The Connection Between OCD and Autism

What is OCD?

True to its name, OCD involves obsessions and compulsions: Its trademark is the cycle of intrusive thoughts followed by neutralizing routines that interfere with the sufferer’s life. For example, an OCD sufferer may experience an intrusive thought that tells them their spouse will die in a car accident unless they organize their shoe rack a particular way. They will then organize their shoe rack to keep the intrusive thought from coming true. This relieves their anxiety temporarily, but it ultimately encourages OCD and increases the incidence of intrusive thoughts and the subsequent compulsions, strengthening the cycle in the process.

Intrusive thoughts, even those that are horrifying, are not unique to OCD and experienced by a large percentage of the population. Yet non-sufferers are able to ignore these intrusive thoughts, labeling them insignificant and nonsensical and casting them aside entirely. The OCD sufferer does the opposite, taking these thoughts seriously. That’s why they are problematic.

Interestingly, the sufferer, even when their OCD is severe, doesn’t entirely believe their OCD thoughts and knows deep down that they’re probably meaningless. But OCD demands 100% certainty and thrives on doubt, which is why it’s considered “the Doubting Disease.”

This need for certainty is marked by unique dysfunctional beliefs, including:

• Thought-action Fusion or “Magical Thinking”: This is the idea that having a thought about something is the same thing as doing it or the idea that something horrible can happen just because you thought of it.
• Hyper-Responsibility: OCD sufferers feel as though they are responsible for things well outside their normal realm of duty and believe they must stop “something bad from happening” by acting on their compulsions.
• Overestimation of Threats: OCD sufferers tend to overestimate danger, equating a hypothetical threat to a probable or certain one.
• Perfectionism: OCD sufferers often hold themselves to impossible ideals even when they are understanding and compassionate towards the imperfections of others.
• A Desire to Control Thoughts: No one can control their thoughts, regardless of their mental status. But those with OCD want this control because their intrusive thoughts inflict such terror. This makes the thoughts more potent and frequent because it’s impossible to not think of something without actually thinking of it.

OCD has no cure, but there are several treatments that help control symptoms. And, when successful, most people with OCD can live normal lives.

The Subtypes of OCD

Many people assume that OCD is a handwashing disease and it does, at times, present in this manner. Yet only around a third of OCD sufferers are consumed with fears and thoughts of germs, contamination, or cleanliness. Everyone else afflicted has other types; in theory, people can have OCD about anything, including whether or not they’re truly alive and living in reality.

OCD is an egodystonic disease, which means the intrusive thoughts are exactly opposite of the OCD sufferer’s true desires, innate nature, and character. For example, someone with Harm OCD will experience intrusive thoughts about hurting others. But the OCD sufferer doesn’t really want to harm others. Conversely, more than anything, they want to not hurt others. Because they want this so much, OCD latches on. It finds the sufferer’s values and attacks.

This leads to varied but common OCD subtypes, including:

• Contamination OCD
• Harm OCD
• Sexual Orientation OCD
• Relationship OCD
• Existential OCD
• Pedophilia OCD

Some people only struggle with one type of OCD while others experience many types. In the latter group, one subtype may still dominate.

What are the symptoms of OCD?

OCD, as mentioned above, involves intrusive thoughts and compulsions (or rituals) the sufferer performs as means to manage their anxiety. These two elements are, perhaps, the most obvious symptoms, though it’s possible to have OCD without overt compulsions (Pure O involves mental compulsions rather than apparent ones).

The specifics of these symptoms depend on which subtype of OCD the sufferer has. Someone with Harm OCD won’t spend hours washing their hands because they are not concerned with contamination. But they may spend hours driving through neighborhoods to make sure they haven’t run anyone over.

All in all, people with OCD may demonstrate the following:

• Checking
• Counting
• Organizing
• Hoarding
• Making sure things are asymmetrical
• Disappearing for long periods of time without explanation
• Spending hours alone
• Arriving tardy for work or school
• Doing things over and over again
• Asking for reassurance
• Questioning their own decisions and whether they are a good person
• Avoiding things, such as driving or public places
• Getting overly emotional about minor details
• Engaging in behavior that makes little sense to others
• Being over focused on morality, responsibility, or fairness

What are the risk factors of OCD?

The risk factors for OCD aren’t anything people can control; OCD isn’t tied to cigarettes or a sedentary lifestyle. Instead, it’s most likely in those who:

• Have an immediate family member with OCD
• Have a history of depression, tics, or anxiety
• Have a history of trauma or illness, especially in childhood
• Have certain structural abnormalities in the deeper areas of the brain or brains that overreact to certain stimuli and make errors in processing information
• Have low levels of serotonin
• Have mutations in some specific genes, including those involved in transporting serotonin

There is some evidence that OCD is slightly more common in females. However, early onset OCD (OCD that appears in childhood) is more common in boys than girls.

How common is OCD?

OCD impacts around 1 in 100 children, though its incidence more than doubles in adulthood, perhaps due to a delay in diagnosis. For adults living in the US, 2.3% of the population has been diagnosed with OCD

OCD is well-known as being a disorder marked by misconception, even among therapists and healthcare practitioners. Unfortunately, it takes between 14-17 years on average for those with OCD to get proper help. The discrepancy between diagnosis and treatment may indicate a discrepancy in the diagnosis itself. In other words, OCD may be more common than the stats suggest, with people suffering from it in silence.

Moreover, because our society as a whole is unaware of some of the less advertised subtypes of OCD (including Sexual Orientation OCD and Pedophilia OCD), it’s likely that many affected people fail to get help simply because they’re unaware they have a mental illness. Some subtypes also elicit an enormous amount of shame, which can act as a deterrent.

When does OCD first appear?

OCD is most likely to appear during two periods of life: Pre-adolescence and late adolescence. Some kids first start showing signs between the ages of 8 and 12, but many people don’t experience a diagnosable illness until their late teens or early adulthood.

In fact, several references point to 19 as the most common age when OCD sufferers are first diagnosed. But, because of the misconceptions of OCD and the probable lag time between the appearance of symptoms and a proper diagnosis, it’s fair to argue that the age of true onset may be much earlier.

How is OCD treated?

OCD is most often treated with a combination of medication and therapy. Some of the most common medications used include SSRIs, specific types of antidepressants that increase serotonin levels. Tricyclic antidepressants and SNRIs may be used as well. Some people also use off-label medications that aren’t explicitly approved for OCD but work to treat it nonetheless

The gold standard therapy used for OCD is cognitive behavioral therapy or – more specifically – exposure response prevention therapy. During ERP, the sufferers are asked to expose themselves to their distressing thoughts and then refrain from engaging in their neutralizing compulsions. While this can be very overwhelming and stressful for the sufferer, it’s highly effective. Medications are prescribed to make ERPs easier to handle.

Acceptance Commitment Therapy (or ACT) is rising in the OCD ranks and becoming a more commonly called upon form of treatment (especially as a supplement to the more traditional cognitive behavioral therapy). Inpatient treatment programs, group therapy, mindfulness-based treatment, or surgery (in rare and severe cases) may be used too.

While stress doesn’t cause OCD, it does exacerbate it, which is why reducing stress wherever possible acts as an additional form of treatment. People with OCD are often encouraged to limit alcohol and caffeine consumption, avoid cigarettes, exercise regularly, take part in a yoga or meditation routine, practice proper sleep hygiene, and eat a diet filled with fruits, vegetables, and whole grains.

What is autism?

Autism falls on a spectrum, with varying symptoms and degrees of severity. Some people are mildly autistic and able to live nearly normal lives; for others, autism is extremely disabling and, as a result, the sufferer requires constant care. Likewise, some people with autism show high intelligence and genius-level skill while others experience difficulty learning and low IQ.

People who suffer from autism experience challenges that interfere with everyday function. In general, they may:

• Have difficulty interacting with others and reading nonverbal cues
• Have limited interests
• Become overly focused on certain things or areas
• Engage in repetitive behaviors
• Experience a compromised ability to function in school, at home, with friends and family, and at work

Autism, like OCD, has no cure. But, also like OCD, treatments are available.

The Subtypes of Autism

Similar to OCD, autism comes in a variety of subtypes, including:

• Autistic Disorder: This is what most people think of when they think about autism; it presents with the most classic symptoms.
• Asperger Syndrome: This usually presents with more milder signs that Autistic Disorder.
• Pervasive Developmental Disorder: This is sometimes called Atypical Autism and includes people who have mild symptoms that meet some of the criteria for Autistic Disorder or Asperger’s.

What are the symptoms of autism?

The symptoms of autism often depend on the disorder’s severity. Yet, in general, children and adults with autism are most likely to demonstrate the following:

• Failure to answer to their name
• Dislike of affection, including being held or cuddled
• Desire to play by themselves in their own worlds
• Avoidance of social interaction
• Lack of expression or eye contact
• Failure to start conversations or engage with others (some people may be fully nonverbal)
• Speech that involves an abnormal cadence that may sound robotic or song-like
• Repetitive behaviors (such as rocking or tapping) and specific routines that appear nonsensical
• Failure to understand the meaning behind words
• Failure to understand questions or directions even when they’re simple and easy to follow
• Failure to show interest in typical toys or activities
• Showing obsessive interest in obscure things
• Failure to recognize nonverbal cues, such as tone of voice or a frowning face
• Aggression or disruption (autism may involve self-harming behaviors such as head-banging)
• Extreme passivity
• Problems with coordination or odd body movements
• Exaggerated body language
• Failure to engage in imaginative play
• Fixation on the details of an object
• Sensitivity to light, noise, and the textures of foods
• Lack of sensitivity to pain or temperature
• Preoccupation with asymmetry or organization
• An inability to go with the flow or adapt to changes
• An inability to understand humor or sarcasm

What are the risk factors for autism?

Like OCD, autism is not related to lifestyle choices made by the sufferer. Instead, those most at risk include:

• Boys: Boys are much more likely to be autistic than girls, at a ratio of 4-1. Some speculate that this is due to biological differences; others believe that girls are underdiagnosed.
• Genetics: Sometimes, autism is associated with genetic disorders, including Fragile X Syndrome, tuberous sclerosis, and Rett Syndrome.
• Exposure to environmental factors in utero: Autism may be linked to elements a baby is exposed to in the womb, including air pollution and viral illness.
• Family history: Children diagnosed with autism are more likely to have a family member who also has autism, ADHD, or an intellectual disability.
• Mental health history of the parents: Autism is increased in the children of those who have schizophrenia, bipolar disorder, depression or anxiety.
• Preterm delivery: Children born extremely premature are more likely to be autistic.
• Age of parents: Parents in their thirties are 10% more likely to have autistic children than those in their twenties. Parents in their forties or fifties are 50% more likely.

For several years, childhood vaccinations were believed to be a risk factor for autism too. However, the original study that hypothesized this connection has been retracted due to questionable science, bad design, and lack of study integrity. Since then, doctors have extensively studied autism and immunizations and have yet to find a convincing connection. Per the CDC, vaccines do not cause autism (nor do their ingredients).

How common is autism?

Autism is more common in kids than OCD, with approximately 1 in 59 children in the nation diagnosed as autistic. Rates have shown a steady increase, going up from 1 in 68 (in 2016) and 1 in 88 (in 2012).

Several decades ago, autism was believed to be extraordinarily rare, with a reported incidence of 1 in 2500 in the eighties and nineties. Yet the recent increase in cases isn’t proof that autism is becoming more common but rather indication that the classification surrounding the disorder has changed dramatically.

For example, the Diagnostic and Statistical Manual (the main diagnostic tool used by the American Psychiatric Association) did not acknowledge Asperger’s until the late 1980s and the requirements for an autism diagnosis as a whole were much more constrictive than they are in present day.

Without consistent criteria, it’s difficult to say whether something is truly increasing.

When does autism first appear?

Autism appears much earlier in life than OCD, with the signs typically showing up in toddlerhood. Sometimes, kids are diagnosed as autistic before they even turn two. It’s possible for those with autism to reach adulthood without a proper diagnosis, especially if they have a mild form that allows them to effectively live a regular life.

How is autism treated?

Autism is mainly treated with behavior and communication therapies, including programs that teach new skills, help with social interaction, enhance communication, improve language, help control emotions, and increase motivation (often through a system based on rewards). If necessary, speech therapy, occupational therapy, physical therapy, or psychological therapy may be used too.

Unlike OCD, there are no medications that directly help autism, though some may be used to control the most problematic symptoms. If applicable, medications may be prescribed for depression, anxiety, hyperactivity, insomnia, or seizures. Antipsychotics may be used as well to manage severe behavioral problems.

Different Diseases, Sometimes Similar Symptoms

People with OCD are typically mindful of these behaviors and aware that they’re acting irrationally. They engage in compulsions intentionally, with reason, and as a way to neutralize their anxiety and stop their intrusive thoughts from coming true. They cannot swap out one ritual for another and feel as though they need to perform whatever ritual their OCD dictates. Without treatment, their obsessions and compulsions tend to get worse over time.

On the flipside, people with autism are generally not aware of their behaviors and engage in compulsions subconsciously or on an innate level. They also engage in compulsions not as a way to stop something from happening but as a way to relieve agitation, drown out noises, feel more secure in their environment, or get some other biological reward. Their compulsions are not ritualized and they can swap out one for another at will. Symptoms tend to moderate as the person ages.

Differentiating between the two diseases is vital to proper treatment, treatment that is unique to each condition. But what happens when people have OCD and autism?

The Connection Between OCD and Autism

Studies suggest that 17% of people with autism also have OCD, which is seven times more than expected and equates to nearly 1 in 5. What’s more, a significant portion of those with OCD may have undiagnosed autism. Some portion of this overlap may be the result of misdiagnoses but, even when that’s taken into account, a connection exists.

The reason is believed to be rooted in neuroscience, with studies finding common neuroimaging patterns. Specifically, those with OCD and autism are believed to have a larger than normal caudate nucleus, located in the center of the brain. This area is linked to habit formation and the ability to start and stop behavior.

They may share similar genetic components as well with both OCD and autism running in the same families.

Serotonin plays a role in both OCD and autism but not the same type of role. While people with OCD have low levels of serotonin, those with autism have high levels. Still, this suggests that both conditions involve deficits in serotonin receptors.

How are OCD and autism treated?

Because of the prevalent partnership between OCD and autism, learning how to treat coexisting disorders is a subject of interest among clinicians. This effectively involves adapting cognitive behavioral therapy so that it works in people with autism.

This treatment involves very personalized care that adjusts the CBT to the needs of the patient. It may include parental participation during sessions, offering rewards (especially for kids), changing language or instruction so that it’s geared towards ability, assigning homework, using handouts, and using visual cues. For clinicians who treat patients with these coexisting disorders, there are several resources available for purchase online.

References:

https://www.verywellmind.com/early-versus-late-onset-ocd-2510673

https://beyondocd.org/ocd-facts

https://iocdf.org/ocd-finding-help/how-to-find-the-right-therapist/

https://contextualscience.org/act

https://www.autismspeaks.org/what-autism

https://www.autismspeaks.org/autism-statistics

https://www.spectrumnews.org/news/autism-runs-families-history-brain-conditions/

https://www.healthline.com/health-news/children-born-to-older-parents-have-a-50-percent-higher-chance-of-autism#The-research-by-the-numbers

https://www.cdc.gov/vaccinesafety/concerns/autism.html

https://www.autismspeaks.org/science-news/cdc-increases-estimate-autisms-prevalence-15-percent-1-59-children

https://pubmed.ncbi.nlm.nih.gov/21735077/

https://pubmed.ncbi.nlm.nih.gov/28705096/

https://pubmed.ncbi.nlm.nih.gov/26558765/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6118182/

https://www.amazon.com/OCD-Autism-Clinicians-Guide-Adapting/dp/178592379X