Obsessive-compulsive disorder (OCD) is a psychological disorder that consists of an individual displaying both obsessions and compulsions. For many years, this disorder was classified with other disorders that were primarily fueled by anxiety (Anxiety Disorders); however, the American Psychiatric Association in its most recent update of its Diagnostic and Statistical Manual for Mental Disorders has placed the disorder in its own category (Obsessive-Compulsive and Related Disorders).
Commonly depicted in the media and entertainment industry as a rather quirky type of disorder, in reality, obsessive-compulsive disorder is a serious psychological disorder that is often debilitating and can be very difficult to treat. It is a serious psychiatric/psychological disorder that significantly affects the lives of people who have it.
The Presentation of OCD
It is important to note that there are two different disorders that are classified as being obsessive-compulsive: obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder. These two disorders are not the same disorder. The obsessive-compulsive personality disorder shares some features with certain manifestations of OCD, but it is not the same disorder and does not present in the same manner. It is a separate disorder that simply shares the same name. This article discusses the features of OCD and its associations with substance use disorders.
- Obsessions: Obsessions are repetitive, intrusive, and/or consistently occurring urges, thoughts, or images that produce extreme anxiety or stress in an individual and result in the person attempting to suppress them by performing some specific action that reduces the stress or anxiety that they induce.
- Compulsions: Compulsions consist of the actions designed to reduce the anxiety produced by the obsessions. These can be either mental acts or physical behaviors. The individual repeats them until they experience a significant reduction in their anxiety or stress levels. Once the obsessions begin again, the individual is driven to repeat these compulsive behaviors over and over again.
The compulsions and obsessions must consume a significant amount of the individual’s time (at least one hour or more per day nearly every day), cause significant impairment in the individual’s daily functioning, and cannot be due to some other medical condition (e.g., a traumatic brain injury) or the use of drugs or medications (e.g., chronic use of many stimulant medications may produce similar types of behaviors to those observed in OCD). In addition, the obsessions and compulsions cannot be better explained by the presence of some other mental health disorder in order for an individual to be diagnosed with OCD.
Are There Different Types of OCD?
All manifestations of OCD present with obsessions and compulsions. Some people may actually recognize that their behaviors are irrational and disrupt their lives. Others may believe them to be perfectly functional and may actually believe their actions to be useful to them despite suffering serious ramifications from their behavior.
There have been efforts to classify OCD into different typologies based on the obsessions and compulsions certain individuals primarily exhibit. There are several different categorizations of obsessions and compulsions that are most commonly observed in individuals with OCD.
One of the most common categorizations identify four subtypes of OCD:
- The contamination subtype: This subtype manifests with obsessions regarding cleanliness, being infected, etc. Compulsions can consist of repetitive hand washing, repetitive cleaning, repetitive avoidance of feared “dirty” situations, etc. This is the most common subtype of OCD and certainly one of the most common presentations of OCD presented in the popular media.
- The checking subtype: This subtype involves constantly checking or investigating aspects of one’s life that are connected to obsessions regarding being unsafe, leaving the oven on, worry that something will happen when one leaves the home, etc.
- The hoarding subtype: This subtype involves being constantly concerned with not disposing of certain types of items or not disposing of anything at all including garbage.
- The rumination (intrusive thought) subtype: This subtype involves intrusive thoughts of a religious, mystical, or even violent nature, and performing obsessions associated with these intrusive thoughts.
Certain genetic associations, neurobiological mechanisms, and gender associations (with adult females being diagnosed with OCD at a higher rate than adult males) are identified to be associated with OCD; however, there is no definitive cause of OCD that can be identified.
The Connection between Substance Abuse and OCD
OCD is a psychological disorder that has high comorbidities with a number of other different psychological disorders (comorbidity is a clinical term that describes a situation when certain disorders occur together). OCD appears to have high comorbidity rates with depression, anxiety disorders, bipolar disorder, personality disorders, and ADHD. Any individual diagnosed with nearly any type of formal psychological/psychiatric disorder is at higher risk to also develop a substance use disorder. While there are some factors that affect the comorbidity of OCD and substance use disorders, it is also true that individuals who have been diagnosed with OCD also tend to have higher rates of substance use disorders than individuals in the general population. While any type of substance use disorder can be comorbid with OCD, it appears that alcohol use disorders are among the most common substance use disorders associated with having a diagnosis of OCD.
In many cases, it appears that the symptoms of OCD may have preceded the substance abuse issues and that at least some individuals with OCD appear to address their own substance abuse. Their substance use may have somehow resolved over time without formal treatment (although it is not clear how this occurs from research studies). While this does not suggest that individuals who have OCD and a co-occurring substance use disorder do not need to have their substance abuse treated, it does suggest that in some cases individuals with OCD appear to be able to recognize and curb their substance abuse, whereas they are not able to recognize and curb the symptoms of their OCD. These findings also suggest that recognizing and treating OCD early in its course or presentation may lead to the avoidance of issues with substance use disorders in many individuals.
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OCD is most commonly treated by using some form of Cognitive Behavioral Therapy (CBT) that assists clients in identifying their irrational thoughts and replacing them with more functional thoughts and beliefs. In addition, CBT helps clients to develop a set of behaviors that are more in line with reality and more functional. One specialized type of therapy that has been used to address OCT is exposure and response prevention therapy.
The premise of exposure and response prevention therapy is quite simple. The therapist exposes the client to the anxiety-provoking obsession and prevents the individual from engaging in the anxiety-reducing response (compulsion). What happens in these therapy sessions is that individuals with OCD will initially become very anxious; however, over time as they are not allowed to engage in their compulsive behavior, their anxiety level will peak and then dissipate.
Anxiety typically is not a longstanding emotion and will dissipate over time. With the help of a therapist who can assist the client to learn to use relaxation and breathing techniques to cope with anxiety and reduce the experience of anxiety while not engaging in compulsive behavior, the client will eventually learn that not engaging in the compulsive behavior does not lead to any traumatic outcome and that the anxiety associated with the obsession is irrational. The client learns to control both obsessions and compulsions, and eventually, the obsessions and compulsions will dissipate.
Therapists who are trained in this intervention will typically start with lower level anxiety-provoking instances that fuel compulsive behavior and then work with the client up the ladder to more intense manifestations of obsessions and compulsions. The repeated success at lower levels helps prepare the client to address the more anxiety-provoking aspects of OCD.
Even though the premise of exposure and response prevention therapy may appear to be rather simplistic, it is a complicated process that can only be effectively implemented by a professionally trained therapist. Individuals without professional training in this technique and who are not licensed professional mental health workers cannot implement these techniques. Moreover, simply reading a book or article about these types of techniques does not induce competence in them. Untrained individuals trying to use these techniques will produce far more harm than good.
Substance abuse treatment for individuals with OCD should be initiated along with the formal therapy for OCD. It is well known that treating one disorder without addressing the other is counterproductive to recovery and treatment progress for either disorder. Individuals who have substance use disorders in addition to OCD need to follow empirically validated treatment protocols for their substance use disorders.
Treatment may include:
- Inpatient treatment as required for medical detox or for serious substance use issues that require removal of the client from a potentially toxic environment
- Medically assisted management of withdrawal symptoms and other issues associated with substance use disorders
- Longer-term outpatient treatment that includes individual and group therapy to address the issues that fueled the substance abuse and help the individual develop coping skills to prevent relapse in the future
- Social support from family and/or in the form of 12-Step group participation
- Other important supports as needed, such as vocational counseling, placement services, etc.
- A long-term aftercare program to assist the individual through all phases of recovery and ensure that the individual has support down the road
There are also a number of pharmacological interventions that can be used to assist in the treatment of OCD; however, these interventions are not long-term solutions. Medications that have been empirically demonstrated to be effective in treating the symptoms of OCD include antidepressant medications (particularly selective serotonin reuptake inhibitors and one tricyclic antidepressant medication), anti-anxiety medications (Many of these have a high potential for abuse and the development of physical dependence; therefore, using these in the treatment of OCD requires close monitoring by a psychiatrist.), and other medications that may affect specific symptoms that occur in individuals. In most cases, the use of medications alone to treat OCD or to treat substance abuse is not conducive to developing lifestyle changes that are associated with positive recovery. Medications can complement therapy, but they are not the best long-term solution for the treatment of OCD in the majority of cases. The goal of treatment should be to get the person to be as functional and autonomous as possible, and therapy will help the individual realize these goals.
The treatment of OCD is generally effective; however, like any psychological disorder, there are some potential setbacks. Recovery can be a long and sometimes difficult process. In addition, there are some cases that do not respond to standard treatment. For example, a small subset of individuals is noted to have very severe OCD symptoms that are not responsive to medication or therapy. In these cases, certain types of psychosurgery and deep brain stimulation may be helpful in curbing obsessions and compulsions.