OCD and Substance Use Disorder IOCDF Conference 2020

OCD and SUD
Stacey C. Conroy LCSW, MPH
Social Work Section Chief, MH
Tampa VA Medical Center
Patrick B. McGrath, Ph.D.
Head of Clinical Services, NOCD
President, OCD Midwest
Member, IOCDF Scientific and Clinical Advisory Board

Disclosure Slide
• Stacey Conroy reports there is nothing to
disclose
• Patrick McGrath reports there is nothing to
disclose.

Learning Objectives
• Attendees will increase their understanding of the
unique treatment needs of those with OCD-SUD.
• Attendees will be increase their understanding of the
need to SUD assessment and treatment with OCD
treatment.
• Attendees will increase knowledge of SUD evidenced
based treatments needed for effective concurrent
treatment of OCD and SUD.

OCD and SUD Research
Paucity
• A presence of something only in small or
insufficient quantities or amounts, scarcity
Dearth
• a scarcity or lack of something.
• "there is a dearth of evidence"

Why Are We Here Today
• 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%
– variation in this estimate are based on which
substance was being studied
– in some cases, differed based on gender

Substance Use Disorders
• In the substance use disorder chapter the biggest
change from the dependence and abuse diagnosis is the
move to Mild, Moderate, and Severe. To determine the
severity of the disorder, a criteria 1-11 has been
established.
• The presence of 2-3 symptoms out of the 11 is defined
as Mild.
• The presence of 4-5 symptoms is defined as Moderate.
• The presence of 6 or more symptoms is defined as
Severe.

Learning and Reward for
both OCD and SUD
• 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 OCD and SUD.
– 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 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.

VHA Diagnosis OCD 2010-2016
N = 38,157 Veteran diagnosed with OCD
• 36.70% also had a SUD diagnosis.
• Specific SUD rates are
– alcohol-use disorder 17.17%
– cannabis-use disorder 5.53%
– opioid-use disorder 3.60%
– amphetamine-use disorder 1.49%
– cocaine-use disorder 3.37%
– tobacco-use disorder 26.50%.
Co-occurrence of Obsessive-compulsive Disorder and Substance Use Disorders Among U.s. Veterans: Prevalence and Mental Health Utilization. Journal of Cognitive
Psychotherapy, 2019;33(1):23-32.

• Veterans with co-occurring OCD and SUD used
more mental health services throughout the
data capture period. Findings suggest that
OCD and SUD co-occur at high rates within the
VHA, and that this is associated with more
burden to the healthcare system.

BDD and SUD
• 48.9% had BDD and a lifetime SUD
– 29.5% had DSM 4 Substance Abuse over lifespan
– 35.8% had DSM 4 Substance Dependence over lifespan
• 17% were active with substances at the time of the study
• 68% of study participants with SUD stated BDD contributed to SUD
• 60% identified BDD onset was about 1 year before SUD
Grant, J. E., Menard, W., Pagano, M. E., Fay, C., & Phillips, K. A. (2005). Substance use disorders in individuals with body
dysmorphic disorder. The Journal of Clinical Psychiatry, 66(3), 309–316; quiz 404–405.

BDD with SUD and without SUD
– Prev. suicide attempt
• w/SUD 38.4% w/o SUD 18.9%
– Outpatient psychiatric treatment
• w/SUD 88.4% w/o SUD 84.4%
– Psychiatric hospitalization due to BDD
• w/SUD 17.4% w/o SUD 6.7%
Grant, J. E., Menard, W., Pagano, M. E., Fay, C., & Phillips, K. A. (2005). Substance use disorders in individuals with body
dysmorphic disorder. The Journal of Clinical Psychiatry, 66(3), 309–316; quiz 404–405.

Opioid Prescriptions and Mental
Health
• Approximately 38.6 million adults had a mental health disorder
• 18.7% were opioid users, compared with only 5.0% who have no
mental health disorder
• 115 million opioid prescriptions are distributed each year in the
United States,
• 51.4% (60 million prescriptions) were received by adults who have a
mental health disorder
Davis, M. A., Lin, L. A., Liu, H., & Sites, B. D. (2017). Prescription Opioid Use among Adults with Mental
Health Disorders in the United States. Journal of the American Board of Family Medicine: JABFM, 30(4),
407–417.

Cannabis
2015 #s for Cannabis use in the U.S.
• 44% of those in the U.S have tried cannabis
• 11% of those in the U.S. were using cannabis
• 18% Under age 30 in the U.S. were more likely to use cannabis
With legalization these numbers have grown and will continue to grow.
Gallup (2015, July 22). More than four in 10 Americans say they have tried marijuana. Retrieved from:
http://www.gallup.com/poll/184298/four-americans-say-tried- marijuana.aspx.

Cannabis
• The use of cannabis or cannabinoids to treat
medical conditions and/or alleviate symptoms
is increasingly common. However, the impact
of this use on patient reported outcomes,
such as health-related quality of life (HRQoL),
remains unclear.

• Authors did not uncover a significant association between
cannabis and cannabinoids for medical conditions and
HRQoL,
– Some patients reported small improvements HRQoL; pain,
multiple
– However, some HIV patients have reported reduced HRQoL.
Goldenberg, M., Reid, M. W., Ishak, W. W., & Danovitch, I. (2017). The impact of cannabis and
cannabinoids for medical conditions on health-related quality of life: A systematic review and
meta-analysis. Drug and Alcohol Dependence, 174, 80–90.
https://doi.org/10.1016/j.drugalcdep.2016.12.030

• Severity of OCD (as indexed by higher scores
on the Obsessive-Compulsive Inventory-
Revised) was unrelated to frequency and
quantity of cannabis use:
– but it was significantly, positively related to
increased cannabis misuse.
Spradlin, A., Mauzay, D., & Cuttler, C. (2017). Symptoms of obsessive-compulsive disorder
predict cannabis misuse. Addictive Behaviors, 72, 159–164.

CBD
• Aims: Cannabidiol is a cannabis-derived medicinal
product with potential application in a wide-
variety of contexts, however its effective dose in
different disease states remains unclear.
Millar, S. A., Stone, N. L., Bellman, Z. D., Yates, A. S., England, T. J., & O’Sullivan, S. E. (2019). A
systematic review of cannabidiol dosing in clinical populations. British Journal of Clinical
Pharmacology. https://doi.org/10.1111/bcp.14038

• In a double-blind RCT in 24 patients
• Low doses (10 mg/Kg) did produce positive responses
in generalized social anxiety disorder (SAD)
• Likewise, in another double-blind placebo- controlled
study, a dose of 6.7 mg/Kg reduced subjective anxiety
in 10 adults with generalized SAD.
• Additionally, in a case report in a child, 0.6 mg/Kg/day
increased sleep quality and duration, and decreased
anxiety secondary to PTSD
Millar, S. A., Stone, N. L., Bellman, Z. D., Yates, A. S., England, T. J., & O’Sullivan, S. E. (2019). A
systematic review of cannabidiol dosing in clinical populations. British Journal of Clinical
Pharmacology. https://doi.org/10.1111/bcp.14038

• Analysis of this data revealed that a greater proportion of studies
reported a beneficial effect of CBD in the add- on therapy group
compared to the monotherapy group
• Historically, there is a striking lack of dose-ranging studies, and
looking forward, there are no registered trials on clinicaltrials.gov
including specific dose-ranging investigations in their study design.
Millar, S. A., Stone, N. L., Bellman, Z. D., Yates, A. S., England, T. J., & O’Sullivan, S. E. (2019). A systematic
review of cannabidiol dosing in clinical populations. British Journal of Clinical Pharmacology.
https://doi.org/10.1111/bcp.14038

Legal Vs. Safe
They Are NOT the Same

Alcohol is Legal
• An estimated 88,0001 people die from alcohol-related causes
annually
– approximately 62,000 men and 26,000 women1 die,
• Making alcohol the third leading preventable cause of death in the
United States.
• The first is tobacco, and the second is poor diet and physical
inactivity.2
• In 2014, alcohol-impaired driving fatalities accounted for 9,967
deaths
– 31% percent of overall driving fatalities3

National Institutes of Health National
Institute of Alcohol Abuse and Alcohol

• Cigarette smoking is the leading preventable cause of death
in the United States.1
• Cigarette smoking causes more than 480,000 deaths each
year in the United States. This is nearly one in five deaths.1
• More than 10 times as many U.S. citizens have died
prematurely from cigarette smoking than have died in all
the wars fought by the United States.1

• Smoking causes more deaths each year than
the following causes combined:2
– Human immunodeficiency virus (HIV)
– Illegal drug use
– Alcohol use
– Motor vehicle injuries
– Firearm-related incidents

Denver ER
• Marijuana ER visit since 2014
• 17% uncontrolled vomiting
– Due to smoking marijuana
• 12% were acute psychotic symptoms in patient
with no MH history
– This happened more with edibles
• 31.6% of ER visits for marijuana lead to a hospital
admission

• Edibles make up 0.3% of the marijuana market
• 2014 Edibles lead to 204
• 2016 Edibles lead to 976

So I’m Cured???
• Key point is that obsession may not go away
forever, neither will SUD cravings.
• The response to obsession and/or SUD cravings is
what is important.
– We will want to normalize that some symptoms may
remain and that it is not a sign that a person lacks
commitment to their recovery from either OCD or
SUD.

Assessment for SUD in OCD TX
Two Question - Assessment
• OCD therapist, you should consider adding the following
questions to your assessment to determine the possibility of a
co-occurring SUD:
– How many times in the past year have you used an illegal
drug or used a prescription medication for nonmedical
reasons?
– In the last year, have you ever drunk or used drugs more
than you meant to?
Brown, R.L.L. (1997). A two–item screening test for alcohol and other drug problems. J Fam Pract, 44(2),
151–160.

Co-Occurring Treatment
• ERP often increases anxiety of OCD, so it is important to not
overwhelm the pt. with ERP – in this case, gradual ERP is
best to help mitigate relapse potential.
– SUD cravings result from stress hormones
• If pt. Is also dealing with hoarding, there may be stash's
of alcohol or drugs all over the house.
• Beware that drugs prescribed to treat anxiety can be
easily abused. Try to remain off benzos.
– Ritalin and Adderall as well 

12 Step
• Often in 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.
• Twelve Step Facilitation (TSF)
– A SAMHSA Evidenced Based Practice (EBP) designed to
enhance engagement in 12 step programs.

Twelve Step Facilitation (TSF)
• An example of a TSF intervention could include
actively reviewing
– The benefits of meetings the patient has been
attending. The goal would be to underscore the value
of decreased isolation and increased recovery-focused
social interactions.
– Specific self-directed activities to include between
sessions, assignments to read and review literature,
like chapters from the AA Big Book.

TSF
Twelve-Step Facilitation (TSF)
providers also strongly emphasize
recovery as a treatment goal, and
assign the patient work between
sessions related to AA engagement

Why TSF?
• Patients are less likely to become
involved in 12-step activities if left
to do so on their own than if more
active encouragement and referral
are provided in treatment.

• 12-step orientation/philosophy is the predominant
approach found in U.S. substance abuse treatment
• 12-step groups represent a readily available, no-cost
recovery resource
• Millions of substance abusers benefit from 12-step
involvement, with increased evidence of its
effectiveness
• Consistent with community-based treatment PEER
support model of treatment

• Combined with other treatment modalities
maximizes success
• Supports skills learned in counseling
• Help clients to:
– Develop self regulation
– Decrease isolation
– Process and reflect
– Generalize new skills in various areas of life

• AA participation is associated with greater
likelihood of recovery, improved social
functioning, and greater self-efficacy
• 12-Step self-help groups significantly reduce
health care utilization and costs
• Combined 12-Step and formal treatment leads to
better outcomes than found for either alone

Therapist Role In 12 Step Facilitation
• Introduces, explains, and advocates reliance on the
fellowship of AA as the foundation for recovery, which
should be thought of as an ongoing process of “arrest”
(as opposed to cure).
• Explains the role of a sponsor and helps patients
identify what they would most benefit from in a
sponsor.
• Answers questions about material found in the “Big
Book,” the “12 x 12,” and other readings.

12-Step Programs Literature
1. The Big Book of Alcoholics Anonymous (Alcoholics
Anonymous World Services, Inc. , Fourth Edition).
2. Twelve Steps and Twelve Traditions (Alcoholics Anonymous,
World Services, Inc.)
3. Clinical Guide to the Twelve Step Principles: by Marvin D.
Seppala, Hazelden/McGraw Hill
4. Al-Anon Twelve Steps & Twelve Traditions: Al-Anon Family
Groups, Inc., New York 1993

Cognitive Behavioral Therapy (CBT)
CBT based approaches have been shown to be helpful for both
individuals with OCD and those with SUD. In a combined model, the
therapist can also help the patient to explore the cognitions and
behaviors that may increase and/or maintain symptoms of the other
disorder. For substance use, this may include exploring the pros and
cons of continued use, self-monitoring to identify triggers for cravings,
identifying situations that might put one at risk for use, and developing
specific coping skills to deal with cravings and high-risk situations.

• CBT treatment for OCD can address the patient’s
reactive response to the experience of
obsessions.
– A CBT therapist in this case might teach the patient
how to increase awareness of when they experience
obsessions and begin to coach different responses the
patient can engage in as opposed to compulsive
behavior.

• SUD – CBT might help a person be aware of the
stressors, situations, and feelings that lead to
substance use so the person can then avoid them
or make different choices when they occur.
• People, Places, and Things
– What people?
– What places?
– What things?

Goals for CBT for SUD Treatment
• Managing cravings and urges to use
– Clarifying triggering event
– Identify coping skills
• Feel more skilled at solving problems
– Solution focused rather than crisis focused
• Feel more committed to making and maintaining
changes in substance use
– Identifying support, motivation and resources

Case Example
• 24 yr old Caucasian Male
• Scrupulous, Existential, and Just Right forms of
OCD
• Experimenting with several types of substances
• Wants relief from the feeling of being stuck
• Notes that when high, it is the only time his brain
gives him a break

Background
• Months prior of living in parents basement and
using various substances
• Always said that tomorrow he was going to make
a change, but tomorrow was not coming
• Parents frustrated and had had the same
conversations over and over
• Parents gave him money which he used to buy
drugs and alcohol

Treatment
• Residential level of care
• Family sessions were an absolute must – parents even flew up
to do in person visits in addition to phone sessions
• Cross tracking with both the addiction and OCD side of the
house
• First week was OCD during day and then 12 step meetings at
night
• Next week started cross tracking two times a week with the
addiction side of the house

Treatment
• Cravings and urges were monitored
• ERP was used for OCD as well as for Addiction work –
use of our Virtual Reality program
• As ERP ramped up, we also made sure that he got
nightly homework for both OCD and addiction
• Motivational interviewing, process groups, and
education groups used for addiction, and CBT and
ERP for OCD were main treatments

End of Treatment
• Able to read a paragraph in a book and not have to go back
and read it over and over again.
• Engaged in political and religious conversations and was able
to not have to argue and be right.
• VR ERP was done to the point of no urges noted, though some
cravings still remained.
• Referred to an individual therapist and 12-step meetings back
home.

Tools for Basic Education
Easy to implement (example)
 Pleasure Unwoven: inexpensive DVD outlining historical and modern concepts of
calling addiction a disease –good for staff and patients/families to view
 Increases discussion on the realities why relapse happens despite honest desire
for recovery
 Increases understanding of the biological aspect of addiction and why someone
may relapse while in treatment
 Chasing Heroin – Frontline DVD also inexpensive discusses national response to
opioid epidemic, histories and new treatment approaches. (NOT GOOD FOR
PATIENT VIEWING)
 Increase understanding that Relapse Sensitive Care is part of a disease model of
care for a chronic health condition
McCauley, Kevin (producer) (2009). Pleasure Unwoven: a personal journey about addiction. (DVD) Institute for Addiction Study.
WGBH (2016) Chasing Heroin: Investigating An American Crisis (DVD) PBS.org

Can You Do Treatment with
Someone Who is Still Using
Substances or Drinking?

Change the Plan
• ACT may be a more effective treatment for
individuals who are actively using than ERP
• Substance use is an avoidance of
– Anxiety; Physical Distress, Response to Obsessions
• Active use does not allow for habituation or
willingness

The Wisdom to Know the Difference
• ACT for Substance Use Disorder

Psychoeducation
• OCD
– What is OCD?
– How has OCD impacted your life?
– How is OCD treated
• SUD
– Biological aspects of SUD
• Pleasure Unwoven
– Behavioral aspects of SUD
– How is SUD treated
• 12 step facilitation
• Medication Assisted Treatment

OCD/SUD Special Interest
Group (SIG) Website
www.ocdsud.com

OCD-SUD Special Interest
Group (SIG)
• To join our SIG email
sconroy1994@gmail.com and
request to be added to the group
list

Additional Information
• Co-Occurring OCD and Substance Use Disorder:
What the Research Tells Us. OCD Newsletter Fall
2015 Volume 24 Issue 4.
• Treating Co-occurring OCD and Substance Use
Disorder: What Professionals Need to Know. OCD
Newsletter Winter 2016 Volume 30 Issue 1.

Alcohol Stats Citations
1 Centers for Disease Control and Prevention (CDC). Alcohol and Public Health: Alcohol-Related
Disease Impact (ARDI). Average for United States 2006–2010 Alcohol-Attributable Deaths Due to
Excessive Alcohol Use. Available at:
https://nccd.cdc.gov/DPH_ARDI/Default/Report.aspx?T=AAM&P=f6d7eda7-036e-4553-9968-
9b17ffad620e&R=d7a9b303-48e9-4440-bf47-070a4827e1fd&M=8E1C5233-5640-4EE8-9247-
1ECA7DA325B9&F=&D=.
2 Mokdad, A.H.; Marks, J.S.; Stroup, D.F.; and Gerberding, J.L. Actual causes of death in the United
States 2000. [Published erratum in: JAMA 293(3):293–294, 298] JAMA: Journal of the American Medical
Association291(10):1238–1245, 2004. PMID: 15010446
3 National Center for Statistics and Analysis. 2014 Crash Data Key Findings (Traffic Safety Facts
Crash Stats. Report No. DOT HS 812 219). Washington, DC: National Highway Traffic Safety
Administration, 2015. Available
at: https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812219.

Smoking Citations
1 U.S. Department of Health and Human Services. The Health
Consequences of Smoking—50 Years of Progress: A Report of the
Surgeon General. Atlanta: U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health Promotion, Office on
Smoking and Health, 2014
2 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of
Death in the United States. JAMA: Journal of the American Medical
Association 2004;291(10):1238–45

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