Obsessive-compulsive disorder (OCD) is often misunderstood as simply a need for cleanliness or order. However, it is more complex. OCD is a condition that affects 2 to 3% of the general population and leads to obsessive thoughts and compulsive actions that can consume hours every day and make it difficult to live a normal life.[1]
For some individuals, drugs or alcohol may seem like an effective way to quiet these thoughts or manage the anxiety that comes with them. But it’s only ever a temporary fix. Alcohol and drugs don’t silence OCD; they can actually worsen it, and the co-occurring disorder that results requires specialized dual diagnosis care to address effectively.
What Is Obsessive-Compulsive Disorder?
Obsessive-compulsive disorder is a type of mental illness in which a person has obsessions, compulsions, or both.[2]
Obsessions are recurring, intrusive, unwanted, and distressing thoughts that cause anxiety and stress.
Compulsions are repetitive behaviors or mental processes that are a response to an obsession. They are performed to relieve anxiety or stress or ”prevent” unpleasant events from happening. But they only relieve anxiety temporarily, until the urge to perform the compulsion arises again.
Obsessive-compulsive disorder is classified in the DSM as an obsessive-compulsive and related disorder, which also includes body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder.[3] It is not the casual “OCD” that people refer to as a synonym for being very organized or particular — clinical OCD involves ego-dystonic intrusive thoughts (thoughts that feel alien or unacceptable) and time-consuming compulsive rituals that are major causes of distress.
The Four Types of OCD
There are four general categories of OCD, though sometimes they overlap, and present in different ways from person to person:
- Contamination and cleaning — Fear of contamination from germs, chemicals, bodily fluids, or other sources, causing compulsive cleaning, washing, and avoidance.
- Harm and checking — Ego-dystonic (meaning unwanted) intrusive thoughts about harm to self or others, leading to compulsive checking to reassure and prevent feared outcomes.
- Symmetry and ordering — A need for objects to be in a specific location or for tasks to be completed in a symmetrical way, with significant distress when this is not achieved.
- Intrusive taboo thoughts — Disturbing or unwanted thoughts about violence, sex, religion, or morality, which may include mental compulsions such as ruminating, seeking reassurance, and mental reviewing.
Symptoms of OCD
OCD symptoms can occur in all three dimensions — cognitive, emotional, and behavioral — and must be time-consuming (typically taking at least an hour every day), cause significant distress or interfere with functioning to meet the diagnostic criteria for OCD.[4]
Obsession Symptoms:
- Persistent intrusive thoughts, images, or urges that are experienced as unwanted and distressing
- Attempts to suppress or neutralize the intrusive thoughts with other thoughts or actions
- Recognizing that the thoughts are a product of their own mind
Compulsion Symptoms:
- Performing repetitive behaviors or actions such as handwashing, checking, ordering, or counting
- Engaging in mental acts like praying, counting, or silently repeating words
- Performing behaviors to relieve distress or prevent a feared event from occurring, that are not realistically connected to what they are designed to prevent
- Temporary relief from anxiety after performing the compulsion, followed by the return of the obsession
Is There a Link Between OCD and Addiction?
The relationship between OCD and substance use disorder is both real and measurable. Clinical research has shown that people with OCD have higher rates of alcohol use disorder, cannabis use, and opioid misuse than those in the general population.[5]
The relationship has a strong basis in self-medication. People with OCD experience high levels of anxiety from intrusive thoughts and will often use substances that relieve anxiety, such as alcohol, cannabis, or opioids, to cope, although the effects are usually temporary. A person with OCD may report using alcohol to stop their intrusive thoughts, cannabis to relieve the hypersensitivity associated with OCD, and opioids for the sedating relief from constant mental chaos.
The cycle of self-medication in OCD results in the same pattern seen with other anxiety disorders: use produces immediate relief, neuroadaptation to the substance occurs, OCD worsens in the absence of the substance, and more of the substance is required to achieve the same relief.
The result is a severe form of OCD with a co-occurring substance use disorder, each condition bolstering the other in a way that requires dual diagnosis treatment of both.[6]
What Substances Make OCD Worse?
Stimulants, including cocaine, methamphetamine, and caffeine, have been found to increase OCD symptoms by increasing arousal, anxiety, and the frequency of intrusive thoughts.[7]
Alcohol, while providing some immediate relief of anxiety in the short term, can worsen OCD when used chronically by dysregulating serotonin production — a neurotransmitter central to the neurobiology of OCD.[8]
Cannabis appears to have a variable relationship with OCD; for some people, low doses can provide some immediate anxiety relief. However, in those who use high doses or use cannabis chronically, the likelihood of increased paranoia, anxiety, and intrusive thoughts is significant.[9] The substances involved in a person’s presentation of OCD and addiction are important in developing an individualized treatment plan.
Compulsive Behavior vs. Addiction
In dual diagnosis practice, it is important to determine the distinction between compulsive behaviors and addictive behaviors. Both are characterized by repetitive behaviors that can be difficult to control and often result in distress. However, there are significant differences.
Compulsions associated with OCD are primarily driven by the desire to reduce anxiety and are usually experienced as inconsistent with the person’s identity, making them ego-dystonic. Addictive behaviors are typically driven by the desire for reward and are often ego-syntonic — meaning pleasurable (at least initially).[10]
While there is often considerable overlap, particularly in the case of behavioral addictions, accurate dual diagnosis evaluation is necessary for appropriate treatment planning.
How to Stop Self-Medicating OCD Symptoms
Stopping the use of drugs or alcohol to self-medicate OCD symptoms cannot be accomplished simply by willpower — it requires treating the OCD itself. If the obsessive anxiety generating the use of the drug or alcohol is not addressed, there will always be pressure to self-medicate.
Proven strategies include:
- Integrated dual diagnosis treatment — Treating OCD and addiction simultaneously, with ERP for the OCD and evidence-based addiction treatment for the substance use.
- Medical detox — For people with significant alcohol dependence, medically supervised withdrawal is an important step before intensive therapeutic work.
- ERP as an anxiety alternative — Developing the ability to tolerate OCD-related anxiety without responding to it — the core skill that makes self-medication unnecessary.
- Serotonin-targeted medication — SSRIs are the first-line pharmacological treatment for OCD and can reduce the obsessive anxiety driving self-medication with alcohol.
- Relapse prevention skills — Identifying OCD triggers as relapse triggers and developing specific coping strategies to address them.
Evidence-Based OCD Treatment
Exposure and Response Prevention (ERP): ERP is the gold-standard evidence-based treatment for OCD, supported by decades of clinical research.[11] ERP involves gradual, structured exposure to obsession triggers while refraining from performing the compulsive response. Through repeated exposures without the feared consequence materializing, the brain learns that the obsessive anxiety does not require a compulsive response, and the anxiety gradually diminishes. ERP is not easy. It requires tolerating significant anxiety in the short term, but it produces lasting results and is the most effective treatment available for OCD.
Cognitive Behavioral Therapy (CBT): CBT for OCD addresses the cognitive appraisals and beliefs that give intrusive thoughts their power. By examining and modifying these beliefs, CBT reduces the distress associated with intrusive thoughts and supports the work of ERP.
Medication Management: SSRIs are the first-line pharmacological treatment for OCD, targeting the serotonin dysregulation that underlies obsessive-compulsive symptoms.[12] Higher doses than are typically used for depression are often required, and response may take several weeks. Medication management at All In Solutions is carefully coordinated with addiction treatment.
