OCD in Autistic Women: Why It's Often Missed and How to Find the Right Treatment
If you're an autistic woman who has spent years trying to understand why your brain works the way it does, you're not alone. And if you've recently started wondering whether some of what you've always called "anxiety" or "just being particular" might actually be OCD, you're definitely not alone.
Here's something I see constantly in my practice: autistic women who have gone years, sometimes decades, without recognizing that OCD has been running alongside their autism the entire time. The two conditions overlap in ways that make them incredibly difficult to untangle, especially when you've spent your whole life masking and adapting to fit into neurotypical spaces.
I'm Dr. Erica Aaten, and I specialize in working with late-diagnosed autistic women and those navigating the complex intersection of autism, ADHD, and OCD. In this post, I want to explore why OCD is so frequently missed in autistic women, what the overlap actually looks like, and most importantly, how to find treatment that actually works for your neurodivergent brain.
The Hidden Overlap: Why OCD and Autism Are So Often Confused
Let's start with why this matters. Research suggests that autistic individuals are significantly more likely to experience OCD than the general population. Some studies indicate that up to 17-37% of autistic people also meet criteria for OCD, compared to about 2-3% of the general population. That's a massive difference.
But here's where it gets complicated. Autism and OCD share surface-level similarities that can make them look almost identical from the outside. Both can involve:
Repetitive behaviors and routines
Strong preferences for sameness
Intense focus on specific topics or activities
Distress when things don't go according to plan
Ritualistic behaviors
So how do you know if what you're experiencing is "just autism" or if OCD is also in the mix? This is where things get nuanced, and honestly, it's one of the reasons I love this work. Untangling these threads requires understanding not just the behaviors themselves, but the function behind them.
Understanding the Difference: Autism Traits vs. OCD
Here's the key distinction that often gets missed: autistic routines and repetitive behaviors typically feel good, regulating, and aligned with who you are. OCD compulsions feel driven, urgent, and often go against what you actually want.
Let me break this down further.
Autistic Repetitive Behaviors and Routines
When you engage in autistic stimming or follow preferred routines, there's usually a sense of comfort, regulation, or genuine enjoyment involved. Your morning routine might be exactly the same every day because it helps you transition into your day smoothly. You might arrange items in a particular way because it's visually pleasing and helps you feel calm. You might have intense interests that you return to again and again because they bring you joy and help you recharge.
These behaviors are ego-syntonic, meaning they feel like a natural extension of who you are. They're not distressing in themselves. The distress comes from the outside world telling you that you're "too rigid" or "obsessive" (which, by the way, is not helpful feedback and I wish people would stop saying it).
OCD Compulsions
OCD operates differently. With OCD, you experience intrusive thoughts (obsessions) that create intense anxiety or distress. To relieve that distress, you feel compelled to perform certain behaviors or mental rituals (compulsions). The compulsions might provide temporary relief, but they don't actually feel good. They feel like something you have to do to prevent something bad from happening or to make an unbearable feeling go away.
The cruel irony of OCD is that the more you perform compulsions, the stronger the OCD becomes. You're not engaging in these behaviors because they align with your values or bring you joy. You're doing them because your brain is essentially holding you hostage. Fun times, right?
Where It Gets Tricky
Here's where the diagnostic waters get murky for autistic women specifically. You may have learned to mask your OCD compulsions just as thoroughly as you've masked your autistic traits. Your compulsions might look like "just being careful" or "being a perfectionist" or "having high standards." You might have internalized the idea that your OCD behaviors are just part of being a "responsible" or "thoughtful" person.
Additionally, some behaviors can serve both functions. For example, you might need to check that the door is locked multiple times. Is that an autistic need for certainty and closure? Or is it an OCD compulsion driven by intrusive thoughts about home invasion? Or could it be both? The answer matters because it affects how we approach treatment.
Why OCD Is Frequently Missed in Autistic Women
If you're reading this and thinking, "Wait, how did no one catch this before?" I hear you. There are several reasons why OCD flies under the radar for so many autistic women.
Diagnostic Overshadowing
This is the clinical term for what happens when one diagnosis "overshadows" another, preventing clinicians from seeing the full picture. If you received an autism diagnosis (or even just started identifying as autistic), providers may attribute all your repetitive behaviors and rigidity to autism without considering that OCD might also be present.
The reverse happens too. Many autistic women receive OCD diagnoses first, and providers stop there, missing the underlying autism entirely. This is particularly common when your autistic traits have been well-masked and your OCD symptoms are more visible.
The Masking Factor
Autistic women are often masters of camouflage. You've likely spent your entire life studying neurotypical behavior and learning to hide the parts of yourself that don't fit. This masking extends to OCD symptoms too.
You might perform your compulsions privately, explaining away any visible behaviors with socially acceptable reasons. You might have developed purely mental compulsions that no one can see. You might have learned to suppress or delay compulsions until you're alone, which takes an enormous amount of energy and often leads to burnout.
Because you've become so skilled at hiding, clinicians (and even you yourself) may not recognize the extent of what you're dealing with. It's honestly impressive in a deeply exhausting way.
Different Presentation of OCD Themes
The content of OCD obsessions can look different in autistic individuals. While anyone can experience any OCD theme, autistic women often experience obsessions related to:
Social interactions (replaying conversations, worrying about having offended someone, seeking reassurance about social performance)
"Just right" feelings (things needing to feel complete, balanced, or symmetrical in ways that go beyond autistic preference into OCD territory)
Contamination fears that may be tangled up with sensory sensitivities
Harm obsessions that may be more focused on accidentally causing harm through social missteps or misunderstandings
Moral scrupulosity and excessive worry about being a "good person"
These themes don't always fit the stereotypical portrayals of OCD (excessive handwashing, checking stoves), so they're easily dismissed or misattributed.
Alexithymia and Interoception Challenges
Many autistic individuals experience alexithymia (difficulty identifying and describing emotions) and interoceptive differences (difficulty sensing internal body states). This can make it harder to recognize and communicate the internal experience of OCD.
You might know that something feels "wrong" or "off" but struggle to articulate that you're experiencing intrusive thoughts and the overwhelming urge to neutralize them. Without the language to describe your internal experience, OCD can remain hidden even from yourself.
The AuDHD Factor: When ADHD Adds Another Layer
I want to take a moment to address something I see frequently in my practice: the intersection of autism, ADHD, and OCD. If you're AuDHD (both autistic and ADHD), the picture becomes even more complex. Because apparently your brain decided one form of neurodivergence wasn't enough of an adventure.
ADHD can influence how OCD manifests in several ways:
Impulsivity may affect compulsions. You might act on compulsions more quickly and impulsively, or you might have learned to suppress them, leading to a buildup of anxiety.
Attention patterns interact with obsessions. Hyperfocus might latch onto obsessive thoughts, or distractibility might provide temporary relief that then feeds the OCD cycle.
Executive function challenges create internal conflict. Difficulty with organization and routines (common in ADHD) combined with rigid needs for routine (common in autism and OCD) can feel like your brain is arguing with itself.
Rejection Sensitive Dysphoria (RSD) adds fuel to the fire. The intense emotional response to perceived rejection common in ADHD can fuel social OCD themes.
Understanding how all three conditions interact is essential for effective treatment. A one-dimensional approach that only addresses one aspect of your neurotype is unlikely to provide lasting relief.
What Happens When OCD Goes Untreated in Autistic Women
Before we talk about treatment, I want to acknowledge what's at stake. Untreated OCD doesn't just stay static. It tends to grow. And when you're already managing the demands of being autistic in a neurotypical world, adding untreated OCD to the mix can lead to some real challenges.
Increased Masking and Burnout
If you're spending mental energy suppressing compulsions on top of masking autistic traits, you're operating at a significant deficit. This is exhausting and unsustainable. Many autistic women with unrecognized OCD experience severe burnout without understanding why their capacity keeps shrinking. You're not lazy or weak. You're running multiple demanding programs in the background all day long.
Misattribution and Self-Blame
Without understanding that OCD is a separate condition that responds to specific treatment, you might blame yourself for not being able to "just stop" your compulsive behaviors. You might see yourself as weak, irrational, or fundamentally flawed. This self-blame compounds the distress and makes it harder to seek appropriate help.
Generalization of OCD Themes
OCD is opportunistic. When left untreated, it often expands into new areas of your life. What started as one specific obsession can grow into multiple themes, affecting more and more of your daily functioning.
Impact on Autistic Needs
Here's something particularly cruel: OCD can hijack the very things that help you regulate as an autistic person. Your safe routines become contaminated by compulsions. Your special interests become sites of obsessive doubt. Your need for certainty gets exploited by a disorder that can never provide true certainty. It's like OCD reads the instruction manual on what helps you cope and then systematically targets those exact things.
Finding the Right Treatment: What Actually Works for OCD in Autistic Women
Now for the hopeful part: OCD is highly treatable. The gold standard treatments, Exposure and Response Prevention (ERP) and Inference-based Cognitive Behavioral Therapy (I-CBT), can be remarkably effective, even when you've been struggling for years.
But here's what I want to emphasize: treatment needs to be adapted for your neurodivergent brain. A cookie-cutter approach that doesn't account for your autism is unlikely to work and may even cause harm.
Exposure and Response Prevention (ERP)
ERP is the most well-researched and effective treatment for OCD. It involves gradually facing the situations that trigger your obsessions while resisting the urge to perform compulsions. Over time, your brain learns that the feared outcomes don't happen (or that you can tolerate the uncertainty), and the obsessions lose their power.
For autistic individuals, ERP needs to be thoughtfully adapted:
Clear, concrete explanations. Understanding the rationale behind ERP is essential. I take time to explain exactly how and why this approach works, because autistic individuals often need to understand the "why" before engaging. No vague hand-waving here.
Collaborative hierarchy building. We work together to identify exposures that are challenging but not overwhelming, respecting your sensory needs and capacity.
Distinguishing OCD from autism. We carefully differentiate between OCD compulsions (which we work to reduce) and autistic accommodations and stims (which we protect and support). This distinction is crucial.
Flexibility within structure. ERP has a clear structure, which can be helpful for autistic individuals. At the same time, I adapt the approach to your specific needs, communication style, and pace.
Inference-based Cognitive Behavioral Therapy (I-CBT)
I-CBT is a newer approach that's particularly useful when obsessions are driven by distrust of the senses and over-reliance on imagination. Instead of focusing primarily on behavioral exposures, I-CBT addresses the reasoning processes that generate obsessive doubt.
This approach can be especially helpful for autistic individuals because:
It takes seriously your internal experience and the logic of your obsessions
It doesn't require you to simply "accept uncertainty" (which can feel invalidating)
It helps you reconnect with your senses and direct experience
It addresses the "what if" reasoning that fuels OCD
For many of the autistic women I work with, a combination of ERP and I-CBT provides the most comprehensive treatment.
What to Look for in a Provider
If you're seeking treatment for OCD as an autistic woman, here are some things to consider:
Expertise in both OCD and autism. These are both specialized areas. A provider who understands OCD but not autism may inadvertently try to eliminate helpful autistic routines. A provider who understands autism but not OCD may not be able to provide effective OCD treatment. Look for someone with genuine expertise in both.
Neurodivergent-affirming approach. This means the provider sees your autism as a difference, not a deficit. They should understand masking, support your authentic self-expression, and adapt their communication style to work for you.
Willingness to collaborate. Good treatment is collaborative. You should feel like a partner in the process, not a passive recipient of interventions.
Flexibility in approach. While ERP has a general structure, it should be adapted to your specific needs, pace, and goals. Rigid adherence to protocols without considering your individual presentation is a red flag.
Moving Forward: You Deserve Treatment That Actually Works
If you've made it this far, I want you to know something: the fact that your OCD was missed for years (or decades) is not a reflection of your intelligence or self-awareness. The overlap between autism and OCD is genuinely confusing, and the mental health system is not well-equipped to recognize neurodivergent presentations of OCD.
But now that you're starting to understand what's happening, you can seek treatment that addresses the full picture of who you are.
Here's what I believe: you shouldn't have to keep managing this on your own. You shouldn't have to white-knuckle your way through intrusive thoughts while also navigating a world that wasn't designed for your brain. And you definitely shouldn't have to accept the message that your struggles are just "who you are" and nothing can be done.
Effective treatment exists. It may look different than what you've tried before, and it absolutely needs to account for your autism, but it can help.
Taking the Next Step
If what I've described resonates with you, I invite you to reach out. I offer a free 15-minute consultation where we can talk about what you're experiencing and whether my approach might be a good fit. I work with clients throughout Oregon and Washington via online sessions, and I specialize in exactly this intersection of autism, ADHD, and OCD.
You've spent enough time trying to figure this out alone. You've masked and adapted and pushed through. And you've probably been told in various ways that your struggles aren't "that bad" or that you should be grateful for how "high-functioning" you are.
I'm here to tell you that your experience is valid, your struggles are real, and specialized treatment can make a genuine difference. Not to make you "normal" or to eliminate your autistic traits, but to free you from the OCD cycle so you can live more fully as yourself.
Ready to learn more? Contact me to schedule a free consultation and let's talk about what support could look like for you.