Several treatments for OCD may target fronto-limbic dysfunction (summarized in Table 3). For example, cognitive behavioral therapy (CBT) is an evidence-based form of psychotherapy for OCD that typically includes exposure and response prevention (ERP) with different formats varying in the degree of and procedures for training in cognitive reappraisal [50]. ERP seems to be mediated, at least in part, by modulation of amygdala-vmPFC connectivity, while cognitive reappraisal appears to dampen fronto-limbic activity via the engagement of top-down dorsal prefrontal regions [35–36, 39, 51]. CBT may therefore target fronto-limbic dysfunction directly via ERP or indirectly via cognitive reappraisal. Neuroimaging studies indicate that better CBT response in OCD is predicted by hyperactive fronto-limbic responses to OCD-provoking stimuli and weaker amygdala-prefrontal functional connectivity [52–53]. These findings lead to the hypothesis that patients who show fronto-limbic dysfunction associated with dysregulated fear may benefit most from CBT. Although not explicitly addressed in treatment, CBT/ERP has been shown to reduce IU in OCD and reductions in IU occurred prior to, or concurrent with, reductions in OCD symptoms [54–55].
