OCD and neurodivergence, synesthesia, and neurodiversity affirming care
*This article reflects an evolving theory and hypothesis. Comments will be taken into account as revisions are made.
While OCD itself is increasingly understood within a neurodevelopmental context, acknowledgement of common co-occurring neurodevelopmental and neurological conditions and traits (e.g. autism, ADHD, Tourette’s/tics ), not to mention common co-occurring mental health symptoms and conditions (e.g. PTSD and trauma, depression, other anxiety disorders, and personality disorder) suggests that many individuals with OCD experience multiple forms of neurodivergence, disabilities, mental illnesses or phenotypic variables (these terms are used interchangeably here to reflect a wide variety of individual preferences). This understanding aligns with transdiagnostic approaches but importantly does not inherently frame these traits or ways of being as deficits or problems to be fixed or pathologized.
Synesthesia, or a mixing of the senses, is considered a neutral and sometimes positive condition that can even allow for greater creativity, memory and other capabilities.
It is defined as “a neurological condition in which stimulation of one sensory or cognitive pathway (for example, hearing) leads to automatic, involuntary experiences in a second sensory or cognitive pathway (such as vision).” Psychology Today notes, “simply put, when one sense is activated, another unrelated sense is activated at the same time. This may, for instance, take the form of hearing music and simultaneously sensing the sound as swirls or patterns of color.” There are less common types of the already uncommon neurological condition, including space-time synesthesia where individuals perceive time in spatial formations.
Questions of whether some subtypes of OCD can be considered a form of synesthesia have been posed by people with OCD themselves, and researchers have also explored links between mental health conditions and synesthesia.
Aside from co-occurring cases (e.g. someone having OCD and synesthesia), can aspects of OCD like magical thinking and emotional contamination have similar phenomenology or even neurobiology to the blending of senses described by synesthesia?
This article does not argue that OCD is always a form of synesthesia. Rather, it suggests that some perceptions and cognitive processes involved in OCD, might be seen as a form of synesthesia or similar neurological condition that affects perception.
OCD has typically been seen as a singular disorder with multiple manifestations. Types or manifestations of OCD can be so disparate that individuals with OCD can even have difficulty understanding one another’s “type.” However, it is possible that some neurological conditions such as synesthesia may underlie subtypes of OCD in different ways, or predispose individuals to develop certain forms of OCD.
There are connections among OCD, tics, Tourette’s, autism, ADHD, and related psychiatric-defined conditions and/or neurotypes. Autism and increasingly ADHD are discussed as lifelong neurodevelopmental conditions, often considered neutral or positive neurodivergent neurotypes by many advocates, despite acknowledged barriers to living full lives imposed by society. Tourette’s is largely accepted as a neurological phenomenon. Yet, OCD is considered a mental health or neuropsychiatric disorder rather than one related to unique neutral or positive neurodevelopmental traits (aside from assumptions that having OCD must be sooooo helpful for staying clean and organized! It’s not.)
Of course, this is likely due to the immense suffering that OCD can cause along with potential for some individuals with OCD to recover or experience significant reductions in symptoms through treatments.
Treatment methods presuppose that OCD is perpetuated by the sufferer’s own maladaptive actions alone (i.e. behavior) and any neurological differences underlying or perpetuating OCD are seen as malleable through behavior. In short, OCD is generally seen as more able to be impacted through behavior and thus any observed neurological differences are not generally discussed as relevant.
“Thought-action fusion”, a core feature of OCD, describes the impression that thoughts are somehow equivalent to one’s actions, whether by thoughts leading to action in the real world (e.g., my sister will get hurt if I don’t tap the table until it feels “just right”), or a cognitive sense (“if I think of harming someone, then I essentially harmed someone”).
It remains a curiosity why people with OCD experience this phenomenon. From my experience, this process is assumed to be defective cognitive assumption that can be unlearned. But is it possible that some or many individuals with OCD experience these thoughts through a synesthesia-like process that make them feel more “real?” Could this perhaps contribute to development of OCD?
If so, can certain manifestations of thought action fusion be akin to synesthesia in which one mental process or perception (thought) is linked to another (sense of action)?
One issue with this idea is that synesthesia is generally considered a neutral or even positive condition, while OCD is a mental health disorder which causes suffering and confers little if any benefit, despite popular stereotypes.
However, is it possible that certain types of synesthesia or similar neurological traits can cause difficulty (i.e. it should not be necessary that synesthesia is only neutral or positive), or that when mixed with certain life experiences or other neurological conditions can maintain a disorder like OCD?
In addition to understanding co-occurring traits, attempts to identify specific phenotypic variables (used interchangeably here with neurodivergent traits) specific to OCD may provide important information for understanding heterogeneity, including neurological conditions and experiences like synesthesia, and understanding aspects of some individual presentations that are not appropriate for existing intervention or require modification, and advancing appropriate treatments.
Research has identified variables that point to underlying neurological conditions in OCD, including sensory phenomena and atypicalities including not just right experiences (NJREs), sensory intrusions, sensory sensitivities, alteration of sensory-motor integration, schizotypy, and internal source monitoring difficulty. More here.
I suspect there is also an emotional processing difference in OCD and related conditions that is internal and not well understood but that additional supports around emotional processing may be required and deserve attention.
This research remains limited, and remains largely limited to description, which can aid individual clinical approach and client understanding but do not translate into clear treatment recommendations.
Many individuals with “treatment resistant” OCD continue to navigate the realities of complex, multifaceted lived experiences including these atypical neurological experiences, and experience self-blame or provider-blame due to failure to sustain treatment response.
One might ask what benefit is there to considering some (or even most?) types of OCD as containing elements of synesthesia and other neurodevelopmental differences? For one, sufferers can realize that it is not their fault that they perceive things the way that they do. Many OCD sufferers feel “crazy,” knowing that their thoughts seem ridiculous or irrational, but that they feel so real that they cannot overcome them. Or they feel ashamed to admit how much they believe their thoughts to be true when they are in the midst of them.
Considering certain types of OCD in neurodevelopmental context, including ties to synesthesia and sensory phenomena, or recognizing the role of synesthesia like processes, doesn’t mean that people with OCD shouldn’t pursue treatment to disentangle anxiety from any perceptual mixing. However, understanding the unique perceptual experiences of OCD suffers can go a long way in enhancing self-understanding and empathy from the broader population that all too often thinks of someone with OCD in terms of stereotypes such as being a neat freak or germaphobe.
Understanding these traits and processes involved in OCD including but not limited to synesthesia may go a long way in enhancing self-compassion and compassion from others who may struggle to understand why it’s so hard for someone to do seemingly basic or simple tasks or why someone might engage in seemingly bizarre behaviors.
Does seeing OCD in this way change how we treat OCD?
While OCD treatment is beyond the scope of this post, there may be some adjustments to treatment that emerge from such a perspective. However, even without changes to mainstream treatment, such understanding can help clinicians to better understand patients’ experiences, build empathy and help sufferers to better understand their own experiences.
The impact of cumulative experiences of interactions among traits and experiences such as atypical sensory phenomena, unsuccessful treatment, internalized blame, poor insight, intrusive thoughts, delayed fear extinction, social isolation, identified or unidentified autism and/or ADHD, trauma, depression, and more deserves its own conceptualization as substantial cumulative experience requiring additional supportive interventions.
While OCD sufferers are continually seen by the broader pubic through stereotypes such as perfectionistic, neat, overly fearful, odd, bizarre, quirky, neurotic, obsessively clean, and germophobic, understanding the processes that contribute to the disorder may help add to greater public understanding and help alleviate stigma. Whether or not OCD is considered to have components of synesthesia or similar neurological conditions, such inquiry allows for greater curiosity about the complexities of OCD, particularly for complex manifestations.
Further consideration of neurodevelopmental traits of OCD suffers may allow better understanding of the specific, underlying needs and sensitivities of individuals with the condition and move toward more effective and compassionate approaches and treatment.
For therapists, working with people with OCD in a neurodiversity-affirming way does not mean simply ignoring these ways of being or necessarily even accommodating them, though that is often necessary, but rather recognizing them, understanding an individual’s way of relating to these ways of being, including past negative treatment, internalized blame, helping decrease internalized stigma while recognizing and validating and supporting the real internal and societal barriers individuals face.
