At first glance, individuals with OCD and autism spectrum disorders (ASD) might appear to show similar behaviors and symptoms, engaging in repetitive actions, having higher-than-normal anxiety levels, experiencing “obsessions” of one sort or another, and so on. But how do they compare when you take a closer look?
To gain some insight into both conditions and learn how they are similar and different, we spoke to NOCD Therapist April Kilduff, LMHC, who specializes in studying and treating people with OCD and ASD.
What is OCD?
OCD is a mental health condition characterized by two primary symptoms: obsessions and compulsions. Obsessions are intrusive, unwanted thoughts, images, and urges that cause significant distress. In response to obsessions, individuals with OCD perform compulsions, which are physical or mental behaviors that are done to alleviate obsession-induced discomfort or prevent negative outcomes associated with them. For example, in response to the intrusive thought, “Was that handrail I touched contaminated?” someone with OCD might wash their hands repeatedly to avoid contracting an illness.
What Are Autism Spectrum Disorders?
Autism spectrum disorders are complex developmental conditions involving deficits in social communication and interactions, learning and cognitive development, and repetitive and ritualized behaviors.
Kilduff emphasizes that it’s essential to recognize the condition is much more subtle and variable than many realize, including practitioners. “As we have heard from more autistic voices about the autistic experience, we understand it’s a lot more nuanced than people originally thought,” she shares. It doesn’t always have to present itself in the form of difficulty maintaining eye contact or expressing emotions. As a result, our understanding of the autism spectrum is still evolving and improving.
Is There any Relation Between OCD and Autism Spectrum Disorders?
OCD and ASD share some important similarities and differences. Here’s how they compare.
Compulsions Vs. Ritualized Behaviors
Both individuals with OCD and ASD might engage in ritualized, repetitive actions that may be considered unusual by others. While they share superficial similarities, there are three key differences between compulsions in OCD on the one hand and ritualized, repetitive behaviors in ASD on the other. Kilduff notes that to be a compulsion, a ritualized behavior must do one of three things:
- Eliminate anxiety (or other unwanted uncomfortable emotion or feeling) stemming from an obsession
- Have been performed to reduce obsession-induced doubt or uncertainty
- Prevent an unwanted outcome from occurring
The repetitive ritualized behaviors performed by individuals with ASD satisfy none of these conditions. Kilduff highlights how “for those with ASD, a lot of their ritualized behaviors are simply done because they are pleasing.” They may also be driven by the calming effects that come from a sense of sameness: “It’s really common for autistic individuals to really just like sameness,” she shares. “Dealing with change is difficult, so they might do something repeatedly just because having that sense of sameness is calming and satisfying.”
Obsessions Vs. Obsessive Interests
Both OCD and Autism involve obsessions, but in very different senses of the word. Individuals with autism develop obsessive interests. They can become hyperfocused on topics they enjoy thinking about, often to a high or excessive degree. However, their enjoyableness is part of what separates them from the obsessions that characterize OCD. ASD obsessions also do not lead to compulsions.
Individuals with OCD or ASD typically experience higher-than-normal levels of anxiety. However, anxious feelings play different roles in each case. With OCD, fear and anxiety primarily result from obsessions and drive compulsions. As Kilduff notes, stress can also occur when compulsion is interrupted. “If you interrupt someone with OCD doing a compulsion, they will get upset because they’re afraid that it’ll cause bad consequences,” she says. “With autism, if you interrupt a routine, they might be annoyed, but it’s because you just interrupted something they were enjoying, not because there’s a feared consequence attached to it.”
Autistic people often experience sensitivity to sensory experiences like light, textures, sounds, and tastes. For example, the feeling of a particular type of fabric against their skin may feel intensely unpleasant or agitating.
While this has long been established for ASD, recent evidence suggests that “sensory over-responsivity” is common among individuals with OCD as well. One study found that 32.5 percent of participants with OCD were over-sensitive to textures and tactile sensations, and around 20 percent were extra sensitive to sounds, smells, and tastes. They also noticed that sensory hypersensitivity was associated with more severe OCD symptoms.
With that said, it’s important to remember that because our understanding of ASD is still evolving, it’s possible that many of those with OCD and sensory sensitivity also have ASD. “There does tend to be a lot of undiagnosed ASD,” shares Kilduff. “So, I would bet a chunk of those people in that study would qualify for a diagnosis.”
Social deficits are one of the hallmark features of ASD. Some examples include difficulties with:
- Initiating interactions
- Maintaining eye contact
- Reading the non-verbal cues of others
- Taking another person’s perspective
However, people with OCD can also experience social difficulties, though this is typically not a direct symptom of OCD itself. “Most of the time, if I see a social issue related to OCD, it’s because of isolation or avoidance.” shares Kilduff. In other words people with OCD can experience problems developing and maintaining relationships because of compulsions that interrupt their social behaviors, fears that keep them from social situations, or shame or embarrassment about their behaviors.
With that said, there may be some social abilities that are diminished in individuals with OCD. For example, a recent study found that those with OCD have a harder time understanding when a facial expression indicates disgust, often overestimating when it does. Because the ability to accurately read facial expressions is important for effective socializing, OCD might come with social deficits of its own.
Evidence suggests that ASD and OCD may share several biological similarities. Kilduff notes that both appear highly heritable, though ASD seems to have a stronger genetic component. For example, studies have found that among identical twins, if one is autistic, there is a 65 to 90 percent chance the other does as well. For OCD, the statistics are similar, ranging from 70 to 80 percent for identical twins.
Both conditions also share abnormalities in some of the same brain regions. In particular, studies have found that individuals with either OCD or ASD show dysfunction in some of the same parts of the prefrontal cortex and a few other regions. However, while some of the same areas are involved, the type of abnormality isn’t always the same. In some cases, there is increased activity in one condition and decreased activity in others. Experts highlight that this helps to explain both the similarities and the differences that we see in OCD and ASD.
Are Autistic People More Likely to Have OCD?
Around 1 in 40 adults have OCD. Individuals with autism are significantly more likely to display OCD symptoms. Estimates suggest that between 5 to 17 percent of patients with ASD also have some OCD symptoms, indicating that ASD comes with an increased chance of having OCD.
Does Autism Make OCD Treatment any Different?
When working with individuals with OCD and ASD, Kilduff notes a few things that patients and practitioners should be mindful of.
First, she highlights how exposure-response and prevention (ERP) therapy, the gold standard for treating OCD, may work more slowly. “For someone who’s autistic, it is going to take them much longer to habituate and generalize than it does someone with OCD who’s not on the spectrum.” This poses a challenge because ERP works partly through habituation. The intervention requires individuals to confront fears or obsessions without engaging in their typical avoidance behaviors. Over time, one gains a tolerance for feelings of anxiety, and their obsessions and associated distress decrease in frequency and intensity. However, because individuals with ASD can take longer to habituate to aversive stimuli, ERP may not work as quickly.
It’s also important to be mindful of sensory processing issues. For someone with autism, if they are overwhelmed from a sensory perspective, it can be difficult for them to focus on anything else. So when using ERP, practitioners must be aware of whether their patient is overstimulated. If they are, it’s best to resume only once they no longer feel overloaded with sensory input.
With that said, ERP still works for people with both diagnoses. As Kilduff shares:
I worked with an autistic woman who had a really intense fear of vomiting and automatic toilets. […] In about a year, they could come back and say, “I went to a bathroom with an automatic toilet flush, and I didn’t even jump,” or “Someone at the house threw up today, and I didn’t run away.” So it’s more of a long game than when you’re working with someone who’s more neurotypical.
There are some things therapists can do to speed up the process. Kilduff recommends tapping into the special interests that autistic people so often have. “People who are autistic often have specialized or intense interests.” shares Kilduff. “Sometimes tying what you’re doing with ERP back to one of those things can be more motivating.”
She also suggests using cognitive flexibility training, which incorporates a range of strategies to help individuals switch their focus from one task or activity to another. “Being flexible and learning to adapt to changes is a helpful life skill that is challenging when you have either OCD or ASD. When you have both, it’s even more important.”
If you’re struggling with OCD, you can schedule a free 15-minute call today with the NOCD care team to learn how a licensed therapist can help. At NOCD, all therapists specialize in OCD and receive ERP-specific training. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP.