CBT with Exposure and Response Prevention for OCD

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Although once considered to be highly treatment resistant, much progress has been made over the last two decades in identifying effective treatments for obsessive-compulsive disorder (OCD).

Randomized controlled trial findings support the efficacy of cognitive behavioral therapy (CBT), pharmacotherapy with serotonin reuptake inhibitors (SRIs), and combined treatment (Watson HJ and Rees CS, J Child Psychol Psychiatry, 2008;49(5):489–498).

According to the National Institute for Health and Clinical Excellence (the health authority for England and Wales that carries out assessments of the most appropriate treatments for different diseases and conditions), CBT that focuses on exposure and response (ritual) prevention (ERP) is considered the psychological treatment of choice for OCD (National Clinical Practice Guidelines 2006, http://guidance.nice.org.uk/TA97).

Studies have shown ERP to be more effective than placebo, clomipramine (Anafranil), and anxiety management in treating OCD (Foa EB et al, Am J Psychiatry 2005;162(1):151–161; Lindsay M et al, Br J Psychiatry 1997;171:135–139). Simply put, while other options are available and viable, ERP cannot be ignored as a “best practice” treatment for OCD.

As far as the SRIs used to treat OCD, those shown to have efficacy include the nonselective SRI Anafranil, and the selective SRIs, such as fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) (Abramowitz JS, J Consul Clin Psychology, 1997, 65(1), 44–52). (For more information about those medications, see “Medications to Treat OCD.”)

The How-To of ERP

ERP for OCD involves gradually exposing patients to objects or situations that trigger both obsessional fears and urges to ritualize, followed by instructions to abstain from compulsive behavior. The primary components of ERP include in vivo exposure, imaginal exposure, ritual prevention, processing, and, when feasible, home visits.

Through this approach, patients learn several important points, including:

  • They can master anxiety provoked by obsessions without performing rituals.
  • The anxiety/distress/urge to ritualize does not last forever.
  • Anxiety decreases even without escaping, avoiding, or ritualizing.
  • Feared consequences are either disconfirmed or shown to have low probability of occurring.

Seven Steps to ERP

Experts recommend the following approach to facilitating in vivo exposure with ritual prevention (Foa EB, Dialogues Clin Neurosci 2010;12(2):199–207; Koran LM et al, Am J Psychiatry 2007;164 (7 Suppl):5–53).

  • Present rationale for ERP. Many patients are initially resistant to the idea of ERP given their long histories of attempts to confront obsessions and stop compulsive behaviors, only to see anxiety skyrocket. Inform patients that by not engaging in their usual rituals, they can learn to cope with distress and that they do not need to perform rituals to keep themselves safe.
  • Introduce Subjective Units of Distress Scale (SUDS). Provide education about the use of SUDS in ERP and determine the patient’s anchors (numeric or word labels that represent different levels of feelings) on that scale. SUDS is a scale that allows patients to self-assess and measure subjective levels of discomfort or disturbance experienced in specific situations. Typical SUDS scales involve anxiety ratings ranging from zero (completely relaxed) to 100 (the worst anxiety imagined). Other scale ranges may be used, such as a ranking of one to 10.
  • Create a list of feared situations. Guide the patient in constructing a list of triggering situations, thoughts, or objects arranged in a hierarchy from the least distressing event to the most distressing (based on SUDS ratings). For example, a patient with contamination fears might rank touching a door handle without washing her hands lower than touching a toilet seat and then touching her face without hand washing.
  • In vivo exposures. Tailor exposure exercises to confront items on the patient’s hierarchy in ascending order, both in session and at home. It is usually helpful for patients to begin exposure therapy with items/activities on their hierarchy that are distressing enough to cause anxiety but easy enough to complete successfully until more confidence is gained. Importantly, instruct patients to stay in the feared situation until their SUDS level decreases by at least 50% (eg, patient initially ranks situation an eight out of 10 and decreases to a four out of 10), or, until anxiety habituates.
  • Response (ie, ritual) prevention. Instruct the patient to abstain from the ritualizing that they believe prevents the feared disaster or reduces the distress produced by the obsession. For example, a person who fears something bad will happen if she does not arrange her shoes in a certain order may be asked to leave these items in disarray or in the “wrong” order.
  • Processing. Discuss the patient’s experience during or after ERP, and how this experience confirms or disconfirms original expectations (eg, “You touched the toilet seat and you did not wash your hands for about one hour. Is your level of distress as high as in the beginning of the exposure? Are current urges to wash as strong as you expected?”).
  • Repeat exposures. Research has demonstrated that fears and compulsions will almost always decrease with consistent ERP practice. Therefore, repeat exposures until the particular item on the hierarchy causes the patient little to no problem (ie, the patient achieves anxiety habituation). The person’s anxiety tends to decrease after repeated exposure until he or she no longer fears the contact.

Importantly, you may need to redirect the patient from engaging in safety behaviors or subtle forms of avoidance during exposures (eg, thinking about other things, talking to someone, touching the toilet seat with one finger instead of the entire hand, etc.), as this prohibits patients from fully experiencing distress, and makes it more challenging to overcome fears in the long run. Also, because family members often play a role in the maintenance of safety behaviors, teach significant others and loved ones to refrain from providing patients with reassurance or performing “OCD by proxy,” for example, by responding to questions about whether certain household objects are contaminated or washing the patient’s clothes so she does not have to confront the OCD-related distress associated with dirty laundry.

The actual form of exposure therapy may differ depending on the particular symptom to be treated, as well as the situations that trigger it. For patients whose intrusive thoughts are dependably triggered by specific events or objects, in vivo exposure is usually effective. Some individuals, however, experience obsessive thoughts and perform no rituals, and the target behaviors are the thoughts themselves. In vivo exposure can be augmented or intensified by less direct exposure methods in which the patient is required to imagine facing the feared situations (ie, imaginal exposure), listen to the bad thought via audio loop tape recordings, or repeatedly watch videotapes with triggering themes. Consider using these techniques when targeting obsessions that may be difficult or impossible to implement through exposure in vivo (eg, worry about killing others or satanic possession).

In summary, while neither psychological nor pharmacological approaches provide a “cure” for OCD, they permit greater control of the symptoms and enable patients with OCD to restore normal function in their lives.

TCBRH’s Take: CBT, especially CBT that incorporates ERP, provides the patient with an approach whose rationale can be easily understood. It is an especially useful approach in that its basic template can be applied to a wide variety of OCD symptoms.