The Intersection of Substance Use Disorders and Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) and substance use disorder (SUD) can look like two very different clinical presentations. One is characterized by intrusive thoughts, doubt, and compulsive behavior, while the other involves problematic patterns of substance use. In practice, however, the two can overlap in important ways. For clinicians working in mental health or addiction treatment, recognizing this intersection matters. When OCD goes unidentified, treatment may focus exclusively on substance use while overlooking a significant factor contributing to a client's distress, avoidance, and difficulty tolerating uncomfortable internal experiences.

OCD and Substance Misuse: What Does the Research Tell Us?

Research suggests that individuals with OCD may be at increased risk for problematic substance use.

Virtanen et al. (2022) found:

“Individuals with an OCD diagnosis had a 3.7-fold elevated risk of any substance misuse outcome.”

Importantly, this relationship was not limited to individuals who already had an OCD diagnosis. The researchers also found:

“Obsessive-compulsive symptoms at 18 years of age were associated with increased symptoms of alcohol dependence and drug dependence.”
— Virtanen et al. (2022)

Other research has demonstrated elevated rates of both alcohol and substance-related problems among individuals with OCD. Osland et al. (2018) found that the OCD population was 3.95 times more likely to meet criteria for lifetime alcohol dependence and 6.83 times more likely to meet alcohol dependence criteria during the previous 12 months compared with the control population. The same study found that the OCD population was 5.45 times more likely to meet criteria for lifetime substance abuse or dependence (including marijuana) and 4.78 times more likely to meet those criteria during the previous 12 months. These findings highlight an important clinical consideration: when we are assessing substance use, we may also need to be asking what is happening underneath or alongside it.

Why Might OCD and Addiction Overlap?

There isn't one simple explanation for why OCD and SUD can co-occur. One area researchers have examined is the role of compulsivity and the brain's reward systems. Figee et al. (2016) explained:

“Compulsivity in OCD and addiction may in part be explained by dysfunctional brain reward systems, driving the development of a restricted behavioral repertoire at the cost of healthy rewarding actions and a relative failure to switch to more adaptive, goal-directed behaviors.”

This is particularly interesting from a treatment perspective. OCD and addiction are not the same disorder, but both can involve patterns that become increasingly rigid and difficult to disengage from. With OCD, a person may experience an intrusive thought, image, sensation, or urge followed by an overwhelming need to do something to reduce distress or gain certainty. That response might involve checking, reassurance seeking, avoidance, rumination, researching, confessing, or another compulsion. With substance use, a person may similarly become caught in behavioral patterns that provide relief or reinforcement in the short term while creating significant consequences over time. Understanding the function of a behavior—not simply what the behavior looks like—can therefore be incredibly important.

Comorbidity Can Complicate Treatment

The presence of both conditions may also affect how clients experience the healthcare system.

Osland et al. (2018) reported:

“Those diagnosed with OCD are more likely to utilize a variety of healthcare services, and are less likely to feel as if they are receiving adequate help for problems they are experiencing.”

This is one reason OCD-informed assessment is so important in addiction and general mental health settings. OCD is not always obvious. A client may not present saying, “I think I have OCD.” Instead, they may talk about guilt, shame, disturbing intrusive thoughts, relationship doubts, fears about harming someone, health concerns, sexual thoughts they don't understand, or hours spent analyzing whether something they did was morally wrong. Without understanding OCD, these concerns can easily be conceptualized as generalized anxiety, trauma, relationship problems, paranoia, or another mental health condition.

When Traditional Therapy Accidentally Feeds OCD

Identifying OCD also matters because some well-intentioned therapeutic interventions can inadvertently reinforce the OCD cycle. For example, repeatedly helping a client determine whether an intrusive thought is "true" can become another form of reassurance. Spending session after session unpacking why a particular thought occurred can turn therapy into co-rumination. Helping clients avoid triggering situations may reduce anxiety temporarily while strengthening avoidance over time. Even mindfulness can be misapplied if the goal becomes monitoring thoughts or internal sensations until the client feels certain that everything is okay. OCD treatment requires clinicians to recognize when therapy itself is getting pulled into the client's compulsive search for certainty.

Treating OCD and SUD Together

When someone meets criteria for both OCD and SUD, treatment planning should consider both disorders rather than assuming one must be completely resolved before the other can be addressed. Depending on the client's substance use and level of care, initial treatment may need to focus on stabilization and medically appropriate withdrawal management when indicated. From there, collaboration between the client's addiction treatment team and an OCD specialist can help determine when and how OCD-specific treatment should begin. One of the primary evidence-based interventions for OCD is Exposure and Response Prevention (ERP). ERP helps clients intentionally approach feared thoughts, sensations, situations, or uncertainty while reducing the compulsive behaviors they normally use to obtain relief or certainty. Acceptance and Commitment Therapy (ACT) and mindfulness-based practices can also complement OCD treatment by helping clients change their relationship with uncomfortable thoughts and emotions rather than continually trying to eliminate them. The goal isn't necessarily to make the intrusive thought disappear. It is to help the person build the ability to experience uncertainty, discomfort, urges, or intrusive thoughts without allowing those experiences to dictate what they do next.

Better Assessment Can Lead to Better Treatment

For addiction professionals, this does not mean every clinician needs to become an OCD specialist. It does mean that recognizing possible OCD—and knowing when additional assessment or referral is warranted—can make a meaningful difference. Consider further OCD assessment when a client seems repeatedly caught in questions such as: What if? How do I know for sure? What does this thought mean about me? What if I'm actually a bad person? What if I did something and don't remember?How can I be certain this isn't going to happen?

The content of the question can change dramatically from person to person. The repetitive search for certainty is often the more important clinical clue. When OCD and substance use occur together, treating only what is most visible may leave an important part of the clinical picture untouched. Recognizing the overlap allows providers to make more informed referrals, coordinate care, and help clients access treatment that addresses both conditions.

References

Figee, M., Pattij, T., Willuhn, I., Luigjes, J., van den Brink, W., Goudriaan, A., Potenza, M. N., Robbins, T. W., & Denys, D. (2016). Compulsivity in obsessive-compulsive disorder and addictions. European Neuropsychopharmacology, 26(5), 856–868.

Osland, S., Arnold, P. D., & Pringsheim, T. (2018). The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: A population-based Canadian study. Psychiatry Research, 268, 137–142.

Virtanen, S., Kuja-Halkola, R., Sidorchuk, A., Fernández de la Cruz, L., Rück, C., Lundström, S., Suvisaari, J., Larsson, H., Lichtenstein, P., & Mataix-Cols, D. (2022). Association of obsessive-compulsive disorder and obsessive-compulsive symptoms with substance misuse in 2 longitudinal cohorts in Sweden. JAMA Network Open, 5(6), e2214779.

By Alyssa Van Boxmeer, LMFT
OCD and Anxiety Specialist