Episode 228: Comprehensive Obsessive-Compulsive Disorder (OCD) Treatment Guide: Evidence-Based ERP Approaches and Best Practices for Clinicians
Writers: Al-Baab Khan, Liam Browning, Joanie Burns DNP, Christopher Campbell, David Puder, M.D.
Audio Episode Host: David Puder, MD
Audio Episode Guest: Fred Penzel, PhD
Corresponding author: David Puder, MD
By listening to this episode, you can earn 1.25 Psychiatry CME Credits.
Other Places to listen: iTunes, Spotify
Date Published: 12/6/2024
In today’s episode, we have the pleasure of talking once again with one of the preeminent OCD experts, Dr. Fred Penzel, who brings over 43 years of experience in treating OCD. Early in his career, Dr. Penzel had a professor say that OCD was simply “too hard to treat.” This challenge motivated Dr. Penzel to dedicate a significant portion of his career to finding effective solutions for treating OCD. In this episode, we will explore the nuances of OCD and the treatment approaches that prove most effective. In previous episodes, we have explored additional aspects of OCD, including a general overview (episode 119), psychotherapy for OCD (episode 126), and the immune-related obsessive-compulsive symptoms associated with PANS and PANDAS (episode 147). We encourage listeners to visit or revisit our prior episodes for additional detail and context on this complex subject. By listening, you’ll not only gain valuable clinical insights but also have the opportunity to earn 1.25 psychiatry CME credits to advance your professional development in mental healthcare.
Introduction To Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder (OCD) is a complex and often debilitating condition, defined by intrusive thoughts and repetitive behaviors that vary widely in severity. OCD affects approximately 1.2% of adults in the United States annually and has an overall lifetime prevalence of 2.3% (National Institute of Mental Health, 2023). Notably, the average age of onset is approximately 19 years old, with up to one third of patients first experiencing symptoms in childhood (Anxiety and Depression Association of America, 2022).
Clinical Definition of Obsessions and Compulsions Obsessions:
Intrusive, persistent thoughts, images, or urges that are experienced as distressing or unwanted, often eliciting significant anxiety or emotional discomfort.
These thoughts or impulses are resisted or managed through avoidance, suppression, or engagement in compensatory actions (e.g., compulsions).
Compulsions:
Repeated actions (e.g., excessive cleaning, checking, or organizing) or mental rituals (e.g., counting, repeating phrases, praying) performed to neutralize obsessions and/or accompanying anxiety, or adhere to strict internal rules.
These behaviors aim to alleviate emotional distress or prevent feared outcomes, but are typically excessive or disconnected from the perceived threat.
Clinical Significance:
Obsessions and/or compulsions are disruptive enough to occupy over an hour per day or significantly impair functioning across social, professional, or personal domains.
The presenting symptoms cannot be fully accounted for by another psychiatric condition, ensuring accurate differential diagnosis.
The above definitions and clinical significance of OCD are drawn from the DSM-V (APA, 2013) and the Substance Abuse and Mental Health Services Administration (SAMHSA, 2016).
How OCD Turns Doubt Into An Obsession
Obsessive-compulsive disorder is often termed the “doubting disease” due to its hallmark feature: an inability to tolerate uncertainty, resulting in repetitive obsessions and compulsions. These behaviors stem from the brain’s misinterpretation of fear signals and a disrupted confidence in memory and decision making. While OCD sufferers generally exhibit intact cognitive abilities, their excessive need for certainty drives compulsive behaviors that aim to mitigate perceived threats, but paradoxically intensify anxiety over time (Grant & Chamberlain, 2023; Song et al., 2022). As Dr. Fred Penzel describes, “Doubt is the central characteristic of OCD—it is what sets the disorder apart from everyday anxiety. OCD sufferers cannot accept even a reasonable degree of certainty in their lives.”
Breaking The OCD Cycle: Stop The Compulsions
Dr. Penzel explains that in OCD, compulsions are performed to alleviate the anxiety caused by obsessions. Therefore, effective treatment focuses on stopping compulsions, which, over time, diminishes the intensity and frequency of the obsessions themselves.
There is a common misunderstanding among patients and providers that the obsession itself is the primary problem, leading to the belief that eliminating obsessive thoughts will reduce anxiety and stop compulsive behaviors. In reality, compulsions occur because the individual feels compelled to act on the obsession in an attempt to gain certainty or relief (e.g., a patient may have an intrusive thought that they forgot to lock their front door, triggering a compulsion to repeatedly check the lock). However, this cycle fails to provide the desired certainty or relief and instead strengthens both the compulsion and the obsession over time.
Performing the compulsion directly reinforces the behavior by providing temporary relief from the anxiety caused by the obsession. This relief serves as negative reinforcement, making it more likely that the compulsion will be repeated in the future. Simultaneously, acting on the compulsion indirectly reinforces the obsession by validating its perceived importance or danger, keeping it prominent in the individual’s mind.
The goal of OCD treatment is not to eliminate the obsession. Instead, it is to help the patient tolerate the discomfort and anxiety caused by intrusive thoughts without resorting to compulsive behaviors. By resisting compulsions, the patient can break the reinforcement cycle that sustains both the compulsions and the obsessions. Over time, they will learn that these intrusive thoughts naturally subside without intervention.
This process of habituation, fundamental to exposure and response prevention (ERP) therapy, requires repeated exposure to distressing thoughts while refraining from compulsive responses. It is not something a patient can simply “think themselves out of”; rather, it is akin to training a muscle. OCD can be conceptualized as a disorder of deeply entrenched habits, and overcoming it takes time, consistent practice, and the willingness to endure discomfort in order to build healthier, more adaptive responses.
The Role Of Ambiguity In OCD
One specific feature of OCD is that obsessions can manifest from even the most ambiguous situations. For example, Dr. Penzel describes a driver obsessing about having killed someone on the road. A speed bump, which triggered the intrusive thought, can create an obsessive-compulsive cycle resulting in the driver going back to the speed bump, checking the roads, calling hospitals, and watching the news to seek certainty that they did not hit anyone. The individual may even avoid driving cars to prevent making the obsession a reality.
Although thoughts associated with safely operating a vehicle and staying vigilant are appropriate, one of the distinctions between appropriate behavior and OCD lies in the ambiguity of the trigger. A speed bump to the average driver, through context cues and reassurance, may not cause much concern. A speed bump to a driver with OCD would trigger a cycle of doubt and uncertainty that will never be resolved (see also Driven To Distraction: “Hit And Run OCD”).
“The problem with OCD lies not in the content of the obsession, but in how the brain misinterprets these thoughts as dangerous, necessitating action.”
-Penzel, 2019
Pathway To OCD Recovery
First Steps for OCD Therapy
When considering the hallmarks of good therapy, Dr. Penzel demonstrates that the first step in OCD treatment is psychoeducation, where he teaches patients about the nature of OCD, what to expect from the illness, and why certain treatment methods are required to get better. This is critical as it encourages patients to be partners in their treatment.
The psychoeducation component of treatment is supplemented with Dr. Penzel’s article 25 Tips for Succeeding with OCD Treatment, which provides key principles of understanding OCD and the treatment path. This guide offers clinicians and patients the same information to start their therapy, keeping the standard of care consistent and reliable. Although the guide shares many critical tips for starting, succeeding, and maintaining OCD treatment, a few of the key tips are highlighted below that are especially important for reshaping the philosophical basis of the disorder.
Try not to be a black-and-white, all-or-nothing thinker.
When you have a choice, always go toward the anxiety, never away from it.
Don’t be sidetracked by perfectionism.
It is sometimes possible for OCD to try to make you doubtful about your homework.
Overall, never forget that OCD is very paradoxical and rarely makes much sense.
When faced with two possible choices of what to confront, choose the more difficult of the two whenever possible.
When faced with a challenging assignment or an unexpected challenging situation, try to look at it as a positive.
Remember that in OCD, the problem is not the anxiety—the problem is the compulsions.
Give your homework your full attention, focus on what you are doing, and let yourself feel the anxiety.
These tips address the reality of OCD while providing meaningful insights on how to manage challenges in treatment objectively without creating opportunities to regress.
OCD Homework for Effective Treatment
These three homework assignments listed below aim to desensitize the patient to the anxiety, control their compulsions, and instill a sense of trust in themselves.
Gradually agree with the obsessive thought.
Sit with the anxiety of the obsessive thought without analyzing it or acting on it.
Refrain from seeking reassurance for the obsessive thought.
The foundation for this homework is in guiding OCD patients to agree with their obsessive thoughts, and to do so gradually so as to not push the patient too far past their comfort zone. Gradual acceptance of the intrusive thought, from acknowledging the presence of the obsession in the periphery to fully agreeing with the obsession for oneself, paves the path to desensitization that is integral for the rest of treatment. For example, if a patient fears that they would kill a civilian while driving, therapy would begin by helping the patient to progressively accept the following thoughts:
People in this world have killed others while driving.
Some people around me have killed others in car accidents.
It is possible that I could kill someone while driving.
I likely have killed someone while driving.
I have killed someone while driving.
By agreeing with the obsessions gradually, patients are able to tolerate the discomfort at each step and work towards breaking the cycle of compulsion when not acting on the anxiety.
In addition to accepting the obsession, it is arguable that the most crucial component of treatment is not providing reassurance. Reassurance can reinforce the obsession by challenging the doubt, thus encouraging the individual to act compulsively, thereby fueling the cycle. Dr. Penzel emphasizes that his patients and their loved ones refrain from reassurance—even from the therapist—as they navigate treatment.
Effective OCD Treatments & Philosophy
Exposure and Response Prevention (ERP)
ERP remains a cornerstone of OCD treatment. As Dr. Penzel has noted, “You can’t fight OCD with logic, because OCD isn’t logical. It’s emotional.” ERP aligns with this principle by focusing on retraining the brain’s response to distressing stimuli. To achieve this, ERP guides patients to confront their fears without engaging in compulsions. The goal is not to satisfy the obsession, but rather teach patients how to live with their thoughts and uncertainty.
Efficacy of ERP Therapy:
Meta-analyses show that ERP results in significant symptom reduction for 60-70% of patients, with effects often sustained long after treatment. ERP is effective across many OCD subtypes, including contamination, harm-related, and existential OCD (Ferrando & Selai, 2021; Song et al., 2022).
Furthermore, ERP is considered widely applicable to various patient populations and settings (Hezel & Simpson, 2019). This speaks to its ability to be effective in both highly structured and real world environments, which makes it ideal for the majority of patients.
Supplementing ERP with additional therapies can also prove beneficial for some individuals in OCD treatment. For example, One study found that this combination led to greater symptom reduction across all main presentations of OCD, with patients achieving clinically significant improvements compared to ERP alone (Rector et al., 2018). Additionally, a review by Hezel and Simpson (2019) saw that patients who took medication (e.g., d-cycloserine) before starting ERP experienced a faster rate of symptom improvement in the first few weeks of therapy.
Cognitive Restructuring
Cognitive restructuring is a core component of cognitive behavioral therapy and can be used to help patients identify negative thought patterns and replace them with more realistic or positive ones. Cognitive restructuring, when used alongside ERP, helps address the distorted beliefs that drive obsessions. A major focus of this is on Thought-Action Fusion (TAF):
Likelihood Thought-Action Fusion: The belief that thinking about an event increases its probability.
Moral Thought-Action Fusion: The belief that having a thought is morally equivalent to acting on it.
“OCD’s distortions often involve an exaggerated sense of responsibility and moral accountability. Cognitive therapy helps patients understand that thoughts do not equal actions” (Penzel, 2000).
For example, someone with violent intrusive thoughts might believe they are at risk of harming others simply because the thought occurred. Restructuring these beliefs—by identifying and challenging their validity—has shown to reduce obsessional thinking (Van Noppen et al., 2021).
Embracing Uncertainty
For individuals with OCD, the obsession with finding certainty is not the solution, but the very trap that keeps them stuck. Treatment strategies focus on breaking this cycle by embracing uncertainty rather than eliminating it.
Agreeing with intrusions: Techniques like leaning into feared outcomes, as Penzel advocates, encourage patients to make peace with uncertainty. For instance, a patient with moral obsessions might practice affirmations like, “Maybe I am bad, and that’s okay,” as part of their therapy.
Sitting with doubt: Sitting with the bodily sensation of anxiety is critical to desensitizing the patient to their obsessions. Dr. Puder’s patients might describe this as tightness or heaviness in their chest, tightness in their throat, or a nauseated feeling of wanting to vomit. Often, patients confuse such discomfort with danger. However, despite this anxiety being uncomfortable, there is no threat or danger to the patient or anyone around them. When this happens in session, we sit with them, without reassuring them, creating a safe space for them to experience such sensations through giving them our calm presence.
Cognitive Mechanisms Shaping OCD
Neurological and Cognitive Drivers
Research highlights that OCD involves intolerance of uncertainty and a tendency to over interpret ambiguous situations as threatening. Computational models suggest that OCD sufferers disproportionately weigh new information over previous knowledge, driving repetitive checking and reassurance-seeking behaviors (Rigoux et al., 2024). As Dr. Penzel elaborates, “For those with OCD, ‘not knowing’ is the equivalent of danger. This drives their need to constantly check or seek reassurance.”
Misinterpretation of Risks & Lack of Trust
Individuals with OCD often overestimate risks and misinterpret benign events as dangers, driven by what Dr. Penzel describes as an “inflated sense of responsibility” and a “need to prevent harm at all costs.” This distorted perception of risk creates a feedback loop where compulsions, intended to reduce uncertainty, paradoxically intensify it. Dr. Penzel explains that the temporary relief provided by compulsive actions strengthens the belief that the compulsion was necessary, thereby reinforcing the behavior (see also How to Defeat OCD by Surrendering).
For instance, someone repeatedly checking if a door is locked may feel more uncertain after each attempt because, as Dr. Penzel points out, the act of checking undermines trust in their memory and their initial decision. This cycle perpetuates a “failure to trust oneself,” further entrenching the compulsion. He likens this to a vicious cycle: “The more you do it, the less sure you are, and the less sure you are, the more you feel you must do it.” By feeding this cycle, compulsions not only fail to provide lasting relief but also deepen the sense of doubt that defines OCD.
Advanced OCD Therapies & Novel Interventions
Narrative Scriptwriting and Imaginal Exposure for OCD
For existential or abstract fears, scriptwriting involves crafting a vivid, detailed narrative of the worst-case scenario and repeatedly exposing oneself to it. This technique leverages the principle of habituation, which Dr. Fred Penzel highlights as a crucial element in reducing the emotional salience of intrusive thoughts. Penzel notes that scriptwriting for existential OCD allows patients to confront their deepest fears—whether about the meaning of life, the universe, or their moral character—without attempting to resolve them. “By sitting with the discomfort,” he explains, “patients gradually desensitize themselves to the anxiety these thoughts provoke, breaking the cycle of avoidance and compulsive analysis.”
Dr. Penzel has observed that this method is particularly effective for moral or existential OCD because it directly challenges the obsessive need for certainty or resolution. He emphasizes that the narrative should be revisited repeatedly and without seeking reassurance, as this helps retrain the brain to tolerate ambiguity and distress. For instance, someone struggling with existential OCD might write and reflect on a script exploring the possibility that life has no inherent meaning, allowing them to embrace the uncertainty rather than fear it (see also “To Be or Not to Be. That is the Obsession: Existential and Philosophical Obsessions”).
Audio Recordings for OCD
Similar to narrative exposure, Dr. Penzel highlights the efficacy of using audio recordings to treat OCD. Effective audio recordings include details of triggering events to activate obsessions and anxieties, which the patient must then overcome. When listening to these recordings repeatedly, patients are activating more memories and details, which are then then built into new recordings and listened to again. The goal is for the patient to strengthen their tolerance to the discomfort from the obsession over time.
The methodology for the recordings is to increase the intensity of the obsession by listening to more detailed and morbid audios until the patient no longer has a reaction to it, or considers it “boring.” During this therapy, the patient is preparing their mind and building tools to address their OCD response. However, if residual obsessions or anxieties are still left, patients will continue listening to recordings and the therapy persists.
Personalized ERP Protocols
Dr. Penzel underscores the importance of tailoring ERP to match the obsessions and compulsions unique to each OCD subtype and patient, emphasizing that “no two cases of OCD are exactly alike.” Customizing exposures enhances treatment efficacy by addressing the specific fears driving the disorder, as illustrated below:
Contamination OCD: Patients might perform tasks such as touching “contaminated” objects like public door handles and resisting the urge to wash their hands. Dr. Penzel notes that gradual exposure, starting with less distressing stimuli, helps build tolerance to anxiety while fostering confidence in the treatment process (see also “Stronger Than Dirt–OCD and Contamination”).
Harm OCD: Exposure tasks often involve handling feared objects, such as knives, while confronting the irrational belief that simply holding them might cause harm. Penzel advises that therapists create a safe environment for these exposures, gradually dismantling the association between intrusive thoughts and danger (see also “Morbid Obsessions: Thought of Harming Others”).
By targeting the specific fears underlying each OCD presentation, personalized ERP allows patients to confront their obsessions systematically and build resilience against uncertainty.
Augmenting ERP with Technology
Digital tools such as virtual reality (VR) and mobile apps are being explored to simulate exposures in a controlled, repeatable manner. For example, VR scenarios can replicate real-world triggers, making ERP more accessible and tailored (Javaherirenani et al., 2022).
Predictors Of Treatment Success
Early Engagement
A meta-analysis revealed that patients who actively engage in ERP early in treatment achieve better outcomes, as success depends on the willingness to confront discomfort. Dr. Penzel stresses the importance of building trust between the therapist and patient during this critical initial phase. According to Penzel, “Patients often come into therapy feeling overwhelmed and hopeless. Helping them take that first step into exposure work, no matter how small, sets the stage for future success.” Early victories, even with less challenging exposures, can boost confidence and reinforce the therapy’s effectiveness.
Penzel also emphasizes the value of psychoeducation during this stage, explaining the mechanisms of OCD and how ERP works to counteract them. As mentioned earlier, when patients understand why they are being asked to endure distress without compulsions, they are more likely to engage actively and maintain commitment to the process. He states, “The more patients understand their enemy, the more empowered they are to fight it.”
Inhibitory Learning
The inhibitory learning model teaches patients to tolerate distress and uncertainty by experiencing anxiety without performing compulsions, gradually weakening the obsession-compulsion cycle. Dr. Penzel emphasizes creating a “library of new experiences” to counteract OCD fears, such as a contamination OCD patient touching feared objects without becoming ill, which rewrites catastrophic associations.
Penzel highlights the importance of varied exposures, cautioning against rigid repetition that leads to habituation. He advises diversifying tasks to “surprise the OCD,” helping patients generalize tolerance for uncertainty across different areas. Mindfulness techniques also reinforce inhibitory learning by fostering nonjudgmental awareness, reducing emotional reactivity to intrusive thoughts, and teaching that anxiety, while uncomfortable, is not dangerous and fades without compulsions.
By combining early engagement, psychoeducation, and inhibitory learning principles, Penzel’s approach enhances evidence-based OCD treatments, boosting long-term recovery prospects.
Social Support
One of the most important pillars of treatment success, especially in OCD, is a consistent and reliable support system. Dr. Penzel mentions this is especially crucial when patients are instructed to not seek out reassurance for their obsessions. When discussing the nature of the disorder to support systems, Dr. Penzel says, “I explain how harmful [reassurance] is and how enabling it is…” to illustrate how families can help or hinder the treatment for the patient. The role of a loved one in a patient’s obsessions also play a critical role in treatment of their OCD (see also “Living With Your Loved One’s OCD: Some Advice for Significant Others”).
For instance, one of Dr. Penzel’s patients received therapy for obsessions he had about killing his girlfriend. In addition to Penzel’s guidance, the girlfriend also played an active role in the treatment plan. She participated in the homework, understood her partner’s obsessions, and would sit next to him while he was holding a big knife* in his hand saying, “Please don’t kill me.” This type of support helped the treatment by forcing the patient to confront his fear in every possible situation where harm could have occured, without reassuring his thoughts.
*We recommend not trying this one without consulting an OCD specialist!
OCD & Comorbidities
OCD can present with other mental illnesses, which, when considering treatment, may require a different approach. Specifically, such cases of comorbidity require identification of the additional mental illness that may be present, and may require treatment of the non-OCD mental illness first.
For example, OCD is one of the most common comorbidities associated with bipolar disorder. During manic or mixed episodes in patients with both OCD and bipolar disorder, the treatment of mood symptoms often takes precedence over the treatment of OCD (Kazhungil, F. & Mohandas, E., 2016). Thus, as Dr. Penzel suggests, managing the bipolar disorder first would offer the necessary stability required to address the OCD. Such approaches are similar to those with comorbid OCD and schizophrenia as well, where managing the more severe illness first gives way to effectively treat the obsessions-compulsions.
On the topic of personality disorders, Dr. Penzel believes that they can be difficult to address in psychiatry, which can make it difficult to identify as a comorbidity with OCD. However, the approach is similar. Patients who present with borderline personality disorder (BPD), or who have trouble regulating emotions, should receive DBT treatment before moving forward with OCD therapy.
Eating Disorders & Body Dysmorphic Disorders
Dr. Penzel discusses the connections between obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), and eating disorders, highlighting both their overlapping features and their important distinctions.
BDD, for instance, is classified within the OCD spectrum in the DSM-V due to shared elements, such as intrusive thoughts and compulsive behaviors. However, BDD is unique in its focus on perceived physical flaws, which drive behaviors like mirror checking or skin picking aimed at “fixing” these flaws (see also “Body Dysmorphic Disorder (BDD) Fact Sheet,” “Eating Disorders are Not the Same as Body Dysmorphic Disorder (And Why It Matters),” “Are Eating Disorders Obsessive Compulsive Disorder? Let Us Discuss,” “Treatment of OCD with Comorbid Eating Disorders,” and “Eating Disorders and OCD: Part of the Spectrum”).
Eating disorders, while they may share some similarities with BDD (such as body image concerns), are distinct conditions. As such, they involve broader psychological and behavioral dimensions and cannot be treated solely through OCD-based methods. Instead, specialized eating disorder therapies are required, though elements of cognitive behavioral therapy (CBT) for BDD, like body image work and exposure therapy, might provide useful tools.
Trauma & Post-Traumatic Stress Disorder
An additional area for exploration is the relationship between trauma and OCD. Although it is possible for obsessions to center around trauma, Dr. Penzel advises that professional judgement is necessary for determining which condition to prioritize for treatment. If the patient’s post-traumatic stress disorder (PTSD) is severe, addressing it first may help the patient effectively engage in their treatment for OCD. Furthermore, treatments for OCD may also be utilized in addressing trauma (i.e., exposure therapy via recordings). By engaging in such exposure, patients are able to build tolerance to their respective PTSD triggers, which can build the foundation to effectively treat the OCD. However, overlapping features of these conditions, such as intrusive thoughts and avoidance behaviors, can often complicate diagnosis.
For example, consider a case in which a patient has been sexually assaulted. This individual may develop a persistent fear of being assaulted again, which can evolve into intrusive, obsessive thoughts about personal safety and lead to compulsive behaviors (e.g., excessive checking of locks). In these cases of trauma, it is critical to determine whether a patient’s symptoms stem from PTSD, OCD, or a combination of both, to develop an effective treatment plan.
Trichotillomania & Skin Picking
Trichotillomania (i.e., hair pulling disorder) or excoriation disorder (i.e., skin picking disorder) are part of body-focused repetitive behaviors (BFRBs), and can have a variety of motivations or inputs. Specifically, it can develop from cognitive, sensory, environmental, or emotional symptoms. Although these disorders are on the spectrum of OCD, Dr. Penzel notes that the treatment for these disorders has to be more comprehensive, as each patient can have a different motivation for their disorder.
For example, a treatment can address the cognitive component for one patient, but a combination of sensory and environmental for another (see also “Comprehensive Behavioral (ComB) Treatment for Skin Picking and Hair Pulling Disorders,” “Excoriation (Skin Picking Disorder) Fact Sheet,” “Skin-Picking and Nail-Biting - Related Disorders,” and “Trichotillomania (Hair Pulling Disorder) Fact Sheet”).
OCD Recovery: After & Beyond
The goal for OCD treatment is to build an individual’s tolerance to their obsessions and anxieties. When thinking about what that looks like, or what the measure of recovery would be, Dr. Penzels explains, “[It’s] when we cannot come up with any more homework assignments to get your anxiety going anymore…[when] the thoughts no longer have an impact on you.”
Through a comprehensive approach, Dr. Penzel is able to illustrate that by requiring the patient to sit with and through the discomfort of their obsessions without engaging in compulsion, they can build the resilience necessary to overcome their OCD. Ultimately, patients will accept their thoughts as exactly that—just thoughts. Dr. Penzel notes that the first half of the treatment involves regaining control over one’s symptoms, and the latter half of treatment involves the maintenance of long-term control over one’s symptoms. Such insight serves as a cautionary note that patient’s must remain vigilant even after they achieve symptom remission in order to guard against future relapse.
The Strain of OCD on Support Systems
Often when patients with OCD struggle, their families struggle as well. Just as the patient loses time doing the obsessions, family time and connection can be lost in the midst of the illness. Attempts to disrupt compulsive routines can sometimes lead to heightened emotions or frustration within the family. Due to the nature of certain compulsions, families as a whole may be limited or restricted from normal activities to avoid triggers. The International OCD Foundation (IOCDF) offers an extensive network of resources and guidance for the families and support persons of patients with OCD.
How to Emotionally Heal from OCD
When a patient is in recovery, they may reach a point where feelings of guilt and depression begin to arise in the midst of seeing the impact of their illness on their loved ones. While these feelings can be challenging, they present an opportunity for patients to begin the process of self-forgiveness and healing. Patients must understand that they did not choose their illness. As such, forgiveness and acceptance of their past, as well as themselves, is a necessary first step in committing to getting better. Through self-forgiveness and embracing their past experiences (which may be explored via techniques such as therapy, journaling, mindfulness, among others), patients can embrace their new, optimistic future ahead of them and implement their new strategies to live in the present. This process ultimately helps patients build trust and security with their support system each day (see also “Coming to Terms With the Lost Years” and “What Do You Say After You Say You're Sorry?”).
Neurobiological Underpinnings of OCD
The roots of obsessions and compulsions in OCD lie in dysregulated brain activity. Historically, early Positron Emission Tomography (PET) imaging studies identified hyperactivity in the orbitofrontal cortex (OFC) and subcortical regions, primarily the basal ganglia (Baxter et al., 1987).
The basal ganglia are a group of deep brain structures, including the dorsal striatum (putamen and caudate), ventral striatum (nucleus accumbens), pallidum, and subthalamic nucleus. Together, they act as a central hub that filters and refines signals between the cortex, thalamus, and other brain regions, regulating movement, habits, and some emotional and decision-making processes. While early imaging studies lacked the resolution to fully map the complex interactions of these regions, they provided foundational evidence linking basal ganglia dysfunction to OCD.
Volumetric & Structural Differences in OCD
Advances in Magnetic Resonance Imaging (MRI) have enabled researchers to investigate structural abnormalities with more precision. A meta-analysis by Del Casale et al. (2024) synthesized data from over 3,000 subjects and revealed:
Increased gray matter volume in the basal ganglia, thalamus, left parietal cortex, and cerebellum.
Decreased gray matter volume in cortical regions such as the medial and superior frontal gyri, as well as subcortical areas like the hippocampus and caudate.
While these findings highlighted structural differences in OCD, most volumetric studies, including this meta-analysis, do not account for confounding variables like comorbid psychiatric conditions, socioeconomic factors, or childhood trauma—all of which are independently associated with brain morphology changes.
Fouche et al. (2022) controlled for some of these factors, including medication use and comorbid depression and anxiety, and found no significant structural differences overall. However, among OCD patients with comorbid anxiety or depression, they observed an increased surface area of the pallidum and a decreased surface area of the caudate, suggesting that structural differences might vary with clinical comorbidity.
Importantly, volumetric differences, while informative, do not necessarily correlate with symptoms (Radua and Mataix-Cols, 2009; Tang et al., 2013) or brain function.
Functional Connectivity and Networks
Because structural studies provide only snapshots of the brain, it is important to examine changes in how parts of the brain interact with each other. Resting-state functional MRI (rs-fMRI) explores the dynamic communication between brain regions while a person is at rest.
Given the findings on the basal ganglia and its potential implication in OCD, initial studies hypothesized there would be connectivity changes between it and other brain regions. Early studies did suggest disrupted connectivity between the striatum and both the PFC and the thalamus (Liu et al., 2023). These findings contributed to the development of the corticostriatal-thalamocortical (CSTC) model, which explains OCD symptoms as arising from dysfunction in these interconnected brain circuits. According to this model, the cortex (OFC and ACC) of a patient with OCD is hyperactive and more likely to produce perceptions of threat or anxiety. This cortical hyperactivity is theorized to be a result of hyperactivity in the thalamus, which relays sensory information to the cortex, and that this thalamic hyperactivity is due to dysfunction of the striatum. However, many of the findings that generated this model were limited by small sample sizes, study heterogeneity, and publication bias, and other studies have suggested that there are other dysfunctional circuits at play.
For example, a recent mega-analysis by the ENIGMA-OCD consortium (Bruin et al., 2023) combined data from 1,024 OCD patients and 1,028 healthy controls across 28 independent studies across the globe using standardized imaging methods. Key findings included:
No significant differences in connectivity between the striatum and PFC, challenging the CSTC models.
Hyperconnectivity between the thalamus and sensorimotor regions, particularly in patients with more severe symptoms.
Sensorimotor hypo-connectivity, suggesting a role for disrupted sensory and motor integration in OCD symptoms.
Interestingly, machine-learning algorithms trained on these connectivity patterns could not reliably classify OCD patients from controls, achieving accuracy only slightly above chance. However, such algorithms performed better in distinguishing medicated versus unmedicated individuals, suggesting medication may be more highly associated with consistent functional connectivity changes than OCD, per se. This may be due to the various ways in which OCD manifests or due to the fact that OCD patients were simply sitting in the MRI machine and not actively experiencing symptoms.
Task-Based fMRI: Inducing OCD Symptoms in Real-Time
Task-based fMRI studies that elicit symptoms of OCD provide a better lens to assess the brains of patients with OCD. Unfortunately, there are relatively few studies that employ this technique because the different symptom triggers associated with each person’s OCD are likely associated with differential brain activity, making these protocols hard to standardize and replicate (Thatikonda et al., 2024 [pre-print]; Viol et al., 2019).
Nevertheless, symptom provocation tasks consistently demonstrate differences in brain regions associated with cognitive control and performance monitoring (e.g., ACC, hippocampus, PFC, amygdala) (De Nadai et al., 2023; Viol et al., 2019).
ERP Therapy & Brain Connectivity
Exposure and response prevention (ERP), the gold standard for OCD treatment, targets the cycle of obsessions and compulsions. Two studies, Moody et al. (2017) and Becker et al. (2024), examined its effects on brain connectivity. Both reported changes in neural networks following ERP, including increased activity in the frontoparietal network and default mode network. However, these changes were not consistently correlated with symptom improvement as measured by the Yale-Brown Obsessive Compulsive Scale (YBOCS).
Insights from Deep Brain Stimulation (DBS) for OCD
While the neurobiology of OCD is not yet fully understood, the disorder is increasingly seen as one of disrupted network dynamics rather than isolated regional dysfunction. Current research supports the notion that OCD reflects over-stimulation of habitual thoughts and compulsions. The anxiety triggered by intrusive thoughts leads to behaviors that provide temporary relief but reinforce maladaptive cycles, likely through aberrant activity in the basal ganglia and reward circuits.
Deep brain stimulation (DBS) targeting areas such as the anterior limb of the internal capsule, which contains a large portion of axons in the CSTC circuit, and nucleus accumbens offers clues about the implicated circuits and holds promise as an intervention for severe cases (Mar-Barrutia et al., 2021).
Conclusion
OCD’s defining feature—chronic doubt—creates unique challenges, but also opportunities for effective intervention. Through evidence-based strategies like ERP, cognitive restructuring, and acceptance of uncertainty, patients can regain control and reduce compulsions. These approaches emphasize that intrusive thoughts are neither reflective of intent nor moral character, but rather byproducts of a misfiring brain. Dr. Penzel poignantly notes, “Recovery begins when sufferers stop fighting their thoughts and instead work on tolerating them, allowing uncertainty to become part of life.” By shifting the focus from eliminating doubt to tolerating it, OCD treatment fosters resilience and long-term recovery, ultimately allowing patients to once again engage fully in all aspects of their life.
References
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