Challenges in treating OCD with co-occurring ADHD Jennifer Sy, PhD, Keith P. Klein, MA, Angela Smith, PhD, & Chad Brandt, PhD

Agenda Introductions Case examples Background Assessment Treatment planning Treatment modifications Adjunctive treatments Case examples If time allows we can discuss case examples from the audience!

Who we are Clinicians from the Houston OCD Program (HOP) Mild to extreme cases of OCD and anxiety disorders Treatment center offers three levels of care Residential treatment for adults (18+) Intensive Outpatient for adults and adolescents ~8 hours daily Outpatient treatment for children (4 and up), adolescents, and adults

Who are you?

What is OCD?

What is ADHD?

Comorbidity of OCD and ADHD Estimates suggest that 10-60% of those with OCD report clinically significant ADHD symptoms This observed co-occurrence is particularly interesting given: OCD causes people to avoid risk ADHD is often impulsive, which often increases risk Contrasting neurobiological underpinnings Preliminary results suggest that OCD and ADHD may co-segregate within families May be better explained by the Executive Overload Model of OCD

Assessment for OCD When assessing for OCD: Examine 1) obsessions, 2) compulsions, 3) their functional relationship, and 4) the level of distress caused by the disorder Structured interviews (e.g., ADIS-V) Self-report meaures (e.g., YBOCS; DOCS) Some symptoms of OCD can be confused for symptoms of ADHD and vice versa

Examples Inattention vs. Perfectionism/Perseveration Perfectionists might over-report attention deficits Inattention because of distraction by obsessions Superstitions affecting responses and accuracy

How to Assess for Differences Utilize objective measures of inattention/impulsivity and records Utilize behavioral observations Do intrusive thoughts trigger distress? Are rituals rigidly adhered to? Is forgetting due to doubting or genuine cognitive deficits that impede the retention of information? Is this individual prone to impulsivity, risk taking, and spontaneous decisions? Those with OCD are characterized by reduced impulsivity compared to non-psychiatric controls and lower behavioral impulsivity and risk taking compared to ADHD

Treatment Planning

Medication Considerations Many ADHD medications are stimulants which may increase anxiety Determine cost/benefit of low/no medication for ADHD Work with patient’s psychiatrist!

Treatment for OCD

Complications from ADHD Problem: Difficulty “staying in the exposure” Problem: Insufficient stimulation at “moderate” exposure difficulty Problem: Differentiating between distraction and effortful avoidance Problem: Staying on task in session

Difficulty Staying in Exposures Continuous engagement with exposure stimuli Focus on factors other than traditional within-trial habituation Create opportunity for expectancy violations through targeted questioning

Insufficient Stimulation Maintain attention by increasing difficulty: Engage in more challenging exposures Move up through ladder during exposure time Keep client fully engaged by adding sensory details to imaginal exposures or adding/repeating imaginal components to in vivo exposures Keep things interesting for client by incorporating play/game element into exposure

Differentiation Between Avoidance and Forgetting Refer to Neuropsych testing when available Assess for function of checking/question Use of memory aids when appropriate; assess to ensure that use is not becoming compulsive in nature (e.g., list-making, taking notes) Using reassurance cards and question cards One reassurance card referenced repeatedly

Staying On Task Combat treatment interfering behaviors linked to attention: Agenda setting Utilize delay tactics to minimize tangential triggers/disruptions Repeat questions Use cues to redirect clients (e.g., Darth Vader buzzer) Immediate rewards

Adjunctive Treatments- Mindfulness Mindfulness: Purposeful, present moment, non-judgmental focus of attention Empirical support across psychiatric disorders and for those in non-clinical samples Trait mindfulness varies across individuals; component of psychological flexibility

Adjunctive Treatments- Mindfulness Mechanisms Benefits Increased attentional control Improved attention Increased awareness Stress reduction Acceptance of present moment experience Improved mood Opportunity to make intentional choice about behavior

Adjunctive Treatments- Mindfulness Other positive findings: Low treatment drop-out rates High treatment satisfaction Mindfulness for those with OCD: Facilitates habituation Facilitates meta-cognitive change (i.e., thoughts are not facts) Increased awareness of urges and behavioral options

Adjunctive Treatments- Cognitive Control Trainings Mindfulness is associated with improved executive functioning Significant improvement in attention and hyperactivity/impulsivity Other neurobehavioral therapies have been designed to target underlying biological mechanisms Exercising prefrontal function in the context of ruminative thinking Use of working memory in the presence of frustration Examples: Attention Training Task; Paced Auditory Serial Addition Task (PASAT)

Adjunctive Treatments: Paced Auditory Serial Addition Task

Case Examples?