.

Depression can be very tough to deal with and can have a significant effect on an individual’s life. It’s often hard to even get out of bed, never mind function daily, when you are depressed. Many people with depression struggle to sleep; to take care of themselves; to keep up with responsibilities; to concentrate; and to engage in pleasurable activities.

Does one cause the other?

It’s very common for OCD and depression to be comorbid. In fact, it’s estimated that between 40% and 75% of people with OCD also have depression. Both OCD and depression have aspects which overlap, and each disorder has symptoms which can contribute to the other disorder. This means one disorder can play a part in causing the other. Which disorder is experienced first depends on many factors about the individual’s situation. However some research suggests that, “depression usually emerges after the onset of OCD”.

Overlapping factors

Research has shown that there are some factors which both OCD and depression share, demonstrating the clear link between the two.

Chemical imbalance

Both OCD and depression involve the individual having a chemical imbalance in the brain. Neurotransmitters are chemicals within your brain which pass messages between different areas of your brain and your nervous system. Essentially they help to maintain good communication, enabling your body and mind to function properly.

When the balance of neurotransmitters is disturbed, it can understandably cause problems, including issues with mood and anxiety. It’s understood that specific neurotransmitters (including serotonin and dopamine) are imbalanced both in those with OCD, and those with depression. This article explains that OCD can perpetuate depression, “simply by enhancing an underlying biochemical imbalance.”

Genetic factors

Both OCD and depression have a strong genetic component, which means that they can run in families. If someone in your family (particularly close relatives such as your parents) have OCD or depression, you are far more likely to develop the disorder yourself.

This study concluded that both OCD and depression symptoms, “co-occur primarily due to shared genetic factors and suggest that genetic, rather than environmental, effects account for the longitudinal relationship.”

Rumination

Those with depression tend to experience rumination regularly. Rumination means that the individual tends to dwell on negative, intrusive thoughts and go over them in their mind repeatedly. This article explains that, “This phenomenon of getting stuck thinking about the same negative things over and over is what psychology researchers call rumination.”

Rumination and obsessive thoughts share some similarities: the propensity to dwell on intrusive thoughts in depression is similar to the thought processes of OCD. In both OCD and depression, the individual attaches a great deal of significance to intrusive thoughts. The repeated feelings such as worthlessness, shame and guilt around these negative thoughts are similar. However those experiencing rumination don’t take action to try to ease negative feelings around their thoughts (as those with obsessions do).

Catastrophic thinking

Those with depression tend to struggle with catastrophic thinking, meaning that their mind jumps to the worst case scenario in any given situation. It’s common to find that you’re expecting bad outcomes. Similarly, those with OCD struggle with a thought process known as overestimation of threat, which means that they see potential threats even where there are none. They also tend to assume the worst, as well as assuming that they will not be able to cope with a negative outcome.

How does OCD contribute to depression?

There are many aspects of living with OCD which can contribute to an individual becoming depressed. Let’s take a look at some of the most prominent causes.

Stress and anxiety

When you live with OCD, you are almost constantly in a state of very high anxiety and prolonged stress. In the short term, stress is a helpful response which keeps us safe. When we’re stressed, we move into a ‘fight or flight’ mode, which gets our body and mind ready for action. However, we are not designed to withstand prolonged stress. Therefore when the stress response becomes prolonged, stress becomes harmful rather than helpful.

Long term stress can lead to many physical health issues, as well as mental health issues such as depression. When you’re always on high alert, emotions are running high, and you don’t get the time you need for relaxation, it can cause your mood to fall dramatically. This article states that, “Sustained or chronic stress, in particular, leads to elevated hormones such as cortisol, the “stress hormone,” and reduced serotonin and other neurotransmitters in the brain, including dopamine, which has been linked to depression.”

Social withdrawal

Those with OCD tend to withdraw socially. This can be because their compulsions take up so much time, or because their mind is so busy with obsessions that socializing becomes less of a priority. Alternatively they may avoid socializing because it might trigger their obsessions. For example, you might avoid social situations if you have obsessions around relationships.

Avoidance can also stem from fear of losing control, which is a common theme in those with OCD. You might avoid being around others because you fear you will lose control of yourself and say or do something you will later be ashamed of.

As humans, almost all of us need regular social interaction to feel happy and content. We’re social creatures by nature. When we begin to withdraw socially, it can have a marked impact on our mood as we start to feel alone and isolated.

Feeling alone

Aside from the social withdrawal aspect of OCD making an individual feel alone, the experience of living with OCD itself can be lonely. You can feel alone even in a room full of people. This is because you might feel ‘strange’ or ‘weird’ because of your obsessions and compulsive behaviours. You might think no one else has intrusive thoughts, and it makes you different from others.

You may see others feeling happy and functioning ‘normally’, and feel that you are very different than they are. It’s common to feel that no one is going to understand how you feel and what you are going through. This sense of being different and alone in the world is understandably very depressing. Over time this can lead to you feeling increasingly isolated.

Feelings of hopelessness

When you live with OCD, it’s very common to feel that there is no hope of things improving. You might fear that you are always going to be stuck in this cycle, and find it hard to see any light at the end of the tunnel. It’s hard to plan for the future when you feel that there is no hope for you overcoming your OCD or being able to function. Understandably, feeling hopeless about your life and your future can lead to low mood and depression.

Feelings of guilt

A common symptom of OCD is experiencing a great deal of guilt. You might feel that your obsessions make you a bad person and feel very ashamed of yourself. This is even more common if your obsessions relate to themes of harm or are of a sexual nature.

Most people with OCD feel very responsible for the safety of others (known as inflated responsibility): many compulsions center around trying to keep other people safe and preventing bad things happening to them. This sense of responsibility can enhance feelings of guilt. Being so emotionally hard on yourself and feeling guilty about your thoughts so much of the time can understandably take its toll on your mood.

Loss of confidence

Over time the experience of living with OCD can reduce your confidence and cause you to be very down on yourself. You might start to question who you really are as a person as you wonder whether your intrusive thoughts align with your real values. You might feel very ashamed of who you are and be harsh with yourself. Lack of confidence can contribute to depression. This study found that both, “depressed and OCD patients hold negative views of themselves.”

Feeling out of control

Often those with OCD will feel that they are not in control of their thoughts or actions. More than that, they feel that they should have full control over all of their thoughts and behaviour. They may experience a great deal of fear around what will happen if they lose control, for example fearing they may say or do something which they might regret later, or fearing acting on their obsessions.

Of course, it’s not possible to have full control over yourself or external factors. This urge to have control and the inability to fulfil it can exacerbate stress and anxiety. The constant fear of what will happen if you lose control can lead to problems with mood regulation.

Emotional and physical fatigue

Living with OCD is exhausting both mentally and physically. Being constantly on the lookout for threats, having high stress and anxiety levels, and feeling that everything you do carries such responsibility, can be absolutely draining. This fatigue can contribute to mental illness.

Problems functioning

Many people with OCD struggle to keep up with daily functioning such as personal hygiene, eating well, exercising, and other self-care activities. These are vital activities for mental health as well as physical health: when they’re lacking, it can lead to depression and worsen anxiety.

Job/study issues

Obsessions can completely occupy your mind, making it very difficult to focus on a task at hand. It can even be tough to process information and make decisions. It’s easy to see how this can affect your performance at work or school.

Compulsions often take up a great deal of time and can make you late or absent from work or school. They can also mean that carrying out certain tasks takes a lot longer. It’s common for people with OCD to get into trouble at work or school because of this, particularly where their employer or teachers don’t know they have OCD.

Problems with school or work can lead to more concerns about the future, disrupt your routine, and reduce confidence: all of these factors can lead to depression.

Lack of pleasurable activities

As well as struggling to function, often those with OCD find it hard to make time for activities they used to enjoy. Hobbies and interests may be set aside. We all need activities which make us happy and bring us joy to maintain a stable mood. Without joy and fun in our lives, things can seem bleak: this can quickly lead to a decline in your mood.

Stigma

Unfortunately stigma around mental health is still prevalent. Living with OCD means that you might experience stigma from loved ones, peers, medical professionals, or even from yourself! This stigma can make you feel ashamed of your OCD, and can even make you less likely to reach out for help for fear of how you will be perceived. Self-stigma can cause you to be very down on yourself. All of these factors can affect your mood significantly.

Lack of sleep

Sleep is vital for both our physical and mental health: without it, we can struggle to function. OCD can make it very difficult to sleep. When you’re stuck in such a high state of stress, it can be difficult to relax enough to get to sleep. As we’ve mentioned, compulsions often take up a lot of time and may mean you get to bed very late. If you wake up in the night and have an obsessive thought, you may then need to get up and carry out compulsions.

This lack of sleep can cause problems with mental health including depression, along with issues with concentration, decision making, memory and emotional regulation. The National Sleep Foundation states that, “When you don’t get the 7-9 hours of quality sleep you need, it can heavily influence your outlook on life, energy level, motivation, and emotions.”

How does depression contribute to OCD?

There are some symptoms of depression which can contribute to OCD and exacerbate OCD symptoms.

Lack of motivation

When you live with depression, you tend to feel fatigued and lack motivation to engage in daily tasks. This lack of motivation could cause someone with OCD to be less likely to engage with treatment for their OCD, which of course can then worsen symptoms. It can also contribute to an individual being less likely to engage in self-care and keep up with responsibilities, which can worsen feelings of guilt and anxiety.

Lack of sleep

Just as OCD can cause lack of sleep, so can depression. When you have a lot on your mind, it can be hard to quiet your thoughts enough to sleep. Often at night when everything else is quiet, your thoughts can feel like they become louder and harder to ignore. It’s common for people with depression to experience insomnia, which can also perpetuate their depression and OCD.

Just as lack of sleep can lead to depression, it can also cause and worsen anxiety. For someone with OCD, heightened anxiety can increase their obsessions and therefore their compulsions.

Feeling hopeless

If you are depressed, it can be very difficult to see any hope for the future. You might feel worthless and hopeless, not seeing a way forward and feeling as though things are not going to get any better. This mirrors the hopelessness that can come with OCD, meaning that in someone with both OCD and depression, the feeling of hopelessness can be amplified.

This study explains that, “Depressed patients score higher on measures of negative thinking about the self, their current situation and the future.” The study then goes on to state that, “negative cognitive errors and hopelessness, were also associated with OCD.”

Just like lack of motivation, this sense of hopelessness can make you less likely to engage in treatment, practice self-care, to seek help, or to actively try to improve your situation. This in turn can worsen symptoms of both depression and OCD.

Heightened emotions

Depression can lead to higher emotions including feeling angry and irritable. Things which might not have previously bothered you can feel overwhelming. You might find that you’re crying or having outbursts of emotions when you usually wouldn’t. It’s also common to find that anxiety and worry is on the rise because you’re stuck in such a negative mindset.

All of these heightened emotions can make someone with OCD feel even less in control, which can cause them to be more anxious and worsen OCD symptoms. If someone with OCD and depression finds that they are irritable and they snap at someone they love, they might then feel even more guilty than they had previously, thinking that this makes them a bad person. If they have intrusive thoughts around harm, they might then take this emotional outburst as ‘evidence’ that they want to hurt their loved one.

Negative thinking

By nature depression makes you think in a very negative way. Likewise, negative thinking is a common trait in those with OCD. When depression is comorbid with OCD, it can worsen this negative thinking and in turn, worsen OCD symptoms.

Self-criticism

As with OCD, depression can cause you to become very critical of yourself. This can worsen symptoms of low confidence and self-negativity which come with OCD.

Fatigue

Depression causes severe fatigue: it can often be tough to find the energy to do the simplest of tasks like walking to the bathroom or taking a shower. This fatigue can add to the fatigue stemming from OCD and make it even more pronounced.

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How does depression affect OCD treatment?

The International OCD Foundation explains that, “having severe depression can interfere with the effects of the most effective treatment for OCD: cognitive behavioral therapy using exposure and response prevention (ERP).”

ERP is the primary treatment for OCD: it involves being guided through gradually facing situations which trigger your obsessions, starting with the least triggering. As you face these situations, you will be asked to stop yourself responding with a compulsion. Over time, you’ll see that nothing bad happened when you didn’t perform a compulsion, and anxiety will gradually lessen. This actively breaks the cycle of OCD.

So how does depression interfere with ERP? Well, as we’ve discussed, when you’re depressed you have very low energy and lack of motivation, so you’re less likely to keep up with treatments. ERP requires a lot of work and dedication: when a patient is also struggling with depression, it can be hard for them to dedicate the time and energy needed to make the therapy successful. Depression can also make you feel hopeless. When you feel there is no point to your future, you might feel that there’s no point trying to get over your OCD.

Another primary reason depression can affect OCD treatment is because your low mood can stop you feeling the reduction in distress normally experienced as ERP progresses. Without this reduction in distress and a more positive association being built, the therapy doesn’t work. This article explains that, “Depression might also make you so upset that the normal reduction in anxiety and distress that should occur with exposure therapy doesn’t happen, and therefore you can’t learn that obsessional anxiety decreases on its own during exposure treatment.”

Treatment options

This all sounds quite negative and worrying, so what are you supposed to do if you have both depression and OCD? Don’t worry! There’s still very effective treatment which can help you to overcome both OCD and depression symptoms.

Medication

Antidepressants can help to treat depression and lessen the anxiety that comes with OCD. Selective serotonin reuptake inhibitors (SSRIs) are typically prescribed, which work to correct the chemical imbalance in the brain we mentioned earlier. For someone with both OCD and depression, medication will often be used in conjunction with ERP to help the patient get the most out of their therapy.

Cognitive behavioural therapy (CBT)

CBT can be very effective at treating both depression and OCD. CBT works to replace negative thinking patterns and behaviours with more positive, helpful thoughts and actions. When used to tackle both disorders, this can bring positive results for patients.

As negative thought patterns are tackled, patients can feel more ready and willing to engage in ERP to overcome their OCD. The International OCD Foundation explains that, “a few weeks of challenging negative thinking styles and engaging in pleasurable activities helps many depressed people with OCD to feel more confident and ready to address their obsessions and compulsions.”

Acceptance and commitment therapy (ACT)

Instead of trying to change negative thoughts, ACT teaches you to accept these thoughts and to understand that they don’t have to lead to actions. This realisation can be freeing for those with both depression and OCD, as they learn that intrusive or negative thoughts don’t have the power they once thought they did.

ACT then guides you through setting goals and committing to behaviours which are going to help you overcome your symptoms. ACT can be used to treat both depression and OCD in conjunction.

Mindfulness

Mindfulness practices teach you to be present in the moment and ground yourself. We know that stress plays a big part in how depression and OCD are linked, as well as in worsening symptoms of each condition individually. Mindfulness can help to break these cycles by reducing stress and anxiety, instead replacing it with a sense of relaxation and calm.

Mindfulness can also help to improve sleep, enhance general wellbeing, and boost cognitive function, all of which can be useful in tackling both OCD and depression. It’s common for mindfulness techniques to be incorporated into other psychological therapies to bring the best results for patients.

Transcranial magnetic stimulation (TMS)

TMS is a non invasive procedure which involves targeting specific regions of the brain with magnetic pulses. The regions of the brain targeted are involved in mood and impulse control. This process is thought to reactivate areas of the brain which have been underactive, and calm areas of the brain which are overactive. The procedure is done while the patient is awake, and isn’t painful.

TMS tends to be used when other treatments have failed and the patient is ‘treatment resistant’. It has proven results in treating depression and promising results in treating OCD, so can be a combined treatment for those who struggle with both disorders. In cases where the patient is struggling with both disorders, TMS is sometimes used alongside ERP to bring the best outcome for the patient.

This article from Joan A. Camprodon-Gimenez, MD, MPH, PhD, the director of the Transcranial Magnetic Stimulation (TMS) clinical service, concludes that, “While TMS for OCD is in the early stages of development, it holds great promise for patients and families, and we are certain to see an increasing number of studies published in the next years.”

What to do if you feel depressed

If you are experiencing depression, whether you also have OCD or not, it’s important you take action. You’re not alone, and there is hope! Let’s take a look at some steps you can take to cope.

Reach out for help

The first stage is reaching out for help. This might feel like the last thing you want to do, but it’s absolutely vital you do, so that things can get better. You can start by going to your doctor and explaining how you feel. If you have OCD and are already under the care of a mental health professional, you should talk about your symptoms with them so that they can direct you to appropriate help.

You may be prescribed medication or referred to some of the treatments we’ve mentioned. You could also choose to seek therapy privately or through online treatment. If you are experiencing a mental health crisis and are feeling unsafe, you should reach out immediately to your doctor, a loved one, a crisis team, or a mental health hotline to get the help you need.

Know that there is hope

It may be hard to feel that there is hope for things improving when you’re in the grips of depression, but please know that things can get better. With the right treatment, you can find your way forward and gradually start to find happiness again.

Practice self care

Even though it’s hard and you might not feel like it, try your best to practice self care. It really can make a difference to your mood. Try to eat well, keep a good sleep routine, do some exercise, keep up with personal hygiene, and make some time to do something you might enjoy. These tasks can feel like climbing a mountain, but if you can manage to work towards them, you will feel the benefit.

Find support

You don’t have to go through this alone. Aside from the professional treatment you need, it’s also vital to have support. If you have loved ones you trust and feel you can open up to, talk to them and let them be there for you. You could also find a local support group or find support online through social media from others who understand. This can make you feel less alone and provide a sense of hope.

OCD and depression are hard enough to deal with as individual mental illnesses: combined together they make life extremely hard. However, no matter how hard it gets, you must remember that if you get help, things can improve! You can fight this and get your life back!

References

Rivier University, (2018), “OCD and Depression”.

The OCD Treatment Centre, (2020), “OCD and Depression”.

Owen Kelly, PhD, (2020), “The Link Between OCD and Major Depressive Disorder”. Very Well Mind.

Bolhuis, K., McAdams, T. A., Monzani, B., Gregory, A. M., et al, (2014). “Aetiological overlap between obsessive-compulsive and depressive symptoms: a longitudinal twin study in adolescents and adults.” Psychological medicine, 44(7), 1439–1449.

Kean J. Hsu, Ph.D., (2017), “Rumination Is A Risk Factor For Anxiety”. Anxiety.org.

Karen Bruno, (2009), “Stress and Depression”.

Kathleen A. Moore, Jacqui Howell, (2017), “Yes: The Symptoms of OCD and Depression Are Discrete and Not Exclusively Negative Affectivity”. Front. Psychol., 12 May 2017.

The National Sleep Foundation, (2020), “The Complex Relationship Between Sleep, Depression & Anxiety”.

The National Sleep Foundation, (2020), “How Does Anxiety Affect Sleep?”

Jonathan Abramowitz, PhD, (2020), “OCD and Depression”. International OCD Foundation.

Joan A. Camprodon-Gimenez, (2015), “Transcranial Magnetic Stimulation (TMS) for Obsessive Compulsive Disorder (OCD)”. International OCD Foundation.

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