Obsessive compulsive disorder and addiction

It’s true that having Obsessive-Compulsive Disorder (OCD) increases an individual’s chances of developing an addiction. In arguing against the concept of behavioral addictions, including porn addiction, skeptics often claim that porn addiction is a ‘compulsion’ not an ‘addiction’. That addiction is “like” OCD. When further pressed as to how a ‘compulsion to use X’ differs (physiologically) from an ‘addiction to X’, a common comeback by these uninformed skeptics is that “Behavioral addictions are simply OCD.” Not true. Research demonstrates that addictions differ from OCD in many substantive ways. In fact, the DSM-5 has separate categories for OCD and behavioral addictions, so its experts realize that the two conditions are physiologically different. An excerpt from this 2016 review sums it up:

Obsessive-compulsive spectrum disorders have been considered to conceptualize sexual compulsivity (40) because some studies have found individuals with hypersexual behavior are on the obsessive-compulsive disorder (OCD) spectrum. OCD for hypersexual behavior is not consistent with DSM-5 (1) diagnostic understandings of OCD, which exclude from the diagnosis those behaviors from which individuals derive pleasure. Although obsessive thoughts of the OCD type often have sexual content, the associated compulsions performed in response to the obsessions are not carried out for pleasure. Individuals with OCD report feelings of anxiety and disgust rather than sexual desire or arousal when confronted with situations triggering obsessions and compulsions, with the latter being performed only to quell uneasiness the obsessive thoughts arouse. (41)

Porn addiction naysayers often claim that CSBD is nothing more than obsessive compulsive disorder (OCD), yet this well-worn talking point has little empirical support: (excerpt from Revisiting the Role of Impulsivity and Compulsivity in Problematic Sexual Behaviors, 2018).

Few studies have examined associations between compulsivity and hypersexuality. Among males with nonparaphilic hypersexual disorder, the lifetime prevalence of obsessive compulsive disorder—a psychiatric disorder characterized by compulsivity—ranges from 0% to 14% (Kafka, 2015). Obsessiveness—which may be associated with compulsive behavior (Minnesota Multiphasic Personality Inventory 2 (MMPI-2); Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989)—in treatment-seeking men with hypersexuality has been found to be elevated relative to a comparison group, but the effect size of this difference was weak (Reid & Carpenter, 2009). When the association between the level of obsessive-compulsive behavior—assessed by a subscale of the Structured Clinical Interview for DSM-IV (SCID-II) (First, Gibbon, Spitzer, Williams, & Benjamin, 1997)—and the level of hypersexuality was examined among treatment-seeking males with hypersexual disorder, a trend toward a positive, weak association was found (Carpenter, Reid, Garos, & Najavits, 2013). On the basis of the aforementioned results, compulsivity appears to contribute in a relatively small manner to hypersexuality.

Relevant excerpts from Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019):

From an impulse control disorder perspective, hypersexual behavior is generally referred to as Compulsive Sexual Behavior (CSB). Coleman [56] is a proponent of this theory. While he includes paraphilic behavior under this term [57], and they may coexist in some cases, he distinctly differentiates it from nonparaphilic CSB, which is what we want to focus on in this review. Interestingly, nonparaphilic hypersexual behavior is usually as frequent, if not more, than some paraphilias [43,58].
However, more recent definitions of CSB usually refer to multiple sexual behaviors that can be compulsive: the most commonly reported being masturbation, being followed by compulsive use of pornography, and promiscuity, compulsive cruising, and multiple relationships (22–76%) [9,59,60].
While there are definite overlaps between hypersexuality and conditions such as obsessive-compulsive disorder (OCD) and other impulse control disorders [61], there are also some notable differences pointed out: for example, OCD behaviors do not involve reward, unlike sexual behavior. Moreover, while engaging in compulsions might result in temporary relief for OCD patients [62], hypersexual behavior is usually associated by guilt and regret after committing the act [63]. Also, the impulsivity that can sometimes dominate the patient’s behavior is incompatible with the careful planning that is sometimes required in CSB (for example, in regards to a sexual encounter) [64]. Goodman thinks that addiction disorders lie at the intersection of compulsive disorders (which involve anxiety reduction) and impulsive disorders (which involve gratification), with the symptoms being underpinned by neurobiological mechanisms (serotoninergic, dopaminergic, noradrenergic, and opioid systems) [65]. Stein agrees with a model combining several ethiopathogenical mechanisms and proposes an A-B-C model (affective dysregulation, behavioral addiction, and cognitive dyscontrol) to study this entity [61].
From an addictive behavior standpoint, hypersexual behavior relies on sharing core aspects of addiction. These aspects, according to the DSM-5 [1], refer to the mentioned problematic consumption model applied to hypersexual behavior, both offline and online [6,66,67]. Evidence of tolerance and withdrawal in these patients might probably be key in characterizing this entity as an addictive disorder [45]. Problematic use of cybersex is also often conceptualized as a behavioral addiction [13,68].

Compulsive sexual behavior disorder in obsessive-compulsive disorder: Prevalence and associated comorbidity (2019) – Study reported that CSBD rates are actually lower in those with OCD than in general population:

In this study, we were interested in the prevalence and the associated sociodemographic and clinical features of CSBD in patients with OCD. First, we found that 3.3% of patients with OCD had current CSBD and 5.6% had lifetime CSBD, with a significantly higher prevalence in men than in women. Second, we found that other conditions, particularly mood, obsessive–compulsive, and impulse-control disorders, were more common in OCD patients with CSBD than in those without CSBD, but not disorders due to substance use or addictive behaviors.

The early estimations of prevalence rates of CSBD provided by Carnes (1991) and Coleman (1992) suggested that up to 6% of people from the general population suffer from compulsive sexual behavior. Although it is unclear how these estimates were obtained (Black, 2000), subsequent epidemiological research confirmed that compulsive sexuality, which may include increased masturbation frequency, pornography use, number of sexual partners, and extramarital affairs, is common in the general population (Dickenson et al., 2018). Our findings on prevalence rates of CSBD in OCD seem roughly comparable to those in the general population (Langstrom & Hanson, 2006; Odlaug et al., 2013; Skegg, Nada-Raja, Dickson, & Paul, 2010).

In conclusion, our data indicate that prevalence rates of CSBD in OCD are comparable to those in the general population and in other diagnostic cohorts. Moreover, we found that CSBD in OCD was more likely comorbid with other impulsive, compulsive, and mood disorders, but not with behavioral- or substance-related addictions. This finding supports the conceptualization of CSBD as a compulsive–impulsive disorder. Going forward, standardized measures with sound psychometric properties are needed to assess presence and severity of CSBD. Future research should continue to consolidate the conceptualization of this disorder and to gather additional empirical data, in order to ultimately improve clinical care.

The rates of co-occurring behavioural addictions in treatment-seeking individuals with obsessive-compulsive disorder: a preliminary report (2020) – Study reported that behavioral addiction rates (including internet addiction and CSBD) are about the same as occur in the general population.  Thus, addiction does not equate with OCD or compulsivity:

In most of the studies listed in the child pages below, researchers compared substance addictions with gambling addiction because gambling addiction is the only behavioral addiction so far officially recognized in the new DSM-5 (2013).