Today we are very happy to have a guest blog post on Asperger’s and OCD from Carol Edwards. Carol is a Cognitive Behavioral Therapist who specializes in the area of OCD. She became interested in the area after one of her family member became misdiagnosed with Asperger’s Syndrome when in fact they actually had OCD. We hope you enjoy this posts which illustrates that while the two conditions have overlaps, they are not always the same.
Asperger’s and OCD – Obsessional Behaviours, Diagnosis and Treatment Options
Copyright 2012 by Carol Edwards
CBT DipHE (D) Dip.ocd (D) ASD credits – CRB Checked
Asperger’s Syndrome
Asperger’s Syndrome, often referred to as Asperger’s or AS, comes under the umbrella for Autistic Spectrum Disorders which is a complex developmental disability that affects the way a person communicates and relates to the people around them. The term autistic spectrum is often used because the condition varies from person to person. For example, some individuals who have accompanying learning disabilities are usually placed at the less able end of the spectrum, while others who have average or above intelligence are placed at the more able end of the spectrum (Asperger’s).
Despite the various differences, everyone with the disorder has difficulty with what is known as the ‘triad of impairments’. These are:
- social interaction and social skills
- social communication
- social imagination
Obsessive Compulsive Disorder
Obsessive Compulsive Disorder, or OCD, is characterised by intrusive thoughts, ideas and images which often follow compulsive behaviours. These can be overt and also covert. For example, an individual whose OCD variation revolves around contamination fears may openly display an urge to repeatedly wash her hands (overt); whereas a person who suffers from disturbing thoughts and images may try to cancel these intrusions out by using a counter phrase or praying ritual in his mind (covert). Both behaviours serve to reduce the anxiety brought on by these intrusions, but only momentarily.
Unless there is an autistic overlap or other pervasive developmental disorder, a person with OCD usually does not present with problems associated with the triad of impairments.
Social imagination
In this article, we’ll be looking at the triad to distinguish what the driving force behind obsessional behaviours mean and whether the findings suggest if a person has developed social imagination or not. Observing how a person reacts in response to his compulsions or rituals can provide us with clues; therefore, let’s consider two individuals with obsessive behaviours:
Jack has an obsessive compulsion where he feels compelled to line up food items in order of size in the kitchen cupboard while Jill repeats a ritual which involves lining up a collection of ornaments in a cabinet in the family’s lounge.
While Jack is generally an honest person, he has none-the-less learned to use deception to manage his OCD. In other words when he is prevented from doing a ritual he uses his imagination to find ways to figure out how to complete the act. For instance, while watching TV, Jack’s wife often prevents him from repeatedly checking that there isn’t a tin, bottle or packet out of place in the kitchen cupboard. This increases Jack’s anxiety but he wants to avoid conflict; therefore, he uses every trick up his sleeve so that he can fulfil his compelling need to check. Using deception provides him with the opportunity to relieve himself of anxiety, e.g. making up the excuse that he’s ‘just nipping through to the kitchen for a snack’.
Now let’s consider Jill’s obsessional behaviour. Basically, the imagination is in the act itself which is part of her daily routine. When Jill lines up the ornaments she experiences organised satisfaction, rather than anxiety relief. When Jill’s mother tries to stop her, explaining that they have to leave for Jill’s scheduled appointment, Jill feels extreme annoyance to the point of anger, just like any person might if they were for example prevented from finishing their housework or something else and in the order they do it. The confused interaction between mother and daughter causes such distress that the appointment has to be cancelled.
What does this mean?
First, Jack can work around his compulsion because he understands that his thoughts affect his feelings and thus behaviours. Thethought is ‘A bottle is out of place in the kitchen cupboard’ which follows with thefeeling ‘When I’m prevented from checking, my anxiety rises’, which leads to deceptive behaviour, e.g.‘I’ll pretend I need a snack’. To add to this, Jack is not only able to understand the connection between his own thoughts, feelings and behaviours, he is also capable of grasping the thoughts, feelings and behaviours of others, hence the deception towards his wife. This tells us that he has developed social understanding which fits neatly with the ‘theory of mind’ (Baron-Cohen et al 1985*). What’s sad however is that while Jack goes to ridiculous lengths to perform his compulsions, he knows the behaviours are attributed to OCD, not him, and he wants to stop.
Second, we’ve already established that Jill’s daily routine involves lining up the ornaments in the family cabinet. Her behaviour when prevented from doing this reveals that social imagination might be lacking, e.g. faking illness to avoid going out so that she can stay home and finish her ritual. Further, the difficult interaction with her mother and her inability to grasp that failing to turn up for an appointment can be problematic for others involved indicates that her obsessional behaviour is stereotyped and therefore characteristic of Asperger’s Syndrome. Jill fights her own corner honestly and has no conscious thoughts about whom and what the obsessional ritual is attributed to, and she doesn’t want to stop. So does this imply a lack of social imagination meaning Jill has not developed a theory of mind? Possibly, but not necessarily as it could be that this area of functioning requires intervention to help tease it into consciousness thus improving social awareness and world perception.
*Theory of mind
Baron-Cohen speculates that having a theory of mind is what gives us the unique ability to work together and execute complex interactions. In other words we are able to understand that we and others have minds with knowledge, feelings, beliefs, motivations, intentions, and so on, which includes presuming our own and others mental states and then being able to explain and predict the behaviours arising from this. Humans are able to assess that others may hold false beliefs about themselves and the world around them. Baron-Cohen’s research suggests that individuals on the autistic spectrum lack a theory of mind and therefore do not have the mental capacity to imagine the world from the perspective of others, which includes failing to question beliefs about themselves or others. They apparently live in a state of certainty in terms of what others may think about them; that is, what someone says is what they mean, and so on. You can find more information on this topic at: www.social-science.co.uk/corestudies/titled ‘Does the autistic child have a theory of mind?’
Treatment for OCD
Some say anxiety is the source of OCD which suggests a neurobiological condition to which pharmacological treatment in the form of Selective Serotonin Reuptake Inhibitors (SSRIs) is the primary tool. Others suggest it’s the other way round in which case a psychological approach to the problem is favoured. The psychological model is viewed from a social learning perspective, is specific in its approach with its cognitive and behavioural strategies and involves exposure response prevention (real or imagined). Its aim is to target obsessions, compulsions and doubt resulting from three underlying factors that maintain OCD: 1) fear 2) anxiety and 3) threat. Depression may also be a factor, which is often secondary to OCD, a result of the disruption caused in a person’s life. There is some evidence which suggests the cognitive approach is as effective as the medical approach (SSRIs) in terms of this treatment modifying biological parameters (Understanding Obsessive-Compulsive and Related Disorders: www.ocd.stanford.edu). However, the level of OCD severity and secondary depression is not overlooked here in which case medication combined with a biobehavioural approach is often an option.
A cognitive dilemma for those with Asperger’s
The cognitive approach casts doubt for those on the high end of the autistic spectrum, which is, since this type of therapy challenges the individual’s belief system and focuses on bringing awareness of the psychological features of OCD, how does this fair when it comes to treating individuals with the disorder if they also have Asperger’s? With regards to Baron-Cohen’s theory and this being correct and in terms of those with AS sharing some features of autism, there is however no delay in language and cognitive development; so the answer in most cases has to be that the prognosis is good.
Back to choosing the right treatment options for OCD
The right choice of treatment takes into account many more factors than already discussed, such as whether pharmacotherapy should be considered, for instance, if a client refuses psychological treatment or has poor response to behavioural methods. Likewise, behaviour therapy might be the appropriate choice if the client refuses medication or if drug therapy is ineffective, if the client is pregnant, is a child etc. Further, a combined approach might be considered a better option because it offers the best of both treatments, especially if the client’s condition has become entrenched over a number of years and/or if the person has depression or other overlapping conditions, or another distinguished disorder such as Asperger’s or Bipolar. In extreme cases, hospitalisation may have to be discussed as a treatment option, such as when a client’s condition is so debilitating that the person whose contamination fears for example are so severe that she isolates herself from other people, including family members; and to which her overall health (and her family’s well-being) is clearly at risk.
What happens when the wrong diagnosis is given?
A true diagnosis for both Asperger’s and OCD can often be confusing. I have known children and adults diagnosed with AS whose traits include aversions to foods touching each other, social avoidance, touch issues, and so on, only to find these features were associated with contamination fears and other OCD problems. I have also come across people diagnosed with OCD appearing to present with contamination fears associated with food, who have later revealed that they preferred their food placed on their plate in a particular order, not because they feared getting germs from food items touching each other. Some individuals also found social interaction difficult because they were touch-sensitive, not germ obsessed which is more likely to be characteristic of Asperger’s, not OCD. These examples only touch the surface but the bigger picture suggests there might be some ambiguity regarding certain statements/questions when determining diagnosis. Thus it is crucial that the person is clear about what box he is actually ticking during assessment for either (or both) diagnosis. Further, be sure about what questions are being asked and what they mean during an assessment before answering.
