Treating Ocd with Exposure and Response Prevention

Obsessive-Compulsive disorder is an anxiety disorder with potentially disabling ramifications. The individual afflicted with OCD becomes trapped in a pattern of repetitive thoughts and behaviors which are very difficult to overcome. A person's severity of OCD can vary, but if left untreated, the disorder can destroy a person's capacity to function at work, school or even at home. For most of the 20th century, treatment focused for OCD centered around providing insight through psychotherapy. This form of treatment was generally ineffective. Since the mid 1970's prognosis for OCD has improved considerably with the introduction of cognitive- behavioral treatment like Exposure & Ritual Prevention, or EX/RP.

For decades, the prevalence of OCD was under-reported. Mental health professionals considered OCD to be a rare disease because only a small number of their clients admitted to having the condition. Additionally, the disorder was often not recognized in therapy because many of those afflicted with OCD were ashamed of their condition and declined to seek treatment for it. Eventually, a survey conducted in the early 1980s by the National Institute of Mental Health (NIMH) provided new knowledge about the prevalence of OCD. The NIMH survey showed that OCD affects more than two percent of the American population. This prevalence means that OCD is more common than such severe mental illnesses as schizophrenia, bipolar disorder and panic disorder.

OCD is characterized by recurrent obsessions and/or compulsions that interfere considerably with daily functioning (DSM-R IV). Obsessions are "persistent, ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress." Compulsions are "repetitive behaviors...or mental acts...the goal of which is to prevent or reduce anxiety or distress" (DSM-R IV). Also, during the course of the disorder, the person must realize that his/her obsessions or compulsions are unreasonable or excessive. This introspective element is not required in the diagnosis for a child, however. Although OCD symptoms typically begin during the teen years or early adulthood, research shows that some children may develop the illness during preschool. Studies indicate that at least one-third of cases of adult OCD began in childhood (NIMH). Suffering from OCD during early stages of a child's development can cause severe problems for the child. It is important that the child receive evaluation and treatment as soon as possible to prevent the child from missing important opportunities because of this disorder. OCD strikes people of all ethnic groups, affecting males and females equally.

The belief that OCD is the result of life experiences has become less valid in light of research focusing on biological factors. Most experts now believe that OCD has a neurobiological basis. OCD is no longer attributed only to attitudes a patient learned in childhood -- excessive importance of cleanliness, or a belief that some thoughts are unacceptable or dangerous.

Once regarded as chronic and untreatable, modern cognitive-behavioral treatments help people with OCD control their symptoms and enable them to restore normal function in their lives (CAMH). In particular, EX/RP is effective for many people. In this approach, the patient voluntarily and deliberately confronts the feared object or idea, either directly or by imagining. At the same time the patient is strongly encouraged to refrain from engaging in the ritualized compulsive behaviors. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges. This process of getting "used to" obsessional cues is called "habituation."

Specific cognitive tasks precede any exposure or ritual prevention. First, the client writes out a complete list of situations, thoughts, images or impulses that make him/her anxious. This list is given a name, like the "obsession list." The client then creates (and names) a list of all the things he/she does to reduce or help manage the anxiety. The next step is writing out (and naming again) a complete list of all the things he/she completely avoids because the anxiety is too overwhelming. When these three lists are done, the client creates a Subjective Units of Distress scale (SUDS), numbered one to ten. "One" represents "calm, cool, and collected" and "ten" equals "worst anxiety ever; panic attack." The client then ranks each item on his/her compulsion and avoidance lists based on what the anticipated anxiety would be if asked to resist doing the ritual or to do what he/she avoids. From this self-reported data, the clinician helps the client generate a fear hierarchy by recording the items ranked from highest to lowest.

EX/RP begins after the fear hierarchy is constructed. Treatment starts with exposure to situations that cause mild to moderate anxiety, and as the patient habituates to these situations, he or she gradually works up to situations that cause greater anxiety. The time it takes to progress in treatment depends on the patient's ability to tolerate anxiety and to resist compulsive behaviors (CAMH). Exposure tasks are usually first performed with the therapist assisting. These sessions generally take between 45 minutes and three hours. In some cases, direct, or "in vivo," exposure to the obsessional fears is not possible in the therapist's office. "Imaginal" exposure, which involves exposing the person to situations that trigger obsessions