Autistic traits and obsessive-compulsive personality traits in OCD patients

Abstract

Background
Studies have reported a high prevalence of autism spectrum disorder in young people with obsessive-compulsive disorder with a negative effect on psychosocial functioning. However, the extent to which autism spectrum disorder and obsessive-compulsive personality disorder traits overlap and by inference, the extent to which these separately classified Diagnostic and Statistical Manual of Mental Disorders disorders five (obsessive-compulsive personality disorder, personality disorder, autism spectrum disorder, neurodevelopmental disorder) may share a nosological relationship has not so far been systematically investigated in clinical samples.
This study is done to detect the frequency of obsessive-compulsive personality traits and autistic traits in a sample of patients with obsessive-compulsive disorder.

Results
Results revealed that younger patients had significantly more severe and extreme obsessive-compulsive disorder scores. Moreover, Structured Clinical Interview for DSM-IV (SCID-II) and Autism Spectrum Quotient analysis revealed that younger patients had a significantly higher prevalence of personality traits and autistic traits respectively. Statistical significance as many patients with severe and extreme Yale-Brown Obsessive-Compulsive Scale showed criteria of obsessive-compulsive personality disorder. No association of statistical significance was found between obsessive-compulsive disorder severity and autistic trait presence. On the contrary, statistical significance was found between autistic traits and obsessive-compulsive personality disorder.

Conclusions
There is the presence of comorbidity of obsessive-compulsive personality traits and autism spectrum traits in obsessive-compulsive disorder patients. Obsessive-compulsive personality traits prevalence in obsessive-compulsive disorder patients was higher than in autistic traits. Several factors of genetic predisposition, environmental factors like education and marital status, employment, and intrinsic factors as age of patients all exhibited a pivotal role in obsessive-compulsive disorder prevalence and severity.

Full text

AbdElgawadetal.
Middle East Current Psychiatry (2022) 29:45
https://doi.org/10.1186/s43045-022-00213-0
RESEARCH
Autistic traits andobsessive-compulsive
personality traits inOCD patients
A. Abd Elgawad1, A. Elbatrawy1, E. Shorub1, M. Ramadan2 and H. Elkhatib3*
Abstract
Background: Studies have reported a high prevalence of autism spectrum disorder in young people with obses-
sive-compulsive disorder with a negative effect on psychosocial functioning. However, the extent to which autism
spectrum disorder and obsessive-compulsive personality disorder traits overlap and by inference, the extent to which
these separately classified Diagnostic and Statistical Manual of Mental Disorders disorders five (obsessive-compulsive
personality disorder, personality disorder, autism spectrum disorder, neurodevelopmental disorder) may share a
nosological relationship has not so far been systematically investigated in clinical samples.
This study is done to detect the frequency of obsessive-compulsive personality traits and autistic traits in a sample of
patients with obsessive-compulsive disorder.
Results: Results revealed that younger patients had significantly more severe and extreme obsessive-compulsive
disorder scores. Moreover, Structured Clinical Interview for DSM-IV (SCID-II) and Autism Spectrum Quotient analysis
revealed that younger patients had a significantly higher prevalence of personality traits and autistic traits respec-
tively. Statistical significance as many patients with severe and extreme Yale-Brown Obsessive-Compulsive Scale
showed criteria of obsessive-compulsive personality disorder. No association of statistical significance was found
between obsessive-compulsive disorder severity and autistic trait presence. On the contrary, statistical significance
was found between autistic traits and obsessive-compulsive personality disorder.
Conclusions: There is the presence of comorbidity of obsessive-compulsive personality traits and autism spectrum
traits in obsessive-compulsive disorder patients. Obsessive-compulsive personality traits prevalence in obsessive-
compulsive disorder patients was higher than in autistic traits. Several factors of genetic predisposition, environmental
factors like education and marital status, employment, and intrinsic factors as age of patients all exhibited a pivotal
role in obsessive-compulsive disorder prevalence and severity.
Keywords: Obsessive-compulsive disorder, Yale-Brown Obsessive-compulsive Scale, Autism spectrum quotient,
Structured Clinical Interview for DSM-IV (SCID-II), Obsessive-compulsive personality, Egypt
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Background
Some behaviors associated with obsessive-compulsive
disorder such as anxiety, repetitive behaviors, and social
problems are also typical of autism spectrum disorder.
While the appearance of autism spectrum disorder and
obsessive-compulsive disorder may be similar on the sur-
face, the processes that drive these behaviors are quite
different; a common though often overlooked comorbid-
ity in treatment-seeking obsessive-compulsive disorder
patients.
ere is a high prevalence of autism spectrum disorder
in young people with obsessive-compulsive disorder with
a negative effect on psychosocial functioning as many
studies showed. However, the extent to which autism
spectrum disorder and obsessive-compulsive personal-
ity disorder traits overlap and by inference, the extent to
Open Access
Middle East Current
Psychiatry
*Correspondence: hossam.elkhateeb@must.edu.eg
3 Faculty of Medicine, Misr University for Science and Technology, October
City, Egypt
Full list of author information is available at the end of the article

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AbdElgawadetal. Middle East Current Psychiatry (2022) 29:45
which these separately classified Diagnostic and Statisti-
cal Manual of Mental Disorders disorders five disorders
(obsessive-compulsive personality disorder, personality
disorder, autism spectrum disorder, neurodevelopmen-
tal disorder) may share a nosological relationship has not
so far been systematically investigated in clinical samples
[1].
Studies suggest a possible neurodevelopmental etiol-
ogy for this comorbid subgroup. Other signs of an altered
neurodevelopmental trajectory, such as traits or symp-
toms of tic disorder, autism spectrum disorder, and atten-
tion deficit hyperactivity disorder, may also be observed
in patients with obsessive-compulsive disorder and their
family members, hinting at the possibility that heritable
neurobehavioral mechanisms contribute to the expres-
sion of at least some forms of obsessive-compulsive
disorder.
Objectives
To detect the frequency of obsessive-compulsive person-
ality traits and autistic traits in a sample of patients with
OCD attending Menoufia Mental Health and Addiction
Treatment Hospital general adult psychiatry outpatient
clinics.
Methods
Study design
is is an observational cross-sectional study.
Study place
Menoufia, Shebin Al-kum Mental Health and Addiction
Treatment Hospital general adult outpatient clinics.
Sample population
Patients diagnosed with obsessive-compulsive disorder
(OCD), attend general adult psychiatry outpatient clin-
ics in Menoufia Mental Health and Addiction Treatment
Hospital.
Sample size
Using PASS Program for sample size calculation and
assuming the proportion of OCD patients suffering
from OCPD = 30% with a 10% margin of error and at
a 90% confidence level, a sample size of 60 patients was
calculated.
Sample selection
A convenient sample of 60 patients was included in the
study. Participating patients were of both genders.
Inclusion criteria
Age was between 18 and 60 years. Patients giving con-
sent and diagnosed with OCD attending general adult
psychiatry outpatient clinics in Menoufia Mental Health
and Addiction Treatment Hospital. Both males and
females will be included.
Exclusion criteria
Patients refused to participate in the study. Known psy-
chiatric illness and substance use disorders other than
OCD. Any current chronic medical illness.
Current medication intake or a substance, e.g., corti-
sone, appetite suppressants
Assessment andprocedures
After explaining the purpose of the study, patients were
informed that participation was voluntary and that any
patient can exit from the study at any time without giving
justification. Subjects of the study were anonymous and
the results of the study would only be used for scientific
purposes. Written informed consent was obtained.
Patients attending general adult psychiatry outpatient
clinics in Menoufia Mental Health and Addiction Treat-
ment Hospital during the study period from the start of
the clinical sample collection stage in July 2020 until the
completion of the sample in February 2021 were inter-
viewed clinically for diagnosing the OCD symptoms
according to the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition (DSM IV) [2], and OCD
symptom by the Y-BOCS symptom severity scale and
symptom checklist interview by an expert psychiatrist.
e total number of cases screened was 110 patients
comorbid with other psychiatric disorders to find includ-
ing 60 patients eligible for this study with compensating
[3] dropped out cases due to refusal to continue complet-
ing the scales to the end excusing by time, poor literacy,
being from the low socioeconomic strata, or minority
race/ethnicity. Participants’ poor health/general condi-
tion status. Data were collected from the patients.
Study procedures
All patients were subjected to the following:
Full personal history, full medical, and neurological his-
tory including a detailed history of substance use disor-
ders, detailed history of psychiatric disorders, detailed
history of a medical disorder, and current medication. A
general and neurological examination.
Patients fulfilling inclusion criteria were subjected to
the following:
Clinical interview for diagnosing the OCD symptoms
according to the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition (DSM-IV), Confirming
Diagnoses using Structured Clinical Interview for DSM-
IV (SCID-I) and excluding any other known psychiatric
illness and substance use disorders [3].

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Assessing OCD symptoms using a Y-BOCS symptom
checklist interview and the Y-BOCS symptom severity
scale by an expert psychiatrist in general adult psychiatry
outpatient clinics [4].
Obsessive-compulsive personality profile was evaluated
using Structured Clinical Interview for DSM-IV (SCID-
II) [5].
Autistic traits assessed by using self-administered
Autism Spectrum Quotient-Arabic version (AQ) [6].
Data analysis
e collected data was revised, coded, and tabulated
using the Statistical Package for Social Science (IBM
Corp. Released 2017. IBM SPSS Statistics for Windows,
Version 21.0. Armonk, NY: IBM Corp.) [7].
Descriptive statistics
Mean, standard deviation (±SD) for numerical data, fre-
quency, and percentage of non-numerical data.
Analytical statistics
An independent t test was used to assess the statisti-
cal significance of the difference between the two study
group means. One-way ANOVA test was used for three
or more groups of data to gain information about the
relationship between the dependent and independent
variables through comparison of mean values. e chi-
square test was used to examine the relationship between
two qualitative variables.
P value: level of significance: P > 0.05: non-significant,
P ≤ 0.05: significant, P ≤ 0.01: highly significant.
Results
Sample description
e current study included 60 eligible patients diagnosed
with OCD by SCID-II. e mean age of included patients
was 37.5 ± 13 years. Seventy percent (n = 42) of included
patients were males and 30% were females (n = 18).
Regarding marital status, 28.3% of included patients
were single (n = 17), 56.7% were married (n = 34), 6.7%
were divorced (n = 4), and 8.3% were widowed (n = 5).
Regarding occupational status, of the included patients,
25% were employed (n = 15), and 75% were unemployed
(n = 45). Regarding the educational level, 25% patients
were illiterate (n = 15), 16.6% (n = 10) had preparatory
education, 31.7% (n = 19) had secondary education, and
26.7% (n = 16) had high education.
Family history of psychiatric diseases was present in
56.7% (n = 34) patients, and further assessment of family
history was subdivided into family history of psychosis in
33.3% of patients (n = 20), family history of neurosis in
23.3% of patients (n = 14), and negative family history of
psychiatric diseases in 43.3% patients (n = 20) (Table1).
Assessment ofY‑BOCS, SCID‑II, andAQ results
incomparison todierent demographic data
Assessment of Y-BOCS results about age revealed that
younger patients had significantly more severe and
extreme OCD scores. Moreover, SCID-II and AQ analy-
ses about age revealed that younger patients had a signifi-
cantly higher prevalence of personality traits and autistic
traits respectively (Table2).
Inter‑comparison ofY‑BOCS, SCID‑II, andAQ results
inincluded patients
a-Comparison of Y-BOCS with SCID-II revealed statisti-
cal significance as many patients with severe and extreme
Y-BOCS scale showed criteria of OC personality disorder
(Table3).
b-Comparison of Y-BOCS with AQ revealed no asso-
ciation of statistical significance between OCD severity
and autistic trait presence (Table4).
Comparison ofAQ withSCID‑II results
Comparison of AQ with SCID-II results revealed statisti-
cal significance as many patients who had autistic traits
showed criteria of OC personality disorder (Table5).
Discussion
Whether ASD or AS traits may have significant impacts
on clinical and psychosocial features as well as a long-
term treatment outcome in adult OCD patients has
been investigated in few studies. In the present study,
we sought to detect the frequency of autistic traits and
obsessive-compulsive personality traits in a sample of
patients with OCD. e current study included 60 eligi-
ble patients diagnosed with OCD by SCID-II. e mean
age of included patients was 37.5 ± 13 years. A significant
male predominance of 70% (n = 42) of included patients
was noticed while 30% were females (n = 18). is can be
due to cultural beliefs that restrict female participation in
psychological based studies.
Contrary to our results, the study population was
reported in different studies. In a study done by Gadelka-
rim etal. [8] included 67 individuals (52.2% female and
48.8% males with mean age of 44.5 years, SD ± 11.47).
Also, Wikramanayake etal. [9] included 73 adult outpa-
tients with DSM-IV OCD with a mean age of 44.7 years
and slight female predominance (53.4%). Using SCID-II
in the assessment of personality profiles revealed that
31.7% of patients (n = 19) had OC personality disorder,
41.7% of patients (n = 25) had OC personality traits, and
26.7% of patients (n = 16) had no OC personality traits.

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Gordon etal. [10] in their study reported that of the
189 participants with a diagnosis of OCD, 104 (55%) did
not meet DSM-IV criteria for OCPD, while 85 (45%)
met the criteria for OCD and OCPD. Moreover, OCPD
was significantly associated with OCD. Results from this
study demonstrate a higher rate of co-occurring OCD
with OCPD than our study. is is probably because all
OCD patients were assessed using the SCID OCPD mod-
ule, not only those who scored positive on the Axis II
SCID screener.
Table 1 Demographic data of included patients

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Mancebo etal. [11] concluded that similarities in phe-
nomenology can make it difficult to differentiate between
OCPD and OCD, giving the example of excessive list-
making, which can count as a preoccupation with detail
in DSM-IV OCPD and may be considered a compul-
sion if it is repetitive, time-consuming, and distressing.
Again, they suggest that perfectionism, while a criterion
for OCPD, is also a symptom of OCD if it involves order,
symmetry, and arranging. Phenomenological differences
occurred between OCD and OCPD, such as the ego-dys-
tonic nature of OCD symptoms which differs from the
ego-syntonic nature of OCPD characteristics, also the
fact that intrusive thoughts and repetitive behaviors are
not typically experienced by individuals with OCPD as
they are in OCD [12].
Our study assessment of OCD symptom severity using
the Y-BOCS scale revealed that 1 patient had mild symp-
toms, 33 patients had moderate symptoms, 14 patients
had severe symptoms, and 12 patients had extreme
symptoms. Certain OC symptoms were more com-
monly endorsed than others within the OCD sample
when patients included in the study underwent a YBOCS
symptom checklist. Similar to the current study, Mito
etal. (2014) reported that aggressiveness followed by con-
tamination and symmetry and exactness were the most
commonly observed obsessions while cleaning, washing,
and checking were the most common compulsions.
On the contrary, Gordon etal. [10] and Gadelkarim
etal. [8] reported that the most common observed obses-
sions were contamination followed by hoarding and
aggression while, the most common observed compul-
sions were cleaning, checking, and repeating. e results
of the current study given the following studies agreed
that a combination of OCD with autistic traits is slightly
associated with higher severity of OCD symptoms.
Table 2 Assessment of Y-BOCS, SCID-II, and AQ results in comparison to age
Y-BOCS Yale-Brown Obsessive Compulsive Scale, SCID Structured Clinical Interview for DSM-IV Disorders, AQ Autism Spectrum Quotient
+ Using one-way ANOVA test
# Using independent t test, *p value ≤ 0.05 is signicant, p value ≤ 0.01 is highly signicant

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Gadelkarim etal. [8] found that assessment of OCD
symptom severity using the Y-BOCS scale revealed
that patients with OCDP had higher Y-BOCS com-
pared to patients without OCPD but with no statisti-
cal significance. Similarly, Mito etal. (2014) reported
a non-significant higher Y-BOCS score in combined
OCD/ASD patients compared to OCD/non-ASD
patients.
Also, Wikramanayake etal. [9] reported a borderline
significant (p value = 0.054) increase in Y-BOCS scores
Table 3 Inter-comparison of Y-BOCS and SCID-II results in included patients
Y-BOCS Yale-Brown Obsessive Compulsive Scale, SCID Structured Clinical Interview for DSM-IV Disorders
Using the chi-square test, *p value ≤ 0.05 is signicant, p value ≤ 0.01 is highly signicant
Table 4 Inter-comparison of Y-BOCS and AQ results in included patients
Y-BOCS Yale-Brown Obsessive Compulsive Scale, AQ Autism Spectrum Quotient
Using the chi-square test, *p value ≤ 0.05 is signicant, p value ≤ 0.01 is highly signicant

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in patients with combined OCD/ASD patients com-
pared to OCD/non-ASD patients.
Regarding the relation between OCPD and ASD, in
contrast to our results, Gadelkarim et al. [8] concluded
that approximately half (54.2%) of those diagnosed with
OCPD were also found to meet diagnostic criteria for
ASD. is conflicting result may be due to high symptom
overlap in patients with high OCD scores in the current
study.
Comparison of Y-BOCS with SCID-II revealed statisti-
cal significance as many patients with severe and extreme
Y-BOCS scale showed criteria of OC personality disor-
der. Our assessment using the Y-BOCS symptom severity
scale of patients’ demographic data revealed that younger
patients had significantly more severe and extreme OCD
scores.
In contrast to our study, Gadelkarim etal. [8] did not
report any significant association between patients’ age
and severity of OCD.
In the current study, the Autism Spectrum Quotient
assessment of included patients revealed that 25% of
patients (15) screened as having autistic traits while
75% of patients (45) have no any autistic traits. Besides,
younger patients had a significantly higher prevalence of
autistic traits. Assessment of AQ in comparison to other
demographic data revealed there was no significant asso-
ciation between AQ scores and any of the demographic
variables. e current study results were conflicting with
data from previous literature.
Chaste and Leboyer, [13] reported the pivotal role of
genetics in the development of autistic disorders. Lord
etal. [14] showed that environmental factors had a major
role in autism development. Maternal age, birth weight,
childhood nutrition, and social factors like education
all participate in the pathogenesis of autistic disorders.
A possible explanation for the discrepancy between our
results and the mentioned research can be due to dif-
ferent research aims needed to demonstrate risk factors
behind shred disease neurodevelopmental basis. In con-
trast to our results, concerning family history and prob-
ability of hereditary role, there is emerging evidence of
shared neurobiology among OCPD and ASD. Research
on twins suggests that OCPD is highly heritable Gjerde
et al. [15], and there is evidence that OCPD, OCRDs,
and ASD cluster are not only found in the same patients
(Hofvander etal. [16]) but also in their family members
(Bienvenu etal. [17]).
ese studies suggest that these disorders may share
genetic factors in their etiology. Hollander et al. [18]
found that the occurrence of obsessive-compulsive traits
or disorders in the parents of autistic children is signifi-
cantly more likely if autistic children have a high occur-
rence of repetitive behaviors, additionally indicating a
possible role for compulsivity as a neuropsychological
factor mediating familial risk across OCD, OCPD, and
ASD diagnoses, supporting the above hypothesis.
In a study by Meier etal. [19] to clarify the patterns
of comorbidity, longitudinal risks, and shared familial
risks between OCD and autism spectrum disorders. e
Table 5 Comparison of AQ with SCID-II results
SCID Structured Clinical Interview for DSM-IV Disorders, AQ Autism Spectrum Quotient
Using the chi-square test, *p value ≤ 0.05 is signicant, *p value ≤ 0.05 is signicant, p value ≤ 0.01 is highly signicant

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risk of a comorbid diagnosis of OCD in individuals with
autism spectrum disorder and aggregation of autism
spectrum disorders in offspring of parents with OCD
were increased. Individuals first diagnosed with autism
spectrum disorders had a 2-fold higher risk of a later
diagnosis of OCD whereas individuals diagnosed with
OCD displayed a nearly 4-fold higher risk to be diag-
nosed with autism spectrum disorders later in life. ere-
fore, the high comorbidity, sequential risk, and shared
familial risks between OCD and autism spectrum disor-
ders are suggestive of partially shared etiological mecha-
nisms between these mental disorders.
Finally, the current study revealed that the comparison
of AQ with SCID-II results showed statistical significance
as most patients who had autistic traits showed criteria
of OC personality disorder. However, there was no statis-
tically significant association between OCD severity and
autistic trait.
In partial agreement with our study, Gadelkarim
etal. [8] reported that the severity of OCPD traits and
ASD traits showed a significant positive correlation as
(50.75%) of OCD patients represented a high overall fre-
quency of ASD traits.
Assessing ASD traits using the Autism Spectrum Quo-
tient (AQ) by Hironori et al. [20] in 81 patients with
OCD, a substantial proportion of OCD patients (35%)
were demonstrated to have clinically significant ASD
traits according to AQ. OCD subjects with higher ASD
trait (ASD+ group) were characterized by a shorter dura-
tion of education, lower Global Assessment of Function-
ing (GAFS), higher proportion of subjects with poor
insight or with tick-related OCD than the other group.
is may be due to methodological differences in the
characteristics of the participants besides the differ-
ent assessment procedures of ASD traits; most of the
subjects were introduced because they had previously
been assessed as treatment-refractory enough to receive
specialized treatments for OCD, treatment-refractory
patients are different types of the patient population dif-
fer from our study population.
Wikramanayake etal. [9] found a high prevalence of
ASD traits (47%) and ASD diagnosis (29%) in the OCD
sample.
OCD patients with autistic traits were more severely
symptomatic on the Y-BOCS, and there was a positive
correlation between OCD and ASD scores. is find-
ing replicates that of Hironoriet al. [20]. It is commonly
found that comorbid disorders predict a greater severity
of index illness. Fineberg etal. [21] and this finding may
therefore simply represent a non-specific effect reflect-
ing the burden of having an additional mental health
diagnosis.
Study limitations
Strengths
ere is relatively adequate patient sample in the studied
disorder. ere are multiple valid self-administrated tools
for gathering data with guiding patients according to
their educational level. is study is considered a newly
admitted academic article in this clinical era. Due to a
small number of clinical researches in this quota of dis-
orders with high symptom overlap, good interpretations
of findings that can be generalized if the sample size is
representative of the study population.
Limitations
Insufficient data was collected from the patients’ charts.
e study underwent during a COVID-19 pandemic; so,
it took a long time because general clinic patients’ flow
rate was reduced to half of its capacity and there was a
lack of non-verbal communication due to discussion 106
of face mask wearing for both psychiatrist and study sub-
jects. One limitation is that the AQ scale is a self-report
open to the bias of subjectivity. ere is probably a need
for developing scales that are still easy to use and are
more objective in the future.
Conclusions
Our data demonstrated that there is the presence of
comorbidity of OCP traits and AS traits in OCD patients.
OCP traits prevalence in OCD patients was higher than
in autistic traits. Several factors of genetic predisposition,
environmental factors like education and marital status,
employment, and intrinsic factors as age of patients all
exhibited a pivotal role in OCD prevalence and severity.
Abbreviations
ASD: Autism spectrum disorder; AD: Autistic disorder; OCD: Obsessive-com-
pulsive disorder; OCP: Obsessive-compulsive personality.
Acknowledgements
None
Authors’ contributions
Authors including AA, EA, SE, RM, and HK shared the steps of design, back-
ground review, statistical analysis, results in representation, and discussion. All
authors read and approved the final manuscript.
Funding
None
Availability of data and materials
Applicable

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Declarations
Ethics approval and consent to participate
Approval from the local ethical committee of the institute of psychiatry in the
Faculty of Medicine at Ain Shams University was obtained. The reference num-
ber is not available as at the time of conducting the study the ethical approval
was a necessity on a departmental level without other pre-requisites from the
university. Written informed consent was given by participants to participate.
Consent for publication
Written informed consent was given by participants for publication
Competing interests
The authors declare that they have no competing interests.
Author details
1 Neuro-Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
2 Menofia University, Shibin el Kom, Egypt. 3 Faculty of Medicine, Misr University
for Science and Technology, October City, Egypt.
Received: 28 March 2022 Accepted: 8 May 2022
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