By Daniel Ifrah, LCSW
No one should ever take finding a competent therapist for granted. While therapists undergo similar training and supervision, in their quest for skill and finesse, there has always been a sort of invisible line that segregates highly reputable professionals from the rest. The ability of a therapist to discern overlapping symptomology belonging to more than one specific diagnosis is one of those areas that can require wisdom and cutting-edge skill.
For illustration, let’s highlight a relatively simple example:
Bobby is in the 4th grade and his grades have recently plummeted. Upon consulting with the teacher, it was reported that Bobby is very unfocused during class. He seems to space out and cannot hold his attention to the lesson at hand. An o”-the-cu” suspicion by a therapist may be to assess for attentive type disorders or ADHD. However, it’s not usually as simple as that. Several other diagnoses can be responsible for a lack of focus besides ADHD. Take anxiety for instance. If someone is consumed with anxiety, that could also be a potential reason that it is difficult to pay attention in school. A good therapist understands the nuances required to ensure an accurate diagnosis.
Nothing is truer when attempting to accurately assess an individual on the ASD spectrum that is presenting with OCD-like symptomatology. First, a little more background…
ASD
You may have heard terms like Autism, PDD, Asperger’s, and more. With the ever-changing titles and acronyms used for mental disorders, ASD is the current all-inclusive acronym for most spectrum disorders. ASD stands for Autistic Spectrum Disorder or AKA being on “the spectrum.” Without going into the enormous detail that this diagnosis deserves, we will mention a few of its behavioral characteristics.
The average person seems to hold somewhat of a balance of logic, emotion, and social intuition. Individual actions and reactions are formed when processing the balanced combination of these elements. The ASD brain, however, tends to be dominated by facts. Perceptions, choices, and beliefs are processed through the “logically dominated” interpretation of the world and its circumstances, while social intuition seems to take a back seat. This unbalanced process can alter a person’s worldview, perceptions, and choices, to name a few. For reasons beyond the scope of this article, certain behavioral changes may take place as well. ASD can invite obsessive-like tendencies, repetitive actions, and susceptibility to pattern-like behaviors.
OCD
OCD also involves obsessive behaviors. Obsessive Compulsive Disorder consists of an obsessive thought or belief that most often is significantly distressing. To counter this plaguing thought, the sufferer engages in a compulsion. This compulsive action serves as a means to neutralize the obsessive thought – the hope being that he or she will relieve themselves and end this fearful belief or thought.
A textbook example (which rarely presents simplistically in the real world) is a person that believes or has a consistent thought that their hands are contaminated by germs. The thought tends to be a source of a great deal of stress. Thus, in order to relieve themselves of the disturbing notion that their hands are full of germs, they wash their hands with soap. The problem is that washing hands never truly puts an end to the distressing thought of contamination. Counterintuitively, engaging in the compulsion of hand washing actually worsens the stress and anxiety of the thought. The more a person does the compulsion, the more the obsession is perpetuated. This never-ending vicious cycle only gets worse and more painful as it intensifies, resulting in untold anguish to the OCD sufferer.
Distinct Characteristics
The point is that both OCD and ASD can have manifestations of obsessive thoughts and behaviors. Let’s explore some of the similarities and distinctions between the obsessive behavior found in ASD versus OCD.
Both spectrum and OCD sufferers include some form of obsessive behaviors; however, behind the surface, they are completely different animals entirely. To gain clarity, it is imperative to understand the inner workings of each respective disorder.
As previously stated, ASD is a disorder of the brain processing its surroundings by logic, facts, and familiarity. One outcome of this is a rigid nature. Rigidity helps ensure that facts and logic remain intact. It also serves as a means of navigating in the absence of social intuition. This causes an inherent need for similarity and sameness, which results in the obsessive-type presentation.
By contrast, OCD’s obsessive component is an anxiety. It is often taxing and painful. The OCD sufferer will do almost anything to rid themselves of the relentless obsession.
Understanding the functionality of the obsessions associated with ASD and OCD sheds clarity on some of the different presentations they manifest. The obsession identified in the OCD sufferer often causes tremendous distress, while the obsessive ASD individual is more of a learned and even sought-out behavior. This hallmark distinction has several implications for both the assessment and treatment plans of any obsessive symptomatology.
A Different Kind of OCD
But things can get even more complex. What happens when the symptoms of OCD and ASD overlap?
For example:
Max was a 12-year-old boy, who was previously diagnosed with a form of ASD. Recently, Max has displayed an increase in his obsessive behaviors. More specifically, Max has always been a very picky eater. Mealtime was difficult as his choice of foods were few and far between. Max insisted on only eating from his “self-proclaimed” personal purple plate and identifiably patterned spoon. Presumably, not so out of the ordinary for someone with an ASD rigid nature. However, as time went on, Max’s dependency on special dietary privileges snowballed. No one else was allowed to touch his plate or cutlery (besides good old mom, of course). Eventually, Max would have a complete meltdown if he saw his cutlery being washed along with everyone else’s dishes. They had to be separate…
Was Max’s ASD just causing him to be more rigid, or was this in fact a new diagnosis of OCD? The reality may very well be that both are indeed at play.
Only a clinician well-trained in both areas can tease out the primary thrust of the targeted obsessions. Only once the nature of the obsessions is accurately conceptualized can an appropriate treatment plan follow.
OCD responds to Cognitive Behavioral Therapy or CBT concepts such as living with uncertainty. This, alongside Exposure and Response Prevention therapy, or ERP, is the gold standard in OCD treatment.
While ASD-type OCD individuals can sometimes benefit from ERP as well, the treatment involves a lot of other components such as an emphasis on behaviors and flexibility training. It is also quite interesting how different classes of medications can laser-target these different OCD types.
Individuals with ASD are a lot more prone to what I refer to as behavioral imprinting. Behavioral imprinting is when a behavior makes a marked impression on the psyche thus increasing the probability the behavior will be repeated. For this reason, people with ASD tendencies may be a lot more at risk for developing OCD.
When a dual diagnosis of ASD and OCD is compounded into “OASCD,” all treatment modalities must be on the table. Through the expertise of a skilled clinician, it will be crucial to break down specific obsessions and treat each compulsion individually with a customized combination of both ASD and OCD treatments.
I cannot tell you how many times individuals have shown up in my office, with OCD-like symptoms, and yet report little or no relief despite years of OCD treatment. Upon closer review, it often surfaces how the very nature of their OCD is not your classic OCD per se but closer to an ASD or rigid OCD type. Keep in mind, that classic OCD usually responds well to classic OCD treatment. More Rigid type OCD, however, needs a very different approach.
Remember, obsessing about addressing an obsessive issue is never productive. Getting the appropriate help will be.