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Summary: Exposure response prevention therapy for OCD (obsessive-compulsive disorder) – called ERP or ERPT – is an evidence-based cognitive-behavioral therapy that’s effective in reducing the symptoms of mild, moderate, severe, and treatment-resistant obsessive-compulsive disorder (OCD).

Key Points:

  • Experts consider severe OCD among the most disruptive and debilitating mental health disorders known, often associated with significant long-term impairment and severe functional disability.
  • Obsessions and compulsions can cause serious emotional and psychological distress, and interfere with relationships, school, and work.
  • People without OCD should understand that OCD is not a joke, but a very real mental health disorder that can dominate daily life.
  • Evidence-based treatments like ERP can help patients manage symptoms and regain control of their lives.

Exposure Response Therapy for OCD (obsessive-compulsive disorder): Basic Facts

The International OCD Foundation (IOCDF) provides this excellent definition of exposure response prevention therapy (ERP or ERPT):

“Exposure and response prevention (ERP) is a form of cognitive behavioral therapy (CBT) that is widely used in the treatment of OCD. It is considered the first-line psychological treatment due to its very strong evidence base and effectiveness in reducing symptoms and improving functioning in people with OCD.”

ERP has become a front-line, first-line treatment for OCD for the simple reason stated above: it works. Studies examining the effectiveness of exposure response therapy for OCD measure changes in OCD symptoms using several standardized metrics, including:

Yale-Brown Obsessive Compulsive Scale (Y-BOCS):

  • Clinician administered and graded scale
  • Includes ten items, with cumulative scores indication level of OCD severity:
    • Score of 0 reflects no OCD symptoms
    • Score of 40 reflect extremely severe OCD

Obsessive Compulsive Inventory – Revised (OCI-R):

  • Self-report scale that assesses six subscales of OCD:
    • Washing
    • Checking
    • Fixing
    • Obsessing
    • Ordering
    • Hording

Florida Obsessive-Compulsive Inventory: (FOCI):

  • Brief self-report scale that measures presence and severity of OCD symptoms

Dimensional Obsessive-Compulsive Scale (DOCS)

  • Clinician-administered metric assesses symptoms across four dimensions:
    • Contamination fears
    • Harm fears
    • Unwanted intrusive thoughts
    • Ordering and symmetry concerns

Across a series of meta-analyses and random-controlled trials (RCTs) – over a hundred total – patients who engaged in ERP consistently showed symptom improvement on all of the scales we list above. Highlights of studies include:

  • Significant symptom reduction: average of 35% improvement on Y-BOCS
  • Long lasting symptom reduction: improvements of 50% – 70% persisted for several months
  • Focused study of 28 patients with an average reduction of 55% post treatment and 60% after six months
  • Meta-analysis with data from close to 2,000 patients found significant reductions in OCD symptoms compared to placebo and standard stress reduction protocols.
  • Meta-analysis of 48 RCTs on ERP treatment protocols showed:
    • Significant symptom reduction immediately post-treatment
  • Meta-analysis of 16 RCTs on ERP showed moderate symptom reductio at follow up

For an in-depth look at the symptoms, prevalence, and detailed facts about obsessive-compulsive disorder, please read this article on our blog:

What’s the Best Treatment for Obsessive-Compulsive Disorder?

That’s the background on ERPT and a brief look at the evidence that supports it. Now let’s dive deeper into how exposure therapy for OCD works.

Exposure Response Prevention Therapy (ERPT): Process and Goals

The goal of ERPT is to reduce the symptoms of OCD. The process involves gradually exposing a patient to their obsessive thoughts in a manner which, over time, reduces the emotional disturbance and fear caused by those thoughts, thereby reducing or eliminating – over time – the drive and overwhelming need to engage in compulsions. The short-term goal is to interrupt patterns of thought that account for the persistent disruption caused by OCD.

Here’s the dysregulated thought pattern that the ERPT can interrupt and restructure to minimize distress, anxiety, and fear associated with OCD, as defined in the publication “Management of Obsessive-Compulsive Disorder in Adults.”

Cycles of Thought, Obsession, and Compulsion in OCD

  1. Typical unwanted or intrusive thoughts occur, including
    1. Doubts
    2. Fears
    3. Anxieties
  2. Misinterpretation of those thoughts occurs, causing:
    1. Exaggerated beliefs
    2. Inaccurate memories
    3. False conclusions
    4. Unsupportable conclusions
  3. Emotional consequences of misinterpretation appear, including:
    1. Anxiety
    2. Guilt
    3. Fear
    4. Distress
  4. Enacting of compulsions ensues, in order to:
    1. Escape distress
    2. Reduce anxiety
    3. Avoid fear
  5. Temporary relief, which fades quickly, resulting in:
    1. Cycle back to [D], recapitulation of compulsions
    2. Cycle back to [B], recapitulating dysfunctional thought cascade
  6. Process repeats

But how does that work, exactly?

During the process, providers work with people with OCD and name the primary fears, worries and anxieties that cause their obsessions and compulsions. In the initial treatment sessions, they grade, rank, or categorize them in order of disruption and severity, from most to least disruptive/intense. Here’s the scale they use: the SUDS.

Subjective Units of Distress Scale (SUDS)

  1. 10 or 100: Highest level of anxiety and distress
  2. 9 or 90: Extremely anxious or distressed
  3. 8 or 80: Very anxious/distressed, unable to concentrate
  4. 6 – 7 or 60-70: Quite anxious/interferes with function
  5. 5 or 50: Moderate anxiety/distress, uncomfortable but able to function
  6. 3-4 or 30-40: Mild anxiety/distress, no interference
  7. 2 or 20: Minimal anxiety/distress
  8. 1 or 10: Alert, awake, concentrating easily
  9. 0 – 0: Totally relaxed

Once they create this list, they work on each ranked worry or fear in a gradual, controlled, and progressive manner. In most cases, they start with a moderate fear – one that ranks around the middle, at (5) or (50).

What happens next?

Time, Trust, and Belief: It’s Possible to Rewire Your Brain

Next, over the course of 12-20 individual ERPT sessions, patients and providers work through the hierarchy of fears/anxieties they create at the beginning of treatment. In a trusting environment characterized by openness, compassion, honesty – and supported by a feeling a safety and comfort – patients and providers follow this general protocol:

  • Expose the patient to the anxiety/fear chosen for the day from the hierarchy of fears they created.
  • Learn and practice techniques to manage – meaning interrupt and reframe – automatic emotional responses to the relevant fear, i.e. automatic responses based on the misinterpretation of unwanted, but common, fears, doubts, and anxieties.
  • Learn and practice techniques to manage automatic behaviors – i.e. compulsions – caused by emotional responses to the persistent misinterpretations of fears, doubts, and anxieties.
  • While maintaining an atmosphere of trust, safety, compassion, and connection, providers and patients repeat the therapeutic protocol until the patient ceases to misinterpret the initial unwanted thoughts, thereby eliminating the dysregulated emotional reaction, which can reduce or eliminate the drive to engage in compulsive behaviors.
  • This process is called habituation, which can result in disentangling common thoughts from dysregulated emotional responses, and dysregulated emotional responses from dysregulated patterns of behavior.
  • When the ranked fears stop triggering misinterpretations and the absence misinterpretations leads to the absence of distressing emotions, patients experience robust symptom reduction and relief from the negative consequences of OCD.

At first blush, it may not seem like a good idea to intentionally expose people with OCD to the exact things that trigger their OCD.

The thing is, though, it works.

Years of studies from every possible angle consistently show that exposure therapy works. The exact mechanism by which it works is undefined, but the functional outcome is logical, when you take a moment to reflect: the problems associated with OCD most often derive from emotional reactions to false or exaggerated conclusions. When a therapist and a patient can get down to the core misses – e.g. incorrect ideas and disproportionate emotions – real healing for people with OCD can start.

What Else Should People With OCD Know About Exposure Response Therapy for OCD?

The most important thing for people with OCD to know is that evidence-based treatment works. It might not be easy, and it may take time, but with an open mind, trust in the process, and belief that healing is possible, healing becomes possible.

We also want people with OCD to understand that the long-term consequences can be severe, and that mild OCD can become moderate OCD and eventually escalate to severe OCD, when left untreated.

Consequences of Untreated OCD

  • Isolation from social activities, friends, and family
  • Problems forming and keeping healthy, fulfilling relationships
  • Decrease or drop in achievement at work and school
  • Difficulty finding and keeping gainful employment
  • Delayed ability to enter adult life and attain financial and personal independence
  • Self-medication with alcohol or drugs
  • Alcohol use disorder (AUD) and substance use disorder (SUD)
  • Co-occurring mental health disorder
  • Suicidal ideation and/or self-harm

In addition, it’s also important to understand that OCD commonly co-occurs with other mental heath disorders. This can complicate both the diagnostic and treatment process. Symptoms often overlap, and treatment for one disorder may not be appropriate for another. In some cases, medication or therapy for one disorder can make the other worse.

That’s why it’s essential to seek professional support: a skilled and experienced professional can offer an accurate diagnosis and offer treatment that helps rather than harms, and identify the presence of co-occurring disorders in the context of an OCD diagnosis.

Evidence shows the following rates of co-occurrence with OCD for the following disorders:

  • One additional mental health disorder: 90% of people with OCD
  • Presence of depression or bipolar disorder: 65%
  • Presence of ADHD or another disorder characterized by impulsivity: 56%
  • Diagnosis of substance use disorder: 40%
  • Diagnosis of additional anxiety disorder: 76%

In addition, International OCD Foundation indicates OCD often appears alongside, and is closely related to hoarding disorder, body dysmorphic disorder, and other maladaptive self- and body-directed behaviors.

Finally, we want to assure people who aren’t interested in the idea of exposure therapy that they can still engage in all the other forms of treatment that help people with OCD, including:

Psychotherapy:

  • Cognitive behavioral therapy (CBT)
  • Eye-Movement Desensitization and Response (EMDR)
  • Acceptance and commitment therapy (ACT)

Medication:

  • Second-generation antidepressants (SSRIs)
  • First-generation antidepressants (TCAs)

Brain stimulation:

  • Transcranial magnetic stimulation (TMS)
  • Deep brain stimulation (DBS)

The message we want you to take away from this article is that if you have OCD, there are a variety of treatments that can work. Evidence shows cognitive-behavioral based exposure therapies are the most effective, but if exposure therapy does not sound like a good match, it’s possible to explore other treatment options on the road to recovery.

Finding Help: Resources

If you or someone you know needs professional treatment and support for obsessive-compulsive disorder (OCD), please contact us here at Crownview Co-Occurring Institute. We know how help. In addition, you can find support through the following online resources: