For patients with both OCD-type thoughts and general anxiety, where do you usually start?

When someone experiences both OCD-type thoughts and general anxiety, I usually begin by understanding how the symptoms function, rather than focusing immediately on diagnostic labels. These difficulties often overlap, and what matters most is identifying the patterns that keep the anxiety going. I start by exploring the nature of the thoughts. OCD-type thoughts are typically intrusive, unwanted, and distressing, and they often lead to compulsive responses such as checking, reassurance seeking, mental reviewing, or avoidance. General anxiety tends to involve more persistent, future-focused worry that isn’t always linked to compulsive behaviours. Clarifying this distinction helps me decide where to begin. I then focus on psychoeducation and stabilisation. Explaining why intrusive thoughts occur, how anxiety is maintained, and why trying to suppress or “fix” thoughts can make them worse often reduces fear and self-blame early on. From there, I prioritise the symptoms causing the most disruption. If compulsions and avoidance are central, I usually start with OCD-informed approaches such as exposure and response prevention, while also addressing broader anxiety. If general anxiety is more dominant, I may begin with worry management, emotional regulation, and reducing safety behaviours, while still teaching skills for responding differently to intrusive thoughts. Medication can be discussed when symptoms are significantly impairing. It’s rarely an either-or decision. Treating OCD processes often reduces overall anxiety, and improving general anxiety makes OCD-focused work more manageable. The goal is a practical, individualised starting point that feels manageable and effective for the patient.

When assessing patients with OCD type thoughts and anxiety it is important to determine what is the driving factor. If intrusive thoughts, rituals, behavioral compulsions and or distress tied to themes such as harm, contamination or morality are the predominant symptoms then we are looking more at OCD as the driving factor. If the patient has a lot of worry that feels constant rather than triggered, physical tension, restlessness, or "what ifs" then anxiety can be the driving factor. Stabilizing the system through sleep regulation, anxiety management skills, psychoeducation about intrusive thoughts and worry loops can help to give the patient some tolerance so targeted work can be done. Since OCD tends to be more impairing and self reinforcing it is important to treat the OCD cycle early through exposure and response prevention, once compulsions weaken the anxiety will also improve. Once the OCD symptoms are less prominent the focus can be to reduce the anxiety through various techniques such as cognitive behavioral therapy, behavioral experiments and worry postponement. Typically the above therapies would be done with a licensed psycho therapist, psychologist or social worker trained in these types of interventions. Medications such as SSRI's and SNRI's can be used to treat both OCD and anxiety. Typically OCD requires a higher therapeutic dose to be treated effectively compared to GAD.

Our evaluation focuses on the symptoms that present the most disruption in your life. While people without OCD may also have intrusive thoughts and even checking behaviours, these are typically not as severe in other conditions. People with ADHD often find they forget things due to distraction and will sometimes develop double or triple checks in their workplace to ensure they aren’t leaving out anything. This is different than a compulsion that is seen in OCD. Our detailed history and evaluation will help to sort out the symptoms and their severity on daily functions. Anxiety is another common symptom among people with ADHD and OCD. We consider treating anxiety first if it does not appear to be a direct result of untreated ADHD, or if it is debilitating. The benefits of controlling the symptoms of ADHD as a first-line approach is that treatment response is quicker and will often resolve co-morbid conditions including anxiety, depression and masking behaviours.

This is a very common and understandably confusing clinical overlap, and it makes sense to want clarity about where treatment usually begins. When intrusive thoughts, checking behaviors, and generalized worry are all present, clinicians typically don’t decide based on diagnosis alone, but on which processes are most actively maintaining distress in daily life. In practice, if the intrusive thoughts are unwanted, repetitive, and followed by checking or other behaviors meant to neutralize anxiety, we may suggest prioritizing these first. The reason is not that OCD is “more serious,” but that compulsive behaviors, even subtle, tend to reinforce fear and uncertainty over time. Reducing those responses often creates space for anxiety to settle overall, including worry that initially looks more generalized. At the same time, generalized anxiety is rarely ignored. If worry is broad, future-focused, and not always linked to specific intrusive fears, we may aim to weave in skills that target anxious symptoms such as intolerance of uncertainty, overestimation of threat, and physiological arousal early on. Rather than choosing one condition over the other, treatment is usually sequenced and integrated, adjusting focus based on how symptoms respond. What ultimately guides the starting point is how symptoms function for the individual, how impairing they are right now, and what feels tolerable to work on. This is typically a collaborative and shared decision making process between the provider and the patient. Further, a thoughtful provider will revisit this formulation over time, using your feedback and symptom tracking to shift emphasis as needed. Having both OCD-type and generalized anxiety symptoms doesn’t necessarily mean treatment is more complicated in a negative way; it simply means it should be responsive, collaborative, and flexible.

When someone comes in with intrusive thoughts, checking behaviors, and a lot of ongoing worry, the work is often less about choosing a single label and more about understanding how these experiences show up in that person’s daily life. OCD and GAD are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Because of this overlap, most psychiatrists think about them as related patterns rather than completely separate conditions. The first question I usually ask a patient is what the anxiety is attached to and how it feels from the inside. GAD tends to feel familiar and understandable, even if it is overwhelming. The worries are often about real-life concerns like health, money, or relationships, and they feel like an extension of the person’s own thinking. Intrusive thoughts related to OCD, by contrast, often feel foreign or deeply unsettling, precisely because they clash with the person’s values or sense of self. They can feel repetitive and hard to disengage from, and checking or other behaviors often develop as an attempt to manage that distress. When checking behaviors and intrusive thoughts are especially rigid or time-consuming, I often start by focusing on the OCD symptoms. This is because these behaviors are usually the main way the mind is trying to regulate anxiety, even though they end up reinforcing it. When we work on reducing the need to check or seek certainty, many patients notice that their overall level of anxiety begins to ease as well. Ultimately, the goal is not to force your symptoms into a single box, but to understand what is driving your distress and what is interfering most with your life right now. A careful, individualized assessment with a professional is the best place to begin, and treatment can then be shaped around your particular needs.

In practice, clinicians usually start with what is maintaining the distress, rather than choosing a diagnosis first. When someone has both OCD-type symptoms (intrusive thoughts, checking, mental rituals) and general anxiety or worry, the key question is which patterns are most strongly keeping the cycle going. If intrusive thoughts are leading to checking, reassurance-seeking, or mental reviewing, treatment often starts with OCD-focused work, because reducing compulsions can also reduce overall anxiety. Even worries that look “general” can sometimes be driven by OCD mechanisms like a need for certainty or fear of responsibility. If, on the other hand, broad anxiety and overwhelm are dominant—affecting sleep, concentration, or emotional regulation—clinicians may begin with general anxiety strategies to stabilize things before moving into more targeted OCD work. Readiness matters too, as OCD treatment can be demanding, and some people benefit from building coping skills first. Importantly, this is rarely an either/or decision. Many clinicians work in an integrated way, addressing OCD processes while also supporting general anxiety, and adjusting the focus over time as symptoms change and capacity increases.

I usually start by taking a careful history and building a diagnostic formulation that focuses on how the symptoms function and how impairing they are. The key questions are about the role the thoughts play in the person’s life: Are they intrusive and repetitive? Do they drive compulsive behaviours or mental rituals? How much time do they take up each day, and how much do they interfere with work, relationships, or daily functioning? Understanding frequency, intensity, controllability, and avoidance gives a clearer picture than diagnosis alone. This formulation helps gauge degree of functional impairment, which is often what guides treatment decisions. Many individuals fall somewhere in between, and it can be clinically appropriate to conceptualize the presentation as generalized anxiety with obsessive features, subthreshold OCD, or OCD, depending on severity and impact. These are not mutually exclusive or rigid categories. Importantly, treatment approaches overlap substantially. CBT with exposure-based elements, work on cognitive flexibility, tolerance of uncertainty, and reduction of reassurance-seeking are useful across this spectrum, and pharmacologic options are also similar. Because of this overlap, it is often not necessary to “pick one” diagnosis at the outset. Instead, starting with a formulation-driven approach allows treatment to target the most impairing features, with diagnostic refinement over time as the response and symptom pattern become clearer.

If symptoms are mild to moderate I will consider treating ADHD first as ADHD patients often develop behavioural patterns, like repetitive checking of tasks, as coping strategies to compensate for the symptoms of ADHD (CADDRA, 2021). Treating ADHD first may actually improve symptoms associated with OCD. If OCD symptoms are moderate to severe or persistent after treatment for ADHD has been optimized I usually treat OCD and ADHD concurrently with a long acting stimulant in addition to an SSRI titrated to effect. Generally treating OCD with long acting stimulants does not increase obsessions or compulsions. If the patient has Tics or Tourettes syndrome long acting stimulants can sometimes worsen tics (CADDRA, 2021). This isn’t an absolute contraindication to using stimulants but may require closer monitoing. Canadian ADHD Resource Alliance (2021). Chapter 2: Differential diagnosis and comorbid disorders. The Canadian ADHD Practice Guidelines. https://adhdlearn.caddra.ca/docs-category/chapter-2/