Charles F. Brady, PhD, ABPP, Lindner Center of HOPE, Clinical Director of Outpatient Services and Staff Psychologist, OCD/CBT Psychotherapist, Associate Professor, University of Cincinnati’s Department of Psychiatry
In today’s culture the terms “obsessive” and “compulsive” have been adopted to refer to excessively repetitive thoughts and hard to resist behaviors. In clinical situations this overly broad definition leads to substantial confusion when discussing obsessive compulsive disorder (OCD) and substance use disorders (SUDS). Individuals who report they are always thinking about using addictive substances and “cannot stop” acting on their urges to use, are often erroneously referred to as obsessing about using or compulsively using. Most often, someone who is struggling with a SUD does not have OCD and vice versa. However, both research and clinical practice reveal that these two conditions co-occur frequently. Mancebo et al, 2009 documented that in their sample of OCD treatment seeking patients, twenty- seven percent were found to have SUDS. To address the inevitable chicken and egg question, they delved further to uncover that seventy percent of the patients with co-occurring OCD and SUDS reported that their OCD symptoms preceded the onset of their SUD by at least one year. They also found that in their sample, the participants who reported childhood onset of OCD symptoms were at higher risk for subsequently developing a SUD. In this article, the similarities and differences between OCD and SUDS will be explained and the pertinent issues regarding the approach to treatment when a person suffers from both OCD and a SUD will be detailed.
Psychologically, the difference between a person struggling with OCD and a person with a SUD lies in what fuels the behavioral urge. For the person with a SUD, the behavior is positively reinforced. By this we mean that the mind anticipates pleasure from completing the action (i.e., using a substance). For the OCD sufferer, negative reinforcement describes the mechanism of striving to reduce distress as the key for driving the behavioral urge behind the compulsion. An additional difference is that thinking about substance use initiates a pleasure experience, whereas the intrusive thought the person with OCD experiences initiates a distress response (e.g., What if I touch a door knob and die?). There are occasions in which the person with a SUD will express that they use their addictive substance even though they do not want to. Typically, such an individual continues to experience pleasure and pleasurable anticipation of the use of the substance, but over time they develop an aversion to the negative consequences that use of the substance has brought into their life (e.g., loss of job, legal problems., relationship damage, shame, etc… ).
Biologically, it appears that the orbitofrontal cortex (OFC) plays an important role for both SUDS and OCD. The OFC is a part of the brain that helps to reign in emotional reactions. For individuals with OCD, the OFC tends to be over activated, even in neutral situations. For individuals with SUDs, the OFC becomes over active in the presence of triggers. For instance, when a person with an alcohol addiction hears or sees a beer can being opened. When the OFC is over activated, the individual experiences an intense drive to act and is overwhelmed by their desire to act. This is why sufferers of both SUDS and OCD struggle to resist their urges to perform a compulsion or to engage in their addictive behavior.
For the individual with OCD and a SUD, the relationship between the two may vary. Some individuals develop addictions as an attempt to soothe and self-medicate the distress caused by their OCD. Yet others may find that their use of addictive substances follows OCD-like rules. For example, the person who must drink 7 ounces of alcohol per night due to the obsession that if they do not, something bad may happen to a loved one. If the use of the substance is nested within a compulsion, exposure and response prevention (ERP)targeting the compulsion may need to be started.
At times if the addiction greatly interferes with treatment for the OCD symptoms then treatment must include aggressive treatment of the SUDS early in the treatment process. There are several ways in which substance abuse disorders, if untreated can impede effective treatment of OCD. First, many substances, including barbiturates, alcohol and benzodiazepines that are involved in SUDs are depressants. They either cause or exacerbate depressed mood. If a person’s mood is depressed, the motivation and drive necessary to engage in ERP treatment for their OCD symptoms may be severely impacted. Also, the essential component of successful ERP treatment involves learning. The person with OCD learns that the obsessive thoughts they experienced are not as dangerous or as intolerable as they previously believed. This learning allows them to free themselves from compulsions and helps them resist relapse. Many individuals develop SUDS in an attempt to self-medicate and soothe the distress caused by their OCD by using drugs like alcohol, benzodiazepines (e.g., valium, Xanax, Ativan, etc…), and marijuana. Unfortunately, these substances impede learning. The patients who are unable or unwilling to reduce or cease their abuse or dependency of these substances while they engage in ERP are going to have a more difficult time accomplishing the learning needed for recovery from their OCD symptoms.
When treating a patient with a co-occurring SUD and OCD, the clinician also must consider how willing and motivated is the person to tackle both the addictive behaviors and the OCD behaviors. It is not uncommon for a person with a co-occurring SUD and OCD to be more hesitant and resistant to let go of their addictive behaviors as they derive some pleasure from them, yet they may be very motivated to rid themselves of their time consuming compulsions and the anxiety triggered by their obsessions. In such instances, the clinician may need to start where the motivation allows, but continue to educate and explore with the patient about how the addiction may impede their OCD recovery and how it also may be negatively impacting their health and well-being.
In conclusion, for clinicians who treat individuals with OCD or SUDs, it is of primary importance to assess for symptoms of both disorders. The person who presents with complaints of a SUD, may be ashamed of the absurdity of their obsessions and compulsions and may not volunteer them. Likewise, the person with OCD may also feel hesitant to report their use of substances. When the clinician discovers that a person may have co-occurring OCD and SUDS, the patient will benefit most from a thoughtfully and collaboratively developed treatment plan to address both conditions.