The Journal of Neurobehavioral Sciences

REVIEW ARTICLE
Year
: 2021  |  Volume : 8  |  Issue : 3  |  Page : 251--261

Is obsessive–Compulsive disorder preventive against addiction?


Oguz Tan 
 Department of Psychiatry, Faculty of Medicine, Uskudar University, Istanbul, Turkey

Correspondence Address:
Oguz Tan
Feneryolu Medical Center, Faculty of Medicine, Uskudar University, Istanbul
Turkey

Abstract

Obsessive–compulsive disorder (OCD) is unique among mental illnesses in that its comorbidity with alcohol use disorders (AUD), substance use disorders (SUD), and smoking has been reported to be common in the community but surprisingly less frequent in clinical settings. To better investigate this dual diagnosis, we screened the Medline, PsychInfo, and Scopus databases. We did not apply strict criteria for the selection of articles because this article is a narrative review. Relatively, mild OCD is characterized by a high prevalence of AUD/SUD. Comorbidity becomes less frequent as OCD grows more distressing up to a certain degree of illness severity, above which it rises once more. In contrast, the prevalence of AUD/SUD in anxiety disorders, depression, and bipolar disorder is higher in clinical samples than in the community. The high prevalence of AUD/SUD accompanying OCD in community settings may be accounted for by self-medication, whereas decreasing prevalence in clinical samples may reflect personality traits common among obsessive-compulsive people, such as an elevated sense of harm and risk avoidance. An increase in more severe patients may imply the interplay between impulsiveness and compulsiveness. The distinct symptom dimensions of OCD, such as washing, checking, and having taboo thoughts, may be associated with varying degrees of predisposition to AUD/SUD as well as with different rates for seeking treatment, thus affecting the contradictions in the comorbidity rates of OCD and AUD/SUD. Our search confirms the U-shaped curve model put forward to explain the intricate relationship between OCD and AUD/SUD.



How to cite this article:
Tan O. Is obsessive–Compulsive disorder preventive against addiction?.J Neurobehav Sci 2021;8:251-261


How to cite this URL:
Tan O. Is obsessive–Compulsive disorder preventive against addiction?. J Neurobehav Sci [serial online] 2021 [cited 2022 Sep 28 ];8:251-261
Available from: http://www.jnbsjournal.com/text.asp?2021/8/3/251/333755


Full Text



 Introduction



It is well-known that substance use, including illicit drugs, alcohol, and tobacco, is exceedingly common among people with psychiatric illness.[1],[2],[3],[4],[5],[6] Almost all of the studies done either in clinical or in community samples have revealed a high prevalence of harmful consumption of various substances. Notwithstanding this finding, an exception is obsessive–compulsive disorder (OCD), which has been found to be accompanied by a frequency of alcohol/substance or tobacco use that is similar to or even lower than that of the general population.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30]

Indeed, OCD sets a good example of discordant findings between clinical and epidemiological research when both are investigating the same disease. Epidemiological surveys generally denote a frequent co-occurrence of OCD with alcohol use disorders (AUDs), substance use disorders (SUDs), and nicotine use,[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] whereas studies conducted in clinical samples[7],[9],[10],[13],[14],[15],16],[17],[18],[19],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30] have usually failed to show an increased risk in patients with OCD.

Cuzen et al.[44] provide a U-shaped curve model as an attempt to designate the relationship between OCD and AUD/SUD. The U-shaped curve model suggests a tripartite pattern characterizing the dual diagnosis. The people who meet the diagnostic criteria for OCD in community studies are commonly afflicted with AUD/SUD as compared with the general population. The patients visiting psychiatric settings for a cure for OCD, although they suffer from a more severe illness, have a lower prevalence of AUD/SUD than community members with OCD. However, the dual diagnosis becomes more frequent again as the OCD becomes more severe and reaches a critical threshold.

One must ask if the-U shaped curve is unique for OCD. A plethora of studies have shown that anxiety disorders, depression, and bipolar disorder are associated with a high prevalence of AUD/SUD in the community as compared to the general population.[2],[3],[4],[6],[45] Yet, AUD/SUD has a considerably higher prevalence among patients with anxiety disorders, depression, or bipolar disorder who apply to clinics, disproving the U-shaped curve model.[2],[3],[4],[6],[45] Among the mental maladies psychiatrists frequently encounter in their everyday practice, only schizophrenia keeps pace with OCD across epidemiological and clinical studies.[5]

In this paper, we first highlight the evidence supporting the U-shaped curve, which characterizes the comorbidity of OCD with AUD/SUD. Then, we discuss the studies on smoking and OCD. Since smoking is the most common addiction in the world, and, to the best of our knowledge, no paper has reviewed the comorbidity of OCD with smoking, this topic deserves further investigation in a separate section. To explain the U-shaped curve, we suggest a multifaceted model that involves some fundamental aspects of OCD, including self-medication, the interplay between impulsiveness and compulsiveness, obsessive-compulsive traits, such as an increased sense of danger and risk avoidance, as well as symptom dimensions producing a substantially heterogeneous phenomenology.

 Materials and Methods



There is no need for ethics committee approval. We searched the relevant English literature in the Medline, PsychInfo, and Scopus databases using the following terms: OCD AND addiction or dependence or substance abuse or SUD or alcohol abuse or AUD or nicotine or tobacco or smoking or cigarette AND comorbidity or community from 1990 to 2020.

Since we aimed to produce a narrative review, not a systematic analysis, we did not assess well-defined eligibility criteria. We included all of the articles that estimated the comorbidity of AUD, SUD, and smoking in the community as well as in the clinical populations diagnosed with OCD. We did not inquire about OCD in individuals who sought treatment for AUD/SUD, since we particularly focused on those who principally complained of the symptoms of OCD rather than alcohol/substance problems.

Various diagnostic tools, such as the DSM-IV and DSM-5, were used in these studies, but this was not as important for our aim as ascertaining the exclusive relationship between OCD and AUD/SUD. Some studies employed the diagnosis “dependence” rather than “use disorder,” which includes dependence as well as abuse; we also avoided using the terms “AUD” and “SUD” when investigating these studies. Since hardly any study on SUD included nicotine, we noted the findings concerned with smoking when occasion arose. The criteria concerning the timeframes for which AUD and/or SUD occurred (i.e., lifetime, 12 months, or current prevalence) were also specified in the text when citing the studies.

 Obsessive-compulsive disorder and alcohol use disorder/substance use disorder



Obsessive-compulsive disorder and alcohol use disorder/substance use disorder in community settings

The US National Comorbidity Survey Replication found the lifetime prevalence of SUD in people meeting the criteria of OCD in community samples more than four times higher than in the general population.[36],[42] SUD, but not AUD, had been estimated to be one and a half times as high in OCD sufferers as in the general population of the US in an earlier survey.[46] Ecker et al.[35] examined OCD and SUD rates among nearly 40,000 American veterans and observed a co-occurrence of 36.7%. Two epidemiologic studies in Canada also revealed a high rate of comorbidity,[37],[38] involving approximately one-third of individuals with OCD.[38] Adam et al.[31] detected an odds ratio (OR) of 3.3 for any SUD, as compared to those having no obsessive-compulsive symptoms, including for nicotine, in 113 German communities. The OR for the association between OCD and AUD was 2.7 in a cross-sectional analysis of more than 10,000 adults in the Australian general population when the people with and without AUD were compared.[33] Individuals with OCD screened among the Dutch population also showed a high prevalence of AUD/SUD.[32],[34]

In contrast, several community studies disavowed the high comorbidity of OCD with AUD/SUD. One is a Zurich cohort study, which showed no significant difference in AUD/SUD between those having and not having OCD.[8],[12] In the Greek general population, OCD was found to be associated with neither frequent alcohol consumption nor current cannabis consumption.[47] AUD was as equally common in OCD as in the general population in an American study, although the prevalence of SUD was high.[46] Furthermore, Hofer et al.[48] found no association between OCD and the subsequent onset of SUD in a population of nearly 3000 adolescents and young adults from Munich, Germany.

The major part of the literature confirms that people having OCD detected during community screenings have a remarkably increased risk of AUD/SUD, although a few exceptions do exist.

Obsessive–compulsive disorder and alcohol use disorder/substance use disorder in clinical settings

[Table 1] summarizes many of the clinical studies on the comorbidity of OCD and AUD/SUD. The Netherlands OCD Association (NOCDA) study, which followed up a clinical cohort of about 400 patients with OCD, calculated that the lifetime and current prevalence for SUD + AUD as a whole was approximately 13% and 5%, respectively.[15],[24] These figures are quite low when compared to the Dutch general population. In that country, the lifetime prevalence for AUD and SUD is 16.3% and 19.1%, respectively, and the 12-month prevalence for AUD and SUD is 4.4% and 5.6%, respectively, as shown by the Netherlands Mental Health Survey and Incidence Study-2.[11]{Table 1}

A Brazilian multicenter sample consisting of 630 participants showed a lifetime frequency of 7.5% for AUD.[13] This sample grew to approximately 1000 subjects by the recruitment of succeeding patients over time and produced three publications, which reported a lifetime prevalence of 8%–9% for AUD and 3.3% for SUD, figures similar to the Brazilian general population.[16],[28],[29]

Only 1.2% of 169 Turkish OCD patients had comorbid current alcohol dependence.[30] Maina et al.[19] detected a lifetime prevalence of 9.7% for SUD in 216 Italian people. A separate Italian sample of OCD sufferers had a low prevalence of SUD (4%) and AUD (4%) when compared to control groups, of which 6% had SUD and an additional 6% had AUD.[22] A multinational study on 457°CD patients found AUD and SUD lifetime comorbidities of 3.3% and below 0.5%, respectively.[18]

The US data derived from clinical settings also generally confirm that OCD patients are not considerably affected with AUD/SUD. Eighty patients recruited from clinics as a part of the Johns Hopkins OCD Family Study showed a lifetime prevalence of 15% for AUD and 8% for SUD.[21] These figures are apparently low when one takes into account the high rates of AUD and SUD in American society, which are 23.5% and 11.9%, respectively.[50] The findings by LaSalle et al.,[17] which were from a study of 344 individuals including not only treatment seekers but also the subjects invited through media advertisements, indicated a lifetime prevalence AUD and SUD, 23.4% and 13.8%, respectively, which were not substantially different from the findings for the general population. Out of the 409 patients from Yaryura-Tobias et al.'s study,[51] 9.8% had substance dependence. Twenty-seven percent of the 323 people recruited for Mancebo et al.'s study[49] admitted to having a lifetime history of SUD, which is the one study showing remarkably high comorbidity in clinical OCD studies.

The literature convincingly illustrates that OCD patients visiting clinics are not prone to AUD/SUD, which is in contrast to those with other psychiatric disorders. This surprising finding merits further consideration. Many of the subjects with OCD who were detected in community studies probably had been undiagnosed and probably had a less distressing disease and were much more predisposed to AUD/SUD, which further confuses the picture.

The U-shaped curve of the relationship between obsessive–compulsive disorder and alcohol use disorder/substance use disorder

Two articles[8],[12] based on the same cohort from Zurich, Switzerland seem to provide the greatest support for the U-shaped curve model.[44] The studies analyzed not only the people meeting the diagnostic criteria for OCD but also two other groups having so-called obsessive-compulsive syndrome and obsessive–compulsive symptoms, terms describing several clinical manifestations of OCD not reaching the diagnostic threshold. The “obsessive–compulsive symptoms” group had the mildest symptoms, whereas “obsessive–compulsive syndrome” ranked between it and full-blown OCD. The fact that OCD corresponded to the most severe end of the spectrum was reflected by the considerably different rates of those seeking treatment, which was one-third for OCD and 6% for obsessive–compulsive syndrome.

[Table 2] shows the prevalence of AUD/SUD in the Zurich cohort classified into four groups, according to the level of obsessive-compulsive symptoms.[8] It is striking that the prevalence of AUD/SUD in OCD was not only lower than the prevalence of AUD/SUD in the people having obsessive-compulsive symptoms, not meeting the criteria of a full-blown illness, but also lower than the prevalence those having no obsessive-compulsive symptoms. It appears that the co-occurrence of AUD/SUD first rose as the spectrum advanced from cases with no symptoms towards the symptomatic but subthreshold cases. The dual diagnosis then declined to even lower levels for patients having full-blown OCD than for those people reporting no symptoms. Although the differences observed in this Zurich sample did not reach the level of significance, a clinical psychiatric condition not associated with a notably high risk of AUD/SUD is on its own well worth attention.{Table 2}

A Dutch study also supports this finding. In a large Dutch representative population, cases without obsessive-compulsive symptoms, subthreshold cases, and cases meeting OCD criteria exhibited no differences in comorbidity with AUD/SUD.[34]

In a study of the Greek general population, people with subclinical obsessive-compulsive symptoms were shown to consume alcohol and cannabis more frequently than those with full-blown OCD as well as those having no obsessive-compulsive symptoms.[47]

Cuzen et al.[44] took one more step to test their U-shaped curve hypothesis. They subdivided their 588°CD cases into higher and lower severity subgroups, relying upon a cut-off score of 25 on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). They estimated that the patients with graver OCD were less likely the victims of AUD/SUD, confirming the U-shaped curve model.

Interim conclusion

The comorbidity of OCD and AUD/SUD is common in community settings as is the case with other psychiatric disorders. Yet, it is intriguing that this familiar finding is contradicted by some data[8],[12],[47],[48] that deny the vulnerability of OCD patients to AUD/SUD.

The bulk of the literature suggests that the individuals visiting psychiatric settings to seek treatment for their OCD are not at an elevated risk for AUD/SUD when compared to the general population, in contrast to the figures seen in anxiety disorders, depression, and bipolar disorder.[5]

 Smoking and obsessive–compulsive disorder



A noticeably high prevalence of smoking in individuals with mental illness has convincingly been demonstrated.[52] Regarding OCD, smoking parallels the relationship seen with AUD/SUD.

Community samples in the UK,[41] Greece,[39],[47] and the US[35] have been characterized by a high prevalence of smoking for individuals with OCD. Two community studies done in the US[43] and Singapore[40] also indicated an increased association between OCD and smoking, although it was accounted for by only female subjects. The sole community-based sample that lacked a relationship between OCD and smoking was adolescents and young adults living in the US.[53]

Individuals seeking treatment for OCD smoke as much as, or even sometimes less than, the general population does, as shown by various studies done in the US,[7],[9],[14] Canada,[20] the UK,[23] Sweden,[10] and Turkey.[25],[26],[27] Dell'Osso et al.[54] looked at cigarette use in OCD patients from ten countries over three continents and found great differences across nations, suggesting a low cooccurrence at least in some societies.

Two studies of ours that investigate the smoking behavior of patients with OCD can shed some light on the subject.[25],[27] The more recent one had fewer limitations because it included not only a clinical sample that was large enough to produce sound results but also a matched control group recruited from the general population. That study, which compared 319 control individuals and 317 subjects with OCD who visited our outpatient clinic in Istanbul (Turkey), showed that the percentage of current smokers was lower in the patient group (31% vs. 36%), albeit not reaching the significance level.[27]

The aforementioned two studies of ours[25],[27] are unique in that they estimated not only the prevalence but also the relationships between the severities of OCD and comorbid addiction. The severity of nicotine addiction measured by the Fagerström Test for Nicotine Dependence was higher in OCD patients than in the controls.[27] We also found a positive correlation of the severity of addiction with the severity of OCD but not with that of anxiety or depressive symptoms. Age, gender, and educational status did not influence the severity of addiction.[27]

In addition, we subdivided our participants into three groups: current smokers, former smokers, and never smokers.[27] Never and current smokers had similar scores in the Y-BOCS total and its subscales. These two subcategories (never and current smokers) had higher scores of compulsions and total Y-BOCS than former smokers did. The scores of anxiety and depressive symptoms were, unlike OCD, similar in all three categories of cigarette use.[27]

 Addiction and Symptom Dimensions in Obsessive–Compulsive Disorder



An impressive aspect of OCD is its heterogeneity of clinical manifestations, as it appears as virtually disparate diseases. Distinct symptom dimensions of OCD are associated with significant differences in age of onset, clinical course, comorbidity, family history, insight into illness, gender preponderance, response to treatment, and neurobiology.[55],[56],[57],[58],[59]

Unfortunately, little research has been done on the distribution of AUD/SUD among different symptom types of OCD. Torres et al.[28] estimated an elevated risk of AUD only in the patients with sexual or religious obsessions when compared to individuals having aggressive, symmetry/ordering, washing, or hoarding symptoms. A low prevalence of AUD as well as diminishing numbers in comparison subgroups after the subclassification of the whole sample (although it was actually large) did not produce significant results. Brakoulias et al.[60] also found a relationship between taboo thoughts and past nonalcohol SUD.

We paid attention to this issue in two studies,[26],[61] both of which showed a significant difference in the prevalence of smoking among the subjects with religious, sexual, or aggressive obsessions and those with symmetry, counting, repetition, or ordering symptoms [Table 3]. It seems that the latter group smoked more commonly than the general population did in the area where our patients lived,[62] in contrast to the case in which washing and taboo thoughts were associated with a low frequency of cigarette use.{Table 3}

A few studies screening the association of obsessive-compulsive symptoms (not full-blown OCD) with AUD/SUD have produced significant results. In a New Zealand birth cohort, the risk for alcohol, drug, and cannabis addiction was highest for individuals with taboo thoughts and lowest for individuals who washed excessively, whereas harm/checking and symmetry/ordering fell in between.[63] In the general population of six European countries, AUD was most commonly associated with washing, followed respectively by sexual/religious obsessions, moral issues, harm/checking, symmetry/ordering, and somatic obsessions.[64]

Dirice,[65] who investigated the relationship between smoking and obsessive-compulsive symptoms among the general population of Istanbul (Turkey), found that nicotine addiction was negatively (significantly albeit weakly) correlated with checking and repetitive behavior (precision). Repetitive behavior was related to moderate smoking, whereas the impulses subscale was related to heavy smoking.

It has been reported that obsessive-compulsive patients with taboo thoughts had the highest rate of treatment-seeking behavior, whereas patients suffering from other symptom dimensions tend to remain untreated.[66],[67] That finding along with the low frequency of cigarette use in our patients with religious, sexual, or aggressive obsessions may at least partially account for the inconsistent prevalence of smoking, which is high in community settings but low in treatment settings. It is apparent that the relationship of symptom dimensions with addiction and abuse merits further research.

 Personality Traits Accompanying Obsessive–Compulsive Disorder: Increased Sense of Harm and Risk Avoidance



OCD must have some unique characteristics accounting for its extraordinary tripartite effect on abuse and addiction. Some features characterizing OCD including an inflated sense of danger and propensity to avoid possible harm, have been suggested as putative mechanisms to account for the relatively low prevalence of a dual diagnosis among these patients.[68]

Increased fear of possible danger, ensuing risk avoidance, and excessive future-oriented planning at the cost of current pleasure, albeit not specified in the diagnostic guidebooks such as the DSM or ICD-10, have traditionally been appraised to be the properties of both OCD and obsessive-compulsive personality disorder (OCPD).[69] OCD plus OCPD is a common comorbidity.[69],[70] OCPD is the most common personality disorder accompanying OCD, and as one expects, OCD is pretty frequent in OCPD, as compared with other neurotic disorders, including generalized anxiety disorder, panic disorder, phobias, depressive episodes, and mixed anxiety and depressive disorder.[70] OCD plus OCPD predicts more severe OCD.[71] Yet OCPD is associated with the lowest prevalence of cannabis use disorder compared with all of the other personality disorders.[72] Cocaine use disorder and AUD are also less common in OCPD than in many other personality disorders.[72]

 Compulsiveness and Impulsiveness



The right leg of the U-curve proposed by Cuzen et al.[44] is supposedly generated by the treatment seekers who have relatively severe OCD. The positive relationship between the severity of OCD or compulsiveness and addiction[25],[27],[44],[65] may give rise to the right upward ascent of abuse or addiction problems.

Indeed, compulsiveness and impulsiveness, despite once considered to reflect the antithetical poles of a spectrum, have increasingly been understood to have not only discrepancies but also striking similarities with respect to phenomenology, comorbidity, heredity, neurobiology, and medication.[73] The scientific journey of these two behaviors, emerging from disparate starting points, has ended up being classified as OCD and impulse control disorders under the same title “obsessive–compulsive and related disorders” in the DSM-5.[74]

Research has shown that OCD patients have high impulsiveness when compared with the general population.[27],[74],[75] The intricate interaction of compulsiveness with impulsiveness, which has a well-established association with substance abuse or addiction,[76] can, at least, partially be responsible for the abstruse picture of AUD/SUD among the OCD patients.[77] Our finding that smokers with OCD had increased impulsiveness compared with never smokers with OCD is a further example of this tripartite figure.[25] We also estimated that the correlations between the severities of addiction and impulsiveness were more significant in the OCD group than in the controls.[27] Other studies also demonstrated a relationship between impulsiveness and smoking in patients with OCD,[7],[78] as is the case with the general population.[79]

 Discussion



Sufficient evidence shows that the comorbidity of AUD/SUD with OCD is high in epidemiological studies, whereas it is low among patients applying to psychiatric facilities, which is in contrast to the figures seen in anxiety disorders as well as for people with depression or bipolar disorder. Moreover, the individuals with obsessive-compulsive symptoms who do not meet the criteria for OCD are more often the victims of AUD/SUD than those having a full-blown OCD. Yet, less robust findings suggest that once OCD has reached a critical severity, its co-occurrence with AUD/SUD exhibits a second increase. Thus, the relationship between OCD and AUD/SUD follows a U-shaped curve. Beyond self-medication, which supervenes upon many other psychiatric disorders, obsessive-compulsive traits (such as heightened feeling of danger and avoidance from risk-taking behavior), distinct symptom dimensions of OCD, compulsiveness, and impulsiveness differentially interact at different stages of disease, thus generating the U-shaped pattern of OCD and AUD/SUD coexistence.

Increased predisposition to AUD/SUD and smoking in community surveys represents the left leg of the U-shaped curve. So-called self-medication is a commonly accepted explanation in order to comprehend the frequent comorbidity of mental illnesses with AUD/SUD.[80] Among community members meeting the criteria for any psychiatric diagnosis, OCD acts like other disorders in its association with AUD/SUD. Accordingly, self-medication may be a satisfactory explanation for the frequent dual diagnosis in epidemiological studies. Although this illness is not as severe in community settings as in clinical settings, even subthreshold OCD is a serious condition, as it decreases quality of life and psychosocial functioning.[81] Yet a few community studies have failed to find a high prevalence of AUD/SUD in people with OCD, as compared to the general population.[8],[12],[34],[47] Since self-medication is a common reaction to mental illness, evidence denying it implies the unique character of OCD and the necessity for explanations other than self-medication.

The inadequacy of self-medication hypothesis becomes more obvious when one considers the reduced susceptibility to AUD/SUD for patients whose OCD grows distressing enough to warrant a visit to the clinic. These patients constitute the basal (horizontal) part of the U-shaped curve and require an account specific for OCD. Low proclivity toward AUD/SUD in clinical samples can be explained by two factors. The first one is the predominance of typical obsessive traits, including an elevated sense of harm and risk avoidance in OCD. To the best of our knowledge, no study has examined whether classical obsessive traits are more widespread or more oppressive in more severe cases of OCD. What we know is that OCPD frequently accompanies OCD and results in a more severe condition.[71] OCPD is associated with the lowest risk of AUD/SUD among other personality disorders.[69],[70],[72] The second factor is directly related to the essential phenomenological disposition of OCD. Disparate symptom dimensions, such as washing, checking, symmetry, and taboo thoughts (i.e., sexual, aggressive, and religious obsessions), distinctively affect the susceptibility to AUD/SUD SUD.[26.60] Research mostly denotes a marked susceptibility of the sufferers of taboo thoughts to AUD/SUD,[28],[60],[63] whereas excessive washing stands out in a study comprising six European countries.[64] We observed that taboo thoughts are less likely associated with smoking than are washing and symmetry, counting, repetition, or ordering.[26],[61] Although the findings are discordant, the differential relationship of distinct symptom dimensions with AUD, SUD, and smoking is apparent. Furthermore, particular subtypes of OCD regarding symptoms are associated with varying rates of treatment-seeking behavior,[66],[67] influencing the appearance of a dual diagnosis in clinics.

Beyond a critical point of illness severity, OCD once more entails the high risk of AUD/SUD.[44] This stage represents the right upward leg of the U-shaped curve. Evidence confirming this view is limited. Our findings on smoking could support Cuzen et al.[44] The high severity of addiction in smokers with OCD, as compared to the controls and despite a similar prevalence, denotes that OCD is associated with not commencing but aggravating addiction.[27] The positive correlation between the severities of OCD and addiction affirms the deteriorating intercourse between OCD and addiction. Another finding corroborating the apparent role of OCD in addiction is that addiction severity in our clinical sample of OCD victims was related to neither gender nor educational status.[27] The fact that the severity of nicotine addiction was not correlated to the severity of anxiety or depressive symptoms[25] further confirms the effect of OCD as an independent factor in intensifying addiction. However, the relationship between anxiety and depression and addiction must be regarded with caution, since this relationship is not parabolic, in contrast to the case seen in OCD. Thus, the findings relying on correlational analysis could be a result of sampling or of not having a broad categorical perspective.

Compulsiveness, which is essentially higher in more severe OCD, may be blamed for the increase in the co-occurrence with AUD/SUD. It has been alleged that there is a link between compulsiveness and addiction.[82],[83] Impulsiveness, which is infamous for its noxious effect in predisposing someone to AUD/SUD,[76] in contradiction to what traditional thinking has assumed, is often intrinsic to OCD.[27],[74],[75],[84] A shift from impulsiveness toward compulsiveness has been seen as responsible for the development of addiction.[85] Compulsiveness may enhance the effects of impulsiveness, laying a bridge that accelerates the transition toward AUD/SUD and plays a detrimental role in aggravating addiction.[77]

Our patients with elevated impulsiveness, albeit with a lack of higher prevalence of smoking[27] may suggest a possible explanation for the paradox of OCD: Smoking provoked by the impulsiveness accompanying OCD, while it is counteracted by some other biological and/or psychological traits intrinsic to OCD. The orbitofrontal cortex (OFC), which is responsible for the inhibitory control of behavior, is well-known to be hyperactive in OCD and can account for risk aversion. Nicotine can enhance frontal neurocircuitry, which is already hyperactive in OCD, thus neutralizing positive reinforcement.[78] Yet the damage or degeneration of the OFC results in increased impulsiveness. OCD also involves the striatum, which interacts with the OFC, encoding the shift between goal-directed and habitual action.[86] The deviation from goal directed to habitual behavior can lead to an increased susceptibility to addiction. Impulsiveness and compulsiveness seem to be mediated to a certain extent by the common anatomical pathways, an imbalance of which results in the marked cautiousness inherent in OCD as well as the recklessness often accompanying AUD/SUD. The biochemical viewpoint also denotes a conspicuously overlapping etiology.[87] The serotonin, dopamine, and opioid system are implicated in OCD as well as in addiction and impulsiveness. Several pharmacological agents used for the treatment of AUD/SUD, including buprenorphine, topiramate, and ondansetron, may help alleviate OCD, whereas opioid antagonists may deteriorate it.[84] Yet OCPD, involving the same biological circuits as OCD,[88] frequently accompanies OCD,[69],[70] and results in a harsher illness (hence, essentially higher compulsiveness),[71] but is associated with an opposition to AUD/SUD.[72]

The comorbidity pattern of OCD with AUD/SUD is only taken after by schizophrenia, which is associated with a higher propensity for AUD/SUD in community settings rather than in clinical ones.[5] It might be assumed that patients with schizophrenia visiting clinics have relatively high insight, better compliance to treatment, and firmer psychosocial support, which all drive them away from AUD/SUD.

The current paper differs from Cuzen et al.'s[44] in several ways. First, we proposed symptom dimensions, which make OCD quite a heterogeneous clinical phenomenon, as factors responsible for the contradictions in the research on dual diagnosis. Moreover, we addressed typical traits of obsessive-compulsive individuals, such as an increased fear of danger, harm-avoidance, and decreased risk taking. These features instantly occur to a clinician when he or she looks at the relationship between OCD and AUD/SUD. We also addressed the interplay between impulsiveness and compulsiveness. We screened the literature as thoroughly as possible, included studies on the comorbidity of OCD with smoking, and supported Cuzen et al.[44] with our own findings.

Limitations

The most important limitation of this narrative review is the scarcity of evidence on the right upward leg of the U-shaped curve, which represents the increased prevalence of AUD/SUD in severe OCD. Two points must be considered when evaluating our assumptions. First, researchers tend to recruit into their studies those patients who regularly visit clinics; however, addicts and abusers are less likely to be regular visitors. Second, physicians are inclined to refer the patients with AUD/SUD to addiction clinics, regardless of whether they suffer from any other mental illness.

We did not look at OCD among individuals who seek treatment for AUD/SUD, since we particularly focused on those whose principal trouble was OCD rather than AUD/SUD. OCD is frequently diagnosed among alcohol and substance abusers and addicts. The fact that we ignored OCD comorbidity in addiction clinics is justifiable for two reasons. First, other psychiatric disorders, especially mood disorders, are also quite widespread in AUD/SUD. Second, the inclusion of studies done in the people with AUD/SUD would confound our results, since individuals complaining primarily of OCD or AUD/SUD have separate characteristics.

 Conclusions and Future Directions



It is impressive that, as OCD worsens, the frequency of AUD/SUD accompanying it decreases at first and then begins to increase again after a critical threshold. Self-medication, acute cautiousness commonly characterizing the people with OCD, disparate symptom dimensions associated with different biological and clinical manifestations, as well as compulsiveness and impulsiveness all could affect individuals with OCD, resulting in a tripartite effect on AUD/SUD or the so-called U-shaped curve. Although our presumptions are corroborated by obvious evidence in part, some of our views remain to be investigated by further studies. Introducing the cut-off points of severity to the research of OCD (i.e., classifying OCD into mild, moderate, and severe categories) will be useful because obsessive-compulsiveness at different stages may interact contradictorily with impulsiveness and addiction. A viewpoint that remains to be investigated is to explore the relationship of OCD with AUD/SUD concerning rumination, cognition, emotion regulation, and coping with stress.

clinical practice is focused on OCD. He published many articles on the relationship among OCD, impulsiveness, and substance (particularly nicotine) use.

Patient informed consent

There is no need for patient informed consent.

Ethics committee approval

There is no need for ethics committee approval.

Financial support and sponsorship

No funding was received.

Conflicts of interest

There are no conflicts of interest to declare.

Author contribution subject and rate

Oguz Tan (100%): Data collection and wrote the manuscript

References

1Conway KP, Compton W, Stinson FS, Grant BF. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2006;67:247-57. doi: 10.4088/jcp.v67n0211.
2Grant BF, Stinson FS, Dawson DA, Chou SP, Dufour MC, Compton W, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2004;61:807-16. doi: 10.1001/archpsyc. 61.8.807.
3Hunt GE, Malhi GS, Cleary M, Lai HM, Sitharthan T. Prevalence of comorbid bipolar and substance use disorders in clinical settings, 1990-2015: Systematic review and meta-analysis. J Affect Disord 2016;206:331-49. doi: 10.1016/j.jad. 2016.07.011.
4Hunt GE, Malhi GS, Cleary M, Lai HM, Sitharthan T. Comorbidity of bipolar and substance use disorders in national surveys of general populations, 1990-2015: Systematic review and meta-analysis. J Affect Disord 2016;206:321-30. doi: 10.1016/j.jad.2016.06.051.
5Hunt GE, Large MM, Cleary M, Lai HM, Saunders JB. Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis. Drug Alcohol Depend 2018;191:234-58. doi: 10.1016/j.drugalcdep.2018.07.011.
6Hunt GE, Malhi GS, Lai HM, Cleary M. Prevalence of comorbid substance use in major depressive disorder in community and clinical settings, 1990-2019: Systematic review and meta-analysis. J Affect Disord 2020;266:288-304. doi: 10.1016/j.jad.2020.01.141.
7Abramovitch A, Pizzagalli DA, Geller DA, Reuman L, Wilhelm S. Cigarette smoking in obsessive-compulsive disorder and unaffected parents of OCD patients. Eur Psychiatry 2015;30:137-44. doi: 10.1016/j.eurpsy.2013.12.003.
8Angst J, Gamma A, Endrass J, Goodwin R, Ajdacic V, Eich D, et al. Obsessive-compulsive severity spectrum in the community: Prevalence, comorbidity, and course. Eur Arch Psychiatry Clin Neurosci 2004;254:156-64. doi: 10.1007/s00406-004-0459-4.
9Baker-Morissette SL, Gulliver SB, Wiegel M, Barlow DH. Prevalence of smoking in anxiety disorders uncomplicated by comorbid alcohol or substance abuse. J Psychopathol Behav Assess 2004;26:107-12. doi: 10.1023/B:JOBA.0000013658.50297.ff.
10Bejerot S, von Knorring L, Ekselius L. Personality traits and smoking in patients with obsessive-compulsive disorder. Eur Psychiatry 2000;15:395-401. doi: 10.1016/s0924-9338(00) 00509-5.
11de Graaf R, ten Have M, van Gool C, van Dorsselaer S. Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Study-2. Soc Psychiatry Psychiatr Epidemiol 2012;47:203-13. doi: 10.1007/s00127-010-0334-8.
12Fineberg NA, Hengartner MP, Bergbaum C, Gale T, Rössler W, Angst J. Lifetime comorbidity of obsessive-compulsive disorder and sub-threshold obsessive-compulsive symptomatology in the community: Impact, prevalence, socio-demographic and clinical characteristics. Int J Psychiatry Clin Pract 2013;17:188-96. doi: 10.3109/13651501.2013.777745.
13Gentil AF, de Mathis MA, Torresan RC, Diniz JB, Alvarenga P, do Rosário MC, et al. Alcohol use disorders in patients with obsessive-compulsive disorder: The importance of appropriate dual-diagnosis. Drug Alcohol Depend 2009;100:173-7. doi: 10.1016/j.drugalcdep.2008.09.010.
14Himle J, Thyer BA, Fischer DJ. Prevalence of smoking among anxious outpatients. Phobia Pract Res J 1988;1:25-31.
15Hofmeijer-Sevink MK, van Oppen P, van Megen HJ, Batelaan NM, Cath DC, van der Wee NJ, et al. Clinical relevance of comorbidity in obsessive compulsive disorder: The Netherlands OCD Association study. J Affect Disord 2013;150:847-54. doi: 10.1016/j.jad.2013.03.014.
16Kim HS, Hodgins DC, Torres AR, Fontenelle LF, do Rosário MC, de Mathis MA, et al. Dual diagnosis of obsessive compulsive and compulsive buying disorders: Demographic, clinical, and psychiatric correlates. Compr Psychiatry 2018;86:67-73. doi: 10.1016/j.comppsych.2018.07.013.
17LaSalle VH, Cromer KR, Nelson KN, Kazuba D, Justement L, Murphy DL. Diagnostic interview assessed neuropsychiatric disorder comorbidity in 334 individuals with obsessive-compulsive disorder. Depress Anxiety 2004;19:163-73. doi: 10.1002/da.20009.
18Lochner C, Fineberg NA, Zohar J, van Ameringen M, Juven-Wetzler A, Altamura AC, et al. Comorbidity in obsessive-compulsive disorder (OCD): A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS). Compr Psychiatry 2014;55:1513-9. doi: 10.1016/j.comppsych.2014.05.020.
19Maina G, Pessina E, D'ambrosio V, Bertetto N, Asinari GF, Albert U, et al. Obsessive-compulsive disorder with concurrent substance use disorders: A clinical study. Minerva Psichiatr 2009;50:301-8.
20McCabe RE, Chudzik SM, Antony MM, Young L, Swinson RP, Zolvensky MJ. Smoking behaviors across anxiety disorders. J Anxiety Disord 2004;18:7-18. doi: 10.1016/j.janxdis.2003.07.003.
21Nestadt G, Samuels J, Riddle MA, Liang KY, Bienvenu OJ, Hoehn-Saric R, et al. The relationship between obsessive-compulsive disorder and anxiety and affective disorders: Results from the Johns Hopkins OCD Family Study. Psychol Med 2001;31:481-7. doi: 10.1017/s0033291701003579.
22Sbrana A, Bizzarri JV, Rucci P, Gonnelli C, Doria MR, Spagnolli S, et al. The spectrum of substance use in mood and anxiety disorders. Compr Psychiatry 2005;46:6-13. doi: 10.1016/j.comppsych.2004.07.017.
23Sharma P, Gale TM, Fineberg NA. Clinical correlates of tobacco smoking in OCD: A UK, case-controlled, exploratory analysis. J Behav Addict 2012;1:180-5. doi: 10.1556/JBA.1.2012.008.
24Schuurmans J, van Balkom AJ, van Megen HJ, Smit JH, Eikelenboom M, Cath DC, et al. The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study: Design and rationale of a longitudinal naturalistic study of the course of OCD and clinical characteristics of the sample at baseline. Int J Methods Psychiatr Res 2012;21:273-85. doi: 10.1002/mpr.1372.
25Tan O, Sayar GH, Unsalver BO, Arat MM, Karamustafalioglu O. The correlations of nicotine addiction with the levels of impulsiveness, depression and anxiety in obsessive-compulsive patients. J Depend 2014;15:124-33.
26Tan O, Taş C. Symptom dimensions, smoking and impulsiveness in obsessive-compulsive disorder. Psychiatr Danub 2015;27:397-405.
27Tan O, Koroglu A. Smoking prevalence, nicotine dependence and impulsivity in obsessive compulsive disorder. Int J Ment Health Addict 2018;18:125-37.
28Torres AR, Fontenelle LF, Shavitt RG, Ferrão YA, do Rosário MC, Storch EA, et al. Comorbidity variation in patients with obsessive-compulsive disorder according to symptom dimensions: Results from a large multicentre clinical sample. J Affect Disord 2016;190:508-16. doi: 10.1016/j.jad.2015.10.051.
29Torresan RC, Ramos-Cerqueira AT, Shavitt RG, do Rosário MC, de Mathis MA, Miguel EC, et al. Symptom dimensions, clinical course and comorbidity in men and women with obsessive-compulsive disorder. Psychiatry Res 2013;209:186-95. doi: 10.1016/j.psychres.2012.12.006.
30Tükel R, Polat A, Genç A, Bozkurt O, Atli H. Gender-related differences among Turkish patients with obsessive-compulsive disorder. Compr Psychiatry 2004;45:362-6. doi: 10.1016/j.comppsych.2004.06.006.
31Adam Y, Meinlschmidt G, Gloster AT, Lieb R. Obsessive-compulsive disorder in the community: 12-month prevalence, comorbidity and impairment. Soc Psychiatry Psychiatr Epidemiol 2012;47:339-49. doi: 10.1007/s00127-010-0337-5.
32Blom RM, Koeter M, van den Brink W, de Graaf R, Ten Have M, Denys D. Co-occurrence of obsessive-compulsive disorder and substance use disorder in the general population. Addiction 2011;106:2178-85. doi: 10.1111/j.1360-0443.2011.03559.x.
33Burns L, Teesson M. Alcohol use disorders comorbid with anxiety, depression and drug use disorders. Findings from the Australian National Survey of Mental Health and Well Being. Drug Alcohol Depend 2002;68:299-307. doi: 10.1016/s0376-8716(02)00220-x.
34de Bruijn C, Beun S, de Graaf R, ten Have M, Denys D. Subthreshold symptoms and obsessive-compulsive disorder: Evaluating the diagnostic threshold. Psychol Med 2010;40:989-97. doi: 10.1017/S0033291709991012.
35Ecker AH, Stanley MA, Smith TL, Teng EJ, Fletcher TL, Van Kirk N, et al. Co-occurrence of obsessive-compulsive disorder and substance use disorders among U.S. veterans: Prevalence and mental health utilization. J Cogn Psychother 2019;33:23-32. doi: 10.1891/0889-8391.33.1.23.
36Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602. doi: 10.1001/archpsyc.62.6.593.
37Kolada JL, Bland RC, Newman SC. Epidemiology of psychiatric disorders in Edmonton. Obsessive-compulsive disorder. Acta Psychiatr Scand Suppl 1994;376:24-35.
38Osland S, Arnold PD, Pringsheim T. The prevalence of diagnosed obsessive compulsive disorder and associated comorbidities: A population-based Canadian study. Psychiatry Res 2018;268:137-42. doi: 10.1016/j.psychres.2018.07.018.
39Politis S, Magklara K, Petrikis P, Michalis G, Simos G, Skapinakis P. Epidemiology and comorbidity of obsessive-compulsive disorder in late adolescence: A cross-sectional study in senior high schools in Greece. Int J Psychiatry Clin Pract 2017;21:188-94. doi: 10.1080/13651501.2017.1324038.
40Shahwan S, Abdin E, Shafie S, Chang S, Sambasivam R, Zhang Y, et al. Prevalence and correlates of smoking and nicotine dependence: Results of a nationwide cross-sectional survey among Singapore residents. BMJ Open 2019;9:e032198. doi: 10.1136/bmjopen-2019-032198.
41Torres AR, Prince MJ, Bebbington PE, Bhugra D, Brugha TS, Farrell M, et al. Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000. Am J Psychiatry 2006;163:1978-85. doi: 10.1176/ajp.2006.163.11.1978.
42Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010;15:53-63. doi: 10.1038/mp.2008.94.
43Wu P, Goodwin RD, Fuller C, Liu X, Comer JS, Cohen P, et al. The relationship between anxiety disorders and substance use among adolescents in the community: Specificity and gender differences. J Youth Adolesc 2010;39:177-88. doi: 10.1007/s10964-008-9385-5.
44Cuzen NL, Stein DJ, Lochner C, Fineberg NA. Comorbidity of obsessive-compulsive disorder and substance use disorder: A new heuristic. Hum Psychopharmacol 2014;29:89-93. doi: 10.1002/hup.2373.
45Vorspan F, Mehtelli W, Dupuy G, Bloch V, Lépine JP. Anxiety and substance use disorders: Co-occurrence and clinical issues. Curr Psychiatry Rep 2015;17:4. doi: 10.1007/s11920-014-0544-y.
46Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry 1988;45:1094-9. doi: 10.1001/archpsyc.1988.01800360042006.
47Skapinakis P, Politis S, Karampas A, Petrikis P, Mavreas V. Prevalence, comorbidity, quality of life and use of services of obsessive-compulsive disorder and subthreshold obsessive-compulsive symptoms in the general adult population of Greece. Int J Psychiatry Clin Pract 2019;23:215-24. doi: 10.1080/13651501.2019.1588327.
48Hofer PD, Wahl K, Meyer AH, Miché M, Beesdo-Baum K, Wong SF, et al. Obsessive-compulsive disorder and the risk of subsequent mental disorders: A community study of adolescents and young adults. Depress Anxiety 2018;35:339-45. doi: 10.1002/da.22733.
49Mancebo MC, Grant JE, Pinto A, Eisen JL, Rasmussen SA. Substance use disorders in an obsessive compulsive disorder clinical sample. J Anxiety Disord 2009;23:429-35. doi: 10.1016/j.janxdis.2008.08.008.
50Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19. doi: 10.1001/archpsyc.1994.03950010008002.
51Yaryura-Tobias JA, Grunes MS, Todaro J, McKay D, Neziroglu FA, Stockman R. Nosological insertion of axis I disorders in the etiology of obsessive-compulsive disorder. J Anxiety Disord 2000;14:19-30. doi: 10.1016/s0887-6185(99)00027-4.
52Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: Results from population surveys in Australia and the United States. BMC Public Health 2009;9:285. doi: 10.1186/1471-2458-9-285.
53Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S, Brook JS. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA 2000;284:2348-51. doi: 10.1001/jama.284.18.2348.
54Dell'Osso B, Nicolini H, Lanzagorta N, Benatti B, Spagnolin G, Palazzo MC, et al. Cigarette smoking in patients with obsessive compulsive disorder: A report from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS). CNS Spectr 2015;20:469-73. doi: 10.1017/S1092852915000565.
55Harrison BJ, Pujol J, Cardoner N, Deus J, Alonso P, López-Solà M, et al. Brain corticostriatal systems and the major clinical symptom dimensions of obsessive-compulsive disorder. Biol Psychiatry 2013;73:321-8. doi: 10.1016/j.biopsych.2012.10.006.
56Landeros-Weisenberger A, Bloch MH, Kelmendi B, Wegner R, Nudel J, Dombrowski P, et al. Dimensional predictors of response to SRI pharmacotherapy in obsessive-compulsive disorder. J Affect Disord 2010;121:175-9. doi: 10.1016/j.jad.2009.06.010.
57Kichuk SA, Torres AR, Fontenelle LF, Rosário MC, Shavitt RG, Miguel EC, et al. Symptom dimensions are associated with age of onset and clinical course of obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry 2013;44:233-9. doi: 10.1016/j.pnpbp.2013.02.003.
58Prabhu L, Cherian AV, Viswanath B, Kandavel T, Math SB, Reddy YC. Symptom dimensions in OCD and their association with clinical characteristics and comorbid disorders. J Obsessive Compuls Related Disord 2013;2:214-21. doi: 10.1016/j.jocrd.2012.10.002.
59Williams MT, Farris SG, Turkheimer EN, Franklin ME, Simpson HB, Liebowitz M, et al. The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. J Anxiety Disord 2014;28:553-8. doi: 10.1016/j.janxdis.2014.06.001.
60Brakoulias V, Starcevic V, Berle D, Milicevic D, Moses K, Hannan A, et al. The characteristics of unacceptable/taboo thoughts in obsessive-compulsive disorder. Compr Psychiatry 2013;54:750-7. doi: 10.1016/j.comppsych.2013.02.005.
61Tan O, Çoban DA. The prevalence of attention deficit and hyperactivity disorder among distinct symptom dimensions in adult patients with obsessive-compulsive disorder. J Mood Disord 2016;6:211-7.
62Ögel K, Tamar D, Özmen E. Prevalence of cigarette use in Istanbul. J Depend 2003;4:105-18.
63Fullana MA, Mataix-Cols D, Caspi A, Harrington H, Grisham JR, Moffitt TE, et al. Obsessions and compulsions in the community: Prevalence, interference, help-seeking, developmental stability, and co-occurring psychiatric conditions. Am J Psychiatry 2009;166:329-36. doi: 10.1176/appi.ajp.2008.08071006.
64Fullana MA, Vilagut G, Rojas-Farreras S, Mataix-Cols D, de Graaf R, Demyttenaere K, et al. Obsessive-compulsive symptom dimensions in the general population: Results from an epidemiological study in six European countries. J Affect Disord 2010;124:291-9. doi: 10.1016/j.jad.2009.11.020.
65Dirice B. Comparing Obsessive-Compulsive Symptoms and Impulsivity between Smokers and Non-Smokers (in Turkish). Master Thesis Done in Uskudar University, Istanbul; 2014.
66Mayerovitch JI, du Fort GG, Kakuma R, Bland RC, Newman SC, Pinard G. Treatment seeking for obsessive-compulsive disorder: Role of obsessive-compulsive disorder symptoms and comorbid psychiatric diagnoses. Compr Psychiatry 2003;44:162-8. doi: 10.1053/comp.2003.50005.
67García-Soriano G, Rufer M, Delsignore A, Weidt S. Factors associated with non-treatment or delayed treatment seeking in OCD sufferers: A review of the literature. Psychiatry Res 2014;220:1-10. doi: 10.1016/j.psychres.2014.07.009.
68Potenza MN, Koran LM, Pallanti S. The relationship between impulse-control disorders and obsessive-compulsive disorder: A current understanding and future research directions. Psychiatry Res 2009;170:22-31. doi: 10.1016/j.psychres.2008.06.036.
69Diedrich A, Voderholzer U. Obsessive-compulsive personality disorder: A current review. Curr Psychiatry Rep 2015;17:2. doi: 10.1007/s11920-014-0547-8.
70Torres AR, Moran P, Bebbington P, Brugha T, Bhugra D, Coid JW, et al. Obsessive-compulsive disorder and personality disorder: Evidence from the British National Survey of Psychiatric Morbidity 2000. Soc Psychiatry Psychiatr Epidemiol 2006;41:862-7. doi: 10.1007/s00127-006-0118-3.
71Lochner C, Serebro P, van der Merwe L, Hemmings S, Kinnear C, Seedat S, et al. Comorbid obsessive-compulsive personality disorder in obsessive-compulsive disorder (OCD): A marker of severity. Prog Neuropsychopharmacol Biol Psychiatry 2011;35:1087-92. doi: 10.1016/j.pnpbp.2011.03.006.
72González E, Arias F, Szerman N, Vega P, Mesias B, Basurte I. Coexistence between personality disorders and substance use disorder. Madrid study about prevalence of dual pathology. Actas Esp Psiquiatr 2019;47:218-28.
73Berlin GS, Hollander E. Compulsivity, impulsivity, and the DSM-5 process. CNS Spectr 2014;19:62-8. doi: 10.1017/S1092852913000722.
74American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
75Benatti B, Dell'Osso B, Arici C, Hollander E, Altamura AC. Characterizing impulsivity profile in patients with obsessive-compulsive disorder. Int J Psychiatry Clin Pract 2014;18:156-60. doi: 10.3109/13651501.2013.855792.
76Kozak K, Lucatch AM, Lowe DJ, Balodis IM, MacKillop J, George TP. The neurobiology of impulsivity and substance use disorders: Implications for treatment. Ann N Y Acad Sci 2019;1451:71-91. doi: 10.1111/nyas.13977.
77Zohar J. Addiction, impulsivity and obsessive-compulsive disorder: New formulation revealing ancient wisdom. Isr Med Assoc J 2010;12:233.
78Bejerot S, Humble M. Low prevalence of smoking among patients with obsessive-compulsive disorder. Compr Psychiatry 1999;40:268-72. doi: 10.1016/s0010-440x(99)90126-8.
79Flory JD, Manuck SB. Impulsiveness and cigarette smoking. Psychosom Med 2009;71:431-7. doi: 10.1097/PSY.0b013e3181988c2d.
80Turner S, Mota N, Bolton J, Sareen J. Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depress Anxiety 2018;35:851-60. doi: 10.1002/da.22771.
81Grabe HJ, Meyer C, Hapke U, Rumpf HJ, Freyberger HJ, Dilling H, et al. Prevalence, quality of life and psychosocial function in obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany. Eur Arch Psychiatry Clin Neurosci 2000;250:262-8. doi: 10.1007/s004060070017.
82Albertella L, Le Pelley ME, Chamberlain SR, Westbrook F, Fontenelle LF, Segrave R, et al. Reward-related attentional capture is associated with severity of addictive and obsessive-compulsive behaviors. Psychol Addict Behav 2019;33:495-502. doi: 10.1037/adb0000484.
83Burchi E, Makris N, Lee MR, Pallanti S, Hollander E. Compulsivity in alcohol use disorder and obsessive compulsive disorder: Implications for neuromodulation. Front Behav Neurosci 2019;13:70. doi: 10.3389/fnbeh.2019.00070.
84Fontenelle LF, Oostermeijer S, Harrison BJ, Pantelis C, Yücel M. Obsessive-compulsive disorder, impulse control disorders and drug addiction: Common features and potential treatments. Drugs 2011;71:827-40. doi: 10.2165/11591790-000000000-00000.
85Vollstädt-Klein S, Wichert S, Rabinstein J, Bühler M, Klein O, Ende G, et al. Initial, habitual and compulsive alcohol use is characterized by a shift of cue processing from ventral to dorsal striatum. Addiction 2010;105:1741-9. doi: 10.1111/j.1360-0443.2010.03022.x.
86Gremel CM, Costa RM. Orbitofrontal and striatal circuits dynamically encode the shift between goal-directed and habitual actions. Nat Commun 2013;4:2264. doi: 10.1038/ncomms3264.
87Escobar AD, Casanova JP, Andrés ME, Fuentealba JA. Crosstalk between kappa opioid and dopamine systems in compulsive behaviors. Front Pharmacol 2020;11:57. doi: 10.3389/fphar.2020.00057.
88Lei H, Huang L, Li J, Liu W, Fan J, Zhang X, et al. Altered spontaneous brain activity in obsessive-compulsive personality disorder. Compr Psychiatry 2020;96:152144. doi: 10.1016/j.comppsych.2019.152144.