Podcast Transcript
ADHD and Obsessive-Compulsive Disorder (OCD)
Summary:
Obsessive-compulsive disorder (OCD) is characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental rituals (compulsions) performed to reduce anxiety. In this episode of the Pocket MD podcast, Roberto Olivardia, PhD, emphasizes that OCD is a serious, often debilitating condition that differs from simply being organized or perfectionistic. Diagnosis is based on a clinical evaluation, and the most effective treatment is exposure and response prevention (ERP) therapy, often combined with medication such as SSRIs.
This podcast also explores the relationship between ADHD and OCD, noting that the two conditions frequently occur together and can make each other more challenging to manage. Although ADHD and OCD both affect attention, ADHD involves difficulty regulating attention, while OCD causes attention to become stuck on perceived threats or intrusive thoughts. Treating both conditions together—including managing ADHD symptoms to support OCD treatment—leads to the best outcomes.
Max Wiznitzer, MD
Max Wiznitzer, MD, is a pediatric neurologist at Rainbow Babies & Children’s Hospital in Cleveland, Ohio. He is a professor of pediatrics and neurology at Case Western Reserve University. He has a longstanding interest in neurodevelopmental disabilities, especially ADHD and autism, and has been involved in local, state, and national committees and initiatives, including autism treatment research, Ohio autism service guidelines, autism screening, and early identification of developmental disabilities. He is on the editorial board of Lancet Neurology and the Journal of Child Neurology and lectures nationally and internationally about various neurodevelopmental disabilities. Dr. Wiznitzer serves on CHADD’s board of directors, professional advisory board, and the editorial advisory board for CHADD’s Attention magazine.
Roberto Olivardia, PhD
Roberto Olivardia, PhD, is a clinical psychologist, a lecturer in the department of psychiatry at Harvard Medical School, and clinical associate at McLean Hospital. He maintains a private practice in Lexington, Massachusetts, where he specializes in the treatment of ADHD and comorbid disorders, obsessive-compulsive disorder, body dysmorphic disorder, as well as issues that face students with learning disabilities. He is a nationally recognized expert in the research and treatment of males with eating disorders. He is coauthor of The Adonis Complex and currently serves on the professional advisory boards for Children and Adults with ADHD (CHADD) and the Attention Deficit Disorder Association (ADDA). He is also a member of the scientific advisory board for ADDitude and a featured expert for Understood. Dr. Olivardia presents at various conferences across the country, has appeared on various media outlets, and has lived experience as someone with ADHD.
Learning Objectives for this podcast:
- Describe the core features of obsessive-compulsive disorder, including the differences between obsessions and compulsions and how OCD affects daily functioning.
- Differentiate OCD from other conditions, including obsessive-compulsive personality disorder (OCPD), ADHD hyperfocus, and rumination associated with depression.
- Explain the relationship between ADHD and OCD, including how the two conditions can co-occur, overlap in symptoms, and influence one another.
- Identify evidence-based treatments for OCD, including exposure and response prevention (ERP), medication options, and the importance of treating both OCD and ADHD when they occur together.
Learning Objectives for CHADD Podcast Series PD4969:
- Identify ADHD symptoms throughout the lifespan to improve diagnosis and treatment precision.
- Describe common coexisting conditions in people with ADHD to enhance care strategies.
- Explain effective principles of ADHD medication management for better outcomes.
- Discuss the importance of integrating behavioral and other interventions in managing ADHD for comprehensive care.
- Describe the role of interprofessional collaboration in delivering effective ADHD treatment.
The following transcript has been edited for clarity.
Announcer: You are listening to Pocket MD: Training on ADHD in Children and Adults.
Dr. Max Wiznitzer: Welcome to Pocket MD from CHADD, the national advocacy group for ADHD. This is an ongoing series of podcasts providing information about ADHD and its associated disorders in order to further the education and knowledge base of those who manage this condition. I am Max Wiznitzer, a child neurologist at Rainbow Babies & Children's Hospital and co-chair of CHADD's professional advisory board. Today, we have the pleasure and honor of having Dr. Roberto Olivardia with us. Roberto, would you please introduce yourself to the listeners?
Dr. Roberto Olivardia: Sure. Thank you, Max. My name is Roberto Olivardia. I am a clinical psychologist and lecturer in the department of psychiatry at Harvard Medical School in Boston, Massachusetts.
I have a private practice where I treat patients of all ages for various things. I specialize in ADHD, obsessive-compulsive disorder, I have a specialty in working with boys and men with eating disorders and body image issues, and also see multiple patients with substance use disorders, depression, and anxiety disorders.
Dr. Max Wiznitzer: As well as ADHD in relationships.
Dr. Roberto Olivardia: Definitely. And I also serve on the CHADD professional advisory board.
Dr. Max Wiznitzer: Exactly. Exactly. Well, thank you for being here today. And the topic for today is basically obsessive-compulsive disorder, or OCD, and its association or relationship with ADHD.
Dr. Roberto Olivardia: Yes.
Dr. Max Wiznitzer: Roberto, what is OCD?
Dr. Roberto Olivardia: So, OCD is a disorder that is characterized by a collection of symptoms in two main categories, obsessions and compulsions. So, obsessions are intrusive thoughts that people will have that are distressing, very anxiety-provoking. These are not thoughts that people want to have. They're thoughts that feel like they are hijacking their attention, and they are often thoughts that, in a sense, attack a certain value system that the person might have.
To give you an example: If somebody obviously loves a family member, they might have an intrusive thought of harming that family member, and this is not someone who has an actual proclivity or desire to harm the person. That's what makes it so distressing. Someone could have an intrusive thought that if they touch a doorknob, they just communicated an incurable disease. They could have an intrusive thought that if they don't do certain kinds of things, then something bad will happen to them.
So, these obsessive thoughts are really tormenting, which can sound dramatic, but OCD is an incredibly tormenting condition for people. Now, the obsessive thoughts in and of themselves could warrant the diagnosis. Oftentimes, you'll see them coupled with compulsions, and compulsions are repetitive behaviors that people will engage in to neutralize the anxiety related to the obsessive thought. Now, sometimes it could be very related to the obsessive thought. The most common thing would be if somebody has obsessive thoughts of germs or disease, that they may wash their hands multiple times.
But most of the time, the compulsions are not really even in alignment with what the thoughts are. So, for example, someone could have an obsessive thought that if they hear the word cancer or think of the word cancer, that someone in their life will get cancer unless they perform a compulsion, and the compulsion could be to touch something seven times. The compulsion could be to say the Our Father prayer fifteen times in their head. The compulsion could be to blink their eyes a certain number of times. It could have literally nothing really even to do with the obsessive thought, but it's just meant to neutralize that anxiety. Keep in mind, most people with OCD are aware that the compulsions may seem irrational, but the fear is so strong that in their mind, they're like, "Well, what if? What if there's a possibility that my mother could die of breast cancer, and if all I need to do is just touch something seven times, then I should just do it." But the problem with OCD is, you give it an inch, it takes a mile—like very, very quickly—without treatment.
Dr. Max Wiznitzer: Are there differences in the presentation depending on age?
Dr. Roberto Olivardia: Typically, we would see there is childhood OCD; we also see an age of onset in late teens, young adulthood, and it can vary. A lot of times with childhood OCD, you'll see more things like contamination fears, you'll see more compulsive behaviors, [like] something bad is going to happen. The more what we call intrusive thoughts, which often take a more violent [direction] or sexual obsessions that people might have, we tend to see in older individuals. That’s not to say I don't see that in kids.
Now, when I'm talking about these obsessions, too, it's very important for people to understand these are not individuals who are at risk of committing violence. In fact, these are individuals who are the least likely to do that. So, there's a type of OCD, for example, called pedophilia OCD. I have a patient now I'm working with who has an intrusive thought that he will molest a child, that he has sexual desire for a child. Now, he doesn't actually have sexual desire for a child. He does not get sexually aroused with children, but he has an intrusive thought that he does, and then he's thinking, "Well, am I getting aroused? Oh my gosh, I might be getting aroused. I think I'm getting aroused." And I should also mention, too, with OCD, it could result in a lot of avoidant behaviors, and in this particular patient's case, he doesn't want to walk past a playground. He fears that he's going to kidnap a child and molest them. When he became a father, he did not want to change his child's diaper for fear that he would molest them. And if you can imagine, now, if you don't understand this type of OCD and you go to a therapist, a therapist might think, "Oh, is this a pedophile that is just aware of their sexual arousal?"
This is not the case with this kind of OCD. So, those thoughts can be really debilitating. But yes, it can start in childhood, and then we often will see those kinds of thoughts or more violent thoughts in adulthood. But OCD can come in many different forms. You have intrusive thoughts. You have contamination. There's something called scrupulosity, where people have thoughts about their morality, being immoral, the fear of going to hell, the fear that they're going to be damned in some way. There's something called magical thinking: "If I don't do this particular thing, then this bad thing will happen." There's what we call responsibility OCD, where people fear that they have to do certain compulsions. If they don't then they're responsible for this thing that they're actually not really responsible for. There's perfectionism, symmetry OCD, where people have to have things be very symmetrical or orderly, and not from an executive function perspective, but because that's the “right thing to do.” There's a type of OCD called just-right OCD, where even patients will say, "I don't know why I'm doing this, but it just feels just right." But that just-right feeling sometimes could be the seventh time that somebody does it or the thirtieth time. It's just completely random.
Dr. Max Wiznitzer: From what you're saying, it sounds like OCD clearly has a negative impact on functioning. This is different than things that people like to do, for instance, areas of fascination, areas of intense interest or major hobbies or things of that nature. Is that correct?
Dr. Roberto Olivardia: Oh, 100%. I mean, I cannot overstate it enough, because I think with OCD, too, it's one of those conditions that—and in the OCD community, they talk about this where it's used in this kind of like, "Oh, I'm so OCD. Like, I like to sanitize my hands after I use the bathroom." It's like: No, no; this is a serious psychiatric condition that can be incredibly debilitating for people. And keep in mind that when we look at the time spent per day of obsessing and compulsive behaviors, for the majority of people with OCD, it's four hours plus. For many of my patients, it's eight hours plus. I mean, their days are completely consumed. It takes up so much energy. It gets in the way of relationships, of their ability to work, of their ability to be students, to be successful individuals. It has a major, major impairment on many, many aspects of their life.
Dr. Max Wiznitzer: How is this diagnosed? Is it a clinical diagnosis? Are there blood tests? Are there imaging studies?
Dr. Roberto Olivardia: So, it's a clinical evaluation. There is an instrument called the Yale-Brown Obsessive-Compulsive Scale or the Y-BOCS, which is, I would say, the most reliable instrument in the sense that it asks, in getting a survey of all the different obsessive thoughts and compulsive behaviors, looking at the time spent, the desire to try to suppress the thought, avoidant behaviors, the time spent in the compulsive behaviors, and really sort of teasing out the difference between is this an obsessive thought? Because an obsessive thought also is one in which when someone has this thought, it often compels them to do something. Like they feel, again, responsible for something—which is very different than a rumination. A rumination, for example, we would see is common in depression, where people might ruminate maybe about this thing that they did in the past that they feel guilty about, or they just ruminate that they feel like worthless individuals. That's a very different thing. It's not an obsession. It doesn't compel them to do something. It's almost like I think of a rumination as someone just marinating in self-loathing or something that they feel very guilty or shameful about. That's a very different thing.
Or a hyperfocus, in what we would see with ADHD, with individuals who might be "obsessed about something," but that is not an OCD thought. That could be they're super-fixated on something that's delivering a high reward or sense of stimulation, a hobby or something that maybe they're diving into, or in autism spectrum [disorder], where people have very fixated interest in things that they're engaging in. That's a very different thing. So, the word obsess is used in so many different ways that it's very important, clinically, that even when I have patients that say, "Oh, I'm so obsessed with X, Y, and Z," to differentiate, okay, is this an OCD obsession or is this a rumination? Is this a hyperfocus?
So, it's mainly a clinical evaluation. Although we know there are neurological studies that sort of implicate different parts of the brain, but it wouldn't be diagnosed from neurological data. It'd be diagnosed through a clinical evaluation.
Dr. Max Wiznitzer: Well, thank you. Now, how does this differ from obsessive-compulsive personality?
Dr. Roberto Olivardia: OCPD, or obsessive-compulsive personality disorder, is actually quite different from OCD. Most people with obsessive-compulsive disorder do not have obsessive-compulsive personality disorder and vice versa. I mean, there is a comorbidity, but the majority of one you do not see in the other. A lot of times people with OCPD might be labeled as having OCD. So, obsessive-compulsive personality disorder is marked by an individual who often is very, very rigid about the way that they do things, and has a very strict sort of order. But unlike OCD, which is ego dystonic—and what is meant by that is someone who is distressed by the symptoms, they do not want these symptoms. OCPD is ego syntonic,
so people with OCPD often don't have a problem with the symptoms, it's the people around them that are reacting to their rigidity and their inflexibility. People with OCPD often have narcissistic traits, so their stance is, "My way is the best way, and everyone should be doing it the way I do it."
They often tend to be individuals that really highly value efficiency but are not always efficient. So, they might have a system of doing something and a coworker could say, "Oh, there's a quicker way to do that," and the person with OCPD has a very, very hard time ungluing themselves from the way they do things, even if it's less efficient in that way. They tend to be individuals who are very frugal, often seen sometimes as miserly, and it's what's been called in the past the anal-retentive personality. These are individuals in whom their emotional processing tends to be very low; they have low emotional insight. They're very almost cut off in some ways from emotion, so you don't see a very high degree of empathy in people with OCPD. But they're not engaging in repetitive compulsive behaviors. They do have a very specific way that they do things, but it's not even a way, unlike with ADHD—as someone with ADHD, I have a very specific way of how I do something because executively it works for me.
With OCPD, sometimes people engage in things that just really don't work for them, but for them to admit, "Oh, there's a better way of doing something," would basically say that the way they were doing it before was not the best way, and they tend to be individuals who are highly perfectionistic.
But again, the distinguishing feature is—I've never had someone come to treatment saying, "I have OCPD, I want help with that"—they might come into treatment because they were fired from job after job because they couldn't collaborate with people, or they're in their second divorce because their spouse is like, "This person doesn't know how to be flexible in ways." And then when I diagnose the OCPD, we talk about it. It's a very different thing than with OCD.
Dr. Max Wiznitzer: Well, thank you. Now, we have a diagnosis of OCD. What do we do about it? How do we intervene?
Dr. Roberto Olivardia: The thing I love about treatment of OCD—and I did my training at McLean Hospital, which is a very renowned psychiatric hospital in the Boston area, and they have, I would say, the world's leading residential program in obsessive-compulsive disorder, and I was very fortunate to have trained there—the hallmark treatment for OCD, and this will sound odd to even clinicians who don't do behavioral therapy, the gold standard treatment is something called vexposure plus response prevention or ERP. Because with OCD, we know because there are compulsive behaviors, avoidant behaviors, and it doesn't respond to cognitive therapy, at least initially. Because honestly, again, many of my patients with OCD have insight to know that what they're doing is irrational, but they still feel compelled to do them. So, to talk someone out of it, to say, "No, you're not going to get AIDS by touching a doorknob," they might get it, but OCD rests on the idea of possibility, not probability: “So, is it possible I could?” And that's all it takes for OCD to take off.
So, the only way for the obsessive or intrusive thought to have no credibility is that you kind of have to go through the thing, expose yourself to the situation without trying to push it off, without avoidance. And what's going to happen is that your cortisol and adrenaline [levels] are going to rise up, but they will come down.
So, to give you an example, the first patient I ever worked with, who had OCD, while I was in grad school at the OCD Institute, she had what's been calleda "hit-and-run OCD." Now, imagine how debilitating this is. She would drive to work, and any bump that she would feel, as we all feel bumps on a highway or whatnot, she would have an intrusive thought of, "Did I—could I have just killed somebody? Oh my gosh, I might have killed somebody." And keeping in mind, too, and it's important, Max, for people to understand, OCD almost capitalizes, again, on people's value system.
Now, I don't live with OCD on a daily basis, but I have had full-blown episodes in my life, and one of them was when I started to drive, I would have these intrusive thoughts of, "Am I going to turn my car and going to hit and kill people with my car? Is my hand moving?" And I am somebody who grew up in a family where our values were so instilled in us to not only not cause harm to other people, but to elevate other people. So, it's not a coincidence that the OCD took its form in the idea that I could harm people in the worst possible way.
So, this woman, similarly, a very kind person, did not want to cause these intrusive thoughts of, "I could have hit someone." She had to stop her car, pull over on the highway, check her car. “Nope, nobody was killed.” Keep driving, and then she'd get another intrusive thought. “Maybe I hit them, and they rolled over to the ditch, and I didn't check the ditch.” Have to get off at the next exit, circle back to where she was, check the ditch. “Nope, nobody was there.” Continue driving to work. Have another intrusive thought. “Maybe somebody found that body, and they brought them to a local hospital.” Would have to call every local hospital. I mean, she'd never get to work.
So, the treatment—and of course, medication is helpful (like SSRIs), but that's a necessary part for people, but not sufficient--was they said, "Okay, Roberto, you're going to take her in your car, and you're going to drive around the town, go around bumps, go around, and she's going to say, “Oh my gosh, I think we killed somebody. Did we kill somebody?” And I have to say, “Maybe we did, maybe we didn't.” And I was like, “What?” I came from a more psychodynamically oriented program. I'm like, “That just sounds so sadistic.” But this is a feature of OCD. People with OCD will ask for a lot of reassurance. And for families, I mean, how do you not want to reassure your child who's being tortured by these thoughts?
Like, “Honey, you're not going to kill anyone. You can use a knife. You're not going to stab mom in the neck. You love mom.” But that doesn't do it, it doesn't help at all. So, I understood, like, no, I can't reassure her, because what's going to happen when she's driving in the car by herself? It's just going to keep happening.
So, the thing with OCD also is not even—this might sound strange to people, the thought that she killed somebody is obviously a terrible thought—but the almost more anxiety-provoking piece of it is the uncertainty. The uncertainty of did I or didn't I? Did I get a disease or not? During COVID, during the pandemic, I got asked this a lot, because I work with a lot of OCD patients.
“Oh my gosh, did you see this total uptick of OCD symptoms during the pandemic?” This is what's interesting, Max. With my OCD patients, when they got COVID, their anxiety totally reduced because, okay, they have COVID. It's there. It's not this uncertainty. It's not this thing that they're trying to prevent. It's there.
And that's the irony of it, that even if, let's say with contamination OCD, if somebody gets the flu or gets sick, their OCD symptoms actually reduce, because there's no uncertainty around it. So, needless to say, I would say to this woman, “Maybe we did, maybe we didn't,” and her anxiety would go through the roof.
But the goal with ERP is not to distract yourself. So, it's not, “Oh, we're going to put on music to have you not think of the thoughts.” It's to actually be in the thought in the uncertainty, I could have killed somebody, and I'm driving and sit because the truth is, what goes up will come down. If we sit with that anxiety long enough and don't try to push it off, our brains then reframe that as, “Oh, well, this can't be that dangerous if we're sitting with it.”
Phobias work the same way. If you have a phobia for cats, let's say, and then eventually you have a cat on your lap, which is, the treatment is similar, and it's sitting on your lap for an hour, your brain now knows, well, this clearly cannot be threatening because you would not have this sitting on your lap for an hour if it was that threatening.
So, we did this, Max, three to four hours a day, five days a week. I mean, this is the hallmark of this program. But this is what I saw: That was miraculous. [On the] fifth day, we're driving, and I'm not even kidding, she was filing her nails and she goes, “Oh my gosh, I just had the thought that we hit and killed someone.” But she said it in this matter-of-fact way, whereas day one, it was like the physiology, the effect of like, “Oh my gosh, oh my gosh.” And she would still have the thought, but the physiology, it was just massively reduced, which then enabled—and this is where the cognitive therapy part can start to take some traction—where her thoughts were like, “Yeah, I'm having the thought, but nothing in my body is resonating with that thought, so we probably didn't kill somebody.” So that's just where we got in five days. And then over time, it got to a place of, “No, I didn't.” Or, “I still don't have certainty, but I can resolve the fact that because there isn't enough evidence, I'm okay with it.”
As a clinician, it's very interesting work to do, because I've had patients who have harmful thoughts that they're going to stab a family member, so they don't use utensils. And the ERP could be they're in session with me and they have a knife to my throat while we're just talking for fifty minutes. And that might seem really strange to people, but to that person, because some—I had a patient whose intrusive thought was that they were going to harm me, and they have a knife to my throat for fifty minutes and nothing's happening. Over time, it starts to dispel the credibility of that obsessive thought. So, ERP is the gold standard and often coupled with medication.
Dr. Max Wiznitzer: If I may summarize ERP, ERP's goal is to turn a mountain into a molehill.
Dr. Roberto Olivardia: Absolutely. Absolutely.
Dr. Max Wiznitzer: And if I can also summarize it, while medication can reduce the intensity of the OCD, it does not teach people how to manage and handle the OCD. So, even if you have an improvement on medication, you still need to learn, again, to turn it from a mountain into a molehill, and using the ERP in order to do that. Well, that's good news for the majority of people who do benefit from these kinds of interventions. Now, how is OCD related to ADHD? What are their similarities? What are their differences?
Dr. Roberto Olivardia: So, I haven't seen studies that have looked at populations of ADHD individuals to see what percentage have OCD, but there have been a number of studies of OCD samples and populations to assess for ADHD, many from a colleague of mine here in Boston, Dr. Dan Geller at Mass General Hospital. Studies show that about thirty percent of people with OCD also have ADHD, which may surprise people because they're sometimes conceptualized as almost opposite disorders, and some of that is based, again, on these stereotypes. Not everyone with OCD is neat and clean, for example, because again, people might confuse the OCPD with the OCD, but OCD has different manifestations[and] it's more prevalent than people think. And in a lot of ways, when I think of both of these conditions, we think of them as almost like a spectrum of when we think about regulation of attention. So, with ADHD, we see this attention dysregulation, where unless somebody's super-stimulated or rewarded or there's some sense of urgency, it can be really hard to pay attention to things that they might “need to pay attention to.”
With OCD, the attentional issue is one in which what is regarded as a threat is getting way too much attention to the exclusion of everything else. So, I think of ADHD as we're oriented attentionally to what is going to stimulate us, and with OCD, the person is oriented to what is the threat here, and everything else falls away. So, for the person with OCD, let's say [someone] who's in a high school biology class. I had a patient—his happened two years ago—where anytime they would hear the word cancer, they would have an intrusive thought that someone in their family is going to get cancer unless they did compulsions. So, imagine being in a biology class where that word is going to pop up a lot. Now, they're not paying attention to what's going on, but not because they have ADHD, but because their obsessive thoughts are being triggered. Now, because there's a comorbidity—I have many patients who have both, and I have to say, what's interesting is, and this is even with young people I work with—[they] are actually quite good at discerning what is an obsessive thought that's getting in the way of their attention and what is an ADHD sort-of moment that's getting in the way of their attention.
I remember this [being] described [by] this young boy I was working with years ago, who was in a [history] class. And he said, “Yeah, beginning of the class, the teacher mentioned something about war, and I had this OCD thought that something bad, like our country would be attacked in war. unless I did these ten things.” And he wrote these ten random things that he needed to do during the day to prevent a war. I mean, imagine just the weight of that responsibility of a ten-year-old thinking that they're responsible for that. And he goes, “And fifteen minutes later, my attention was all over the place, but because of ADHD reason, I was just bored.”
But what happens is when people have both OCD and ADHD (and this is always the foundation of every time I talk about comorbidity), when ADHD is not treated it will undermine and/or exacerbate the treatment or exacerbate the symptoms of any comorbid disorder. So, when he was bored and his brain was looking for something to attach to, unfortunately the OCD was right there to attach to it. But he was able to say, because I always say, “Who's driving the bus? Is it the OCD? Is it the ADHD?” And he goes, “That was the ADHD driving the bus and it delivered me,” he said, “to the OCD.” And then when the war example, he goes, “That was the OCD driving the bus, totally.” And interestingly, neurological research on looking at what parts of the brain are either hyperactivated or hypoactivated (not activated enough), it's pretty similar parts of the brain for OCD and ADHD, except with OCD you see too much activation, and with ADHD you don't see enough activation.
And that could be in various parts, like the thalamus, which is part of the brain implicated in alertness and arousal. You see an overactivation with OCD, often underactivation with ADHD. The anterior cingulate cortex, which is often implicated in emotional regulation, you see a delayed or underactivation with ADHD and too much with OCD, meaning that the person is almost trying so hard and almost overthinking things and their feelings and their emotions. The parts of the brain implicated in decision-making, you see with ADHD don't get enough juice: with OCD, you're getting too much. And again, if we're almost overthinking a decision, now we're caught in this conundrum, in this loop where we're trying to almost make the perfect decision that immunizes us, in a sense, from any kind of stress or anxiety.
And that's the piece with OCD, is [that] a lot of people are really trying to find a way to immunize themselves from anything that feels anxiety-provoking for them.
So, it's very important especially because in OCD and ADHD, a lot of symptoms can mimic the other to when a clinician, and most of my practice are people with ADHD with comorbidities, is to tease out, okay, this is OCD versus, oh, this is ADHD, and for people who have both, it's okay, let's try to tease out what symptoms are part of the ADHD, what symptoms are part of the OCD.
Perfectionism is a good example. I recently had a patient I was working with who was diagnosed with an OCD perfectionism, and it really wasn't an OCD. An OCD perfectionism is someone whose need to do something a certain way is not serving them well. It's actually inefficient. It's not moving them forward, versus this was someone who was overcompensating for ADHD symptoms. When this person was young, they did make a lot of careless errors. They did forget to carry the one or put a negative sign in front of the number, which I used to do all the time. Their handwriting was, they were dysgraphic when they were young, so it was drilled in them, “Double-check, triple-check. You make so many careless errors.” And that was slowing them down, but that wasn't coming from a, a moral, “I have to be perfect and just right.” It was, “No, if I'm not careful, I am the person that could leave the stove on and leave the house. So, I have to check because of ADHD,” kind of reason. So, that's the thing with OCD. When I ask patients who, let's say, have checking behaviors, I'll say, “Have you ever left the stove on?” And the answer is always, “No, that's never happened.” “Have you ever left the house without locking the door?” “No, that's never happened.”
With my ADHD patients, “Have you ever done that?” They'll say, “Yes, not only have I done that, but I left the stove on, and it boiled, and it burnt the linoleum on my kitchen floor, and I literally almost set my house on fire.” Well, then that checking behavior is coming from a different place. Now, certainly, it can morph sometimes into sort of more obsessive-compulsive sort of symptoms, but that's so important to tease apart, like the story behind the symptom.
Dr. Max Wiznitzer: Well, can any of the ADHD medications negatively impact OCD?
Dr. Roberto Olivardia: No. So, this is the good thing: the psychopharmacological interventions are not contraindicated. I have many patients with OCD and ADHD who take both an SSRI and [can] also be on a stimulant. The SSRIs are the frontline treatment for OCD; In particular, there are SSRIs that have more anti-obsessional properties to them, even though they're antidepressants, but they have anti-anxiety components. Now, this is the thing though, however, is there are some patients, I would say probably thirty percent if I think clinically, with OCD who also have ADHD, who when they take a stimulant, unfortunately it has them think and focus more on their obsessive thought, which we don't want to happen.
For those individuals, if they do want a medication for their ADHD, a nonstimulant would be more indicated. However, it's interesting that the perception, even among many psychiatrists who may not be experts in ADHD, is that [people] assume that it's immediately contraindicated, and that's not true. The majority of my patients who have both can take a stimulant, and the stimulant helps them regulate and focus on what they want to focus on, which means indirectly it's helping the OCD, because it almost like tightens their attentional zone in such a way that the OCD doesn't creep in as much.
Again, it's not a direct treatment for the OCD, but they find that it increases the threshold of which the OCD might present itself. So, you can be on both of those medications. And as you know, Max, with stimulant medication, it's very trial-friendly. You don't need to be on it for three weeks. You can be on it for a day or two and see what it does. And with my patients with OCD, they'll know, “Oh yeah, I'm just more into my obsessive thoughts.” But just because one stimulant does that doesn't mean all of them will. And I've had patients with both for whom it could [take] three or four different trials of different stimulants, and then they find one that helps the OCD and does not worsen the OCD. And then I have had some patients, they've tried six, seven stimulants, and they have to be on a nonstimulant.
Dr. Max Wiznitzer: Well, to summarize, what you're saying is that getting the ADHD under control can clearly help the OCD.
Dr. Roberto Olivardia: Oh, 100%.
Dr. Max Wiznitzer: And getting the OCD under control can help the ADHD.
Dr. Roberto Olivardia: Absolutely. Absolutely.
Dr. Max Wiznitzer: And what closing thoughts do you have for our listeners?
Dr. Roberto Olivardia: I would say just on that note, I always say with comorbidities—especially with something like ADHD, which is still I don't think as clinically appreciated from the idea of how much impact it can really have—I always say it's one plus one equals five. Meaning that when people, and studies have shown this with ADHD and OCD, when people have both the age of onset of the OCD tends to be earlier. The symptoms tend to be more severe in both conditions, unless, again, they're getting adequately treated. So, the whole becomes greater than the sum of its parts, and that's why it's so important to make sure both conditions are being treated.
And with ADHD, particularly, because it's not a mental illness it's a neurodevelopmental disorder, a neurodiverse condition that, in a lot of clinical spaces, there's this implication that, oh, we'll treat the OCD first and then we'll deal with the ADHD. And I'm, like, the ADHD is dealing with you whether you like it or not. So, we have to treat the ADHD because it will undermine. To have my patients do ERP work and have their ADHD not be managed is almost impossible to do. They're not focused on it. They're not going to be following through. It takes a certain level of executive function to do behavioral kind of work.
So, definitely treating both conditions, but to also know both of them are treatable. And although OCD can be incredibly debilitating and tormenting, the treatment also has very high success rates. ADHD can really get in the way of people's lives, and when properly treated, medication and skills can really get a lot of those symptoms in order.
So, these are treatable conditions, and I highly recommend for people to just get more information and seek information and community. And with ADHD, of course, we have CHADD. With OCD, there's a wonderful organization called the International OCD Foundation, and their website has everything you want to know about OCD.
They have a conference every July that is wonderful, and we of course have our conference, and this year it's going to be in December in Baltimore. That's very important, too, because when you have community, there's more understanding, more validation, less stigma, and more engagement in treatment.
Dr. Max Wiznitzer: Well, thank you, Roberto, for an expert discussion about OCD and its association and relationship with ADHD. Our speaker today was Roberto Olivardia, who clearly has lots of expertise in this. He's a clinical psychologist in the Boston area. I'm Max Wiznitzer, your host for today's Pocket MD podcast from CHADD. Thank you all for listening.
Announcer: Pocket MD is brought to you by CHADD with funding from the US Centers for Disease Control and Prevention, and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.