Exposure and response prevention for OCD - Himle & Franklin (2009) - Article

Exposure (EX) and response prevention (RP) are techniques aimed at teaching someone with OCD to approach rather than avoid feared stimuli. The cause of OCD remains unknown and there is no theory that fully explains this disorder. It is quite certain that the cause is multifactorial involving interactions between, genetic, physiological, behavioural including cognitive, emotional and social factors.

Theoretical Rationale for EX/RP

The two-factor theory of fear states that when an individual is faced with a situation that elicits a physiological fear or anxiety state, an unconditioned behavioural reaction to escape is initiated. If the action performed to reduce the anxiety is successful , the action is strengthened and more likely to occur in the future. Someone can be said to have OCD when this escape response is compulsive. EX/RP is based on the assumption that if an individual is systematically exposed to stimuli that elicit obsessional thoughts and anxiety, and is prevented from escaping or neutralizing the anxiety, the anxiety will diminish over time through the process of extinction. In the therapy the relationship between someone’s obsessions and compulsions is tried to be modified. The client has to experience that the feared consequences do not actually occur if the compulsions are not performed. The cause and content of the compulsions is not of relevance for the treatment. Attempts to investigate the cause of OCD are discouraged, since it can make the symptoms worse.

Empirical Support for EX/RP for OCD

Based on the literature EX/RP seems to be an effective treatment for 60% to 90% of the individuals. In addition, the effects last to 2 years after the treatment has finished. The improvement rates are higher than those of pharmacological studies and head to head behaviour therapy.

Case Conceptualization

The described case is about Caroline whose primary obsessional theme is a fear that she will cause harm to her family members or friends by spreading bad energy or illness. This bad energy gives her the feeling of dust on her hands. Caroline’s compulsions to prevent harm were first flicking her fingers to remove the dust but now she is afraid to spread the bad dust. Therefore she closes her hands into fists if she gets the feeling of dust, she prays to god to protect others around her, she repeats the phrase ‘’just goodness’’, she avoids saying goodbye out of fear to harm someone with the gesture, she wipes her hands before visiting someone who is ill and she performs rituals to remove contaminants after visiting someone who is ill. These are all overt compulsions. By proxy rituals, often referred to as accommodation, are rituals in which the close others of someone with OCD have to engage. Covert compulsions are not visible. Caroline creates an imagined circle around someone who needs protection to prevent possible harm.

In therapy, in addition to EX/RP, cognitive therapy techniques can be included to target maladaptive cognitions. This might also lead to greater compliance to the EX/RP. However, the use of cognitive therapy is not meant to change or suppress irrational obsessions because that can make them worse. Cognitive therapy can be used to teach Caroline to make better estimates of the likelihood that certain damages will occur. First, Caroline has to know that she performs those rituals to decrease the anxiety and that the relief this brings is a maintaining factor. Not performing the rituals is the only way to experience that her feared harm will not occur. According to Abramowitz (2006), to achieve success, patients should expect to feel uncomfortable and not try to fight this discomfort.

Implementation of EX/RP

The amount of sessions is, among others, depended on the severity of the symptoms. In general, individuals need 12 to 15 sessions conducted weekly lasting 60-90 minutes. The primary components of EX/RP include assessment of OCD symptoms, psycho-education, treatment rationale, symptom monitoring, developing fear hierarchies, in and out-of-session exposure, relapse prevention and generalization training.

Assessment and Review of OCD Symptoms

OCD symptoms are assessed with the Yale/Brown Obsessive Compulsive Scale. In addition, other structured interviews (such as the SCID) and self-report instruments (such as the NIMH-GOHCS) can be used.

Psycho-education

During the first few sessions and if necessary psycho-education is given. The purpose is to provide an overview of recent research on the biology and behavioural characteristics of OCD, removing blame by telling that it is a neurobehavioural disorder with unknown cause (if someone is really focused on finding a cause), avoid analysis to find the cause of OCD, and to outline how OCD is impairing the patient’s daily life. The focus lays on the present and future. Psycho-education stimulates externalizing of OCD, this makes it easier for the patient to believe that new ways to manage OCD can be learned by engaging in EX/RP. The externalization is a therapeutic technique through which the therapist and patient can work better together.

Providing a Cogent Rationale for EX/RP

The main aim of EX/RP is to teach the person how the rituals are currently maintained. Obsessions give rise to distress, compulsions reduce distress and behaviour to reduce this distress will be strengthened and repeated. The rituals are actually maintaining the obsessions, which evoke anxiety and discomfort. Increasing the distress is important but they will decrease overtime. It is therefore important to limit rituals and avoidance behaviour instead of changing and fighting the obsessions. It might be helpful to illustrate these principles with neutral examples (e.g. were you nervous on your first date, what might have happened if you did not go there, did it become easier on the second/third date, are you happy you did it although you were nervous etc.). The ‘’you want me to do what’’ phenomenon shows that people are often hesitant in engaging in the treatment. The therapist can say that a patient is already having great discomfort but with no positive effects. ‘’You have to feel bad to feel good’’ and ‘’the more you do it the easier it gets’’ are appropriate statements that describe the situation.

The Nuts and Bolts of EX/RP

Once the client has started with the therapy it is of relevance to determine the triggers and rituals by both self-monitoring and a clinician interview. In the beginning of the treatment patients are taught to rate anxiety on a 0-to-100 scale, using a Subjective Units of Distress Scale (SUDS). The SUDS will be used in making a fear hierarchy. Exposure begins with moderately easy items (rated less than 30) and gradually progresses to more difficult items. Exposure is performed accompanied by the therapist but also alone, to generalize the effects. The most important aspects of the exposure is (a) that the exercises are manageable, (b) refrain from all ritualistic behaviour during exposure, (c) continue exposure until it can be performed with ease alone and with therapist, (d) conduct the exposure repeatedly.

Possible Difficulties and Barriers to Caroline’s Treatment

The most common barrier is noncompliance with exposure exercises and difficulties achieving successful response prevention. This can be due to lack of motivation, disagreement with behavioural model, interpersonal factors, poor therapist-client match, moving to rapidly through the hierarchy and comorbid or co-occurring psychological issues that need to be treated first. Another barrier is unintentional subtle avoidance. This means that a patient is substituting one ritual for another less visible ritual. Most of the time patients are unaware of doing this. If someone starts to seek reassurance from the therapist the therapist should be careful in answering these questions to not reinforce the OCD. Another factor that may complicate treatment is when family or friends are involved in rituals. If so, then it is good to let them be involved in therapy, also because they can function as models and provide support. A last factor that can be complicated is comorbidity, such as other kinds of anxiety (social anxiety etc.).

What does the future hold for treatment?

Studies suggest that the better someone does on short-term, the better someone will be doing on the long-term. However there are different indicators that treatment will be successful such as motivation and support, the client has to be warned that periodic instances of OCD can come back, though, they now have tools to manage them.