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  • Writer's pictureDr Jennifer Turner

OCD and / or Autism?

When I asked a local group for ideas for a blog, one of the topics which was suggested was OCD. It's a complex topic and diagnosis in autistic individuals requires detailed assessment to develop a full understanding of the symptoms and their function.

OCD is a mental health condition closely aligned with anxiety. It is characterised by obsessions, usually relating to something bad happening and compulsions (behaviours) designed to prevent that bad thing from happening. Sometimes the compulsions can be very logical, such as checking the door is locked to prevent a burglary, checking electrical items are turned off to prevent a fire or washing excessively to prevent illness or infection. The function of the behaviour may also be to prevent something bad happening to someone else. Some of the behaviours appear less logical, for example counting to a specific number, clicking the tongue, repeating a phrase, crossing a doorway, chewing food a certain number of times, not eating certain foods to name a few.

Lots of us will check or double check things, but it becomes problematic when the individual feels the behaviour is taking too much time or stopping them doing things which are important to them.

Obsessions and compulsions and routines and rituals are also very common and important to autistic individuals but they do not always have OCD (sometimes they do). The difference is the belief that there behaviour prevents something bad happening. Often the repetitive nature of the compulsion is comforting, regulating and even relaxing. It might be a sensory strategy such as enjoying the sound made by clicking or tapping or the sensation of hand washing. The behaviour may be designed to keep others at a distance, for example not allowing others to touch their things or sit in their chair. It might be a way to focus the brain and give them space from the other demands in their environment.

The behaviour may become distressing because others try to stop it or they recognise that it makes them stand out as socially different. Or perhaps it means that they cannot keep to others' agendas or move quickly on to another task.

Understanding the function of the behaviour is key to knowing how to support the individual. If it is OCD, the recognised and evidence based treatment is ERP (exposure response prevention). This should be undertaken by a trained professional and involves gently exposing the individual to the situation which causes distress and preventing the response behaviour (compulsion). If the person is ready and the professional well trained in ERP with a good understanding of autism, this can be incredibly effective.

However, if the person's behaviours have a different (or even sometimes parallel) function, as described above, ERP is rarely successful on its own. If the individual wants to change the behaviours then it is usually best to try to find another behaviour which fulfills the need whilst working for them in their day to day life. For example an individual who enjoys hand washing but has very sore skin, may be able to replace this with another behaviour such as a wipe or submersion in water without the rubbing. If it is the rubbing sensation this may be replaced with rubbing the hands with a fabric.

If the individual does not want to change the behaviour or see reason to, then it is going to be more difficult to change. The first step is finding more about why that behaviour needs to change? Who would the change benefit? Is their a clear reason why the behaviour needs to change? If these questions cannot be answered to the benefit of the person doing the behaviour, it may be that there needs to be consideration of how the behaviour can be accommodated.

The area I have yet to address is compulsive behaviours linked to anxiety. This is one of the main presentations I see. Living in a neurotypical world can invoke incredible high levels of anxiety. Rituals, routines and compulsions can be used to try to manage this. Lots of people find comfort in behaviours such as tapping, counting, moving in certain ways. The best way to support them in this is to try to support and manage the environment to reduce the anxiety and in turn reduce the need for the comforting behaviours.

An interesting analogy I saw recently, if you have a wilting house plant, you do not just name it as 'wilting plant' you would give it some water or move it (change the environment). Similarly, if you are or live with an autistic person, don't label them with autism and OCD or autism and anxiety, try to change their environment to help them. This in many cases is likely to have at least some positive effect.

In conclusion, autism and OCD is neither straightforward or easy to treat. The first step is a good understanding of the behaviour. If the person has their own understanding try to talk to them about their compulsions and find out what they mean to them. With this understanding you will develop more of an idea of how to help. If you feel you or your child has compulsions which are interfering with their day to day life please contact your GP, adults can self refer to their local IAPT service or children may be able to seek support through early intervention teams through their school nurse. I have also uploaded a record sheet where you can record compulsions, the length of time they take to complete and the level of distress caused if they cannot be completed. This can be used to show professionals to seek help.

These websites may also be helpful

National Autism Society

OCD UK (not specific to autism)

Get Self Help (not specific to autism)

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