Repetitive Behaviors in OCD and Autism

By Jeremy Shuman, Psy.D.

A common reason clients wind up in my office is that they feel stuck in a behavioral loop.  They find themselves repeating some action or thought, and they are upset about some unintended consequences in their lives from that repetition.  Examples include being late because of a habit like checking appliances before leaving and social consequences related to disruptive bodily motions.  

Folks ask for help with reducing their repetitive behaviors in therapy, and sometimes I tell them that I don’t think they should stop.

In OCD, repetitive behaviors are in response to aversive internal experiences that feel like they need to be resolved.  For example, if someone has a thought that everything around them is contaminated with dangerous germs and that a feeling of unease in their body is a good indicator of actual danger, they will do what it takes to feel safe including washing every time they touch something innocuous or washing for hours until they holistically no longer feel contaminated even though their hands were sanitized after a few seconds.  They would most likely hate washing and wish the world wasn’t so scary so they could stop.

In autism, repetitive behaviors are not trying to resolve anything.  They just feel good.  Autistic folks have a preference for predictability and familiarity.  When the world gets intense, they need a break, and when they are resting, engaging with the things that feel good is recuperative.  There is no belief in a protective element to this behavior any more than listening to your favorite song protects you from wallowing when you have a bad day, or resting in the shade feels helpful on a hot day.  You don’t hate listening to your favorite song when you are glum, and it does help to cheer you up rather than making the rest of the day feel worse.

When a person with OCD swipes their finger on a wall it’s because they get a feeling that something is wrong and if they swipe they can prevent it. They hate swiping because it gets in the way of life and sleep and they wish they could stop. They try to swipe until the feeling goes away, but often they bargain with themselves and stop because of a contrived rule, or running out of time, or getting exhausted and quitting.

When an autistic person swipes their finger on a wall it’s because they like how it feels to do that and they want to feel good— especially if they are worn out.  They like swiping and wish they had some more textures to play with and more time alone with their textures. They swipe until they have to do more important things, but they might sneak some extra swiping in here and there because they genuinely enjoy it.

If a repetitive behavior is part of OCD, repeating it over time will worsen obsessions and reduce quality of life.  When the OCD sufferer takes the risk about what will happen when they stop doing the repetitive behavior, they get immediate feedback that their life gets easier.  If a repetitive behavior is part of autism, using it to cope will make the world less overwhelming.  The world is intense and overwhelming for autistic people.  When an autistic person withholds from themselves the repetitive and predictable things they enjoy, they get immediate feedback that the world becomes harder to navigate.  

So an empathetic approach to OCD is to refuse to accommodate compulsive repetition, and an empathic approach to autism is to negotiate equitable accommodation of all parties’ needs.

This is not to say that the tendency of repetition of autistic people has only positive consequences.  Repeating a phrase while you and your peers are concentrating on a test would be distracting, watching the same movie for the 50th time this year could be boring to friends and partners, strict rule-governed behavior around environmental justice can feel unnecessary and masochistic.  But these are the grievances of the people affected by my clients, not my clients’ complaints.  In contrast, the repetitive behaviors of my clients with OCD are distressing to the clients themselves.  So whereas repetitive behaviors in OCD are a negative thing in the life of the individual and are seen as negative in their community, in autism, the repetitive behaviors are a positive thing in the life of the individual even as they are regarded as rude and selfish in the community.  The pathologizing of repetition ignores the effective coping function of repetition in autism.  

Interventions in psychotherapy and occupational therapy can reduce repetitive behaviors regardless of if the behavior served any real value to the individual.  But there are many reasons why these interventions can lead to changes in behavior.  In the best case we would see an individual stop their repetitive behavior because they no longer believed in a frightening obsession that was justifying the behavior, or they gained mastery over coping on the fly with an overwhelming stimulus and no longer do repetitive behaviors in that context.  But we can also see people inhibit their behavior for a variety of other reasons including that they practice distress tolerance through mild or moderate distress to accommodate the comfort of others, or they learn that they are helpless against severe distress because their attachment figures demand their behavior be a performance of “normal.”

We can empathetically choose to negotiate and optimize compromises with our autistic friends and loved ones who use repetitive behavior to adaptively cope, rather than assume the autistic person can “act normal” if they try.  Asking autistic folks to make their coping skill use invisible is expecting them to live in distress that we ourselves are unwilling to tolerate.

For the clinicians out there, compulsions are trying to neutralize fear/disgust/NJRE based obsessions. RRBs are ego-syntonic efforts to feel good, discharge energy, and cope with overwhelm. Compulsions make obsessions worse. RRBs are intuitive coping tools that improve the quality of life for autistic people.

So, though OCD and autism both feature repetitive behaviors that can look the same from the outside, the way those behaviors affect the individual is widely different depending on the reasons the individual is doing the behaviors.  Not all repetition, rigidity, rule-based behavior, or insistence on sameness is OCD, and if it is adaptive we can encourage it.