Phenomenological Overlap Between the Obsessive-Compulsive

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Phenomenological Overlap Between the

Obsessive-Compulsive and Autism

Spectrums

Gregory S. Chasson, Ph.D.

Department of Psychology

Towson University

[email protected]

Licensed Clinical Psychologist

CBT Solutions of Baltimore

WHAT IS OCSD

� Linked because of similar

� Genetic and family risk factors

� Neurocognitive profiles (e.g., local

processing)

� Response to behavioral and

pharmacological interventions

� Pathophysiology (e.g., Striatrum)

� Symptom function and

presentation (e.g., compulsive

behavior)

� Traits (e.g., perfectionism)

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WHAT IS OCSD

OBSESSIVE-COMPULSIVE DISORDER (OCD) (APA, 2000)

� Obsessions = repetitive thoughts, impulses, or images

� Intrusive

� Inconsistent with values and self-image (i.e., ego-dystonic)

� Distressing� fear, disgust, guilt, etc.

� Compulsions = repetitive responses to obsessions

� Serve to decrease distress elicited by obsessions

� Can be mental or behavioral

� Can manifest as ritualistic, avoidance, or escape behaviors

WHAT IS OCSD

OBSESSIVE-COMPULSIVE DISORDER (OCD)

� Symptom themes:

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WHAT IS OCSD

Body Dysmorphic Disorder (BDD) (APA, 2000)

� Preoccupation with body part(s); > 1 hr/day

� Imagined defect, or if real, negligible to others

� Distressing� fear, disgust, guilt, etc.

� Common body parts: skin, nose, lips, hair, stomach, and size of breasts, penis, or muscles

� Compulsions = repetitive responses to preoccupations

� Serve to decrease distress elicited by preoccupations

� Can manifest as ritualistic, avoidance, or escape behaviors

� Examples: touching, checking, grooming, camouflaging, reassurance seeking, seclusion, etc.

WHAT IS OCSD

Tourettes Syndrome and Tic Disorders (APA, 2000)

� Tic = seemingly involuntary movement or vocalization

� Motor tic examples: nose crunch, facial grimace, mouth movement, eye movement, head turn, shoulder shrug

� Vocal tic examples: sniffing, coughing, throat clearing, repeating words or statements, animal noises, coprolalia.

� Premonitory Urge

� Tics preceded by the build-up of an urge, often in the bodily location of the tic

� For vocal tics, the urge often occurs in the throat or mouth

� Commonly reported as a tension or burning

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WHAT IS OCSD

Trichotillomania, Dermatillomania, and other Habits (APA, 2000)

� Trichotillomania (TTM) = pathological hair pulling habit

� Dermatillomania (DTM) = pathological skin picking habit

� Common features of habits

� Often prompted by stress, boredom, or tactile sensations (e.g., feeling the texture of the hair)

� Often, but not always, preceded by an urge

� Often, but not always, followed by a sense of relief

� Not uncommon for patients to eat or save pulled hair or picked skin

WHAT IS OCSD

Hoarding Disorder (Mataix-Cols et al., 2010)

� Excessive saving of items that most would consider valueless

� Examples: bottle caps, newspapers and magazines, string, junk

mail

� Difficulty discarding the valueless items

� Various beliefs, such as 1) the item may be needed later, 2) it has

sentimental value, 3) it’s aesthetically pleasing and shouldn’t be

discarded

� The pathological acquisition and difficulty discarding often lead

to substantial clutter

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WHAT IS OCSD

Hypochondriasis (APA, 2000)

� Preoccupation with the belief that one has a disease, despite

disconfirming evidence

� Misinterprets normal bodily signs as markers of the disease

� Compulsions to gain disconfirmation or verification of disease

� Seek physician reassurance and testing, scan and check body for

signs and symptoms, explore internet resources endlessly

WHAT OF ASD & OCSD?

Diagnostically

� For comorbid OCD diagnoses in samples with ASD, rate has ranged

widely between 1.5% and 81% (Leyfer et al., 2006)

� Likely due to methodological variability

� Conversely, between 3% and 7% of individuals diagnosed with OCD also

meet diagnosis for Asperger’s (LaSalle et al., 2004)

� Thus, 6 to 14 times the prevalence rate of Asperger’s Disorder in

those with OCD compared to the general population (i.e., .48%

prevalence) (Fombonne & Tidmarsh, 2003)

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WHAT OF ASD &OCSD?

Subthreshold

� OCD symptoms are among the most common anxiety manifestations in

ASD (Gillott, Furniss, & Walter, 2001; Russell & Sofronoff, 2005)

� As many as 20% of individuals with OCD may have autistic features (Bejerot,

2006; Bejerot, Nylander, & Lindstrom, 2001)

STATE OF THEORY

� Unclear if overlap between ASD and OCSD is best characterized

as (Chasson et al., 2011)

� An illusion of resemblance

� An autistic subtype of OCD (Bejerot, 2007)

� A specific autistic-compulsive syndrome (Gross-Isseroff et al., 2001)

� The convergence of different clusters of features within OCSD (Hollander, 2005)

� None, some, or all of the above.

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BREAKING DOWN AUTISM

WHERE TO START?

� At this time, language deficiencies not a huge target of research on

OCSD/ASD overlap

� It’s not a universal characteristic of ASD (e.g., Aspergers), and not a

common problem in OCSD

� Social impairment, perhaps the cardinal feature of ASD, has only

recently received attention in the OCSD literature.

� Repetitive and restricted behavior is the obvious area of overlap

� So let’s start there

� But first, a caveat…

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REPETITIVE PHENOMENA

� Research on repetitive phenomena is riddled with methodological problems

� Poorly characterized samples

� Conflation of ego-syntonic and ego-dystonic thoughts

� Disregard for the function of repetitive behavior

� Failure to consider insight , IQ, communication deficits

� Measurement challenges

� Thoughtless comparison groups

� Disregard for Type I error


� Bodfish (2011) has been the most accurate in characterizing the

difference in OCD and ASD repetitive phenomenon

� The function of repetitive behavior in ASD is heterogeneous

� Functions to provide pleasure

� Functions to reduce overall or specific stress

� Not necessarily ego-syntonic or elicited by an ego-syntonic

thought, image or impulse

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� According to Bodfish (2011), the function of repetitive behavior in

OCD is more homogenous

� Functions to reduce specific stress from an ego-dystonic thought,

image or impulse, or

� The behavior itself is perceived as ego-dystonic

� Functionally, behavior in OCD and autism are similar only when

they serve to decrease specific stress associated with an ego-

dystonic thought


� Most studies do not account for the function of the repetitive behavior, or they do not discuss it at all, leaving the reader to guess if it was addressed

� Evidence from the best available research suggests

� Obsessions in ASD tend to involve folk physics, or an ego-syntonic interest in how objects and machines work (Baron-Cohen

and Wheelwright , 1999)

� Compulsions elicited by ego-syntonic obsessions are often pleasurable

� However, individuals with ASD can still present with clinically signifcant ego-dystonic obsessions and compulsions (Russell,

Mataix-Cols, Anson, and Murphy,2005)

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� Not everything fits neatly into Bodfish’s (2011) conceptualization

� His conceptualization is elegant but generally only distinguishes between OCD and ASD, not OCSD and ASD

� OCSD with functional pleasure: Trichotillomania, Dermatillomania, Hoarding

� Ego-syntonicity might not be a categorical phenomenon

� Not Just Right Experiences

� Similar pathophysiology—striatum

� Tics = ego-dystonic, but considered distinct from an OCD repetitive behavior

� Similar purported mechanisms of behavioral treatment—extinction

� Habit Reversal Training, Direct Reinforcement of Other, Exposure and Response Prevention


� So, the jury is still out. There is no universal rule to differentiate repetitive phenomena in OCSD versus ASD

� Best bet is to ask,

� “What is the function of the behavior?”

� “To what degree is the patient’s experience ego-dystonic?”

� “To what degree is the patient obtaining pleasure from the behavior?”

� “Is this a behavioral response to a specific distressing thought, image, or impulse?”

� The best-guess differentiation lies in the pattern of answers to these questions, rather than the answer to any one question

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GOING BACK…

SOCIAL COMPETENCE

� Social competence impairment is not specific to ASD

� This is a common clinical correlate or presentation in multiple

psychiatric conditions (e.g., Schizophrenia) (Pousa et al., 2008)

� Social competence may reflect multiple underlying

endophenotypes that transcend traditional nosological boundaries (Chasson et al., 2011)

� Evidence for social competence impairment is just starting to

emerge in the literature on OCSD

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SOCIAL COMPETENCE

(Chasson et al., 2011)

SOCIAL COMPETENCE

� OCD probands and relatives exhibit more difficulties with pragmatic social rules (e.g., exchanging pleasantries) compared to healthy control counterparts (Cullen et al., 2008)

� Parental-report suggests that children with OCD have more difficulty with social self-control (e.g., spontaneous initiation of social behaviors) (Adams, 1995)

� Individuals with OCD have demonstrated elevated rates of shyness (Ivarsson & Winge-Westholm, 2004) and social anxiety disorder (Angst et al., 2004). Individuals with BDD have shown pronounced elevations in social anxiety severity (Wilhelm, Otto, Zucker, & Pollack, 1997)

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SOCIAL COMPETENCE

� Individuals with OCD may have difficulty processing

emotions displayed by faces (Corcoran, Woody, and Tolin, 2008;

Sprengelmeyer et al. ,1997)

� According to work by Feusner et al. (2007), individuals

with BDD process faces similar to those with ASD

(Deruelle et al. , 2004). They use brain pathways associated

with high-spatial frequency perception to process low-

and normal-spatial frequency faces

� Individuals with BDD and ASD visually process

faces using brain pathways designed for visually

processing inanimate objects (Schultz et al., 2000)

SOCIAL COMPETENCE

� Much like in ASD (Happe & Frith, 2006), individuals with OCD

and BDD present with local processing biases and

set-shifting difficulties (Deckersbach et al., 2000; Savage et al.,1999)

� These neuropsychological tendencies may be related

to social competence impairments (Aigner et al., 2007)

� Local processing tendencies may cause individuals

with OCD and BDD to miss global features when

processing faces, and set-shifting difficulties could

hinder their ability to transition visually from one facial

feature to another

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SOCIAL COMPETENCE

� Social competence abnormalities may be particularly

heritable (Bolton, Pickles, Murphy, & Rutter, 1998) and

genetically independent of other facets of autism (Ronald

et al., 2006)

� A rare missense I425V mutation in the SERT gene

may be associated with psychiatric disorders with

social dysfunction (e.g., ASD, social phobia, OCD) (Wendland et al., 2008)

� The mutation = an A to G transversion substituting

Val425 for Ile425 that results in a gain-of-function

of SERT (Chasson et al., 2011)

SOCIAL COMPETENCE

� Serotonin and dopamine have both been implicated in social processing in OCSD and ASD populations

� Based on pharmacotherapy studies (Jenike, 2004;

McDougle et al., 1996)

� Glutamate has been implicated in social processing impairment (Montag, Schubert, Heinz, & Gallinat, 2008), as well as the pathophysiology of OCD (Chasson et al., 2010) and ASD (Jamain et al., 2002; Shuang et al., 2004)

� Oxytocin facilitates social connectedness and may play a role in both OCD (e.g., Altemus et al., 1999) and ASD (e.g., Bartz & Hollander, 2006, 2008; Bejerot, 2006; Insel, O'Brien, & Leckman, 1999).

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SOCIAL COMPETENCE

� The amygdala has been proposed to play a critical

role in early-stage processing of facial emotion (Chasson

et al., 2011), and is hypothesized to play an important role

in a proposed social processing neural circuit (Brothers,

Ring, and Kling, 1990)

� Irregularities in structure and function of the amygdala

have been demonstrated in individuals with OCD (Britton

et al., 2010; Cannistraro et al., 2004) and ASD (Baron-Cohen et al., 2000;

Mosconi et al., 2009)

SOCIAL COMPETENCE

Concluding thoughts on OCSD/ASD and social competence impairment

� Remains unknown if any social competence impairments observed in ASD and

OCSD mostly arise before, during, or after onset of the disorder

� However, subtle abnormal social functioning is associated with genetic

risk.

� Thus, it’s unlikely that social competence impairments are solely caused

by inadequate or missed social development

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SOCIAL COMPETENCE

Concluding thoughts on OCSD/ASD and social competence impairment

� Formulating a theoretical framework for understanding the overlap between

OCSD and ASD may require integration of candidate endophenotypes

� Corroborating a link between OCSD and ASD may facilitate development of

new diagnostic, prevention, and intervention techniques.

� Because individuals who present with features of both disorders may be

more clinically severe (Bejerot, 2007) and resistant to treatment (Humble, Bejerot,

Bergqvist, & Bengtsson, 2001)

CONCULSION

� OCSD and ASD share many features, some in obvious ways (e.g., repetitive

behaviors) and some in not so obvious ways (e.g., social competence

impairment

� Future research would benefit from sampling that transcends codified

diagnostic categories. NIH seems to agree (see RDoC)

� Differentiating ASD and OCSD can be quite challenging in some cases.

� In some cases, there is a legitimate comorbidity between ASD and OCSD

� In some cases, comorbidity is superficial or inaccurate

� Sometimes, all you can do is provide an educated guess and treat the

patient as an n = 1 experiment

� Test different treatment approaches to see what works best

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Phenomenological Overlap Between the Obsessive-Compulsive