OCD and addiction

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Kenneth Anderson

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Sep 11, 2016, 12:49:23 PM9/11/16
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What are the best arguments in favor of and against lumping OCD and addiction into the same category? Send links to pubmed abstracts if you can. Thanks.

Trent Codd

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Sep 11, 2016, 1:19:24 PM9/11/16
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OCD, the anxiety disorder (yes, they moved it into its own category in DSM-V, but it’s still an anxiety disorder), is really properly defined functionally. Let me explain what I mean by that with an example. When I was in graduate school I worked in a behavioral pharmacology lab. We used an operant methodology with white albino rats, sprague dawley strain. There were a number of ways a rat could push the lever in the operant chamber…right paw, left paw, nose, tail, butt,…I had one that would crawl to the top of the chamber and let its body fall on top of the lever. To someone who thinks structurally (most psychology/psychiatry types) those are all different behaviors because the form or structure is different. To someone who thinks functionally (like me…and all behaviorally inclined persons) those behaviors are the same because the purpose or function is the same: To push the lever. It doesn’t matter what the behavior looks like. In fact many other response topographies are possible. The DSM is largely based on a structural approach…one of the reasons it keeps growing. They keep defining more and more response forms….pretty soon there will be more disorders than there are people.

 

Take the example of the anxiety disorders…they all have the same function: escape or avoid anxiety eliciting stimuli. And, the treatments that work all do the same thing at the functional level. Block escape and expose to those stimuli repeatedly (there are different models as to why this works, but that’s tangential to this discussion). We really don’t gain much by defining many instances of escape based on the stimuli and behavior involved.

 

With that background in mind…on to your question. OCD is no different than the other anxiety disorders (it’s all about escape and avoidance behavior).   “Obsessions” are intrusive ideas that elicit anxiety, whereas “compulsions” are responses which function to escape or avoid the elicited anxiety. At one point the DSM defined (purely structural) obsessions as purely mental and compulsions as purely behavioral (overt behavior). This led to a number of problems to include the idea that there was a subset of OCD clients that could be labeled as “Pure Obsessionals.” The idea was that there were some who presented with no compulsions. We know this isn’t true…there’s no such thing as “Pure O,” those persons have mental compulsions. That is, they avoid and escape covertly (in their head). So, functionally this disorder is all about escape of anxiety provoking stimuli.

Addiction, could involve this function (i.e., escape), but it could also involve other functions (e.g., appetitive functions). Additionally the escape functions could involve escape of private experiences other than anxiety (although in a purely functional approach it really doesn’t matter that the private experience is that is being escaped – the function is escape).

 

So the argument I would present to you is that they are different because they contain different functions. Simply labeling something as “obsessive” or “compulsive” to denote that it contains behavior that is repetitive contributes nothing and does not point the way to effective treatment. It’s also clearly different than the anxiety disorder.

 

Hope this helps.
Trent

 

PS-I wish I had time to say more, but I’m buried at this moment. If you want to know more look up functional assessment and intervention.


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Tom Horvath

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Sep 11, 2016, 6:23:27 PM9/11/16
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I'll add that at least initially addictive behavior is approach behavior that is positively reinforced. To say it one way, one uses heroin to enjoy some aspect of it; people don't keep using heroin unless it provides something positive (some people try it and decide it is not for them).

Obsessive/compulsive behavior, as Trent notes, is escape behavior that is negatively reinforced. One escapes a negative feeling (e.g., "dread") by engaging in the behavior.

These starting points can become confused in advanced addiction because one can escape strong craving by using, and then perhaps also enjoy the high. One can "want" but not necessarily "like" anymore, as Kent Berridge and colleagues have pointed out. At that point addiction can look like compulsion, I would say, but it did not start there. 

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Kenneth Anderson

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Sep 11, 2016, 7:27:58 PM9/11/16
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Interesting because there seems to be a behaviorist theory that compulsions develop through initial reinforcement in OCD--don't know how current it is

On Sun, Sep 11, 2016 at 6:23 PM, Tom Horvath <tom.h...@practicalrecovery.com> wrote:
I'll add that at least initially addictive behavior is approach behavior that is positively reinforced. To say it one way, one uses heroin to enjoy some aspect of it; people don't keep using heroin unless it provides something positive (some people try it and decide it is not for them).

Obsessive/compulsive behavior, as Trent notes, is escape behavior that is negatively reinforced. One escapes a negative feeling (e.g., "dread") by engaging in the behavior.

These starting points can become confused in advanced addiction because one can escape strong craving by using, and then perhaps also enjoy the high. One can "want" but not necessarily "like" anymore, as Kent Berridge and colleagues have pointed out. At that point addiction can look like compulsion, I would say, but it did not start there. 
A. Tom Horvath, Ph.D., ABPP, President
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Maia Szalavitz

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Sep 12, 2016, 8:04:44 AM9/12/16
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For some people they are the same, for others they are not:  the classic heterogeneity of addiction, basically.

For me (and I also have either OCD or OCD-ish symptoms of Asperger's, depending on which of my multiple diagnoses you prefer), they are and always tended to be similar.

The idea that OCD is 'ego dystonic' (ie, you don't like doing it) and addiction is 'ego syntonic' (ie, you like getting high) is silly, at least in my experience.  You may feel compelled to do your compulsions and not "enjoy" them, but the reason you do them is that somewhere you believe they will relieve your anxiety, which is definitely a rewarding thing!

Similarly, you may start out enjoying your high (as noted above) but then move to wanting it not but liking it any more (more true for stimulants than opioids).

Neuroananatomically, the shift towards compulsive behavior in addiction is accompanied by a change in wiring that moves from the ventral to the dorsal striatum (I may have this backwards, so check).

The person you want who wants to group addiction into OCD spectrum (along with autism) is Eric Hollander, who has published on this in terms of DSM.  I pretty much agree with him, though I expect, as with all of this as noted initially, there is heterogeneity.

On Sun, Sep 11, 2016 at 7:27 PM, Kenneth Anderson <ham...@gmail.com> wrote:
Interesting because there seems to be a behaviorist theory that compulsions develop through initial reinforcement in OCD--don't know how current it is
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Trent Codd

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Sep 12, 2016, 9:33:41 AM9/12/16
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Hi Doug,


I can assure you that the behavioral view I conveyed is very current. I keep up on the OCD literature.

 

I should emphasize that the behavioral view I shared does not negate the role of other contextual factors including biological factors which transact with these environmental events. There’s been a long-standing misperception that behaviorists discount the role of biology. That’s never been true…Skinner, for example, always held that to account for behavior one must account for 3 things: selection by consequences (operant learning), natural selection (biology) and culture. Even Skinner gave 1/3 of the variance to biology.

 

Let me also note that the current American Psychiatric Association guidelines specify the first line treatment for OCD to be Exposure and Response Prevention – a treatment which targets the function I detailed previously. They specifically do not suggest a medication as a first line treatment despite their bias for biological treatments. Further, their guidelines suggest that if there hasn’t been a favorable response after 17 sessions, then one should augment (not replace) with medication. I think the APA’s endorsement of this treatment over their preferred methods to be good evidence of the current state of this functional view.

 

Hope this helps.

Trent

 


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From: ham...@googlegroups.com [mailto:ham...@googlegroups.com] On Behalf Of Kenneth Anderson
Sent: Sunday, September 11, 2016 7:28 PM
To: ham...@googlegroups.com
Subject: Re: OCD and addiction

 

Interesting because there seems to be a behaviorist theory that compulsions develop through initial reinforcement in OCD--don't know how current it is

On Sun, Sep 11, 2016 at 6:23 PM, Tom Horvath <tom.h...@practicalrecovery.com> wrote:

I'll add that at least initially addictive behavior is approach behavior that is positively reinforced. To say it one way, one uses heroin to enjoy some aspect of it; people don't keep using heroin unless it provides something positive (some people try it and decide it is not for them).

 

Obsessive/compulsive behavior, as Trent notes, is escape behavior that is negatively reinforced. One escapes a negative feeling (e.g., "dread") by engaging in the behavior.

 

These starting points can become confused in advanced addiction because one can escape strong craving by using, and then perhaps also enjoy the high. One can "want" but not necessarily "like" anymore, as Kent Berridge and colleagues have pointed out. At that point addiction can look like compulsion, I would say, but it did not start there. 

A. Tom Horvath, Ph.D., ABPP, President

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Maia Szalavitz

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Sep 12, 2016, 9:51:28 AM9/12/16
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Keep in mind though, that many people with OCD, cannot make themselves go through with exposure treatments— so while it may be the first line treatment, many
people prefer medication.  Exposure for PTSD suffers from the same problem.  If you have great treatments that no one will do, you need many options.

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pferentzy pferentzy

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Sep 12, 2016, 10:07:49 AM9/12/16
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I agree your your take on this, Tom. There can come a point when one really does not enjoy the addiction at all, and then it's more like an OCD. I know, for example, that if I were to lapse onto one of my addictions, it would give me some pleasure, at least at first. Though the distinction isn't perfect. I'm thinking now about my smoking: sometimes it gives pleasure, at others it's more like a pure compulsion. Some refer to the latter as "ego dystonic", and I find the terminology useful.

---------- Original Message ----------
From: Tom Horvath <tom.h...@practicalrecovery.com>
Date: September 11, 2016 at 6:23 PM

I'll add that at least initially addictive behavior is approach behavior that is positively reinforced. To say it one way, one uses heroin to enjoy some aspect of it; people don't keep using heroin unless it provides something positive (some people try it and decide it is not for them).

Obsessive/compulsive behavior, as Trent notes, is escape behavior that is negatively reinforced. One escapes a negative feeling (e.g., "dread") by engaging in the behavior.

These starting points can become confused in advanced addiction because one can escape strong craving by using, and then perhaps also enjoy the high. One can "want" but not necessarily "like" anymore, as Kent Berridge and colleagues have pointed out. At that point addiction can look like compulsion, I would say, but it did not start there.

A. Tom Horvath, Ph.D., ABPP, President

This communication and any attachments may contain information that is legally privileged, confidential or exempt from disclosure. If you are not the intended recipient, please note that any dissemination, distribution, or copying of this communication is strictly prohibited. Anyone who receives this message in error should notify the sender immediately by telephone or by return e-mail and delete it from his or her computer.

On Sun, Sep 11, 2016 at 10:19 AM, Trent Codd < rtc...@behaviortherapist.com> wrote:

 

 

OCD, the anxiety disorder (yes, they moved it into its own category in DSM-V, but it’s still an anxiety disorder), is really properly defined functionally. Let me explain what I mean by that with an example. When I was in graduate school I worked in a behavioral pharmacology lab. We used an operant methodology with white albino rats, sprague dawley strain. There were a number of ways a rat could push the lever in the operant chamber...right paw, left paw, nose, tail, butt,...I had one that would crawl to the top of the chamber and let its body fall on top of the lever. To someone who thinks structurally (most psychology/psychiatry types) those are all different behaviors because the form or structure is different. To someone who thinks functionally (like me...and all behaviorally inclined persons) those behaviors are the same because the purpose or function is the same: To push the lever. It doesn’t matter what the behavior looks like. In fact many other response topographies are possible. The DSM is largely based on a structural approach...one of the reasons it keeps growing. They keep defining more and more response forms....pretty soon there will be more disorders than there are people.

 

Take the example of the anxiety disorders...they all have the same function: escape or avoid anxiety eliciting stimuli. And, the treatments that work all do the same thing at the functional level. Block escape and expose to those stimuli repeatedly (there are different models as to why this works, but that’s tangential to this discussion). We really don’t gain much by defining many instances of escape based on the stimuli and behavior involved.

 

With that background in mind...on to your question. OCD is no different than the other anxiety disorders (it’s all about escape and avoidance behavior). “Obsessions” are intrusive ideas that elicit anxiety, whereas “compulsions” are responses which function to escape or avoid the elicited anxiety. At one point the DSM defined (purely structural) obsessions as purely mental and compulsions as purely behavioral (overt behavior). This led to a number of problems to include the idea that there was a subset of OCD clients that could be labeled as “Pure Obsessionals.” The idea was that there were some who presented with no compulsions. We know this isn’t true...there’s no such thing as “Pure O,” those persons have mental compulsions. That is, they avoid and escape covertly (in their head). So, functionally this disorder is all about escape of anxiety provoking stimuli.

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Author: Dealing With an Addict -- what you need to know if someone you care for has a drug or alcohol problem
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Trent Codd

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Sep 12, 2016, 10:13:50 AM9/12/16
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This is, of course, a different issue from the classification question that I was addressing. But yes, no treatment is tolerated by 100% of patients. That includes exposure and it also includes medication. In fact the data on medication compliance (across clinical problems) is pretty abysmal.

 

To be clear, I don’t personally  have a problem if a patient chooses which treatments they pursue  – even if they choose the less efficacious treatment. I respect their choice. But, I do think it’s important to provide them with the opportunity for an informed choice. This should include informing them of the likelihood of a poorer outcome (if they have OCD) if they receive medication only.

 

The data on treatment tolerance and drop out is complicated, and much like substance abuse tx, likely related (at least in part) to therapist variables.

 

Trent

 

 

 


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From: ham...@googlegroups.com [mailto:ham...@googlegroups.com] On Behalf Of Maia Szalavitz
Sent: Monday, September 12, 2016 9:51 AM
To: ham...@googlegroups.com
Subject: Re: OCD and addiction

 

Keep in mind though, that many people with OCD, cannot make themselves go through with exposure treatments— so while it may be the first line treatment, many

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Kenneth Anderson

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Sep 12, 2016, 1:49:08 PM9/12/16
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Thanks Maia--I found a good paper by Hollander thanks to your suggestion

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