Behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD)

Aim of the review

The aim of the review is to see if cognitive behavioural therapy (CBT) can help people who have OCD who also have ASD.


People who have been given a diagnosis of ASD tend to have certain things in common. They often understand social interactions and communication differently to other people. People with ASD may also be less flexible in their thinking than other people, which may make it more difficult for them to use psychological therapies in the way that they are usually presented. The opinions of people with ASD are valuable in helping clinicians decide which research areas related to ASD should take priority.

Someone who has been diagnosed with OCD has certain symptoms which, to some extent, affect how they are able to get on with their lives. Someone with OCD has persistent thoughts, although they don't want the thoughts and often think that the thoughts are unreasonable. These thoughts are often worries about themselves or someone else being harmed or about something not being perfect or just right. Sometimes the person with OCD feels as if they have to think thoughts or do actions repeatedly to 'make things right', even though they often really know that they don't need to. The repeated actions might be something like washing their hands.

Research has shown that people with ASD are more likely to develop OCD. People may have certain genes that make them more likely to develop both ASD and OCD, or it may be that the way people with ASD tend to think makes them more likely to have OCD.

Cognitive behavioural therapy (CBT) has been used for a long time to treat OCD. CBT is usually carried out by visiting a therapist, but it can be delivered in different ways, such as online. CBT involves talking about the repeated thoughts that occur and helping the person manage and reduce them, and also involves trying to carry out compulsive actions less often. Because people with ASD sometimes have a different way of thinking and communicating, clinicians have wondered if CBT would be as useful to treat OCD in people with ASD as it is in people who have OCD but don't have ASD. Other researchers have devised ways to change the way that CBT is delivered to people with ASD to help them to get the most out of the treatment, and this is called 'adapted CBT'. Studies have shown that adapted CBT is useful for some anxiety disorders that occur in ASD. However, not as many studies have looked at how adapted CBT might be useful for OCD in people with ASD.


We searched for randomised controlled trials of delivery of CBT to people with OCD who also had ASD. A randomised controlled trial is a trial where the participants are randomly allocated to CBT or another treatment group so that the people running the trial have no say about and do not know to which group the participants belong. The other treatment group is called the control group. In these studies, the people in the control group do not receive CBT, but they may have sessions with their therapists that do not include CBT, or they may be on a waiting list. If meeting with your therapist or waiting for time to pass were just as helpful as CBT, for example, then the results would be less likely to show a difference between the outcomes of the treatment group and the control group. Conversely, if CBT was more effective, then we might expect to see the CBT group doing better than the control group. Therefore, at the end of each trial, when the results in the treatment group are compared to the results in the control group, it gives information about how effective CBT might be for people with OCD and ASD. The evidence in this review is current to August 2020.


We found that there was only one published randomised controlled trial of delivery of CBT to people with OCD and ASD that met our search criteria. The control group in this trial was given a treatment called 'anxiety management' which helped the participants to manage anxiety but did not help them to deal specifically with repeated thoughts and actions, as CBT does. This study aimed to see if either anxiety management or CBT was better at treating OCD in people with ASD, but the study did not find a difference in response between the two treatments.

Authors' conclusions: 

Evidence is limited regarding the efficacy of CBT for treatment of OCD in ASD. There is much scope for future study, not only examining the efficacy of CBT for OCD in ASD, but also the particular ways that OCD manifests in and affects people with ASD and the role of the family in treatment response.

Read the full abstract...

Autistic spectrum disorder (ASD) is an increasingly recognised neurodevelopmental condition; that is, a neurologically-based condition which interferes with the acquisition, retention or application of specific skills. ASD is characterised by challenges with socialisation and communication, and by stereotyped and repetitive behaviours. A stereotyped behaviour is one which is repeated over and over again and which seems not to have any useful function. ASD often co-occurs with mental health disorders, including obsessive compulsive disorder (OCD). People with ASD may show certain cognitive differences (i.e. differences in ways of thinking) which influence their response to therapies. Thus, there is a need for evidence-based guidelines to treat mental health issues in this group.

OCD, a common condition characterised by repeated obsessional thoughts and compulsive acts, occurs with greater frequency in persons with ASD than in the general population. Genetic, anatomic, neurobiological and psychological factors have been proposed to explain this co-occurrence. However, care should be taken to distinguish stereotyped and repetitive behaviours characteristic of ASD from obsessive compulsive acts in OCD.

Cognitive behavioural therapy (CBT) is the recommended treatment for OCD, but studies have suggested that this treatment may be less effective in those with OCD co-occurring with ASD. Hence, modifications to CBT treatment may be helpful when treating OCD co-occurring with ASD to optimise outcomes.


To assess the effectiveness of behavioural and cognitive behavioural therapy for obsessive compulsive disorder (OCD) in children and adults with autism spectrum disorder (ASD).

Search strategy: 

We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, five other bibliographic databases, international trial registries and other sources of grey literature (to 24 August 2020). We checked the reference lists of included studies and relevant systematic reviews to identify additional studies missed from the original electronic searches. We contacted subject experts for further information when needed.

Selection criteria: 

We included randomised controlled trials (RCTs), cross-over, cluster- and quasi-randomised controlled trials involving both adults and children with diagnoses of OCD and ASD. We included studies of participants with co-occurring conditions (i.e. those experiencing other mental illnesses or neurodevelopmental conditions at the same time), but we did not include individuals who had a co-occurring global learning difficulty. Treatment could be in any setting or format and include behavioural therapy (BT) and cognitive behavioural therapy (CBT), which may have been adapted for those with ASD. Comparator interventions included no treatment, waiting list, attention placebo (where the control group receives non-specific aspects of therapy, but not the active ingredient) and treatment as usual (TAU, where the control group receives the usual treatment, according to accepted standards).

Data collection and analysis: 

Three review authors independently screened studies for inclusion. The authors extracted relevant data from the one eligible study, assessed the risk of bias and certainty of evidence (GRADE). Outcomes of interest were changes in OCD symptoms and treatment completion (primary outcome), and severity of depressive symptoms, anxiety symptoms and behavioural difficulties, as well as degree of family accommodation (secondary outcomes). We did not conduct meta-analyses as only one study met the selection criteria.

Main results: 

We included only one RCT of 46 participants in our analysis. This study compared CBT for OCD in persons with high-functioning ASD with a control group who received anxiety management only. There were no differences in rates of treatment completion between the CBT (87%) and anxiety management (87%) groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.80 to 1.25; low-certainty evidence). Behavioural difficulties were not included as an outcome measure in the study. This study showed that there may be a benefit at the end of treatment favouring CBT compared with anxiety management in OCD symptoms (mean difference (MD) -3.00, 95% CI -8.02 to 2.02), depression symptoms (MD -1.80, 95% CI -11.50 to 7.90), anxiety symptoms (MD -3.20, 95% CI -11.38 to 4.98), and quality of life (MD 5.20, 95% CI -1.41 to 11.81), but the evidence was of low certainty.