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Inattention, Hyperactivity, and Impulsivity in Youth with Ocd: Comorbid Adhd Or a Consequence of Obsessions and Compulsions?

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Inattention, Hyperactivity, and Impulsivity in Youth with Ocd: Comorbid Adhd Or a Consequence of Obsessions and Compulsions? INATTENTION, HYPERACTIVITY, AND IMPULSIVITY IN YOUTH WITH OCD: COMORBID ADHD OR A CONSEQUENCE OF OBSESSIONS AND COMPULSIONS? By ANDREW GILES GUZICK A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2016 © 2016 Andrew Giles Guzick To the families who participated in this study ACKNOWLEDGMENTS This thesis would not have been possible without the support and guidance of Dr. Gary R. Geffken, Dr. Joseph P.H. McNamara, Dr. Regina Bussing, Mr. Adam M. Reid, and Ms. Amanda Balkhi. I would also like to thank Dr. Wayne Goodman and collaborators at the University of South Florida (USF), Drs. Tanya Murphy and Eric Storch, who were instrumental in writing the grant that funded this study and for leading data collection at the USF site. I would also like to thank the other members of the study team who helped collect these data and all the families who participated in the study. 4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES ...........................................................................................................................7 LIST OF FIGURES .........................................................................................................................8 LIST OF ABBREVIATIONS ..........................................................................................................9 ABSTRACT ...................................................................................................................................10 CHAPTER 1 INTRODUCTION ..................................................................................................................12 2 METHODS .............................................................................................................................19 Participants .............................................................................................................................19 Procedure ................................................................................................................................20 Measures .................................................................................................................................20 Demographics ..................................................................................................................20 Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS) ................................20 Swanson, Nolan, and Pelham-IV (SNAP-IV) .................................................................21 Children’s Depression Rating Scale-Revised (CDRS-R) ................................................21 Treatment-Emergent Activation and Suicidality Assessment Profile (TEASAP) ..........22 Statistical Analyses .................................................................................................................22 Preliminary Covariate Analyses ......................................................................................22 Aim 1: Predicting Change in OCD Severity ...................................................................23 Aim 2: ADHD Symptom Reduction during Treatment ..................................................23 Hypothesis 1: ADHD symptoms at baseline will be significantly greater than ADHD symptoms at the end of treatment ............................................................23 Hypothesis 2: Reduction in OC symptoms will predict reduction in ADHD symptoms ..............................................................................................................23 3 RESULTS ...............................................................................................................................26 Preliminary Correlational Analyses ........................................................................................26 Aim 1. Predicting OC Symptom Reduction ...........................................................................26 Aim 2. ADHD Symptom Reduction during Treatment ..........................................................27 Hypothesis 1: ADHD symptoms at baseline will be significantly greater than ADHD symptoms at the end of treatment ....................................................................27 Hypothesis 2: Reduction in OC symptoms will predict reduction in ADHD symptoms .....................................................................................................................27 4 DISCUSSION .........................................................................................................................33 5 REFERENCES ..............................................................................................................................39 BIOGRAPHICAL SKETCH .........................................................................................................45 6 LIST OF TABLES Table page 2-1 Sample demographics (n=48) ............................................................................................25 3-1 Correlations between potential regression model covariate and independent and dependent variables of interest...........................................................................................30 3-2 Regression model predicting change in CYBOCS score before and after treatment ........30 3-3 Regression model predicting change in SNAP-IV score before and after treatment ........31 7 LIST OF FIGURES Figure page 3-1 Mean ADHD symptom reduction across treatment. ..........................................................32 3-2 ADHD symptom reduction among those in remission and those not in remission ...........32 8 LIST OF ABBREVIATIONS ADHD Attention-Deficit/Hyperactivity Disorder CBT-E/RP Cognitive-Behavioral Therapy with Exposure and Response Prevention CDRS-R Children’s Depression Rating Scale-Revised CYBOCS Children’s Yale-Brown Obsessive-Compulsive Scale K-SADS-PL Schedule for Affective Disorders and Schizophrenia for School-Age Children- Present and Lifetime Version OC Obsessive-Compulsive OCD Obsessive-Compulsive Disorder RegSert Regular Titration of Sertraline SlowSert Slow Titration of Sertraline SNAP-IV Swanson, Nolan, and Pelham-IV SSRI Selective Serotonin Reuptake Inhibitor TEASAP Treatment-Emergent Activation and Suicidality Assessment Profile 9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science INATTENTION, HYPERACTIVITY, AND IMPULSIVITY IN YOUTH WITH OCD: COMORBID ADHD OR A CONSEQUENCE OF OBSESSIONS AND COMPULSIONS? By Andrew Giles Guzick May 2016 Chair: Gary R. Geffken Major: Psychology Attention-Deficit/Hyperactivity Disorder (ADHD) is reported to be highly comorbid in children and adolescents with Obsessive-Compulsive Disorder (OCD) and has been shown to cause substantial functional impairment and hinder treatment response. It may be, however, that obsessive distress and compulsive rituals cause inattention, impulsivity, and other ADHD-like symptoms. If this were the case, the reported comorbidity rate may be an overestimate of the true prevalence of ADHD in youth with OCD. Analyses in the present thesis tested this hypothesis by evaluating whether children who successfully complete combined psychological- psychopharmacological treatment for OCD experience a reduction in both ADHD and OC symptoms. It also evaluated whether ADHD symptoms measured continuously predict treatment outcome. A paired-samples t-test revealed modest, significant reductions in parent-reported ADHD symptoms after treatment. Hierarchical linear regression analyses indicated that OC symptom reduction predicted ADHD symptom reduction, suggesting that children who respond to OCD treatment also experience a reduction in inattention, hyperactivity, and impulsivity. Regression analyses failed to support the hypothesis that greater ADHD symptoms at baseline predict treatment outcome. These results indicate that obsessional distress may exacerbate 10 inattention, hyperactivity, and impulsivity, often resulting in inappropriate diagnoses of ADHD in those with OCD. 11 CHAPTER 1 INTRODUCTION Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric condition characterized by obsessive, intrusive, disturbing thoughts, and/or compulsive behaviors that are done in an attempt to alleviate the distress caused by obsessions. (American Psychiatric Association, 2013). Once thought to be relatively rare in childhood, it is now recognized that early adolescence is one of the peak times at which people are at risk for developing OCD (Chabane et al., 2005). In addition to causing substantial impairment in school, social, and family functioning, children with OCD are more likely to have other psychological conditions including major depression, anxiety disorders, and externalizing problems such as Attention- Deficit/Hyperactivity Disorder (ADHD; Ivarsson, Melin, & Wallin, 2008). ADHD is estimated to occur in 18-43% of children with OCD (Geller et al., 2001; Ivarsson et al., 2008; Storch et al., 2007; Storch et al., 2008). The high risk for ADHD in children with OCD is particularly alarming when considering the detrimental effects of co- occurring ADHD and OCD. Specifically, those with both OCD and ADHD often have an earlier age of onset compared to those with OCD only, are even more functionally impaired, perform worse in school, and
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