Effective Treatment of OCD

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Obsessive Compulsive Disorder (OCD) is a psychiatric disorder that occurs in approximately 2% - 3% of the population, the treatment of which has been extensively studied.

Research indicates that the most effective treatments for OCD include a specific type of Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP or EX/RP), and/or psychopharmacological treatment with selective serotonin reuptake inhibitors (SRIs).

  ERP has been shown to result in a 60% - 80% reduction in OCD symptoms, while SRIs have been demonstrated to lead to improved symptoms in approximately 40%  - 60% of patients with OCD who report a 20%-40% reduction in symptoms. Each of these treatment strategies are considered to be “first line” treatments, resulting in symptom improvement in approximately 70% of those receiving treatment, with the most effective strategy being a combination of ERP and SRIs.

What is ERP?

Despite the robust data to support the efficacy of ERP in the treatment of OCD, it is often misunderstood.  ERP is a process based on the principles of learning and emotional processing theories.  It is a systematic, gradual process in which the therapist guides the patient through a hierarchy of increasingly anxiety-provoking stimuli related to the patient’s obsessions and feared outcomes, while prohibiting the performance of rituals (compulsions) that have historically been carried out in an effort to decrease anxiety and distress.

 With repeated ERP, the patient’s fear response typically diminishes (habituation) to the extent that the obsession triggers no longer evoke a drive to engage in compulsion (extinction).

For example, ERP for a patient who fears the possibility of losing control and harming someone may include tasks such as writing and reading stories about wanting to harm a loved one, imagining stabbing a family member, using knives to cut vegetables in the kitchen with a relative standing nearby, and holding a knife while making statements indicating the intention to stab the therapist, all while refraining from any avoidance or safety behaviors, mental rituals, checking rituals, and reassurance provision.

 With repeated exposures, the fear response is diminished, allowing the patient to move on to more challenging exposures. Ultimately, at the end of the hierarchy, the patient experiences little to no anxiety associated with the previously identified obsessions and has significantly reduced or eliminated compulsions.

Why does ERP work?

It is believed that ERP is effective due to new associative learning. When obsessions and compulsions are entrenched, and the individual comes into contact with something that triggers their obsession (for example, a stain on a waiting room chair), the individual immediately appraise this as potentially dangerous (“This could be a blood stain, which, if touched, may transmit HIV and harm me.”) The individual then reacts with emotional and physiological distress and arousal. Because this feels so threatening, the individual chooses to engage in a compulsion (such as, avoiding the chair or washing hands if the chair was touched) in an attempt to bring down the distress and decrease the perceived risk.

 It is believed that repeated exposures to that which evokes an individual’s misperception of danger and fear response, without minimizing perceived risk via compulsion, allows the individual to disconfirm their unrealistic fears. Thus, these ERP experiences activate the individual’s unreasonable associations of danger and fear, when coupled with an absence of the safety behaviors they are accustomed to carrying out, allowing them to learn that their interpretation of danger is incorrect and their distress unwarranted.  This newly learned information is then incorporated into the individual’s cognitive and emotional processes, thereby eliminating OCD symptoms.

To access information regarding the treatment of OCD and learn where to find an OCD therapist near you, visit www.iocdf.org

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