Autistic spectrum disorder (ASD) is a Neurosviluppo disorder Characterized by the impairment of language, communication, and social interaction associated with the presence of restricted interests and stereotyped and repetitive behaviors.
The obsessive compulsive disorder (DOC) is instead a disorder characterized by the presence of unwanted thoughts, defined as obsessions, which cause a state of discomfort to those who experience them and which, consequently, lead the person to implement a series of strategies, called compulsions, in order to free themselves from these thoughts.
As we will see below, although these two conditions are clinically very different from each other, they share some common traits. In particular as regards the presence of rituals which often take on a rigid and stereotyped shape.
From a clinical point of view, therefore, it is important to know how to recognize the demarcation line between these two conditions. This is in order to understand their operation and implement effective therapeutic interventions.
The diagnosis of autistic spectrum in DSM 5
In DSM 5 the diagnosis of autism becomes dimensional and, inside the label Autistic spectrum disorderfour previously separated conditions are included. These conditions are autistic disorder, Asperger’s syndrome, the pervasive development disorder not otherwise specified and the disintegram disorder of childhood.
The two main criteria necessary for the diagnosis of autistic spectrum disorder concern the presence of persistent deficit in social communication and social interaction (Criterion a). As well as a restricted and repetitive pattern of behaviors, interests or activities (criterion B).
The restricted pattern can concern the presence of movements, eloquium or use of stereotyped or repetitive objects, the presence of a rigid and inflexible adherence to certain routines or rituals of behavior, the presence of very limited and fixed interests and, finally, a hyper-reactivity or a hypo-reactivity in response to sensory stimuli or the presence of unusual interests towards specific sensory aspects.
The severity of the disorder is expressed in relation to the amount of support necessary in relation to the level of compromise with respect to the two criteria above.
The diagnosis of obsessive compulsive disorder in DSM 5
With reference to obsessive compulsive disorder, which in DSM 5 is separated from anxiety disorders and inserted in a separate category. The main diagnostic criteria that justify the diagnosis concern the presence of obsessions and/or compulsions (criterion A). These cause clinically significant discomfort, they consume time or negatively impact on the functioning of the individual (criterion B).
Symptomatological overlap and comorbility between ASD and DOC
As can be seen from the diagnostic criteria of the DSM, there is a partial overlap between some manifestations of the autism spectrum disorder and the obsessive compulsive disorder.
This overlap mainly concerns the use of fixed routine and ritualistic gestures and, as can be understood, can complicate the evaluation of the symptom. It is difficult to choose whether to place it inside the ASD framework or whether to imagine a comorbilities with an obsessive-compulsive disorder.
In this regard, some studies highlight how about 18% of adults with diagnosis of Asperger syndrome Although evident clinical signs of an obsessive-compulsive disorder (Vicestensel et al., 2011) were present.
The most frequently found obsessive issues found in the spectrum disorder concern the fear of contamination and the perfectionistic appearance. There may also be obsessive themes referring to the fear of being criticized or taken around and the fear of making mistakes (McDougle et al., 1995).
The most evident overlapping between autistic spectrum and doc therefore concerns the washing rituals, in particular those induced by a feeling of disgust and the rituals of order and symmetry relating to the obsessive theme of the incompleteness and the feeling of “not in place“.
DOC and ASD in adulthood
A further aspect to be taken into consideration in the diagnostic process concerns the fact that within the ASD the perfectionist aspects, rituals and routines are much more common in “high functioning” autism (also known as Asperger’s syndrome). While the motor stereotypies typically associated with the most serious forms, often resulting completely absent in this syndrome (Kent et al., 2013).
Especially in reference to the adult population, this can further complicate the evaluation. It is known, in fact, that clinical attention to autism spectrum disorder has undergone significant growth in recent decades. Compared to the past, therefore, it is currently easier for a child who manifests the disorder reaches clinical attention.
This is not as true for the adult population. In fact, it is assumed that, especially in reference to the less disabling forms of the autistic spectrum, characterized by a discreet social adaptability, the disorder is widely sub-diagnosed.
It is therefore plausible that many Adults with Aspergerhaving not received a diagnosis of childhood, they simply do not know they suffer from this disorder. They come to the attention of the clinician due to the symptoms that most impact on the quality of life such as, for example, the presence of obsessive rituals.
The differential diagnosis
From these elements it is clear how the ability to carry out a correct differential diagnosis and possibly identify the presence of a comorbility between obsessive compulsive disorder and the less disabling forms of autistic spectrum disorder, in particular in the adult population, is of fundamental importance not only for professionals who specifically deal with autism but also for those who deal with obsessive compulsive disorder.
In this sense, the differential diagnosis, where necessary, allows not only to understand more deeply the functioning of the obsessive symptom and identify the most effective forms of treatment but can represent, for the adult person with an unreacted Asperger, the first point of contact with a therapeutic perspective and with the awareness that the difficulties encountered in the newspaper are not caused by a bizarre staff but are part of a complex and multifaceted function, shared with many others, shared with many others people.
The symptoms that help to distinguish the two conditions
A first general difference that can be made between obsessive rituals and those linked to autistic spectrum disorder concerns the function that these rituals perform for the individual.
Both in obsessive compulsive disorder and in the autism spectrum disorder, in most cases, the functional objective of the implementation of the ritual is to modify a negative emotional experience.
In the doc often this experience is associated with anxiety but can also bind to disgust or the feeling of “not in place“.
Also in the DOC, the implementation of the compulsion relieves in the short term the negative emotion associated with the evaluation that the individual makes compared to a thought or a doubt that crosses his mind.
In the Autistic spectrum disorder Instead, although the ritual helps to appease an emotional hyper-activation, it can be more difficult to find an evident link between the appearance of a doubt/disturbing thought, its evaluation and the consequent emotional response.
The ritual therefore assumes a wider function, which involves the need to restore an internal balance also in relation to the sensory hyper-reactivity typical of this condition.
Another central aspect that can help the clinician, but also the person himself and his family, to distinguish the routine and rituals typical of the ASD and the presence of a frankly compulsive obsessive disorder concerns the degree of egosintonicity with which the rituals are carried out.
In people with Asperger, in fact, the rituals are mostly egosintonic. Their execution, even if it interferes with the quality of life, is lived with a certain degree of pleasantness.
In patients with obsessive compulsive disorderon the other hand, the rituals are mostly egodistonics and the inability to refrain from their execution is experienced as a remarkable source of suffering.
A careful evaluation of these aspects is important both in cases where there is already a diagnosis of autistic spectrum disorder and the presence of a comorbility with obsessive compulsive disorder is suspected, and in those in which a person requires help for an obsessive symptomatology.
In the latter case, an investigation aimed at excluding the presence of Asperger’s syndrome is necessary especially in situations in which the internal functioning of the disorder is unclear to the clinician and when, in the evaluation phase, alarm bells emerge that can hypothesize the presence of a impairment of social interactions and communication independent of obsessive aspect.
Bibliography
- American Psychiatric Association. (2014). Diagnostic and statistical manual of mental disorders. Fifth edition. Raffaello Cortina publisher.
- Attwood, T. (2019, March). Complete guide to Asperger’s syndrome. Edra.
- Kent, R., J. Carrington, S., Le Cuteur, A., Gould, J., Wing, L., Maljaars, J., … & R. Leekam, S. (2013). Autism Spectrum disorder diagnosing: Who Will Get a DSM-5 Diagnosis? Journal of Child Psychology and Psychiatry, 54 (11), 1242-1250.
- McDougle, CJ, Kresch, Le, Goodman, WK, Naylor, ST, Volkmar, FR, Cohen, DJ, & Price, LH (1995). At Case-Controlled Study of Repetitive Thoughts and Behavior in Adults with Autistic Disorder and Obsessive-Compulsive Disorder. The American Journal of Psychiatry.
