OCD commonly co-occurs with both ADHD and autism,
And it's my suspicion that when you're ADHD,
ADHD and autistic,
That the rates for us are even higher.
But what does it actually feel like to live with all three?
In this video,
I want to dive deeper into the lived experience of what it's like to live with all three of these,
As well as to start to look at diagnostically what are some of the ways that we might begin to tease apart what's ADHD,
What's OCD,
And what's autism.
A few years ago,
I made this diagram,
And we'll use this as a visual prompt to walk through this conversation.
First of all,
Let's look a little bit at ADHD and OCD because this one can be particularly complex,
Especially diagnostically.
So first of all,
When it comes to ADHD,
One of the things that we know is impacted is something called working memory.
So that's the ability to hold information in mind while we're working with it.
For example,
The ability to remember I went downstairs to get a glass of water or when you're cooking to hold the steps of the recipe in mind as you're working with it.
This is something we know is impacted in the case of ADHD,
But both anxiety and OCD can also impact working memory,
But for a slightly different reason.
In the context of anxiety or OCD,
It tends to be because those anxious thoughts or those intrusive thoughts are crowding out the space,
Which doesn't leave a whole lot for your mind to hold on to other information.
Now,
This is especially true if the person is having a lot of intrusive thoughts or if there's a lot of internalized compulsions that are happening.
For example,
One of the compulsions might be to count a certain way or to say a prayer over and over.
Or there might be some other internalized rituals that they're doing that makes it hard to focus on anything else in the room,
Which could look a lot like ADHD.
So it's going to impact focus,
Attention,
And working memory,
But for different reasons,
Not because of.
A baseline struggle there,
But because there's so much that that person is holding in mind,
And it just doesn't leave space for much else.
So this is one of the reasons,
Especially for children,
Providers will often want to get the OCD under control before assessing for ADHD,
And this simply makes sense.
It's really hard to get the baseline sense of a person's executive functioning or their working memory when OCD,
Especially moderate to severe OCD,
Is in the mix.
And so if a provider suggests that,
It actually does make sense.
And there is a reason why it's hard to diagnose ADHD when severe OCD is also in the mix.
Now one of the ways that ADHD can impact OCD when they're both in the mix One of the things we know about ADHD is that it's harder to regulate our attention,
Meaning where it goes,
And it tends to go to things that are emotionally loud.
OCD intrusions and OCD thoughts tend to be very loud.
And so one of my suspicions of one of the ways ADHD can make OCD harder is that it's probably harder to pull our attention away from those OCD fears and loud thoughts.
Because ADHD makes it hard to pivot our thoughts away from the loud.
Emotions and thoughts that are pulling our attention.
And so that's one of the ways that ADHD can contribute to the increased suffering from OCD when both are present.
And then the way OCD can increase the distress of ADHD is because if the person's already having a baseline struggle with executive functioning and working memory,
Now there's all the other thoughts that are crowding out an already limited working memory.
So things like focus and attention are going to get harder in the context of ADHD.
So when both are present together,
That's often referred to as complex ADHD,
It's going to make the impact from the ADHD trait more distressing.
And I think it's reasonable to assume it's also going to make some of the symptoms of OCD more distressing and hard to manage.
Now,
Another area of overlap between ADHD and OCD that can also lead to some diagnostic confusion has to do with compulsive checking.
Now,
Because working memory struggles,
Are part of the ADHD experience.
We tend to make more mistakes.
We also might not remember where things are.
For example,
I'm often walking through my day and if I set my phone down or my keys down and I'm not exactly paying attention to where,
I'm going to then be searching for them later.
And so that working memory struggle leads to more lack of remembrance of where my stuff is or what I've done or what I've not done.
Have I taken my medication today?
Have I not?
Did I turn off the stove?
Did I close the garage?
These are reasonable questions given my history.
And so some checking behavior is actually a way that we're compensating for our ADHD.
It's a way that we have less mistakes in our life.
And so not all checking behavior is necessarily bad,
But then sometimes we can get pulled into a loop.
Where we perhaps have gone back and checked,
But maybe it still just doesn't feel right in our body.
We feel unsettled or we don't trust it.
So we go back a third time and a fourth time,
And then we're pulled into a compulsive check-in loop.
When I get pulled into these compulsive loops,
The shift is subtle,
But it is there.
I can feel it.
So for example,
When I'm in a compulsive loop at this point,
I know I'm not going to find an air,
But I'm simply trying to make the anxiety that's in my belly go down.
And so I'm going back to ease the sensation of the anxiety,
Not because I can't remember.
So one of the ways we can check in with ourselves here or sort of litmus test we can do is to consider Is this something I'm doing to manage the anxiety or to try to make the anxiety go away?
Or am I doing this because I literally cannot remember whether or not the garage door is open or closed or if the stove is on or off?
And sometimes I do make that mistake.
So are you doing it for a memory reason or are you doing it because you're trying to manage some anxiety and you actually have a clear memory of having checked it once and knowing that it's okay?
And so that's one way that we can begin to tease out what is an ADHD compensation and what is an OCD compulsion.
And of course,
Sometimes it can be both where it starts as an ADHD compensation,
But then it spirals into an OCD compulsion loop.
Now for people who are diagnosing or pre-diagnosing.
Clinically trying to help tease us apart.
Some of the things that we want to be considering is,
Is destructibility and working memory struggles,
Is this part of the person's baseline experience?
And is it happening in most contexts?
Now,
For ADHD,
It actually doesn't have to be in all contexts.
But you will see a more historic baseline global struggle with things like executive functioning,
Working memory,
Distractibility.
However,
In the context of anxiety or OCD,
There might not be that same historic baseline struggle,
Or it might be more specific to when the anxiety is high or when there's been an OCD trigger and they've been pulled into some intrusive thoughts or a loop.
Now,
Another way that I like to try and tease out the difference is to look for the additive things.
By that,
I mean the things that ADHD adds that wouldn't necessarily be there if the person was non-ADHD.
So,
For example,
Does the person have an interest-based nervous system?
We know that for ADHDers,
Interest is what harnesses our engagement and our focus.
And while for all humans,
Of course,
It's easier to engage when we are interested,
The flavor and the tone of that and that pattern is a bit sharper and more present in the ADHD nervous system.
Also,
We can consider,
Does the person hyperfocus?
If we're just looking to define ADHD through a deficit framework of either working memory struggles or executive functioning struggles,
It is going to be harder to tease it out between things like ADHD and trauma or ADHD and OCD.
But there are things that are often present.
In the context of ADHD that are additive that a person who's non-ADHD wouldn't necessarily have.
So that's another thing that we can be softly looking for when we are considering is this ADHD,
OCD,
Or both.
Okay,
And now let's shift a bit and look at autism and OCD and what can show up when those two intersect.
So things that are.
A bit more baked into personality or temperament tend to overlap here.
So that can also make it tricky.
So for example,
It's more common for both autistic people and people with OCD to be a bit more risk-averse,
To crave predictability and familiarity.
Now for the autistic person,
This is largely due to how our bottom up processing and thinking works.
All brains build prediction maps.
Of what is going to happen next.
And that influences literally everything we perceive.
How we experience any given moment,
How our body responds to any moment.
You are literally predicting the words that are about to come out of my mouth.
Now,
Autistic prediction mapping tends to be more precise and specific than allistic prediction mapping.
Allistic prediction maps tend to be a bit more flexible,
Meaning that autistic brains What we tend to do is we deprioritize our past experiences that inform what's about to happen next.
And we highly prioritize the sensory information coming in in this moment.
That is part of what it means to be a bottom-up processor.
Now,
Allistic brains tend to do more of the opposite.
They tend to prioritize past experiences and prediction maps to inform what's about to happen and deprioritize the sensory information coming in in this moment.
So for example,
Just pay attention to what happens to your body when I say a few sentences.
Each peach pear plum,
I spy Tom Thumb.
Roses are red,
Violets are blue.
Now,
If you're at all familiar with those idioms,
Your brain was predicting the end of that sentence before I got there.
Now notice what happens when I say,
Each peach pear plum,
I spy Tom Pickle.
Or if I say roses are red.
Violets are obnoxious.
Now you might have noticed a slight jolt of energy or discomfort with those second lines that I said,
And that is what we call a prediction error.
Your brain was predicting certain words to come out of my mouth,
But it didn't match that.
And that can be unsettling for our nervous system when we encounter a prediction error.
Now,
Interestingly,
When reading sentences like the ones I just gave you,
Where the end of the sentence ends differently than what you would expect,
Autistic people made less errors.
And that.
Is,
Again,
Because of how we tend to value the sensory input coming in more so than audio.
The past that the brain is using to predict what comes next.
So that is a very abbreviated walkthrough of the predictive brain theory or predictive processing and how the brain works.
But I think that is a really important concept for understanding why routines,
Familiarity and predictability are so important for us.
It creates less prediction errors.
Peter Vermilion is someone who does incredible work in this area.
And in one of his books,
One of the things he says is Autistic people don't need more certainty than allistic people.
We all need certainty.
It's just that because of how our brains are wired,
The world that we are navigating is significantly more uncertain,
And it's connected to this predictive processing.
And so as a way to accommodate ourselves,
We bake certainty in,
We bake prediction in through our routines,
Through what's familiar,
Because that is the way that preserves a lot of energy and it is more grounding for our nervous systems.
So for example.
We might not have a large prediction map for what a restaurant is.
We would have a very specific map for each specific restaurant and perhaps for each specific meal,
Or even for each specific bite.
So every time we encounter a new environment,
Our brain is needing to work harder because we're encountering more prediction errors,
We're creating more prediction maps,
And it creates that jolt of arousal that you might have just experienced with that lines.
That's our experience of new environments or unfamiliar routines.
And it's because our brain is working so hard to try to make sense of what's happening.
And so it's energetically costly when we do things that are not familiar.
So that is a bit about autism and familiarity.
Now for OCD,
Familiarity,
Risk adversity,
And a desire for predictability is often a way to manage anxiety and to reduce the possibility of getting pulled into OCD compulsions or having an OCD trigger.
So this tends to be more about avoidance-based anxiety.
And a desire to shield ourselves from things that might create OCD or create an OCD trigger.
Now,
This can be hard to tease out because autistic people,
We don't necessarily always have language for why we need routines or why we like predictability.
I know when my routines are disrupted,
I get what I call free-floating anxiety.
So I might describe my need for familiarity or my need for routines using anxiety-based language.
I might say,
I don't know,
It just makes me anxious when my routine changes.
And so that can confuse diagnosticians,
But also it can confuse us when we don't have language to describe why we need familiarity or routines.
Now,
Another area that can cause some confusion is around rituals.
Autistic people tend to have a lot of rituals.
We might put our socks on the same way every day or have the same breakfast.
And perhaps if we don't follow those rituals,
Something just feels off for us.
And again,
This is related to predictive processing.
We also might have specific rituals because those are sensory supportive for us.
Rituals are regulating and calming and grounding.
So the felt experience of them tends to be something that is soothing.
Now,
OCD compulsions.
Can take on the feel or the flavor of a ritual.
And in the very short term,
They might also be calming because the function of them is to reduce or push away the anxiety.
For example,
If I'm worried that my hands are contaminated,
Washing them will soothe the anxiety in the short term.
But by the time I'm scrubbing them or I've washed them four or five times in a row,
And it feels like something I have to do,
That at that point is becoming more stressful and agitating.
I'm feeling compelled to do it.
It's not something that is soothing and regulating and grounding.
And so that's one of the ways to tease out an OCD compulsion versus an autistic ritual.
Another way to tease out OCD compulsions from autistic rituals is to look for equations.
For example,
A lot of OCD rituals might have something like,
I must do this or X will happen.
For example,
When I was a child,
I needed to leave my parents every time by saying goodbye,
I love you,
Don't die.
And every time I left them and I didn't say that,
I'd have incredible anxiety throughout the day because I hadn't sealed them with safety.
I felt that this ritual was the thing that was keeping them safe.
And the OCD compulsions,
They're often,
There's some magical thinking in them.
They're not necessarily logical.
And so the correlation between,
I need to,
You know,
Tidy my shoes or this terrible thing is going to happen.
There's not a logic to them.
And I say that because there could be something that looks a bit like that for the autistic person of like,
I need to do it a certain way.
Otherwise something bad will happen.
But there,
If you drill down,
There will be a logic.
So maybe it's.
I need to make my smoothie this very specific way.
Otherwise I'll have a bad day.
Well,
Maybe the way that person makes their smoothie is to blend the spinach with the milk before adding in the berries and the banana,
Which that makes the spinach a much better texture than if you add it at the very end.
And maybe if it's a terrible texture,
They can't drink it.
And then their blood sugar is crashing.
So maybe they do have a terrible day,
But there's actually a logic to it.
And so if you're hearing the,
Um,
Kind of,
If I don't do this,
Something bad will happen.
If you drill down and there's a logic to it,
Especially a sensory based logic,
That could still be an autistic ritual,
Not necessarily an OCD compulsion.
And now let's look a little bit about when they all three overlap.
So all three of them on their own have higher rates of things like insomnia,
Co-occurring mental health conditions,
Substance misuse,
And self-harm.
I think this simply makes sense.
All of these bodies are working really hard to manage and hold a lot.
So on one hand,
Life is just harder when you live with any of it.
Of days.
And then we also know that there are some genetic and neurological overlap,
Meaning that there are some similar neurocircuits involved in all three.
And so it also makes sense beyond kind of neatly dividing these things up as we do in the DSM,
That there might be some shared vulnerabilities from perhaps some shared genetic blocks that we might all share.
Intrusive thoughts,
While they can have a slightly different feel,
They can also be common among all of us.
Skin picking or hair pulling also tend to be more common among all three of these.
Behaviors that are classified as an umbrella term known as BFRB,
Body focused repetitive behaviors.
And they're more common for all three of these neurologies.
For some people,
It might initially start as a form of stimming or fidgeting,
And then they get pulled into it.
For many people,
This can be a way of working to manage anxiety.
So these can be common among all three of these neurologies.
Now,
For different reasons and with slightly different flavors,
Executive functioning tends to be impacted by all three of these,
But can behave a bit differently and can be strained for different reasons.
Now in OCD,
Like we've already discussed,
It tends to be crowded out.
And so that can make executive functioning difficult.
In ADHD,
Executive functioning behaves a bit differently,
And that's a really core part of the ADHD experience.
Now,
In autism,
We are often processing so very much information,
Especially from the bottom up.
That that also can crowd out executive functioning and working memory,
But for a slightly different reason than it gets crowded out for OCD.
It's more about the mass amount of sensory input that we are digesting in any given moment.
And then finally,
Sensory sensitivities can be,
Or sensory differences can be common for all three.
This is part of the diagnostic criteria for autism.
It is not yet part of the criteria for ADHD.
I hope to see that change someday.
But in OCD,
We also tend to see more increase in sensory processing differences or sensory sensitivities.
Now,
With OCD and anxiety,
It's common to see more sensory processing sensitivities.
And partly that's because when we have anxiety or OCD,
The nervous system is typically in a heightened or alert state.
So then when we're taking in sensory information,
It's more intense.
And that does tend to calm down a bit once the anxiety and the OCD is addressed.
So it can be more situational.
However,
Other studies have also found sensory differences in people with OCD.
Kind of across the lifespan.
Okay.
So that was a bit of information unpacking the specifics of how these three experiences can show up and overlap.
If you are someone who lives with all three or suspect you might,
I think one of the most helpful things is that ability to start noticing,
To start pausing and to start teasing out what is what,
Because some of these things benefit from more neurodivergent accommodations and support.
And then some of these things are things that we want to treat and address.
And so knowing what is an OCD compulsion,
What's an autistic ritual,
This becomes really important for supporting ourselves.
So being able to notice when am I supporting my neurodivergence and when am I feeding the OCD or feeding the anxiety,
That becomes really important for those of us living with all three.
So the very first step is often starting to pay attention to our patterns,
Our behaviors,
With a lot of gentleness and curiosity so that we can begin to track what is the OCD,
What is the ADHD,
What is the autism,
And start teasing them apart so that we can become curious observers of our behavior,
What it means,
And identify unmet needs behind the behavior.
Thank you.
