Recently, a mother brought her 12-year-old daughter to my office for a neuropsychological evaluation. The child had been exhibiting a constellation of symptoms since early elementary school, including anxiety, awkward social skills, difficulty developing peer relationships, a need for sameness and routine, resistance to transitioning between tasks, repetitive behavior/speech, adherence to rituals, and sensory sensitivity to certain noises and textures.
However, language development was within a normal range. Academically, she has been in a gifted program since the third grade and achieves straight A’s.
My initial diagnostic thoughts centered around Asperger’s Syndrome (AS). Most, if not all, of the primary characteristics were present. It should be noted that as of 2013, AS is now known as a mild form of Autism. However, there are important differences between the two (Duffy, Shankardass, McAnulty, Als, 2013; Cohen, H., 2018), which require careful assessment.
Asperger’s Syndrome generally involves:
- Social awkwardness, involving a failure to comprehend conventional social rules, blunted affect, limited eye contact, lack of empathy, and/or inability to understand gestures or sarcasm
- Highly restricted, but fixated interests. In other words, there is a tendency to become obsessive with the few interests that are demonstrated. Often times, individuals with AS collect categories of items (e.g., rocks, comic books)
- Good language skills, but unusual speech characteristics (e.g., lack of inflection, verbal perseveration, underlying rhythmic patterns)
- Average to above-average intelligence
- Ritualized behavior/Inflexible adherence to routine
- Poor relationships with peers
- Difficulty transitioning between tasks
- Significant anxiety
- Problems with sensory integration
Upon completion of the evaluation, it became apparent that this child possessed every hallmark characteristic of AS listed above. Yet, she did not have Asperger’s Syndrome. Often times, there is symptom overlap among various psychological conditions and clinicians are faced with the task of making a differential diagnosis. Although this child’s clinical presentation was quite consistent with AS, the underlying motives for her symptoms were better explained by Obsessive-Compulsive Disorder.
Similarities between Asperger’s and OCD are:
- Ritualized patterns of behavior: Individuals with Asperger’s intentionally engage in “sameness” because it provide a sense of control and predictability in a world experienced as chaotic. With OCD, these ‘rituals’ are compulsions used to neutralize or counteract a particular obsessive thought. For instance, a child may eat the same meal every day for lunch in the same sequence of events; eating the sandwich first, then carrots, followed by pretzels, and then drinking the milk. The child with AS does this to gain a sense of safety through predictability. For the child with OCD, this eating ritual represents a response to some type of obsessive thought (e.g., all other foods are contaminated. The foods have to be eaten in a specific order to prevent something bad from happening).
- Trouble shifting between tasks: To a child with AS, a directive to change activity without enough advanced notice represents a disruption in routine. However, a child with OCD may be reluctant to switch tasks because the first task didn’t feel sufficiently completed due to perfectionistic tendencies or a compulsive need for symmetry/balance.
- Unusual speech patterns: In both OCD and AS, we often see verbal perseveration, which is an inappropriate recurrence or repetition of a previously produced word or thought. For a child with AS, this could represent a problem solving strategy in an attempt to help process the word/thought. In OCD, it is a compulsion that helps the child gain a sense of internal control. For instance, a child with OCD who believes she may have offended another person acts on an impulse to repeatedly say the word “sorry.” This is driven by a compulsive need for reassurance (that the other person is not upset with them).
- Anxiety: Children with OCD and AS spend much of their time feeling tense and anxious. In AS, the anxiety is typically generated by either overstimulation due to sensory overload (loud noises) or anticipatory anxiety stemming from uncertainty of what to expect next. In OCD, the anxiety pertains to their obsessive thoughts and the worry of not performing the compulsions properly.
- Impaired peer relationships: Asperger’s Syndrome is primarily a problem of social communication, which causes significant difficulties in establishing relationships. Because children with AS tend to be socially awkward and lack the ability to understand conventional social rules, they are frequently viewed as being uninterested and distant. However, many individuals with AS have a desire for relationships, but struggle with the ability to express that desire in ordinary ways. In contrast, children with OCD can develop poor relationships with peers, but not because of impaired social skills. Rather, depending on the severity of the OCD, they may direct most of their attention on their obsessive thoughts and compulsive behaviors, appearing aloof to others. Sometimes, the compulsions are so strong, the child is unable to hide them from peers, resulting in teasing and social ostracization.
- Sensory processing issues: Children with AS have a heightened experience of sensory information due to a sensory processing disorder (SPD), which is a deficit in the brain’s ability to process information through multimodal sensory systems (Miller and Lane, 2000). As a result, they may not like certain smells, sounds, textures, etc. Children with OCD may also have sensory issues, which are attributable to a sensorimotor obsession (Keuler, beyondocd.org); a preoccupation with bodily sensations. As an example, a child with AS may refuse to wear jeans because their experience of denim on their skin is relatively painful. However, a child with OCD may also complain about wearing jeans, because they are hyper-focused on the dissymmetry of the inner seams against their skin.
Making a Differential Diagnosis Between AS and OCD
On the surface, AS and OCD can appear identical, particularly the obsessive and repetitive behaviors. This gray area consisting of symptom overlap can pose significant challenges in making a differential diagnosis.
However, the primary distinguishing factor between these two conditions is the internal experience of the symptoms. For the most part, traits of OCD are unwelcomed and anxiety-provoking. Individuals with OCD feel as though they are being held prisoner by their disorder. They would rather not have to engage in these time-consuming acts in order to suppress recurrent, disturbing thoughts.
On the other hand, anxiety is not the driving force behind repetitive behaviors in AS. In fact, individuals with AS experience their ritualized behaviors as pleasurable and may become distressed if deprived of such repetition.
It is also important to note that AS and OCD are not mutually exclusive conditions, and often co-exist. Research suggests that OCD is more prevalent among individuals with Autism Spectrum Disorders (AS falling on the mild end of this spectrum) than among the general population (van Steensel FJ, Bogels SM, Perrin S., 2011).
Additional studies have identified many shared neural markers between OCD and Autism Spectrum Disorders, as well as genetic links, presenting even more diagnostic challenges (Neuhaus E, Beauchaine TP, 2010; Bernier R., Hultman CM, Sandin S, Levine SZ, Lichtenstein P, Reichenberg A, 2011).
Van Steensel FJA, Bögels SM, Perrin S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14, 302–317.
Neuhaus E, Beauchaine TP, Bernier R. (2010). Neurobiological correlates of social functioning in autism. Clinical Psychology Review, 30, 733–48.
Hultman CM, Sandin S, Levine SZ, Lichtenstein P, Reichenberg A. (2011). Advancing paternal age and risk of autism: new evidence from a population-based study and a meta-analysis of epidemiological studies. Molecular Psychiatry, 16, 1203–12
Duffy, F., Shankardass, A., McAnulty, G., Als, H. (2013). The relationship of Asperger’s syndrome to autism: a preliminary EEG coherence study. BMC Medicine, 11:175.
Miller, L. J., & Lane, S. J. (2000). Toward a consensus in terminology in sensory integration theory and practice: Part 1: Taxonomy of neurophysiological processes. Sensory Integration Special Interest Section Quarterly, 23, 1–4.
Keuler, D. When Automatic Bodily Processses Become Conscious: How to Disengage from Sensorimotor Obsessions. Retrieved from www.beyondocd.org.
Dr. Natalie Fleischacker is a clinical psychologist specializing in neuropsychology. She has a doctorate from the Minnesota School of Professional Psychology and received her fellowship training at Yale University School of Medicine. Dr. Fleischacker is a member of the International Neuropsychological Society and Pennsylvania Psychological Association. She is currently in private practice, with a focus on neuropsychological evaluation of traumatic brain injury, cerebrovascular disease, and dementia.