Challenges in treating OCD
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Challenges in treating OCD

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Challenges in treating OCD

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Presentation on theme: "Challenges in treating OCD"— Presentation transcript:


Challenges in treating OCD with co-occurring ADHD

Jennifer Sy, PhD, Keith P. Klein, MA,

Angela Smith, PhD, & Chad Brandt, PhD





AssessmentTreatment planning Treatment modificationsAdjunctive 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 careResidential 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 riskADHD is often impulsive, which often increases risk Contrasting neurobiological underpinningsPreliminary results suggest that OCD and ADHD may co-segregate within familiesMay 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



Inattention vs. Perfectionism/Perseveration

Perfectionists might over-report attention deficits

Inattention because of distraction by obsessionsSuperstitions affecting responses and accuracy


How to Assess for DifferencesUtilize objective measures of inattention/impulsivity and recordsUtilize behavioral observationsDo 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 anxietyDetermine cost/benefit of low/no medication for ADHD

Work with patient’s psychiatrist!


Treatment for OCD


Complications from ADHDProblem:

Difficulty “staying in the exposure”


: Insufficient stimulation at “moderate” exposure difficulty Problem: Differentiating between distraction and effortful avoidance



Staying on task in session


Difficulty Staying in ExposuresContinuous 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 ForgettingRefer 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 cardsOne reassurance card referenced repeatedly


Staying On Task

Combat treatment interfering behaviors linked to attention:

Agenda setting

Utilize delay tactics to minimize tangential triggers/disruptionsRepeat questionsUse 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


Increased attentional control

Increased awareness Acceptance of present moment experience

Opportunity to make intentional choice about behavior


Improved attention

Stress reduction

Improved mood


Adjunctive Treatments- Mindfulness

Other positive findings


Low treatment drop-out ratesHigh 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


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?