Psychotherapies for obsessive-compulsive disorder have distinct effects on brain activity during emotional processing

Abstract Background To clarify the working mechanisms of psychotherapy for obsessive-compulsive disorder (OCD), we studied the neural effects of two psychotherapies: cognitive behavioral therapy with exposure and response prevention (CBT-ERP) and inference-based cognitive behavioral therapy (I-CBT). Methods Fifty-five individuals with OCD completed an emotional processing task during fMRI before and after 20 weekly psychotherapy sessions, using general fear and OCD-related visual stimuli. Forty-two healthy controls performed the task once. We used Bayesian region-of-interest analyses to assess changes in brain activation in prefrontal, limbic, sensory, subcortical, and visual areas, and their association with symptom improvement. Results After treatment, the CBT-ERP group (N=28) showed strong credible evidence for decreased activation across all brain regions during fear (but not OCD) versus neutral stimuli, especially in treatment responders. Conversely, the I-CBT group (N=27) showed increased activation during fear versus neutral stimuli in the precentral gyrus and lateral occipital cortex (LOC), which correlated with symptom improvement. A similar but weaker pattern was observed for OCD-related stimuli. Across all ROIs, baseline fear-related activity was associated with symptom improvement in CBT-ERP, while lower baseline activity was associated with improvement in I-CBT in, amongst others, the precentral gyrus and dorsolateral prefrontal cortex. Lower baseline LOC activation during OCD-related stimuli was linked to symptom improvement after both psychotherapies. Conclusions The results support CBT-ERP’s mechanism of fear reduction and I-CBT’s mechanism of sensory engagement. Visual brain activity during emotional processing may predict treatment response across psychotherapies.