For years, the patient scrubbed her hands until they were raw, counted steps to the letter, obsessively searched her own name on Google, and even traced the sign of the cross on her chest, despite not being remotely religious.
It took all of 20 minutes for a doctor to say she had obsessive-compulsive disorder.
The rituals, they said, were classic signs of the psychiatric disorder that affects between one and three per cent of the global population.
An evaluation from a psychiatrist wouldn’t be necessary. Just take this low-dose antidepressant and try cognitive behaviour therapy, they said. And off she went.
But what if her rituals weren’t OCD? A speculative hypothesis – not yet backed by peer-reviewed research but nonetheless compelling – suggests a radical rethink.
What if OCD symptoms could be something else entirely: the hidden language of an autistic brain, starved of its natural coping mechanisms?
Lindsey Mackereth, a licensed therapist who treats neurodivergent adults, proposes a theory that autism and OCD may be more closely linked than previously thought.
Current research shows that while autism and OCD can occur side by side – autistic individuals are about twice as likely to also have OCD – they are recognised as distinct neurological conditions, not simply different sides of the same coin.
Lindsey Mackereth, a licensed therapist who treats neurodivergent adults, proposes a theory that autism and OCD may be more closely linked than previously thought (stock image)
Mackereth, who runs two popular Substack newsletters with over 30,000 subscribers, argues that some behaviours labelled as obsessive-compulsive may actually represent an overlooked facet of autism – meaning certain patients could be misdiagnosed with OCD when undiagnosed autism is the underlying condition.
As she explains: ‘As a licensed therapist who focuses on the presentation of neurodivergence in highly masked adults, I believe that attempts to compensate for needs in autistic wiring may resemble, and be misconstrued as, some subtypes of OCD.’
The theory is divisive: critics point to the absence of peer-reviewed evidence, while many of Mackereth’s Instagram and Substack followers say her ideas resonate – at least anecdotally.
Jessica Herrington, a follower of Mackereth’s as well as a therapist who works with autism and ADHD, said she ‘always, always checks for an OCD comorbidity’.
A woman named Jaclyn who was diagnosed with ADHD and autism spectrum disorder said she used to think she had obsessive-compulsive disorder for years, only to realise that her ‘OCD-type behaviours stemmed more from autism’.
According to recent estimates, OCD impacts roughly half a million Australians.
The DSM-5-TR – the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is used to diagnose both conditions – states that the most marked characteristics of OCD include obsessions that are repetitive and intrusive, as well as compulsive, repetitive behaviours, like handwashing, counting and praying.
Just like other neurodivergent conditions, such as ADHD and Tourette syndrome, autism diagnoses are on the rise.
Mackereth argues that some behaviours labelled as obsessive-compulsive may actually be the consequence of suppressing autistic stimming. The theory is divisive, with critics pointing to the absence of peer-reviewed evidence, but many say her ideas resonate – at least anecdotally
ABS data shows autism diagnoses surged by nearly 42 per cent in just four years – from 205,200 Australians in 2018 to about 290,000 in 2022, representing 1.1 per cent of the population.
That figure is expected to climb as diagnoses rise – and the increase is already most pronounced among Australians under 25.
The DSM-5 identifies autism as having three major deficits: qualitative impairment in social interaction, qualitative impairment in communication, and restricted, repetitive patterns of behaviour and interests.
A key element of Mackereth’s theory centres on ‘stimming’, or self-stimulatory behaviour – a term that’s gained popularity online and on TikTok to describe any repetitive action that brings comfort.
For autistic people, stimming often means hand flapping, rocking, head-butting or repeating words and phrases to help regulate their emotions, or simply because it feels good.
Mackereth suggests that when stimming is discouraged by teachers, caregivers or society, that need for repetition turns inward and becomes repetitive thinking. As she puts it: ‘Starve an autistic nervous system and it starts looking like OCD.’
‘Imagine a highly masked autistic individual who has suppressed their need to use repetitive behaviours (or stimming) to adequately tend to the needs of their nervous system for most of their life,’ she writes.
‘Might the mind begin to… obsess on particular areas of thought as a way to manufacture a stimming opportunity for the nervous system?’
Mackereth suggests that ‘what we call compulsions might actually be a masked autistic nervous system in distress’.
Lena, the mother of an autistic child previously thought to have OCD, said she felt ‘seen’ by this hypothesis. She said her son’s OCD was ‘severe’ before he received the necessary support and diagnosis for his autism.
‘Since then, his OCD has faded away,’ she said.
But not everyone is convinced. Dr Iain Perkes, a senior lecturer in child psychiatry at the University of New South Wales who specialises in OCD research and behavioural neuroscience, calls it a ‘tricky’ area.
‘It’s true that anxiety and stress can impact OCD and that [autism and OCD] can co-occur, but to my knowledge I’ve seen no data to support the thesis that compulsive thoughts and actions are a subset of autism.’
Dr Perkes adds that while people like to say they ‘have a bit of OCD’, it is a debilitating mental illness.
‘Obsessions are highly distressing and there are repetitive, intrusive thoughts a person with OCD can’t control. They might believe, for instance, that they or their loved ones are in grave danger,’ he explains.
‘People with OCD spend hours each day consumed by this cycle.’
Dr Perkes says a diagnosis can take up to nine years because sufferers are so ashamed of their intrusive thoughts, sometimes believing that if they voice them they will somehow come true.
As for autism stimming being confused for repetitive OCD rituals, Dr Perkes had this to say: ‘Excessive stimming, which can include repetitive movements, is sometimes mistaken for OCD.
‘However, recognising and offering treatment for OCD and any other mental or physical condition is important as we know that OCD and autism do co-occur.
‘That does not mean that autism, or family responses to it, cause OCD.’
Dr Perkes concluded with a warning about Mackereth’s theory.
‘To suggest that OCD occurs because stimming was prevented could risk people feeling blamed for something that is out of their control,’ he said.
‘However, preventing stimming could cause stress – and stress often worsens OCD symptoms – so perhaps that is what has been observed.’