Evidence regarding the treatment of OCD among people with AOD use disorders is lacking, with most studies of OCD treatment excluding people with AOD use disorders [102]. Only one RCT has examined the concurrent treatment of OCD and AOD use. In this study, Fals-Stewart and Schafer [1233] examined the efficacy of CBT with exposure response therapy (ERP), for the treatment of OCD among people attending residential rehabilitation for their AOD use.
CBT incorporating ERP has long been considered an evidence-based treatment for OCD as a single disorder and continues to be recommended as a first-line treatment option [731, 1234, 1235]. Evidence-based psychological treatments should be given an adequate trial before pharmacological treatments are considered. ERP involves repeated, prolonged and systematic exposure with certain objects or situations that trigger obsessional responses (exposure) and resisting the compulsive urges that arise in response to the triggers (response prevention) [728]. The nature of the exposure therapy can be in vivo (e.g., physically touching a light switch) or in the imagination (e.g., confronting images of loved ones dying). In this way, ERP can teach people to tolerate the distress associated with obsessions without engaging in maladaptive behaviours like compulsions, and can provide corrective feedback that challenges the fear response [731, 732]. Fals-Stewart and Schafer [1233] found that clients who received concurrent CBT with ERP for their OCD remained in treatment longer, and had lower OCD symptom severity and higher abstinence rates during treatment and at the 12-month follow-up, compared to those who received AOD treatment alone or AOD use plus progressive muscle relaxation.
Based on the limited evidence regarding the treatment of co-occurring OCD and AOD use [1233], and evidence pertaining to the treatment of OCD and AOD use as single disorders, Klostermann and Fals-Stewart [1230] recommend five steps for treating people with co-occurring OCD and AOD use. The five steps include:
- Assessment of both OCD and AOD use: This can be difficult if clients are attempting to conceal their symptoms for fear of embarrassment, and OCD can often be confused with other psychiatric illnesses (e.g., phobia, depression, and psychosis).
- Assessment of symptom type and quality using validated assessment tools: For example, intrusive thoughts, feelings and behaviours, detailed description of the anxiety-provoking stimuli typically experienced, and the ritualistic behaviours performed in response.
- Psychoeducational therapy.
- Creation of a fear or stimulus hierarchy.
- Treatment: Concurrent delivery of ERP and AOD use treatment.
Although these findings and recommendations are promising, more evidence is clearly needed. In particular, the cyclical nature between OCD and AOD use suggests there is a need for the development of integrated treatments that simultaneously address both disorders [1236, 1237]. Stewart and O’Connor [1237] suggest that such an integrated approach may consist of psychoeducation to explore the cyclical relationship between OCD symptoms and AOD use; targeting AOD use during ERP treatment if it is identified as a safety behaviour (a behaviour that temporarily relieves the distress associated with obsessions); and therapeutic work focused on increasing self-efficacy, in order to help the client believe they can cope without AOD use [1237].
There is also a need to investigate alternative approaches to ERP. While ERP continues to be recommended as the first line psychotherapy for OCD as a single disorder, recent reviews have demonstrated that other approaches including behavioural and cognitive therapies may be equally effective [1231, 1232, 1238]. Other approaches that show promise for single disorder OCD include ACT and EMDR [1236].
Psychotherapy has consistently been found to be more effective than pharmacotherapies for treating single disorder OCD; however, it should be noted that most psychotherapy trials have included patients who were taking stable doses of antidepressants [1232]. Furthermore, the superiority of psychological therapies is marginal when compared to adequate doses of pharmacotherapy for OCD [1238].