CNS Spectr. 2007;12(5):338-342
Faculty Affiliations and Disclosures
Dr. Josephson is clinical associate professor of psychology in psychiatry at Cornell University Medical School New York City. Dr. Hollander is the editor of this journal, Esther and Joseph Klingenstein Professor and Chairman of Psychiatry at the Mount Sinai School of Medicine, and director of the Seaver and New York Autism Center of Excellence in New York City. Ms. Sumner is a doctoral student in the Department of Psychology’s clinical psychology program at Northwestern University in Chicago, Illinois.
Disclosures: The authors do not have an affiliation with or financial interest in any organization that might pose a conflict of interest.
Submitted for publication: August 4, 2006; Accepted for publication: April 18, 2007.
Please direct all correspondence to: Stephen C. Josephson, PhD, 16 East 65th Street, Fourth Floor, New York, NY 10021; Tel: 212-288-2777, Fax: 212-288-4843.
• Task-completion difficulties and organizational problems are seen in various disorders.
• Individuals with comorbid attention-deficit/hyperactivity disorder and obsessive-compulsive personality disorder symptoms may experience significant difficulties with these performance issues.
• Treatment that combines specific medications and cognitive-behavioral coaching modalities may be particularly helpful for individuals with attention-deficit/hyperactivity disorder and obsessive-compulsive personality disorder-related performance problems.
Three patients were seen in an outpatient setting with work difficulties involving disorganization and task completion. They were evaluated and found to have significant symptoms of both attention-deficit/hyperactivity disorder, inattentive subtype and obsessive-compulsive personality disorder and were then treated with a creative combined behavioral and medication treatment, which emphasized the use of external aides (eg, paraprofessionals). Significant symptom reduction was observed as a result of this combined intervention.
Comorbidity is common in outpatient psychiatric settings. This case report identifies individuals with comorbid obsessive-compulsive personality disorder (OCPD) and attention-deficit/hyperactivity disorder (ADHD) who present with symptoms that include severe chronic procrastination with significant personal and professional consequences; distractibility and problems in completing projects; perfectionism and rigidity; and disorganization, clutter, and avoidance of dealing with the clutter.1 Because these patients may experience anger difficulties and other problems, including repetitive behaviors and/or impulsivity, misdiagnosis is common. Often, obsessive-compulsive disorder (OCD) or bipolar spectrum disorder diagnoses may be erroneously given. Underperformance in school, beginning in elementary school, and/or at work are the norm, often provoking anxiety and/or depression. This results in a referral to a mental health professional. A commitment to productivity, often high intelligence, and enhanced attentional focus (ie, hyperfocus) at the time of the deadline may have permitted success until later in life (eg, college) when academic demands increase. The patients reviewed here showed ADHD (predominantly inattentive subtype) symptoms since childhood, with OCPD symptoms becoming evident in adolescence.
Grisham and colleagues’2 discussion of early- and late-onset hoarding subgroups is particularly relevant with this small cohort falling into the former category. It is unclear as to why hoarding may begin at different times developmentally, but there are probably different causal factors based upon age of onset. Task-completion difficulties in these patients may also be related to perfectionism and their inability to allow others to help and collaborate. Activities that require decision-making, such as organizing or decluttering, are particularly problematic.
There are often differences between ADHD and OCPD with respect to money management. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision,1 ADHD is generally associated with excess spending and OCPD is related to penuriousness. Furthermore, ADHD sufferers may have associated features, such as low frustration tolerance and temper outbursts, whereas individuals with OCD tend to become annoyed in situations that they are unable to control although the anger is typically expressed indirectly. Despite the overlap in symptoms in these three patients, we see the differences between many individuals with these complaints.
The patients were screened with DSM-IV-TR criteria for ADHD and OCPD diagnoses and met all criteria for both disorders. They were screened through a clinical interview. The Personality Diagnostic Questionnaire-4 (PDQ-4)3 was used to assess for OCPD. The PDQ-4 is a self-report questionnaire that is used to assess the 10 DSM-IV-TR personality disorders, plus two provisional disorders (depressive personality disorder and negativistic personality disorder). Each of the 100 true/false items corresponds to a single diagnostic criterion, and “true” responses are scored as pathological. Consistent with DSM-IV-TR, the OCPD diagnostic scale requires that an individual endorse at least four out of eight criteria in order to qualify for a diagnosis of OCPD. Even though the immediate predecessor of the PDQ-4, the Personality Disorder Questionnaire-Revised, has been suggested to be reliable and valid,4 some issues regarding the internal consistency and rate of false-positive diagnoses of the PDQ-4 have been raised.5,6 Given these concerns, the Clinical Significance Scale, a mini-structured interview, was also used in an attempt to validate the information obtained from the questionnaire. This component of the PDQ-4 assesses the duration of the behavioral traits, the situations in which they occur, the extent to which the traits have caused problems for the patient, whether the traits are concurrent with Axis I problems, and the degree to which the patient is bothered by the behaviors.
In order to assess for ADHD, the Adult ADHD Self-Report Scale Symptom Checklist (ASRS),7 the Brown Attention-Deficit Disorder Scale (BADDS),8 and the Brown Attention-Activation Disorder Scale (BAADS)9 were used. The ASRS is comprised of 18 items that each map onto one of the DSM-IV-TR diagnostic criteria for ADHD. Six of the items have been found to be the most predictive of symptoms characteristic of ADHD.10 These six items make up a screening scale, and the endorsement of at least four of these items in the past 6 months is suggestive of an adult profile of ADHD, and warrants further investigation. The ASRS has been demonstrated to be a reliable and valid scale for evaluating ADHD in adults, and it shows high internal consistency and concurrent validity with a rater-administered ADHD Rating Scale.11 The BADDS consists of 40 self-report items that measure core symptoms of ADHD. The BADDS assesses five clusters of ADHD-related executive functioning impairments: organizing, prioritizing, and activating work; focusing, sustaining, and shifting attention to tasks; regulating alertness, sustaining effort, and processing speed; managing frustration and modulating emotions; utilizing working memory and accessing recall; and monitoring and self-regulating action. The scale provides age-based norms, and has been demonstrated to have good internal consistency and good test-retest reliability. The total score can range from 0–120; scores >55 are highly suggestive of ADHD, scores ranging from 40–54 are suggestive of “probable” ADHD, and scores <40 are suggestive of “possible” ADHD. The BAADS is a self-report scale designed for retrospective use with adults with possible ADHD. The scale consists of five symptom clusters: activating and organizing work; sustained attention and concentration; sustained energy and effort; irritability and sensitivity; and memory and recall. For each cluster, participants rate the extent to which each item is problematic and how frequently it occurs on a scale from 0 (“not at all a problem, never occurs”) to 3 (“very much a problem, occurs every day”). A total score >12 for a given cluster is indicative of a problem in that area. If a patient met criteria for current ADHD based on the above three measures, then clinical interviewing was utilized to examine whether the symptoms had been present since 7 years of age.1
Case Report 1
Mr. S is a 52-year-old man who presented with work difficulties, including extreme disorganization (ie, piles of paper) and profound difficulties in completing written projects. He worked as a corporate attorney and was responsible for managing his team on long-term projects. His history included missing work deadlines, frequent conversational interruptions, physical agitation, forgetfulness, and anger outbursts. He stayed at work much later than was necessary and would frequently work on the weekends. He found it difficult to work as part of a team and would stubbornly insist that things be done his way. He found it almost painful to “spend” money. His global BADDS score was 96 and his ASRS score was 4, which suggests “symptoms that are highly consistent with ADHD in adults”. His BAADS score was 51 and his PDQ-4 score indicated that he met criteria for OCPD and negativistic personality disorder. The PDQ-4 Clinical Significance Scale indicated that these negativistic personality items have only been present for the last 1–5 years raising the relevance of this diagnosis. In addition, they only seemed to induce impairment at work.
This patient responded to a combination of stimulant therapy (ie, amphetamine salts extended-release 20 mg/day) and a selective serotonin reuptake inhibitor (SSRI) (escitalopram 10 mg/day) combined with cognitive-behavioral therapy (CBT). His therapy included having a professional organizer come to his office and create a filing system and “declutter.” In addition, daily brief phone-coaching sessions were employed to help him identify to-do-list items and be accountable for task completion. E-mail feedback was used to report on progress. He also benefited from CBT around anger-provoking situations and imaginal-coping desensitization of anger-inducing situations.12 This resulted in him becoming more appropriately assertive with coworkers. He subsequently joined a gym and attended yoga classes bi-weekly.
Case Report 2
Mr. P is a 48-year-old attorney with a history of erratic academic performance. He has not worked as an attorney for the past 5 years but acquired a job in a publishing house that was lower in stress and salary. He had significant mood lability, low frustration tolerance, and a history of alcoholism (alcohol free for the last 10 years). His childhood report cards noted difficulties with frequent interruptions and remaining seated. As an adult, he spent a lot of time on his computer developing templates and schedules for various projects. He kept records of the money he spent, yet at times bought many books he never had time to read. He researched decisions so extensively (eg, buying a car) that it would frequently take years for him to make a decision. He became critical of certain judges whom he felt did not follow correct legal protocol and would be somewhat inappropriately outspoken in his remarks toward them. Recently, there was an increase in marital conflict due to the piles of newspapers he refused to discard, protesting that he was going to read them in the future. His BADDS score was 90, his ASRS score was 5 (“consistent with ADHD in adults”), his BAADS score was 45, and his PDQ-4 score indicated OCPD and negativistic personality disorder. The PDQ-4 Clinical Significance Scale indicated that both Axis II diagnoses were clinically significant.
Mr. P was also on amphetamine salts 20 mg BID and was encouraged to hire a college student to work with him in his office. His wife was included in the treatment and she was counseled to help him deal with decluttering the home. In addition, a professional organizer was sent to his home to help clear out his closets which were full of paperwork. He was trained in time management and was willing ultimately to make a contract about the buying of books on the Internet. He continued to go to Alcoholics Anonymous to remain sober and he was persuaded to establish weekly staff meetings to include delegation and collaborate on large cases. Assertiveness training helped him to communicate to his colleagues that he needed an administrative assistant to help him with paperwork.
Case Report 3
Mrs. C was an oral surgeon who presented with symptoms of long-standing procrastination and disorganization. She reported an inability to write reports on new consultations and would frequently not return phone calls as well as spending an inordinate amount of time doing rounds in the hospital. This set the stage for sleeping little and keeping patients waiting for a long time. Her history included late night academic cramming, alcohol and marijuana abuse, and significant collegial conflict. She would spend hours trying to get the patients charts to look a certain way and was unable to delegate insurance and other forms to clerical staff. Her ASRS score was 5, her BAADS score was 55 her global BADDS score was 97, and her PDQ-4 results indicated OCPD.
This patient was on citalopram 40 mg/day and methylphenidate 30 mg PRN and also required contracts for complying with sleep difficulties (ie, she stayed up too late). Her office manager was included in the treatment and developed cost efficient administrative forms as well as computerizing charts. Eventually she was able to delegate duties to her staff and allowed her nurses to prompt her to move more quickly through the patients. Her depressed mood responded to structured assignments which focused on increasing activity level and challenging negative automatic thought patterns.13
These three cases illustrate the ways in which OCPD and ADHD symptoms often coexist. Each of the above patients had unsuccessful trials of insight oriented psychotherapy, self-help, time management type courses, and medication monotherapy. The comprehensive and specialized type of intervention plans developed for each individual seemed to have resulted in significant symptom reduction as evidenced by patient and spouse corroborative report. One of the unique features of this multicomponent treatment was the emphasis on using paraprofessionals as an external intervention. This patient population is notoriously difficult to treat on an outpatient basis. It is crucial to get someone to supervise, model and support patients completing exposure assignments. Patients were told that their problems had a biological basis necessitating medication and that their responsibility for getting well included allowing others to help. We explained how rigidity interfered with outcome and that the treatment required gradual relinquishing of control. We found that by introducing the organizer early on in treatment sessions with the clinician, the patients became desensitized and developed rapport and trust. Home visits and ongoing phone calls were emphasized as a core dimension of successful treatment. We used motivational interviewing techniques to highlight the consequences of failure to aggressively intervene. Patients all reported social limitations associated with their hoarding. Other consequences, including fire hazards and allergy symptoms, were raised. Unfortunately because these problems have a chronic course, long-term follow-up would be necessary to assess the duration of the changes we witnessed in job performance and household organization. With each of these patients, pre- and post-Polaroid’s were also taken to show the effects of decluttering suggestions.
We have found the following combined treatment regimen to be of value. Pharmacotherapy which addresses the rigidity, anger and anxiety (ie, SSRI), and stimulants to enhance task performance attention and decrease impulsivity. Standard CBT includes weekly sessions. We begin with a comprehensive evaluation and psychoeducational component followed by daily telephone coaching and periodic in person meetings. Specific attention is also paid to primary treatment components, including physical exercise and relaxation methods (eg, meditation, biofeedback); comprehensive cognitive therapy to address benefits, such as self-defeating thoughts that reinforce procrastination (eg, “I will do it later”) and perfectionism (“it is unacceptable to make a mistake”); self-criticism/self-esteem related beliefs, low frustration tolerance, and rigid “shoulds” regarding self and others; methods for improving time utilization, organizational skills, impulse control, and interpersonal effectiveness skills (eg, assertion, active listening). The focus is on concrete daily goals and occasional home or office in vivo meetings. Paraprofessionals trained as professional organizers can be extremely useful as well.
CBTs have often emphasized the need to teach patients self-control skills. This current treatment approach represents a significant shift in accepting their “self-discipline” deficits and using external assistance. The hoarding that we witnessed in this subpopulation could be related to a variety of variables. OCPD often involves significant difficulties in discarding worn out or worthless objects. DSM-IV-TR lists the characteristics of this patient population and the social consequences of hanging on to objects that lack even sentimental value. The DSM-IV-TR’s description of ADHD indicates how materials for various tasks are often scattered and the disorganized nature of work habits. Lastly, under OCD, we see that when hoarding is extreme a diagnosis of OCD should be considered.1 One way of looking at all of these issues is the notion that hoarding has been linked to a host of neuropsychological deficits in inhibition, planning, and verbal and non-verbal memory.14-16 Hoarding seems to be a disorder involving indecision, procrastination, and disorganization. In addition, neuroimaging studies of hoarders are quite different than results seen with “simple” OCD.17 Despite this, many clinicians have continued to treat cluttering with self-management approaches and SSRIs, which, in our experience, has proven to be futile. Effective treatment for the subgroup we have described may require SSRIs for the anxiety and perfectionism component combined with stimulants to address the procrastination and distractibility.
These three cases emphasize the need to develop comprehensive, creative, and individualized treatments. This comorbidity between Axis I and Axis II symptoms is common and, by addressing both, we have found that concrete and practical outcomes in previously treatment resistant individuals can be obtained. Clinicians need to systematically screen for both conditions with the expectation that comprehensive results are achieved when comprehensive assessment and intervention plans are applied. Clearly, more research needs to explore these relationships, both from a biological and psychological perspective.
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text rev. Washington, DC: American Psychiatric Association; 2000.
2. Grisham JR, Frost RO, Steketee G, Kim HJ, Hood S. Age of onset of compulsive hoarding. J Anxiety Disord. 2006;20:675-686.
3. Hyler SE. Personality Diagnostic Questionnaire-4 (PDQ-4). New York, NY: New York State Psychiatric Institute; 1994.
4. Hyler SE, Skodol AE, Kellman HD, Oldham JM, Rosnick L. Validity of the Personality Diagnostic Questionnaire-revised: comparison with two structured interviews. Am J Psychiatry. 1990;147:1043-1048.
5. Fossati A, Maffei C, Bagnato M, et al. Brief communication: criterion validity of the Personality Diagnostic Questionnaire-4+ (PDQ-4+) in a mixed psychiatric sample. J Personal Disord. 1998;12:172-178.
6. Wilberg T, Dammen T, Friis S. Comparing Personality Diagnostic questionnaire-4+ with Longitudinal, Expert, All Data (LEAD) standard diagnoses in a sample with a high prevalence of axis I and axis II disorders. Compr Psychiatry. 2000;41:295-302.
7. Adler LA, Kessler RC, Spencer, T. Adult ADHD Self-Report Scale-v1.1 (ASRS-v1.1) Symptom Checklist. New York, NY: World Health Organization; 2003.
8. Brown TE. Brown Attention-Deficit Disorder Scales (BADDS). San Antonio, Tex: The Psychological Corporation. Harcourt Brace & Company; 1996.
9. Brown TE. The Brown Attention-Activation Disorder Scale (BAADS). New Haven, Conn: Yale University Press; 1992.
10. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35:245-256.
11. Adler LA, Spencer T, Faraone SV, et al. Validity of pilot Adult ADHD Self-Report Scale (ASRS) to rate adult ADHD symptoms. Ann Clin Psychiatry. 2006;18:145-148.
12. Novaco RW, Welsh W. Anger disturbances: cognitive mediation and clinical prescriptions. In: Howells K, Hollin C, eds. Clinical Approaches to Violence. London, UK: John Wiley & Sons; 1989:39-60.
13. Leahy R, Holland S. Treatment Plans and Interventions for Depression and Anxiety Disorders. New York, NY: The Gulford Press; 2000.
14. Hartl TL, Frost RO, Allen GJ, et al. Actual and perceived memory deficits in individuals with compulsive hoarding. Depress Anxiety. 2004;20:59-69.
15. Lawrence NS, Wooderson S, Mataix-Cols D, David R, Speckens A, Phillips ML. Decision making and set shifting impairments are associated with distinct symptom dimensions in obsessive-compulsive disorder. Neuropsychology. 2006;20:409.
16. Saxena S. Is compulsive hoarding a genetically and neurobiologically discrete syndrome? Implications for diagnostic classification. Am J Psychiatry. 2007;164:380-384.
17. Saxena S, Brody AL, Maidment KM, et al. “Cerebral glucose metabolism in obsessive-compulsive hoarding”. Am J Psychiatry. 2004;161:1038-1048.