The Relationship Between OCD and Addiction

Obsessive-compulsive disorder (OCD) and addiction both involve strong urges to repeatedly engage in activities that interfere with one’s goals, values, and ability to function. This raises other important questions about the potential relationship between the conditions. For example, does addiction involve obsessions and compulsions? Are people with OCD addicted to performing their compulsions?

We surveyed the latest research and talked with in-house experts here at NOCD to address these questions and more. Here’s what we learned. 

What is OCD?

OCD is a mental health condition characterized by two primary symptoms: obsessions and compulsions. 

Obsessions are persistent and recurring intrusive thoughts, images, and urges that cause anxiety or distress. They give rise to compulsions, which are mental or physical actions performed to alleviate obsessions-induced discomfort (which can be anxiety, guilt, shame, disgust, etc.) or prevent some bad outcome. Often, the need one feels to complete a compulsion is so overwhelming that people with OCD feel that they cannot help but engage in the behavior, even when doing so comes at a cost to their well-being, job performance, social relationships, and more.  

What is addiction?

Addiction is a mental health condition characterized by strong, unyielding urges to engage in activities such as administering drugs or gambling at the expense of other needs and despite the possibility of significant adverse consequences to oneself or those around them. 

According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V TR), there are two types of addiction. They differ mainly in terms of the type of thing one is addicted to. The first, called substance use disorder (SUD), involves the use of addictive substances such as tobacco, alcohol, or cocaine. The second, called non-substance-related disorders, involves addiction to particular behaviors that don’t involve ingesting addictive substances. Currently, gambling is the only non-substance-related disorder recognized distinctly by the DSM.

Though there are subtle differences, the symptoms of both types of addiction are similar. Here are the general features. 

• The substance (or behavior) is taken in larger amounts over a longer period of time than was intended
• There have been repeated unsuccessful attempts to reduce the substance use or behavior
• Attempts to avoid the substance or behavior result in intense feelings of stress or irritability
• A significant amount of time is spent thinking about, obtaining, using, or recovering from the substance or behavior
• There are intense and overwhelming cravings to use the drug or engage in the behavior
• Feelings of distress, such as anxiety or sadness, often trigger addictive behaviors
• Addictive behaviors continue despite knowledge of significant negative consequences for one’s health as well as their relationships and obligations
• Tolerance develops, meaning one needs more of the substance or behavior to achieve the same effect over time

Can addiction involve obsessions?

One of the main features of addiction is an inability to stop thinking about what one is addicted to. Moreover, these unwanted thoughts can result in a strong urge to perform a particular action to alleviate stress, such as ingesting a substance or gambling. From this perspective, it can look very much like addiction involves obsessions. 

However, while this might show that addiction involves obsessions in some sense of the word, it doesn’t demonstrate that they are the same type of obsessions that characterize OCD. In fact, OCD-based obsessions and the urges and distress involved in addiction are notably different. Obsessions in OCD are ego-dystonic, meaning that they are misaligned with what the individual genuinely wants or values. While individuals with addiction may wish they didn’t have the desire to engage in actions associated with their intrusive thoughts, like gambling or drug-taking, they find themselves unable to stop nonetheless. 

This isn’t so with OCD, and people with OCD do not actually engage in the actions involved in their obsessions. For example, an individual who experiences intrusive thoughts about incest doesn’t actually want to have sex with a relative—in fact, nothing could be further from the truth. On the other hand, intrusive experiences related to drug use and behavioral addictions do produce genuine urges to engage in those behaviors in individuals with addiction.

Does addiction involve compulsions?

Since individuals dealing with addiction often seem compelled to engage in addictive behaviors, it’s tempting to say that addiction involves compulsions. However, this isn’t entirely accurate. Dr. Patrick McGrath, Chief Clinical Officer here at NOCD, notes that “compulsions are done for one reason and one reason only, and that’s to neutralize obsessions.” As was stated above, addiction does not involve obsessions in the sense that OCD does, which means it can’t involve compulsions in the same sense, either. 

Another reason that addiction does not involve compulsions is that, at least at the outset, the addictive behaviors are pleasurable or rewarding, though this may change later on in the course of addiction. This is why those with SUDs or behavioral addictions engage in the behaviors in the first place. Compulsions are not similar in this way. Dr. McGrath notes, “I’ve never heard anyone with OCD say at any point, ‘wow, I’m really enjoying these compulsions’ or ‘it feels so great to be doing this again.’” They are always done either to provide relief from obsessions or prevent some bad outcome, and this is so from the beginning of the disorder. 

“As opposed to addiction, rituals in OCD are associated with negative reinforcement from the onset of the disorder,” according to Drs. Amitai Abramovitch and Dean McKay, two leading experts in the study of OCD and addiction. “Impulsive acts intended to bring positive reward seen in addiction are not a part of the strong behavioral addiction mechanism seen in OCD.”

As a result, though we may find it appropriate to use the word “compulsion” to describe the behavior of people struggling with addiction, this doesn’t indicate a point of similarity between OCD and addiction. 

Does OCD involve problems with impulsivity?

Dr. McGrath argues that “addiction is more closely connected to impulsivity than compulsivity.” But what is the difference? And might there still be an element of impulsivity to OCD?

There are many conceptions of compulsivity and impulsivity. According to one popular way of thinking about the distinction, impulsivity and compulsivity exist on opposite ends of the spectrum. Compulsions are repetitive and generally unpleasant behaviors done to neutralize harm. Impulsivity is associated with urges to engage in enjoyable activities without due consideration of the potential harms brought about in the process.

OCD and compulsive rituals, in general, stand in stark contrast to this sort of impulsivity. Studies have found that they are often carefully planned, timed, and executed. Moreover, OCD involves a hypersensitivity to risk and harm, and compulsive actions are performed explicitly to avoid harm to oneself or others. 

Interestingly, despite not showing signs of increased impulsivity, individuals with OCD often self-report higher levels of it, meaning they feel more impulsive even though they aren’t. This makes sense, given how patients often describe the experience of having OCD noting that they feel “out of control.”

Does OCD make you addicted to compulsions?

Since individuals with OCD have trouble preventing themselves from performing compulsions, one might be tempted to say they are addicted to them. This conclusion might seem even more justified when considering the criteria for addiction, as OCD appears to check off many of the boxes. For example, one might note that many people with OCD: 

• Perform their obsessions more frequently over time
• Have made repeated and unsuccessful attempts to stop doing their compulsions
• Feel intense urges to perform compulsions and feel extreme distress when they cannot
• Are more likely to engage in compulsions when they are stressed
• Continue to perform compulsions despite significant negative consequences

However, a few important differences show why individuals with OCD are not addicted to compulsions. For example, Dr. McGrath highlights how there are different reasons that explain why those with addictions and individuals with OCD escalate their behaviors. “One of the reasons you see an addictive effect with drugs or alcohol is because somebody’s building up a physiological tolerance to the substance they are using.” But individuals with OCD do not build up a tolerance to obsessions. This is significant because tolerance is a key diagnostic criterion used to determine whether or not someone has an addiction. However, similar to physiological tolerance, people with OCD can build a tolerance for compulsions, in a sense, leading them to engage in them for longer periods of time or more intensely in order to get the same relief. 

Another important difference goes back to the fact that the compulsions that characterize OCD are not intrinsically rewarding at any point. Whereas those suffering from addiction enjoy engaging in the acts they are addicted to, at least early in the course of their addiction, this is never the case for individuals with OCD. Those compulsions are merely a means to an end. They provide relief from the stress of intrusive thoughts or from thinking some bad outcome will occur, but are never done because they seem pleasurable in their own right. Because this type of reward or pleasure is a necessary component of addiction, it doesn’t make sense to say that individuals with OCD are addicted to their compulsions. 

Does OCD involve the brain’s reward system?

Our brains have a carefully crafted reward system to guide us toward healthy goals by helping us learn from the results of our previous behaviors and assess the value of future actions. 

Addiction is characterized by dysfunction in the brain’s regions, such as the nucleus accumbens, that keep this system running. Does OCD involve abnormalities in the same areas in the same ways?

Research on this topic is in its early stages, and certain aspects of the initial experiments make it difficult to come to a clear answer. For example, to get a clear picture of how the brain’s reward system is involved in OCD, we need to be looking at people with OCD but not addiction. However, Dr. Jamie Feusner, Chief Medical Officer at NOCD, notes, “the reward system has not been studied well in people with OCD without SUDs.”

With that said, we have learned a few things. In particular, both OCD and SUD seem to involve, or be influenced by, the nucleus accumbens, which, as Dr. Feusner notes, is “a central part of the reward circuit.” One of the pieces of evidence he cites is the use of deep brain stimulation, a non-invasive technique that utilizes magnetic fields to stimulate parts of the brain. He notes that this intervention can be used to stimulate the nucleus accumbens and improve the symptoms of OCD, SUD, as well as other psychiatric disorders. 

There is still much to learn, and researchers will continue to uncover the connection between OCD and the brain’s reward system. 

Can substance use disorders make OCD worse?

OCD and substance use disorders often co-occur. One study found 38.6% of patients with OCD also met the criteria for an SUD. Another found that the co-occurrence of SUD and OCD is higher than for other non-OCD disorders among men. 

This raises the question, can SUD make OCD worse? The answer is yes. One of the more obvious reasons for this is that being under the influence of drugs can exacerbate OCD symptoms. As Dr. McGrath notes, “Any stimulant could make OCD worse.” If one were addicted to one of these substances, they could continuously exacerbate their OCD symptoms. Some adverse effects may also persist after use. Recent research has found that higher rates of comorbid OCD and SUD are associated with worse mental health outcomes. 

While SUD can make OCD worse, Dr. McGrath shares that “it’s most likely the other way around, where OCD will make substance abuse worse.” The idea here is that some substances may provide relief from OCD symptoms, which may lead to them being abused over time. Recent research seems to support this notion. For example, one study which examined the temporal order of OCD and SUD found that 70% of participants with comorbid SUDs reported that OCD preceded SUD onset by at least one year. This suggests not only that they are correlated, but that having OCD can predispose one to develop an SUD. 

While drug use may provide temporary relief, it is a dangerous and ill-advised way to deal with OCD that can quickly result in tragic endings. This has given rise to organizations such as Riley’s wish, which seek to educate and raise awareness about OCD and addiction, as well as its diagnosis and treatment.