Nordic Journal of Psychiatry

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Are anxiety disorders a pathway to obsessive-

compulsive disorder? Different trajectories of OCD
and the role of death anxiety

Rachel E. Menzies , Matteo Zuccala , Louise Sharpe & Ilan Dar-Nimrod

To cite this article: Rachel E. Menzies , Matteo Zuccala , Louise Sharpe & Ilan Dar-Nimrod (2020):
Are anxiety disorders a pathway to obsessive-compulsive disorder? Different trajectories of OCD
and the role of death anxiety, Nordic Journal of Psychiatry, DOI: 10.1080/08039488.2020.1817554

To link to this article: https://doi.org/10.1080/08039488.2020.1817554

Published online: 12 Sep 2020.

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NORDIC JOURNAL OF PSYCHIATRY
https://doi.org/10.1080/08039488.2020.1817554

ARTICLE

Are anxiety disorders a pathway to obsessive-compulsive disorder? Different

trajectories of OCD and the role of death anxiety
Rachel E. Menzies , Matteo Zuccala , Louise Sharpe and Ilan Dar-Nimrod
School of Psychology, The University of Sydney, Sydney, NSW, Australia

ABSTRACT ARTICLE HISTORY

Objectives: A body of research has demonstrated high rates of comorbidity among individuals with Received 22 June 2020
obsessive-compulsive disorder (OCD). Further, recent empirical evidence has demonstrated the rele- Accepted 25 August 2020
vance of death anxiety in OCD. Given that the trajectory towards OCD remains unclear, the current
KEYWORDS
study aimed to examine which disorders individuals typically experience prior to the onset of this dis-
Obsessive-compulsive dis-
order. Further, the study aimed to explore the role of death anxiety in the developmental pathways to order; death anxiety;
the disorder. comorbidity; prevalence
Methods: The present study involved administering a measure of death anxiety and conducting struc-
tured diagnostic interviews among a treatment-seeking sample of 98 individuals with OCD.
Results: First, the findings revealed a number of anxiety-related disorders commonly experienced prior
to the development of OCD, the most frequent of which were separation anxiety disorder, specific
phobias, and generalised anxiety disorder. Second, consistent with hypotheses, individuals with higher
death anxiety experienced more disorders prior to the onset of OCD. Conversely, those with lower
fears of death were significantly more likely to develop OCD as their first disorder.
Conclusions: These findings support the argument that death anxiety may influence the trajectory
towards OCD, and the comorbidity among anxiety-related disorders. However, further research is
needed to clarify whether death anxiety plays a causal role in this trajectory.

Introduction
Obsessive-compulsive disorder (OCD) is a psychological con-
dition which affects approximately 1–3% of the population
[1]. The lifetime comorbidity rates of OCD are extremely
high, with one study reporting that 92% of individuals with
OCD had at least one additional disorder [2]. Further, certain
disorders appear to typically accompany OCD, with the most
frequent comorbid disorders being major depressive disorder
(MDD), generalised anxiety disorder (GAD), separation anxiety
disorder (SAD), social anxiety disorder, and specific phobias
[2,3]. For example, among Nordic children and adolescents
with OCD, anxiety disorders are the most frequent comorbid
diagnosis [4]. However, little is known regarding the the
order in which OCD and its comorbid disorders emerge. That
is, although the specific disorders experienced comorbidly
with or subsequent to OCD may be well understood, the dis-
orders which typically precede a diagnosis of OCD
remain unclear.
Notably, a more thorough understanding of which disor-
ders an individual experiences prior to OCD appears to have
prognostic value. Prior diagnoses have been shown to pre-
dict various outcomes associated with not only OCD severity,
but also the risk of additional disorders. For example,
between 17% and 27% of adults with OCD are estimated to
have previously experienced SAD [2,5]. Among adults with
OCD, those with a prior diagnosis of SAD show earlier onset
and heightened severity of OCD [5], in addition to increased
depression, anxiety, and anxiety-related disorders, including
panic disorder, agoraphobia, and PTSD [2,5]. While SAD has
been recognised as the most common first disorder experi-
enced prior to OCD [2], arguably due to its earlier age of
onset relative to other disorders, few studies have explored
the order in which other disorders develop within the devel-
opmental trajectory of OCD.
OCD and death anxiety
One construct that may play a role in determining the trajec-
tory of OCD is death anxiety. Death anxiety has been pro-
posed to be a transdiagnostic construct, underpinning a
number of mental health conditions [6]. This may explain the
‘revolving door’ (p. 590) often observed in mental health
services, in that individuals often receive successful treatment
for the disorder with which they initially present, only to
return to treatment later in life with a seemingly different
diagnosis. In line with this, rates of comorbid anxiety-related
diagnoses across the lifespan are around twice those of cur-
rent disorders [7]. Consistent with the argument that death
anxiety may be driving numerous conditions, moderate to
large correlations have been found between death anxiety

CONTACT Rachel E. Menzies rmen9233@uni.sydney.edu.au School of Psychology, Griffith Taylor Building (A19) The University of Sydney, Sydney, NSW,
2006, Australia
ß 2020 The Nordic Psychiatric Association
2 R. E. MENZIES ET AL.
and the number of diagnoses an individual experiences
across their lifetime [8,9].
Further, growing evidence supports the particular role of
death anxiety in OCD. Menzies, Menzies, and Iverach [10]
note that fears of death appear to underlie many of the
common subtypes of the disorder. For instance, within the
contamination subtype, many individuals attribute their com-
pulsive washing behaviour to fears of contracting deadly ill-
nesses (e.g. HIV) as a result of contact with germs [11].
Similarly, among those with the checking subtype of OCD,
verbal reports indicate that the compulsive checking of
powerpoints, stovetops, and door or window locks are often
driven by fears of electrocution, household fires and invasion,
all of which have the direct potential to result in death [12].
For individuals with aggressive obsessions, fears of death
may be seen as underlying the intrusive and distressing
imagery of harming oneself or others. Such individuals typic-
ally worry that they may ‘snap’ and act out violently, result-
ing in the death of a stranger or loved one [13]. Even in less
common presentations, which may feature tapping, magical
numbers or counting, such individuals typically report that
the reason behind their behaviour centers around preventing
harm to oneself or loved ones [13].
In line with this proposal that death anxiety is at the heart
of many manifestations of OCD, Menzies and Dar-Nimrod [8]
found large correlations between death anxiety and overall
OCD severity among a large treatment-seeking sample. In
addition, one recent study found that death anxiety signifi-
cantly correlated with six OCD symptom domains (i.e. con-
tamination, checking, hoarding, ‘just right’, indecisiveness,
and obsessions) among a sample of treatment-seeking indi-
viduals with OCD [14]. All of the aforementioned relation-
ships remained significant after controlling for neuroticism.
While causation cannot be inferred from these correlational
findings, experimental evidence has demonstrated the driv-
ing role of death anxiety in some compulsive behaviours.
Menzies and Dar-Nimrod [8] found that reminders of death
produced significantly elevated cleaning behaviours among
individuals with the compulsive washing subtype of OCD,
suggesting that death anxiety plays a causal role in at least
this subtype.
Consistent with this, if death anxiety does indeed contrib-
ute to the ‘revolving door’ phenomenon, one might expect
individuals with more severe fears of death to cycle through
numerous disorders before later developing OCD, compared
with individuals with lesser death concerns. For example, a
highly death anxious individual might develop separation
anxiety in childhood, panic disorder in adolescence, and
then may manifest with compulsive checking of stovetops in
adulthood. Thus, their OCD may be merely one of many
manifestations of death anxiety across their lifespan, and the
fear that once appeared in their worries about a heart attack
is currently manifesting in their fear of household fires.
Conversely, it is possible that those with lower death anxiety
may be more likely to develop OCD as their first disorder,
and indeed, to experience fewer disorders across their life-
span. For these individuals, their obsessions or compulsions
may be less focused on preventing death, perhaps instead
centering on obsessions of a sexual nature (e.g. obsessions
relating to homosexuality, incest, or pedophilia), which are
well-represented in OCD [15] and appear less directly related
to death than other symptom domains. At present, no study
has explored this intriguing possibility – that is, does death
anxiety predict the pathway to OCD?
The present study
Although the empirical literature has identified common
comorbidities with OCD, few studies have examined which
disorders patients experience prior to the onset of this condi-
tion, and in what order this typically occurs. Further, despite
recent evidence for the role of death anxiety in OCD, no
study has examined the relevance of this construct to the
trajectory of OCD. The present study aimed to explore
pathways to the development of OCD among a treatment-
seeking sample. In addition, it aimed to explore the role of
death anxiety in these pathways, and whether levels of this
construct predict the number of disorders experienced prior
to OCD. Given the transdiagnostic role of death anxiety in
mental health, it was predicted that individuals with higher
death fears would have more disorders before developing
OCD. In a similar vein, it was hypothesised that individuals
with low death anxiety would be more likely to experience
OCD as a first disorder.
Method
Participants
The sample consisted of 98 treatment-seeking individuals (51
females), who were recruited from a psychological practice
in Sydney, Australia. The sample was recruited for a study
exploring the relationships between death anxiety and the
severity of various disorders, including OCD (see further,
Menzies, Sharpe, & Dar-Nimrod [9]). Within the current sam-
ple, 79 (80.61%) had a current diagnosis of OCD, while the
remaining 19 (19.39%) had been diagnosed with the condi-
tion previously but no longer met criteria. Of those with a
present diagnosis of OCD, the majority (58.2%) also currently
met criteria for an additional comorbid disorder.
Within the sample, 91 participants identified as Caucasian,
6 as Asian, and 1 as Indigenous Australian. Mean age was
33.71 years (SD ¼ 11.54 years; ranging 18–65 years), and
mean amount of education was 15.56 years (SD ¼ 1.92 years;
ranging 11–21 years). Average duration of OCD was 15 years
(SD ¼ 11.54 years; ranging 1–53 years). Ethical approval was
granted by the University of Sydney Human Research Ethics
Committee (protocol number 2017/118), and participants
gave consent for their data to be used in the research.
Materials and procedure
The following measures1 were administered to all
participants:

Figure 1. Mean MFODS score as a function of number of disorders developed
prior to the onset of OCD. A higher MFODS score indicates lower death anxiety.
Error bars represent standard deviation.
The anxiety and related disorders interview schedule for
DSM-5: Lifetime version (ADIS-5L)
A structured clinical interview used to ascertain current diag-
nostic status, previous diagnoses across the lifespan, and age
of onset for all reported diagnoses [16]. The ADIS-5L assesses
a number of diagnostic categories, including anxiety disor-
ders, mood disorders, obsessive compulsive disorders, and
trauma-related disorders. In the current study, it was admin-
istered to all participants by a senior clinical psychologist
with more than three decades of research and clinical experi-
ence. The administrator was blinded to the hypotheses and
aims of the present study. The ADIS-5L is based on the crite-
ria of The Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5; [17]). The previous edition of
the ADIS has demonstrated good psychometric proper-
ties [18].
Multidimensional fear of death scale (MFODS)
A self-report measure which was completed by participants
to assess levels of death anxiety [19]. It consists of 42 items,
each of which is scored on a 5-point scale, with lower scores
indicating higher levels of death anxiety. The MFODS is
made up of the following eight subscales: ‘Fear of the dying
process’, ‘fear of the dead’, ‘fear of being destroyed’, ‘fear for
significant others’, ‘fear of the unknown’, ‘fear of conscious
death’, ‘fear for the body after death’, and ‘fear of premature
death’. The total MFODS score has previously been used as a
meaningful indication of overall death fears (e.g. [9,20]) and
in the current sample, the overall scale showed excellent
internal consistency (a ¼ 0.97).
The big five aspects scale (BFAS)
The Neuroticism subscale of the BFAS, consisting of 20 items,
was included in order to control for neuroticism (i.e. one’s
tendency towards emotional lability and proneness to nega-
tive emotions) [21]. The decision to control for neuroticism
as a potential confound was based on a multitude of studies
finding a significant positive relationship between this per-
sonality variable and death anxiety (e.g. [22,23]). The internal
consistency of the BFAS in the current study was
high (a ¼ 0.86).
NORDIC JOURNAL OF PSYCHIATRY 3
Statistical analyses
Initially, we created two categorical variables: ‘OCD order’
(whether OCD was a first or subsequent disorder) and death
anxiety status (high versus low death anxiety), based on indi-
viduals scoring in the lowest and highest tertiles on the
MFODS. In order to determine whether those who had
another disorder prior to OCD were more likely to have high
death anxiety, we conducted Chi-square analyses on these
two categorical variables: OCD order and death anx-
iety status.
To determine whether the level of death anxiety also con-
tributed to the number of disorders that an individual experi-
enced prior to developing OCD, we constructed a stepwise
hierarchical regression equation. The number of disorders
experienced prior to OCD was the dependent variable, and
the MFODS score was entered in the first step of the regres-
sion equation. To ensure that neuroticism could not account
for the impact of death anxiety on number of disorders, we
added neuroticism in the final step to determine whether
death anxiety still contributed independent variance to the
number of disorders. Lastly, to outline the common trajecto-
ries towards OCD, frequencies were recorded for each dis-
order, and what order it was experienced in that
individual’s life.
Results
Death anxiety and onset of OCD
A total of 42 (42.86%) individuals experienced OCD as their
first diagnosis. In contrast, 56 (57.14%) were first diagnosed
with a condition other than OCD. The results of a chi square
analysis revealed that only 7 out of 32 (21.88%) individuals
in the high death anxiety group developed OCD first, com-
pared to 26 out of 33 (78.89%) individuals in the low death
anxiety group. As hypothesised, individuals with greater fears
of death were significantly more likely to develop other dis-
orders before being diagnosed with OCD, v2(1) ¼ 21.05, p
< .001.
Additional analyses were conducted in order to examine
whether death anxiety predicted not only whether OCD
would be the first disorder developed, but also how many
disorders participants experienced before the onset of OCD.
The results of a stepwise hierarchical regression revealed that
death anxiety significantly predicted the number of diagno-
ses before OCD onset, above and beyond the effects of neur-
oticism, b ¼ .431, t(95) ¼ 4.82, p < .001, R2 ¼ .30.
Specifically, individuals in the high death anxiety group aver-
aged 2.06 (SD ¼ 1.65) diagnoses prior to the onset of OCD,
whereas those in the low death anxiety group averaged just
0.24 (SD ¼ 0.50).2 The mean MFODS score as a function of
number of disorders prior to OCD onset is presented in
Figure 1.
Common disorders prior to OCD
Among the 56 individuals for whom OCD was not their first
diagnosis, the most common disorder first experienced
4 R. E. MENZIES ET AL.
was SAD. That is, 46.43% of those who would later develop
OCD were first diagnosed with SAD. Other common first dis-
orders prior to OCD were specific phobia (26.79%) and GAD
(10.71%). In addition to being one of the most common first
disorders prior to OCD, specific phobias were also the most
common disorder to develop second, reported by 14.29% of
individuals. No other disorders appeared to dominate this
position in pathways to OCD; both illness anxiety and GAD
manifested second for 7.14% of individuals. Illness anxiety
continued to appear relevant for individuals with greater
numbers of disorders, as 7.14% of the sample experienced
this condition as their third disorder. In sum, of the individu-
als who experienced at least one disorder prior to OCD,
46.43% experienced SAD, 26.79% GAD, 23.31% a specific
phobia, and 21.43% illness anxiety. Panic disorder was also
reasonably common, and was reported by 16.07% of partici-
pants. The developmental pathways of these disorders, and
the frequency of these conditions prior to OCD across the
entire sample are depicted in Figure 2.
Discussion
The current study sought to explore the pathways precipitat-
ing the development of OCD amongst a sample of treat-
ment-seeking individuals. Additionally, the role of death
anxiety in these pathways was investigated, focusing on
whether this predicted number of diagnoses prior to OCD. It
was hypothesised that heightened death anxiety would be
associated with a higher number of disorders experienced
prior to the development of OCD. The results demonstrated
that individuals with higher levels of death anxiety were
more likely to have experienced a range of anxiety-related
disorders before meeting criteria for OCD. These findings are
consistent with the argument that the fear of death may be
an important transdiagnostic construct, influencing the
development of various mental health conditions [6]. In add-
ition, the results revealed a number of anxiety diagnoses
commonly experienced before the development of OCD. In
support of previous research [2], SAD was found to be the
most common diagnosis of precedence, being the first dis-
order for nearly half of the individuals in this sample. This is
likely due to the earlier mean age of onset for this disorder.
The findings were also consistent with previous research
showing that an additional diagnosis of SAD predicts greater
number of disorders later in life [24]. Specific phobias, GAD,
Illness Anxiety Disorder, and Panic Disorder were also fre-
quently experienced prior to the development of OCD. Thus,
despite the exclusion of OCD from the ‘anxiety disorder’ cat-
egory of DSM-5, the present findings demonstrate the fre-
quent co-occurrence of anxiety-related disorders, including
not only obsessive-compulsive and related disorders, but
somatic symptom-related disorders (e.g. illness anxiety dis-
order). This also supports findings showing that death anx-
iety cuts across diagnostic categories, and is not limited to
conditions which are formally classified as ‘anxiety disorders’
in the DSM-5 (e.g. [25]). Notably, themes of death often
appear at the heart of many of these common preceding dis-
orders, adding further weight to the idea that these
conditions may serve as different manifestations of death
anxiety alongside OCD (see further, Iverach et al. [6]).
As hypothesised, death anxiety was found to be associ-
ated with an individual’s diagnostic history prior to OCD.
First, those with lower levels of death anxiety were signifi-
cantly more likely to have experienced OCD as their first dis-
order, compared to individuals with more pronounced fears
of death. Second, levels of death anxiety significantly pre-
dicted the number of diagnoses received prior to OCD onset.
Specifically, individuals with more severe death fears experi-
enced, on average, more than double the number of diagno-
ses prior to OCD, compared with those low in death anxiety.
Importantly, this finding remained significant after controlling
for neuroticism. These results support previous findings dem-
onstrating that death anxiety is associated with greater num-
bers of lifetime diagnoses [8], while also mapping out
common trajectories of disorders prior to the onset of OCD
specifically. These findings suggest that the fear of death
may predict important outcomes in the developmental path-
ways of anxiety-related disorders, and support the argument
that it contributes to the ‘revolving door’ of mental health
[6, p.590]. That is, individuals with greater death anxiety
appear to cycle through a greater number of disorders. This
may potentially indicate that OCD is just one of many mani-
festations of this underlying existential dread. On the other
hand, those who experience OCD as their first disorder
report significantly lower fears of death. For these latter indi-
viduals, future research is needed to investigate whether
their obsessions and compulsions are less likely to center on
death, and instead focus on other themes, such as sexual
obsessions which do not appear to relate to harm or mortal-
ity. Indeed, such sexual obsessions appear to be a unique
feature of OCD, in contrast to the concerns about broad
harm (e.g. illnesses) that feature across numerous anxiety-
related disorders. Therefore, it is possible that it is these indi-
viduals who experience OCD as their first disorder, and this
may explain why this subgroup do not typically develop one
disorder after another with a focus on physical harm.
However, examining the particular obsessions and compul-
sions of individuals who experienced OCD first was beyond
the scope of the present study. On a similar note, whilst sex-
ual obsessions do not directly relate to death, individuals
with these obsessions may fear consequences of their
thoughts following death (e.g. religious punishment in the
afterlife or eternal damnation). Future research is needed to
examine these possibilities.
The present study highlights several potential implications
for clinical practice. Overall, these findings suggest that the
treatment of death anxiety may be an important step
towards preventing the ‘revolving door’ phenomenon. At
present, individuals presenting in clinical settings are often
treated with diagnosis-specific interventions and, following
apparently successful treatment, subsequently present again
for treatment with a seemingly different constellation of clin-
ical symptoms. If the fear of death is the core underlying
construct driving the manifestation of clinical anxiety, then
treatment targeted towards ameliorating such mortality con-
cerns may prove a valuable transdiagnostic remedy. Further,

Figure 2. Representation of the most common disorder pathways to OCD. Percentages indicate what percent of the sample experienced that disorder at that time-
point (e.g. 17% of individuals experienced OCD as their third disorder). GAD: generalised anxiety disorder; IAD: illness anxiety disorder; OCD: obsessive-compulsive
disorder; SAD: separation anxiety disorder; SP: specific phobia.
interventions which aim to ameliorate death anxiety may
help prevent the development of additional mental illnesses
later in life. With regards to treating death anxiety, one
recent meta-analysis found CBT interventions with a focus on
exposure therapy to be effective in reducing fears of death
[26]. Thus, current treatments may benefit from implement-
ing CBT strategies (e.g. graded exposure to the individual’s
specific feared situations relating to death) in order to
improve a client’s death anxiety. However, it remains to be
seen whether, consistent with theoretical arguments, treating
fears of death directly will indeed improve an individual’s
broader mental health and symptomology.
The limitations of the present study should be noted.
First, death anxiety scores were not measured prospectively,
therefore the direction of causality between variables cannot
be made. Although individuals with higher death anxiety at
present had exhibited a greater number of lifetime diagno-
ses, it is unclear whether death anxiety was similarly elevated
during previous periods of pathology. It may be that such
elevated death anxiety levels at present are a consequence,
rather than driver, of the greater number of lifetime diagno-
ses. However, it should once again be noted that all findings
remained significant even after controlling for neuroticism,
suggesting that trait anxiety is unlikely to explain these
effects. In addition, the idea that death anxiety drives these
anxiety-related disorders (rather than the reverse causal dir-
ection) is supported empirically. Recent experimental evi-
dence demonstrates that reminders of death worsen
behaviours associated with many of the disorders identified
in the present study, including specific phobias [27]; illness
anxiety disorder [25] and of course, OCD [8]. In light of these
previous experimental findings, the current interpretation
regarding causality seems plausible. However, in order to
clarify the causal role of death anxiety in psychopathology,
future empirical investigation would benefit from employing
prospective study designs. Further research may also benefit
NORDIC JOURNAL OF PSYCHIATRY 5
from examining whether the current findings replicate using
a larger sample of individuals diagnosed with OCD.
Having acknowledged the limitations, the strengths of the
present study are noteworthy. First, the current study is the
first to examine the order in which common comorbidities
occur on the developmental pathway to OCD, in addition to
the novel role of death anxiety. Second, the utilization of a
treatment-seeking sample of individuals diagnosed with OCD
represents a significant strength of the current study. This is
particularly the case given that the death anxiety literature
has been critiqued for its over-reliance on convenience sam-
ples (e.g. [28]). Thus, the present results are likely to have
good external validity, reflecting the reality of clinical set-
tings in which patients are often presenting with high rates
of historic comorbidity. Third, the decision to measure and
control for neuroticism is also a notable strength of the pre-
sent study, and strengthens the implications of the findings
concerning the unique role of death anxiety, above and
beyond trait anxiety.
In conclusion, the results of this study demonstrate a
common series of disorder pathways leading to the develop-
ment of OCD. The findings also indicate that individuals who
report elevated levels of death anxiety are likely to experi-
ence greater number of disorders prior to developing OCD.
Overall, the results may support the notion that, for individu-
als demonstrating more pronounced fears of death, OCD is
just one manifestation of underlying mortality fears, which
have appeared previously in the form of other anxiety-
related disorders centering on illness or harm. This is consist-
ent with a number of correlational and experimental studies
demonstrating the important role of death anxiety in OCD
(e.g. [8,14]). The results of this study emphasise the import-
ance of understanding the role of death anxiety in psycho-
pathology, and the imperative to consider this
transdiagnostic construct for efficacious clinical intervention.
6 R. E. MENZIES ET AL.
Notes
1. A number of additional measures were also administered to this sample.
These are described and reported elsewhere (see further, Menzies,
Sharpe, & Dar-Nimrod [9]).
2. Notably, when the analyses were conducted on groups created using a
median split of MFODS scores, rather than a tertile split, the pattern of
results and their significance remained unchanged.
Acknowledgements
The authors are deeply grateful to all participants who generously
shared their time for the purposes of this research.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes on contributors
Rachel E. Menzies is a PhD candidate in the School of Psychology at
the University of Sydney.
Matteo Zuccala is a PhD candidate in the School of Psychology at the
University of Sydney.
Louise Sharpe (PhD) is a Professor of Clinical Psychology at the
University of Sydney.
Ilan Dar-Nimrod (PhD) is a Senior Lecturer in the School of Psychology
at the University of Sydney.
ORCID
Rachel E. Menzies http://orcid.org/0000-0001-6905-4873
Matteo Zuccala http://orcid.org/0000-0001-7845-9071
Louise Sharpe http://orcid.org/0000-0002-8790-6272
Ilan Dar-Nimrod http://orcid.org/0000-0003-2308-3673
Data availability statement
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
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