OCD & Autism: Understanding the Link

What Is Autism?

While presentations are incredibly varied from person to person, autism can be broadly characterized by core features in two areas–social communication and restricted and/or repetitive behaviors.¹ Examples of features commonly attributed to autism include difficulties with shared imaginative play, insistence on sameness in routine, and repetitive motor movements (e.g., lining up toys, arm flapping). Autism can be diagnosed by a variety of different professionals, often following a clinical observation and caregiver interview.

Autism may be evident throughout childhood following delays in milestones (i.e. language development, social skills) or as the result of restricted interests that differ from same-aged peers.³ Many autistic children also present with co-occurring conditions such as speech delays, learning difficulties, restricted food choices, and gastrointestinal problems.³ Many of these coexisting problems are well addressed through various therapies, though they are not “treating” the underlying autism diagnosis, per se.

Just as the signs and symptoms of autism vary greatly, so too do the outcomes. Some autistic people grow up to live independently in the community, while others need more support from trained professionals.

What Is Obsessive Compulsive Disorder (OCD)?

Obsessive compulsive disorder (OCD) is diagnosed when people have recurring, unwanted, or distressing thoughts (obsessions) followed by ritualistic behaviors to try to manage the anxiety of the obsessions.¹ Obsessive thoughts are often viewed as being intrusive and impair someone’s ability to function. In other words, the nature of these thoughts for people with OCD significantly interferes with their quality of life.

Compulsions can be visible to others, such as hand-washing or cleaning, or they can be harder to notice, such as counting or repeating specific words or phrases.⁴ Many people with OCD report tension or anxiety that only resolves once they’ve completed a compulsive behavior.

Is OCD Autism?

OCD is not a form of Autism, and it is not on the Autism spectrum. OCD is a mental health disorder that is closely linked with anxiety.⁵ Some research shows OCD is a form of neurodivergence. Autism diagnoses now encompass diagnoses that used to be considered separate, including Asperger’s syndrome, childhood disintegrative disorder, and an unspecified form of pervasive developmental disorder.⁶

How Do Symptoms of OCD and Autism Overlap?

At first glance, there can appear to be pretty significant overlap between autism and OCD. Symptoms of both conditions include the presence of some behaviors that may seem atypical. However, it is the individuals’ experience of these symptoms that can offer important evidence about how to differentiate them. Ultimately, these are unique disorders that require different levels of intervention and long-term support.

Restrictive-Repetitive Behaviors

Repetitive behaviors can include almost any type of mental or physical act, often occurring more frequently than what is typically expected. To an outside observer, it may not be clear whether a person engaging in repetitive behaviors has autism, OCD, or no diagnosis at all. However, what distinguishes them is the person’s understanding of these behaviors.

Among autistic folks, these behaviors may be vocal (e.g. humming, scripting movie lines or song lyrics) or motoric (e.g., arm flapping, body rocking, lining up items/objects). While the purposes of these actions vary by the individual, they are generally practiced to meet some kind of need. For instance, an autistic person might be seeking some type of sensory stimulation or reacting to a social situation, often called stimming.

Repetitive behaviors in OCD often involve an excess amount of otherwise common behavior, such as locking doors or washing hands. Whereas a person without OCD might do these things automatically, an individual suffering from OCD may spend several minutes or even hours engaging in these behaviors. Unlike repetitive behavior in autism, OCD compulsions occur as a means to reduce distress. While these excessive behaviors may be in response to a particular obsession, they can also be entirely unrelated.⁴

Obsessions

Obsessions are typically recurrent and persistent, meaning they can become preoccupying for someone, and make it difficult to focus on other things. Obsessions can take up a great deal of mental energy, resulting in inflexibility and exhaustion.

Obsessive thinking most commonly seen in autistic people typically involves highly preferred topics. One of the key diagnostic indicators for autism involves restricted interests and activities, meaning that these individuals are more likely to be consumed by their fascinations, and it is common for an autistic person to become a true expert in any given area.¹

Conversely, people with OCD experience obsessions as being far more distressing and unwanted. The anxiety or sense of dread resulting from such thoughts, urges, or mental images can be consuming, sometimes resulting in an OCD attack. Examples include a person feeling responsible for something bad that happened or having concerns about perfection. Importantly, these thoughts are distinguished from everyday preoccupation by how intrusive and time-consuming they become.

Thought Rigidity & Inflexibility

Rigid thinking involves the inability or unwillingness to modify one’s thoughts or beliefs, even in the presence of contrary evidence. It is quite common, and indeed appropriate, to hold on to certain personal concepts as these reflect one’s values. However, for those with autism and OCD, this rigidity can cause difficulties adapting to new situations or learning new skills.

Rigidity for autistic folks often involves some difficulty generating more than one solution to a problem (often referred to as “black and white” thinking). This quality, which can be a strength in many contexts, is sometimes viewed negatively as stubbornness. Other forms of rigidity may involve a very literal understanding of the world and social interactions. This can make certain things feel harder, such as using context clues to infer others’ meaning.

Thought rigidity common in OCD can refer to challenges with accepting alternate ways of performing actions or routines.⁷ Specifically, these individuals may feel unable to change a compulsive routine (e.g. checking that the door is locked four times in a minute) to one that achieves the same objective more realistically (e.g. checking that the door is locked once).

Social Difficulties

Social challenges are common in people with Autism and OCD, and both populations might experience increased anxiety in social situations. Having difficulty relating to others in social interactions and expressing your thoughts and feelings are also commonly experienced by people with either diagnosis.

Moreover, thoughts and behaviors related to OCD can interfere with social functioning, making it difficult to form friendships or keep a job.

Issues With Sensory Processing

Sensory processing issues are common in both Autism and OCD. Research has found that sensory processing sensitivities in childhood are linked with OCD symptoms later in life.⁸ This was particularly true for oral and tactile hypersensitivity. It is thought that intolerance to sensory stimuli contributes to ritualistic behavior in children with OCD.⁹

Sensory issues are very common for people with Autism, and are even a part of the diagnostic criteria. People with Autism can experience hypersensitivity (over-responsiveness) to sensory stimuli, including sounds, lights, smells, tastes, touches, movements, and others, or they may experience hyposensitivity (under-responsiveness). Sensory overload can occur when a stimulus overwhelms a person’s ability to cope, which can feel like intense anxiety.¹⁰

Difficulty Functioning Day-to-Day

A person with OCD may struggle with daily functioning, but for different reasons than are common for a person with Autism. With OCD, thoughts and rituals can become so time-consuming and emotionally overwhelming that the person is unable to carry out their daily responsibilities. This often feels burdensome and discouraging to the person with OCD.

Autism can impair daily functioning in a variety of ways, depending on the individual. The term “spectrum” associated with Autism Spectrum Disorder refers to the wide range of symptoms and severity that people with Autism can experience. Communication difficulties, deficits in organizational skills, fine and gross motor development, and other challenges related to Autism can affect a person’s ability to function at home, work, and school.

Key Differences Between OCD and Autism

Although OCD and Autism may present similarly, they have a distinct difference – while OCD is a mental health disorder, Autism is a neurodevelopmental disorder. Many people with Autism embrace their neurodiversity as simply another way of being in the world.

Other differences between OCD and Autism include:⁵

• People with OCD often experience distress as a result of their symptoms, while people with Autism do not.
• While people with Autism might feel that their obsessions enhance their lives and bring enjoyment, people with OCD experience decreased life enjoyment as a result of their obsessions and compulsions and most often wish to do away with them.
• People with Autism also exhibit a number of social, linguistic, and cognitive differences that people with OCD do not have.
• Autism is something a person is born with, while OCD can develop at any point in a person’s lifetime.

OCD Vs. Autism Chart

Can You Have OCD and Autism?

It is fairly common for autistic individuals to be diagnosed with a secondary psychiatric disorder, with up to 80% having at least one comorbidity.¹¹ In one study, OCD was reported to co-occur with autism in 37% of the population.¹² More specifically, autistic people are twice as likely to receive a diagnosis of OCD, while those with OCD have a four times higher risk of a later autism diagnosis.¹³

While there are many similarities between the intrusive thoughts and compulsive behaviors attributed to people with OCD and the repetitive patterns of behavior among autistic individuals, they are not identical. Importantly, the most reported differences between the two populations involve the person’s subjective experiences of these thoughts and behaviors.

Do OCD and Autism Have Similar Causes?

Experts are not sure of the exact causes of either OCD or Autism. It is thought that genetics, brain abnormalities, stress, and environmental factors may play a role in the development of OCD. Similarly, researchers think that autism may come from a mix of genetic and environmental factors. Some preliminary research supports some possible shared genetic components between OCD and Autism.¹³ Especially since the rate of Autism is higher in those with OCD than in the general public, experts are curious about similar genetic pathways.¹³

How Are Autism & OCD Diagnosed?

Autism and OCD are diagnosed by trained professionals using a standardized set of criteria outlined by the DSM-5. There are currently no medical tests that can identify either disorder.

Autism can sometimes be diagnosed as early as age two. In young children, medical professionals monitor specific developmental milestones such as playing, speaking, and learning new things to see if a child is on an expected trajectory. If such developments are delayed, a family may receive a referral to other healthcare professionals for additional screening. Typically, regardless of the age of the individual, a diagnostic evaluation for autism involves assessments of cognitive and language abilities, an observation of their behavior, and a structured interview with caregivers about their concerns.

OCD can also be diagnosed at almost any age, though young children may have difficulty articulating the nature of some of their thoughts or behaviors. A trained mental health professional will conduct a thorough psychological evaluation in order to provide a diagnosis of OCD. A referral for a physical exam might also be recommended in order to rule out any organic causes for the symptoms.

Are OCD Diagnoses More Commonly Missed in Those With Autism?

Autism and OCD share many symptoms, making it difficult to correctly diagnose.¹⁴ A recent study found that OCD is a common misdiagnosis in children who grow up to be diagnosed with Autism later in life.¹⁵ Someone with both OCD and Autism may have their symptoms attributed to only one diagnosis.

An experienced clinician will be able to tease apart these symptoms to provide a correct diagnosis through a comprehensive assessment. The key differences between Autism and OCD, including how a person feels about their obsessions and ritualistic behaviors, and viewing the person’s story through a developmental lens, will aid the clinician in arriving at the most fitting diagnosis.

How to Treat OCD in Autism

Autism is not a condition that necessarily requires intervention. Many autistic folks can live perfectly happy lives with minimal or no support. However, there may be certain challenges associated with an autism diagnosis that can be the focus of various types of treatment. If an autistic person also has OCD, it is likely that they will need the help from one or more trained mental healthcare professionals.

Therapy for OCD

Treatment for OCD typically involves helping patients to gain insight into their obsessions and compulsions. ERP for OCD is one of the most frequently-used interventions, which involves exposing patients to challenging situations while discouraging them from engaging in compulsive behavior.¹⁶ This work is often conducted by a psychologist or therapist with specialized training in ERP and OCD.

Medication

As many as 64% of autistic children with comorbid conditions may be prescribed at least one medication throughout treatment.¹⁷ To address repetitive behaviors and anxiety, the most commonly prescribed class of medications for autistic children are serotonin selective reuptake inhibitors (SSRIs).

SSRIs are generally thought to be safe, with low side effect profiles and have some demonstrated effectiveness in reducing obsessive compulsive symptoms in children and adolescents without autism.¹⁸

How to Cope With OCD as an Autistic Person

Learning to cope with behaviors like obsessions and compulsions can be a challenge, regardless of whether there are comorbid diagnoses. These behaviors can range from mildly annoying to significantly interfering, and so it might be hard to know where to start. However, there are some steps you can take to help you cope throughout treatment.

Below are some ways to cope with OCD and autism:

• Challenge yourself: Try gradually challenging yourself to tolerate difficult situations while not engaging in compulsive behavior. This can help you slowly ease yourself into new patterns of behavior and thinking.
• Seek support: It is extremely important to identify a support system, such as family members, friends, or support groups, who can help you work towards your goals. This process of change can be difficult, requiring support and encouragement from loved ones.
• Seek treatment: Effectively treating OCD involves modifying one’s lifestyle with support of a therapist in order to minimize avoidance and actively challenge obsessive thoughts and behaviors.