OCD and Substance Abuse
Obsessive-compulsive disorder (OCD) is a very severe mental health disorder that occurs in about 1 percent of the population.
In the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM–5), OCD has been placed in its own separate category. Traditionally, OCD was considered to be an anxiety disorder. Anxiety disorders are mental health disorders that are primarily driven by expressions of dysfunctional anxious behaviors, and individuals diagnosed with OCD certainly experience quite a bit of dysfunctional anxiety. However, in the latest diagnostic scheme, OCD is considered to be a separate disorder that consists of a group of disorders, and it is placed between the anxiety disorders and the trauma and stress-related disorders, indicating that the obsessive-compulsive disorders are related to both anxiety disorders and stress-related disorders. Thus, while OCD is related to the anxiety disorders (e.g., panic disorder, phobias, etc.), it is now considered to belong to a different class of disorders.
The American Psychiatric Association, publisher of the DSM–5, lists the primary features of OCD as occurring when a person experiences:
- Obsessions: Obsessions are repetitive and intrusive thoughts, urges, or even images that produce very severe anxiety in the individual who experiences them. The anxiety is so severe that the person attempts to suppress the obsessions by taking some specific action that results in a decrease in their anxiety. Individuals with OCD experience repetitive obsessions of a similar nature or even numerous different obsessions.
- Compulsions: Compulsions represent the behavioral or mental responses that the individual performs to reduce the anxiety and stress elicited by the repetitive of sessions. Compulsions are often repetitive actions, such as continually checking something, continually cleaning oneself, or continually reciting biblical verses, etc. The specific obsession will drive the types of compulsions that individuals engage in.
- Distress: OCD is diagnosed only when these obsessions and compulsions take up at least one hour a day (though many times the obsessions and compulsions take up far more time), cause significant distress for the person, and interfere with the person’s ability to perform daily activities, such as working, attending school, engaging in relationships with others, etc.
The American Psychiatric Association also requires that the obsessions and compulsions cannot be better explained by the individual’s use of drugs or medications; some other mental health disorder, such as schizophrenia or a personality disorder; or a medical condition, such as a head injury or stroke, before a diagnosis of OCD can be made. This qualification rules out other potential causes for the individual’s behavior. For instance, individuals with severe types of head injuries may begin to display repetitive obsessions and compulsions. These individuals obviously have a cognitive disorder related to their head injury and not a mental health disorder. People with severe developmental disorders, such as severe autistic spectrum disorders, may display obsessive-compulsive behaviors and would not be diagnosed with OCD.
Individuals with OCD may have different understandings or insights to their disorder. The individual’s insight into their condition can be an important factor in their treatment. Some individuals diagnosed with OCD recognize that their obsessions are probably not realistic, and these individuals are diagnosed with OCD with good or fair insight. Others believe that their obsessions and compulsions are probably realistic (OCD with poor insight). Other individuals are completely convinced that their obsessions and compulsions are realistic and true (OCD with absent insight/delusional beliefs).
As mentioned above, OCD-like presentations are noted in individuals who use certain drugs and individuals who have certain types of brain injuries. Aside from these specific instances, there is no identified cause for OCD, and it is generally accepted that OCD results from an interaction between genetic and environmental issues. Females are diagnosed with OCD more often than males as adults; however, males have slightly higher rates of diagnoses in childhood.
A Myriad of Obsessions
Certain types of obsessive-compulsive behaviors were recognized by researchers as being prevalent in many people with OCD. This resulted in a number of research attempts to categorize the disorder into a number of different subtypes. Some researchers even suggested that eating disorders, such as anorexia and bulimia, represented manifestations of OCD. One of the most common attempts to identify distinct subtypes of OCD resulted in the identification of four subtypes of OCD:
- Hoarding subtype: A commonly diagnosed subtype of OCD is the hoarding subtype where individuals experience obsessions about disposing certain types of items or items in general because they believe they will need them someday. This subtype is now considered to be a separate but related disorder to OCD that is classified under the same category as OCD: The Obsessive–Compulsive and Related Disorders category in the DSM–5 as hoarding disorder.
- Checking subtype: People diagnosed with this subtype of OCD have obsessions regarding the creation of situations that are unsafe, such as leaving doors unlocked, leaving the stove or oven on, forgetting to secure pets, etc. The obsession leads to continual checking the imagined unsecure situation, even after checking it and ensuring the situation is under control (e.g., the door really is locked; the oven is off, etc.). This continual checking interferes with the individual’s ability to function normally.
- Contamination subtype: Individuals with this type of OCD obsess over sterility, cleanliness, or other similar situations and often find themselves spending hours washing, cleaning, changing clothes, etc. This behavior interferes with their ability to carry out their daily routine.
- The intrusive thought subtype: People with this subtype of OCD experience repetitive intrusive obsessions, most often of a religious or mystical quality, that result in engaging in compulsions to reduce the anxiety that these obsessions create, such as needing to read specific biblical verses over and over, saying a specific prayer repeatedly, repetitively performing incarnations, etc.
OCD and Substance Use Disorders
The term comorbidity refers to the co-occurrence of one or more disorders in the same person. OCD appears to have significant comorbidities with major depressive disorder, bipolar disorder, a number of different anxiety disorders, and several personality disorders. Individuals diagnosed with OCD also are noted to have significantly higher rates of substance abuse and substance use disorders than would be expected, and these are significantly higher than the rate of substance use disorders that occur in individuals without any type of mental health disorder.
A 2009 study reported in the Journal of Anxiety Disorders suggested that about 25 percent of the OCD sample in the study had a comorbid substance use disorder and that the development of OCD in childhood or adolescence was more often significantly associated with the development of substance abuse. The most common substance of abuse was alcohol in this study, and it appears that the most common substance use disorder diagnosed in individuals with OCD across the majority of research studies is an alcohol use disorder. There is some evidence from the research to suggest that men diagnosed with OCD are more likely to develop alcohol use disorders than women diagnosed with OCD; however, this finding also applies to the development of alcohol use disorders in general. Men are more likely to develop alcohol use disorders that are women.
In addition, the research is mixed regarding the notion that having a comorbid alcohol use disorder exacerbates the symptoms of OCD. Nonetheless, there is research to suggest that individuals with comorbid OCD and alcohol use disorders are at increased risk for suicidality compared to individuals only diagnosed with OCD. This finding is consistent with the notion that increased risk for suicidality occurs in many individuals who suffer from substance use disorders.
There is also research that suggests that in individuals who have comorbid OCD and a substance use disorder, the substance abuse occurred after the development of the symptoms of OCD, but that many of these individuals also curb their substance abuse over time without formal treatment. This is an interesting finding that suggests that even though these individuals may be unable to either recognize the absurdity of their OCD behavior or curb their symptoms, they are somehow able to reduce their substance abuse without formal treatment.
How Is OCD Treated?
OCD is commonly treated using a combination of medications to address specific symptoms and psychotherapy. One of the most successful forms of psychotherapy that is used to treat OCD is a form of Cognitive Behavioral Therapy (CBT) termed Exposure and Response Prevention Therapy. In this form of CBT, the therapist and client work together to induce situations that will produce the obsessions in the person (the exposure component) and then prohibit the individual from engaging in their compulsive behavior (the response prevention component). In many instances, the therapist trains the client in diaphragmatic breathing and relaxation techniques so they can induce a state of relaxation during the exposure component. This reduces stress and discomfort as the individual is not allowed to engage in their compulsive behavior. Over time, the individual learns that not engaging in their compulsive behavior does not result in any traumatic events or situations, and they can learn to ignore their obsessions and eventually are rid of them. While the premise is simple, this is a very advanced form of therapy that requires targeted and advanced training and expertise.
Certain medications, such as certain types of antidepressant medications (e.g., selective serotonin reuptake inhibitors), anti-anxiety medications, and other medications, can be used to control the anxiety associated with the obsessions. Medications can be a useful addition to a treatment program for OCD; however, medications alone are not considered to be a long-term solution for individuals with OCD. They work best when combined with psychotherapy.
Some individuals have a very severe presentation of OCD that does not respond to therapy or medications. These individuals often go through years of frustrating attempts to control their obsessions and compulsions, and eventually will need to be involved in more targeted forms of intervention that can give them some form of relief. The use of deep brain stimulation techniques and, in some very specific cases, the use of psychosurgery (the removal or surgical alteration of certain areas of the brain) have been shown to be of use in curbing these very extreme forms of OCD.
A person who has a co-occurring diagnosis of OCD and a substance use disorder would need to be treated for both disorders at the same time. The OCD would be treated in a manner similar to that described above, and the substance use disorder would be treated according to the designated protocol for the particular drug that the individual has been abusing. This could include an inpatient withdrawal management program to assist with withdrawal symptoms if the particular drug has a high probability of producing physical dependence, initial residential treatment to isolate the person from potential environmental situations that would interfere with the treatment of both disorders, individual or group therapy/counseling targeted at the individual’s substance use disorder, social support group participation (e.g., Alcoholics Anonymous, Narcotics Anonymous, etc.), and long-term relapse management program participation.
OCD represents a severe form of pathology where individuals have repetitive thoughts or urges that create significant anxiety and drive them to commit repetitive behavioral acts to reduce this anxiety. Individuals with OCD are also at increased risk for the development of substance use disorders, particularly alcohol use disorders. The treatment for OCD is very intense and targeted at changing the person’s behavior (behavioral modification). Individuals who have co-occurring OCD and substance use disorders require a very specific and intensive treatment approach.