What involves repeatedly exposing the client to the focus of an obsession and preventing compulsive responses to the resulting anxiety?

Exposure and response prevention for OCD

Exposure and response prevention (EX/RP) is widely regarded as the treatment of choice for OCD. In this treatment approach, patients are exposed to the feared stimuli in a hierarchical manner, beginning with stimuli that evoke less anxiety and gradually moving to more-distressing stimuli. During exposure therapy for OCD, patients are encouraged to refrain from engaging in any neutralizing thoughts or behaviors, which is the response prevention component of the treatment. In vivo exposures are commonly used, though imaginal exposure is implemented when in vivo exposure would not be possible or should not be implemented.

Empirical support for the efficacy of EX/RP is strong. Several randomized controlled clinical trials have investigated the efficacy of EX/RP in the treatment of OCD and have found that EX/RP results in a significant reduction in OCD symptoms that is generally maintained at follow-up, though some residual symptoms often remain. EX/RP has demonstrated superior outcomes in the treatment of OCD when compared with psychopharmacological interventions (e.g., clomipramine) and comparable outcomes when compared with CBT. Support for the effectiveness of EX/RP for OCD was reported by Franklin and colleagues, who found similar rates of improvement as a result of EX/RP among patients treated in a fee-for-service clinic, with no exclusionary criteria based on comorbidity, treatment history, or concomitant treatments, compared with those reported in published controlled clinical trials.

5.14.5.2.1.2.3 Exposure and Response Prevention

ERP consists of two parts: exposure to obsession-provoking situations, and response prevention, or the reduction or prevention of compulsions or safety behaviors. Once exercises have been identified on a hierarchy, a therapist's primary role is to continually challenge their patients to engage in ERP exercises that are as demanding as they are willing to do, both in and out of session.

An understanding of the mechanisms of change that occur through exposure therapy broadly can help a therapist design and implement ERP exercises that are as effective as possible. At its core, exposure therapy is based on extinction learning, or creating new learning associations between a feared stimulus and safety, certainty, security, or at the very least, tolerance of distress (Craske et al., 2014; Foa and McLean, 2016). Craske et al. (2014) provided a review of exposure mechanisms for anxiety-spectrum disorders, proposing an inhibitory learning model to exposure. From this framework, new learning that occurs through exposure “inhibits” previous learning networks that have linked a stimulus with disgust, anxiety, incompleteness, or other forms of distress associated with OCD. Craske et al. (2014) suggested that inhibitory learning can be enhanced through a number strategies, many of which have long been emphasized in CBT with ERP protocols (e.g., reducing safety behaviors or compulsions, conducting in- and out-of-session exposures). They also suggest violating feared expectations (e.g., that they cannot tolerate uncertainty, that something bad will happen, that a feeling of incompleteness will last forever), completing exposures with separate stimuli and then combining them, occasionally experiencing a feared outcome (e.g., getting an “imperfect” grade on a test after doing an exposure targeting perfectionism, which may lead to less return of fear in future situations when this occurs), and increasing variability in exposure contexts, including exposure objects, situations, places, people, and distress levels.

A similar perspective of exposure mechanisms is articulated in Foa and colleagues' emotional processing model (Foa and McLean, 2016). From this framework, exposure works through emotional processing that occurs during exposure, or developing competing associative networks. From an emotional processing perspective, corrective learning occurs during exposure when there is fear activation (i.e., the exposure elicits an emotional response that would normally provoke a need to engage in a compulsion), cognitive change (e.g., development of new beliefs about obsessions), and between-session habituation, or decreased distress upon multiple exposures to the same stimulus. Although emotional processing theory had initially prescribed within-session habituation as a critical ingredient for corrective learning, or decreases in anxiety during prolonged exposure to obsession-provoking situations, this process has not been consistently associated with improved outcomes, and thus is no longer recognized as an indicator of emotional processing (Foa and McLean, 2016).

Although these models of exposure process have been developed based on research with anxiety-spectrum disorders primarily with adults, exposure mechanism research specifically with pediatric OCD has provided preliminary support for both of these models. In one recent study of 31 children and adolescents with OCD participating in CBT, more variability between expected and actual distress during exposures and a higher proportion of distress expectancy violations corresponded with greater symptom reduction, supporting expectancy violations as an indicator of inhibitory learning (Guzick et al., 2020b). Further, a recent study reviewed therapy sessions with 111 children from the POTS trials to evaluate whether habituation that occurs without using safety behaviors would results in improved outcomes (Benito et al., 2018). They found that children who had more exposures in which distress reduced “on its own” (i.e., without subtle avoidance behaviors, compulsions, reassurance, or stopping the exposure) experienced greater symptom reduction, more global improvement, and a higher likelihood of being a “treatment responder.” Measuring habituation in this detailed way (i.e., accounting for whether habituation occurred without safety behaviors) provided compelling support for the emotional processing theory's initial emphasis on within-session habituation among children with OCD (Benito et al., 2018). In contrast, fear variability and fear activation were not associated with treatment outcome, which have also been emphasized in extinction learning models of exposure.

6.17.6.1.2 Decontextualizing Inhibitory Associations

For ERP to be maximally effective, safety learning must also be generalized by disconfirming fear-based predictions in different contexts. This is because inhibitory associations are context-specific, such that if safety is learned in context A, it may not necessarily be recalled in context B. Exposure tasks should therefore be deliberately conducted under various conditions, be they stimuli-specific (e.g., a toilet versus the floor), geographic (e.g., the floor at home versus one in a public place), interpersonal (e.g., with the therapist versus alone), affective (e.g., when calm versus when feeling distressed), or physiological (e.g., when relaxed versus caffeinated).

Combined Treatment

Combined pharmacotherapy and ERP is sometimes used in clinical practice, despite a paucity of empirical evidence supporting this approach. Although some studies have reported superior efficacy of simultaneous SRI/ERP therapy compared with SRI monotherapy, these are often limited by methodological biases and low statistical power.

Nonetheless, there is some evidence that adjunctive ERP may be helpful in individuals with SRI-resistant symptoms. Several studies have reported that ERP augmentation of SRI treatment may lead to significant symptom improvement in individuals who have shown minimal response to pharmacotherapy alone. In a large, well-controlled augmentation study, Tenneij and colleagues randomly assigned 96 individuals with OCD who had responded to 3 months of drug treatment either to continue drug treatment alone or to receive additional behavior therapy for 6 months.41 Those individuals who had received the additional behavior therapy showed a greater symptom improvement than those who had continued with drug treatment alone.

There is also a body of work examining the efficacy of D-cycloserine, a partial agonist at the glycine modulatory site on N-methyl-D-aspartate (NMDA) glutamate receptors, in augmenting psychological therapy in treatment-resistant individuals. Enhancing NMDA receptor function is hypothesized to promote synaptic plasticity during learning. For example, 100–125 mg D-cycloserine, administered to patients approximately 1–2 hours before each exposure therapy session, may be associated with significant symptom improvement, decreased number of sessions required to achieve significant clinical improvement, and reduced therapy dropout rate (compared with a placebo control group). Thus, it seems that combination therapy may be efficacious in individuals who have responded to initial pharmacotherapy and in those who have shown treatment resistance.

Future Directions

Despite the effectiveness of ERP and pharmacotherapy, many individuals do not adequately benefit from these treatments. Therefore, other treatments continue to be explored. Several treatments are emerging that use a mindfulness-based approach to OCD. Mindfulness-based interventions may be particularly well suited to the treatment of OCD because of the fact that individuals with OCD tend to ascribe special meaning and significance to their obsessions, and mindfulness training fosters a nonjudgmental stance toward one's thoughts and feelings. Some treatment approaches that have been applied to OCD are acceptance and commitment therapy (ACT) and metacognitive therapy (MCT).

ACT posits that experiential avoidance, which is the tendency to avoid or control thoughts and emotions, is a key process of any psychological disorder. Rather than targeting the form, frequency, or situational sensitivity of thoughts and emotions, ACT therapists instruct individuals in various exercises, including mindfulness exercises. These exercises are designed to assist individuals in experiencing their obsessions as just thoughts and their anxiety as just an emotion, thereby reducing the need to ritualize. Like CT, ACT can be conducted with or without in-session exposure therapy. When exposures are conducted, the purpose is to help individuals develop willingness to experience thoughts and emotions in the service of moving toward their values, not to achieve habituation.

MCT is another approach that incorporates mindfulness. MCT is based on a theory of psychological dysfunction that suggests that all disorders are a result of a dysfunctional pattern of cognition – specifically, inflexible self-focused attention, perseverative thinking (i.e., worry and rumination), attentional strategies of threat monitoring, and coping strategies that fail to challenge and modify maladaptive beliefs. To combat this dysfunctional thinking pattern, MCT therapists incorporate detached-mindfulness techniques. Detached mindfulness, which is considered to be incompatible with the dysfunctional thinking style that is characteristic in psychological disorders, consists of being conscious of one's thoughts, comprehending that thoughts are not facts, being able to refocus one's attention flexibly, having low conceptual processing of one's thoughts, and not having the goal of removing or avoiding threat.

The efficacy of these approaches is not yet well established, as no randomized controlled trials for ACT or MCT for OCD have been conducted. However, one multiple baseline study suggests that ACT may produce clinically significant reductions in compulsions. ACT may also be beneficial for other OC-related disorders, such as trichotillomania and skin picking. Evidence from experimental and case studies is also emerging that MCT may be an effective treatment for OCD. In many ways, these mindfulness-based approaches may not differ radically from more standard approaches. For example, the metacognitive approach to obsessions is also used in standard CBT for OCD; the detached-mindfulness techniques of MCT are similar to imaginal exposures used in ERP; and, even though habituation is emphasized, ERP promotes willingness to tolerate anxiety to pursue one's values. To sort out whether there are meaningful differences between these mindfulness-based approaches and standard CBT approaches, head-to-head comparisons of these treatments will need to be conducted.

6.17.6.2.2 Specific effects of exposure and response prevention

Examining the separate effects of exposure and response prevention on obsessions and compulsions, Foa and colleagues, as well as other investigators, found support for the behavioral model from which ERP is derived. In their first trial with 21 patients (Foa & Goldstein, 1978), 86% had stopped ritualizing after treatment, but only 57% improved substantially on obsessions, suggesting that compulsions responded more to ERP than obsessions. According to behavioral theory, exposure should particularly reduce anxiety associated with obsessions, whereas prevention of ritualistic behavior should influence rituals more than obsessions. This dual hypothesis was supported in multiple case studies of OCD patients (Mills, Agras, Barlow, & Mills, 1973; Turner, Hersen, Bellack, Andrasik, & Capparell, 1980), as well as in group trials. Both interventions delivered separately reduced obsessions and rituals, but exposure affected subjective anxiety more than rituals, and response prevention reduced rituals more than obsessions. The addition of the missing component led to maximum improvement in both symptoms (Foa et al., 1984; Foa, Steketee, & Milby, 1980). These findings support the suggestion that exposure and prevention of rituals operate by separate mechanisms.

6.24.10.3.2 Exposure and Response Prevention

As displayed in Table 3, exposure and response prevention typically starts at about session 3 and continues to the end of treatment; the work prior to this can be regarded as preparation for exposure. In the following, we present some concrete tips when conducting exposure in the treatment of health anxiety.

Make sure that the patient has understood the rationale for exposure. We recommend that the clinician regularly asks the patient questions such as “So, a part of this treatment is that you should read a book about a person who suffered from ALS, why should you do this when we both know that you will become very anxious?”, “Why on earth should you refrain from seeking health care if you have a new symptom - everyone else does it!”, or “You have done this exercise twice now and it is still very stressful to do it, does this mean that exposure doesn't work for you?”.

Prepare the patient for anxiety. Conducting exposure in the treatment of health anxiety means to encourage the patient to approach thoughts of acquiring serious disease and dying. This may in the short-term lead to increased disease conviction and anxiety several days after exposure has ended (“I felt pretty good this morning, but now, after having read my therapist's text about brain tumors I'm convinced that I have cancer”). In this way, health anxiety exposure differs from that in other anxiety disorders where distress is typically very low or absent after exposure has ended (e.g., when the agoraphobic person has left the crowded subway he or she typically has no marked anxiety). Against this backdrop, we therefore highly recommend that patients from the start are informed that the treatment will probably lead to increased anxiety and that this is perfectly ok, even if it does not feel that way. We also encourage our patients not to they use their experienced degree of anxiety as an indicator of whether the treatment works or not, but to try and wait until the 12 weeks of treatment have passed before giving their verdict. Exposure is not to try something once and see what happens, but do to it systematically for the duration of the treatment.

Be honest about uncertainty being a requisite for improvement. For the majority of patients with health anxiety, working with exposure and response prevention triggers an increased sense of uncertainty. Refraining from checking one's body or calling the GP, not asking friends or family members about what a symptom could mean almost inevitable leads to uncertainty, which for many is perceived as threatening and difficult to tolerate. Sometimes patients ask questions such as “But how do you know that this is not a symptom of heart disease?” or “What if I'm really sick and refrain from seeking care instantly - then I might have a poorer treatment prognosis or even die!”. As the clinician is in no position to provide a guarantee that the patient is not sick (or will soon become sick), it is essential that the clinician is honest about increased uncertainty is the price that needs to be paid in order for exposure to work. When addressing this with the patient it is essential not to try to persuade the patient to expose to uncertainty, but instead strive for an open discussion when reviewing the options. We often say something like: “You have told me that there are a several things that you do in order to keep track of your health and to minimize the risk of missing something that could be of importance. While these things make you feel safer when you do them, you have also noticed that they have some negative effects; they are a source of conflict with your partner, and you have become worried that your anxiety will spread to your children. And as we have talked about, these behaviors might also be perpetuating your health anxiety. Conducting exposure and response prevention means to do less of these things and I know that one of your worst fears is that you will fail to detect disease, which could ultimately lead to you dying prematurely. So, one way for you is to keep doing what you have been doing for several years. You will feel certain about your health status, but the suffering you feel and the strain on the relationship to your family members will probably be about the same. Another possibility is that you go through CBT. This might lead to less health anxiety in the long run and perhaps less conflict in your family, but there is one important price that comes with this. You will have to do things that will make you feel more uncertain and less safe. I can't guarantee that you will not become seriously ill during therapy, you might even be ill already. So, you have an important decision to make that shouldn't be stressed. You are in your full right to decline CBT, but if you are interested in trying this new road I will be here for you'."

Be aware of “exposure” being safety behaviors in disguise. As the function of health anxiety behaviors may change over time within the same individual, one potential risk in exposure treatment is that what was once a good therapeutic target for exposure has become something that prevents the patient from approaching what they fear. A sign of this happening is if the patient reports, for example, that “I exposed to seeing my GP, which felt really good as I have been so worried about my stomach symptoms lately”, or “As for response prevention, I canceled the appointment with my diabetes nurse, which made me relieved to be honest”. As a general rule, if the patient does not feel an element of apprehension before the exercise it is probably not exposure. To guide patients who are unsure of whether a given action is exposure or avoidance, we recommend the very simple but often effective instruction “Do you instinctively feel that you want to do this? If yes, don't do it. If no, then go for it”.

Exposure-based treatments

Another treatment that has stemmed from behavioral models is exposure and response prevention (ERP; Verdellen, Keijsers, Cath, & Hoogduin, 2004). During ERP, the person is exposed to anxiety-producing stimuli and is then prevented from neutralizing or escaping the anxiety until the person habituates to the anxiety (Grayson, Foa, & Steketee, 1982). The rationale for the use of ERP with tics and hair pulling is based on the automatic negative reinforcement model of these disorders. ERP involves creating a graded hierarchy of stimuli that elicit the premonitory urge and then introducing these stimuli in a systematic manner while simultaneously preventing the performance of the habit behavior. Verdellen et al. (2008) administered ERP for tics to 19 individuals with TD to examine if habituation to the urge is the underlying factor of change in treatment. Both within and between sessions, subjective unit of distress scale (SUDS) scores reduced significantly, and tic frequency in session was related to decreases in severity ratings (i.e., participants who ticced less during sessions had a more significant reduction in SUDS-scores). Thus, habituation to the urge seems to be an important factor in using exposure as a treatment of tics.

Several small studies have shown ERP to be effective for reducing tics. Verdellen et al. (2004) randomly assigned 43 TD individuals to either ERP or HRT. Both treatments were equally effective. In another study, Wetterneck and Woods (2006) used ERP to treat complex tics in an adolescent male with multiple motor and vocal tics. They found that ERP not only reduced the tic that was targeted for intervention, but also generalized to other complex tics. Unfortunately, research has yet to evaluate whether ERP is effective in the treatment of hair pulling. Table 8.1 summarizes treatment recommendations.

Table 8.1. Treatments for tics and hair pulling.

•

When possible, use extinction and implement stimulus control procedures.

Utilize habit reversal for tics and hair pulling exhibited by adults.

Consider the use of operant procedures and stimulus control procedures with children or individuals with disabilities.

ERP is a promising procedure in need of further study.

Cognitive behavioral therapy

CBT involves psychoeducation, cognitive therapy, and exposure and response prevention. Exposure and response prevention is the core of CBT for OCD and involves gradual, systematic exposure to distress-producing stimuli without engaging in associated rituals or avoidance (i.e., response prevention). The putative mechanism of exposure is extinction, whereby repeated presentations of a conditioned stimulus in the absence of a previously paired unconditioned stimulus lead to reductions in the conditioned response. Methodologically rigorous studies among children and adolescents with OCD have established the superiority of CBT to placebo/waitlist, attention control conditions, and SRI medications.61,63–66 A metaanalysis on 54 trials for management of OCD in adults showed that psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were on stable doses of antidepressants.67 A metaanalysis demonstrated that the effect size for CBT with SRI therapy (d=1.704) and without (d=1.203) was superior to SRI treatment alone (d=0.745).68 A metaanalysis on 20 RCTs for the treatment of youth with OCD suggested that greater cooccurring anxiety disorders, therapeutic contact, lower treatment attrition, and the presence of comorbid tic disorder were associated with greater CBT effects.69 A metaanalysis of 18 remote CBT trials for OCD found that remote treatment for OCD produces a decrease in symptoms of a large magnitude (g=1.17; 95% CI: 0.91–1.43).70 Between-group analyses on the four studies that compared remote treatment to face-to-face treatment did not reveal a meaningful differences in outcome (g=−0.21; 95% CI: −0.43–0.02), hence Internet-, telephone-, or videoconferencing-administered CBT may be a good way to overcome barriers to accessibility.70

10.04.3.6 Obsessive Compulsive Disorder Apps