Obsessive-Compulsive & Related Disorders & Substance Abuse
Obsessive-compulsive disorder (OCD) and related disorders feature some type of driving belief, thought, or urge that results in discomfort for the person. That discomfort is generally relieved when the person performs some type of repetitive behavior.
For most of the major obsessive-compulsive and related disorders, there is an increased risk for the development of substance abuse. This may result in a diagnosis of a co-occurring substance use disorder.
Whenever someone is diagnosed with a substance use disorder and another mental health disorder, treatment becomes more complicated. Both disorders must be treated simultaneously in order for full recovery to be reached.
Types of Official Diagnoses
The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) is the go-to manual published by the American Psychiatric Association (APA) for diagnosing different forms of mental illness.
The DSM-5 notes the following types of obsessive-compulsive and related disorders:
- Obsessive-compulsive disorder (OCD)
- Hoarding disorder
- Body dysmorphic disorder
- Excoriation disorder
Other manifestations of obsessive-compulsive disorder and related behaviors can occur as a result of a medical condition or drug use.
The DSM-5 also lists several more poorly defined disorders in this category that are rather vague. These are diagnosed when someone appears to be displaying OCD-like behaviors but does not meet the full criteria to be diagnosed with the above disorders.
In previous editions of the DSM, OCD and related disorders were diagnosed as anxiety disorders, but in the latest version, they are given their own category separate from the anxiety disorders. Even though anxiety plays a significant role in OCD and related disorders, it is no longer believed to be the major feature of this class of disorders. Clinicians now separate anxiety disorders from syndromes that were once thought to be subtypes of anxiety disorders.
Obsessive-Compulsive Disorder (OCD)
In the current context, OCD refers to a clinical disorder where a person displays obsessions and compulsions.
The DSM-5 also refers to a personality disorder labeled obsessive-compulsive personality disorder. OCD is not this disorder, even though there are some similarities between the two.
The major features of OCD include:
- Obsessions that are intrusive and repetitive thoughts, urges, or even images, which will often produce significant anxiety. The anxiety is so powerful that the person must find an outlet to release it.
- Compulsions, which are the behavioral responses the person uses to relieve the anxiety associated with the obsession. These behavioral responses are often repeated numerous times. These compulsive behaviors are determined by the types of obsessions the person experiences.
Both obsessions and compulsions result in significant distress and impairment in everyday functioning.
In order for obsessive-compulsive disorder to be diagnosed, the obsessions and compulsions cannot be due to the use of drugs or other medications, and they cannot be the result of a medical condition like a head injury. The obsessions or the compulsions must also occupy a significant amount of time — at least one hour a day or more.
The most common forms of OCD include compulsive handwashing (an obsession often centered around infection or untidiness), compulsive checking (centered around numerous issues), and obsessions and compulsions of a religious nature (such as constant praying or singing.).
There are numerous manifestations of obsessive-compulsive disorder. In some cases, individuals may recognize that their behavior is dysfunctional (OCD with good insight), whereas others may not recognize that their behavior is causing them distress or that it is unrealistic (OCD either with poor insight or with absent insight/delusional beliefs).
The prevalence of obsessive-compulsive disorder is reported at around 1.2 percent in any year. Females have a slightly higher rate of the disorder compared to males.
OCD & Substance Abuse
People who are diagnosed with OCD have significantly higher rates of substance use disorders than people without any mental health disorder.
Research studies suggest that as many as 20 to 30 percent of individuals with OCD may have some type of co-occurring substance use disorder. Men diagnosed with OCD may be more likely to have a substance abuse issue than women who are diagnosed with the disorder. Alcohol is the most common substance of abuse in this demographic.
Hoarding disorder, which may also be referred to as compulsive hoarding, was once considered to be a type of obsessive-compulsive disorder. In the DSM-5, it is now a standalone diagnosis under the category of obsessive-compulsive and related disorders; it is not an addiction.
The disorder is diagnosed when an individual continues to collect and keep numerous different objects, many of which have little functional value at all. They have extreme difficulty discarding such objects. Their living space is often very cluttered and may even become unsanitary.
The person often becomes very anxious when confronted with getting rid of the items they have collected, and this anxiety is very similar to the types seen in anxiety disorders. The hoarding results in impairment in social functioning, occupational functioning, or other areas of functioning. It usually causes the person significant distress.
In order for a diagnosis to be made, the hoarding behavior cannot be better explained by some other mental health disorder, the use of drugs, or a medical condition. As with OCD, individuals with this disorder may have good insight into the problem, or they may have no insight at all into the distress their hoarding produces.
The prevalence of hoarding disorder in the United States is estimated to be between 2 percent and 6 percent. Higher rates of the disorder appear in individuals over the age of 55, although hoarding behaviors usually begin in early adolescence for most people.
Addiction & Hoarding Disorder
Some sources, particularly media sources, have attempted to portray hoarding disorder as a different type of addiction or addictive behavior. However, APA has looked at this evidence and decided that there are major differences in the neurobiology, reasons for the behavior, and other factors among people with a diagnosis of hoarding disorder and people diagnosed with behavioral addictions, such as gambling addiction. These differences would not classify hoarding disorder as a type of addictive behavior.
While nearly three-quarters of people diagnosed with hoarding disorder also have a diagnosis of some type of co-occurring anxiety disorder, major depressive disorder, or similar disorder like bipolar disorder, it is estimated that a very small percent have a co-occurring substance use disorder (less than 5 percent).
Body Dysmorphic Disorder
When a person has body dysmorphic disorder, they are preoccupied with a perceived flaw in their physical appearance, even though this flaw may not be observed by others. The person engages in numerous repetitive behaviors associated with this concern, such as excessive grooming, skin picking, seeking reassurance from others, or even getting multiple surgeries to change this perceived deficit.
The person’s obsession with this perceived flaw in their appearance results in significant impairment in functioning or substantial distress.
Rates of substance abuse in people who have this disorder may be extremely high. Some research studies suggest the rates are 30 percent or higher.
APA defines trichotillomania as a disorder where someone recurrently pulls out their hair, resulting in hair loss. They engage in repeated attempts to decrease or stop pulling out their hair but are unsuccessful.
The hair pulling causes the person significant distress or problems with social functioning, occupational functioning, or in other areas of everyday life.
Women are more frequently diagnosed with this disorder than men. The overall prevalence is rather low, probably only 1 to 2 percent of the population.
Research has suggested that a significant portion of people with this diagnosis may have co-occurring substance use disorders. Rates could be as high as 15 to 19 percent.
Excoriation disorder is often referred to as compulsive skin picking disorder. The person repeatedly picks at their skin, resulting in lesions. They have made numerous unsuccessful attempts to either cut down or stop picking at their skin. The behavior results in significant impairment or dysfunction for the person.
Nearly 75 percent of people with this disorder are women. The overall prevalence is 1 to 2 percent.
This disorder is commonly accompanied by other disorders, particularly other obsessive-compulsive and related disorders. Substance abuse within this group is not well studied, but if someone has a comorbid (co-occurring) diagnosis of an obsessive-compulsive or related disorder, their potential risk for substance abuse would also be considered high.
According to APA, the causes of obsessive-compulsive and related disorders are not well described. Instead, it is a believed that a combination of heredity and experience works together to produce these disorders.
Disorders like OCD tend to run in families, and this may reflect genetics and even learning. Other environmental experiences that may contribute to the development of OCD behaviors include stress or trauma at an early age, the presence of some other psychiatric disorder, or a history of a substance abuse problem.
Treatment for Substance Abuse
There are a number of older research studies that have suggested that individuals who have OCD or related disorders are often able to address issues with substance abuse (if they have a co-occurring substance use disorder) without significant treatment. This finding has not always been replicated, but it appears that people who have good insight regarding their obsessive-compulsive behaviors (realize that these behaviors are dysfunctional for them) are better at addressing issues with substance abuse than individuals who do not have this insight. In many of the studies, individuals diagnosed with an obsessive-compulsive or related disorder admit to a history of abusing substances, but they have already addressed their substance abuse issues.
Nonetheless, when a mental health clinician is confronted with a person who has an obsessive-compulsive or related disorder and a co-occurring substance use disorder, the approach is to treat both disorders at the same time. It is essentially ineffective to try to address one of the disorders and hope the other will remit on its own.
There are no specific medications that address any obsessive-compulsive and related disorder in its entirety. Instead, antidepressants, anti-anxiety medications, and antipsychotic medications may address some of the symptoms of the particular disorder in question, particularly issues with anxiety or depression.
Medications are commonly used in conjunction with behavioral interventions like psychotherapy to restructure the person’s understanding of their compulsions and obsessions, and to change their behavior. Most often, forms of cognitive behavioral therapy are considered to be the most useful. In very severe cases of OCD where intensive treatment protocols have not been helpful, psychosurgery may be effective.
Likewise, medications can be used to address certain problems related to substance abuse, such as to manage withdrawal symptoms or control cravings for the drug. However, long-term treatment plans feature behavioral interventions as the core component of treatment.
The key to effective treatment for co-occurring substance abuse and obsessive-compulsive or related disorders is comprehensive care. Each client must be treated as a whole person, and therapy must effectively address all aspects of their disorders.
The co-occurring disorders diagnosis then comes into play with each phase of treatment, from the initial assessment to the creation of the treatment plan to its implementation and aftercare planning. At every step of the recovery journey, both the obsessive-compulsive or related disorder and the substance use disorder are taken into consideration and treated accordingly.
As with all addiction recovery plans, treatment will likely change as the person progresses in recovery. There isn’t a one-size-fits-all solution that will work for each individual, and likewise, there isn’t a plan that will fit perfectly throughout the entirety of treatment. It must be malleable and changed according to the person’s needs at that point in time.