By Fugen Neziroglu, Ph.D. and Jill Henriksen, MS
This article was initially published in the Spring 2015 edition of the OCD Newsletter.
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 normal 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 Yaryura-Tobias (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 homework 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 (McDouglet 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 (McDouglet 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, PhD 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.