Repetitive and ritualistic behaviors are a hallmark feature of obsessive compulsive disorder (OCD) and autism spectrum disorder (ASD).1 While these diagnoses are understood as being unique in many ways, there is also considerable overlap in the way that symptoms impact individuals.2 Specifically, compulsions and rituals in both populations can serve to relieve or prevent underlying anxiety or distress.
What Is Autism Spectrum Disorder (ASD)?
Individuals with autism spectrum disorder (ASD) can be remarkably different from one another. However, autism can be broadly characterized by core features in two areas–social communication and restricted and/or repetitive behaviors.1
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 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.
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 individuals grow up to live independently in the community, while others need more support from trained professionals.
What Is Obsessive Compulsive Disorder (OCD)?
While obsessive compulsive disorder (OCD) used to be considered a type of anxiety disorder, it is now viewed as being a distinct disorder.1 OCD is diagnosed when people have recurring, unwanted, or distressing thoughts (obsessions).1 These often include themes of contamination, thoughts of harm, forbidden thoughts, and concerns related to symmetry.
Obsessive thoughts are often viewed as being intrusive and functionally impairing. In other words, the nature of these thoughts for individuals with OCD significantly interferes with their quality of life.
To respond to these thoughts, individuals often feel forced to engage in some types of actions (compulsions) to provide temporary relief.4 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.5 Many individuals with OCD report tension or anxiety that only resolves once a compulsive behavior occurs.
Can Autism & OCD Be Comorbid?
It is fairly common for autistic individuals to be diagnosed with a secondary psychiatric disorder, with up to 80% having at least one comorbidity.6 In one study, OCD was reported to co-occur with autism in 37% of the population.7 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.8
While there are many similarities between the intrusive thoughts and compulsive behaviors attributed to individuals 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 individuals’ subjective experiences of these thoughts and behaviors.
How Are OCD & Autism Related?
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.
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 an individual 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.
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.5
Obsessions are typically recurrent and persistent, meaning they can become preoccupying for an individual and make it difficult to focus on other things. These thoughts are similar for those with both autism and OCD in that they can cause a significant negative impact on one’s life. Obsessions can take up a great deal of mental energy, resulting in inflexibility and exhaustion.
Obsession-like 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.1 For instance, an autistic person may become a true expert in any given area.
Conversely, individuals with OCD experience obsessions as being far more distressing and unwanted. The anxiety or a sense of dread resulting from such thoughts, urges, or mental images can be consuming. 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.
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.9 Specifically, these individuals may feel unable to change a compulsive routine (e.g. checking that the door is locked 4 times in a minute) to one that achieves the same objective more realistically (e.g. checking that the door is locked once).
How Are Autism & OCD Diagnosed?
Autism and OCD are diagnosed by trained professionals using a standardized set of criteria outlined by the DSM-5. Unfortunately, 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.
How Are Co-Occurring OCD & Autism Treated?
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.
Treatment for OCD typically involves helping patients to gain insight into their obsessions and compulsions. Among the most frequently used intervention procedures for addressing symptoms of OCD is exposure and response prevention (ERP), which involves exposing patients to challenging situations while discouraging them from engaging in compulsive behavior.4 This work is often conducted by a psychologist or therapist trained in behavioral or cognitive behavioral therapy (CBT).
As many as 64% of autistic children with comorbid conditions may be prescribed at least one medication throughout treatment.10 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.11
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.
Repetitive and ritualistic behavior in autism can look quite similar to compulsions in OCD. Behavioral treatments have been found to be effective in addressing these symptoms, but individual differences may make some strategies more effective than others. While there can be considerable overlap between diagnoses, the factor most relevant for treatment involves the level of distress that the individual feels about their thoughts and behaviors.