Is it Autism or OCD?

Sundar Pichai, CEO of Google, was not in the mood to answer his phone. It was the third day of my client’s son Joey sitting on hold with Pichai. Joey was determined to get through. The phone system’s automated prompts were confounded by his request, “Can you make Google go back to how it was in May 2020 when I looked up swashbuckler films?”

Joey was a 15-year-old autistic ADHDer. Hospitalizations due to seizures had also complicated his early life, resulting in premature separation from his parents. In the early months of the pandemic, Joey had found a new hobby, sword fighting with light sabers, and happened upon Errol Flynn and the swashbuckling movies of the 1940s and 50s. Joey and his parents spent the next two years of COVID working their way through the Google list of those classic films. His mother lamented the misogynistic plot lines, but Joey was mesmerized by pirated treasures and rousing battles.

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Google’s search results for swashbuckler movies seemed to diminish over time, and Joey grew despondent that his beloved films were disappearing off the internet. He was convinced fewer were showing up in the search engine’s listings, and he was increasingly anxious about it.

For Joey, there was something profoundly magical about those first days of encountering the swashbuckler genre. The movies had left an indelible print on Joey’s brain, and the desire to return to the original Google search felt like the quest for the Holy Grail. After searching through eBay and countless thrift shops, Joey found the most obscure film of all, a 1950s film called The Avengers. Because this one was the hardest film to find and, therefore, the most precious, Joey believed if he watched it exactly three times per day, it would bring back his beloved swashbucklers to Google.

Perseveration is the continual involuntary repetition of a thought or behavior. Autistic perseverations can be verbal, motor, or cognitive. In autistic people they seem to stem from several possibilities — anxiety, thought rigidity, difficulty regulating impulses, or hyper-focusing on something of interest. Part of an autism diagnosis constitutes “restricted, repetitive behaviors” (RRBs) that are rigid and invariant. Recently, I came across the term “polling” online. This refers to the repetitive asking of questions that so many autistic people engage in. One explanation for the behavior is that they are doing a mood check, and upon receiving a reassuring response, over and over, they feel safe enough to proceed.

Joey was not new to perseverative thinking. At the particularly poignant transition to puberty, he became captivated by the idea that Peter Pan was coming to take him to Neverland. The fantasy of prolonged youth and his sense of being an outsider left him in a futile battle with the grips of adolescence.

To help Joey’s mother make sense of this latest swashbuckler fixation, I got buried in a Google search rabbit hole of my own.

OCD occurs in 17-37% of autistic children and adolescents (Martin et al., 2020). While autism and OCD often co-occur, there is a primary difference between OCD symptoms and the repetitive behaviors seen in autism. OCD obsessions are intrusive and distressing, and the compulsions are directly tied to the obsessive thoughts. The compulsions are a form of “undoing,” an attempt to prevent the feared consequences of the obsessive thought from happening. Through this lens, Joey’s compulsion to watch The Avengers seemed more aligned with OCD.

On the other hand, the autistic’s ritualistic behavior may appear to lack purpose and is not directly linked to their perseverative ideas. The repetitive behavior can often be pleasurable or self-soothing and can even become self-stimulatory. If the autistic behavior is not distressing to the person themselves, there is no reason to treat it.

I am indebted to an online community of autistic adults willing to share their subjective experiences. I learned that for some, perseverating can be “emotionally and mentally draining,” even when the content of the thoughts or behavior is pleasant. The experience of being “stuck” and “hyper-fixated” seems to contain a negative component.

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Although exposure and response prevention is generally indicated as the treatment of choice, many case studies in the psychoanalytic literature demonstrate how bringing the unconscious conflict to light can alleviate OCD symptoms (Chlebowski et al., 2018). Psychoanalysts going back to Freud have found “obsessional neuroses” to be deeply symbolic. Freud proposed that repressed sexual and aggressive drives may result in a defense of obsessive thoughts and compulsions that protect the ego from these forbidden wishes and fears. The compulsive patient feels both love and hate toward an attachment figure, and they struggle to differentiate their thoughts from actions. In helping to tease apart thoughts from actual behavior, the OCD symptoms can lessen their grip.

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One day, after sitting with one of my adult ADHD clients, she was perseverating on a long-dreamed of wedding venue that was no longer viable. She wasn’t ready to let go of “the wedding that could have been.” I pondered the function of perseveration in staving off the mourning that needed to be done. Maybe going over and over an image or thought in one’s mind is a way of holding onto something in danger of slipping away. It seemed to be a defense against loss.

Maybe this was the role of Joey’s fixation on the swashbucklers that had been left behind. As the pandemic uprooted life as he knew it, these films offered a return to a time long gone. Through the hoped-for return of his original Google search, Joey was attempting to fill a much earlier loss, of childhood separations buried deep in the unconscious.