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Key points
- Most people living with ADHD also experience other related conditions, such as anxiety or OCD.
- When ADHD and OCD occur together, they can exacerbate each other.
- Effective care starts with recognizing both conditions, and then implementing evidence-based interventions for both.
Attention-deficit/hyperactivity disorder (ADHD) is best thought of as a disorder of executive function, skills we use to organize and plan our lives. One important concept to know around ADHD is that of "comorbidity"—when someone has ADHD, it’s likely they have something else, too, like a learning disability or anxiety. It’s even possible to have ADHD, which tends to cause disorganization, and symptoms of an obsessive-compulsive disorder (OCD) at the same time.
Dr. Roberto Olivardia is a Harvard psychologist and expert on both ADHD and OCD. I had the opportunity to ask Dr. Olivardia recently what it's like when someone is living with both ADHD and OCD.
For starters, Dr. Olivardia, how do you define ADHD, and what leads to a diagnosis of OCD? What separates them both from the type of stuff we all experience at times?
ADHD is a condition of neurodiversity marked by dysregulation of attention, executive functioning issues (problems with time management, organization, task initiation, working memory, etc.), and sometimes hyperactivity and impulsivity. Although everyone can relate to having problems paying attention to some things, people with ADHD find it very difficult to regulate their attention when they are not inherently stimulated. The executive functioning issues people with ADHD experience are constant and cause much interference, impairment, and frustration in their lives. That is very different than the occasional forgetting or procrastination people may typically have experienced in isolated incidents.
OCD is characterized by obsessions and/or compulsions. Obsessions are persistent thoughts, impulses, or images that are intrusive in nature and cause distress and anxiety. Worries about real-life problems are not the same as obsessions. Even though logic may inform them that this is irrational, it is still very difficult to just pass it off. Compulsions are repetitive physical behaviors (such as checking or hand washing) or mental acts (such as saying words silently, praying, counting, creating images) that a person feels compelled to do in order to undo, neutralize, or cope with the obsession. The compulsion may have nothing to do with the actual obsession. This is constant for sufferers and causes much impairment and interference in their lives.
How common is it to have both ADHD and OCD?
It is unclear how many people with ADHD also have OCD, but studies have looked at the prevalence of ADHD in OCD populations and estimate that approximately 30 percent of patients with OCD also have ADHD.
In my clinical practice, ADHD and OCD tend to be more comorbid in individuals with pure obsessional OCD (also known as "pure-O"), hoarding, tic disorder, Tourette’s disorder, dermatillomania (compulsive skin picking), and trichotillomania (compulsive hair-pulling).
It is important to properly diagnose when someone struggles with OCD, ADHD, or both. When people have both, it is common that one disorder is diagnosed while the other goes undiagnosed. Having both disorders can be incredibly challenging, as having both is associated with more severe symptoms of both than having either alone.
What’s uniquely challenging, then, about having both ADHD and OCD?
Having either ADHD or OCD can be challenging in itself. But having both is greater than the sum of its parts. It is not 1+1=2, as much as it is 1+1=5. The two disorders can feed off each other, like a toxic couple. For example, a student could be in class and getting bored and distractible (ADHD) and then find themselves gravitating to an OCD ritual (like praying silently in the middle of a class).
The two conditions can sometimes have a "whack-a-mole" effect, where symptoms of one disorder may be dominant, but then, once those decrease, the other disorder takes over. Someone can be working on impulsive spending (ADHD), and when they find themselves successfully managing the impulsivity, they may lapse into more compulsive thinking (OCD).
The challenge is being able to distinguish which diagnosis is "driving the bus" and tailoring interventions to that diagnosis. It is possible to manage these two conditions, but it takes some work and understanding of each condition and how they present when together.
What does treatment look like when someone is struggling with both conditions?
The most essential treatment for OCD is exposure plus response prevention (ERP). This includes confronting the thought, image, object, or situation that makes a person with OCD anxious. ERP will also include confronting an exaggerated symptom of OCD. For example, if someone fears their mother will get breast cancer if they think of the word “cancer” and either anxiously avoids anything that may trigger that thought or has to ritually pray if they do think of the word in an effort to neutralize the thought, an adequate ERP would include having a person write the word “breast cancer” 100 times, read about breast cancer, and watch YouTube videos about breast cancer, and be prevented from praying. They may even write, “My mother has breast cancer” repeatedly. The goal is to habituate to the anxiety and realize that those thoughts have absolutely no effect on whether their mother would get cancer.
Medication is also very helpful and highly effective for treating OCD. The most common class of effective medications are antidepressants known as selective serotonin reuptake inhibitors (SSRIs). They include fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and paroxetine (Paxil). They can help by boosting serotonin levels in the brain.
OCD medications do not make ADHD symptoms worse. However, stimulant medication used to treat ADHD can sometimes make OCD worse. Patients with ADHD and OCD sometimes find that stimulants enable them to focus more on their obsessions.
At other times, though, ADHD medication positively impacts OCD. Frequently, it neither increases nor decreases OCD symptoms.
Working with specialists in ADHD and OCD is essential. Psychotherapy can also be helpful in discussing issues related to OCD, such as shame and self-esteem issues. Couples or family therapy is also recommended, as OCD impacts loved ones as well.
Not all therapists are trained in doing ERP with patients. If you have OCD, your therapist should have experience in this treatment modality. Support groups can aid patients with OCD not feel so alone. An understanding of ADHD is also important. If you cannot find a therapist who specializes in both, consider working with both an OCD expert and an ADHD therapist or coach. Proper treatment can pave the way for a healthy, fulfilling life free of tormenting obsessions and time-consuming compulsions.
What should I do if someone I know may have both ADHD and OCD?
If someone you know is experiencing symptoms of both ADHD and OCD, it is important to validate their concerns and encourage treatment. Living a healthy life is possible.
References
Connect your loved one with support like the International OCD Foundation (IOCDF), Children and Adults with ADHD (CHADD), or Attention Deficit Disorder Association (ADDA).
