Ryan S. Sultan, MD
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📂 Category: ADHD Comorbidities
By Ryan S. Sultan, MD
Assistant Professor of Clinical Psychiatry, Columbia University
February 13, 2026
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OCD and ADHD co-occur in 10-15% of cases, creating the paradox of perfectionism versus inability to be perfect. OCD involves intrusive thoughts requiring rituals, while ADHD involves distractibility preventing ritual completion. |
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Quick Summary: OCD and ADHD are distinct disorders but frequently occur together (10-15% comorbidity). OCD involves intrusive thoughts and compulsive behaviors driven by anxiety; ADHD involves attention, impulsivity, and executive dysfunction. They can look similar (both cause repetitive behaviors and difficulty completing tasks) but have different mechanisms and treatments. You can have both, and treatment must address each condition separately. |
| Feature | OCD | ADHD |
| Core Problem | Intrusive thoughts (obsessions) + rituals (compulsions) | Inattention, hyperactivity, impulsivity |
| Primary Emotion | Anxiety, fear, doubt | Boredom, restlessness, frustration |
| Thoughts | Unwanted, intrusive, repetitive, distressing | Racing, jumping between topics, distractible |
| Repetitive Behaviors | Rituals to reduce anxiety (washing, checking, counting) | Stimming, fidgeting for regulation (not anxiety-driven) |
| Why You Repeat | "If I don't do this, something bad will happen" | "My brain needs stimulation" or "I forgot I already did it" |
| Task Completion | Can't finish because it's "not right" (perfectionism) | Can't finish due to distraction or forgetting steps |
| Organization | May be overly organized (compulsively) | Usually disorganized (executive dysfunction) |
| Resistance | Want to resist compulsions (recognize they're irrational) | Often unaware of impulsive behaviors until after |
| Brain Regions Involved | Overactive orbitofrontal cortex + basal ganglia | Underactive prefrontal cortex + dopamine deficiency |
| Treatment | SSRIs + Exposure therapy (ERP) | Stimulants + CBT |
Obsessive-Compulsive Disorder (OCD) is characterized by:
1. Obsessions: Unwanted, intrusive thoughts, images, or urges that cause distress
Common obsessions:
2. Compulsions: Repetitive behaviors or mental acts done to reduce anxiety from obsessions
Common compulsions:
Key feature: You know the thoughts are irrational, but you can't stop them. The compulsions temporarily reduce anxiety, reinforcing the cycle.
Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by:
1. Inattention:
2. Hyperactivity/Impulsivity:
Key feature: Executive dysfunction—difficulty with planning, initiating tasks, regulating emotions, and managing time.
| Behavior | OCD Reason | ADHD Reason |
| Rechecking work | Anxiety that you made mistake (compulsion) | Actually did make mistakes; poor working memory |
| Rereading sentences | Didn't feel "right" the first time | Mind wandered, didn't register the words |
| Asking questions repeatedly | Need reassurance to reduce anxiety | Forgot the answer you just got |
| Organizing/reorganizing | Need perfect order to reduce anxiety | Hyperfocus on organizing as procrastination |
OCD: "I can't finish because it's not perfect, not done 'right,' or I keep redoing parts."
ADHD: "I can't finish because I got distracted, forgot what I was doing, or lost motivation."
OCD: Specific, disturbing, repetitive thoughts that cause intense anxiety ("What if I left the stove on and the house burns down?")
ADHD: Racing thoughts, jumping between topics, but not distressing or ritualized
OCD: Lose track of time doing compulsions (washing hands for 45 minutes)
ADHD: Lose track of time due to poor time perception (hyperfocus or time blindness)
Yes. Comorbidity is common.
Statistics:
"I have intrusive thoughts about harm (OCD), and then my ADHD brain latches onto them and won't let go. I try to do compulsions to feel better, but my ADHD makes me forget mid-ritual, which increases the anxiety."
"My OCD tells me everything must be perfect. My ADHD makes me incapable of being perfect. It's exhausting."
"I lose things constantly (ADHD), which triggers obsessive checking and anxiety (OCD) that I've lost something important."
If you have repetitive behaviors, ask:
If you have intrusive thoughts, ask:
Problem 1: SSRIs (for OCD) can worsen ADHD
Problem 2: Stimulants (for ADHD) can worsen OCD
Solution: Careful medication sequencing and monitoring
Option 1: Treat ADHD First
Option 2: Treat OCD First
Option 3: Treat Both Simultaneously
| For OCD | For ADHD | Notes |
| Fluoxetine (Prozac) | Adderall or Ritalin | Common, generally well-tolerated |
| Fluvoxamine (Luvox) | Vyvanse | Luvox specifically FDA-approved for OCD |
| Sertraline (Zoloft) | Strattera or Wellbutrin | Non-stimulant ADHD meds may be better tolerated |
| Clomipramine (Anafranil) | Stimulant | Clomipramine is most effective OCD med but has more side effects |
For OCD: Exposure and Response Prevention (ERP)
For ADHD: CBT + Skills Training
When you have both: Therapist must address both conditions, often alternating focus or using integrated approach.
OCD says: "Everything must be perfect, controlled, orderly"
ADHD says: "I can't maintain order, I forget things, I'm impulsive"
Result: Constant internal conflict and exhaustion
1. Compulsive Checking vs. ADHD Forgetfulness
"Did I lock the door because I'm anxious (OCD), or because I actually forgot and need to check (ADHD)?"
Solution: Use external systems (smart locks, photos of locked door, alarms)
2. Perfectionism vs. Inability to Execute Perfectly
"My OCD demands perfection. My ADHD makes perfection impossible. I'm stuck."
Solution: Therapy to reduce perfectionism standards + ADHD accommodations to improve execution
3. Cleaning/Organization Compulsions vs. ADHD Clutter
"I need everything organized (OCD) but I can't maintain organization (ADHD)."
Solution: Simplified organization systems + acceptance of "good enough"
Sarah, 28, was diagnosed with OCD because she rechecked her work constantly and was "obsessed" with not making mistakes. She tried ERP therapy and SSRIs, but they didn't help.
When re-evaluated, she actually had ADHD—not OCD. She was rechecking work because she did make frequent mistakes (poor attention), not because of irrational anxiety. She wasn't ritualistic; she was compensating for executive dysfunction.
Treatment with ADHD medication (Vyvanse) dramatically reduced her need to recheck, because she was no longer making as many errors.
Marcus, 34, had been treated for ADHD since childhood. In his 20s, he developed intrusive thoughts about harming others and compulsive checking behaviors. His ADHD medication helped his focus but didn't touch the obsessions.
He was diagnosed with OCD in addition to ADHD. Treatment: continued Adderall for ADHD + added Prozac 60mg for OCD + ERP therapy. After 6 months, both conditions were well-managed.
Lisa, 42, had mild OCD (contamination fears) that was manageable. When she entered perimenopause, her ADHD symptoms worsened dramatically (hormones affect ADHD). The increased executive dysfunction made her OCD spiral—she couldn't remember if she'd washed her hands, leading to more checking and anxiety.
Treating her ADHD (adding stimulant medication) improved her executive function, which indirectly reduced her OCD symptoms by decreasing uncertainty.
Consider evaluation for comorbid OCD + ADHD if:
Key takeaways:
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Think You Have OCD, ADHD, or Both? Dr. Ryan Sultan provides comprehensive evaluation and treatment for both conditions. Accurate diagnosis is crucial for effective treatment. |
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