Dual Diagnosis or ‘Miss’-diagnosis of OCD with ADHD and Autism Spectrum Conditions (ASC)

30 Jan

It’s estimated that around three-quarters of a million people (1.2%) in the UK live with Obsessive Compulsive Disorder (OCD), at any one time (OCD-UK). OCD can be defined as a common mental health condition where an individual has frequent obsessive thoughts and compulsive behaviours.

Defining ‘Obsession’ & ‘Compulsion’ vs ‘Impulsion’

Obsessions could include unwanted and unpleasant disruptive thoughts, images or urges that enter your mind repeatedly, which creates feelings of anxiety, disgust, or unease.

Compulsions could be defined as repetitive behaviours, or mental acts, that an individual feels they need to do to temporarily relieve the unpleasant feelings, or beliefs created by their obsessive thought. However, compulsions are learned behaviours, which become repetitive and turn into habits that are associated with reducing anxiety. A dominating effect could then stop you from enjoying and even prevent you from doing the things you need to do.

Nevertheless, compulsions are conscious and intentional to lessen our fear, anxiety, or stress. Impulsions on the other hand, are performed without considering the consequences, and individuals might not necessarily understand why they did what they did.

OCD could be due to a variety of reasons, such as genetics, or chemical, structural, and functional changes in the brain. Moreover, distorted beliefs can also reinforce and maintain OCD symptoms.

Strengths and Positives Associated with OCD

When OCD is managed effectively, individuals can possess the following attributes:

Learn to accept uncertainty (Insider.com)
Organised (Tobias et al., 2017)
High-achieving and driven
Detail oriented
Creative (which could relate to problem-solving skills) (Avalon Malibu)
Cautious (individuals can think things through and recognise potential risks) (PULSE TMS)
Determined
Empathetic

ADHD, OCD and the Brain

Brain studies on individuals diagnosed with OCD have shown overactivity in the executive functioning parts of the brain, such as the brain regions involved with habit-forming, reward, movement, stability control and impulse control. Studies have shown these parts may be poorly controlled by an under-functioning part of the brain in charge with mediating decisions.

ADHD, on the other hand, displayed under activity in some executive functioning brain regions, related to challenges regulating attention and impulse control.

Dual Diagnosis or Misdiagnosis?

Comorbidity (having both) of OCD and ADHD is estimated at 2-22.9% of the adult population.

Someone with ADHD could find themselves successfully managing their impulsivity but may lapse into more compulsive thinking. However, this could look like ‘habit monitoring’. So, it could mean, if you’re not diagnosed with ADHD and you’ve mastered ‘masking’, the symptoms reported could be associated with OCD.

Studies have shown ADHD stimulant medication may make OCD worse by increasing obsessive compulsive thoughts and behaviours, as it increases (frontostriatal) activity which can be related to various motor, cognitive and emotional processes, such as working memory, decision making, and attention, which tends to be underactive in ADHD.

However, other studies have also found OCD medications do not make ADHD symptoms worse. ADHD medication could positively impact OCD, as well as frequently neither increasing nor decreasing OCD symptoms (Psychology Today).

ASC & OCD

ASC and OCD can be similar but have different motivations (Care & Support in Cornwall).

Comorbidity of OCD and high functioning ASC is estimated at 6-36% of the population.

Society normally likes groups and labels, and people may usually associate OCD with the following groups: ‘Checkers; Hoarders; Washers; Counters & Sinners’ (Jacqueline Sinfield).

ASC symptoms can overlap with OCD, in that ASC is also characterised by repetitive behaviours such as: ‘compulsive like behaviours, restricted and repetitive behaviours, fixation on routine, ritualised patterns of behaviour and resistance to change and restricted interests’ (National Autistic Society).

However, the main differentiation between ASC and OCD are their motivating factors. An individual with OCD would feel ‘compelled’ to act on behaviours, find them unpleasurable, and they can cause high levels of distress. Such behaviours tend to be fear and anxiety driven. Usually with Autism, these behaviours are enjoyable but if the individual has OCD, these are obsessive and compulsive behaviours that may be intrusive and upsetting.

ASC – Overlaps & Under-Diagnosis

Autistic individuals may engage with repetitive movements as a form of self-stimulation (also known as ‘stimming’) to stimulate the senses and help regulate emotions and reduce anxiety.

Often, autistic individuals enjoy fixed routines, putting objects into order and having an environment that’s the same and predictable. Whilst individuals with OCD may feel compelled to order objects in symmetry with the fear that something bad would happen if they weren’t specifically, neatly ordered.

Repetitive touching with ASC is usually enjoyable because they may have a specific interest and preference for items and may have hyper-focused interests which could appear to be obsessions, but autistic individuals often find this highly enjoyable.

However, the overlapping symptoms may mean an underdiagnosis of OCD in autistic individuals (National Autistic Society).

Treatment and Management Strategies for OCD (via Mind)

Treatment options tend to include Cognitive Behavioural Therapy (CBT), Exposure and Response Prevention (ERP) and Cognitive Therapy.

Cognitive therapy focuses on the present moment, identifying negative thoughts and changing unhelpful behaviours and responses. Whilst CBT focuses more on your beliefs and attitudes that affect your feelings and behaviours. In ERP, a therapist helps the individual deliberately put themselves in anxiety-inducing situations. The individual then tries to tolerate the uncomfortable feeling without performing their usual compulsion. It’s been identified that this therapy can be challenging and could make individuals feel anxious at the beginning; discussing with a therapist if this is right for you is recommended (Mind UK).

The NHS tends to recommend Cognitive Behavioural Therapy. OCD-UK offers a range of self-help resources and a ‘Books on Prescription’ Scheme to borrow self-help books, such as from a local library.
Stress and anxiety can trigger OCD. Finding techniques to manage your stress could support your OCD (this list is not exhaustive).
Relaxation techniques, for example, making time for mini pockets of de-stress time throughout your day to relax, such as going for a run, reading a book, or watching some TV.
Refocusing your attention when you feel like you need to complete an obsession:
- Physically refocus your attention: for example, take a walk, hum a song, use a fidget toy or fidget with a small object.
- Mentally refocus your attention: for example, list things you see, or name every colour you can think of. You can try repeating the method again if you feel like you need to complete an obsession.
Mindfulness to help with noticing the present moment, without judgement. This could help you with becoming more self-aware, feeling calmer, less stressed and coping with challenging or unhelpful thoughts.
Getting enough sleep, thinking about your diet, and trying some physical activity can also support managing and improving your mood.
Practice self-compassion by reminding yourself that living with OCD can be challenging and can be even harder when stress is present. OCD is a mental health condition, so try and treat yourself nicely, like you would with a friend.
Reward yourself and celebrate your successes (big or small achievements), for example waiting 20 seconds before doing a compulsion.

Conclusion

In conclusion, OCD with ASC or ADHD can be quite complex, in that the symptoms can look similar across the neurodifferences. For example, when neurodivergent individuals are trying to manage their challenges. However, with OCD, individuals feel ‘compelled’, find the behaviours unenjoyable and they can cause distress. Whilst ASC and ADHD are neurodifferences that are present in both childhood and adulthood, OCD is a mental health condition that can arise at any given point in an individual’s life (Psychiatry-UK). More research is needed to understand the comorbidity of OCD with ASC and OCD with ADHD. Nevertheless, Lance Weiss’s blog highlighted five positive attributes he experiences with his OCD including when managed effectively: creativity, attention to detail, determination to perfect their craft, being sympathetic and learning anything is possible when realising that OCD can be managed, for example, by helping to rewire the brain’s negative thoughts into positive thoughts.

Jing-Ying Wong

Assistant Psychologist

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