A friend and reader shared this recent article on the similarities and differences between OCD (obsessive, compulsive disorder) and Asperger's disorder, which is a high functioning level of autism. The two disorders have many similar traits and sufferers display some of the same mannerisms, which often confuses parents and even doctors and counselors.
. It's a little "academic" but the case studies are interesting and you may recognize you own child in some of the stories. Read on.
Differentiating Between Asperger’s and Obsessive-Compulsive DisorderBy Fugen Neziroglu, Ph.D.
and Jill Henriksen, M.S.
In recent years clinicians have continually seen a rise in Asperger‘s
Disorder (AD), especially among child and adolescent populations.
Whether this rise is due to an actual increase in AD or merely a result
of improved definitions and increased awareness is unknown. In 1994, AD
was first added to the DSM-IV (Kirby, 2003), therefore, it is only
recently that parents and professionals are more aware of this disorder.
AD is a complex disorder that resembles OCD in several ways; therefore,
it becomes increasingly important to have an understanding of AD so one
can better differentiate it from OCD. The purpose of this article is to
help individuals, family members, and professionals better understand
how these disorders are similar and how they can be differentiated from
one another. A couple of case examples will be used to illustrate
certain behaviors before we go on to the specific characteristics of the
two disorders. For consistency purposes, the male gender is used
throughout this paper because males outnumber females in AD. However,
one should note that this is not the case with OCD.
Case Example 1
Matthew is a
9-year old boy.* He performs well academically in school. In class, he
pays excellent attention; however, his teachers have noted some
underlying anxiety regarding his academic performance. For example,
Matthew takes a long time to complete tests and writing assignments. His
teachers report that he is well behaved and follows classroom rules,
but at the same time, Matthew will report to his teacher when his peers
do not demonstrate the same behavior. Additionally, Matthew becomes
agitated or upset when he is rushed and is unable to complete an
assignment. At home, mornings and evenings are particularly difficult
for Matthew.
He takes a long time getting ready for school, e.g., brushing his
teeth a long time, dressing and redressing, going in and out of the
room, etc. Also, he gets to bed later than he should making mornings
even more difficult. He reports that he is unable to fall asleep because
of “certain thoughts” and his bedtime rituals. Matthew’s mother is
concerned with her son’s outbursts of anger. These fights usually occur
around dinnertime when Matthew does not have his own way, such as,
having his plate and silverware washed again before his food touches it.
Matthew’s mother has also become increasingly concerned about her son’s
peer relationships. She feels that Matthew is having difficulty making
friends. As his friends become more interested in sports, Matthew has
less in common with them and has started to spend more time alone.
Case Example 2
Eric is a 12-year old boy. Eric’s academic
performance is strong. He is currently taking advanced coursework in
mathematics and science. Eric’s teachers are impressed with his language
ability in these areas. He uses adult words and has an advanced
vocabulary surrounding science and history. Recently, Eric has been
having trouble in school. More specifically, Eric only wants to read,
write, and research specific topics, such as European history. If his
teacher asks him to write about something else, Eric becomes very upset
and argues with the teacher endlessly. In exasperation the teacher
usually allows him to write about whatever he wants. Other times he is
sent to the principal’s office. Additionally, Eric becomes irritable
when things are out of the routine, for instance if he has to read a
book different from the one he had been told to originally. Eric has one
or two friends, but does not usually initiate social contact with
children. Eric frequently needs to be redirected by his teacher to
complete his work.
In addition, he often requires extra time to complete
his exams. Eric often appears anxious in school and when he feels this
way he will continually ask the teacher questions and seek reassurance
from her. At home, Eric demonstrates difficulty completing his homework
assignments. He becomes fixated on one small aspect of his assignment
and then runs out of time to complete the rest. After school, Eric can
spend hours reading about history and will engage in hours of discussion
about the topic. He enjoys comparing one history book to another. He
will line up his books in alphabetical order and then analyze each one
of them. Eric prefers “sameness”. He enjoys eating the same kind of
foods over and over again. He also prefers soft fabrics and puts his
clothing on each morning in a particular order.
The first case example is that of OCD and the second of AD. AD is at
the mildest and highest functioning end of what is known as the
Pervasive Developmental Disorder spectrum. As described by Treffert
(1999), the disorder is characterized by normal speech development in
childhood (e.g. single words by 2-years of age and use of communicative
phrases by 3-years of age). Despite nor- mal verbal development, an
individual’s speech may be repetitive or of unusual voice quality. For
example, a child may repeat back what you just said, or he may repeat
his own words. Furthermore, the child may demonstrate poor turn-taking
skills during conversation and may dominate the conversation, especially
when it concerns his special area of interest. Nonverbal skills in
individuals with AD are also impaired. For example, individuals may not
express a full range of facial expressions. At times, it may appear as
though the child is looking through you and he evidences poor eye
contact. Failure to develop social relations is another characteristic
of this disorder.
Some believe that the insufficient conversational and
nonverbal skills lead to poor social relationships. Children with OCD do
not lack the social skills as those with AD do. However, in some
instances a child with OCD may develop poor relationships with his/her
peers. This may occur when a child’s obsessions and compulsions occupy a
lot of their time, which can lead to social withdrawal. Furthermore, if
the compulsions are severe the child may be unable to hide them from
his friends, which could lead to teasing. The child may also develop
poor self-esteem because he views himself as being different from other
children, but overall children with OCD have normal peer relationships
(Fruehling, Johnston, & March, 1998). Children with OCD can follow
social rules, but they may adhere to an adult moral code and become
upset when their peers do not follow certain rules (Neziroglu &
Yaryura-Tobias, 1997).
Without training, guidance, or instruction AD children will demonstrate
difficulty adhering to social rules, such as not talking while others
are talking or knowing when to appropriately end a conversation. Many AD
children will also demonstrate poor motor coordination and clumsiness.
For example, elementary school children with AD may have penmanship
problems and experience difficulty with activities during physical
education class (Williams, 1995).
As demonstrated by the case
examples, there are several similarities between OCD and AD including:
shifting, incompleteness, emotions and compulsions. In both disorders
the children have strong academic skills. Children with AD often
demonstrate strong rote reading skills, calculation ability, and
excellent memory (Bauer, 1996). Neziroglu and YaryuraTobias (1997) also
report that children with OCD usually have above average academic
ability. Both children will rarely feel relaxed and they will spend most
of their day feeling anxious. In AD, this is especially true if the
child does not know what to expect next or is overwhelmed by stimuli
such as loud noises. In OCD, the child is anxious in regards to their
obsessive thoughts and whether or not they are performing their
compulsions correctly. Both children may experience incompleteness and
require extra time to complete assignments at school and home. For the
AD child, this is because they are distracted by internal and external
stimuli. Therefore, they need an adult near by to redirect them to the
task at hand. For the OCD child the reason differs. The child may take a
long time to complete a task because they are concerned with perfection
and/or doing a task until it feels right (i.e., doing it a set amount
of times). Therefore, they may rewrite a paper, erase frequently, or
reread the same passage repeatedly.
Children with both disorders will demonstrate a need for sameness.
Usually the child with AD chooses to eat the same food each day, wear
the same clothing, or play the same video game, whereas the child with
OCD is looking for sameness in his/her daily routines. If the OCD child
exhibits the “sameness” of the AD child it is for a different reason.
Both children desire control over their environment so that they may
perceive it as safe and predictable. However, children with OCD may eat
the same foods each day because they are “safe” or not contaminated. In
children with AD the reason varies. Children with AD have sensory
issues, so they may not like certain textures, smells, fabrics, or
sounds (Kirby, 2003). Sometimes children with OCD may also complain of
not liking the feel of the seam on their socks, or be concerned with
smells that are “dirty”.
Both children will demonstrate difficulty with shifting or
transitioning between tasks. For the OCD child, this is because of the
need for symmetry or balance. For example, if a child is working a home-
work assignment on the computer and he is called for dinner, he will
want to complete the entire assignment before he begins eating. If he
does not complete the assignment, he will continue to feel anxious.
Another example may include a child in school who has to tap the left
side of the desk the same amount of times as he tapped the right side of
the desk. Individuals with AD are resistant to change in their
routines, prefer “sameness,” and have difficulty transitioning between
tasks. For example, the child may like to always have breakfast before
getting dressed and then having the parent take the same route to school
each morning. An AD child may become overly upset with even the
smallest changes in his environment, such as, the teacher switching the
types of crayons used in the classroom. Repetitive activities are a
defining characteristic of this disorder. These activities are preferred
and engaged in at length. Similarly, the individual often has an
intense preoccupation with one or two areas (i.e., weather, history,
trains, or dinosaurs). Therefore, the child may engage in repetitive
play surrounding his area of special interest, such as, lining up his
model car collection on the floor. This preoccupation is abnormal in its
focus and/or its intensity. In the area of interest, the individual has
an incredible capability to memorize facts. Although overall
conversation ability is typically poor, when discussing his area of
interest, the individual may possess advanced knowledge on the topic
(Treffert,1999). However, when discussing his area of interest, the
conversation is usually one sided and the child may not pick-up on
social cues regarding the other person’s disinterest or know when to
stop speaking.
Since common features of AD include anxiety, repetitive behavior, and
fixed habits, it is apparent that this disorder can mimic OCD
(Yaryura-Tobias, Stevens, & Neziroglu,1998). Research studies in the
psychology literature have focused on distinguishing between the
restricted, repetitive, and stereotypic behavior associated with AD as
compared to the compulsions found in OCD (Baron-Cohen, 1989; McDougle,
Kresch, Goodman, Naylor, Volkmar, Cohen, & Price, 1995). In general,
AD is typically characterized by a more severe impairment in social
interactions (e.g., poor social reciprocity, poor peer relationships,
and poor verbal and non-verbal skills). In addition, individuals with AD
tend to have a more restricted pattern of interests and activities than
those individuals with OCD. For example, a child with OCD may be
obsessed and fearful of contamination and germs, whereas, a child with
AD has a positive interest in a particular area. The next section will
focus on some of the important differences between AD and OCD that can
assist one in further differentiating between the two disorders.
As previously mentioned, a defining feature of AD is that obsessive
thoughts surround involvement in an activity or area of specific
interest. For example, an individual with AD may have a restricted
interest in the area of trains. The high level of interest in this area
may appear obsessional; however, it is important to bear in mind the
definition of an obsession. By definition, obsessions are recurrent and
persistent thoughts, impulses, or images that cause marked anxiety or
distress. Individuals with AD typically do not experience anxiety or
distress surrounding their area of interest. In fact, they derive
pleasure from it. However, in OCD individuals experience a marked level
of anxiety or distress. Therefore, ways to further differentiate AD and
OCD is to assess whether the individual experiences anxiety or distress
related to his obsessive thought patterns or compulsions. If the
individual derives pleasure from the repetitive behavior and not just
pleasure from anxiety reduction, then this feature is more likely linked
to AD than OCD.
To minimize or neutralize the distress, an individual with OCD will
engage in compulsive behavior. In AD, obsessional thoughts do not have
specific compulsions attached to them.
Researchers have hypothesized that individuals with Pervasive
Developmental Disorders may be unable to monitor their internal states
and report anxiety related to obsessive thoughts (McDougle et al.,
1995). Therefore, it is important to also examine the content of the
behavior that occurs. It has also been found that some of the more
common compulsions in OCD patients, such as checking and hand washing,
are rarely found in AD (McDougle et al., 1995). Although, restrictive
and repetitive behavior may mimic a compulsion, it is not completed with
the intent to minimize anxiety or distress, nor is it specifically
associated to intrusive thoughts.
Distinguishing between AD and OCD is potentially easier when each
disorder is occurring on its own. However, as we have seen in our
clinical experience, patients present with co-morbid AD and OCD.
Co-morbidity is defined as the co-occurrence of two separate disorders
at the same time. In these instances, it can be very difficult for
clinicians to distinguish between what may be repetitive behaviors
related to AD and what may be an OCD compulsion. Exposure and response
prevention (ERP) to minimize rituals and restrictive interests in an
individual with AD is not very effective because the child does not
experience anxiety and therefore there is nothing to “habituate” to
(habituation is the process by which anxiety is extinguished). It is
through habituation that compulsions are reduced in OCD (there is
neuronal fatigue occurring in the brainstem reticular formation).
Rituals related to AD provide comfort to the individual and are not
anxiety provoking. There is no negative situation to expose the
individual to, however, one can limit some of the repetitive activity.
If we attempt to strip the individual of this activity entirely, we
potentially risk removing one’s positive coping strategy. On the other
hand, if a clinician can distinguish between behaviors related to OCD
and those that belong to AD, then one can attempt to successfully treat
the OCD related symptoms with ERP. If an individual with co-morbid
Asperger’s and OCD presents with an overwhelming amount of compulsions
and ritualized behavior, by treating the OCD with ERP the amount of
compulsive behavior that the person engages in can be reduced. After the
OCD symptoms are treated, then one can proceed with other treatments to
address the AD related behavior. Treatment of AD typically involves
social skills training, parent training, and behavior therapy to
decrease unacceptable behavior, while increasing more adaptive skills.
For example, if a parent wants to increase desirable homework
performance in his or her child, then the parent can make activities
related to the specific area of interest (i.e., reading history books)
contingent upon homework completion. One should note, that targeting
undesirable behavior in AD children does not mean changing those
behaviors that are considered “odd,” rather interventions should target
behaviors such as repetitive questioning, inappropriate homework
behavior, or increasing appropriate social skills.
In summary, individuals with AD or OCD may evidence similar symptoms,
including, shifting, incompleteness, anxiety, compulsions, and adherence
to rituals. In general, individuals with AD are more socially impaired
and demonstrate difficulty forming reciprocal relationships. In AD,
individuals may have obsessive thoughts surrounding a restricted area of
interest, but these thoughts do not likely cause a marked level of
anxiety or distress as they do in OCD. Lastly, compulsive behavior in
OCD is completed with the intent to minimize anxiety. In AD, individuals
derive pleasure from engaging in these activities.
* To protect confidentiality, case descriptions in this article are based on composite or fictionalized clients.
Fugen Neziroglu, Ph.D., is a
board certified Behavior and Cognitive psychologist involved in the
research and treatment of OCD for 25 years. She is the Clinical
Director of the Bio-Behavioral Institute in Great Neck, NY and Professor
at Hofstra University. Jill Henirksen, MS, is a school psychologist
who works with children and adolescents and interned with Dr. Neziroglu
at the Bio-Behavioral Institute.
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