Obsessive-compulsive disorder may be one of the most misunderstood, and misrepresented, mental illnesses in the eyes of the general public. When substance abuse is factored in, the impact on the lives of those who suffer from it can be significant. OCD and drug addiction are co-occurring disorders that can exacerbate the effects of both conditions, but treatment is always a possibility.
One of the Least Understood Mental Illnesses
Obsessive-compulsive disorder has long been a mental health condition that has been ripe for parody or mockery in the media and in the public consciousness. Psych Central writes of how people casually talk about being “OCD” about their habits, and US News & World Report mentions the television show Monk as an example of how obsessive-compulsive disorder is treated with undue lightness.
But the truth of OCD being a serious mental health issue for 2 percent of the American population is what led FOX News to claim that it is “one of the least understood mental illnesses.”
What OCD Is
Clarifying what OCD is – and what it isn’t – will help with understanding how substance abuse can be a factor in such a significant way.
People who have obsessive-compulsive disorder are unconsciously driven to focus all their thoughts and behavior on controlling a characteristic in their environment, which is a source of stress (or even fear) to them. Someone who is afraid of their home being broken into will not be able to function until all doors and windows are checked for being locked (and then repeatedly checked, so much so that time is consumed and daily functioning is disrupted). Someone who is afraid of catching a disease will literally be unable to think about anything else, until hands are washed and surfaces are wiped (and then washed and wiped again, no matter how many hours it takes and no matter how many other plans are ruined).
A reasonable level of attention to details of safety and hygiene is not obsessive-compulsive disorder, and neither is a meticulous level of cleanliness. But if a person had intrusive, disturbing thoughts about hypothetical situations that affects their sense of safety or wellbeing (for example, leaving work to go home and make sure all the doors are locked, and being utterly convinced that by not doing so, a home invasion was inevitable; or being unable to sleep because of concern that the carpet has not been adequately shampooed), and if these continued in an “endless cycle,” then this might be a symptom that a doctor would look for to make a diagnosis of OCD.
What OCD Isn’t
What obsessive-compulsive disorder is not is simply fastidious and perfectionist behavior. Psychology Today writes of how people will describe themselves (or others) as “being OCD” about a particular task, like cleanliness or timeliness. The big difference is that the people who are “being OCD” (in the colloquial sense) can go on with their daily (or even hourly) lives if they do not do the task at hand; someone who is “being OCD” about tidying a bedroom will not leave a social engagement to go home and tidy the bedroom. Someone who actually has obsessive-compulsive disorder might literally never stop arranging (and re-arranging and re-arranging) their room.
The problem with such inaccurate appropriation is that people who legitimately have obsessive-compulsive disorders might feel marginalized by the degree to which their condition is belittled. They may be dissuaded from seeking help to address the nature of their behavior and fears, if there is a genuine chance that their concerns are dismissed by them as just “being OCD” (as opposed to actually having obsessive-compulsive disorder).
But the common idea of “being OCD” doesn’t begin to cover the level of disruption and hardship that occurs in a clinical case of obsessive-compulsive disorder. There is a big difference about “being OCD” about hygiene and washing hands for 60 minutes at a time – and then doing so repeatedly during the course of a day, to the point where other activities and relationships are negatively affected.
If the behavior causes demonstrable and tangible impairment in a person’s life, then that could be considered criteria for an OCD diagnosis. The National Institute of Mental Health and the Anxiety and Depression Association of America estimate that 50.6 percent of the 2.2 million Americans with OCD have a severe form of the disorder.
Signs of Obsessive-Compulsive Disorder
Obsessive-compulsive disorder can take many forms, but the symptoms tend to fall into some common, connected categories.
Intrusive thoughts can be considered the driver of obsessive-compulsive disorder, so much so that a writer for The Atlantic says that it is the obsessive thinking, not the compulsive behavior, that can be the most debilitating part of the condition. They are thoughts that arise unbidden, from no external stimuli; but once they are in the person’s mind, they cannot be budged or dealt with until the compulsive behavior is carried out. For people with genuine OCD, even engaging in the compulsive behavior cannot dislodge the intrusive thoughts, or it is successful in alleviating the obsession only temporarily. The persistence of the thoughts, their vividness and seeming randomness, are what a psychologist might look for in a diagnosis for obsessive-compulsive disorder.
A characteristic of intrusive thoughts is that there is often no tangible logic behind them. A person with OCD might become obsessed with the idea of not crossing a certain street, because there is a chance of being struck by a vehicle on that particular street. Logically, there is a chance of being struck by a vehicle on any street; but for someone with OCD, their stress is fixated on that one street, to the point where they may avoid traversing that street – even at the cost of regular (and otherwise unnecessary) inconvenience (such as choosing not to board a bus that goes down that street) – because they cannot get the obsessive idea out of their head.
Unsurprisingly, avoidance is a very common way that people with OCD deal with their fears, but this isn’t a true way of “dealing” with the problem; it is merely indulging in the false sense of security that obsessive-compulsive disorder leads to, like scratching a mosquito bite.
Intrusive thoughts and avoidance come together in another characteristic of OCD, which is when the person envisions committing acts of abuse (whether violent or sexual) on another person. These can be especially distressing, because these people normally have absolutely no intention of harming another person, but they nonetheless feel incredible guilt and shame for having such thoughts. People who have this form of OCD may go out of their way to avoid spending any time with the person they imagined abusing, perhaps going so far as to break off all contact with the perceived victim. The avoidance itself may be a compulsive behavior, leading to a situation where the person cannot feel calm, relaxed, or “normal” unless extreme actions are taken to avoid the person at the heart of the intrusive thoughts.
Perinatal and Relationship OCD
Sometimes, the intrusive thoughts hit close to home. The International OCD Foundation explains that there are parents with OCD who have thoughts about hitting, abusing, or even killing their children (even their unborn children, a condition known as perinatal obsessive-compulsive disorder). The parents have no real intention of committing any such acts and feel absolutely horrified at the thought, but they are nonetheless victimized by the unbidden, graphic images of violence and death that come forth.
Other intrusive thoughts can take on the form of someone in a relationship unable to control their suspicions that their partner is being unfaithful. There may be no evidence to suggest infidelity, but what would make this a case of obsessive-compulsive disorder is if the person is compelled to carry out behaviors to determine whether the partner is cheating. Even if doubts are allayed, the intrusive thoughts remain, leading to an never ending cycle of more compulsive behaviors and intrusive thoughts. CBS News writes that people with OCD in situations like these may understand that their suspicions are baseless; however, what makes this a case of obsessive-compulsive disorder is that the people cannot stop the fears of unfaithfulness from coming into their heads, and they cannot stop the drive to spy on their partners or confront their partners, even to the detriment of the relationship itself.
Checking represents one form of the compulsive behavior dynamic of OCD, such as people repeatedly ascertaining that potential sources of harm to themselves are closed off. Someone may leave work and check that their front door at home is closed, performing this action over and over again throughout the day. Someone may check their stove repeatedly to make sure that it’s turned off or turn their television on, only to turn it off again, to make sure that it was turned off – and then turning it back on to make sure it gets turned off. This repetition can occur over and over again.
Telling someone with OCD to not engage in checking behaviors will likely not have any effect on stopping them. Physically impeding them from carrying out their checking behaviors might cause them to have a panic attack, as they believe that not being allowed to verify their safety will guarantee some kind of harm befalling them.
Causes and Origins of OCD
In 2008, the Depression & Anxiety journal published the results of a study that found a connection between childhood trauma and adulthood symptoms of obsessive-compulsive disorder. Specifically, researchers discovered that “high levels” of OCD symptoms could be traced to emotional and physical abuse, suggesting that the intrusive thoughts that OCD patients have may be a subconscious way of controlling elements of their environment that remind them (either subtly or obviously) of the trauma they experienced during childhood.
Not everyone who endures trauma at a young age goes on to develop OCD. The journal of Molecular Psychiatry speculated the existence of a “genetic marker” for obsessive-compulsive disorder, saying that people whose brains have neurochemically developed in this way would be more susceptible to the development of OCD, especially when they are confronted by traumatic events at a vulnerable age.
OCD and Substance Abuse
There are a great number of other mental health disorders associated with obsessive-compulsive disorder, both as a cause and result thereof. Most common are stress and depression that are borne from the effects of OCD in people’s lives (for example, as a result of relationships and jobs ending or the relentless intrusive thoughts). It is not unheard of for patients to resort to abusing drugs and alcohol to cope with the extreme thoughts that come into their heads, or to alleviate some of the guilt and shame that come with obsessive thoughts and their compulsive disorders.
The Journal of Anxiety Disorders published the results of a study that found that 70 percent of the 323 participants in the study reported that they had had obsessive-compulsive disorder for at least a year before going on to develop a substance abuse disorder. Specifically, drugs like alcohol and prescription medication are used to induce feelings of calm and relaxation, granting patients a sense (or illusion) of control.
Overall, people who have obsessive-compulsive disorder have a greater chance of using alcohol or drugs than the general population, according to the Anxiety and Depression Association of America, largely due to the stress and fear that are part of their everyday existences. Additionally, New Scientist magazine writes OCD is a form of addiction itself, since research has indicated that OCD patients and people with drug and alcohol problems are unable to moderate their behavior in the face of stressful events (either in childhood or adulthood). Patients who drink to control the intrusive thoughts and compulsive behaviors are effectively “obsessive-compulsive chronic alcoholics,” in the words of the American Journal of Psychiatry.
When treating a client with co-occurring obsessive-compulsive disorder and substance use disorder, therapists tend to focus on issues of confidence and ego, building up the client’s strength to slowly start taking control of situations, instead of giving way to the stream of intrusive thoughts and the compulsive behaviors that follow them.
A therapist will know how to gently point out flaws in the pattern of intrusive thoughts, and instead suggest healthier ways to moderate the stress that a client might feel. Some of that might entail working with the client to develop an understanding of being unable to control every given situation, or accepting that a reasonable amount of risk is part of everyday life.
One way to do this is by employing Exposure and Response Prevention Therapy, where a therapist and a client work together on imagining a situation that would normally induce the intrusive thoughts of obsessive-compulsive disorder, but then denying the compulsive behavior that would normally follow (the “response prevention” part of the therapy). Gradually, the client will get used to controlling what were hitherto unstoppable desires. Exposure and response prevention therapy can go on for an average of 16 weeks. The Journal of Obsessive-Compulsive and Related Disorders writes that this form of therapy has the most scientific and research-backed support for its effectiveness in helping clients with OCD.
Clients can also be prescribed anti-anxiety drugs to help the process of behavior control and response prevention along. Medications most often used for this are selective serotonin reuptake inhibitors (SSRIs), which work by preventing the brain from reabsorbing serotonin, a neurotransmitter that facilitates communication between brain cells. The more serotonin there is in a person’s central nervous system, the less likely the person is to feel depressed and stressed, which may help with controlling undesirable behavior. SSRIs ensure that the serotonin neurotransmitters remain in the person’s nervous system for longer periods of time, which explains why the Dialogues in Clinical Neuroscience journal writes that SSRIs “are the established pharmacologic first-line treatment of OCD.”
Obsessive-compulsive disorder may be fodder for television shows and popular jokes about fastidiousness, but for millions of people, it is a very real and scary mental health disorder that drives them to alcohol and drug abuse. With treatment and therapy, however, people can learn how to retake control of their lives and feel at peace with their world.