We see obsessive and compulsive symptoms in many neuropsychiatric disorders like autism, intellectual disability, severe brain injury, and dementia. We also see them in ADHD, anxiety and depression, bipolar disorder, and schizophrenia. However, they additionally occur in otherwise healthy people, with rates that range from 45% to 75% (Fullana MA et al, J Affect Disord 2010;124(3):291–299). Within this spectrum, classic obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) are just the tips of the iceberg.

The “OC disposition” is a subclinical cluster of traits, such as perfectionism, a need for control, and a hypersensitivity to sensory stimuli, often accompanied by typical obsessions and compulsions. They are the kind of thing one might describe as personality quirks. Such people rarely meet diagnostic criteria for OCD or OCPD, yet an OC disposition can influence their emotional response to events, their behavior, and the complaints they voice to psychiatrists. The disposition is found in many kinds of people, but it is particularly common among those who are conscientious and high-achieving—especially in engineering, science, technology, and medicine.

Recognizing this “OCD of everyday life” informs practice, and in this article, I’ll share some common examples of how it appears.

OC traits vs ADHD
An OC adult complains that she can’t focus. She has an important job and is worried that she can’t get it done. Her high school GPA was over 4.0, and she has a doctoral degree. “Yes,” she says, “I had excellent grades in school. But I had to work so much harder than anyone else.”

She’s right about that. Neither anxiety nor OC are associated with cognitive impairment as such, but they reduce the efficiency of one’s mental operations. Even simple tasks are effortful and time-consuming (Eysenck MW and Calvo MG, Cognition and Emotion 1992;6(6):409–434). Such patients believe they have ADHD, but they really have an inefficient, OC cognitive style.

The latest data show that 4% of commercially insured Americans were prescribed a stimulant in the past year (Danielson ML et al, MMWR Morb Mortal Wkly Rep 2023;72:327–332). Only a fraction of those many millions have ADHD, a neurodevelopmental disorder. Many probably have an OC disposition. Anxiety in general and OC in particular are distracting. Intrusive thoughts are a distraction, as is an emotional bias to the effect of “something is wrong.” When perfect is the enemy of good, productivity falls. Perfectionism, the need to control, and moralistic posturing make one inefficient if not ineffective. That isn’t ADHD. It’s OC.

Yet this reality can be difficult to communicate to patients. Once an OC patient latches onto an ADHD diagnosis, it’s hard to dislodge it. In my clinic, I run a full battery of computerized cognitive tests. I show the patient that they are average or above in every cognitive domain, including attention. But there is no amending a fixed idea. They go looking for another provider.

Stimulants and OC traits
Stimulant effects are not specific to a particular diagnosis, so it’s not surprising when patients with OC traits report that stimulants help them concentrate. Of the millions of Americans taking stimulants, some feel sharper on them—not because of ADHD, but because the medication quiets the mental noise of OC. For these patients, stimulants can offer temporary relief from intrusive thoughts and mental fatigue. But the benefits are short-lived. In people without ADHD, these cognitive benefits are transient at best (Ilieva IP and Farah MJ, Front Neurosci 2013;7:198).

A more immediate problem is that psychostimulants are on-off drugs. Patients feel them kick in within 30–60 minutes and then later feel them fade. Even long-acting versions can’t fully smooth out the peaks and valleys. Because OC patients are already hyperfocused on their mental state, they notice these shifts. As a result, the drugs lead to even more obsessive self-monitoring.

When stimulants wear off, the result is usually a sluggish, foggy state, and OC patients may feel compelled to raise the dose as a result. Unfortunately, higher doses of stimulants actually impair cognitive abilities. People are less flexible, spontaneous, and creative. They perseverate, have trouble shifting gears, and are cognitively slower (Sprague RL and Sleator EK, Science 1977;198(4323):1274–1276).

Just how high is too high? It varies from person to person, but low to moderate doses are 20–40 mg/day for Adderall and methylphenidate, and 50 mg/day for Vyvanse.

OC traits in children
An intelligent, creative 9-year-old girl has trouble paying attention in class. She is irritable and prone to outbursts. She is highly critical of others, often insulting or hitting her younger siblings when they do something she thinks is stupid (which is most things). When things don’t go her way, she explodes in protest. A trial of stimulants did not help and may have made her more volatile when the drugs wore off.

Amid the legion of inscrutable behaviors expressed by children, the problems of chronic irritability, angry outbursts, and aggression rank high. In some cases, we can identify a specific cause, like autism, ADHD, a mood disorder, or neglect or abuse. Too often, the diagnosis is just a reiteration of symptoms like disruptive mood dysregulation or oppositional-defiant disorder. In many of the kids, what’s really driving the chaos is an OC disposition. They are angry, controlling children who are unusually sensitive to what they perceive as disorder.

With further inquiry, one might learn that a child reacts sharply to sounds, textures, odors, and tastes. Examples include the tag on the back of a T-shirt, the texture of tissue paper, or the sound of someone chewing. One of my patients kept his hair long because he couldn’t stand the sound of scissors.

To clarify, I’ll ask about eating behaviors. Is the child restricted to only a few foods? Do they eat one thing at a time? Are they repelled by certain textures? Do they refuse to eat if their servings touch on the plate? I’ll also ask about tics or repetitive movements, like eye blinking, facial twitches, shoulder shrugging, vocal grunts, or throat clearing. These often accompany OC and ADHD traits in a syndrome known as Tourette’s clinical triad (Robertson MM et al, Br J Psychiatry 2008;193(1):31–36). The full syndrome usually subsides with age, but most patients have OC traits when they grow up.

Additionally, OC traits tend to run in families. Are the patient’s close relatives perfectionistic or controlling? We might learn that a patient’s father is a workaholic IT professional, while their mother won’t let anyone into the house who hasn’t taken their shoes off. Psychotherapy with these kids has to focus on their need for control—not defiance, not mood, but control. In adults misdiagnosed with ADHD, the work is similar and involves breaking the habit of obsessive self-monitoring that clogs up their thinking.

CARLAT VERDICT
OC traits are common and easy to mistake for other disorders. Look for them in adults who present for ADHD and have perfectionistic tendencies, or in children who are angry, aggressive, and controlling. Be cautious with stimulants, which can worsen OC traits and are cardiovascular risk factors in adults.