Can Trauma Cause OCD? Why Treating OCD and PTSD Requires Two Different Toolkits

An attempt to answer some of my own questions about how OCD and trauma interact

How OCD and Trauma Get Confused For One Another

OCD and PTSD have many overlapping symptoms: intrusive thoughts and images, dissociation, avoidance, anxiety, distorted beliefs about the self and the world, guilt, depressive symptoms, concentration difficulties, and hypervigilance. But the people experiencing these symptoms have them for different reasons, and their symptoms serve different functions.

If you are a client trying to pick a therapist or online resources that will help you grow, the overlapping symptoms can be very confusing. It’s even confusing for therapists who are trying to figure out where to start after hearing your symptoms. Do we address your symptoms as trauma or do we address them as OCD? If you are familiar with the differing approaches, you’ll know that trauma therapy is typically very validating and gentle in the way it asks you to do exposure and reprocessing. OCD therapy is not typically as validating and gentle because the content of what the person is struggling with is less rational and often not rooted in reality or experience. OCD fears are scary, but they aren’t usually based on an actual event.

How do we pick a lane—trauma or OCD—if both are present? How do we combine both lanes strategically if both are relevant? Below I have all of the answers! Not really, but I think we can make some more sense out of how to approach this issue if we look at how and why evidence-based treatments work for each of these mental health conditions.

Trauma Has The Upper Hand In Advertising, Clinical Interest, and Popularity

What usually happens for most clients is that their OCD gets treated OR their trauma gets treated. Rarely do both get treated. In my experience, usually only their trauma gets treated. I’m sure there are many reasons for this, but I think one simple explanation is that trauma is simply popular and fascinating, so that’s what clinicians hone in on. There seems to be an assumption that if trauma is in someone’s story, then that trauma is the cause of everything else they are coming to counseling for. I understand why clinicians would feel that way because nobody goes through something severe and remains untouched by it in a significant way; therefore, those impacts need to be unpacked and addressed. That being said, just because that trauma inevitably has an impact on that person’s life doesn’t mean that trauma is causing their OCD symptoms specifically.

As an aside, there is such a fascination with trauma and treatments for it that I sometimes hear about clinicians using EMDR or going back over and over through clients’ pasts for traumas that aren’t really causing symptoms or distress in their present lives. There is a good impulse here to go toward the pain and not just talk about the week’s events every session, but I sometimes wonder if this is happening because it’s the only way we have been taught to help and the only thing we’ve been taught to look for. As another therapist friend recently said to me… We are trauma-informed now, but are we anxiety-disorder-informed?

Has trauma so taken over that we’ve lost our imagination for the idea that someone can have genetic and biological factors that make them more predisposed to struggling with anxiety, instead of it having to be some major event in their story that caused it? Both are relevant, and we have to figure out which one is most relevant for the person sitting in front of us.

An Example of OCD and Trauma Intertwined

Let’s say someone was abused by an authority figure and now they experience extreme religious guilt. If the person has anxiety-inducing, repetitive questions in a “what if?” pattern and they constantly research, confess, ask for reassurance, and feel like God is displeased with them despite what anyone tells them, then they probably qualify for an OCD diagnosis. When talking with the person, they have the insight that their religious guilt was made worse by the abuse they experienced by the authority figure, and now they feel like the ultimate authority figure, God, is displeased with them. This is a really clean link between OCD and trauma where trauma is making the OCD worse and harder to overcome. The person has, in their lived experience, a history of their fear somewhat coming true. OCD then takes that and runs with it, and it fuels their obsessive thoughts, anxiety reactions, and desperate need for compulsive reassurance or avoidance.

I think the prevailing wisdom is that trauma is the principal diagnosis and must be treated first. But here’s the problem: if that person has fully diagnosable OCD and not just some OCD-like symptoms, then treating the trauma alone likely will not help them overcome the OCD symptoms to the degree you hope it will. In fact, it may do very little to curb their OCD symptoms at all. Trauma is a reaction to something that happened in the past. OCD is a fear that something will happen in the future. Yes, someone can be afraid of something that might happen in the future because of something that happened in the past, but these two diagnoses must be treated differently. In this case, the trauma is almost certainly making the OCD worse, but trauma isn’t the only process that must be fully addressed.

Why Treating Only Trauma May Not Help OCD

Trauma heals, in oversimplified terms, when a person faces what happened to them head-on, comes to a place where they cognitively and emotionally understand and feel that they are no longer under that threat, reckons with and grieves its impacts, and no longer feels powerless when they encounter events and relationships that consciously or subconsciously remind them of that trauma.

OCD heals when a person realizes that the story they are struggling with is imaginary, repeatedly faces their fear via doing and thinking the opposite of what OCD tells them to do and think, and then gets to the point where they no longer care what thoughts and terrible feelings OCD throws at them because they realize that they are unfounded or that OCD’s questions are unanswerable by design.

Although these diagnoses have similar symptoms and were entangled in the person’s story, the way they heal is quite different because where they come from and how they are perpetuated are quite different.

We can’t know if trauma causes OCD or not. I personally do not think that it does. It might cause some OCD-like symptoms, such as perfectionism, paranoia about others’ intentions, repetition of certain behaviors, reassurance seeking, guilt, etc. Those symptoms will likely be less repetitive in the person’s life if they stem from trauma rather than OCD. I treat too many young kids with very supportive families and no significant trauma history who have severe OCD for me to believe that it’s not primarily genetic. And I’ve seen too many times when good trauma treatments alone don’t remove OCD symptoms. I do believe that when somebody has a genetic predisposition to OCD and they have experienced severe trauma, that trauma can manifest in their OCD and make it much more difficult to treat and overcome.

Treatment for Trauma and OCD has Different Aims, Therefore Treatment for Each Requires Different Approaches

Trauma reprocessing and integration is about facing something that DID happen.

Exposure and Response Prevention for OCD is about thinking and responding differently to something that COULD happen.

One cannot fully address the other.

What it Looks Like When You Just Treat the Trauma

Since I treat OCD as a primary specialty, I’m often seeing clients who were treated for trauma, but their OCD symptoms weren’t treated appropriately or fully.

Let’s imagine we only treated this person’s trauma using EMDR, Written Exposure Therapy, Cognitive Processing Therapy, or whatever evidence-based model you prefer. The focus would be looking at past traumatic memories and updating them with real-time experiences of safety and new meaning. This work could certainly help dampen OCD symptoms when this person is able to mentally connect their present fears with their past sense of powerlessness and shame, but OCD has a life of its own. That person is still going to have an intense anxiety reaction when the “what if?” questions about God (or whatever their OCD theme is) resurface for them, and that trauma processing—no matter how thorough and high-quality it was—is going to be no match for the overwhelming need to seek compulsive reassurance and avoid triggers.

What it Looks Like When You Just Treat the OCD

A less common problem in my experience occurs when a purely behavioral, present-focused approach is taken. Whether working with a therapist who utilizes ERP, CBT, and ACT—choose your three-letter approach—or working through a workbook you found online, the focus is almost exclusively on working on how the OCD and anxiety are presenting in the here and now. I’m biased toward starting here because the person needs understanding and some relief before we can do anything else, but there are some downsides to not taking a deep dive into past trauma. This is especially true if the trauma logically connects to the OCD theme and content or if the trauma occurred right as the OCD symptoms began or shortly before.

A couple of issues may occur if you don’t address your story and trauma. For one, you simply may not be able to do the exposure work necessary to overcome your OCD because it’s eliciting a trauma reaction that you haven’t worked through. Another thing that may happen is that you do get better temporarily as a result of OCD treatment, but you keep relapsing into content that it seems like you once mastered. It’s possible that it’s not just that you haven’t done enough ERP, but that you are getting tripped up by conscious or subconscious trauma reminders that you have not yet overcome to the degree necessary for ERP to work.

What It Could Look Like When You Treat OCD and Trauma Together Strategically

There is a lot that can be said about the nuances of trauma and OCD therapy from the pens of the experts, but let’s take some simple examples from two evidence-based therapies that prescribe writing to overcome PTSD and OCD: Written Exposure Therapy for PTSD and writing-based imaginal exposures for OCD. These are highly studied treatments that I use in my practice, and they provide some of the most concrete examples of what we are doing differently to treat each of these conditions.

Here are some key samples from Written Exposure Therapy for PTSD that demonstrate the perspective the protocol wants you to write from:

“Just focus on writing about the trauma with as much detail as possible and include the thoughts and feelings you experienced during and immediately afterward. Remember, the trauma is not actually happening again. You are simply recounting it as you look back upon it now.”

Later sessions move the focus more towards meaning and impacts:

“Today, I would also like you to write about how the traumatic event has changed your life. You might write about if the trauma has changed the way you view your life, the meaning of life, and how you relate to other people. Throughout the session I want you to really let go and write about your deepest thoughts and feelings.”

Now compare that to what I would ask someone to do for OCD after several sessions of warming up and getting ready for this level of work:

“I would like for you to write as if your fear is true and happening now or is definitely going to happen in the future. Include as much sensory detail as possible, and I essentially want you to write as if all of your most catastrophic fears are coming true and there’s nothing you can do to escape them. End with uncertainty on purpose, and be sure to not reassure yourself or argue with your fear like you typically do. Keep writing until your highest anxiety comes down by half, and then you can stop.”

One is looking backward at reality, and the other is looking forward at imagined possibilities. One is written from a distanced perspective looking for insight and organization of fragmented trauma memories, and the other is written from an immersive perspective looking for inhibition of typical resistance behaviors and fear responses. Both are exposure therapies, but written exposure for PTSD uses exposure to reduce avoidance of memories and consolidate them into an organized narrative so your brain and body don’t feel like those memories are jumping out at you like a ghost at random times. Written exposure for OCD is showing you that you can face the thoughts and your anxiety actually goes down, not up, when you stop resisting—and it often produces the felt experience that these thoughts are mostly irrational.

So let’s briefly imagine going back to our client who was abused by an authority figure and now struggles with religious scrupulosity. If we progressed him strategically through an evidence-based trauma treatment, he could potentially see and clearly articulate the roots of his fear in his past experiences with this authority figure, organize that narrative and expose himself to the details of it via writing so that its conscious and subconscious reminders are not so triggering, understand the details of how it has impacted his life, and grieve the injustice of abuse as the reason why he always feels guilty instead of reflexively blaming himself for not being good enough every time he feels that way. That work will probably motivate some healthy behavior change in his life and relationships. Now he has a foundation to do Exposure and Response Prevention treatment for OCD, and his mind and body will be less likely to completely revolt when he engages in behavioral and imaginal exposures. He must still do this work because the compulsive behaviors and fears will most likely not disappear on their own if he has OCD, and he probably has other not-so-rational obsessions and compulsions that are maintaining his OCD that are not linked to the trauma. But now, because we’ve addressed both issues that have different origins and perpetuating factors strategically and not just hoped that addressing one took care of the other, he has a chance to be more present and regulated to enjoy his life.

Mental health outcomes are rarely this clean and tidy, but we might have more power to influence really positive outcomes if we take time to think thoroughly about what clients are struggling with and strategically apply treatments that incredibly creative people have developed for specific diagnoses.

Sources

Evidence-based imaginal exposure scripts for OCD: https://adaa.org/learn-from-us/from-the-experts/blog-posts/professional/write-your-fears-away

Sloan, D. M., & Marx, B. P. (2025). Written exposure therapy for PTSD: A brief treatment approach for mental health professionals (2nd ed.). American Psychological

Read more about Written Exposure Therapy for PTSD on our Trauma page. It’s a lot cooler than it sounds: https://www.ocdanxietyms.com/trauma-ptsd-therapist-brandon-mississippi

Info on the overlap between OCD and PTSD: https://iocdf.org/wp-content/uploads/2023/07/Double-Trouble-Addressing-OCD-in-the-Context-of-Co-Occurring-Posttraumatic-Stress.pdfhttps://spaces-cdn.owlstown.com/blobs/ymrzxam2v700p83qi1oeexcj8ujn