Compulsively Impulsive / Impulsively Compulsive

The tug-of-war that goes on when one person lives with two very different disorders

by Bryan Goodman, MA

THE DEATH OF A LOVED ONE IS DEVASTATING FOR ANY CHILD, but for nine-year-old Pat Swanson the death of her beloved uncle triggered thoughts and behaviors that she had never before experienced.

“I developed a number of rituals that I wouldn’t tell people about. I’d have to touch things a certain amount of times. When I was reading, I’d have to count certain words. I also felt that I had to touch certain things so that bad things wouldn’t happen. It was magical thinking,” explains Swanson, now 58 and living on the East Coast.

She now knows that the magical thinking stems from obsessive-compulsive disorder or OCD, which co-occurs with her AD/HD. OCD is a condition that is still not well understood by most people, including medical professionals, according to Thomas E. Brown, assistant professor at the Yale University School of Medicine and an expert on overlapping mental health disorders. As a result, he says, the debilitating symptoms of the disorder are usually accompanied by enough stigma and shame to prevent many people from ever mentioning them even to their closest loved ones. (Editor’s note: Because of her concerns about the stigma attached to OCD, Attention magazine editors took the unusual step of using a pseudonym rather than Swanson’s real name.)

Symptoms and overlapping conditions

People with OCD can have very irrational and obsessive thoughts, such as an unreasonable fear of being exposed to the AIDS virus or thoughts about family members being killed in car accidents because they are running a few minutes late. Swanson, for example, recalls ruminating about negative thoughts that wouldn’t allow her to move forward from even minor problems.

Then there is the compulsive side of the disorder. In some cases, people create rituals, including repeated handwashing or avoiding cracks in the sidewalk. Others struggle with excessive perfectionism, unable to complete writing assignments until they feel that they have absolutely perfected each sentence. Usually individuals with OCD recognize that these thoughts and practices are irrational, but they find it almost impossible to avoid them; “it just doesn’t feel right” otherwise.

Classical literature has captured characters who possess at least some of the symptoms. It was the ambitious and compulsive Lady Macbeth, after all, who repeatedly washed her hands in Shakespeare’s Macbeth. The medical community’s understanding of the disorder goes back to the early part of the twentieth century. Research shows that OCD is a genetic disorder, though there is a rare phenomenon, termed PANDAS, in which strep throat can cause the immune system to produce antibodies that interact with the brain in such a way that it triggers the onset of OCD.

As for Swanson, like so many others with OCD, co-occurring AD/HD and anxiety complicated matters. Swanson, who comes off as very bright, struggled for years with underachievement in school. It was only after she had one of her daughters evaluated for behavioral problems that she recognized her own symptoms on the AD/HD rating scales.

“It’s a hard combination. If you have the OCD you want everything to be perfect. But when you have AD/HD, everything can’t be perfect because it’s so scattered,” Swanson says. She reports that both of her daughters have been diagnosed with co-occurring AD/HD and OCD.

The Multimodal Treatment Study of Children with AD/HD found that 70 percent of children seven to nine years old with AD/HD had at least one other mental health condition. Moreover, studies show that AD/HD and OCD may overlap as much as 33 percent of the time.

Is AD/HD a foundational disorder?

“Perhaps we shouldn’t look at AD/HD as just another disorder among disorders, but rather as a foundational disorder for other disorders,” says Brown. “So AD/HD wouldn’t be like a defective software program that impairs a very limited range of tasks. It would be more like a defective operating system in a computer that affects a variety of functions,” he explains.

Because the two disorders involve different neurochemistry and different parts of the brain, treatment professionals use different medications to treat people who live with both disorders. The medications used to treat depression and anxiety, called SSRIs in medical parlance, are often effective in treating OCD though they have not been shown to be effective in treating ADHD. Other medications, such as stimulants, have been shown effective in treating AD/HD, but they do not generally alleviate OCD symptoms and sometimes they make them worse.

There hasn’t been much research on the comorbidity of AD/HD and OCD, according to Brown, and it’s hard to find treatment professionals who understand both disorders. So, in many cases, it puts the impetus on people like Swanson to coordinate their own medication treatment. Swanson, who has been far more concerned with her symptoms of anxiety and depression, has had some difficulty finding the right medication that will treat all of her symptoms. She is now on an antidepressant that she says has been effective in treating the OCD and has helped her focus.

Behavioral treatment has also helped Swanson a great deal. She meets regularly with her therapist to talk about the rituals and obsessive thoughts that come with OCD. The therapist challenges Swanson’s irrational beliefs and behaviors, while addressing the low self-esteem that comes with some of the travails of living with AD/HD.

Swanson describes her OCD symptoms as moderate and not necessarily representative of more severe cases. And Brown is quick to caution people against taking a one-dimensional view of the disorder, as it’s not just about repeated handwashing and rituals. He said he treated one young man who quit going to church because he kept worrying he would stand up in the middle of a sermon and start using vulgar words. Other clients have told Brown that if they drive past someone standing at the curb and then cannot see that person in the rearview mirror, they feel they must circle back to make sure they haven’t run over and hurt the curbside pedestrian.

“People really get stuck,” says Brown. “These habits can become time consuming and embarrassing.” He agrees with Swanson’s assessment that there is an added complication when AD/HD is factored into the equation. He treated one person, for example, who devised a checklist to combat his AD/HD symptoms. Paying rent was the third item on the list and it followed two long-term tasks. Because of his OCD symptoms, the man was unable to move beyond the first two items and ended up being very late in paying his rent.

Some OCD characteristics can work to a person’s advantage, says Brown. “If you have someone flying a plane or doing your accounting, you’re going to want them to have careful attention to detail. But that same person may also have problems adapting flexibly to certain interpersonal situations.”

In the end, Swanson and Brown agree, living with OCD and AD/HD and other disorders can really be difficult. “I was always like the walking wounded,” Swanson says of the days when her disorders weren’t treated. “Just being able to tell someone about what I was feeling and having that person understand helped so much.”

When Are Recurrent Thoughts or Repetitive Behaviors Excessive and Impairing?

It’s important to remember that many people may have some characteristics of OCD, but to have the disorder the obsessions and compulsions must be excessive and significantly impair a person’s life. According to Thomas E. Brown, PhD, here are some of the symptoms to look for:

Three Helpful Tips

Learn as much about OCD as possible.
One book you may find helpful is Over and Over Again: Understanding Obsessive-Compulsive Disorder by Fugen Neziroglu, PhD, and Jose A. Yaryura-Tobias, MD (Jossey-Bass, 1997, revised edition). You can also visit the website of the Obsessive-Compulsive Foundation.

Talk with your treatment professional.
This could be a clinical social worker, registered nurse, psychologist, or psychiatrist. Be sure to ask your treatment professional how much experience he or she has treating both AD/HD and OCD or whatever disorder you suspect you may have. More detailed information for professionals is available in “Obsessive Compulsive Disorder and ADHD” by Daniel A. Geller and Thomas E. Brown, published in ADHD Comorbidities: Handbook of ADHD Complications in Children and Adults (TE Brown, editor, American Psychiatric Publishing, 2009).

You don’t have to box yourself in by focusing on labels of disorders.
Many people have more than one disorder. When you’re talking with your treatment professional, focus on your symptoms. Remember: It may take more than one medication to treat problematic symptoms.

Bryan Goodman, MA, is director of communications at CHADD and the executive editor of Attention.

From the February 2010 issue of Attention magazine. Copyright © 2010 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).