The Obsession-Compulsion Cycle: Why Exposure is Critical

Obsessive-Compulsive Disorder (OCD) is defined by a cycle of intrusive, disturbing thoughts (obsessions) that become followed by behaviors intended to neutralize the distress of those thoughts (compulsions). While compulsions can provide a fleeting moment of comfort, they reinforce an unhelpful belief: the only way to survive an intrusive thought is to "do" something right now to make it go away.

In many cases, traditional therapy strategies—like creating more realistic thoughts or using breathing exercises to calm your body—can actually become new compulsions. These strategies turn into new actions people use to make their obsessions disappear. However, the obsessions keep coming back. This is where exposure and response prevention (ERP) comes in.

• The Goal: To break the learned association between a feared thought and a protective behavior.

• The Process: Gently and consistently expose yourself to the situations that trigger your obsessional fears.

• The Key is “Response Prevention”: By sitting with the distress (without performing a compulsion), your brain eventually recalibrates itself. You can learn through experience that the "feared event" doesn’t actually happen and you are able to tolerate discomfort without compulsions.

The Tension of Tics: When Waiting Doesn’t Feel Sufficient

While OCD is driven by irrational fears, tic disorders and body-focused repetitive behaviors—such as hair pulling (trichotillomania) or skin picking—are often experienced as more "basic" physiological urges. Patients may describe a building sense of internal tension like a "physical itch" that they feel can only be satisfied by performing the tic behavior. Unlike an OCD obsession, this tension is not necessarily tied as directly to an illogical fear.

When people with prominent tics try to use ERP (e.g., waiting for the tension to go down), they can sometimes feel defeated. The tension doesn't always dissipate like an irrational fear does. Instead, they experience tension that simply continues to build and pull for their attention. For these symptoms, it can be useful to try habit reversal training (HRT), often delivered via the comprehensive behavioral intervention for tics (CBIT) protocol.

If ERP is about rising above the fear, HRT is about interfering with the action. Because HRT is designed for behaviors that often feel semi-automatic or sensory-driven, it uses a three-pronged approach:

1. Awareness Training: Learning to notice the subtle urge or tension before the behavior happens.

2. Competing Response: Introducing a "substitute" behavior that is physically incompatible with the behavior (e.g., if you engage in hair pulling, you might practice gently tensing your hand muscles in your pockets).

3. Social/Environmental Support: Modifying your daily environment to reduce triggers and building a support system that reinforces your new competing behaviors.

ERP vs. HRT: Opposite Paths to the Same Goal

Because OCD and tic disorders are frequently comorbid (occurring together), it isn't always obvious which treatment to start with. In my practice, I focus on a functional assessment to see what is driving the behavior:

• Is it an irrational fear? If the maladaptive behavior is a response to a thought like "If I don't tap this object, my family will be in danger," we lead with ERP.

• Is it a physical urge? If the maladaptive behavior is a "release valve" for a physical sensation or occurs almost automatically without a lot of thought (like nail biting), we lead with HRT.

For complex cases, we may even alternate between these strategies, using HRT to manage highly disruptive motor tics with clearly defined patterns while using ERP to address the underlying anxieties.

Break Your Behavior Patterns

Whether you are struggling with the behavioral cycles of OCD or the urges of a tic disorder, you don't have to stay stuck in a pattern of frustration. Both ERP and HRT offer evidence-based pathways to help you move toward reclaiming your life.

In my telehealth private practice in Saint Paul, Minnesota, I specialize in using assessments to pair patients with the right psychotherapy treatments. By understanding the functional connection between your internal experiences and your outward behaviors, we can design a treatment plan that actually works with your brain and body rather than against it.