Challenges in Treating Comorbid OCD and ADHD
Patricia M. Perrin, Ph.D.
OCD and Anxiety Treatment Center of Houston
This article is aimed at helping therapists, parents, and sufferers to tease out which disorder is causing which symptom in individuals with comorbid obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD), in order to facilitate understanding and to determine the proper interventions. It is not uncommon for school children or adults to be diagnosed with ADHD, and to have all their problematic behaviors attributed to ADHD. These problems may include not completing homework, tests, or work-related tasks, checking with others repeatedly, or getting to bed easily at bedtime. OCD can also influence these behaviors. For example, if one is not completing work, it may be due to someone with ADHD not being able to focus, or it may be due to someone with OCD engaging in covert or overt rituals. They may be engaged in reviewing, rewriting, rereading, checking, or ordering rituals, aimed at either attaining the “just right” feeling, completing something perfectly, or relieving anxiety due to obsessions. In addition, individuals with OCD may have difficulty organizing, remembering, and completing things not exclusively because of interference from rituals, but also because of difficulty focusing due to ADHD.
Misdiagnosis, or incomplete diagnosis can lead to inappropriate or inadequate treatment and ongoing suffering. This article will help to identify when behavior is influenced by ADHD, OCD, or both, and when certain interventions should be added or deleted. Cognitive-behavioral therapy approaches will be discussed, both exposure and response prevention for OCD, as well as, providing structure and ordering techniques for ADHD.
WHY LOOK AT COMORBID OCD AND ADHD?
Children and adolescents with OCD have been found to have high rates of comorbidity, i.e., having two concurrent diagnoses, with attention deficit/hyperactivity disorder (ADHD) of 25-33%. Yet there is little discussion of this comorbidity at conferences addressing ADHD or OCD, or in books on ADHD or OCD. There is also little research addressing both ADHD and OCD. And there is little research on the effects of the subtypes of ADHD: the predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type, as a comorbid conditions of OCD.
The most common misdiagnosis given for anxiety disorders and OCD is ADHD. Of course, there are treatment implications of this error. In addition, when someone with OCD also has ADHD, it might make it more difficult to make progress in treating OCD. Time must be given to ADHD as well as OCD, individuals may need to be treated for ADHD with stimulants first to help their attentiveness, and ADHD may cause difficulty in focusing on treatment, for example, focusing during exposures.
Expectations for outcomes may have to be revised as well. In one study by Storch, et al., 92% of those with OCD alone responded to treatment, but 69% of those with one or more comorbid condition (ADHD, anxiety disorder, depression, bipolar disorder, or disruptive disorders) were treatment responders.
PROBLEM BEHAVIORS FOUND TO BE DUE TO OCD, WHICH MAY BE ATTRIBUTED TO ADHD, OR MAY ACTUALLY BE DUE TO ADHD, OR WHICH ARE PATIALLY DUE TO EACH DISORDER
Many individuals who have OCD are misdiagnosed because they exhibit problem behaviors that are interpreted as caused by having ADHD. In some cases the behaviors are due to OCD, in others due to ADHD, and sometimes caused by both disorders. Some of these problem behaviors include:
– Appearing not to listen when spoken to
– Difficulty leaving the house in time to get to school or work
– Need for stimulation
– Checking repeatedly with parents (about plans, for reassurance, etc.)
– Slowness or nor finishin work due to repeating, rewriting, rereading
– Bedtime rituals / avoidance- Hoarding
Following is a sampling of how a few of these behaviors might be understood if due to ADHD, and if due to OCD, and recommended interventions.
Appearing Not To Listen When Spoken To:
If one appears not to listen when spoken to, this may be due to ADHD. The ADHD may be causing this behavior by causing:
– Difficulty focusing attention
– Distraction by something in the environment
– Feeling bored, restless, or not “present focused”, or feeling “on the go” or “driven by a motor”.
On the other hand, if the individual has OCD one may not appear to listen because one is preoccupied with an obsession, i.e., not due to an attention deficit.
OCD might cause this behavior by causing:
– Self-reassurance that an intrusive thought (of harming someone or saying something inappropriate, like a racial slur) is not something he or she wants to do.
– Mental rituals, e.g.,:
– Canceling bad thoughts with good thoughts
– Saying silent prayers
– Thought suppression (pushing the thought away)
– Repeating what the person is saying to oneself
– Counting the number of letters in words someone is saying
– Watching a clock for specific numbers to come or go, or adding numbers on a clock to be an even or odd number.
What kinds of interventions should be used based on the cause of the behavior?
If the behavior is due to ADHD, recommendations include:
– Wait until person is attending
– Write down anything important (a To Do list, schedule for the day, etc.)
– Ask the person to put information into a planner or phone calendar
If the behavior is due to OCD, recommendations primarily include using the evidence-based cognitive behavioral therapy called exposure and response prevention (ERP). ERP involves confronting a trigger for anxiety without doing a ritual or avoidance, and then experiencing a habituation or fading of anxiety. This leads to weakening both the strength of the ritual and the urge to do a ritual or avoidance in when exposed to that trigger in the future. Recommendations of ERP interventions include:
– Ritual prevention, e.g., if one counts steps or words, block counting by:
– Using large numbers (6472, 6473…),
– Singing a song,
– Reciting the alphabet from a letter other then “a”, or
– Reciting the Pledge of Allegiance, or something else memorized.
Difficulty Leaving House In Time To Get To School / Work:
ADHD might cause this behavior by causing:
– Indecision in choosing clothes
– Distractibility by siblings, TV, games
– Sleep disturbance and difficulty awakening
– Taking a long time to pack backpack
– Losing track of time / poor time management
– Taking long showers
OCD might cause this behavior by causing:
– Changing clothes repeatedly to get “just right” feeling
– Taking shirt on and off a certain number of times as a ritual to protect
someone and to get the “just right” feeling
– Brushing teeth or hair a certain number of times to get “just right” feeling
– Rearranging or checking backpack repeatedly
– Getting stuck counting steps, or repeating one’s last action
– Checking house for plastic bags to be sure pet cannot get in one and suffocating
– Checking appliances or water faucets, to be sure they are turned off
What kinds of interventions could be used to help one leave the house in a timely manner based on the cause of the behavior?
If the behavior is due to ADHD, recommendations include:
– Lay out clothes the night before
– Make “To Do” List with essentials:
– Get up by 6:45
– Get dressed
– Comb hair
– Eat breakfast
– Brush teeth
– Pack and take lunch
– Leave for bus by 7:45
– Set 2 alarms 10 min. apart, the latter one out of reach of bed.
– Leave TV, other distractions off
– Set alarm (e.g., on cell phone) 5-10 minutes before having to go
– Pack backpack night before and leave by door. Include homework, permission slips, etc.
– Place homework in “to be turned in” folder
If the behavior is due to OCD, recommendations include:
– Doing exposure and response prevention (ERP) by
– Not doing ritual of taking shirt on and off, noting discomfort level
and watching it slowly habituate (decrease)
– Not changing clothes, watching “not right” feeling habituate
– Blocking counting steps when walking, or changing surfaces
– Packing backpack once without checking or repacking
– In all exposures, rate anxiety (0-10) and watch it habituate
– Reward getting to school on time (for OCD or ADHD)
Bedtime Avoidance or Rituals:
ADHD might cause avoidance or delay in getting to bed due to:
– Being distracted, taking a lot of time in bathroom, or playing videogames, causing a delay in starting bathroom routine
– Doing homework that had been forgotten or overlooked
OCD might cause delay in getting to bed due to doing bedtime rituals, e.g.,:
– Arranging stuffed animals
– Arranging bedcovers in ritualized way
– Doing ritual of saying prayers to attain “just right” feeling, or to reduce anxiety caused by obsession that one might not be pleasing to God’
– Saying “good night” in scripted way and requiring parents to do the same
What kind of interventions could be used to help one get to bed without distraction or interference based on the cause of the behavior?
If the behavior is due to ADHD recommendations include:
– Promote routine to prevent forgetting things, to provide structure
– Do homework earlier in the evening
– Set alarm for time to start bathroom routine, and to stop other activities
If the bedtime delay is due to OCD bedtime rituals, recommendations include using ERP as follows:
– Do rituals wrong (e.g., leave one stuffed animal off bed)
– Say prayer slightly differently; say different prayers each night
– Do not say “good night” according to ritual, but say it differently and have parents say their part differently each night.
– Touch items in a different order, or don’t touch at all.
– In doing all exposures, note anxiety level (0-10) and watch it habituate.
Being aware that a problem behavior can be due to either ADHD, OCD or both, and identifying the responsible disorder can lead to more accurate understanding and diagnosis. As a result, more effective treatments for OCD and ADHD can be designed and individuals with the problem behaviors discussed can be helped.