Obsessive-compulsive disorder: beyond segregated cortico-striatal pathways
Open accessAbstract
Obsessive-compulsive disorder (OCD) affects approximately 2-3% of the population and is characterized by recurrent intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions), typically performed in response to obsessions or related anxiety. In the past few decades, the prevailing models of OCD pathophysiology have focused on cortico-striatal circuitry. More recent neuroimaging evidence, however, points to critical involvement of the lateral and medial orbitofrontal cortices, the dorsal anterior cingulate cortex and amygdalo-cortical circuitry, in addition to cortico-striatal circuitry, in the pathophysiology of the disorder. In this review, we elaborate proposed features of OCD pathophysiology beyond the classic parallel cortico-striatal pathways and argue that this evidence suggests that fear extinction, in addition to behavioral inhibition, is impaired in OCD.
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Neurobiological theories implicate cortico-striato-thalamo-cortical (CSTC) circuits in the etiology of OCD.
“These range from neurobiological theories implicating cortico‐striato‐thalamo‐cortical circuits in the etiology of the disorder (Chamberlain et al., 2005; Graybiel & Rauch, 2000; Milad & Rauch, 2012; see also, van den Heuvel et al., 2016);”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Milad & Rauch, 2012
Research has implicated parallel CSTC circuits in the pathophysiology of OCD, and these circuits are responsible for reward- and motivational-related processes, executive function, motor and response inhibition, and habit-based behavior.
“Research has implicated parallel CSTC circuits in the pathophysiology of OCD (Chamberlain et al., 2005; Graybiel & Rauch, 2000; Milad & Rauch, 2012; see also, van den Heuvel et al., 2016), that is, responsible for reward‐ and motivational‐related processes, executive function, motor and response inhibition, and habit‐based behavior (Fineberg et al., 2018).”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Milad & Rauch, 2012
Such models have been revised over the years and now adopt a more dynamic view of CSTC circuits, for example, as functionally interacting rather than being fully segregated.
“such models have been revised over the years and now adopt a more dynamic view of CSTC circuits, for example, as functionally interacting rather than being fully segregated”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Milad & Rauch, 2012
These models are now more elaborate, for example, consider specific functions of OFC subareas (lateral versus medial) in relation to affective-, reward- and fear-based computation.
“these models are now more elaborate, for example, consider specific functions of OFC subareas (lateral versus medial) in relation to affective‐, reward‐ and fear‐based computation”
From Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction (2023) · cites this paper as Milad & Rauch, 2012
Neurobiological models emphasise abnormal communication between the orbitofrontal cortex, anterior cingulate cortex, dorsolateral prefrontal cortex, basal ganglia, and thalamus in OCD.
“Neurobiological models emphasise abnormal communication between the orbitofrontal cortex, anterior cingulate cortex, dorsolateral prefrontal cortex, basal ganglia, and thalamus, regions involved in action selection, error detection, threat evaluation, cognitive control, and habit formation [11,12,13].”
dACC is hyperactive in OCD patients during tasks involving error monitoring and/or conflict resolution.
“several studies have shown hyperactivity of dorsal ACC (dACC) in OCD patients during performance of tasks involving error monitoring and/ or conflict resolution, suggesting that dACC and connected regions might function differently in OCD 65”
From DISSECTING OCD CIRCUITS: FROM ANIMAL MODELS TO TARGETED TREATMENTS: Review: Dissecting OCD Circuits: Animals to Treatments (2015) · cites this paper as [65]
Anxiety is an important component of OCD.
“Regardless, it is clear from both clinical presentation and ongoing research that anxiety is an important component of the disorder.”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
Patients with OCD compulsively engage in repetitive or ritualistic behavioral sequences to alleviate or avoid severe distress and anxiety that often accompanies obsessive thoughts.
“Patients with OCD compulsively engage in repetitive or ritualistic behavioral sequences, which are typically performed to alleviate or avoid the severe distress and anxiety that often accompanies obsessive thoughts (Stein et al., 2010; Milad and Rauch, 2012; de Haan et al., 2013; Pauls et al., 2014; Ahmari and Dougherty, 2015).”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
Other brain regions, including dorsal striatum, are clearly important to the pathophysiology of OCD, and circuits including dorsal and VS are likely cooperative, not antagonistic.
“(3) We focus on VS circuitry, with the understanding that other brain regions, including dorsal striatum, are clearly important to the pathophysiology of OCD, and that circuits including dorsal and VS are likely to be cooperative, and not antagonistic (Insel and Winslow, 1992; Graybiel and Rauch, 2000; Milad and Rauch, 2012; Burguière et al., 2013, 2015; Gremel and Costa, 2013; Gillan and Robbins,”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
Compulsivity is often driven by anxiety, threat avoidance, or aberrant motivation in OCD patients.
“As mentioned above, compulsivity is often driven by anxiety, threat avoidance, or aberrant motivation in OCD patients (Milad and Rauch, 2012; Pauls et al., 2014; Ahmari and Dougherty, 2015).”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
Investigating corticolimbic-VS circuitry and developing more expansive OCD models that take limbic information processing into account are likely to help elucidate the pathophysiologic processes leading to OCD.
“Despite these caveats, investigating corticolimbic-VS circuitry and developing more expansive OCD models that take limbic information processing into account (Milad and Rauch, 2012; de Haan et al., 2013; Ahmari and Dougherty, 2015) are likely to help elucidate the pathophysiologic processes leading to OCD.”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
mOFC lesions impair the ability of non-human primates to select the most advantageous option when comparing differently-valued outcomes.
“mOFC lesions impair the ability of non-human primates to select the most advantageous option when comparing differently-valued outcomes (Rudebeck and Murray, 2011; Milad and Rauch, 2012; Noonan et al., 2012)”
From A framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors (2015) · cites this paper as Milad and Rauch, 2012
Conditioned fear and anxiety are thought to be important for OCD and can bias healthy individuals to behave habitually.
“Beyond irrational belief, conditioned fear and anxiety are also thought to be important for OCD (10) and indeed can bias healthy individuals to behave habitually 11, 12.”
From Enhanced avoidance habits in obsessive-compulsive disorder (2014) · cites this paper as [10]
Neuroimaging research using de novo fear-conditioning and extinction paradigms has revealed areas in the brain associated with experiencing conditioned fear (a fear expression network) in the amygdala and dorsal anterior cingulate cortex (dACC) and other areas associated with memory for the extinction (inhibition) of this fear (an extinction memory network) that includes the hippocampus and ventro
“Neuroimaging research using de novo fear-conditioning and extinction paradigms has revealed areas in the brain associated with experiencing conditioned fear (a “fear expression network”) in the amygdala and dorsal anterior cingulate cortex (dACC) and other areas associated with memory for the extinction (inhibition) of this fear (an “extinction memory network”) that includes the hippocampus and”
From Sleep and REM sleep disturbance in the pathophysiology of PTSD: the role of extinction memory (2015) · cites this paper as [61]
A deficit in the ability to encode, consolidate, or retrieve extinction memory is believed to play a role in the development and perpetuation of anxiety and trauma-related disorders.
“A deficit in the ability to encode, consolidate, or retrieve extinction memory is believed to play a role in the development and perpetuation of such disorders [6, 59, 61, 87].”
From Sleep and REM sleep disturbance in the pathophysiology of PTSD: the role of extinction memory (2015) · cites this paper as [61]
OCD share features of affective dysregulation linked to abnormal dACC activity.
“and share features of affective dysregulation linked to abnormal dACC activity (Milad and Rauch, 2012, Wood and Ahmari, 2015).”
From Inhibitory control in obsessive compulsive disorder: a systematic review and activation likelihood estimation meta-analysis of functional magnetic resonance imaging studies (2022) · cites this paper as Milad and Rauch, 2012
The connectivity from cortex to dorsomedial (caudate) and dorsolateral striatum (putamen) constitute parallel loops, namely the associative and motor loops.
“Previous studies proposed that the connectivity from cortex to dorsomedial (caudate) and dorsolateral striatum (putamen) constitute parallel loops, namely the associative and motor loops, respectively (Middleton, 2000, Milad and Rauch, 2012, O’Doherty et al., 2017, Seger, 2018, Yin and Knowlton, 2006).”
From Imbalance between the caudate and putamen connectivity in obsessive–compulsive disorder (2022) · cites this paper as Milad and Rauch, 2012
Abnormalities across different neurocircuits likely interact to produce the complex OCD phenotype.
“Abnormalities in these different neurocircuits likely interact with each other to generate the complex OCD phenotype [13–14].”
From Toward a neurocircuit-based taxonomy to guide treatment of obsessive-compulsive disorder (2021) · cites this paper as [13]
OCD has traditionally been linked to dysfunctional cortico-striatal-thalamo-cortical circuits, but alterations in fronto-limbic, fronto-parietal, and cerebellar circuits also contribute.
“OCD has traditionally been associated with dysfunctional cortico-striatal-thalamo-cortical (CSTC) circuits [12–13], although it is now recognized that alterations in other circuits (fronto-limbic, fronto-parietal, cerebellar) also play a role [14].”
From Toward a neurocircuit-based taxonomy to guide treatment of obsessive-compulsive disorder (2021) · cites this paper as [13]
SSRIs are the first-line pharmacological treatment for OCD.
“there is evidence that selective serotonin reuptake inhibitors (SSRIs), the first-line pharmacological treatment for OCD [13]”
From Toward a neurocircuit-based taxonomy to guide treatment of obsessive-compulsive disorder (2021) · cites this paper as [13]
Recent evidence indicates that the cortico-striato-thalamocortical model may still be refined and extended, especially by including brain regions implicated in anxiety.
“Although valuable, recent evidence indicates that this model may still be refined and extended, especially by including brain regions implicated in (the expression of) anxiety.7”
From Electrical stimulation in the bed nucleus of the stria terminalis alleviates severe obsessive-compulsive disorder (2016) · cites this paper as [7]
The classical neurocircuitry model of OCD should be extended to include other brain areas, for example those implicated in the expression of fear and anxiety.
“It has been argued that the classical neurocircuitry model of OCD should be extended to include other brain areas, for example, those implicated in the expression of fear and anxiety.7”
From Electrical stimulation in the bed nucleus of the stria terminalis alleviates severe obsessive-compulsive disorder (2016) · cites this paper as [7]
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- Authors
- Milad, M. R., & Rauch, S. L.
- Affiliations
- Harvard University (US)
- Corresponding author
- Milad, Mohammed R.
- Venue
- Trends in Cognitive Sciences
- Publisher
- Elsevier BV
- Published
- 2012-01
- Volume
- 16
- Issue
- 1
- Pages
- 43-51
- ISSN
- 1364-6613 (ISSN-L)
- PMC
- PMC4955838
- OpenAlex
- W2159370497
- Cited by
- 847
- References
- 101
- Citations by year
- 2026: 62 · 2025: 57 · 2024: 57 · 2023: 49 · 2022: 61 · 2021: 83 · 2020: 67 · 2019: 70 · 2018: 63 · 2017: 61 · 2016: 59 · 2015: 73 · 2014: 39 · 2013: 33 · 2012: 12
- FWCI
- 4.11
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Trends in Cognitive Sciences (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (5r01mh081975-05)
- National Institute of Mental Health (R01-MH081975)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- obsessive-compulsive disorder, OCD pathophysiology, corticostriatal circuits, orbitofrontal cortex, dorsal anterior cingulate cortex, amygdala, fear extinction, behavioral inhibition, obsession, compulsive behavior
- MeSH terms
- Amygdala, Anxiety Disorders, Cerebral Cortex, Compulsive Behavior, Corpus Striatum, Humans, Obsessive-Compulsive Disorder, Neuroimaging
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