Is it OCD? ADHD? Or Both?

By Jordan Mayfield, LSCSW, LCSW, LCAC

  In recent years there has been a lot of new information regarding the comorbidity of Autism (ASD) and Attention Deficit Disorder (ADHD) sometimes referred to as AuDHD. Another lesser-known neurodivergent combination is ADHD and Obsessive Compulsive Disorder (OCD). Like AuDHD, the OCD/ADHD combo has a lot of symptom overlap and can be hard to differentiate. Additionally, OCD or OCD-like symptoms can manifest as a masking attempt by the ADHD person to manage their symptoms more effectively.

ADHD is a neurodevelopmental disorder that affects the development and functioning of the brain and central nervous system. It can be best understood as an executive functioning disorder. It impacts a variety of different areas including response suppression or impulsivity, distractibility, the ability to return attention once side-tracked, impaired organization, planning and problem-solving, motor coordination deficits, time-blindness, hyperactivity, and self-regulation problems. It is a disorder that can be treated with medication and behavioral accommodations, but not cured (Russell Barkley, Ph.D.).

While OCD is not technically classified as a neurodevelopmental disorder, brain imaging and clinical observation suggest that there are neurodevelopmental origins. Obsessions are recurrent and persistent thoughts, images, impulses, sounds or psychosomatic symptoms that are experienced as intrusive. The OCD individual does not want these obsessions, they are often not consistent with the person’s values, and they create anxiety and distress in the individual. Compulsions are repetitive behaviors, either internally or externally the individual feels compelled to perform to diffuse or reduce the distress prompted by the obsessions. Internal compulsions could include checking, mental reviewing, counting, self-reassurance, or even avoidance (Roberto Olivardia, Ph.D.).

At first glance, a practitioner or layperson might consider these disorders opposites to one another, however current research shows the comorbidity rate is close to 30%. OCD and ADHD enhance the symptoms of each other, and OCD generally has an earlier onset when ADHD is also present.  OCD also significantly impacts executive functioning including working memory issues, a deficit in filtering out relevant data, selective attention, impaired inhibition, and decision-making problems (Roberto Olivardia, Ph.D.).

Body Focused Repetitive Behaviors (BFRBs, OCD and ADHD)

While BFRBs and OCD are distinctly different conditions there are overlaps. Both include participating in repetitive behaviors, generally to relieve distress or anxiety. Like compulsions, BFRBs are challenging to control and usually triggered by stress and anxiety. However, BFRBs are usually done “mindlessly” or if intentional are not done in response to fear.  Compulsions are done as a response to an obsession and usually to prevent negative consequences, often promoted by a sense of fear and urgency. As a result, treatment approaches differ. BFRBs can often show up in ADHD individuals because of sensory needs and the preference for certain stimuli. ADHD individuals also can find BFRBs satisfying because the behavior may be goal-oriented and provide dopamine (such as popping blemishes). Nail biting, hair twirling, or lip picking, etc. can all serve as a sensory distraction, relieve anxiety, or a fidget for focus in the ADHD individual (The TLC Foundation).

Distraction

Both OCD and ADHD often present with high levels of distraction. This is because both disorders often cause both internal and external distraction. The OCD individual may appear disinterested in what their partner is telling them because they are caught up in obsessions in their mind. Similarly, an ADHD person may also appear disinterested because they have a vivid internal world they are focusing on instead. Obsessions and compulsions are usually extremely time consuming and therefore a person can be late, disengaged, make unintended errors or mistakes or present with other hallmark ADHD symptoms. An ADHD individual might also be late or disengaged because they are hyper focusing on something. The main difference is the hyper focusing of the ADHD individual is due to interest, not fear (International OCD Foundation).

Compulsivity and Impulsivity

Compulsivity associated with OCD, as stated above is done as a response to an obsession, to alleviate anxiety, and typically feels urgent. Impulsivity associated with ADHD is when the person acts without thinking but is driven by instant gratification. Impulsivity is usually driven by a logical purpose i.e. “that looks like it tastes good so I’m going to eat it.”  Compulsive behavior usually serves no logical purpose and can be accompanied by magical thinking. Similarities are that both behaviors may not be understood by those surrounding the individual. And both often lead to feelings of shame within the individual (Lakeside-Milam).

Masking

Both ADHD and OCD individuals “mask” or behave in ways that take energy and effort to hide or mitigate their symptoms, particularly in social environments. If a person has an ADHD/OCD combination, some masking efforts can turn compulsive. These can be even more challenging to treat because there is evidence to support their effectiveness and need for the individual and they can be value driven. An ADHD person may struggle with remembering their keys. As a result, they check their belongings for their keys before they leave. However, if the person has a history of repeatedly misplacing their keys the urgency and fear associated with checking may increase. For the ADHD/OCDers this could turn into compulsive checking. Other common masking behaviors that can turn compulsive might be list making, list checking, calendaring, reviewing/re-reading e-mails or texts, replaying conversations, checking locks, or reassurance seeking through reminders.

There is a subset of data in the field that suggests that having both disorders is literally impossible because the symptoms contradict each other. For instance, ADHD individuals are more inclined to be risk taking while OCD individuals are often risk averse. ADHD is known as more of an externalizing disorder where the person is responding to their external environment while OCD is an internalizing disorder. However, like most mental health diagnoses we are starting to understand that things are just not so black and white. Compulsivity and impulsivity, for example are on a continuum and a person can experience both. If you have a busy mind because of ADHD that focuses on distressing things, over and over as a result of OCD it may feel like agony.  Find a practitioner that understands both. Because unfortunately, some OCD interventions will not work for ADHD and vice versa. This co-morbidity is real. It is treatable. And help is closer than you think.