الفهرس 
Psychological Models Correlating Addiction to Compulsivity and ObsessionlityOnly 14 pages are availabe for public view
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Abstract
The word compulsion was introduced into the intellectual heritage of addiction medicine in the twenties and thirties, where it has been used ever since. Most formulations of the addiction model include the concept of compulsion.
There is a high prevalence of psychiatric comorbidities (especially anxiety disorders) with psychoactive substance abuse and many psychological models were constructed to explain this high rate of comorbidity including; the “self-medication model” of addiction and the “disease model of addiction”.
For decades, basic research on drug addiction has been largely devoted to understanding the mechanisms underlying the acute rewarding effects of drugs and the subsequent development of uncontrolled compulsive drug dependence.
It is postulated that while reward circuits may be crucial to initiate drug self-administration, the addictive state also involves disruption of circuits involved with compulsive behaviors and with drive. Intermittent dopaminergic activation of reward circuits secondary to drug self-administration leads to dysfunction of the orbitofrontal cortex via the striato-thalamo-orbitofrontal circuit.
It has been found that across all drug groups, the severity of drug use was correlated with frontostriatal dysfunction, inhibitory impairment and decision-making skills. It remains unclear whether these frontal abnormalities predate chronic drug consumption or not.
On the other hand, the pathophysiology of OCD remains controversial, there is substantial evidence suggesting that disturbances in the frontal-striatal-thalamic circuits may be implicated. These circuits have been the basis of several of the neuroanatomical models of OCD.
It is not surprising that there are several commonalities between OCD and SUD; for example; although primarily conceived as an anxiety disorder, OCD has features resembling addictive behavior. Compulsions could be viewed as addictive because of their rewarding effects following reduction of obsession-induced anxiety. Findings also suggest an important role for the NAc in the pathophysiology of OCD. Those results match up remarkably with the findings of functional imaging studies in addiction disorders.
Compulsive behaviour, as seen in both intractable addiction and OCD, requires dysfunction within two highly interconnected cortical systems (ACC and OFC) critically involved in self-regulation (i.e. the inhibitory system).
The review then deals with the concept of comorbidity and it also reviews various studies of comorbidity between OCD and SUD;
It is estimated that 24% of individuals with OCD meet lifetime criteria for an alcohol use disorder, 18% meet lifetime criteria for a drug use disorder and individuals with OCD are at increased risk for substance use dependence. OCD prevalence rates among individuals receiving treatment for a substance use disorder range from 6 to 12%, two to six times higher than those found in the general population.
OCD patients with comorbid substance use disorders are presented with more severe OCD symptoms, poorer insight regarding their OCD symptoms, poorer quality of life, greater impairment in overall psychosocial functioning, and were more likely to report suicide attempts than those without substance use disorders.
Surprisingly, there has not been enough synthesis of research to inform clinicians of treatment combinations that are likely to be effective in clinical practice. It has been found that patients who received treatment for their drug addiction and engaged in behavior therapy for OCS demonstrated a greater reduction in OCD symptom severity, and had superior outcome compared with those patients whose OCD symptoms were not specifically addressed .
Thus, accurately diagnosing OCD among substance abusers and concurrently treating each condition appears to improve markedly the prognosis for both disorders.
However, studying the mutual impact of substance abuse & OCD on each other has been the subject of very few studies and to our knowledge none of the Egyptian studies.
The main Hypothesis of this study is that comorbidity of OCD &/or association of OC symptoms in substance abuse has a significant incidence & may affect the severity of both conditions.
Aim of this work is to verify the hypothesis, and to evaluate the following points if the hypothesis is verified;
1- To evaluate the incidence of OCD comorbidity as well as OC symptoms association in patients with SUD.
2- To find out the impact of OCD & OC symptoms on the severity of substance abuse disorders.
3- To assess the pattern of substance abuse in patients with high prevalence of OCD comorbidity & OC symptoms association.
Subjects and methods:
The study was carried out at the Institute of Psychiatry, Ain Shams University Hospitals. It is a psychiatric hospital, located in Cairo. It serves a catchment area encompassing approximately 3 million people.
50 cases were conveniently selected from SUD patients attending the outpatient clinic and admitted in the addiction department of Institute of Psychiatry, fulfilling the diagnosis of one or more substance abuse disorder (excluding nicotine) as outlined in the DSM IV criteria.
The study also included a control group of 30 healthy Egyptian individuals with no apparent medical, neurological or psychiatric morbidity. They were matched for age, sex, and other demographic variables as far as possible with the patient group.
An informed written consent was obtained from all patients involved in the study.
All subjects involved in the study were assessed using:
1- Structured clinical interview for DSM-IV Axis I Disorder (SCID-I) (first et al., 1996) for diagnosis of OCD & SUD.
2- Addiction severity index (Mclellan et al., 1985).
3- The Yale- Brown Obsessive-Compulsive Scale (YBOCS) (Goodman et al., 1989 a,b) for detecting OC symptoms by the Y-BOCS symptom checklist & to rate the severity and type of symptoms in patients with obsessive compulsive disorder (OCD) .
The main findings of this study were:
Studying the characteristics of the group of patients showed no significant demographic differences between cases and controls, except for lower level of education in SUD patients.
Regarding SUD; The majority of participants (70%) met criteria for more than one lifetime dependence, with the most common primary drugs of choice being opiates (N = 47, 94 %) and cannabis came in the second rank.
Regarding Non-SUD psychiatric disorders; The presence of a lifetime Axis I disorder other than SUD among substance users was of prevalence of 54%, with the most common lifetime Non-SUD psychiatric disorders being; depression (24 %), followed by BAD (12 %), then come somatization and panic disorder.
Those figures are much more common when compared to controls; where the total incidence of any psychiatric disorder was only 16.6%.
In contrast to our hypothesis, there was only one patient in this sample (2 %) met criteria for OCD. However, 40% of the patients, who didn’t meet diagnostic criteria for OCD, suffered from OCS, which were in 80% of them subclinical, 15% were mild in severity and only one with severe symptoms.
This is comparable to the control group where prevalence of OCS was also 40 % and no significant difference in total Y-BOCS severity distribution.
But as expected, the mean scores on the Y-BOCS in group I were higher compared to that of group II significantly. No correlation was found between OCS and the mean severity profile scores of ASI.
When we compared our results with the results of the previous studies we found multiple differences, that we referred to the diversity in methodology; but we concluded that the greatest common multiple results that agreed upon by most of the studies and also ours is that most of substance abusers report more than one substance of abuse at life-time. Similarly, they are at greater risk of developing non-SUD psychiatric disorders than those who are substance naive.
Regarding the incidence of OCD among SUD, our study showed that it was 2%, which agree with the available epidemiological data on prevalence of OCD in general population. And so did the prevalence of association of OCS with SUD, which came equal to that of controls.
Our results were consistent with two recent studies (Chen et al., 2011) and (Al-khafaji, 2010) with rates of comorbidity of 3% and 2.7% respectively. Yet, our figures did not agree with previous studies of Fals-Stewart & Angarano, (1994) and Reimann et al. (1992), which reported much higher rates than our current results (11% of their sample). We attributed this discrepancy to different methodological approaches, the substance being abused by the subjects or the large sample of their study.
However, our research revealed that SUD, though not increasing the total incidence of OCD or OCS, it increases the severity of symptoms, if already present.
Yet, in contrast to our hypothesis, no significant correlation was found between OCS and the severity of addiction. To our knowledge, no similar data were found to compare those results with.
A larger study is recommended, that would preferably target a community sample. Also, a more comprehensive study would correlate the OCD- SUD comorbidity to functional imaging findings e.g. functional MRI or PET study. This would have needed a specialized center with guaranteed accuracy and much more resources.