You're a cutting edge psychiatrist. Not only are you great with meds, but you have a passing knowledge of CBT (cognitive-behavior therapy) techniques for the treatment of OCD.

Sorry. You're already behind the curve. "ERP," and not CBT, are the current hot initials when discussing therapy for OCD. ERP stands for "exposure with response prevention," and it is hands-down the most effective nondrug approach to treating OCD. And many would argue that it is superior to psychopharmacologic treatment.

Most review articles on OCD treatment refer to a specific meta-analysis that makes ERP sound utterly invincible. In this paper, researchers analyzed 16 studies of ERP conducted between 1974 and 1992. They reported that 76% of OCD patients maintained good responses after an average post-treatment follow-up of 29 months (Foa and Kozak, Psychological Treatment for OCD, in Long-term Treatments of Anxiety Disorders, APA Press, 1996). This is a pretty astounding result. It certainly beats results of most drug studies, which range from 40-60% response rates, with follow-up usually limited to only 10 to 12 weeks.

Okay, these studies were far from perfect in terms of methodology. Most did not include a control group; they tended to be quite small; and many of the patients had received other forms of treatment during the long follow-up periods. Nonetheless, ERP clearly has something going for it, and you'd do well to understand its basics.

There are two aspects of ERP, and each one may be separately curative. In exposure, you encourage your patients to confront the situations that provoke their obsessive thoughts. Have your patient write down a graded hierarchy of anxiety-producing situations, from least to most threatening. For example, patients with contamination fears might start by imagining a dirty bathroom, then move on to standing outside a bathroom, then walking inside the bathroom without touching anything, then touching progressively "dirtier" parts of the bathroom, etc.... This is exposure without the response prevention, and it helps many patients by simply habituating them to these situations.

However, most experts believe that adding response prevention enhances the effectiveness of the therapy, and this is borne out by some research (J Consult Clin Psychol, 1980; 48:71-79). In this technique, you list the compulsive rituals your patient performs in order to lessen the anxiety associated with her obsessions, and you ask her to practice refraining from these behaviors for an hour or two after the exposure. For maximal therapeutic effect, your patient should practice this at least once a day and should expose herself to the obsession-provoking stimulus for at least an hour at a time.

Patients with significant OCD symptoms are not always thrilled with these assignments, to put it mildly. Tell your patient that he will feel a little worse initially as he faces his fears, but that the intensity of the anxieties will inevitable lessen with time, as he realizes that items that he thought were "dangerous" are actually benign. Tell him that it's like stepping into a hot tub--there's an unpleasant sensation initially, but it becomes quite tolerable as you get used to it.

Don't forget good old cognitive therapy techniques--they are still considered quite useful for OCD treatment. Redefine your patient's obsessions as "automatic thoughts" and encourage her to question them. She may believe that she has to get out of bed in the middle of the night to check her car door for the fourth time. But how likely is it that she would not have locked it the other three times she checked? Can she delay the actual checking behavior for a few more minutes, while she evaluates how rational her obsessive belief really is?

Several studies have compared pharmacotherapy with various versions of ERP and CBT. In general, they appear to work equally well. When patients have clear behavioral compulsions, therapy alone often does the trick, but when pure obsessions are dominant, adding SSRIs to therapy has been shown to be beneficial (Broocks and Hohagen, Psychotherapy in OCD, in Obsessive Compulsive Disorder: A Practical Guide, 2001, Martin Dunitz). Of course, on a practical level, there is a shortage of CBT therapists available for referrals, and many of our patients prefer to take a medication because they find it more convenient than therapy.

TCR VERDICT: Got ERP? Your patients are asking....