Do you need to fidget, or is it that you have to move your hands in a particular way?
Are you unable to focus, or could something else be going on in the background—like a cycle of obsessive thoughts that’s stealing your time and attention?
Are you forgetful—misplacing your keys, forgetting that your sunglasses are on top of your head—or could your absentmindedness be a signal of a bigger mental health issue?
If you’ve ever wondered about these things, you may already know that attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) share some characteristics.
There’s also—news alert—a chance that you could have both conditions. Research suggests that around 12% of people with OCD are also diagnosed with ADHD.
What you should know is that these conditions aren’t uncommon. And they are manageable. The first step, though, is getting the right diagnosis.
So we spoke with Patrick McGrath, PhD, psychologist and Chief Clinical Officer, and Tracie Ibrahim, LMFT, CST, and Chief Compliance Officer. They are two experts here at NOCD, the leading telehealth provider of OCD treatment. Their insights provide a nuanced take on OCD and ADHD, how they can be related, whether you can have both, what the treatments are, and more.
“I’ve worked with people who at first didn’t know what condition they had—all they knew was that they were preoccupied with something that caused them a lot of distress. They didn’t know how to stop being hyper fixated or obsessed,” says Dr. McGrath. “What I want people to know, if they relate to this, is that they aren’t alone, and it’s normal to need expert guidance—especially when it comes to diagnosing a mental health condition.”
What I want people to know, if they relate to this, is that they aren’t alone, and it’s normal to need expert guidance.
Dr. Patrick McGrath
What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is a mental health condition that affects around 1 in 10 children and 1 in 20 adults. ADHD can involve a pattern of hyperactivity and impulsivity, a persistent struggle to focus, or both. In any case, the symptoms can interfere with your daily life and functioning.
Some signs that you might have ADHD include:
- Being easily distracted
- Being forgetful
- Having trouble staying organized
- Regularly failing to complete chores, schoolwork, or workplace duties
- Often losing things
- Frequently interrupting others or not waiting your turn
- Regularly leaving your seat when you’re expected not to
- Talking excessively
- Often feeling restless
Among children, many of these symptoms are common to some degree. (They’re kids after all, and their brains haven’t yet developed an adult sense of self-control.) To qualify as ADHD, the symptoms have to be more severe than is normal for a person’s age and development.
For example, a child with ADHD may struggle far more than their classmates to pay attention to details, follow instructions, or sit still. As a result, they could be unable to complete tasks at school, or develop normal friendships.
It’s also worth noting that ADHD tends to present differently in girls. They tend to be more day-dreamy than hyper, compared to boys. And because of this, it can be harder to spot the signs and get a diagnosis.
What is OCD?
Meanwhile, OCD involves unwanted images, thoughts, beliefs, sensations, feelings, and urges that cause distress or anxiety (called obsessions). Some examples include:
- Fearing germs, dirt, contamination, and sickness
- Fearing losing control
- Fearing harming yourself or others
- Needing to have things perfectly balanced and orderly
OCD also involves repetitive physical behaviors or mental actions (called compulsions) that are done to try to relieve the distress caused by obsessions, or to avoid unwanted outcomes. For example, if you have OCD, you might get out of bed every 15 minutes to check that your door is locked because you’re afraid that someone will break into your home if you don’t.
How Are OCD and ADHD Different?
1. Intrusive thoughts don’t trigger symptoms in ADHD.
Anyone can experience an unwanted thought from time to time, and this may be even more common for people with ADHD, according to a small study published in Psychiatry Research. But intrusive thoughts are not a distinguishing feature of ADHD the same way they are for OCD. So, if you find that you’re distressed by intrusive thoughts, images, feelings, sensations, or urges, this may suggest OCD.
2. Compulsions are a key symptom of OCD—not ADHD.
Most people with ADHD don’t experience compulsions as people with OCD do. If you don’t find yourself performing mental or physical actions to rid yourself of anxiety and uncertainty or to prevent an unwanted outcome, you’re less likely to have OCD.
3. ADHD is more likely to make you impulsive.
ADHD is often characterized by impulsivity and risk-taking behaviors. Meanwhile, individuals with OCD tend to be fairly cautious and opposed to taking risks. In many cases, they avoid acting impulsively because they are very concerned about the consequences of their actions.
Similarities Between OCD and ADHD
Despite the differences, these two conditions have similarities.
1. Both ADHD and OCD may involve the same brain areas
Both OCD and ADHD may be partly caused by a dysfunction in the same area of the brain. Specifically, they’re associated with abnormal activity in an area that’s involved in executive functions such as short-term memory, planning, and behavioral control.
This region of the brain is often in overdrive for people with OCD, but it tends to be less active in people with ADHD. Interestingly, though, the effects can be similar—as we will explore in a moment.
Brain chemicals can also play a part in both disorders. With ADHD, though, the issue tends to be a dopamine dysfunction, whereas the neurotransmitter serotonin is often out of whack for people with OCD. This plays a role in which medications are best for each condition.
2. OCD and ADHD can both mess with your cognitive function.
OCD can often be misdiagnosed as ADHD. That’s because people with OCD often have problems with attention and executive functioning—which are key traits of ADHD. For instance, if you have OCD, you may become severely distracted by intrusive, upsetting thoughts, which can make it difficult to pay attention to anything else. This can interfere with your daily functioning, and your performance at work or school.
“It can appear as if you’re not paying attention, when the reality is that you’re doing all sorts of stuff involving obsessions and compulsions in your head,” says Dr. McGrath. “Because of that, you might look like you have ADHD when that’s not actually the case.”
Be sure to tell your provider if your difficulty focusing is the result of obsessions and compulsions. It can make a real difference in your diagnosis.
3. ADHD and OCD can be mistaken for each other.
It’s also possible for ADHD to be misdiagnosed as OCD.
Generally speaking, ADHD doesn’t involve obsessions or compulsions, although Dr. McGrath notes that it can appear that way. For example, researchers have found that people with ADHD can become “hyperfocused” on particular tasks or topics.
However, this type of “obsession” is entirely distinct from the kind associated with OCD. This is because it is generally not related to intrusive or unwanted thoughts, images, feelings, sensations, and/or urges. Instead, hyperfocus tends to happen when you find something fun or interesting. For example, you might spend all day absorbed in a book or video game.
Likewise, if you have ADHD, you might engage in behaviors that seem similar to compulsions. For example, if you’re easily distracted you might spend an excessive amount of time cleaning, ordering, and arranging things. But while these may appear similar to certain OCD behaviors, they’re not done to alleviate anxiety associated with obsessions, or to prevent a bad outcome.
For these reasons, it’s not uncommon to be misdiagnosed. That’s why it’s so important to see a mental health professional with extensive experience in both OCD and ADHD who can distinguish between the two.
Living with both OCD & ADHD
As we mentioned before, it is possible to have both ADHD and OCD. But some experts argue that many cases of this may be a matter of misdiagnosis, and that a genuine combined diagnosis is actually fairly rare. The reason is that people with OCD rarely exhibit impulsivity or risk-taking behavior. Also, because ADHD and OCD are associated with opposite activity in certain parts of the brain, it may be unlikely to have both conditions.
Here’s how neuropsychologist Amitai Abramovitch, PhD explained his stance in an article for the International OCD Foundation: “Can one person be both impulsive and careful—be both a risk taker and avoid risks—and exhibit opposite patterns of brain activity at the same time?”
However, not all experts agree. “I believe it’s quite common to have OCD and ADHD—not because one causes the other, but because we see them together all the time,” says Ibrahim. “I have three children, and two of them have ADHD and OCD.”
In any case, many people show sufficient symptoms of both conditions to be diagnosed with OCD and ADHD. And this is associated with worse symptoms for both disorders. For example, one study found that compared to adults with OCD alone, those who were also diagnosed with ADHD had more obsessions and compulsions. The authors noted that symptoms of ADHD might make it harder for people with both disorders to resist compulsions.
And the combination of disorders may make some intrusive thoughts and OCD subtypes more common. In this same study, researchers found that obsessions and compulsions related to hoarding, symmetry, and fears about disorder were more common among those with both conditions.
How Is OCD Treated?
OCD is typically treated with a particular type of therapy. In some cases, it may also be treated with medication.
Therapy
Exposure and response prevention (ERP) is the most popular and effective treatment for OCD. In this treatment, you are exposed to something that triggers an obsession, and then you’re guided on how to resist the urge to perform compulsions in response.
A trained therapist who specializes in OCD will create a custom ERP therapy plan, so it’s never one-person-fits-all. Gradually, you’ll confront the situations that trigger your OCD symptoms, then resist the urge to respond with compulsions using specific therapy techniques.
For example, if you have an intense fear of germs, your therapist might have you put only one finger on a doorknob to start. Eventually, you may tackle a bigger fear, like riding a subway without gloves on. By seeing that nothing bad happens, or realizing that you handled the discomfort better than you thought you could, your brain gets the message that there was nothing to fear in the first place.
ERP is considered the gold standard for OCD treatment and has been studied extensively in decades of clinical research.
Medication
OCD isn’t always treated with medication. But when it is, it is typically treated with selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). These medications impact serotonin, a chemical messenger believed to play a role in the symptoms of OCD, anxiety disorders, and depression.
How Is ADHD Treated?
ADHD is generally treated with a combination of therapy and medication. But some patients are treated with just one or the other.
Therapy
The therapy of choice for ADHD is behavioral therapy. This educates people—and their guardians, in the case of children—about how to opt for healthy behaviors instead of disruptive ones. For example, you might learn about token reward systems that give you positive feedback for practicing good behaviors.
Cognitive-behavioral therapy (CBT) is particularly effective if you have ADHD. It teaches you how to adjust not only your behaviors, but also your thinking patterns. ERP is one form of CBT, but it’s typically not used for ADHD. That’s because ERP helps you deal with obsessions and compulsions, which most people with ADHD don’t have.
Many people with ADHD also receive lifestyle skills training, which is meant to help you improve your social, organizational, and problem-solving skills. Talk therapy is also common, and can allow you to process the issues that are bothering you. Sometimes, partners and family members are involved, in the form of couples or family therapy.
Medication
ADHD is often treated with a class of medications known as stimulants, such as methylphenidate. Stimulants increase the amount of dopamine in your brain—a chemical messenger involved in motivation, attention, and reward-guided learning.
Can OCD and ADHD Be Treated at the Same Time?
Yes, they can through therapy, medication, or both. It’s crucial to work with a clinician who has specialty training in OCD, as well as ADHD, so treatment approaches are appropriate for both conditions, says Ibrahim.
Therapy
If you have ADHD and OCD, you’ll generally receive respective treatments for both conditions. But as Ibrahim points out, the therapy may look a little different.
“We tailor the treatment to everybody and their individual needs,” she says. “So if somebody with ADHD also has OCD, we make accommodations.”
For example, if you have OCD and ADHD, you may benefit from getting some of your energy out while in therapy for your OCD. Sometimes, Ibrahim has her patients with comorbid ADHD sit on a yoga ball so they can bounce while they talk. Or she’ll give them something to keep their hands busy—like Legos or even a piece of paper to doodle on.
She also often has her patients with ADHD repeat things back to her to make sure they’ve heard what she said and really digested it. And sometimes she shortens sessions or gives breaks if the client can’t focus for an hour.
Another factor that can play a big role in treatment? Scheduling. “For my own kids, they had about a four-hour window after they took their ADHD medications in which their focus was the best,” says Ibrahim. “So I would schedule their sessions within that window.”
A good therapist will work with you to make sure ADHD symptoms don’t get in the way of treatment. For instance, Ibrahim describes a young patient whose ADHD symptoms sometimes made it hard for her to focus during ERP.
“The goal in many cases of ERP is to sit with an exposure for 15 minutes, but that’s not realistic for many people with ADHD,” says Ibrahim. So she started this patient off with just a few seconds of exposure. Over time, they worked their way up to the maximum amount of time the patient could manage—a couple of minutes. And that was enough.
“Through that, she was successfully treated for her OCD and incorporated ERP into her school day and into her home life. And at the same time, she uses some of the techniques we use to deal with ADHD,” says Ibrahim. “So she graduated middle school, and is now a successful high schooler.”
Medication
A comorbidity of OCD and ADHD has important implications for the medications a person might take. As Dr. McGrath explains, the stimulants typically used to treat ADHD generally shouldn’t be used to treat people with both conditions: “You don’t give people with OCD a stimulant medication.” This is because it can intensify their anxiety and magnify their symptoms.
Fortunately, there are also several non-stimulant medications for ADHD. Some examples include Atomoxetine, Clonidine, Guanfacine, and Viloxazine.
These medications work on different chemical responses in the brain to avoid the possible anxiety-inducing effects of traditional stimulants.
Ibrahim can attest to this with her personal experience. “That was true of my own two children. Initially, everything got worse, because they were on stimulants,” she says. “Then I found out there were nonstimulants, and when they started taking them it was just a whole lot better. They were able to calm down and focus a little bit better, but it didn’t make the other symptoms escalate.”
Medications used for OCD may be combined with the non-stimulant alternatives listed above if you have both OCD and ADHD.