Intractable Obsessive-Compulsive Disorder

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Ovid: Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder?

The Journal of Nervous & Mental Disease Issue: Volume 187(4), April 1999, pp 243-245 Copyright: © 1999 Lippincott Williams & Wilkins, Inc. Publication Type: [Brief Reports] ISSN: 0022-3018 Accession: 00005053-199904000-00008

[Brief Reports]

Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder? van der Feltz-Cornelis, Christina M. M.D., M.Sc.1

Author Information 1 Department of Psychiatry, Vrije Universiteit Amsterdam, PCA Valeriuskliniek, Valeriusplein 9, 1075 BG

Amsterdam, The Netherlands. Send reprint requests to Dr. van der Feltz-Cornelis. Evidence is emerging that attention-deficit hyperactivity disorder (ADHD) can persist into adulthood and that this is a valid, and not uncommon, diagnosis (Spencer et al., 1998). It can successfully be treated with methylphenidate (Spencer et al., 1995) or with antidepressants (Wilens et al., 1995, 1996); treatment with other pharmacological agents, as well as nonpharmacological treatment, is still under scrutiny (Spencer et al., 1995; Wilens et al., 1995). One problem is that ADHD often goes unrecognized, due to comorbidity with other psychiatric syndromes (Fargason and Ford, 1994). In the event of comorbidity, a diagnosis of childhood-onset adult ADHD is difficult to establish retrospectively (Craig, 1996). In such cases, the Wender Utah Rating Scale (Ward et al., 1993), specially designed for the retrospective diagnosis of childhood-onset adult ADHD, can be used to verify the diagnosis. Comorbidity has been reported between ADHD and various depressive and anxiety disorders (Spencer et al., 1995), substance abuse (Stratton and Gailfus, 1998; Wilens et al., 1998), bipolar disorder, antisocial disorder, mental retardation, Tourette's disorder (Biederman et al., 1991), and atypical neuroleptic-refractory psychosis (Pine et al., 1993). However, obsessive-compulsive disorder (OCD) has not yet been studied in relation to comorbidity with ADHD. This article discusses two cases which indicate that OCD can coexist with adult ADHD and that the symptoms of OCD can subside completely after treatment of ADHD alone.

Cases Patient A, aged 45, partially deaf, married, and father of two, was referred to our outpatient clinic because of memory problems. Previous neurological examination had yielded no evidence of dementia, epilepsy, or other neurological syndromes. During the psychiatric examination, the patient complained of compulsions, such as tidying up the room, occurring on an almost daily basis and lasting up to 12 hours. The patient felt deeply ashamed about this. He also suffered from obsessive rumination about the difficulties he had with concentration. A constant sense of loss of control was another source of embarrassment. He had trouble falling asleep and awoke repeatedly with nightmares. His behavior had given rise to conflicts at work and at home. Symptoms worsened when stressful events occurred. Childhood-onset learning difficulties had hampered his education and working career since primary school. During puberty, he had been chaotic and suffered concentration problems. Yet no ADHD diagnosis was ever made, possibly because his learning difficulties were ascribed to his partial deafness. He currently still had persistent difficulties in focusing and maintaining attention.



Ovid: Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder?

During psychiatric examination his attention lapsed every few minutes. His thinking was slow, and he was evasive, with a striking inability to come to the point in providing details. His obsessions centered on his lack of control over his cognitive functions. His memory functions were intact and no other pathology was found. An OCD (DSM-IV 300.30; American Psychiatric Association, 1994) based on an underlying childhood-onset adult ADHD, combined type (DSM-IV 314.01), was diagnosed, and the diagnosis was discussed with the patient and his wife. The hypothesis was made that the OCD had developed as a consequence of stress at work and at home and as a fruitless attempt by the patient to maintain control over his attention and concentration. Our first therapeutic option was therefore to treat ADHD with methylphenidate, on the assumption that his obsessions and compulsions would recede if he could regain control over his concentration. Methylphenidate was started at a dosage of 10 mg twice daily, at 08:00 and 12:00 hours. Blood pressure and heart rate remained normal, as did Hb/Ht, leukocytes, differentiation, and thrombocytes. Within a few days, the patient noticed improvement in his concentration, so that he could resume work promptly and at a higher level than ever before. His nightmares ceased and he slept better than ever. The compulsions and obsessions vanished completely. In the event of stressors requiring extra concentration, he was advised to take an extra dose of 5 mg, but never to take methylphenidate after 16:00 hours, to avoid having his sleep disturbed by the medication. The patient and his family received counseling about ADHD. He is now, 1 year later, still on methylphenidate and has suffered no relapse, even though he had previously never been without symptoms. Patient B, a 30-year-old single man, prone to complex partial epileptic seizures that were under control with valproic acid 1500 mg and clonazepam 4 mg daily, had been treated unsuccessfully for OCD with clomipramine 300 mg daily for a year before referral. During the psychiatric consultation, he could not stop asking if he was going insane, and he complained of obsessions centering on a lack of control over his thoughts and on his fear of insanity. He also had to wash his hands repeatedly and check whether everything he touched was clean. He had experienced learning difficulties and restlessness since childhood, and had always had trouble concentrating; however, this had always been blamed on his epilepsy. Although a neurologist had now confirmed that his EEG showed no current epileptic activity, his attention still slipped about every 5 minutes during the psychiatric examination. Some questions had to be repeated several times before he could reply. His thinking was impeded by his obsessive ruminations, and he appeared very anxious. There were no other signs of pathology. An OCD (DSM-IV 300.30; American Psychiatric Association, 1994) based on an underlying childhood-onset adult ADHD, combined type (DSM-IV 314.01), was diagnosed. The diagnosis was discussed with the patient, along with our hypothesis that the OCD was a fruitless attempt on his part to gain control of his attention and concentration and that his obsessions and compulsions would disappear if he could regain control. Methylphenidate was started at a dosage of 10 mg twice daily, at 08:00 and 12:00 hours. Blood pressure, heart rate, Hb/Ht, leukocytes, differentiation, and thrombocytes all remained normal. Within a few days, the patient noted improvement in his concentration, and after elevation of the dosage to 30 mg twice daily, his obsessions and compulsions remitted completely within 4 weeks. Rebound restlessness occurred at the end of the afternoon, but this was successfully eliminated by an extra dosage of 5-mg methylphenidate at 16:00 hours. Slow, stepwise discontinuation of clomipramine was started without relapse of the OCD. Nor did any epileptic seizures occur during methylphenidate maintenance treatment.

Discussion In the two cases described, intractable OCD coexisted with previously undiagnosed childhood-onset adult ADHD. Both patients responded well to explanation of their symptoms and to treatment with methylphenidate. OCD subsided completely and ADHD symptoms improved significantly. In both cases, we hypothesized that the OCD was the result of unsuccessful attempts by the patients to gain control over their cognitive functioning. Both patients complained about loss of control, which they tried to cope with through their compulsions and their obsessive self-analyses. In this light, the OCD could be regarded as a complication of ADHD.



Ovid: Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder?

The treatment described here appears to have achieved a two-track improvement of their coping abilities. First, the patients were informed about the underlying basis of their sense of lack of control-the presence of unrecognized childhood-onset adult ADHD-and given hope of treatment. This provided them with a frame of reference that may have helped them overcome their excessive rumination about their symptoms. Second, because their feeling of loss of control may have derived from their concentration difficulties, this was countered by treating the ADHD with methylphenidate. Alternatively, both the OCD and the ADHD may have had a common neurophysiological basis, with both responding to the same pharmacological treatment. There are some indications that this is indeed the case. For example, in child psychiatry, ADHD, OCD, and Tourette's syndrome have been found to coexist (Scahill et al., 1993). About 50% of children with Tourette's disorder exhibit ADHD, and 60% OCD (Hanna, 1995). Both conditions have been associated with lesions in the basal ganglia (Laplane et al., 1989), prompting speculations that Tourette's disorder and OCD either are closely linked in heritability or share the same neuropathological substrate (Cummings, 1995). Wender (1998) has suggested that ADHD may be produced by decreased catecholaminergic functioning, resulting in a low turnover of dopamine and possibly norepinephrine. For Tourette's disorder, a similar mechanism has been proposed by which an excess of autoreceptors reduce the production and release of dopamine. Another amine implicated by a few reports is serotonin (Arnold and Jensen, 1995). Although OCD has been linked to dysfunctions of the serotonergic as well as the adrenergic system, studies suggest that a comprehensive model of OCD must be based on a multiple neurotransmitter system (Jenicke, 1995). Tourette's disorder is one of the tic disorders, and it can show high variability within the clinical phenotype (McMahon et al., 1996). Tics can subside partially or fully in adulthood. However, the patients described in this article did not report tics in childhood, nor did they develop them during treatment with methylphenidate, as might be expected in the event of Tourette's disorder (Clementz et al., 1988). It thus seems plausible that, distinct from the triad Tourette's disorder, ADHD, and OCD in childhood, a cluster might exist that is made up of childhood-onset adult ADHD and OCD, and that possibly has a similar neuropathological, genetic, or neurophysiological substrate in adults. This has the following clinical implications. When confronted by intractable OCD, clinicians should be alert to the possibility of an underlying, previously unrecognized childhood-onset adult ADHD. This may particularly be true if comorbidity exists which might have disguised the ADHD symptoms, as was found in both the patients described here. Patient A had received extensive counseling, but his learning difficulties were blamed on his partial deafness; patient B's concentration problems were known, but they were attributed to epilepsy. It should be kept in mind that ADHD is found in association with epilepsy too (Young et al., 1995), and that, if properly medicated, the epileptic symptoms do not deteriorate during treatment with methylphenidate. The Wender Utah Rating Scale (Ward et al., 1993), specifically developed for adult ADHD, can be used to confirm the diagnosis. If ADHD seems likely and the patient has no symptoms of tic disorder, treatment with methylphenidate can be commenced at dosages of up to 1 mg/kg daily. Normally, dependence can be expected to develop only at dosages in excess of 300 mg daily in adults. Methylphenidate should be given twice a day, at 08:00 and 12:00 hours, and the patient should be initially monitored for adverse reactions. Within a few days, the symptoms should diminish, and dosage can be adjusted accordingly. Sometimes patients grow more restless during the afternoon due to withdrawal, in which case a 50% additional dose should be given at 16:00 hours. Patients should not take methylphenidate any later, to avoid possible sleep disturbances. Occasionally, if patients need to perform temporarily at higher attention levels (e.g., at a party or exam), they can take an extra dose 1 hour before the stressor begins.




Ovid: Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder?

Patients and their families should receive counseling on the symptoms of ADHD and on ways to cope with it. It should be explained that the OCD is probably a concomitant of that disorder. With the treatment described here, the OCD symptoms are likely to remit completely and ADHD symptoms to improve significantly. Methylphenidate maintenance treatment is necessary. If serotonergic medication has been given previously, stepwise discontinuation can be initiated as soon as the OCD has abated. Further study is now needed on the assessment, treatment, and possible classification of a distinct patient group with OCD and childhood-onset adult ADHD. Christina M. van der Feltz-Cornelis, M.D., M.Sc.1

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Ovid: Intractable Obsessive-Compulsive Disorder: Comorbidity with Unrecognized Adult Attention-Deficit Hyperactivity Disorder?

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