Why OCD and Autism Often Overlap, and What You Can Do About It

Many autistic children, teens, and young adults (and the people who love them) notice strong, repetitive thoughts and actions. Sometimes these look like obsessive-compulsive disorder (OCD), and sometimes they look like atusim (i.e., restricted and repetitive behaviors, or RRBs).

Knowing the difference and what helps can reduce confusion, lower stress, and lead to better support and treatment. This article explains the overlap between OCD and autism, how clinicians try to tell them apart, what treatments have the best evidence, and practical steps families and autistic people can use right away.

What is the overlap, and why does it matter?

Autistic people are more likely than the general population to experience anxiety disorders, including OCD (Postorino et al., 2017). Many studies show considerable overlap in the appearance of repetitive behaviors across autism and OCD. For example, rituals, checking, or intense routines can all make diagnosis tricky (O’Loghlen et al., 2024). That matters because the best supports and treatments differ depending on whether a behavior functions as a soothing routine tied to sensory or predictability needs (more typical in autism) or as a compulsion aimed at reducing distress from an intrusive obsessive thought (more typical in OCD). Getting the correct label leads to more useful strategies.

How clinicians try to tell them apart (in plain language)

There is no single test that always works, but clinicians look at several helpful clues:

• Why the behavior happens — In OCD, compulsions (e.g., checking, counting, repetitive washing) are usually driven by an upsetting, intrusive thought or fear (an obsession) and aimed at preventing something bad. In autism, RRBs are often calming, engaging, or driven by sensory differences and do not always come from intrusive, distressing thoughts. Asking “what is the behavior doing for the person?” is a key step. (O’Loghlen et al., 2024; Postorino et al., 2017.)

• Emotional reaction to stopping the behavior — If stopping the routine causes intense, anxiety-filled thoughts and the person does the action to avoid those thoughts, that might suggest OCD. If stopping the routine causes frustration or irritation but not an intrusive, catastrophic thought, it may be autism-related RRBs. (Postorino et al., 2017; Bedford et al., 2020.)

• Content and form — Sometimes the content of the thought (e.g., “If I do not lock the door 10 times, someone will get hurt”) points to OCD; repetitive interests or sensory rituals (e.g., lining objects by color) often point to autism. However, there is overlap, so clinicians use careful interviews and multiple sources of information to ensure accuracy. (O’Loghlen et al., 2024.)

Because assessment can be hard, recent reviews emphasize using adapted assessment tools and careful interviews and recommend specialists who know both autism and OCD. (Bedford et al., 2020.)

Treatments with the best evidence (what actually helps)

There are two evidence-backed approaches people should know about:

1. Adapted cognitive-behavioral therapy (CBT), including exposure and response prevention (ERP)

CBT that is adapted for autistic people (clear structure, visual supports, involvement of family or care takers, focus on function of behaviors) is an effective first-line therapy for OCD or OCD-like problems when they co-occur with autism. Randomized trials show adapted CBT can produce meaningful reductions in OCD symptoms in adolescents and adults with autism (Russell et al., 2013), and reviews describe it as a promising, evidence-based approach (Bedford et al., 2020). Family involvement is often important: family accommodation of compulsions (helping or enabling rituals) predicts poorer outcomes, so therapists usually work with caregivers to change accommodation patterns gently and supportively.

Practical tip: If CBT is recommended, ask whether the therapist has experience adapting ERP for autistic clients (visual aids, short exposure steps, concrete language). Look for clinicians who incorporate family coaching and can individualize their approach to pacing.

2. Medication (SSRIs), limited but sometimes useful

Selective serotonin reuptake inhibitors (SSRIs), a typical class of antidepressants often used for OCD, have been studied in autistic children and adolescents. A large randomized clinical trial found that fluoxetine produced statistically lower obsessive-compulsive scores at 16 weeks compared with placebo in children and adolescents with autism. However, results were complex and not uniformly conclusive across all analyses (Reddihough et al., 2019). Reviews note that medication can be beneficial for some people, but the effect sizes are modest, and benefits should be weighed against side effects and individual needs (Postorino et al., 2017; Bedford et al., 2020).

Practical tip: Medication decisions should be made with a child/adolescent psychiatrist or physician familiar with autism. Medication is often paired with behavioral therapy — and is usually not a stand-alone solution.

Strategies families and autistic people can try now

Whether a repetitive behavior is autism-related or OCD-related, many supportive strategies help reduce distress and improve daily functioning:

1. Map the function — Keep a simple diary for a week: what triggers the behavior, what comes before it, what happens if it is interrupted, and how the person feels after. This helps decide whether the behavior reduces an intrusive fear (suggesting OCD) or is self-soothing/interesting (more likely autism-related). (See clinician guidance in Bedford et al., 2020.)

2. Respect and replace — If a behavior helps with sensory needs or emotional regulation, provide safer or more flexible alternatives (e.g., similar sensory input, scheduled routines, or “stimming boxes”). If the behavior is driven by anxiety, introduce gentle exposure steps only with professional guidance.

3. Family coaching — Reduce family accommodation slowly and with support. For example, if a parent always completes a ritual for a child, the therapist can help plan small, supervised changes so the child learns to tolerate reduced rituals and learns new coping skills. Russell et al. (2013) found that family factors influenced outcomes, indicating that parent coaching truly matters.

4. Build supports for transitions and uncertainty — For autistic people who rely on sameness, adding visual schedules, timers, and advance notice of changes can lower baseline anxiety and make both RRBs and OCD symptoms more straightforward to manage.

5. Ask for an assessment that considers both conditions. If a behavior is causing distress or getting in the way of daily life, ask for an evaluation that assesses both autism-typical RRBs and OCD symptoms (Postorino et al., 2017). Accurate assessment helps match the proper treatment.

When to seek professional help

Reach out sooner rather than later if:

• Repetitive behaviors or thoughts are taking up large parts of the day or stopping school/work/social life.

• The person reports intrusive, distressing thoughts that they cannot control.

• Stopping a behavior causes intense panic or risks safety (e.g., excessive checking that leads to injury).

• Medication side effects or mood changes occur.

A good team includes clinicians experienced with autism and with OCD (psychiatrists, psychologists, behavioral therapists). Reviews recommend specialized, adapted CBT programs and careful use of medication when indicated (Bedford et al., 2020; Reddihough et al., 2019).

You’re Not Alone

Distinguishing OCD from autism-related repetitive behavior is hard even for experts, but it is important because treatment differs. Adapted CBT (with family support) and, in some cases medication, have research support; and practical, respectful strategies at home make a big difference. If you are supporting an autistic child or teen, start by tracking function (what the behavior does), ask for an autism-aware OCD assessment, and look for therapists who adapt approaches for autistic clients. You and your family deserve clear explanations, kind support, and concrete tools. The research base is growing, so better options are available now than in the past. 

If you are curious about treatment and assessment for OCD and Autism, reach out to the team at Autism Learning Lab to learn more about our assessment-specific retreats and our individualized coaching.

References

Bedford, S. A., Hunsche, M. C., & Kerns, C. M. (2020). Co-occurrence, assessment and treatment of obsessive compulsive disorder in children and adults with autism spectrum disorder. Current Psychiatry Reports, 22(10). https://doi.org/10.1007/s11920-020-01176-x

O’Loghlen, J., McKenzie, M., Lang, C., & Paynter, J. (2024). Repetitive behaviors in autism and obsessive-compulsive disorder: A systematic review. Journal of Autism and Developmental Disorders, 55(7), 2307–2321. https://doi.org/10.1007/s10803-024-06357-8

Postorino, V., Kerns, C. M., Vivanti, G., Bradshaw, J., Siracusano, M., & Mazzone, L. (2017). Anxiety disorders and obsessive-compulsive disorder in individuals with autism spectrum disorder. Current Psychiatry Reports, 19(12). https://doi.org/10.1007/s11920-017-0846-y

Reddihough, D. S., Marraffa, C., Mouti, A., O’Sullivan, M., Lee, K. J., Orsini, F., Hazell, P., Granich, J., Whitehouse, A. O., Wray, J., Dossetor, D., Santosh, P., Silove, N., & Kohn, M. (2019). Effect of fluoxetine on obsessive-compulsive behaviors in children and adolescents with autism spectrum disorders. JAMA, 322(16), 1561. https://doi.org/10.1001/jama.2019.14685

Russell, A. J., Jassi, A., Fullana, M. A., Mack, H., Johnston, K., Heyman, I., Murphy, D. G., & Mataix-Cols, D. (2013). Cognitive behavior therapy for comorbid obsessive-compulsive disorder in high-functioning autism spectrum disorders: A randomized controlled trial. Depression and Anxiety, 30(8), 697–708. https://doi.org/10.1002/da.22053