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When OCD + Autism co-habit!

Single diagnoses of OCD are becoming rarer. Instead, we are seeing a high rate of complex diagnoses where clients present with OCD and co-occurring conditions. In some studies the rate is as high as 69% [1] suggesting that 69% of people with OCD have another mental health condition during their lifespan of OCD. One of the most common of these is Autism, otherwise

known as ASD (Autism Spectrum Disorder), particularly in the male OCD population (in the general population, males are 4 times more likely to have Autism [2]).

When it comes to OCD and Autism, complexity really is the order of the day because the relationship between OCD and Autism is complicated and far from clear. Take this fact for starters: 84% of autistic people have some form of anxiety and as many as 17% may have OCD [3]. Conversely, in another study 27.8% of people with OCD met the diagnostic criteria for Autism [4]. Confused yet?

In my experience, there are shared traits. I have noticed that clients with OCD can have abnormal responses to sensory experiences, as is often the case for those with Autism. Both conditions can be characterised by repetitive behaviours and a desire for structure and order. However, there are key and distinct differences. People with OCD aren’t easily able to replace current rituals with other rituals whereas someone with Autism may be able to select from a number of self-soothing behaviours. Similarly, people with OCD may not struggle as much with self-insight, expression or have the verbal, communication or intellectual challenges that some people with Autism face.

The point is that researchers have only recently been studying the joint existence of these two conditions and what they are finding is that those with OCD and Autism seem to have symptoms and experiences which are quite unique, even from those who have either condition alone. Based upon this, there is the suggestion that the standard treatments for OCD may need to be adapted when it comes to OCD with Autism.

By ‘treatments’, researchers are looking at both psychopharmacological and psychotherapeutic treatments. A team at the OCD Research Clinic at Yale University has been looking at the neurobiology of OCD and Autism and more specifically, at the striatum. As far as a genetic link between the two, Christopher Pittenger, the director at Yale, admits that they know 'embarrassingly little' about the generics of OCD in comparison to Autism [5]. It would therefore appear that a neurobiological treatment is some time away.

In the meantime, how can psychotherapy therapy models be adapted to treat those with OCD and Autism? In my experience of treating both conditions concurrently I have developed some general guidelines:

  1. Individual rather than group treatment is advisable

  2. Be flexible when it comes to expressing feelings and emotions (Alexithymia can exist)

  3. Break goals down into smaller, more manageable tasks

  4. Use imagery, visuals and other client-preferred tools, such as music or movies

  5. Use and demonstrate examples wherever possible

  6. Involve family or carers where possible

  7. Introduce appropriate breaks and rewards

  8. Be sensitive to eye contact, homework setting and direct therapy propositions

We are some way from understanding the exact relationship between OCD with Autism (and vice versa) and further still from standardising a treatment protocol for the existence of both. The answer may lie in team work, whereby two therapists can synergistically combine skill sets. In any case, understanding and treating OCD with Autism will be careful, long-term work.

1.Sharma E, Sharma LP, Balachander S, et al. Comorbidities in Obsessive-Compulsive Disorder Across the Lifespan: A Systematic Review and Meta-Analysis. Front Psychiatry. 2021;12:703701. Published 2021 Nov 11. doi:10.3389/fpsyt.2021.703701

3. Postorino V, Kerns CM, Vivanti G, Bradshaw J, Siracusano M, Mazzone L. Anxiety Disorders and Obsessive-Compulsive Disorder in Individuals with Autism Spectrum Disorder. Curr Psychiatry Rep. 2017 Oct 30;19(12):92.

4. Wikramanayake WNM, Mandy W, Shahper S, Kaur S, Kolli S, Osman S, Reid J, Jefferies-Sewell K, Fineberg NA. Autism spectrum disorders in adult outpatients with obsessive compulsive disorder in the UK. Int J Psychiatry Clin Pract. 2018 Mar;22(1):54-62.

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