Education

OCD and Addiction
By Sara Jenike, MA, Ethan S. Smith and Riley Sisson

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"Addiction is universal. It is not a new problem, but recently record numbers of Americans have lost their lives to addiction. Families and professionals alike seem confused as to the best way to combat this growing, deadly problem. Frederick “Riley” Sisson was excited to share this article to raise awareness to those afflicted with obsessive-compulsive disorder (OCD) and addiction; sadly he lost his courageous battle to OCD and addiction from an accidental overdose on September 1, 2014. He was just 25 years old. Right up until his death, he was an advocate for those suffering from OCD and addiction. This article reflects Riley’s work. Riley inspired many people not only in his short life, but also in his death. Margaret, his mother, is devoted to carrying on his work and his message. So here’s to you, Riley!"

Mental Illness and Alcoholism/Addiction

Addiction often accompanies other mental health problems. Some experience symptoms of mental illness after periods of drug use. Many people use drugs to self-medicate, or to “treat” symptoms of other mental health disorders. Self-medicating clearly does not work as a long-term solution. Drugs can induce psychosis, and drastically exacerbate various symptoms.

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder that includes obsessions and compulsions. Obsessions are thoughts, images or impulses that occur over and over again and feel outside of the person’s control. Individuals with OCD do not want to have these thoughts and find them disturbing. In most cases, people with OCD realize that these thoughts don’t make any sense. Obsessions are typically accompanied by intense and uncomfortable feelings such as fear, disgust, doubt, or a feeling that things have to be done in a way that is “just right.” Compulsions are often part of obsessive-compulsive disorder. These are repetitive behaviors or thoughts that a person uses with the intention of neutralizing, counteracting, or making their obsessions go away. People with OCD realize this is only a temporary solution but without a better way to cope, they rely on the compulsion as a temporary escape. Compulsions can also include avoiding situations that trigger obsessions. Compulsions are time consuming and get in the way of important activities the person values.

Illicit stimulants in particular exacerbate obsessive-compulsive disorder symptoms, such as anxiety and paranoia. Central nervous system depressant drugs, such as alcohol and opiates, can also increase the severity of OCD symptoms and anxiety, especially during periods of withdrawal from the substance(s). It’s difficult to say with certainty if the drugs cause the symptoms, or if the untreated symptoms result in drug use. It likely can go either way. Symptoms of OCD, including increased anxiety and depression, increase the cunning and compelling thoughts and feelings (obsession) around wanting to use drugs and/or alcohol to reduce symptomology. Symptoms of alcohol and drug withdrawal or intoxication can increase OCD symptoms and therefore encourage more “using” behavior.

OCD: Severity, Debilitating Nature and Treatment

Dual diagnosis or comorbidity is a term used to describe a situation in which a person is diagnosed with more than one co-occurring mental health disorder. This is more prevalent than assumed, particularly in the context of addiction. Among all anxiety disorders, OCD has the highest percentage of severe cases (50.6%). (Karno, Golding, Sorenson, & Burnam, 1988; Kessler et al., 2005; Lensi, 1996; Pigott, L’Heureux, Dubbert, Bernstein, & Murphy, 1994; Wahl et al., 2010). OCD’s severe and disabling nature often causes a sharp decline in an individual’s daily functioning (Abramowitz, 1996). According to the World Health Organization, OCD remains in the top ten most debilitating illnesses in the world (as cited in Kessler et al., 2005). However, research and treatment has come a long way.

Extensive empirical literature has indicated the effectiveness of Exposure and Response Prevention (ERP) therapy in reducing anxiety and the compelling urges to perform rituals. (Abramowitz, 1996; Himle & Franklin, 2009; Vogel, Stiles, & Gotestam, 2004). ERP is a form of Cognitive Behavioral Therapy (CBT). The exposure portion of ERP entails confronting the thoughts or things that cause the anxiety (e.g. going into a public bathroom, driving, being around animals). The response prevention entails choosing not to participate in the ritual that is generally associated with this exposure (e.g. refusing to excessively wash, engaging in counting rituals). If a person remains exposed to the anxiety-producing thing or situation, eventually their anxiety-level decreases. Doing this over and over, with professional assistance, has been found to decrease symptoms over time. A person’s brain learns that it’s OK to be exposed to such things, without engaging in rituals (compulsions).

OCD and Substance Use Disorders (SUDs)

Substance use disorders (SUDs) are categorized by the dysfunctional use of a substance causing significant impairment in functionality or marked distress. SUDs generally include cravings in between instances of using, obsessions around wanting to use, and the compulsive ingesting of substances. The diagnostic criteria for SUDs, as outlined in the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), are separated into categories of abuse and dependence depending on the presence of withdrawal symptoms when substance(s) are absent from the body (4th ed.; DSM-IV; American Psychiatric Association, 1994).

Both OCD and SUDs involve obsessions and compulsions. OCD can manifest in a variety of ways. With OCD, obsessions generally coincide with the fear that something bad will happen if compulsions are not carried out. With SUDs, triggers can include emotions, cognitive distortions, false beliefs, and other people, places, and things. Addicts/alcoholics generally obsess about using. With SUDs, rituals include finding ways to use, using, and preparing to use again. With OCD, rituals can include a variety of behaviors and thoughts. Using drugs and/or alcohol can be one of them.

Those with obsessive-compulsive disorder often know that their obsessions and compulsions are not based in reality. They often know that what they’re doing isn’t realistic, that it doesn’t make sense. They often see a decline in functioning, they’re aware of the time they are wasting, and they experience distress. However, they still continue to obsess and carry out the associated compulsions.

Those with SUDs are not so different. Addicts/alcoholics often see the negative consequences associated with their use, and they know the high isn’t worth it. They see clear indications of dysfunction, physical illness, distress, etc. However, they too struggle to stop themselves without help. Many scholars have collected data indicating a strong positive correlation between OCD and SUDs.

Twelve Step Groups and Alfred Adler

A need for social support is important in maintaining any type of recovery. Alcoholics Anonymous and other Twelve Step groups are often recommended to assist in the treatment of a variety of ailments, but particularly for addiction issues. These groups provide structured peer support, including group meetings, speaker events, social activities, literature, sponsorship, and, of course, the Twelve Steps.

Alcoholics Anonymous (AA) was the first Twelve Step fellowship to come to fruition. Bill Wilson and Dr. Bob Smith founded AA in Akron, Ohio in 1939 (Wilson & Smith, 2001). Extensive empirical research has found AA and related programs to be effective (Kelly, Magill, & Stout, 2009). However, the research faces some limitations due to the anonymity tradition. The practice of anonymity, however, drives the program: People feel safe going to meetings knowing that they can receive help while remaining anonymous.

The concept of social support, however, is not new. According to Alfred Adler (1870– 1937), humans are not equipped to survive without fellow humans. As opposed to his colleague, Freud, who focused on sexual drives in psychoanalysis, Adler focused on the social aspect of life, including the need for social support in overcoming obstacles or challenges. Adler’s writings became regularly used in 20th century psychology, looking at the individual, but studying the person in the context of the entire environment including other people (individual psychology). Adler described the holistic person as striving from inferiority in infancy to superiority by becoming a member of the whole community or society. Basically, he described the highest expression of a social being as one who functions in cooperation with others, while helping the group function at a higher level.

OCD and SUDs isolate people. Both illnesses can drive a person to disconnect from family and friends. This further emphasizes the importance of social support in recovery. Recovering from a debilitating illness requires an entire lifestyle change. Going from isolation to surrounding oneself with solid peer support is a massive step.

Bridging the Treatment Gap and Social Interest

A combination of regular attendance at Twelve Step meetings, CBT, and other similar forms of social support is likely to be effective in the treatment of comorbid OCD and SUDs. A lifelong commitment is needed to maintain recovery. Involvement in the Twelve Step process includes participating in meetings (not merely attending), sponsoring others, helping with planning and administrative tasks. ERP can also be continued on an ongoing basis, self-directed following the completion of professionalassisted therapy. Both are behavioral approaches.

A large part of Twelve Step groups is the concept of “paying it forward.” It’s a peer-run program. Once a person is stable in their recovery, he or she is encouraged to begin helping or sponsoring others. The commonly used AA literature states, “Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics, and to practice these principals in all our affairs” (Wilson & Smith, 2001).

The International Obsessive-Compulsive Disorder Foundation (IOCDF) already uses some of these principals. Annual conferences are held, where social support is encouraged. Additionally, mental health disorder support groups are rapidly emerging. Although not commonly known, Obsessive Compulsive Anonymous (OCA) groups exist. These groups utilize similar principals as those found in AA. An empirical study by Mclean et al. (2001) found that ERP is more effective in group therapy settings. This all supports the importance of social interest in treating not only SUDs, but also OCD. Dr. Michael Jenike is the chair of the OC Foundation Scientific Advisory Board and a professor at Harvard Medical School. He has worked with many patients over the years and stated:

"In working with OCD patients since the late 1970’s, I have seen some remain very ill, thousands of patients get moderately better, and a few make dramatic strides and totally reclaim their lives. It has seemed to me that the ones who do best are those who feel obligated to give back and help other patients. Somehow this drive to help others energizes them to fight off their own OCD and stay well and productive. (as quoted in Bell, 2009)."

Addiction is a problem that is worsening and it’s difficult to find a person who hasn’t been impacted by this epidemic: mothers are losing children, brothers are losing their sisters, colleagues are losing friends, and children are losing classmates. Many addicts suffer from co-occurring mental health disorders, such as obsessive-compulsive disorder. In treating both illnesses together, we’re likely to see better treatment outcomes. Social interest needs to be considered, in addition to an emphasis on maintaining long-term recovery.

Sara Jenike is a master’s level therapist working in the Salem, MA area. She works primarily with adolescents and enjoys working with individuals and families impacted by addiction. Sara is a heroin addict-who is maintaining recovery and success thanks to professional help, family support, and Twelve Step fellowships. Sara can be contacted at sjenike@gmail.com.

Ethan S. Smith currently lives in the Los Angeles area working as a successful writer/director/producer. Ethan was born with OCD and struggled the majority of his life until receiving life-changing treatment in 2010. Ethan was the keynote speaker at the 2014 annual OCD conference in Los Angeles and recently became a national spokesperson for the International OCD Foundation. Ethan can be contacted at Ethancreativela@gmail.com.

Riley Sisson graduated from Kennesaw State University with a bachelor’s degree in psychology. He had begun his master’s program in social work and was planning to become a therapist, specializing in mental health and addiction. Tragically, Riley lost his own battle with severe OCD and addiction Sept. 1, 2014 from an accidental overdose. Riley presented “Treatment of OCD and Addiction/Alcoholism (Dual-Diagnosis): An Integrated Treatment Approach” at the 2014 annual OCD conference in Los Angeles. Riley also co-authored a paper that was submitted to the Culture Diversity and Ethnic Minority Psychology Journal. He also presented this paper at the American Psychology Association meeting in Washington, DC in August 2014.

Riley often said, “I believe it is paramount to be of service to others, and I would like to devote my career to helping others in need.” Riley’s mother, Margaret Riley Sisson, is starting the Riley’s Wish Foundation and she plans to continue Riley’s work by educating, raising awareness and research for OCD and addiction. Margaret may be contacted at Margaret.fayettems@gmail.com.

References

Abramowitz, J.S. (1996). Variants of exposure and response prevention in the treatment of obsessive compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600.

American Psychiatric Assocation (2000). Diagnostic and statistical manual of mental disorders- 4th edition. Washington, D.C.: Author

Bell, J. (2009). When in doubt, make belief: An OCD-inspired approach to living with uncertainty, field tested (and re-tested and re-re-tested) strategies for confronting fear and worry. Novato, California: New World Library.

Himle, M.B., & Franklin, M.E. (2009). The more you do it, the easier it gets: Exposure and response prevention for OCD. Cognitive and Behavioral Practice, 16(1), 29-39. doi:http://dx.doi.org.proxy.kennesaw.edu/10.1016/j.cbpra.2008.03.002

Karno, M., Golding, J.M., Sorenson, S.B., & Burnam, M. (1988). The epidemiology of obsessive compulsive disorder in five US communities. Archives of General Psychiatry, 45(12), 1094-1099. doi:10.1001/archpsyc.1988.01800360042006

Kelly, J. F., Magill, M., & Stout, R.L. (2009). How do people recover from alcohol dependence? A systematic review of the research on mechanisms of behavior change in alcoholics anonymous. Addiction Research & Theory, 17(3), 236-259.

Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005).

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 593-602.

Lensi, P., Cassano, G.B., Correddu, G., Ravagli, S., Kunovac, J.L., Akiskal, H.S. (1996). Obsessive-Compulsive Disorder: Familial-developmental history, symptomatology, comorbidity and course with special reference to gender-related differences. British Journal of Psychiatry, 169(1), 101-107.

McLean, P.D., Whittal, M.L., Thordarson, D.S., Taylor, S., Sochting, I., Koch, W.J., Paterson, R., & Anderson, K.W. (2001). Cognitive versus behavior therapy in the group treatment of obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 69, 205-214.

Pigott, T.A., L’Heureux, F., Dubbert, B., Bernstein, S., & Murphy, D.L. (1994). Obsessive Compulsive Disorder: Comorbid conditions. Journal of Clinical Psychiatry, 55, 15-32.

Sisson, F.R. (2014). Treatment of OCD and addiction/alcoholism (dual-diagnosis): An integrated treatment approach. Unpublished manuscript, Department of Psychology, Kennesaw State University, Kennesaw, Georgia, United States.

Vogel, P.A., Stiles, T.C., & Götestam, K.G. (2004). Adding cognitive therapy elements to exposure therapy for obsessive compulsive disorder: A controlled study. Behavioural and Cognitive Psychotherapy, 32(3), 275-290.

Wahl, K., Kordon, A., Kuelz, K.A., Voderholzer, U., Hohagen, F., & Zurowski, B. (2010). Obsessive compulsive disorder (OCD) is still an unrecognised disorder: A study on the recognition of OCD in psychiatric outpatients. European Psychiatry, 25(7), 374-377. doi:10.1016/j.eurpsy.2009.12.003

Wilson, B., & Smith, B. (2001). Alcoholics Anonymous: The story of how many thousands of men and women have recovered from alcoholism (4th ed.). New York: Alcoholics Anonymous World Services.


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