The Clinical Characteristics of ADHD and Obsessive-Compulsive Disorder Comorbidity

Abstract

Objective: To investigate the clinical implications of obsessive-compulsive disorder (OCD) and ADHD comorbidity in adults. Method: The OCD patients who had and had no diagnosis of adulthood ADHD were compared in terms of several demographic and clinical variables. Results: The mean number of obsessions and compulsions; hoarding, symmetry, and miscellaneous obsessions; ordering/arranging and hoarding compulsions; total, attentional, and motor subscale scores of Barratt Impulsivity Scale (BIS)-11 were more frequent among the patients with OCD-ADHD. The mean age of onset was more likely to be earlier in ADHD-OCD group than in OCD group. Impulsivity, symmetry obsessions, and hoarding compulsions strongly predicted the coexistence between ADHD and OCD. Conclusion: OCD-ADHD comorbidity in adults seemed to be associated with an earlier onset of OCD, with the predominance of impulsivity, and with a different obsessive-compulsive symptom (OC) profile from OCD patients without a diagnosis of ADHD.

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Journal of Attention Disorders
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DOI: 10.1177/1087054716669226
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Article
Introduction
Obsessive-compulsive disorder (OCD) and ADHD are very
common psychiatric disorders in childhood and youth. Up
to 30% of children and adolescents with OCD also meet
diagnostic criteria for ADHD (Geller et al., 2002), while the
rate of OCD among children with ADHD is estimated to be
8% to 11% (Arnold, Ickowicz, Chen, & Schachar, 2005).
The comorbidity rate of ADHD among adults with OCD
was estimated to be 2.0% to 22.9% (Anholt et al., 2010; de
Mathis et al., 2013; Frost, Steketee, & Tolin, 2011;
Jaisoorya, Janardhan Reddy, & Srinath, 2003; Ruscio,
Stein, Chiu, & Kessler, 2010; B. Sheppard et al., 2010). In
addition to differences in sample size, age of participants,
the presence of other comorbid disorders, particularly tic
disorders, may affect reported ADHD rates in OCD sam-
ples. Longitudinal data demonstrate that the participants
who had ADHD during childhood were at risk of OCD in
adult periods, whereas those diagnosed with OCD during
childhood were not likely to develop ADHD (Peterson,
Pine, Cohen, & Brook, 2001). These findings suggest that a
subset of patients with ADHD may be at elevated risk of
developing OCD (Masi et al., 2006).
Walitza et al. (2008) reported that ADHD was the most
common comorbidity in early-onset OCD, when Tourette
syndrome (TS) were exclusion criteria. Comorbidity of
ADHD in early-onset OCD was found to be associated with
a higher severity and persistence of OCD (Walitza et al.,
2008) and hoarding symptoms (Fullana et al., 2013; B.
Sheppard et al., 2010). ADHD and OCD appear to be con-
siderably different in terms of their phenomenology.
However, both can present with symptoms of inattention
and distraction, and differentiating between primary atten-
tional symptoms and attentional symptoms secondary to a
core anxiety disorder. In this comorbidity, it is uncertain
yet, whether inattention, impulsivity, and hyperactivity are
consequences of OCD and related anxiety symptoms or
represent a co-occurring ADHD (Geller et al., 2002).
Patients with OCD and ADHD have been found to present
several cognitive deficits related to frontostriatal functions
(van den Heuvel et al., 2010). Previous studies reported that
patients with OCD have various deficits on tasks of
669226JADXXX10.1177/1087054716669226Journal of Attention DisordersMersin Kilic et al.
research-article2016
1Karsıyaka State Hospital, Izmir, Turkey
2Aydin State Hospital, Aydin, Turkey
3Adnan Menderes Universitesi Tip Fakultesi, Aydin, Turkey
Corresponding Author:
Levent Sevincok, Adnan Menderes Universitesi Tip Fakultesi, Aydin,
Turkey.
Email: lsevincok@adu.edu.tr
The Clinical Characteristics of ADHD
and Obsessive-Compulsive Disorder
Comorbidity
Sanem Mersin Kilic1, Ayse Dondu2, Cagdas Oyku Memis3, Filiz Ozdemiroglu3,
and Levent Sevincok3
Abstract
Objective: To investigate the clinical implications of obsessive-compulsive disorder (OCD) and ADHD comorbidity in
adults. Method: The OCD patients who had and had no diagnosis of adulthood ADHD were compared in terms of several
demographic and clinical variables. Results: The mean number of obsessions and compulsions; hoarding, symmetry, and
miscellaneous obsessions; ordering/arranging and hoarding compulsions; total, attentional, and motor subscale scores
of Barratt Impulsivity Scale (BIS)-11 were more frequent among the patients with OCD-ADHD. The mean age of onset
was more likely to be earlier in ADHD-OCD group than in OCD group. Impulsivity, symmetry obsessions, and hoarding
compulsions strongly predicted the coexistence between ADHD and OCD. Conclusion: OCD-ADHD comorbidity in
adults seemed to be associated with an earlier onset of OCD, with the predominance of impulsivity, and with a different
obsessive-compulsive symptom (OC) profile from OCD patients without a diagnosis of ADHD. (J. of Att. Dis. XXXX; XX(X)
XX-XX)
Keywords
ADHD, OCD, age onset
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2 Journal of Attention Disorders
attentional processing (Schmidtke, Schorb, Winkelmann, &
Hohagen, 1998) and executive and visual memory func-
tions (Purcell, Maruff, Kyrios, & Pantelis, 1998).
Although OCD-ADHD comorbidity was investigated in
children and adolescent OCD samples in numerous studies,
only a few studies examined the characteristics of OCD-
ADHD comorbidity in adults. Hence, the primary aim of
our study was to consider the clinical implications of
ADHD-OCD comorbidity, examining in a consecutively
referred adult OCD patients with or without ADHD. Our
main hypothesis was that ADHD comorbidity would influ-
ence the clinical manifestation of OCD in adult ages. Given
the confounding and strong influences of TS and major
depression (MD) on OCD and ADHD, we preferred to eval-
uate the potential affects of ADHD on OCD in a sample of
adult OCD patients without these two comorbid diagnoses.
Method
Participants
Seventy-two participants (50 women and 22 men) aged
between 18 and 65 years with OCD were recruited consecu-
tively between April 2012 and February 2015 at the psychia-
try outpatient clinics of the Adnan Menderes University
Hospital. Because we primarily aimed to examine the clinical
characteristics of ADHD and OCD comorbidity, we tried to
form a pure OCD group to obtain more precise results avoid-
ing the confounding effects of comorbid diagnoses of many
psychiatric and neurological disorders. Therefore, our exclu-
sion criteria were the diagnoses of psychotic disorders, autism
spectrum disorders, other anxiety disorders, bipolar disorder
(BD), mental retardation, substance use disorders, and any
organic mental disorders. We also excluded those with TS or
MD (defined as a score of 15 or more on the Hamilton
Depression Scale [HDRS]; Hamilton, 1960), to avoid from
the confounding effects of these disorders on both ADHD and
OCD. The patients were drug-naive at the time of assessment
or discontinued antipsychotics and antidepressants at least 3
months prior to the study. None of the patients had a previous
history of stimulant-induced OCD. The study was approved
by the local ethics committee of the Medical Faculty of Adnan
Menderes University. All participants gave their written
informed consent prior to inclusion into the study.
The current diagnosis of OCD was obtained through the
Structured Clinical Interviews for Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American
Psychiatric Association, 1994) Axis I Disorders (SCID-I;
First, Spitzer, Gibbon, & Williams, 1997; Özkürkçügil,
Aydemir, & Yıldız, 1999). The Yale-Brown Obsessive
Compulsive Scale (YBOCS; Goodman et al., 1989) was
applied to all patients to determine the severity of current
obsessive-compulsive symptoms (OCs). The types of OCs
were identified using YBOCS symptom checklist.
We first retrospectively assessed the ADHD symptoms in
the participants who reported symptoms of either inattention
or hyperactivity-impulsivity before age 7 (criterion B) using
the Turkish version (Oncu, Olmez, & Senturk, 2005) of
Wender Utah Rating Scale (WURS-25; Ward, Wender, &
Reimherr, 1993). WURS-25 is a 25-item self-report question-
naire with a 5-point Likert-type scale. We applied DSM-IV
criteria for ADHD to the participants who had a cutoff score
of ≥36 in WURS-25 to establish a diagnosis of ADHD during
childhood. For a clinical diagnosis of adult ADHD, we
required six symptoms of either inattention or hyperactivity-
impulsivity during the 6 months before the interview (DSM-IV,
criterion A), some impairment in at least two areas of living
during the past 6 months (criterion C), and clinically signifi-
cant impairment in at least one of these areas (criterion D). To
establish the diagnosis and the severity of ADHD in adult-
hood, we used the Turkish version (Gunay, Savran, & Aksoy,
2005) of Turgay’s Adult ADD/ADHD Diagnosis and
Evaluation Scale (Turgay, 1995). The first (attention deficit)
and second (hyperactivity) sections of the Adult ADD/ADHD
Scale are based on 18 DSM-IV diagnostic symptoms. Because
five of these participants did not meet the criteria of ADHD
during adulthood, they were not included in the study.
Therefore, OCD patients, those with (n = 32) and without
diagnosis of ADHD (n = 35), were separated into two groups.
Then, these two groups were compared in terms of several
sociodemographic and clinical variables.
The Turkish version (Tamam, Gulec, & Karatas, 2013)
of Barratt Impulsivity Scale (BIS-11; Patton & Stanford,
1995) was administrated to assess the severity of impulsiv-
ity in all the participants. This scale has 30 questions, each
of which required the responder to choose between rarely/
never, occasionally, and often and almost always. It consists
of subscales of Attentional Impulsiveness (AI), Motor
Impulsiveness (MI), Non-Planning Impulsiveness (NP).
Items are scored from 1 to 4.
Statistical Analyses
The two groups were compared using chi-square test for
categorical variables. Student’s t test was used to compare
the continuous independent data. We performed a binary
logistic regression analysis to examine potential predictors
for ADHD and OCD comorbidity. Overall percent correct
classification for regression was 51.5%. All statistical tests
were two-tailed at p = .05. The analyses were performed
using SPSS.
Results
As illustrated in Table 1, there were no significant differences
between the groups with respect to age, gender, educational
level, and family history of OCD and ADHD. As expected,
ADHD-OCD patients had significantly higher scores of
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Mersin Kilic et al. 3
WURS-25 compared with OCD patients (p < .0001). Total (p
< .001), attentional (p < .0001), and motor subscale scores (p
= .009) of BIS-11 were significantly higher in ADHD-OCD
group compared with OCD group. The mean age of onset for
OCD was found to be earlier in ADHD-OCD group com-
pared with pure OCD patients (p = .001). The rate of the
patients whose OCs were first noticed before the age of 18
years seemed to be higher in ADHD-OCD group than in the
OCD group (p = .011). The total and subscale scores of
obsession and compulsion did not differ significantly between
the groups. The mean number of obsessions (p = .005) and
compulsions (p = .003) were significantly higher in ADHD-
OCD group than in OCD group. We have also found that
symmetry (p < .0001), hoarding (p = .042), and miscella-
neous obsessions (p = .04); and ordering/arranging (p = .007)
and hoarding compulsions (p = .008) were more frequent
Table 1. Demographic and Clinical Comparisons of Patient Groups.
OCD
(n = 35)
OCD-ADHD
(n = 32)
Statistical
analyses
MSD MSD t df p
Age 34.37 12.04 29.65 9.26 1.78 65 .07
Educational level (years) 11.28 2.88 11.21 3.04 0.09 65 .92
Wender Utah 16.65 8.97 51.78 11.82 −13.76 65 <.0001
Age at onset of OCD 25.54 10.43 17.50 8.18 3.48 65 .001
Barratt Impulsivity Scale 60.61 9.56 70.03 11.02 −3.71 64 <.0001
Attentional 15.88 3.52 19.87 3.67 −4.50 64 <.0001
Non-planning 26.11 4.42 28.56 5.82 −1.92 64 .058
Motor 18.67 3.98 21.59 4.75 −2.70 64 .009
26.11 4.42 28.56 5.82 −1.92 65 .058
18.67 3.98 21.59 4.75 −2.70 65 .009
Y-BOCS Total 25.37 7.54 27.93 7.27 −1.41 65 .16
Obsession 12.61 3.87 14.12 3.54 −1.64 65 .10
Compulsion 12.47 3.62 13.81 3.86 −1.45 65 .003
The mean number of obsessions 2.50 1.72 3.90 2.16 −2.92 65 .005
The mean number of compulsions 2.61 1.53 3.90 1.88 −3.04 65 .003
n%n%χ2df p
Gender 1.09 1 .29
Female 27 77.1 21 65.6
Male 8 22.9 11 34.4
Family history of OCD 8 22.9 9 28.1 0.24 1 .62
Family history of ADHD 2 5.7 1 3.1 0.26 1 .60
Onset of OCD before the age of 18 years 10 28.6 19 59.4 6.46 1 .011
Obsessions
Aggression 14 41.2 15 46.9 0.21 1 .64
Contamination 25 73.5 21 65.6 0.48 1 .48
Sexual 1 2.9 1 3.1 0.02 1 .96
Hoarding 3 8.8 9 28.1 4.12 1 .042
Religious 4 11.8 5 15.6 0.20 1 .64
Symmetry 7 20.6 22 68.8 15.52 1 <.0001
Miscellaneous 16 47.1 23 71.9 4.20 1 .04
Somatic 3 8.8 6 18.8 1.37 1 .24
Compulsions
Cleaning 27 79.4 22 68.8 0.98 1 .32
Ritualistic 20 58.8 23 71.9 1.27 1 .26
Counting 12 35.3 19 59.4 3.83 1 .05
Ordering/arranging 8 23.5 18 56.3 7.39 1 .007
Hoarding 2 5.9 10 31.3 7.11 1 .008
Miscellaneous 15 44.1 18 56.3 0.97 1 .32
Note. OCD = obsessive-compulsive disorder, Y-BOCS = Yale-Brown Obsessive Compulsive Scale, SD=Standart Deviation.
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4 Journal of Attention Disorders
Table 2. Logistic Regression Analysis of ADHD Comorbidity With OCD (n = 67).
Predictor variable Cox & Snell R2Nagelkerte R2HL χ2Significance Wald2df p Exp(B)
Model 0.511 0.681 7.783 0.352
Age at onset of OCD 3.539 1 .060 0.915
BIS-11 8.394 1 .004 1.137
Symmetry Obsessions 8.528 1 .003 27.440
Counting Compulsions 0.008 1 .929 1.079
Ordering/arranging Compulsions 0.121 1 .728 1.415
Hoarding Compulsions 5.356 1 .021 11.445
Note. OCD = obsessive-compulsive disorder; BIS-11 = Barratt Impulsivity Scale, HL = Hosmer and Lemeshow’s.
among the patients with OCD-ADHD compared with patients
with OCD.
Binary logistic regression was used to predict an out-
come of ADHD comorbid to OCD order among 67 partici-
pants. The final model was able to explain between 51.1%
and 68.1% of variance. The model was found to fit the data
adequately (Hosmer and Lemeshow’s χ2 = 7.783, p = .352),
and was able to predict ADHD comorbidity status to OCD
(Omnibus χ2(6) = 47.207, p < .001). Overall, the model was
able to correctly predict 51.5% of all cases. Six predictors
were included in the model, using the Enter method. Three
of these successfully predicted ADHD status (squared Wald
statistics are displayed in Table 2). Improvements in total
scores of BIS-11, symmetry obsessions, and hoarding com-
pulsions were significantly associated with increased odds
of ADHD comorbid with OCD (OR = 1.137, 27.440,
11.445, respectively). Assumptions for linearity and multi-
collinearity were satisfied (Table 2).
Discussion
In the present study, we investigated the clinical character-
istics of OCD and ADHD comorbidity by examining the
differences between the adult OCD patients with and with-
out ADHD in the absence of tic disorder, MD, or BD. We
also excluded the other anxiety disorders to form a pure
OCD group. Therefore, we attempted to demonstrate that
OCD patients comorbid with ADHD may represent a dis-
tinct subgroup of OCD in these very selected patient groups.
The relatively smaller sample size could have reduced the
power of the analyses. In contrast to previous findings that
reported the preponderance of males in comorbid OCD and
ADHD (Biederman et al., 2002; Masi et al., 2006), there
was not a gender difference in our sample. Consistent with
the findings of some of the previous studies (Geller et al.,
2002; Geller et al., 2003; Masi et al., 2006; Moll et al.,
2000; Walitza et al., 2008), we have found that the comor-
bidity of ADHD was associated with an earlier onset of
OCD. Our findings also demonstrated that the frequency of
participants whose OCs were first observed before the age
of 18 years tended to be higher among OCD patients with a
diagnosis of ADHD. Given that only 25 to 50 of adults with
OCD have onset before age 18 (Ruscio et al., 2010), the
higher proportion of early-onset OCD in patients comorbid
with ADHD should lead to consider the presence of diagno-
sis of ADHD in adult OCD patients. Early-onset OCD with
comorbid ADHD could be a specific subtype with persis-
tence of both ADHD and OCD. As Walitza et al. (2008)
suggested, such a subtype might be related to an underlying
dysfunction of motor and cognitive inhibition, which results
in hyperactivity, compulsion, and obsessional symptoms.
However, this finding should be replicated in a sample of
OCD patients including the participants with the other anxi-
ety disorders, mood disorders, or TS to better understand
whether an early onset of OCD might be associated with
comorbid conditions as well as ADHD.
The high prevalence of ADHD and OCD in childhood
and the high degree of comorbidity between these disor-
ders suggest that they share genetic factors. Geller,
Biederman, and Faraone (2001) found that children who
are at risk of OCD are those whose first-degree relatives
have OCD and ADHD, suggesting that OCD and ADHD
can be inherited together. When the relatives of patients
with ADHD were also affected by ADHD, they had a sig-
nificantly elevated risk of OCD compared with relatives
without ADHD (Geller et al., 2007). In contrast, our find-
ings indicated that OCD and ADHD-OCD groups were
similar with respect to family history of ADHD and OCD.
Although primarily limited to pediatric populations, prior
studies indicated a genetic association between ADHD
and OCD symptoms in pediatric populations (Geller
et al., 2007; Masi et al., 2006). OCD and ADHD twin and
family studies indicate high familiarity in both disorders
(Franke et al., 2012; Walitza et al., 2010). However, some
of the previous studies suggested that comorbidity
between OCD and TS is pronounced primarily by envi-
ronmental factors rather than genetic (Pauls, Towbin,
Leckman, Zahner, & Cohen, 1986; Santangelo et al.,
1994; D. M. Sheppard, Bradshaw, Purcell, & Pantelia,
1999). Further studies are required in larger samples to
determine the genetic and environmental factors in
comorbid patients with OCD and ADHD.
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Mersin Kilic et al. 5
Our study demonstrated that two groups did not differ in
the severity of current OCs. Similar to findings of some
studies, which reported that individuals with tic-related
OCD experienced a greater number of obsessions (Leckman
et al., 1997), we have found that mean number of obsession
and compulsions were more frequent in ADHD-OCD group
compared with OCD group. This finding might indicate that
the presence of ADHD could lead to a reduced resistance
against obsessions and compulsions, as Walitza et al. (2008)
suggested. Some of the previous studies reported that the
content of OCs did not seem to be affected by comorbidity
with ADHD (Brown, Katz, Roth, & Beers, 2014; Geller
et al., 2003; Masi et al., 2006). In contrast, other studies
found that various OCs are observed during the course of
comorbidity in children with ADHD and OCD (Biederman
et al., 2002; Moll et al., 2000). In the present study, we have
found that symmetry and hoarding obsessions, as well as
ordering/arranging and hoarding compulsions seemed to be
associated with ADHD and OCD comorbidity. OCD
patients with symmetry obsessions (OR = 27.440) and
hoarding compulsions (OR = 11.445) were more likely to
have comorbid ADHD. B. Sheppard et al. (2010) have
found a strong association between ADHD and clinically
significant hoarding behavior in a sample of individuals
with childhood-onset OCD but without comorbid tic disor-
ders. In a few studies (Grisham, Brown, Savage, Steketee,
& Barlow, 2007; Hartl, Duffany, Allen, Steketee, & Frost,
2005), hoarders reported higher rates of both inattentive and
hyperactive ADHD symptoms and had higher rates of cog-
nitive functioning deficits compared with non-hoarders.
Aggressive and sexual obsessions were also found to be
prevalent in tic-related OCD (George, Trimble, Ring,
Sallee, & Robertson, 1993; Holzer et al., 1994; Leckman
et al., 1997). Our findings might suggest that the OCD
patients with and without comorbid ADHD obviously dif-
fered with respect to obsessive-compulsive symptomatol-
ogy. Particularly, symmetry obsessions and hoarding
compulsions were significantly associated with OCD and
ADHD comorbidity.
Impulsivity is one of the prominent features of ADHD
(Malloy-Diniz, Fuentes, Leite, Correa, & Bechara, 2007;
Winstanley, Eagle, & Robbins, 2006). In recent years, sev-
eral studies have investigated the relationship between
OCD and impulsivity, as well as ADHD. It is not so definite
if inattention and impulsivity are consequences of OCD or
represent a comorbid ADHD (Masi et al., 2006). For exam-
ple, some of the studies have reported that patients with
OCD experienced higher levels of impulsive behavior than
do non-clinical controls (Ettelt et al., 2007) and those with
tics (Hollander & Wong, 1995; Summerfeldt, Hood, Antony,
Richter, & Swinson, 2004), while some studies
(Ketzenberger & Forrest, 1998; Stein, Hollander, Simeon,
& Cohen, 1994) showed that impulsivity levels of OCD
patients did not differ from those of non-clinical samples.
Shoval, Zalsman, Sher, Apter, and Weizman (2006) have
found that adolescent patients with OCD were less impul-
sive than controls. Zermatten and Van der Linden (2008)
reported several relationships between various OC and
impulsive symptoms in a non-clinical sample of 220 indi-
viduals. In some studies, it was found that there were sig-
nificant correlations between the attentional subscores of
BIS-11 and total obsession and compulsion subscale scores
of YBOCS among patients with OCD (Ettelt et al., 2007;
Stein et al., 1995). As far as we know, the relationship
between impulsivity and OCD symptomatology has not
been investigated among OCD participants associated with
a diagnosis of ADHD. In our study, the patients with ADHD
and OCD had significantly higher total, attentional, and
motor subscale scores of BIS-11 compared with pure OCD
patients. Particularly, total scores of BIS-11 were strongly
associated with comorbid diagnosis of OCD and ADHD.
Therefore, our findings might suggest that impulsivity
might be one of the significant indicators of a comorbidity
between OCD and ADHD.
Conclusion
In the present study, we tried to investigate the clinical char-
acteristics of ADHD and OCD comorbidity in adult patients.
According to our findings, these patients had an earlier
onset of OCD. The mean number of obsession and compul-
sions were more frequent in ADHD-OCD group compared
with OCD group. Symmetry and hoarding obsessions, in
addition to ordering/arranging and hoarding compulsions,
seemed to be related to ADHD and OCD comorbidity. The
symmetry obsessions and hoarding compulsions as well as
with impulsivity strongly predicted the comorbid diagnosis
of ADHD and OCD. Therefore, our findings might suggest
that the diagnosis of ADHD in adult patients with OCD
might be associated with an earlier onset of OCD, with the
predominance of impulsivity, and with a different OC
symptom profile from OCD patients without ADHD.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
American Psychiatric Association. (1994). Diagnostic and statis-
tical manual of mental disorders (4th ed.). Washington, DC:
Author.
Anholt, G. E., Cath, D. C., van Oppen, P., Eikelenboom, M., Smit,
J. H., van Megen, H., & van Balkom, A. J. (2010). Autism
at CORNELL UNIV on September 23, 2016jad.sagepub.comDownloaded from

6 Journal of Attention Disorders
and ADHD symptoms in patients with OCD: Are they associ-
ated with specific OC symptom dimensions or OC symptom
severity? Journal of Autism and Developmental Disorders,
40, 580-589.
Arnold, P. D., Ickowicz, A., Chen, S., & Schachar, R. (2005).
Attention-deficit hyperactivity disorder with and without
obsessive-compulsive behaviours: Clinical characteristics,
cognitive assessment, and risk factors. Canadian Journal of
Psychiatry, 50, 59-66.
Biederman, J., Mick, E., Faraone, S. V., Braaten, E., Doyle, A.,
Spencer, T., . . . Johnson, M. A. (2002). Influence of gender on
attention deficit hyperactivity disorder in children referred to a
psychiatric clinic. American Journal of Psychiatry, 159, 36-42.
Brown, F. C., Katz, L. J., Roth, R. M., & Beers, S. R. (2014). The
relationship of self-reported subclinical obsessive-compul-
sive symptoms and impulsivity among adults with AD/HD.
Psychiatry Research, 216, 131-136.
de Mathis, M. A., Diniz, J. B., Hounie, A. G., Shavitt, R. G.,
Fossaluza, V., Ferrão, Y., . . . Miguel, E. C. (2013). Trajectory
in obsessive-compulsive disorder comorbidities. European
Neuropsychopharmacology, 23, 594-601.
Ettelt, S., Ruhrmann, S., Barnow, S., Buthz, F., Hochrein, A.,
Meyer, K., Kraft, S., . . . Grabe, H. J. (2007). Impulsiveness in
obsessive-compulsive disorder: Results from a family study.
Acta Psychiatrica Scandinavica, 115, 41-47.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.
(1997). Structured Clinical Interview for DSM-IV Axis I
Disorders: Clinician Version (SCID-CV). Washington, DC:
American Psychiatric Press.
Franke, B., Faraone, S. V., Asherson, P., Buitelaar, J., Bau, C.
H., Ramos-Quiroga, J. A., . . . Reif, A. (2012). The genetics
of attention deficit/hyperactivity disorder in adults, a review.
International Multicentre persistent ADHD Collaboration.
Molecular Psychiatry, 17, 960-987.
Frost, R. O., Steketee, G., & Tolin, D. F. (2011). Comorbidity in
hoarding disorder. Depression and Anxiety, 28, 876-884.
Fullana, M. A., Vilagut, G., Mataix-Cols, D., Adroher, N. D.,
Bruffaerts, R., Bunting, B., . . . Alonso, J. (2013). Is ADHD
in childhood associated with lifetime hoarding symptoms? An
epidemiological study. Depression and Anxiety, 30, 741-748.
Geller, D. A., Biederman, J., & Faraone, S. V. (2001). Developmental
aspects of obsessive compulsive disorder: Findings in children,
adolescents, and adults. Journal of Nervous Mental Disorders,
189, 471-477.
Geller, D. A., Biederman, J., Faraone, S. V., Cradock, K.,
Hagermoser, L., Zaman, N., . . . Spencer, T. J. (2002).
Attention-deficit/hyperactivity disorder in children and ado-
lescents with obsessive compulsive disorder: Fact or artifact?
Journal of the American Academy of Child & Adolescent
Psychiatry, 41, 52-58.
Geller, D. A., Coffey, B., Faraone, S., Hagermoser, L., Zaman,
N. K., Farrell, C. L., . . . Biederman, J. (2003). Does comor-
bid attention-deficit/hyperactivity disorder impact the clinical
expression of pediatric obsessive-compulsive disorder? CNS
Spectrums, 8, 259-264.
Geller, D. A., Petty, C., Vivas, F., Johnson, J., Pauls, D., &
Biederman, J. (2007). Further evidence for co-segregation
between pediatric obsessive compulsive disorder and atten-
tion deficit hyperactivity disorder: A familial risk analysis.
Biological Psychiatry, 61, 1388-1394.
George, M. S., Trimble, M. R., Ring, H. A., Sallee, F. R., &
Robertson, M. M. (1993). Obsessions in obsessive compulsive
disorder with and without Gilles de la Tourette’s syndrome.
American Journal of Psychiatry, 150, 93-97.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C.,
Fleischmann, R. L., Hill, C. L., . . . Charney, D. S. (1989). The
Yale-Brown obsessive compulsive scale: I. Development, use,
and reliability. Archives of General Psychiatry, 46, 1006-1011.
Grisham, J. R., Brown, T. A., Savage, C. R., Steketee, G., &
Barlow, D. H. (2007). Neuropsychological impairment asso-
ciated with compulsive hoarding. Behaviour Research and
Therapy, 45, 1471-1483.
Gunay, S., Savran, C., & Aksoy, U. M. (2005). The norm study,
transliteral equivalence, the validity and reliability of the
Turkish version of Adult ADD/ADHD DSM-IV Based
Diagnostic Screening and Rating Scale. M.Ü. Atatürk Eğitim
Fakültesi Eğitim Bilimleri Dergisi, 21, 133-150.
Hamilton, M. (1960). A rating scale for depression. Journal of
Neurology, Neurosurgery & Psychiatry, 23, 56-62.
Hartl, T. L., Duffany, S. R., Allen, G. J., Steketee, G., & Frost, R. O.
(2005). Relationships among compulsive hoarding, trauma, and
attention-deficit/hyperactivity disorder. Behaviour Research
and Therapy, 43, 269-276.
Hollander, E., & Wong, C. M. (1995). Obsessive-compulsive spec-
trum disorders. Journal of Clinical Psychiatry, 56(Suppl. 4), 3-6.
Holzer, J. C., Goodman, W. K., McDougle, C. J., Baer, L.,
Boyarsky, B. K., Leckman, J. F., & Price, L. H. (1994).
Obsessive-compulsive disorder with and without a chronic tic
disorder. A comparison of symptoms in 70 patients. British
Journal of Psychiatry, 164, 469-473.
Jaisoorya, T. S., Janardhan Reddy, Y. C., & Srinath, S. (2003).
Is juvenile obsessive-compulsive disorder a developmen-
tal subtype of the disorder? Findings from an Indian study.
European Child and Adolescent Psychiatry, 12, 290-297.
Ketzenberger, K. E., & Forrest, L. (1998). Compulsiveness and
impulsiveness: Unidimensional or bidimensional constructs?
Psychological Reports, 83, 303-306.
Leckman, J. F., Grice, D. E., Barr, L. C., de Vries, A. L., Martin,
C., Cohen, D. J., . . . Rasmussen, S. A. (1997). Tic-related
vs. non-tic related obsessive-compulsive disorder. Anxiety, 1,
208-215.
Malloy-Diniz, I., Fuentes, D., Leite, W. B., Correa, H., & Bechara,
A. (2007). Impulsive behavior in adults with attention deficit0
hyperactivity disorder: Characterization of attentional, motor
and cognitive impulsiveness. Journal of the International
Neuropsychological Society, 13, 693-698.
Masi, G., Millepiedi, S., Mucci, M., Bertini, N., Pfanner, C., &
Arcangeli, F. (2006). Comorbidity of obsessive-compul-
sive disorder and attention-deficit/hyperactivity disorder in
referred children and adolescents. Comprehensive Psychiatry,
47, 42-47.
Moll, G. H., Eysenbach, K., Woerner, W., Banaschewski, T.,
Schmidt, M. H., & Rothenberger, A. (2000). Quantitative
and qualitative aspects of obsessive-compulsive behaviour
in children with attention deficit hyperactivity disorder. Acta
Psychiatrica Scandinavica, 101, 389-394.
Oncu, B., Olmez, S., & Senturk, V. (2005). Wender-Utah
Derecelendirme Ölçeği. Türkçe Formunun Erişkin Dikkat
Eksikliği ve Hiperaktivite Bozukluğunda Geçerlik ve
Güvenilirlik Çalışması [Reliability and validity study of
at CORNELL UNIV on September 23, 2016jad.sagepub.comDownloaded from

Mersin Kilic et al. 7
Wender-Utah Rating Scale Turkish Version at Adult Attention
Deficiency and Hyperactivity Disorder]. Türk Psikiyatri
Dergisi [Journal of Turkish Psychiathry], 16, 252-259.
Özkürkçügil, A., Aydemir, Ö., & Yıldız, M. (1999). DSM-IV
Eksen I bozukluklarıiçin yapılandırılmış klinik görüşmenin
Türkçe’ye uyarlanması ve güvenilirlik çalışması [The study
for reliability of Turkish Verison of Stuctured Clinical
Interview of DSM-IV Axis I Disorders]. İlaç ve Tedavi
Dergisi [Journal of Drug and Treatment], 12, 233-236.
Patton, J. H., & Stanford, M. S. (1995). Factor structure of the
Barratt impulsiveness scale. Journal of Clinical Psychology,
51, 768-774.
Pauls, D. L., Towbin, K. E., Leckman, J. F., Zahner, G. E., &
Cohen, D. J. (1986). Gilles de la Tourette’s syndrome and
obsessive-compulsive disorder: Evidence supporting a
genetic relationship. Archives of General Psychiatry, 43,
1177-1179.
Peterson, B. S., Pine, D. S., Cohen, P., & Brook, J. S. (2001).
Prospective, longitudinal study of tic, obsessive-compulsive,
and attention-deficit/hyperactivity disorders in an epide-
miological sample. Journal of American Academy Child &
Adolescent Psychiatry, 40, 685-695.
Purcell, R., Maruff, P., Kyrios, M., & Pantelis, C. (1998). Cognitive
deficits in obsessive-compulsive disorder on tests of frontal-
striatal function. Biological Psychiatry, 43, 348-357.
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010).
The epidemiology of obsessive-compulsive disorder in
the National Comorbidity Survey Replication. Molecular
Psychiatry, 15, 53-63.
Santangelo, S. L., Pauls, D. L., Goldstein, J. M., Faraone, S. V.,
Tsuang, M. T., & Leckman, J. F. (1994). Tourette’s syndrome:
What are the influences of gender and comorbid obsessive-
compulsive dis-order? Journal of the American Academy of
Child & Adolescent Psychiatry, 33, 795-804.
Sheppard, B., Chavira, D., Azzam, A., Grados, M. A., Umana, P.,
Garrido, H., & Mathews, C. A. (2010). ADHD prevalence and
association with hoarding behaviors in childhood-onset OCD.
Depression and Anxiety, 27, 667-674.
Sheppard, D. M., Bradshaw, J. L., Purcell, R., & Pantelia, C.
(1999). Tourette’s and comorbid syndromes: Obsessive com-
pulsive and attention deficit hyperactivity disorder. A com-
mon etiology? Clinical Psychology Review, 19, 531-552.
Schmidtke, K., Schorb, A., Winkelmann, G., & Hohagen, F.
(1998). Cognitive frontal lobe dysfunction in obsessive-com-
pulsion disorder. Biological Psychiatry, 28, 666-673.
Shoval, G., Zalsman, G., Sher, L., Apter, A., & Weizman, A.
(2006). Clinical characteristics of inpatient adolescents
with severe obsessive-compulsive disorder. Depression and
Anxiety, 23, 62-70.
Stein, D. J., Hollander, E., Simeon, D., & Cohen, L. (1994).
Impulsivity scores in patients with obsessive compulsive
disorder. Journal of Nervous and Mental Disease, 182,
240-241.
Stein, D. J., Mullen, L., Islam, M. N., Cohen, L., DeCaria, C. M.,
& Hollander, E. (1995). Compulsive and impulsive symptom-
atology in trichotillomania. Psychopathology, 28, 208-213.
Summerfeldt, L. J., Hood, K., Antony, M. M., Richter, M. A., &
Swinson, R. (2004). Impulsivity in obsessive-compulsive dis-
order: Comparisons with other anxiety disorders and within
tic-related subgroups. Personality and Individual Differences,
36, 539-553.
Tamam, L., Gulec, H., & Karatas, G. (2013). Barratt Dürtüsellik
Ölçeği Kısa Formu (BIS-11-KF) Türkçe Uyarlama Çalışması
[The study for Turkish version of Barratt Impulsivity Scale
Short Form (BIS- 11-SF)]. Archives of Neuropsychiatry
[Archieves of Neuropsychiathry], 50, 130-134.
Turgay, A. (1995). Adult Hyperactivity Assessment Scale based on
DSM IV (Unpublished scale). Integrative Therapy Institute,
Toronto, Ontario, Canada.
van den Heuvel, O. A., van der Werf, Y. D., Verhoef, K. M., de
Wit, S., Berendse, H. W., Wolters, E., & Groenewegen, H.
J. (2010). Frontal-striatal abnormalities underlying behav-
iours in the compulsive-impulsive spectrum. Journal of the
Neurological Sciences, 289, 55-59.
Walitza, S., Wendland, J. R., Gruenblatt, E., Warnke, A., Sontag,
T. A., Tucha, O., & Lange, K. W. (2010). Genetics of early-
onset obsessive-compulsive disorder. European Child and
Adolescent Psychiatry, 19, 227-235.
Walitza, S., Zellmann, H., Irblich, B., Lange, K. W., Tucha, O.,
Hemminger, U., . . . Warnke, A. (2008). Children and ado-
lescents with obsessive-compulsive disorder and comor-
bid attention-deficit/hyperactivity disorder: Preliminary
results of a prospective follow-up study. Journal of Neural
Transmission, 115, 187-190.
Ward, M. F., Wender, P. H., & Reimherr, F. W. (1993). The
Wender Utah Rating Scale: An aid in the retrospective diag-
nosis of childhood attention deficit hyperactivity disorder.
American Journal of Psychiatry, 50, 885-890.
Winstanley, C. A., Eagle, D. M., & Robbins, T. W. (2006).
Behavioral models of impulsivity in relation to ADHD:
Translation between clinical and preclinical studies. Clinical
Psychology Review, 26, 379-395.
Zermatten, A., & Van der Linden, M. (2008). Impulsivity in
non-clinical persons with obsessive-compulsive symptoms.
Personality and Individual Differences, 44, 1824-1830.
Author Biographies
Sanem Mersin Kilic, MD, is a psychiatrist at Karsiyaka State
Hospital, (Izmir, Turkey). Her special areas are ADHD and anxi-
ety disorders. She cooperates several researches at Department of
Psychiatry of Adnan Menderes University.
Ayse Dondu, MD, is a psychiatrist at Aydin State Hospital,
(Aydin, Turkey). She is particularly interested in obsessive-com-
pulsive disorder. She also cooperates several researches at
Department of Psychiatry of Adnan Menderes University.
Cagdas Oyku Memis, MD, is a psychiatrist, and Assistant
Professor of the University of Adnan Menderes Medical School
(Aydin, Turkey).
Filiz Ozdemiroglu, MD, is a psychiatrist, and assistant professor
of Psychiatry Department of Adnan Menderes University (Aydin,
Turkey). She is particularly interested in mood disorders and
ADHD.
Levent Sevincok, MD, is a professor of Psychiatry, and is the
Head of Psychiatry Department of Adnan Menderes University.
He has several articles on OCD and anxiety disorders.
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