by Stacey Conroy, LCSW, MPH
Stacey C. Conroy LCSW, MPH is the supervisory social worker for mental health & substance abuse at the Richmond VA Medical and a clinical instructor in psychiatry for Virginia Commonwealth University.
This article was initially published in the Winter 2015 edition of the OCD Newsletter.
For those who live and struggle with both obsessive compulsive disorder (OCD) and substance use disorder (SUD), life, treatment, and recovery come with several challenges. All too often providers and patients lack the necessary resources and knowledge to address co-occurring OCD-SUD effectively. This article is intended as a review of our current understanding of OCD-SUD research. A companion article with more specific therapists tips and strategies was published in the Spring 2016 edition of the OCD Newsletter and can be found by clicking here.
OCD and SUD: An Overview
Obsessive compulsive disorder (OCD) and substance use disorder (SUD) are neuropsychiatric disorders involving unwanted repetitive behaviors, often with negative consequences on work and/or school, personal relationships, and social activities. In each disorder, an individual seeks to escape from unwanted emotional and/or physical distress by engaging in behaviors that, over time, become unwanted and time consuming. For OCD, this involves rituals, either overt (behavior anyone can see) or covert (for example mental reviewing or counting). For SUD, this involves the repeated pursuit of, getting ahold of, and use of a substance (drugs and/or alcohol). In each instance, the relief is gratifying but temporary, and the unwanted symptoms of emotional and/or physical distress eventually return, leading back to ground zero: obsessional thoughts and the desire to seek relief.
While its difficult to determine exactly how many people with OCD are also dealing with an SUD, studies of OCD have found that the lifetime prevalence for a co-occurring SUD is consistently in the range of 25 percent1,11 (Variation in this estimate are based on which substance was being studied and, in some cases, differed based on gender). The accuracy of co-occurring statistics are complicated by several factors: 1) OCD treatment programs often refer individuals with SUD to substance abuse treatment as a prerequisite of admission, 2) SUD programs often do not screen specifically for OCD, and 3) individuals with co-occurring OCD-SUD will often deny or under-report symptoms upon intake to a treatment program (be it for OCD or SUD), fully aware of the barrier to acceptance represented by the co-occurring disorders. Despite these factors complicating prevalence statistics, research findings consistently indicate the prevalence rate for SUD is higher when an individual is diagnosed with OCD as compared to the general population.1
Contributing Factors in the Development of OCD and SUD
Family history of OCD14 and/or SUD10 provides an indication of the potential for co-occurring OCD-SUD to develop; as such, this should be assessed carefully by clinicians. However, as with many psychiatric disorders, the contribution from families could be genetic, environmental, and/or cultural. In other words, the presence of a family member with OCD or SUD may not be enough on its own for either OCD or SUD to develop.
Neuroscience research on OCD and SUD has shown that several different brain chemicals (known as neurotransmitters), including serotonin, glutamate, and dopamine may be involved in OCD and SUD. Neurotransmitters allow the structures of the brain to communicate and perform important functions. Research on the brains of individuals with OCD and/or SUD, for example, show abnormal levels of glutamate in the brain, which may contribute to symptoms of both OCD2,16 and SUD.7 However, research to date has not been able to clarify if this is a cause or a consequence of the disorders. The neurotransmitter dopamine is a brain chemical that affects both behavioral control and motivation 3 and is thought to play a role in the development of both OCD and SUD. Loss of behavioral control is a diagnostic feature of both OCD and SUD and often a contributing factor in seeking treatment.
Some researchers have targeted regions of the brain to determine if differences in brain structure and functioning may play a part in both disorders. One such region is the prefrontal cortex, responsible for decision-making as well as cognitive and behavioral control.15 Changes to the prefrontal cortex in those with OCD13 or SUD15 may impact the ability to make decisions or maintain behavior control over repetitive behaviors common in both OCD and SUD. This makes sense based on work with patients with OCD-SUD: oftentimes, it is reported that even with full awareness of known negative consequences of engaging in the repetitive behaviors of either disorder, patients persist in engaging in these behaviors. Therapists and families are often frustrated with patients’ continuation of these damaging, repetitive behaviors despite mounting negative consequences, and often interpret these behaviors as a lack of commitment rather than an involuntary process with a neurobiological contribution. In other words, neuroscience has provided a partial explanation of factors not within the control of the patient. However, this only highlights the importance of consistently engaging in behavioral interventions to assist the recovery process and is not meant to abdicate responsibility of the patient during treatment.
Neuroscience research is crucial to our understanding of OCD and SUD. One critical factor for clinical treatment providers is that neuroimaging studies of patients after behavioral treatment have shown changes in brain functioning consistent with symptom reduction and improved functioning, thus demonstrating behavioral interventions are effective in the treatment of OCD13 and SUD.4
Treatment of OCD-SUD
The increased prevalence for co-occurring SUD is not unique to OCD; several studies8 on post traumatic stress disorder (PTSD) have found a higher prevalence rate for SUD among those with a diagnosis of PTSD. A distinct difference between co-occurring PTSD-SUD diagnosis and co-occurring OCD-SUD diagnosis, however, is the availability of an evidence-based treatment protocol, Seeking Safety©. Seeking Safety12 was developed to treat PTSD and SUD at the same time rather than separately. This is in contrast to the current standard of care in which clinicians typically try to treat one (usually the SUD first), then the other.
However, one study5 investigating the effectiveness of treating OCD and SUD at the same time reported positive outcomes, including reduction in severity of OCD symptoms, longer engagement in treatment, and higher abstinence rates at 12 month follow-up compared to the “treatment as usual” group. Treatment focused on addressing two disorders at once has also been referred to as “dual diagnosis treatment.”
While there are treatment programs that offer specialized treatment for dual diagnosis, programs often utilize a traditional cognitive behavioral therapy (CBT) treatment approach for the presenting dual disorders. CBT for anxiety disorders, depression, and a host of other disorders has a strong evidence base; however, traditional CBT — when it has a strong “C” or cognitive therapy component — isn’t always as effective for the treatment of OCD. In fact, a significant barrier to effective dual diagnosis treatment of OCD-SUD is lack of adequate training among professionals in dual-diagnosis programs in exposure response prevention (ERP), which has been found to be highly effective in the treatment of OCD.6
In addition to a lack of ERP knowledge, another barrier is the common practice of using a punishment model that removes (discharges) patients from treatment for experiencing a return of SUD symptoms (relapse). This is common for individuals with co-occurring OCD-SUD in both OCD and SUD treatment programs. The potential for a lapse or relapse to substance use increases with a co-occurring disorder such as OCD. Thus, a strategy to address relapse needs to be part of a treatment plan. One approach would be to adopt a relapse sensitive care (RSC) model of treatment with the goal of maintaining patients in treatment despite the return of SUD symptoms. In my experience, if patients know a program or provider will work with them in spite of a “slip,” the potential for early self-disclosure can be established and treatment gains can be maintained.
Though more research on this topic is needed, it is possible that the recovery process for OCD-SUD might be stronger if treatment for both disorders was delivered at the same time. At this point in time, protocols for such treatment, if they exist, have yet to be disseminated within OCD or SUD treatment communities. One obstacle to adopting a dual diagnosis approach is that this treatment may have data points that resemble more of a stock report with peaks and valleys rather than a linear progression. This will present unique challenges to treatment providers.
Medications are important tools in the treatment of OCD and SUD, with each specialty having its own prescribing protocols used during treatment. However, to date, we are lacking studies that directly address medication for co-occurring OCD-SUD.
Medications for OCD typically start with using Serotonin Reuptake Inhibitors or SRIs, though for many with OCD, these medications have limited effectiveness. Also, the dosing and duration for effective treatment of OCD with SRIs does not follow standard prescribing protocols for treating depression. Treatment for OCD often requires higher doses and can take up to 12 weeks before assessing how effective it might be for the individual (a reality not always recognized by a non-OCD specialist).
Medications for SUD are mostly substance specific and in many cases, individuals with SUD use more than one substance. There are two FDA approved medications to assist with the cravings for heroin/opioids, but have no effect on cocaine cravings. There are a handful of medications that will assist with alcohol use, but have no effect of marijuana use.
Also of note, speaking with patients about expectations for medications is a necessary factor and is by no means outside the scope of practice for a non-medically trained therapist. You are not prescribing, but are clarifying the role of medication in treatment. It is important to balance expectations of medications and behavioral interventions: medications can assist, though rarely eliminate symptoms completely. Far too often, this is the expectation of the individual in treatment. If this belief is not addressed head-on, it is likely the patient will not fully engage in the behavior therapy component of treatment. “Medication assisted treatment” options for either OCD or SUD require willingness of the patient to engage in behavioral treatment to enhance the potential for positive outcomes in the treatment of OCD-SUD. Hence the term medication assisted treatment: It is important to underscore that the medications are an adjunct to behavioral interventions using evidence-based practices such as ERP.
If the field does move in the direction of dual diagnosis treatment for OCD-SUD, at this point in time, it appears that OCD treatment programs are in a stronger position to adapt treatment for co-occurring SUD due to knowledge of ERP and medication practices specific to OCD. In addition, OCD treatment programs should be able to incorporate aspects of SUD treatment, though this would need to be done in a more comprehensive and sophisticated way. For example, many patients report that when they attended OCD-specific treatment, the only attempt to address their SUD symptoms was a referral to an Alcoholics Anonymous-type meeting. While an AA model can be a helpful adjunct to SUD treatment, it is not a substitute.
Additional research, treatment protocols, and provider education are desperately needed to meet the needs of this population. However, there appears to be a foundation in which to increase our ability to engage and treat individuals struggling with both OCD and SUD effectively.
Recovery is a journey, not an event.
Resources for Prescribers – Addiction Medicine: www.pcssmat.org
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