Unraveling a Tangled Web: Exploring the Intricate Relationship Between ADHD & OCD

Apr 18

In this episode of The ADHD Podcast, we delve into the complex and often misunderstood connection between Attention Deficit Hyperactivity Disorder (ADHD) and Obsessive-Compulsive Disorder (OCD). Joined by Dr. Roberto Olivardia, a renowned Clinical Psychologist and Lecturer at Harvard Medical School, the trio embarks on a journey to unravel the intricacies of these two conditions and shed light on the challenges faced by those who experience them simultaneously.

With his extensive expertise in treating ADHD, OCD, and Body Dysmorphic Disorder, Dr. Olivardia provides invaluable insights into the signs, symptoms, and treatments associated with OCD. He explores the common misconceptions surrounding the disorder and discusses how the casual misuse of the term "OCD" in everyday conversation can hinder patients from receiving the proper recognition and support they need.

As the conversation unfolds, we navigate the intricate relationship between ADHD and OCD, examining how the symptoms of one condition can influence and exacerbate the other. They explore the potential impact of ADHD's hyperfocus on OCD symptoms and delve into the effectiveness of treating both conditions simultaneously.

Join us, and Dr. Olivardia as we embark on this exploration of the ADHD-OCD connection, offering a platform for understanding, empathy, and support for those navigating the complexities of these often intertwined conditions.

Links & Notes

Pete Wright:
Hello everybody and welcome to Taking Control: The ADHD Podcast on TruStory FM. I'm Pete Wright and I'm here with Nikki Kinzer. Hello, Nikki.

Nikki Kinzer:
Hello everyone. Hello, Pete.

Pete Wright:
You've been pretty excited about this conversation.

Nikki Kinzer:
Yes. Yeah.

Pete Wright:
I feel like-

Nikki Kinzer:
It's so interesting to me.

Pete Wright:
Yes. I am very excited about this conversation too, because actually I was super jealous the last time we had our fantastic guest on. I did not participate because I had a fantastic stand-in of your daughter. But that's okay because now I get a shot. I get a shot at the interview. I'm very excited about this. Before we dig in to ADHD and OCD, you got to head over to the website, takecontroladhd.com. You can get to know us a little bit better. You can see all the programs that we have going on. You can see the upcoming events and it get ready because GPS signup is coming in a matter of just weeks. So we're really excited about all the great things you can learn over at the website. Takecontroladhd.com. You can connect with us on Facebook or Instagram or Pinterest at Take Control ADHD. But to really connect with us, jump into the ADHD discord community. It's super easy to participate in the general community chat channels. Just visit takecontroladhd.com/discord, and you'll be whisked over to the general invitation page and login.
Now, if you're looking for a little bit more, and we hope you are, if this show has ever touched you, we hope you'll visit patreon.com/theadhdpodcast. Patreon is listener supported podcasting. If you sign up there for a few bucks a month, that supports this show directly. We do a lot of things at Take Control ADHD, but Patreon supports this show and the team that makes it work behind the scenes. Not just me and Nikki, but it keeps things ... It keeps us in microphones. It keeps Melissa on the back end supporting this show. It really is a massive lift for you to support the show via Patreon. So again, patreon.com/theadhdpodcast to learn more. Thank you for your support.
Today's discussion about ADHD and OCD will express the opinions of Dr. Roberto Olivardia and should not be taken as medical advice. The conversation is being provided for informational purposes only. Everyone's situation is different, so please consult your healthcare professional for any and all matters regarding these topics.
Dr. Roberto Olivardia is a clinical psychologist, lecturer in psychology in the Department of Psychiatry at Harvard Medical School and clinical associate at McLean Hospital. He maintains a private psychotherapy practice in Lexington, Massachusetts, where he specializes in the treatment of a ADHD, obsessive compulsive disorder, and body dysmorphic disorder, as well as issues that face students with learning disabilities. He is back on the show with us today to talk about ADHD's relationship with OCD. Roberto, welcome back to the ADHD Podcast.

Roberto Olivardia:
Oh, my pleasure. I'm very glad to be here.

Pete Wright:
We are very excited to have you, particularly this conversation around comorbidities with ADHD. Talking about the relationship of OCD. And just in preparing this show, we've had a number of people reach out to us saying, I was diagnosed with this thing, ADHD and OCD. How common is it?

Roberto Olivardia:
It's much more common than people think. It's always important first to understand that it is the rule rather than the exception that people with ADHD will have what we call a comorbid ... It sounds like a depressing word, comorbid. But an associated condition or disorder. Whether it's depression, eating disorder, addiction, anxiety disorder. And OCD is one of them but interestingly, we think of ADHD and OCD as being very opposite conditions. The research shows that amongst people with OCD that about 30% of people with OCD have ADHD. 30%. That's a very, very high comorbidity. There hasn't been studies looking at ADHD populations in really doing adequate screening for OCD so we don't know the percentage on that end. But clinically speaking, I've seen a lot of people who come in having an ADHD diagnosis and then through that it's become clear that something else is going on that might be interfering with their attention or executive functioning. And I've more likely seen it the other way.
One patient, for example, that comes to mind who was referred to me, he had obsessive-compulsive disorder. He was 22 years old, and he would be like 45 minutes late for a 50-minute session week after week. And nicest guy. He would come in, he'd be sweating, he'd feel so bad. He's like, "I'm so sorry I'm late all the time and I just get stuck." Now, his language, understandably, sounds like, okay, your OCD symptoms are probably getting in the way. He would get stuck and whatnot, and he goes, "Please don't fire me." Which was painful to hear. I'm like, "I'm not going to fire you. We're going to work on ... Clearly, I know you want to be here."
And I asked him why and he said, "I had been fired from two other therapists because they said I was either being treatment resistant or I must not really be motivated enough to really work on my OCD because of this problem being late." So we dug into that and I said, "Okay. Well, we have five minutes. Let's use these five minutes." And so we would get a better sense of it. And it turns out that he wasn't late because of his OCD rituals, which he had a number of different, what we call scrupulosity, which is a form of OCD that often involves hyper morality or high religiosity. People who have a fear of going to hell so they might do mental rituals to prevent damnation or punishment or feeling like they'll be immoral people.
So I'm thinking that maybe these are these rituals. So when we dug into it, lo and behold, it was not the OCD rituals at all. It was what we all, and your listeners can probably relate to as very classic ADHD executive functioning. He would wake up too late, miss his alarm. He had trouble getting to sleep the night before, not because of anxiety and OCD, but because he'd get just caught up in a rabbit hole on YouTube and playing video games and would wake up, miss his alarm, realize as he was driving to my office, his car is almost out of gas, had to go to the gas station, lost his credit card, had to borrow ... This literally happened. He had to borrow a stranger's ... Kindness of a stranger that paid for his gas because he left his credit card at home. It was just all of these things. And I said, "Okay. This is not OCD." And I asked him if he had been assessed for ADHD. He said, no. And again, these are in five to 10 minute spurts because he would be late all time.

Pete Wright:
He's always late.

Roberto Olivardia:
He's always late. So this is over five weeks to really get this information. And in between, I would email him. I said, "I want more data to use the time." So I said, "Email me the responses." And he would. When you look back in his life history of academic difficulties, executive function issues, but all of these things were conceptualized as being part of his OCD that people assumed his attention issues was because he's having these very intrusive thoughts. When he was younger, they came in the form of what we call bad thoughts OCD. So he would have these thoughts that he would stab a classmate and not have the desire to do it. This is a form of OCD where people have these unacceptable images or thoughts and then fear, oh my gosh, because I thought that maybe I'm going to do it. And so he didn't want to go to school because of these intrusive thoughts. But it turns out amongst that was this other piece that even when ... And he said, he goes, "I always knew that there was something that even when I wasn't activated by the OCD ..." And basically making a really long story short that he had a family history of ADHD. And when we did a full assessment, lo and behold, he had ADHD and an undiagnosed dyslexia as well.

Nikki Kinzer:
Wow.

Roberto Olivardia:
So I said, "Okay. Before we can even treat the OCD, we need to get you here. And so we're going to just work on the executive functioning component." And when we started to work on that ... I remember the first time he was only a half an hour late where we had 20 minutes left. It was like a win. We were both like, yes, and celebrating that. And he thought ... It was so eye-opening for him because he assumed as a therapist that I'd be like, "You're still a half hour late," as opposed to, "Well, you're only a half hour late. We have 20 whole minutes now that we can get more work done." And we kept working. And the first time I opened that door and he was in my waiting room, high-fiving each other. Yes.

Nikki Kinzer:
I bet.

Roberto Olivardia:
But it was about two and a half months from when I started working with him, and then we could start treating the OCD and then we also moved the time around. But that's a good example of ... That ADHD was always the attention issues. Well, yes, he has OCD, he has these intrusive thoughts, and he, as a lot of people with ADHD and OCD would say, is they're well aware of the difference of sitting, let's say in a classroom. And with ADHD, maybe we're bored. I have ADHD myself so we can get bored. We get distracted. Our thoughts go somewhere else. That's a different experience than with OCD. If somebody's attentive to something and they feel like there's an intrusive thought, something that comes in that demands their attention in a high anxiety threatening way. And just briefly just to talk about what OCD is-

Pete Wright:
Yeah. I need that because you have described so many different characteristics of what you're referring to as OCD that are not what I ever presumed OCD to be. I probably would've characterized it as anxiety, some cases severe anxiety. And I know OCD as a term is often overused in just cultural context and slang. So yes, please. What is it?

Roberto Olivardia:
Yeah. So with OCD, obsessive compulsive disorder includes obsessions and compulsions, and you can have both, or you can just have one of those to be diagnosed with OCD. So an obsession is a thought that's typically an intrusive thought. Which means that it's not really something that feels like this line of thought that somebody might be in. So for example, if I'm reading an article on cancer and then suddenly there's this thought of, oh my gosh, my mother could have cancer. It almost is like this jolting ... It's your own thinking, but it almost feels ... It just doesn't seem along the lines of what you were thinking. And the intrusive thought often is very anxiety provoking. But it could also be an intrusive image that you have in your head and something that causes a lot of anxiety.
Now, someone could just have an obsession, but most of the time you'll see an obsession coupled with a compulsion. And by the way, with the obsession, someone is trying not to think of it. It's not like they're engaging really with the thought. They're like, "Oh, I don't want to think of it." Now, the more we try to push away a thought, the more intrusive and demanding that thought becomes. And these thoughts are not pleasant or these images are not pleasant. So they could be imagining yourself, again, stabbing somebody in the case of bad thoughts OCD. They could be a thought of, oh my gosh, my sister is going to get cancer. And they feel so anxiety provoking that it almost ... Even if the person knows and has insight like, okay, well, just because I'm thinking that it doesn't make it true, the anxiety, the physiology is so intense that now a compulsion, which is basically a behavior or some ritual that is meant to neutralize or undo the obsessive thought or make it right. Now, sometimes the compulsion is very linked to the obsession. So if somebody has an obsessive thought of, okay, I touched this doorknob and there's probably lots of germs that could make me sick, the compulsion is I'm going to wash my hands, but I'm going to wash them maybe 30 times. That makes sense with that kind of obsession.
Now, what happens though, is that a compulsion, it starts to ... It's like OCD is the thing, you give it an inch, it takes a mile very, very quickly. So washing our hands once doesn't do it because it's like, well, how do I know I didn't wash them enough? OCD is a disorder of doubt. It's a disorder that has such intolerance of uncertainty that then it becomes like, well, let me wash them again because at least if I wash them again, my anxiety will become reduced. So the compulsion is meant to reduce anxiety.
Now, the compulsion isn't always even aligned with the obsession. So for example, somebody could suddenly have an intrusive thought of, oh my gosh, my mother could have breast cancer. I need to count things in sevens, and if I count things in sevens then she won't get breast cancer. So there's this what we call magical thinking that can occur with OCD. That's not psychosis, but is this sense of here's this anxiety ridden thought. And the person with OCD often feels this high degree of responsibility. People with OCD often carry the weight of the world on their shoulders. So they have this sense of ... They might even know, maybe this sounds silly to people to have to go one, two, three, four, five, six, seven and then my mom won't get cancer. But what if I don't do that thing and my mom gets cancer, that I could have prevented that and it would be my fault so why not just do it in sevens. Now, that compulsion can go from a one-time thing to then four hours doing compulsions. It could just grow and grow.

Pete Wright:
Truly disruptive.

Nikki Kinzer:
I remember when we were talking at the conference, you were telling me a story about a client who was afraid that when they were driving that they would run over someone.

Roberto Olivardia:
Yes.

Nikki Kinzer:
And I thought that was really interesting because then you said that that person stopped driving.

Roberto Olivardia:
Yes. In my clinical training at McLean Hospital, which has the premier residential program for people with OCD ... It's called The OCD Institute. It's a one-of-a-kind ... Lives literally change in that program. I was very, very fortunate to have training there. And my first OCD patient ... Because the model of the treatment is what we call exposure and response prevention, because people with OCD will end up avoiding certain situations to try to not even trigger the obsessive thought or compulsion. And OCD makes your world very, very small if you don't treat it. And then the exposure is you literally expose them to the thing that makes them anxious for the purpose of increasing their anxiety so that they can habituate to their anxiety. Because our bodies are not designed to be sitting with ... If we're sitting with our anxiety, we can't be anxious all day long. Our cortisol levels, our adrenaline levels will eventually ... We just have them in limited supply.

Pete Wright:
Yeah, we'll tap out.

Roberto Olivardia:
We'll tap out. Now we could push away something and have it come back and push it away and have it ... We could do that all day long. Bang, boom, bang, boom. But if we're sitting with something, like if you have a phobia for cats, you can avoid cats, and then when you see them, your cortisol levels and adrenaline levels. But if I eventually put a cat in a room and you sit with it, you're going to be super uncomfortable. But then at some point, you're just going to be like ... You might not like it, but your physiology won't be as hyped up around it. So this particular patient had what they sometimes in the OCD community call hit-and-run OCD, which is when this woman would drive to work, any non-smooth thing on the road, any bump, anything that felt ... She would've an intrusive thought of, could I have hit somebody? What if I hit somebody and I killed them?
Now again, the range of insight varies. Some people with OCD automatically believe the thought, and a lot of people know, I probably didn't, but probably isn't good enough. For an OCD patient it's not about probability. Their world almost rests more in the possibilities of things rather than the probability of things. Whereas most people get on an airplane and the probability that plane is going to crash is very, very, very, very, very low. Is it a possibility? Yeah, it's a possibility. I would never tell a patient, it's impossible that the plane will crash. The plane could crash. It's a possibility, but it's a very low probability.
So she would be so distressed by this intrusive thought. Because again, in her mind is if I did hit and kill somebody, I'm responsible and I'm committing a crime by going away. So she would get off the next exit on the highway, circle back to see if there was a body there or anyone. She would look. Nope. Nobody was there. She'd keep driving. Another intrusive thought. Maybe I hit them and they rolled into the ditch and I didn't really look that well into the ditch. She would circle again, go back to the ditch. And then, okay, the anxiety would go down, then she'd drive. Maybe they rolled to the ditch and somebody found them and brought them to a local hospital. She would call every local hospital asking for an unidentified person that could have been hit on route 95, blah, blah, blah in this town. It was so disabling. So she didn't want to drive anymore because this was so disconcerting. And this is the thing with OCD is that OCD has a way of almost capitalizing on the thing that matters most to people.
So in other words, the irony is even with bad thoughts OCD ... So if I have a patient that ... There is a type of OCD called pedophilia OCD where people fear that they will sexually abuse a child or sexually abuse their children. They fear they're a pedophile. Now, if you are a clinician that does not understand OCD, and you have a patient that says, "I don't want to put my son on my lap and play horsey with them because I could get an erection, and I don't want to molest him." Someone might say, "Whoa. Do I need to call DSS and maybe ask a couple questions?" But when you ask those questions, these are not people that have a sexual interest in children. They're repulsed actually by it. But the fact that they had the thought, now they feel almost like, well, because I had that thought, maybe it means that I am. And if I am, I don't want to do that, so I'm going to avoid children. So I've had patients that don't want to even hug their children because they have this intrusive thought that they're going to abuse them.
So just quickly back to this woman. So her life was totally debilitated by this. She goes to the program. My job as her exposure coach, come into my car and I would drive on these bumpy roads and everything, and if she says, "Do you think we hit and kill somebody?", I had to say, "Maybe we did, maybe we didn't." Which as a clinician-

Pete Wright:
Wow.

Roberto Olivardia:
That sounds so sadistic to me. My training was more what we call more psychodynamic, like talk therapy, Freudian, until I started doing this work with OCD, which is very behavioral. But if we understand why that is, if I said to her, no, we didn't hit and kill someone, I'm providing reassurance, which people with OCD will seek reassurance and it doesn't help. It's not going to help her because once I'm not in that car anymore, or no one is there to give her that reassurance, it's going to be right back to where it was before.
And so with OCD and family members who have loved ones with OCD fall into this and it's hard because you want to say to the person with OCD, no, you're not going to get AIDS by touching a doorknob. No, you're a good person. Of course you wouldn't harm any ... It really doesn't help them. And if they're seeking it. So I would say, maybe we did, maybe we didn't. And so she has to sit with this uncertainty and really go to relying on what would that even look like? What could that sound like? Would it be a little bump if we hit somebody? If we killed somebody? And I'd keep driving and for three hours be driving and her anxiety ... It would be very unpleasant. And she would say, "We get arrested, you're getting arrested with me. You're complicit." And I'm like, "Okay. Then I guess I'll go jail."

Nikki Kinzer:
You're going to go with me.

Roberto Olivardia:
Yeah. I said, "I guess I'm going to go to jail."

Pete Wright:
Maybe I will.

Roberto Olivardia:
Yeah. Maybe I will. I'm like, "And I'll meet some friends in jail, I guess." But what was awesome about this treatment, which I love doing ... Well, first, for anyone, treatment is a very courageous journey. With OCD treatment, it's just a different dimension because the core part of this treatment is saying to someone, okay, this thing that gives you the most anxiety, we're going to have you do that a lot. Imagine whatever your phobias are or whatnot, and me saying, "Oh, okay, we're going to put you in a room full of rats for a good three hours." But by the end of the fifth day doing this three to four hours a day, I was going through these roads and she was filing her nails. She would still have the thought. She's like ... But it just wouldn't elicit that physiology anymore. And she would still kind of believe it, but the thing with OCD is that physiology is what confirms the thought.
Because if anyone who's listening to this has a random thought of something that doesn't matter to them and it doesn't do anything, your physiology, it's so easy to say, okay, that's a weird thought. But if it's something that matters to me and I have a certain ... Because I have OCD traits, I wouldn't say that I have OCD only because I don't live with it on a daily basis. But I absolutely had episodes of it in my life and one of those came in the form of harmful thoughts. When I started driving, I was not rushing to get my driver's license and driver's ed was free in my high school at the time. My dad said, "Do it now. I'm not going to pay for it after." I'm like, "Oh, okay." But part of it is because my value ... And this is what OCD does. It infiltrates your value system.
So for people who know me, my value system is I not only don't ever want to cause harm to people, but my value is really in elevating people. That's like my spiritual value is I always want to do positive and really bring people up. So when I started driving, I would have these intrusive thoughts and images of, do I want to go like this with my car and I will smash into this car and I could kill a family of four. I can cause the most irreparable harm. And not because I felt incompetent as a driver, but almost like it just hijacked this value system that I had. And so then I'm like, oh my gosh. And I would grip that steering wheel because I felt this impulse that I'm going to just do something. I would sweat through my shirts. I was in grad school at the time and I'm like, you know what? I can just take the subway. I would avoid driving. And then eventually, this is where my ADHD won over because I'm like, okay, I can drive for 20 minutes or take the subway and that could take two hours.

Pete Wright:
Right. Yeah.

Roberto Olivardia:
Exactly. To Boston. So I'm like, oh. And Boston was going through this thing called the big dig where they were doing this massive reconstruction. And driving in Boston, honestly, is crazy even on a good day. But I did it, and I'm like, okay. And it was my own exposure. I'm like, I listen to music. I put on Enya. Enya, she could solve lots of world problems.

Pete Wright:
Lots of world problems, for sure.

Roberto Olivardia:
And I just got more and more used to it and more and more comfortable. But it wasn't coincidental that that's how.

Pete Wright:
You're exhausting the system to get to the other side of it.

Roberto Olivardia:
Totally. That's exactly what ... I would literally bring a change of clothes to ... I was going to school. To change into because I would sweat through it.

Pete Wright:
Sweat through it.

Roberto Olivardia:
But when I tell you that impulse, that image felt so real though. It felt so ... I don't know. I really remember thinking my hands will take that ... It's going to do that, even though that's the last thing I wanted to do.

Pete Wright:
This is the same experience, and I know I'm not alone here. We've got a number of parking garages in Portland that have rooftop parking and really absurdly low railings for being 10 stories off the ground. I often have that experience of, I have the agency right now to jump off this thing. And that gives me anxious, intrusive thoughts. What you are describing ... I guess I'd like to take just a quick step back because you've just described OCD in a way that I feel like I've experienced through just anxiety. How are OCD and anxiety different from your perspective as a clinician?

Roberto Olivardia:
Yeah. So with OCD, it used to be grouped in the anxiety disorders in the DSM, and now it has its own obsessive compulsive spectrum disorders. In a way it is marked by anxiety as the main emotion in there. With OCD though, it's more around this level of responsibility that people feel towards that. A lot of times, it's not even something that would even exist in their life. Where anxiety could be, okay, I'm on a plane and I'm anxious that the plane might crash, that's a real life event that's happening. Now maybe our thinking gets catastrophic around that. We could see that with OCD. But with OCD, it can take this whole other level of something that's not even happening or close to happening. There might be no evidence of it. If somebody, again, sees the word cancer and then thinks, if I don't do this ritual, then someone is going to get cancer in my life.
So there's a sense of this responsibility around it. Whereas anxiety, sometimes we do, we have avoidant behaviors with anxiety and whatnot, but it doesn't always include this notion of I need to do that. And with anxiety, it can certainly have ... There's a value system that can be integrated in that and sometimes it's not. I guess a plane crashing, we value our life, but here's a situation that my thinking is a little bit catastrophic around it, and I'm just sitting with this feeling. Whereas with OCD, it's not even ... Let's say if we take contamination forms of OCD, which is the one that people most commonly hear about in Hollywood movies. Interestingly, it's not really about being sick per se. COVID was a very interesting experiment. It was obviously very horrible thing that happened. But as far as with my OCD patients, because now here was a time where everybody's sanitizing and everybody's washing their hands. For some of my patients, it was the fear of getting COVID. Now, when people with OCD actually let's say get sick, their anxiety goes down. It's almost like it's a done deal. I'm sick now. I just have to deal with it in a way. So much of OCD is trying to prevent something from happening. It's this sense of what often might make people feel bad is not that they're sick, although no one likes to be sick. But I could have prevented this.

Pete Wright:
I could have done it.

Roberto Olivardia:
I could've done something different. And people with OCD, their personality traits typically are people that really have a very difficult time with uncertainty and not feeling in control. And that doesn't mean that they're control freaks or things like that, but more this sense of not having a sense of control over curveballs and bad things that could happen. Cancer can affect anybody at any time, but to someone with OCD, that's a really, really hard concept. And OCD almost creates this rubric of here's this thing you can do to prevent this thing. Whereas with just-

Pete Wright:
Even if that thing is count to seven.

Roberto Olivardia:
If it's count to seven, if it's blink five times. It could get so debilitating. This has happened with a couple of patients I worked with, but I had a patient once who his contamination fears went from the doorknob to breathing air, because in his mind, it was like there were contaminants and air, so he would hold his breath until he passed out. That's so unsustainable. It's tormenting. OCD can be very, very tormenting. And whereas with anxiety, anxiety can also be very specific to a certain situation or a certain scenario. Whereas with OCD, it's more thematic. There might be certain triggers for that like that example of me driving. But if it wasn't in that, there are other ways that same theme itself in other venues. So it's more thematic that unless you get treatment, it really takes up more and more space in your life.

Pete Wright:
I'm having a mind-blowing experience right now and I'll get to why momentarily. But can we talk a little bit more about how OCD exacerbates or is exacerbated by the ADHD experience?

Roberto Olivardia:
Yeah. What we know also is, so with ADHD ... So untreated ADHD ... Here we're the choir, but when I give talks to people that don't understand ADHD or dismiss it as like, oh, it's just an academic thing. Is untreated ADHD, studies show will undermine the treatment of any comorbid condition. So the notion of when clinicians say, oh, well we're going to treat the bipolar disorder first and then the ADHD, we're going to treat the OCD first. I'm like, no, the ADHD is there. It's like a little imp that's going to be there whether you like it or not. You have to treat the ADHD in accordance with it because that patient who needs to take, let's say, their medication for their OCD, they're going to forget to take their medication if their ADHD is not treated. They're not going to get the prescription. They're going to even forget. They might take two. I had a patient that would double and overdose on medication sometimes because they forgot that they took it already. So I said, you have to definitely be treating the ADHD.
Studies show when people have both that ... And again, both assuming that they're not treated, with comorbidity, it's not one plus one equals two. It's like one plus one equals five, meaning that the whole is greater than the sum of its parts because they really have a way of feeding off each other. Now, sometimes there's this interesting phenomenon with ADHD and OCD where patients will say there are aspects of either that almost compensate for the other, meaning that if let's say somebody has OCD issues, maybe their executive functions might be a little bit sharper because they fear the consequence of something so much more. That the anxiety almost has a mitigating factor in some ways.

Pete Wright:
Just because it's front of mind more than some other area.

Roberto Olivardia:
Exactly. Studies show actually that impulsivity sometimes with the exception of compulsions, which I guess is compulsive, but also has this impulsive element, but impulsivity is sometimes lower in people with ADHD and OCD versus people with just ADHD. Because people with OCD often are very risk-averse in lots of ways. And fear, again, uncertainty. Not that there aren't substance abusers that have ADHD and OCD, but a lot of my OCD patients are very fearful of being high, which is a good thing I guess. That works out good because substance abuse makes things a lot more complicated. And I've certainly worked with that in the mix as well. But I would say a lot of it is even in doing the OCD treatment is understanding the impact of the ADHD. Because let's say with that exposure treatment, the purpose is to have somebody be engaged in the anxiety and not be ... This is isn't where we want you to deep breathe and think about a beach and visualize. No, no, no. We want you to think about the nasty germs that are on your hand. These exposures, I go down to the restroom down the hall, and I have patients put their hands on the toilet seat on the bathroom floor and sit in my office.

Nikki Kinzer:
That just makes me cringe.

Roberto Olivardia:
I know. It sounds-

Pete Wright:
We're being recorded right now. You know that?

Roberto Olivardia:
I totally am aware this will make me sound so sadistic but I trust you people who listen to this, this is the treatment for OCD. I had somebody who feared the number six was so attached. It was like 666 is the devil sign. They literally turned down buying a house because it had a number six. They could not go into a building that had the number six. So their exposure was they had to wear a T-shirt that we made where they wrote the number six 666 times on this T-shirt and had to wear the shirt. These are the kinds of things. It sounds so bizarre. And then sometimes it's just the response prevention sometimes is preventing the ritual. So let's say if somebody has a certain thought and then they have to say the Hail Mary prayer 15 times in their head, we have them not say that, which is hard because it's almost like there's such a pull, but it's like, nope, we're going to now do something else and not do the ritual. Because what you want is to disconnect this idea that once you realize, oh, wait a minute, my mother didn't get cancer and I didn't say the Hail Mary, clearly that has nothing to do with it. If my mother ends up getting cancer, it has nothing to do with whether I said the Hail Mary or not.
So yeah, I'll have people rub their hands on the bathroom floor. They sit in my office for an hour or two and we can talk, and they're sitting there with the anxiety. But it's also think about all the people that walked into that bathroom with their nasty ... Doing whatever. Now, why the ADHD is important to assess is in my training, many years ago at The OCD Institute, I had a patient, and it was like a side note that he happened to have ADHD. And he had his hands in garbage, literally in a trash can. And he looked too calm almost for anyone, let alone someone who had OCD around that.
And I said, "What are you thinking right now?" And he said, "Oh ..." There was another patient who was wearing a Disney shirt. Disney World. And he says, "Oh, I'm seeing that guy's shirt. It reminds me of this trip to Disney World." And he went on this tangent about Disney. I'm like, "Oh, no, no. We don't want you thinking about Disney World right now. I want you to think about your hands in the disgusting trash." And he's like, okay. And then two minutes later, he was thinking of something else. And the ADHD ... And it's different because it can almost look like a defensive ... Almost like anxiety at work to be like, oh, I'm going to think of something else. But he said it wasn't that. And I could see it in his face. It was more like, I'm bored putting ... He was off. And I'm like, no, this is where we want you to sit with the anxiety to bring what we call the SUDS or subjective units of distress level up. But you bring it up on a scale of one to 10. A nine, 10 is panic level. We don't want to panic. So we have to create a hierarchy to work our way up because we don't really habituate to panic.
If you're in a burning building, your body is designed to never be okay with that. Your body won't be like, oh, a little burning building, whatever.

Nikki Kinzer:
It's fine.

Roberto Olivardia:
Fine. You are going to run out, or you're going to grab a fire extinguisher and put out that fire, and that's good. We want that. But at an eight, you could withstand ... There are lots of anxiety provoking situations that we have to sit with. And again, unlike with just even generalized anxiety disorder, which is worry basically about something, with OCD, it is this very active treatment of not avoiding certain things and engaging. So with that individual who had that OCD where he feared molesting kids, his exposure was to walk past childhood playgrounds because he wouldn't even want to drive down them. He would play horsey with his son. Now, his thoughts would go to, "Oh my gosh, what if I get an erection? Maybe I have one." And the thing is you know when you have one. But the OCD will almost convince somebody, well, how do I know for sure? I had a patient say, "Well, sociopaths, they don't know that they're sociopaths, so maybe I'm a sociopath." And of which I responded, "Most sociopaths and psychopaths don't question that they're ... They don't care enough. So that's the problem."
And so it's very active. But the ADHD piece definitely, definitely has to be contained in that way. And again, with situations, it's also assessing what's the ADHD and what's the OCD? And even young kids I work with who have both, I have to say, are pretty good at recognizing when one is happening and the other. And sometimes have to inform their clinicians or their parents and saying, "Oh no, that's not the OCD. That's like I was bored and my head just ... And when I'm bored, it can give rise to the OCD." So for example, if somebody's ADHD doesn't have them grounded and present and stimulated, it's almost like their mind starts opening up. Now, if you have OCD, guess what's going to fill that? It's not going to be, I don't know, thinking of playing video games. That OCD is going to fill up that space. And an ADHD brain, we lean towards what is stimulating. Not everything that's stimulating is pleasurable. Anxiety is very stimulating, but not pleasurable.

Pete Wright:
That's the trick. You just described something I thought was really fascinating about this person whose ADHD is distracting them from their exposure therapy. That seems like a significant twist. And on the other side of that, all I can think about is the hyper focus just amplifying the experience of the OCD.

Roberto Olivardia:
Absolutely. And I do see a difference when it's just OCD versus OCD and ADHD in terms of that fixation. And just even from my experience, I have a very visual imagination. I think in pictures. So when I would have these scenarios and images ... I don't know. I'm not in anybody else's brain, but they feel on a whole other level than something else that I'm experiencing. So when individuals would have that, they would almost say, I almost feel like I'm leaning into the OCD, but I don't want to be. And that's where treating the ADHD ... And the more grounded somebody is, the less we want ... We don't want that portal opened for the OCD basically. We want to close that. And the more grounded and present somebody is, the less likely that happens.
So why it's so important of treating ADHD, because it is sometimes so foundational. I see that with people on the bipolar disorder spectrum. And studies show this, and I've seen this clinically. When the ADHD is managed, people's lives are less chaotic, they're sleeping better, they're eating better, their stress management is better. And when those are not working, those are all triggers for manic episodes. So if you have somebody who's better emotionally regulated, sleeping better, organized, you are drastically reducing the risk of a manic or depressive episode or psychotic episode, like, oh my gosh, this is big in that way.

Nikki Kinzer:
So important. Right.

Roberto Olivardia:
So important.

Nikki Kinzer:
So important. Wow.

Pete Wright:
Fascinating.

Nikki Kinzer:
You've talked about the different kinds of treatment. When do you know that they ... Like that lady that was the driver and you did the three hours of the driving. Is she able to drive now and those thoughts get passed or do you relapse in OCD? How does that look?

Roberto Olivardia:
That's a great question. It really does require consistent work. Because OCD really breeds on avoidance and absolutely people can relapse. And at the same time, once people can have that experience, sometimes they'll still have the thought, but the thoughts aren't sticky, we say. They just are like, eh. And then sometimes people don't have the thoughts anymore. I don't have that thought anymore with the driving at all. At all. It's just not even there. And one of the things, particularly when people leave an intense residential program like The OCDI, there's so much work and keeping that momentum in their outpatient care. Because once it starts with somebody just saying ... It's almost like an analogy to an addiction in some ways. If you lapse and say, oh, maybe one drink. Let me just do that checking just once. What's the harm? It can easily spiral.
Now, having said that, a lot of times when people have done good ERP, exposure response prevention work, the spiral, they can get back to their foundation quicker because they've now had the experience of, wait a minute, I was doing that and it worked. I need to just get my skills. So the gold standard treatment is the ERP and typically medication. So for moderate to severe OCD medication is a very important part of the picture. The medication of choice are the SSRIs and particularly two of the SSRIs, Zoloft and Luvox, that are antidepressants, but they have a lot of anti-obsessional properties to them. So people find that they're better able to ... Almost like the thoughts aren't so fast that they almost are just blinded by them, that they can almost pause and think, okay, wait a minute, that's not realistic. Me doing X, Y, and Z is really not going to help it.
Or it gives them that extra oomph to be able to do the exposure. Because the other part of ADHD is we don't like to feel bad. No one likes to feel bad. But people with ADHD really don't like to feel bad. We like our pleasure, fun things to do. So there is something I find with ADHD of doing that work and leaning into something that feels very uncomfortable. And for a group of people, as we know, emotional regulation is an executive function. So sometimes the work in even doing the OCD work is just like with that patient I mentioned. We need to first do some skills on emotional regulation before we can even put you into a situation where we know you're going to be really taxed. Because an ADHD person might really have no coherent organized way of processing those emotions. So that's where having that understanding again of ADHD is so key and central in doing the OCD work.

Nikki Kinzer:
Right. Right. Wow.

Pete Wright:
This is my mind-blowing experience right now. I a month and a half ago was prescribed a medication I had never taken before, and I've done the adjustment on it and I have noticed over the last probably three to four weeks that things have been appreciably different. That the intrusive thought spirals are no longer plaguing me. Not once have we ever said the words OCD, but I want to call my doctor and just say, "Do we think that I have ... Are we really treating OCD here?" Because the OCD stuff feels better. And I did not ever know that's what I was ... I've just been calling it just oh, anxiety. This is what my anxiety looks lik but having some specificity to it describes my lived experience in a way I've never thought about. That's crazy. It's amazing to me right now.

Nikki Kinzer:
Well, and I think just the way you explain it too, it's just so interesting because I just never knew that that was the in-depth of it. Because you're right. In Hollywood and TV, you see the person who's hand washing and won't shake hands or whatever, but there's so much more. I just really appreciate the way you explain it and talk about your past patients because it really just starts to put it together and makes sense.

Roberto Olivardia:
And it really can come in different forms. Again, there's a type of OCD where people fear that they're offending somebody. And again, the difference between anxiety and especially when you put ADHD in the mix. So people with ADHD sometimes do say things that offend people without meaning to. They might be impulsive. They can point to this real life thing of, oh, I said this offensive thing and I didn't mean to blurt it out, or I did interrupt that person. So they can feel anxiety around that, feel anxious around that. Whereas with OCD, it goes on to this other level of I fear offending somebody. Now there are clear ways that we can see. But then it gets to places like I was talking about my favorite movie being Batman, and how do I know that that person might have had some negative experience with Batman, and if I made them feel bad and I offended them, that makes me a horrible person.
And so OCD gets into the character of somebody in a way that generalized anxiety doesn't always hit that level. It's like we're worried about something. We might worry about failing a test. And anxiety is debilitating too. But it is this different animal in that with OCD, it gets into this characterological thing in some sense of what this means of who you are. And I now must do something with this and fix it.

Nikki Kinzer:
Fix it to make it not happen.

Roberto Olivardia:
Exactly.

Nikki Kinzer:
Yeah.

Roberto Olivardia:
I remember the OCD Institute and there was, I ran a group for people with body dysmorphic disorder, people who have preoccupations with part of their appearance. And there was a patient in that group who had OCD and BDD. And on the chair I was sitting in it said, "Dr. Olivardia should die a miserable death." And I know this is somebody's exposure. And sure enough, it was. This patient who risked offending people. But their OCD got to such a degree that they didn't go to work because they feared anything that would come out of their mouth could be misinterpreted in such a way that would be offensive. And this is somebody who really ... Again, sweet, sensitive. The last person who would do that, which is why the thought is so disconcerting. So I saw the note and I just put it aside and I could see the anxiety in her face. And of course I wasn't going to say, "Oh, I know this is your ERP and you don't want me to die a miserable ..." I didn't say that because I knew.
So the ERP sometimes is not even just exposure to the everyday situations, but just like rubbing your hands. I don't recommend that people rub their hands on a nasty bathroom floor every day. But if you have that kind of OCD where you're not touching anything, it may require you to go way in because if you can habituate to that, then you can easily habituate to touching a doorknob. If you can habituate to literally saying writing, someone should die a miserable death, then you're going to be fine with saying, oh, I like coffee even if the other person doesn't like coffee, it doesn't mean you've offended them in that way.
But it's so important to know OCD runs in families as ADHD does. And interestingly, when we look at the comorbidity that ... There are parts of the brain where they have in common where the OCD is hyper activating, the ADHD might be not activating enough. But you know what's interesting? The most prevailing theory is to this high comorbidity because there are lots of reasons it shouldn't be as comorbid. And it comes down to a term that we refer to as non-random mating, which is basically the phenomenon that people with ADHD hook up with people with OCD or on that spectrum, ADHD spectrum, OCD spectrum, they couple together and they mate. And because both are heritable, you're going to have a kid with ADHD, you might have a kid with OCD and you'll have a kid with both. When I say that in audiences, and especially where there are couples, you always see couples looking at each other like mm-hmm. Yep. We know. And there is this unconscious coupling. It's really weird. You see it a lot. I definitely saw it in my parents.
And it's not like someone with ADHD is like, you have wonderful executive functionings, therefore I will mate with you. Or the person with the anxiety may not be saying, oh, this person is spontaneous and free, and that's very freeing and flexible. I like that. But clearly that's unconsciously happening. And so genetically, these are two very heritable conditions. So anxiety and OCD traits run in my family. ADHD definitely runs in my family, but it could be, again, varying degrees depending on the genetic loading and certain environmental experiences that people have had.

Nikki Kinzer:
Wow.

Pete Wright:
Well, this has been an incredible hour. Thank you so much.

Roberto Olivardia:
Oh, my pleasure.

Pete Wright:
Dr. Olivardia for being here and for blowing my mind. And I know from the chat room that other minds have been completely blown. This has been a really wonderful conversation. Where can we send people to learn a little bit more about you and your work?

Roberto Olivardia:
So I don't have any social media presence or website. I'm in the dark ages with that. Part of to manage my own ADHD-

Pete Wright:
You can give your home address if you want. We'll just come to your house.

Roberto Olivardia:
I do recommend though good old-fashioned email. If people have any questions, if wherever you are in the US or the world, if you're looking for OCD treatment, I'm more than happy to direct people to resources. My email is Roberto R-O-B-E-R-T-O, _Olivardia, O-L-I-V-A-R-D-I-A, @hms.harvard.edu. I would also direct people to, of course, ADHD organizations like CHADD and Adam. And for OCD, the organization is the International OCD Foundation. They do phenomenal work. They have a conference that I highly recommend. It's usually in July. This year, I think it's in Orlando. And it's similar to Nikki like the ADHD conference. It's not just professionals, it's families. And the OCD conference, because it's in July, they also have a young person's track where kids and teens, they attend talks and they get a sense of community. It's such a great conference. I highly recommend. But that organization, you want to know anything about OCD, go on that website. Webinars, podcasts, information, articles, books that they recommend. They do great work.

Nikki Kinzer:
Great.

Pete Wright:
Outstanding.

Nikki Kinzer:
Thank you so much.

Pete Wright:
Thank you so much. We will put links to all of those resources in the show notes and we so appreciate you.

Roberto Olivardia:
My pleasure.

Pete Wright:
We sure appreciate all of you for downloading and listening to this show. Thank you for your time and your attention. Don't forget if you have something to contribute to the conversation, we're heading over to the show talk channel in our discord server, and you can join us right there by becoming a supporting member at the deluxe level or better. On behalf of Dr. Roberto Olivardia and Nikki Kinzer, I'm Pete Wright, and we will see you right back here next week on Taking Control: The ADHD Podcast.