ERP for OCD: A Brief Primer

OCD is a debilitating disorder, but treatment is available.

Posted Jan 19, 2019

Obsessive-compulsive disorder (OCD) is an oft-debilitating disorder that affects 1-3% of the U.S. population. The main symptoms of OCD are, as the name suggests, obsessions and compulsions. Obsessions are intrusive unwanted thoughts, images, or impulses that cause much distress and anxiety. Compulsions are behaviors or rituals that are performed repeatedly in order to reduce the anxiety. Obsessions tend to cluster around common themes: Contamination worries, doubting/harm fears, symmetry/completeness urges, and unacceptable thoughts (blasphemous, violent, sexual). Compulsions, too, tend to fall into fairly clear categories: Cleaning/washing, checking, arranging/ordering, and counting/mental rituals.

The causes of OCD are not known. Biology is certainly involved, as obsessions and compulsions run in families, and appear in various medical conditions, including Huntington’s chorea, Parkinson’s disease, Tourette disorder, schizophrenia, and certain epilepsies, brain injuries, and tumors. The disorder may appear in childhood or later; it is often chronic, exacerbated by stress, and co-morbid with other anxiety and mood difficulties.

People with OCD characteristically find themselves preoccupied with distressing unwelcome thoughts. For example, they may believe they are responsible for some harm that may come to themselves or others, and assume that any influence they have over an outcome equals total responsibility for it (“I will fail to do something and it will lead to myself/others being hurt”). They often seek perfection and are distressed by its unattainability (“my hands are not perfectly clean; not clean enough”). People with OCD often experience what is known as, ‘thought-action fusion,’ equating a thought with an action. When distressing thoughts come to occupy and overwhelm them, they will often attempt to suppress the thoughts directly, a futile effort sometimes known as the ‘white bear problem’ (if we try not to think of a white bear, we end up thinking about it). Preoccupations with dangers, flaws, or mistakes are common. People with OCD often spend much energy and time ‘looking for trouble’ so to speak, acutely attuned to the cloud in the silver lining.

To deal with the distress caused by fearful thoughts and images, people with OCD turn to increasingly elaborate rituals and safety behaviors. These rituals of cleaning, checking, ordering, or counting are a means of anxiety avoidance. Like many other avoidance strategies, they work well in the short term. Alas in the long term they become a problem themselves. People with OCD end up working for their rituals long after the rituals have ceased working for them. In this, the underlying dynamics of OCD resemble drug addiction, in which the substance that was used for stress relief over time becomes a destructive stressor itself.

Obsessions and compulsions may be thought of as extreme, grotesque permutations of common and benign thoughts and behaviors. Many of us have occasional repetitive, intrusive, or strange thoughts. You imagine punching your boss in the face. You ruminate over lost love. Many of us perform stereotyped or superstitious behaviors. You wear your lucky tie to the job interview. You press the elevator button several times in a row. These behaviors may resemble OCD, but what sets them apart from the disorder is that they do not overwhelm you or cause significant distress and disruption in your life. In this case, to paraphrase Marks, quantity often creates quality. Washing your hands routinely after you go to the bathroom is not OCD. Washing your hands 100 times until they are red and raw is. 

By the available empirical evidence, the best behavioral treatment for OCD is Exposure and Response Prevention (ERP). ERP is designed to break the two maladaptive associations that reside at the core of OCD: The association between sensations of distress and the objects, situations, or thoughts that produce the distress, and the association between performing ritualistic behaviors and decreasing the distress.

With regard to obsessions, the goal of ERP is to have the client learn that they can have intrusive thoughts and experience distress without losing control of their behavior and without having to suppress their feelings or escape (or avoid) fearful situations. Exposure is the key therapeutic component to that end. Exposure is a procedure in which the client purposely confronts objects, images, thoughts, or situations that elicit distress and anxiety (but pose no real danger). The client then stays in those situations long enough for the anxiety to decrease.

Such a decrease in anxiety is achieved via several concurrent processes. First is physiological habituation, a process whereby nervous system arousal (which is necessary for the experience of anxiety) is reduced upon prolonged exposure to the same stimulus. Second is inhibitory learning, a process whereby new associations inhibit (rather than extinguish) old ones. Third is psychological empowerment, whereby the client learns from experience that they can manage distress, thus developing greater self-efficacy regarding coping. Fourth is skill acquisition whereby practice makes competence and competence reduces the need for fear. Finally, change during exposure happens through what is known in the literature as expectancy violations, as predicted disastrous consequences fail to materialize.

With regard to compulsions, the goal of ERP is for the client to learn, through experience, that they don’t need rituals to manage anxiety well. Response prevention is the key component here. It involves, as the name indicates, preventing the client from performing the ritual behaviors they engage in to reduce anxiety. As mentioned above, compulsive rituals are a form of anxiety avoidance. As such they prevent the clients from ever experiencing the benefits of true exposure. Response prevention, in contrast, facilitates the client’s heightened anxious arousal during exposure, and therefore helps the exposure exert its therapeutic effects.

Generally, ERP treatment will proceed in an orderly sequence of stages. Treatment will usually begin with a thorough assessment of symptoms. The therapist will work with the client to 1. Identify the client’s obsessions, their intrusive thoughts, images, or urges. 2. Identify the client’s rituals, what they do to decrease their anxiety, get rid of the thoughts, images, or urges, or minimize the likelihood of a feared consequence. 3. Identify the feared consequences (“if you had thought X and couldn't perform ritual Y what are you worried would happen?”) 4. Identify avoidances, situations that the client avoids so as not to feel anxious or have intrusive thoughts, images, or urges.

The second step is a process known as psycho-education in which, as the name implies, the client will receive accurate information about OCD, including prevalence statistics, common symptoms, available treatments and their effectiveness. The ERP approach is usually introduced during the process of psycho-education, and the client learns about the treatment rationale, goals, structure and components.

Then, the therapist and client will usually develop an ‘exposure hierarchy,’ (AKA ‘anxiety ladder’) consisting of feared and avoided things, places, and situations. To gauge the client’s distress, the therapist will often use a Subjective Units of Distress Scale (SUDS). Each item in the hierarchy will receive a SUDS rating (0-100), ranking items in order from least distressing to most distressing.

Once the hierarchy is set, ERP sessions will tackle each item on it, working gradually up the levels of distress. As the client faces distressful items, they are concurrently prevented from engaging in corresponding rituals or distracting ‘safety behaviors.’ ERP can be conducted in session—in the therapy room, with a therapist; or In Vivo—in real life situations with a therapist. It can also be carried out as homework without a therapist, and the therapist may also use ‘imaginal exposure’—having clients use their imagination to picture an exposure situation.

ERP works best when the exercises are specific and well designed, when the client’s anxious arousal is intense, and when the ‘dose’ of exposure is substantial and systematic. Sessions are often longer than usual (90-120 minutes), and twice or thrice weekly sessions are common. ERP is a sort of psychological workout. As in any workout, you tend to get out of it what you’ve put in. ERP is also aversive by design. It works through pain, not away from or around it. Thus, many people with OCD ask for constant reassurance during therapy. While reassurance is often useful in therapy, it undermines the effectiveness of ERP, interfering with full exposure. Reassurance seeking is in essence an OCD symptom (a ritual). Both client and therapist need to be aware of this. The therapist must remain accepting and non-punitive yet firm in emphasizing the importance of full exposure head on, sans distractions or detours. The client needs to summon their courage and perseverance, and accept the fact that short-term pain is the price of acquiring long-term health and wellbeing. The short-term pain of ERP is a better deal than living with the long-term punishment of untreated OCD.

If you are curious about your own OCD symptoms, here is a link to a solid screening instrument.

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