Part 1 OCD – A Biological Perspective looks at how certain brain parts responsible for OCD become locked.  It discusses how a person attempts to correct their obsessional problem by yielding to compulsive behaviours to make the obsessions go away (albeit unsuccessfully) and to relieve anxiety momentarily.  Part 2 explains how treatment is able to weaken the disorder on a bio-behavioural level – that is, with cognitive behavioural therapy (CBT), exposure response prevention (ERP) and medication.

PART 2: How psychological factors play a role in OCD

Is it true that paying attention to intrusive thoughts maintains OCD?

It’s more likely that a person’s attention is drawn to the types of beliefs seen in OCD. These beliefs serve only to compound the disorder. [2] For example, when a non-OCD person gets a fleeting thought about harming someone and then questions that thought, such as: “I wonder what made me think that?” and then lets it drop, this brief error in thinking will filter out automatically along with the initial intrusive thought.  As a psychiatric disorder however, thinking errors that link to certain types of beliefs are much more intense. A moral tone, for example, is often added to the cognitive error – in this instance, labelling. 

John says: “I am fearful that I could have harmed a person today (thinking error); deep down I must be a dangerous person (labelling).”

Why does this happen?

The person mistakenly believes that their thoughts are in some way linked to actions (thought-action fusion (TAF); Rachman, 1993). This has been divided into moral TAF and likelihood TAF. In moral TAF a person may believe that having an intrusive thought about harming someone actually makes them as guilty as if they’d literally committed the offensive act. In likelihood TAF people believe they are more likely to do the offending act. [3] Still, while thinking errors may compound the disorder, it is the self-reinforcing behaviours known as compulsions that feed and maintain OCD.

So if compulsions reinforce and support OCD, what can change this?

The gold standard treatment for OCD is cognitive behavioural therapy (CBT) with exposure response prevention (ERP). This is a scientific-researched therapy. Medication (a selective serotonin reuptake inhibitor) is usually combined with therapy. The first actively alters brain chemistry; and the second improves serotonin levels and is known to reduce symptoms by up to 60%.

How does ERP work with cognitive behavioural therapy?

First, cognitive therapy helps to alter the types of beliefs seen in OCD, noted earlier; and the behavioural part (ERP) helps to prevent the self-reinforcing behaviours that are a direct consequence of the obsession [3]. Put another way, cognitive therapy teaches rational awareness and acts as the foundation for facing obsessions (exposure) and to resist yielding to corresponding compulsions (response prevention) while at the same time riding out raised anxiety. The end result is that the person is able to shift more freely to the next thought/behaviour (see neostriatum – part 1).

But why tolerate increased anxiety to recover?

The simple answer is to build distress tolerance. As a result, the person becomes habituated to whatever it is that causes them fear. Thinking/filtering plus movement thus reverts back to automatic, or at least becomes less sticky. [1]

Anxiety Tip: Being aware that anxiety reaches a peak during ERP and knowing that it reduces all by itself is key to losing a certain amount of fear when the gut feeling strikes. In other words, anxiety cannot go any higher after it’s reached its peak and therefore begins to subside without intervention, usually within 15-30 minutes and no longer than an hour. The more a person faces their obsessions in graded steps and resists giving into compulsions, the sooner their anxiety reduces overall.

Some people have an aversion to ERP. Is there an alternative?

Yes, behavioural experiments can replace ERP and work effectively with CBT. By gathering information to test a person’s prediction, hypothesis or belief a therapist helps them reason out alternative choices for more favourable outcomes.


The interacting parts of the brain that cause OCD become locked (see part 1).  As a consequence sensible reasoning becomes confused and attempts to correct the obsessional problem with compulsive behaviours (emotional responses) serve only to reinforce the problem. CBT with ERP is the treatment of choice, which leads ultimately to recovery, or at least reduced symptoms. In moderate-severe cases medication is often also prescribed. Behavioural experiments are also effective.

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[1] Brainlock by Jeffrey M. Schwartz, M.D. with Beverley Beyette covers a cognitive bio-behavioural approach that can help you free yourself from obsessive-compulsive disorder.

[2] Radomsky and his colleagues found that the thoughts, images and impulses symptomatic of obsessive compulsive disorder (OCD) are widespread. “Almost everyone has these kinds of thoughts. They’re normal, and they’re a part of being human,” Radomsky said. For people who suffer from OCD, this knowledge “can be incredibly helpful to change the meaning that they ascribe to the intrusive thoughts.”

[3] Cognitive Therapy – Obsessive Compulsive Disorder – A Guide for Professionals by Sabine Wilhelm, PH.D. and Gail S. Steketee, PH.D