Obsessive Compulsive Disorder (OCD)

The Truth About Obsessive-Compulsive Disorder

OCD is largely misunderstood and commonly difficult to manage. Symptom control is only possible with a thorough understanding of symptoms and their manifestations. So start here by delving into OCD and its link to ADHD.

Understanding OCD: The Symptom Overlap with ADHD

Obsessive-Compulsive Disorder (OCD) is a tormenting mental illness that affects approximately 1 in 100, or 3 million, adults, and 1 in 200, or 500,000, children and adolescents. People with OCD and ADHD have their hands full managing both.

The ABCs of OCD

OCD is characterized by obsessions and/or compulsions. Obsessions are persistent thoughts, impulses, or images that are intrusive and cause distress and anxiety. Worries about real-life problems are not the same as obsessions. People with OCD try to ignore the obsessions or neutralize them with some thought or action. Even though logic says that the obsession is irrational, it is hard to ignore it.

Common obsessions include contamination (fear of contracting a disease), harm (fear of being responsible for something bad happening to a loved one), perfectionism (a need to have everything symmetrical, “just right,” or ideal), scrupulosity or religious obsessions (fear of offending God), and intrusive sexual or violent thoughts.

Compulsions are repetitive physical behaviors (such as hand washing or praying) or mental acts (such as saying words silently, counting, creating images) that a person feels compelled to do in order to undo or cope with the obsession. The compulsion may have nothing to do with the obsession.

Common compulsions include checking (calling a family member to make sure your thought of them being harmed did not actually harm them), washing and cleaning, mental rituals (counting, praying, reviewing every moment of the day to ensure that you did not commit an offensive act), and avoidance (refusing to go into your child’s school for fear that you will be exposed to germs).

Like ADHD, OCD has a strong genetic component and tends to run in families. Although some with OCD may not have a family member with OCD, they will likely have a family member with a disorder on the OCD spectrum: an eating disorder, body dysmorphic disorder, social anxiety disorder, trichotillomania (compulsive hair pulling), dermatillomania (skin picking disorder), panic disorder, hypochondriasis, hoarding, Tourette’s disorder, or Autism spectrum Disorders. OCD has a strong biological basis. Studies have found chemical imbalances in the neurotransmitter serotonin to be associated with OCD. A large body of research has suggested that the basal ganglia and the frontal lobes of the brain don’t function correctly in OCD patients, leading to rigid, obsessive thoughts and repetitive movements.

The age of onset for OCD typically falls within two age ranges: The first is between the ages of 10-12, the other is late teens into early adulthood.

OCD symptoms interfere with a person’s social, academic, occupational, and overall life functioning. The exhausting battle with OCD leads to low self-esteem, mood disorders, substance abuse problems, relationship problems, school failure, and job problems.

OCD, EFs, and ADHD

It is unclear how many people with ADHD 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.

At first glance, ADHD and OCD may seem to be opposite clinical conditions. Those with ADHD are characterized as being spontaneous, impulsive, and oriented toward pleasure and stimulation. People with OCD are typically methodical, compulsive (thinking too much before acting), and oriented toward avoiding anything that can generate anxiety.

However, if the two disorders are considered in terms of executive functioning, it is clear that people with OCD have certain attention and executive functioning deficits similar to those who have ADHD.

  • People with OCD have a selective attention problem. They pay too much attention to something they regard as a threat.
  • They find it hard to move away from certain stimuli, and they are unable to filter out irrelevant data, lest they miss something that could bring a negative consequence.
  • Prioritizing can be challenging. A student with perfectionism frantically writes down everything the professor says in class. To the student, not writing everything down may mean that he will fail the class. However, this can lead to the student missing the bigger picture.
  • People with OCD are unable to filter out obsessive thoughts, which are a distraction from tasks.
  • People with OCD have been shown to have cognitive deficits in visual memory tasks, when they focus on a small detail and can’t remember the bigger issue.

Studies have demonstrated that having both OCD and ADHD is associated with more attentional, social, academic, and family problems than is having either alone. The age of onset for OCD is earlier in those who also have ADHD.

Treating OCD

Two interventions have been demonstrated by numerous studies to be effective in treating OCD. The first is cognitive behavioral therapy (CBT), specifically Exposure Response Prevention therapy (ERP). The other is medication. The cognitive part of CBT focuses on targeting negative thoughts, identifying distortions, and reframing the thoughts in an accurate light.

The most essential treatment for OCD is ERP. This involves confronting the thought, image, object, or situation that makes a person with OCD anxious. ERP also includes confronting an exaggerated symptom of the OCD. If someone avoids touching doorknobs, due to fear of contamination, an ERP therapist would have the person put his hands on the toilet seat in a public bathroom for 15 minutes.

The response prevention refers to making a choice not to do a compulsive behavior after the exposure. No washing hands for at least an hour after touching the toilet seat. No mental rituals to undo the offensive thought. ERP works on the notion that what goes up must come down. The purpose is to raise one’s level of anxiety, and engage it, without avoidance, until the body eventually tolerates it.

Medication is highly effective for treating OCD symptoms. The most common class of effective medications is antidepressants, known as Selective Serotonin Reuptake Inhibitors (SSRIs). They include fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and paroxetine (Paxil). These medications boost serotonin levels in the brain.

OCD medications do not make ADHD symptoms worse. However, ADHD stimulant medication can sometimes make OCD worse. Patients with ADHD and OCD sometimes find that stimulants make it difficult to focus on anything but their obsessions. For others, stimulants may positively affect OCD, or they may have no effect on OCD symptoms. Psychotherapy is also helpful in facing the challenges related to OCD, such as shame and low self-esteem. Couples or family therapy is also recommended.

Working with specialists in ADHD and OCD is essential. Not all therapists are trained in CBT or ERP. If you have OCD, your therapist should have experience in this treatment. Proper treatment can pave the way for a fulfilling life free of tormenting obsessions and compulsions.

It is important to properly diagnose symptoms when someone struggles with OCD, ADHD, or both.

When people have both, one disorder is usually missed. Here are common ways ADHD or OCD can be under-diagnosed or confused with one another:

1. ADHD is under-diagnosed in adult OCD populations, due to the lack of recognition of ADHD in adults.

2. It is a common perception that all those with ADHD experience academic failure, when many with ADHD perform adequately in school settings. Patients who have both OCD and ADHD report that their ADHD made school hard, but the OCD symptoms disguised their struggle by creating severe anxiety around failure.

3. Inattentive ADHD is under-diagnosed, so the lack of hyperactive symptoms can result in ADHD not showing up on the radar of people who have both OCD and ADHD.

4. Sometimes symptoms of ADHD and OCD intertwine or mimic each other. A patient with both ADHD and OCD had to clean his room meticulously before writing a paper, stating that he would be too distracted if there were any clutter or mess in his room. Although the cleaning behavior might be seen as OCD, it was more related to his ADHD. When he does not have to write a paper, he is fine with a messy room.

5. Another common misinterpretation is the confusion between ADHD-related specificity and OCD-related perfection- ism. A person may be wedded to a certain pen for writing, or wearing certain kinds of clothes to class. All of this is to create the optimal environment for focus.

In addition, many ADHDers are sensitive to certain textures, clothing, or sounds. This can be incorrectly diagnosed as Perfectionism OCD, which is different. Perfectionism OCD is more about a desire to achieve a “moral right.” If one fails to achieve perfection, the per- son is immoral or bad and feels devalued. Sometimes it is difficult to articulate why one needs things to be perfect. Patients with OCD often seek the “just right” feeling, which is less about a sensory experience. One can wash their hands 30 times and get the “just right” feeling on the 30th wash, even though the sensory experience is identical in all 30 washes.

6. The hyperfocus seen in people with ADHD and the overfocus seen in OCD may be confused with each other. Hyperfocus is an intense level of attention when people with ADHD feel productive and fluid. This is markedly different from being overfocused, which leaves one paralyzed and stuck.

7. OCD can be missed in ADHD populations due to misconceptions about OCD. A common misconception is that all people with OCD are neat and highly organized. Being messy does not exclude an OCD diagnosis, since there are many manifestations of OCD.