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

2. 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!

3. 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

4. Who are you?

5. What is OCD?

8. What is ADHD?

10. 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

11. 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

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

13. 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

14. Treatment Planning

15. 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!

16. Treatment for OCD

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. Adjunctive Treatments: Paced Auditory Serial Addition Task

27. Case Examples?