Abstract
Autism and obsessive-compulsive disorder (OCD) share clinical and behavioural similarities, including engagement in repetitive behaviours. Due to their high co-occurrence and similarities in observable behaviours, it can be challenging to differentiate between the restricted and repetitive behaviours and interests (RRBIs) characteristic of autism and the compulsive behaviours attributable to OCD. This study explored the lived experiences of repetitive behaviours in autism and OCD to improve differential diagnosis and inform appropriate supports. Semi-structured interviews were conducted with 21 participants: 7 autistic adults, 7 adults with OCD, and 7 with both diagnoses. Participants discussed the motivations and functions of their repetitive behaviours and, for participants with both diagnoses, how they differentiated between autism-related RRBIs and OCD-related compulsions. Thematic analysis identified three key differences: (1) ego-syntonic versus ego-dystonic experiences, (2) the differing role of anxiety, and (3) differences in the urgency associated with the behaviour. Autistic individuals viewed RRBIs as enjoyable and stress-relieving, while those with OCD found compulsions distressing and anxiety-inducing. Autistic participants could manage the discomfort of suppressing RRBIs, but OCD sufferers found the urge to complete compulsions overwhelming. These findings underscore the importance of understanding and distinguishing between different forms of repetitive behaviour to support accurate diagnosis and tailored intervention.
Lay Abstract
Autism and obsessive-compulsive disorder (OCD) can look similar because both involve repetitive behaviours, which make it difficult to tell them apart. This study explored how people with autism, OCD, or both conditions experience these behaviours in their daily lives. Researchers interviewed 21 adults (7 autistic adults, 7 with OCD, and 7 with both diagnoses) to understand what these behaviours feel like, why they happen, and how they are managed.
The study found three key differences between autism-related behaviours and OCD compulsions:
How the behaviours feel: Autistic people often enjoy their repetitive behaviours and find them calming, while people with OCD find their compulsions upsetting and stressful. The role of anxiety: OCD compulsions are often driven by anxiety and a need to prevent something bad from happening. In contrast, autism-related behaviours are usually not driven by fear or anxiety. Urgency of the behaviours: Autistic people can often choose whether or not to do their repetitive behaviours, even if it's uncomfortable to stop. People with OCD, however, feel a strong urge to complete their compulsions and find it very hard to resist. Importantly to note, urgency is in the opposite direction to helpfulness. While urgent in people with OCD, engagement is ultimately unhelpful. In contrast for autistic people, suppression may be ultimately unhelpful long-term with harm associated with masking or camouflaging autistic repetitive behaviours.
These insights can help health professionals better understand the differences between autism and OCD, leading to more accurate diagnoses and better support for each person. The findings also show the need for more research that includes a wider range of people and experiences. This should involve studies that continue to explore people's personal perspectives in depth, as well as larger studies that examine how different types of repetitive behaviours overlap and how they affect wellbeing and daily life.
Background
Autism and obsessive-compulsive disorder (OCD) share similar clinical and behavioural features, and each includes forms of repetitive behaviour as part of their diagnostic criteria (APA, 2022). Given the high levels of co-occurrence between autism and OCD, and similarities in behavioural presentations, it can be difficult to differentiate between repetitive behaviours attributable to autism (i.e., restricted and repetitive behaviours and interests [RRBIs]) and those attributable to OCD (i.e., compulsions) (Guertin et al., 2022; Jiujias et al., 2017). While a wealth of research has explored repetitive behavioural presentations within each condition, there is comparatively little research aimed at differentiating these behaviours between conditions in terms of the underlying motivations, experiences, and differential outcomes associated with engaging in repetitive behaviours (De Caluwé et al., 2020). This is important as, without a clear understanding of the function of different repetitive behaviours, traditional interventions aimed at reducing these behaviours may have deleterious effects on the quality of life of people who engage in repetitive behaviours for protective, restorative, or self-regulatory purposes (Collis et al., 2022; Harrop et al., 2019).
RRBIs are a core feature of autism, comprised of a heterogenous list of behaviours broadly organised into four distinct sub-categories: (1) stereotyped or repetitive behaviours, (2) insistence on sameness/ritualistic behaviours, (3) restricted or circumscribed interests, and (4) sensory hyper- or hypo-reactivity and/or sensory pre-occupations (APA, 2022). Some of these behaviours, such as repetitive motor behaviours or sensory pre-occupations are referred to within the autistic community as ‘stimming’ (i.e., self-stimulatory behaviours) or ‘glimmers’ (i.e., sensory occurrences that resonate intensely with autistic people). Autism frequently co-occurs with psychiatric conditions such as anxiety disorders (40–85%) (Amend, 2018; Amend & Beljan, 2009; Assouline et al., 2010; Zaboski & Storch, 2018) and OCD (17–37%; Leyfer et al., 2006; Reaven & Blakeley-Smith, 2013), which can make differential versus co-occurring diagnosis challenging, particularly in the case of OCD where repetitive behaviour may present as outwardly similar (O’Loghlen et al., 2025).
OCD is a psychiatric disorder characterised by the presence of ego-dystonic obsessions (i.e., intrusive/unwanted recurrent and persistent thoughts, urges, or images) and/or compulsions (i.e., repetitive behaviours or mental acts that a person feels driven to perform) (APA, 2022). Diagnosis may be characterised by the presence of ‘pure’ obsessions (e.g., persistent fears of harming yourself, a loved one, or a stranger), or, more often, a combination of obsessive and compulsive symptoms (e.g., an obsessive fear of contamination and compulsive washing) (APA, 2022). However, recent research suggests that OCD diagnoses pertaining to “pure” obsessions are unlikely, as patients who do not display overt (motor) compulsions will still often experience covert (mental; e.g., counting) compulsions in response to obsessive symptoms (Fontenelle, 2022).
Symptoms of anxiety are often associated with both RRBIs and compulsions. In OCD, anxiety plays a direct and significant role in the manifestation of core obsessive and/or compulsive symptoms (APA, 2022). Jiujias et al. (2017) acknowledged the dual, cyclic role of anxiety in OCD, wherein obsessions cause anxiety and compulsions alleviate anxiety. Despite the brief relief experienced by engaging in compulsive behaviours, the outcomes associated with engaging in compulsive behaviour in the context of OCD are fundamentally negative and distressing (Coughtrey et al., 2012; Keyes et al., 2018). Cognitive models of OCD support this summation, positing that maladaptive interpretations of intrusive thoughts (obsessions) trigger anxiety, which in turn drive engagement in compulsions aimed at neutralising perceived threats associated with these ego-dystonic cognitions. While compulsions provide temporary relief, they prevent disconfirmation of dysfunctional beliefs, reinforcing obsessional thinking and ultimately increasing anxiety over time, perpetuating more frequent and more intense engagement in compulsions (Rachman, 1998; Salkovskis, 1985).
High correlations between anxiety and RRBI intensity are likewise found in autistic people, with greater anxiety symptoms associated with more intense RRBI engagement (Spiker et al., 2012). Yet, in contrast to people with OCD, autistic people frequently characterise engaging in RRBIs as positive, functional, and/or beneficial (Collis et al., 2022; Harrop et al., 2019; Manor-Binyamini & Schreiber-Divon, 2019). In line with this, a recent scoping review of the functions of RRBIs in autism highlighted the adaptive functions of these behaviours for autistic people, including regulation of sensory experiences and supporting greater coping (Lung et al., 2024). That RRBIs are used by many autistic people as a mechanism for achieving self-regulation and comfort (Collis et al., 2022) or coping with, and counteracting distress (Manor-Binyamini & Schreiber-Divon, 2019), suggests different outcomes of engaging in repetitive behaviours in autism versus OCD. For autistic people, RRBIs may have a soothing or regulatory effect in the face of anxiety or distress, whereas in OCD, anxiety exists in a negatively reinforced cycle which is associated with worsening severity of anxiety as well as worsening of compulsions over time (Wairauch et al., 2024).
Qualitative research further indicates differences in the experience of engaging in repetitive behaviour for autistic people compared to people with OCD, and key differences in how different behaviours support or impact upon function. Autistic adults have reported that engaging in RRBIs improves their ability to function or cope with daily demands, assists with emotion regulation, alleviates stress and tensions, and fosters enjoyment and comfort (Collis et al., 2022; Manor-Binyamini & Schreiber-Divon, 2019). These findings indicate the important functional role that RRBIs can play for many autistic people, and can often represent an important mechanism for self-regulation and coping (Manor-Binyamini & Schreiber-Divon, 2019). In contrast, a smaller body of research suggests that, for some autistic people, RRBIs can also be associated with psychological distress (Istvan et al., 2020; Joyce et al., 2017) and poorer adaptive functioning (Hong & Matson, 2021).
In contrast to research emphasising the adaptive benefits of RRBIs for autistic people, qualitative accounts of repetitive behaviours in OCD are typically associated with escalating anxiety and distress, with compulsions primarily serving the function of neutralising discomfort provoked by obsessions (Coughtrey et al., 2012; Keyes et al., 2018; Mulhall et al., 2019). Engagement in compulsive behaviours is often driven by a need to ‘feel just right’, which is a short-lived experience followed by feelings of frustration, anger, and despair (Keyes et al., 2018). Exploratory studies aimed at understanding the development of OCD amongst adults with OCD posit that the condition may manifest as a coping mechanism following trauma or intense emotional suffering, wherein engagement in obsessive-compulsive behaviours enables people to achieve a brief sense of comfort and control (Håland et al., 2019). In line with this, others have posited that intolerance of uncertainty may play a central role in the onset and maintenance of OCD, with people often displaying a pronounced aversion to uncertainty or unpredictably, which can trigger a perceived loss of control and increase reliance on compulsive rituals to restore a sense of order (Tolin et al., 2003). Clinical observations similarly indicate that heightened uncertainty amplifies anxiety and the need for control, leading to more frequent or rigid compulsive behaviours (Grayson, 2010). In either case, completing a compulsion may offer a fleeting increase in perceived control and a reduction in feelings of uncertainty, though such benefits are typically short-lived and associated with a return of anxiety that becomes more intense over time, leading also to an increased reliance on compulsions over time. Overall, this body of research indicates that anxiety is associated with repetitive behaviours in both conditions, though these behaviours oftentimes result in opposite outcomes in the medium to long term: they tend to reduce anxiety in autism and increase anxiety in OCD. Thus, repetitive behaviours may be viewed as adaptive in autism but maladaptive in OCD.
Previous research has not directly compared experiences of repetitive behaviours between diagnostic groups; one study has explored experiences of repetitive behaviours for autistic people with co-occurring obsessive-compulsive features. Long et al. (2024) interviewed 15 autistic adults experiencing both obsessive-compulsive disorder symptoms and RRBIs, identifying three ways in which autistic adults understood similarities and differences between RRBIs and OCD symptoms. First, RRBIs were recognised by participants as intrinsic to their identity and useful for managing anxiety, whereas obsessive-compulsive behaviours were inherently incongruent with identity, unwanted, and a cause and perpetuator of anxiety. Second, participants described a relationship between RRBIs and compulsive behaviours wherein OCD negatively impacted RRBIs, intensifying rigid and routine behaviours to the point of uncontrollability, and feeding off focused interests leading to less enjoyment and greater fixation and disruption to daily life. Finally, participants reported masking as a shared process for both RRBIs and compulsive behaviours, albeit with different methods and motivations.
Clinically, differentiating between repetitive behaviours associated with autism and those arising from OCD are essential for accurate diagnosis, effective support, and targeted intervention, not only for clinicians but also for educators, families, and the people themselves. Failure to distinguish and disentangle these behaviours can lead to misdiagnosis and subsequent harmful interventions (e.g., encouraging suppression of adaptive RRBIs in autistic people). Understanding these distinctions through the lens of lived experience ensures that interventions are both relevant and respectful, providing practical guidance for real-world applications and supporting the overarching aim of research to explore how people experience and make sense of their repetitive behaviours to inform more accurate assessment and responsive support.
While autistic people and people with OCD can show behaviours that look similar, research to date suggests different functions and experiences. However, there is an important gap wherein experiences between autistic people, people with OCD, and those with co-occurring experience of both conditions, have not been compared in a single study. This is vital to enable direct comparisons and to contrast the experiences of those people with one or the other condition, with the experiences of those who experience both types of behaviour. The differential role of anxiety in the manifestation of RRBIs in autism versus obsessive-compulsive behaviours emphasises the degree to which the formulation and function of these behaviours can differ. In instances of co-occurring diagnosis (i.e., autism and OCD), differentiating the underlying function of different types of repetitive behaviours appears especially challenging, and up to this point has not been explicitly explored. Research that emphasises lived transdiagnostic experience offers another important lens through which clinicians can clarify repetitive behavioural functions and, in turn, improve decision-making regarding supports and interventions for these people.
Thus, the aim of this qualitative study is to explore the factors that differentiate RRBIs in autism from compulsive behaviours in OCD, from the lived-experience perspectives of autistic people, people with OCD, and those with co-occurring diagnoses (i.e., autism and OCD). Interviews are aimed at understanding differences in experiences of, motivations for, and/or functions associated with these different types of repetitive behaviours. This study will explore particularly how people with co-occurring diagnoses differentiate between their own experiences of RRBIs (specific to autism) and obsessive-compulsive behaviours (specific to OCD). Understanding how to differentiate is essential to diagnosis, formulation, and targeted supports that lead to better outcomes for people with either or both conditions.
Methods
Study Design and Participants
We used a qualitative design with a pre-cursory online survey, collecting demographic and quantitative data on RRBIs, OCD features, and autism traits before the interview. We used this subjective descriptive data to inform interviews as per Collis et al. (2022). Questions were neutral and open-ended to ensure authentic, unbiased participant responses, free from assumptions or leading.
Inclusion criteria were English-speaking adults (aged 18 + years of age), with a diagnosis (formal or self-identified) of autism, OCD, or both conditions. Diagnoses were confirmed only via self-report, with 13 reporting formal diagnosis and one being self-identified as autistic. This participant was included on the basis of obtaining a clinically significantly cut-off score on the AQ-10 and reporting a variety of repetitive behaviours consistent with the experiences of other autistic participants. Exclusion criteria were people with an intellectual disability or co-occurring psychiatric condition (e.g., psychosis) which would inhibit their ability to comprehend and/or respond during a semi-structured interview. We recruited a convenience sample of participants via a series of social media advertising campaigns posted to target groups on Facebook, X, and Reddit. To mitigate non-genuine respondents (e.g., bots), survey links were not publicly distributed. Instead, prospective participants were asked to electronically contact the research team and were subsequently screened, and where appropriate privately sent the study link. Participants were each compensated for their participation with an e-gift card equivalent to $20 (Australian Dollars; AUD).
The final sample included 21 participants who completed the online survey and interview components of the study, including seven participants with co-occurring diagnoses (i.e., autism and OCD), seven autistic participants, and seven participants with OCD. Total scores for each group on measures of RRBIs (RBQ-2A), obsessive-compulsive symptomology (OCI-R), and autistic traits (AQ-10) are outlined in Table 1.
Total Scores on Measures of Repetitive Behaviour and Autistic Traits.
Demographic characteristics of the individual participants are outlined in Table 2. Four additional participants (autism and OCD n = 1; autism only n = 2; OCD only n = 1) completed the online survey and were contacted for an interview, but subsequently did not respond and were withdrawn.
Participant Demographics.
*Self-identified diagnosis.
Materials
Pre-Interview Online Questionnaires
Interview Schedule
The interview schedule was adapted from Collis et al. (2022) (see Appendix A). Participants completed a semi-structured interview on their RRBIs/compulsions, exploring type, frequency, motivations, experiences, and psychological impacts. Wording was tailored to each individual's behaviours.
Procedure
We pilot tested the online questionnaire and interview schedule with two volunteers with lived experiences of repetitive behaviours (one autistic adult and one adult with OCD) prior to data collection to refine and confirm the appropriateness of the wording. No changes were indicated.
Participants completed online questionnaires on RRBIs, OCD symptoms, autism traits, and demographics. Interviews were offered via Microsoft Teams or written responses, with schedules provided in advance, which has been indicated in previous research as a helpful approach for engaging with autistic people in qualitative research (Howard et al., 2019). We conducted 12 online interviews, adjusting conditions to suit sensory preferences (e.g., individualising sound and lighting preferences, inviting participants to choose if they engaged with their cameras on or off to support preferences for interaction). Interviews were transcribed (via Microsoft Teams live transcription), edited, and returned for participant review. Aggregated results and themes were also shared, with no feedback received.
Analyses
We analysed the interview data via reflexive thematic analysis (Braun & Clarke, 2006; Braun & Clarke, 2019; Terry et al., 2017). This allowed the experiences of each participant to drive the analysis and interpretation of these data. This process was guided by the six phases of thematic analysis originally outlined by Braun and Clarke (2006). Analysis was supported by the software package NVivo. Critical to adopting a reflexive methodology is acknowledging that deducing meaningful information from qualitative research is inherently contextual, grounded in personal circumstance, perception, and interpretation (Braun & Clarke, 2019). Reflexive analysis prioritises participants’ unique experience and context, aligning with the study's objectives. It encourages awareness of potential biases in interpreting data, fostering critical, deliberate analysis. Authors actively questioned their assumptions during thematic analysis, particularly as non-autistic interpreters, ensuring more accurate and reflexive theme validation through participant feedback.
Community Involvement and Author Positionality
We conducted this research with an emphasis on transparency, reproducibility, and inclusive practice. This included pre-registering the project on the Open Science Framework (OSF; Link: osf.io/5z8ur). Our project conception and focus on mental health were informed by mental health being a high priority area for autistic people in community priority setting studies (Roche et al., 2021) and drew from clinical and lived experience. While no authors identify as autistic, all have worked closely with autistic people and people with OCD including three authors as clinical psychologists and one as a research psychologist. Further, we consulted with two volunteers with lived experience of repetitive behaviours (one autistic adult and one adult with OCD) to ensure that the project materials were accessible and appropriate for use with these two groups. Author 1, who conducted interviews and analysis, is a postgraduate provisionally registered psychologist who identifies as a White, non-autistic female and drew from discussions with the broader research team that includes more diverse ethnicities, genders, socioeconomic statuses, and experiences to regularly question and consider the impact of positionality on interpretation of findings and conclusions drawn.
Results
Participants identified three overarching themes that differentiating their experiences of RRBIs from compulsions: the ego-syntonic versus ego-dystonic nature of the experience, the differing role of anxiety, and differences in the urgency associated with the behaviour.
Theme 1. The Ego-Syntonic Nature of RRBIs Versus the Ego-Dystonic Nature of Compulsions
A key factor differentiating RRBIs from compulsions was the way in which RRBIs were described by participants as ego-syntonic (i.e., in harmony with the person's sense of self and personal identity), while compulsions were described as ego-dystonic (i.e., unwanted, intrusive, and not aligned with the person's sense of self). Sophie, a participant with co-occurring diagnoses, explained, “My autistic behaviours feel like me, like home. The OCD ones feel like someone else, like an enemy within.” Regina, another participant with co-occurring conditions, also clarified, “I want to stop more doing the OCD behaviours whereas, because the autism ones are more of a comfort instead of a compulsion, it's not like it's coming from a bad place.”
Autistic participants corroborated this same ego-syntonic experience of RRBIs, reporting that their repetitive behaviours formed a part of who they are, and that these behaviours were automatic, and felt natural and welcomed. Keelan explained, “They make me feel better and stuff, so I don't think they’re something I really think about. It's more like a built-in sort of behaviour. It's just something I do.” Selena explained, “I don’t do any of these things because I feel something outside me is compelling me.”
In addition to the ego-syntonic experience of RRBIs, many participants acknowledged that engaging in RRBIs felt good and represented a source of pleasure and joy in their lives: In regards to the rearranging of things, repeating of sound bites, mouth noises and the hand stuff, it's…like soothing ruffled feathers or combing the fur of cats – there's like an indescribable feeling of satisfaction and happiness. It's like running one's hands over one's goosebumps. Or scratching that itch. Or the number 16 and 42. – Cynthia (autistic participant)
Others acknowledged the ways in which different types of RRBIs serviced different needs, “Physical stims feel good physically and [re-]reading feels good emotionally” (Shae, an autistic participant).
In comparison, participants with OCD experienced compulsions as wholly ego-dystonic and typically associated with negative emotions. Chloe explained, “There's no enjoyment at all… it feels like something I have to do… it's a lot of anxiety which fuels anger, which also it could just be me feeling extremely bad or guilty that I've allowed something to happen as well.” Wendy, a participant with co-occurring diagnoses, also acknowledged, “I don’t enjoy these behaviours [compulsions] but I feel I have to do it. If I knew how to stop… I would have done so by now.”
Theme 2. The Differing Role of Anxiety
Anxiety was a common factor associated with engagement in repetitive behaviours. However, anxiety played a different role depending on whether the associated repetitive behaviour was attributed to autism or OCD. For autistic participants, episodes of anxiety were often soothed or regulated by RRBIs, with participants describing the protective use of RRBIs in environments that evoked anxious or uncomfortable feelings. In this way, RRBIs were reported to be extremely beneficial, and supported autistic participants to soothe, relax, and cope without getting “lost in the internal turmoil” (Cynthia, an autistic participant). Participants with co-occurring diagnoses also reported that the repetitive behaviours they attributed to autism could serve several adaptive functions: Sometimes I’m calmed by doing the behaviours. Sometimes I am energised by doing the behaviours. Sometimes I am focussed by doing the behaviours… If I’m in an environment which is sensorily overwhelming I will engage in the behaviours to try to reduce sensory stimuli. Like listening to the same song over and over again. Listening to music blocks out other noises which are overwhelming. Specifically listening to the same song adds a sense of predictability and can regulate my distressed nervous system. – Sophie (participant with co-occurring diagnoses)
Participants with OCD reported a similar motivation to engage in compulsive behaviours in attempts to reduce anxiety. Shane, a participant with co-occurring diagnoses, reported a clear distinction between RRBIs and compulsions based on the presence of fear and anxiety: “Any behaviour that I’m doing to reduce a feeling of anxiety or fear or some other feeling I don’t think I will be able to handle, I attribute to OCD.” This was corroborated by Emery, who has OCD, who explained, “[The behaviours] are a response to anxiety that otherwise feels world-ending. They feel like the only thing standing between me and immense hurt or disaster in my life.” However, compulsions did not provide the same sense of comfort and regulation as autistic RRBIs, and more often perpetuated further anxiety and distress for participants with OCD: The longer a compulsion happens, the more worried, tense, and frantic I am. During long sets of compulsions, for example, I often notice my core tenses, it almost feels like my heart drops into my stomach. Whether this is an anxiety response or more of a “oh no, not this again” kind of response, I’m uncertain. Sometimes I notice my throat getting dry and muscles in my throat tense as though I am about to start hyperventilating – Emery (participant with OCD)
Theme 3. The Urgency of the Behaviour
While both autism-related and OCD-related behaviours were often associated with a certain degree of urgency, autistic participants frequently reported it was much easier to suppress their performance of RRBIs when/if needed, compared to participants with OCD, who reported compulsions to be all-consuming, as well as an inability to complete activities of daily living or work tasks if compulsions were left undone or incomplete. Autistic participants reported that cessation or an inability to engage in RRBIs could lead to feelings of sadness, disappointment, annoyance, or resentment, but that generally they were able to manage these feelings. For example, Selena explained, “if someone told me to stop it, I’ll be a bit sad, a little miffed, but I will try to stop it. It just feels like something has been taken away from me.” Craig, a participant with co-occurring conditions, agreed, “[stopping the RRBI] can also cause stress, but I think not so much like engaging into a compulsion. It's more manageable for me.” Shae also acknowledged: “I do not feel like anything bad will happen if I don’t do it… I will feel upset and resentful about being interrupted or if I need to do other things and can’t engage with them; but I do not feel bad or scared that I have missed out on doing them, I am simply eager to return to them.”
Importantly, while withdrawal from RRBIs was tolerable, it was equally apparent that removal of these behaviours was still associated with poorer well-being amongst autistic participants, highlighting again the important adaptive and protective function these behaviours appeared to serve for autistic people. One participant with co-occurring diagnoses explained the negative consequences of not being able to engage in RRBIs when being treated for her OCD: But the problem is that early on, when I was sort of in more intensive treatment with my OCD, some of the behaviours got confused and overlapped… I would have to resist every single time. But sometimes it was coming from a different place [in reference to RRBIs] and we couldn't really recognise […] where it was actually coming from. So sometimes it was actually more harmful and caused a lot more anxiety and overwhelming panic episodes and panic attacks. – Regina (participant with co-occurring diagnoses) Sometimes it feels like an itch you can't scratch, like it's just there and wrong and it just has to be fixed. It has to be itched and that's why it's such a compulsion, because I can try it – like if I get the thought I can sort of try and be like ‘no, I know that like I don't need to do it’, but then it's like, ‘no, I just, I have to do it’. – Regina (participant with co-occurring diagnoses)
Another participant with OCD corroborated this urgent and uncomfortable experience when compulsions were interrupted: When a compulsion is disrupted, it's like the anxiety balloons back to pre-compulsion levels. I’ve sometimes felt like it's a struggle to breathe, like my airway is tightening due to anxiety… that ‘almost-a-panic-attack’ type response. There's a feeling of my skin crawling. My hands feel mildly tingly. It's like my fingers feel the need to move in order to release the pent-up anxiety-energy, but also as though doing anything other than the compulsion won’t be a sufficient release of that anxious energy. Sometimes I find myself clenching and unclenching my hands as, especially with more intense compulsions, my body seems shaky. It's as though that's an inefficient way of releasing that anxious energy caused by the obsessive thoughts. That energy needs another way out, but nothing else feels right. I feel jittery, shaky, and as the compulsions are pushed off more, the obsessive thoughts speed up like the whirlpool of water circling a drain. – Emery (participant with OCD)
This theme highlights a clear distinction between RRBIs and compulsions, in that, for repetitive behaviours which enabled a sense of pleasure or provided positive/adaptive support (i.e., RRBIs), distance from these is tolerable, albeit with some discomfort or dysregulation. In contrast, reported experiences of compulsions indicated that functioning without attending to compulsions was near impossible and led to extreme levels of distress and disruption in participants’ daily lives. This theme raises important questions regarding the extent to which autistic people, as opposed to those with OCD, should suppress their behaviours, and the potential long-term implications of doing so. For participants with OCD, many acknowledged that it is constructive for them to be able to resist compulsions, despite it being extremely difficult. For autistic participants, it was manageable to resist RRBIs, but not necessarily constructive, and potentially even harmful in the long term.
Discussion
Using a qualitative approach, we explored the factors that differentiate RRBIs in autism from compulsive behaviours in OCD based on the lived experiences of participants with one or both conditions. Thematic analysis of participants’ responses identified three key factors differentiating experiences of autism-specific repetitive behaviours (RRBIs) from compulsive behaviours in OCD. These were (1) the ego-syntonic versus ego-dystonic experience of the behaviour, (2) the differing role of anxiety, and (3) differences in the urgency associated with the behaviour. From these findings, key experiential differences, and important clinical considerations including the need to accurately distinguish harmful repetitive behaviours from those that are adaptive are discussed. Collectively, these findings underscore the importance of carefully assessing the function of repetitive behaviours when conducting diagnostic assessments and implementing interventions. For people with co-occurring autism and OCD, clearly distinguishing between RRBIs and compulsions is especially vital to prevent the unintentional suppression of behaviours that aid self-regulation, while ensuring that interventions effectively target repetitive behaviours linked to the anxiety cycle of OCD. Overall, the results support the need for individualised and nuanced treatment approaches that target anxiety cycles without compromising the well-being afforded by adaptive forms of repetitive behaviour.
Ego-Syntonic Versus Ego-Dystonic Experiences of Behaviour
A primary distinction identified by autistic participants was that RRBIs were experienced as ego-syntonic, meaning they were experienced as a natural and fundamental part of the person's identity, providing comfort and pleasure. In contrast, compulsions attributed to OCD were described as ego-dystonic – unwanted, intrusive, and anxiety-driven – echoing the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (APA, 2022). These contrasting experiences mirror the findings of Long et al. (2024), wherein autistic participants with obsessive-compulsive features identified RRBIs as “a part of me” and OCD as an “internal intruder” (p.2901). This distinction appears to play a central role in differentiating autism- and OCD-related repetitive behaviours and should be carefully assessed when evaluating potential differential diagnoses. In instances where repetitive behaviour is present, considering the immediate and longer-term emotional outcome of engaging in the behaviour (e.g., pleasure/ satisfaction versus relief immediately, and regulation versus fear/anxiety/despair in the longer term) may provide insights for differential diagnosis and formulation. The results of this and previous research indicate that OCD is inherently intrusive and distressing (Keyes et al., 2018; Long et al., 2024; Wairauch et al., 2024). Thus, where repetitive behaviours are not experienced with distress or as part of a clear anxiety cycle, other diagnoses – one of which may be autism – should be routinely considered when repetitive behaviours are observed.
The Differing Role of Anxiety Symptoms
While both RRBIs and compulsions were linked to anxiety symptoms, how anxiety and repetitive behaviours interacted was different based on whether those behaviours were associated with autism or OCD. For autistic people, RRBIs were often a means of self-regulation and a way to cope with overwhelming or anxiety-producing situations, providing comfort, relief, and safety, consistent with previous qualitative accounts (Collis et al., 2022; Long et al., 2024; Manor-Binyamini & Schreiber-Divon, 2019). Conversely, while compulsions were primarily driven by a similar desire to alleviate anxiety (albeit, from intrusive obsessions, rather than environmental stressors), they did not offer the same calming or protective effects as RRBIs. Rather, they often exacerbated anxiety and led to further distress, with people describing both physical and mental manifestations of tension and panic when unable to complete compulsions.
The cyclic and central role of anxiety in OCD is well recognised in theoretical models of OCD, corroborating the current findings (Citkowska-Kisielewska et al., 2020; Long et al., 2024; Wheaton et al., 2012). Functionally, compulsive behaviours in the context of OCD may fleetingly increase perceived control and reduce feelings of uncertainty in the wake of obsessional thinking, but such benefits are known to be short-lived, with anxiety returning and becoming more intense over time. The brief relief provided by completing a compulsion reinforces reliance on compulsions over time, leading to increased OCD severity (Håland et al., 2019). Thus, the distress and disruption caused by OCD can be immense, and these findings speak further to the need for timely support for these people. In contrast, the functional nature of RRBIs reported by participants in this study suggests that autistic repetitive behaviours, unlike compulsions in OCD, are not likely to be an appropriate target of interventions, and deliberate suppression of these may lead to poorer psychological outcomes.
Urgency Associated with Behaviour
Differences in the urgency associated with engaging in repetitive behaviours were also identified. For autistic people and people with OCD, disruption of repetitive behaviours was met with some degree of distress, but the intensity of this distress, and the ability to stop, differed substantially between diagnostic groups. Previous literature looking directly at the impact of resisting urges to engage in autistic repetitive behaviours is limited. Research examining social camouflaging behaviours (i.e., behaviours used in social situations to mask or compensate for autistic characteristics) indicates that resisting RRBIs is possible and even common for autistic people (Cook et al., 2022; Hull et al., 2017).
This study is perhaps the first to explore autistic people's experience of repressing these behaviours in that moment. This novel finding – that autistic people tend to tolerate removal of their RRBIs, at least in the short-term, but still experience some level of internalised distress or discomfort – is therefore important. Though suppression of RRBIs may be tolerable in the short-term, this is a form of social camouflaging and the longer-term costs of camouflaging autistic traits, including exhaustion and adverse psychological consequences, are well documented (Beck et al., 2020; Hull et al., 2017; Hull et al., 2021). This theme highlights the potential long-term implications of personally or therapeutically suppressing autistic RRBIs. For autistic participants, resisting RRBIs was described as manageable but not necessarily beneficial, often leading to negative or distressing emotions and a sense of loss, as though something meaningful had been “taken away.” In contrast, for people with OCD, resisting compulsions, although highly uncomfortable and challenging, is considered therapeutically constructive, as it disrupts the obsessive-compulsive cycle and supports the process of regaining autonomy and relief from the disorder.
Participants with OCD described a profound sense of powerlessness and an inability to resist performing repetitive behaviours. Experiences of resisting urges to complete compulsions are more available in the existent literature, given the ego-dystonic experience of these behaviours and the associated motivation to try to stop them. Aligned with the current findings, many people with OCD in previous research acknowledge a complete inability to resist compulsions alone (Keyes et al., 2018), and regular disruptions to their daily life and functioning, such as taking time away from work when urges to complete compulsions become more intense (Robinson et al., 2017). Others recount feeling as though they are a slave to their OCD, implying the helplessness and loss of control felt by people attempting to resist their compulsions (Wairauch et al., 2024). The internal conflict perpetuated by compulsions is particularly significant, as the very act of resisting compulsions is central to effective treatment approaches for OCD such as Exposure and Response Prevention (ERP) (Law & Boisseau, 2019). Consequently, this perception of being controlled by compulsions has important implications for treatment engagement and outcomes. The distress and perceived impossibility of resisting urges may reduce a person's likelihood of seeking professional support, as attempts to confront compulsions can initially intensify anxiety despite having positive functional and mental health benefits in the longer-term. Even when treatment is accessed, adherence and sustained engagement can be challenging, as therapeutic progress requires tolerating significant discomfort and refraining from compulsions that temporarily alleviate distress. Therefore, interventions must account for this perceived loss of agency, emphasising gradual exposure, strong therapeutic alliances, and motivational enhancement to improve treatment uptake and adherence for people with OCD.
Strengths, Limitations and Directions for Future Research
A key strength of this study is its explicit focus on the lived experience perspectives of autistic people and people with OCD, providing nuanced insight into how repetitive behaviours are experienced and understood from the perspective of those directly experiencing them. Incorporating first-hand accounts enhances the ecological and clinical relevance of the findings, grounding theoretical distinctions in real-world experience. Additionally, the methodological flexibility employed in this study, such as adapting data collection approaches to improve accessibility, further strengthens the work by ensuring that participation was inclusive and reflective of diverse communication needs.
An important limitation to acknowledge is the positionality of the authorship team and the interviewer, which may have impacted the data collected and the interpretation of the results. For example, interviews were conducted by a non-autistic researcher which may have influenced how autistic participants engaged in the research process. Participants may have been more likely to employ social camouflaging behaviours when interacting with someone with a different neurotype (Cage & Troxell-Whitman, 2019; Cook et al., 2021). However, to minimise the risks of participants feeling compelled to camouflage, the researcher pilot-tested language and interview questions, used preferred language, and provided a range of communication options to provide a neurodiversity-affirming experience to facilitate comfort and authentic sharing of experiences. With reference to the validity of interpretation of the results, we also acknowledge that, while validation of the themes was sought from participants, no feedback was received. This may have been due to satisfaction with initial participation and the outcome of the findings but may also have been associated with loss of contact, disengagement, fatigue or discomfort, or competing demands. To facilitate authentic interpretations and minimise bias, interpretation was discussed with the full team who brought a range of experiences in mental health and clinical experience. Nevertheless, findings should be considered within the context of the positionality of the researchers, recognising that interpretations reflect both participant accounts and the analytical lens of the researchers.
Given the heterogeneity of repetitive behavioural presentations across autism and OCD, the current findings may not generalise to some members of the autistic and OCD communities that engage in other types of repetitive behaviours (e.g., self-injurious behaviours) which may be experienced differently and have different associated outcomes. For other common autistic repetitive behaviours that may be associated with harm (e.g., skin-picking, hair-pulling), more research into the function and impact of these behaviours is needed. Previous research has also highlighted potential overlaps and distinctions between sensory experiences and RRBIs in autism (Lung et al., 2024; Zetler et al., 2022), or the “just-right” compulsions characteristic of OCD (Ben-Sasson & Podoly, 2017; Dar et al., 2012; Ferrão et al., 2012). In both conditions, researchers have posited that some repetitive behaviours may be driven by an intrinsic need to achieve a sense of completeness, symmetry, or sensory equilibrium, thus characterised as achieving the “just-right” feeling. For autistic individuals, such behaviours frequently serve an adaptive sensory-regulatory function, helping to manage sensory overload or achieve sensory satisfaction (Lung et al., 2024). In contrast, “just-right” compulsions in OCD are typically experienced as ego-dystonic, performed to alleviate discomfort or tension arising from an internal sense that something is incomplete or imbalanced (Poletti et al., 2023). While both conditions may share a sensory component and a drive to correct perceptual or bodily unease, their underlying motivations and emotional valences likely differ based on these previous findings. Sensory phenomena was an area not explicitly explored in the current study, which may provide further insights into the nuanced differences driving engagement in repetitive behaviours across autism and OCD, warranting further targeted qualitative exploration in future research.
It is also important to acknowledge that the current sample is not representative of all autistic people or people with OCD. For example, this sample did not include autistic people with co-occurring intellectual disability or language differences. As well, most participants reported part- or full-time employment, indicating that people with more chronic or severe forms of OCD (i.e., such as those who may not be able to sustain employment due to the intensity of their experiences) were underrepresented. Underrepresentation of these groups highlights a key need for future research which incorporates the experiences of more diverse samples of autistic people and people with OCD, to ensure that findings are inclusive of and applicable to people across the full spectrum of support requirements. Greater sampling diversity may also highlight additional differences in experiences with repetitive behaviours that are not captured in the current sample. Future research with paid co-researchers with lived experience and from diverse socio-economic backgrounds may facilitate engagement of more diverse groups and further sharing of the diversity of lived experiences.
Research directly comparing experiences of repetitive behaviours in autism and OCD remains limited, and improving qualitative understanding of experiences associated with the wide range of repetitive behaviours in autism and OCD remains a priority to inform accurate diagnosis and supports. This would be complemented by quantitative studies examining overlaps in symptom expression, and outcomes associated with engaging in different repetitive behaviours. This is pertinent given the overlaps observed in quantitative scores in this study alone, highlighting the critical need to understand experience and function rather than relying on observations of behaviour alone to inform diagnosis and/or treatment. Quantitative studies would enable a greater breadth of experiences to be included through greater sampling, and in turn improve generalisability of any subsequent findings.
Implications and Conclusion
Our findings indicated, in line with a recent systematic review (O’Loghlen et al., 2025), that quantifying observable repetitive behaviours is insufficient for differentiating autism from OCD, and qualitative examination of experiences is needed for differentiation. Differentiating repetitive behaviours in these two conditions could only be accurately ascertained by gleaning the experience of the person engaging in the behaviour. An important implication of this is that the experience of repetitive behaviours must be considered when working with people presenting with repetitive behaviours. This is especially critical in cases where repetitive behaviours are the target of interventions, such as in the case of ERP for OCD (Law & Boisseau, 2019).
The concept of RRBIs as ego-syntonic and connected to personhood offers important clinical implications. For many autistic participants, when asked to consider their repetitive behaviours, responses commonly centred on the idea that engaging in RRBIs was simply a part of who I am, in the same way that many autistic people acknowledge that being autistic is a part of who they are (Bagatell, 2007; Cooper et al., 2021). In this way, RRBIs offer autistic people an opportunity to connect with their authentic selves, which is associated with better mental health and well-being (Bradley et al., 2021; Seers & Hogg, 2023). In fostering better mental health within autistic populations, it is important to acknowledge that engagement in RRBIs can be helpful and protective. For clinicians, acknowledging the protective role that RRBIs can play, and accepting and encouraging their use, is a practice in neurodiversity-affirming care (Najeeb & Quadt, 2024). These findings indicate emphatically that RRBIs such as sensory-motor self-stimulatory behaviours (e.g., rocking, spinning, flapping), repetitive vocal stimming, or engagement with focussed interests should not be the target of interventions but rather should be encouraged and leveraged for better psychological health. Unfortunately, research also continues to indicate that suppression of autistic behaviours (including RRBIs) in the form of masking is common (Cage & Troxell-Whitman, 2019; Collis et al., 2022; Cook et al., 2022; Seers & Hogg, 2023). This is an area requiring more advocacy and awareness, to ensure that autistic people have access to environments that are accepting and affirming, in which they feel comfortable to engage in RRBIs.
The current findings also offer clinical implications for supporting people with co-occurring conditions. The gold standard of treatment for OCD typically involves resisting, and ultimately eliminating, compulsive actions (i.e., ERP). For people who engage in both RRBIs and compulsions, difficulties distinguishing between the two types of behaviours can complicate this treatment. Careful consideration of the function of different repetitive behaviours is essential, so that treatment can target problem behaviours (i.e., those causing distress because of OCD) while not suppressing RRBIs which may be helpful for self-regulation. The alternative, if not correctly assessed, is simultaneous suppression of all repetitive behaviours, which may lead to worsened anxiety and other negative outcomes for autistic people being treated for OCD. Inappropriately targeting adaptive behaviours risks on-going or worsening distress and direct harms to people who rely on these behaviours for self-regulation and distress management. Understanding and appropriately differentiating repetitive behaviours in autism versus OCD is a critical aspect of safe and supportive care, which will ultimately lead to better clinical outcomes.
Supplemental Material
sj-docx-1-ndy-10.1177_27546330261417368 - Supplemental material for Exploring Repetitive Behaviours in Autism and Obsessive-Compulsive Disorder: A Qualitative Analysis
Supplemental material, sj-docx-1-ndy-10.1177_27546330261417368 for Exploring Repetitive Behaviours in Autism and Obsessive-Compulsive Disorder: A Qualitative Analysis by Jessica O’Loghlen, Matthew McKenzie, Cathryne Lang and Stephanie Malone, Jessica Paynter in Neurodiversity
Footnotes
Acknowledgements
The authors acknowledge the generous contributions of each of the people that participated in this study. They extend their sincere gratitude to these participants for contributing their expertise and experiences to this research. The authors also wish to thank the pilot testers for contributing their expertise to the refinement of this project.
Ethics & Pre-Registration
This study was pre-registered on the Open Science Framework Registry 
). Ethical approval was given by the Griffith University Human Research Ethics Committee in Queensland, Australia (GU ref no: 2023/327). All participants provided both written and verbal consent to take part in this research, and consented to its subsequent publication, prior to participation.
Authorship Confirmation Statement
All authors contributed to the conceptualisation of the project and have read the transcripts. J.O. coded the data in the initial phases, and all authors collaboratively reviewed these data and contributed to refining the final themes. J.O. wrote the first draft of the article. All authors revised, commented on, and accepted the final article. The article has been submitted solely to Autism in Adulthood.
Funding
This work was supported by the Australian Government Research Training Program (RTP) Stipend Scholarship.
Author Disclosure Statement
The authors declare that the research was conducted without any commercial or financial relationships that could potentially create a conflict of interest.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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References
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