The steps involved in ERP are listed in Table 2. At the core of the treatment program is the hierarchy of exposure exercises that constitute the patient’s treatment plan. It is important to be very specific when constructing the exercises; otherwise, the patient will simply do whatever is easiest. Take, for example, the patient who is afraid to use public telephones. His exercise plan should specify which public phones to use—for example, those near the bathrooms in restaurants, not just those near the front reservation desk.
The hierarchies used at my institution contain dozens of exposure exercises. These exercises are grouped according to the level of anxiety they generate for the patient, on the graduated scale of 0 to 7 that I described earlier. I start my patients on the exercises that provoke an anxiety level of about 3 on the scale.
The treatment schedule varies with the severity of OCD. Patients who score roughly between 18 and 23 on the Yale- Brown Obsessive Compulsive Scale (Y-BOCS)—the gold standard for OCD assessment—generally respond well to 1 to 2 hours of CBT a week. Persons who score roughly between 23 and 29 generally need 4 or 5 visits a week, for about 3 to 4 weeks. At the OCD residential program at Rogers Memorial Hospital, which serves those with a YBOCS score of about 30 or higher, patients get 50 hours of treatment a week, including both therapist-aided and self-exposure.
Persons who hoard deserve special comment, because their treatment plan differs slightly from that for others with OCD. Leaders in the hoarding field are beginning to consider that hoarders are different from other subtypes of OCD patients and may, in fact, not have OCD. Hoarders tend to have less insight into their illness and their thoughts related to their belongings appear less unwanted. As a result, they receive more cognitive therapy than other persons with OCD typically would. Also, if the patient hoards, therapy almost always needs to be done intensely and home visits become a must.
Patients who have severe, treatmentrefractory OCD that does not respond to intensive ERP either alone or in combination with medications are potential candidates for referral to a center that offers various forms of neurosurgery. One new, alternative type of neurosurgery is deep brain stimulation. This procedure is done at various US sites, including Massachusetts General Hospital, Brown University, and the University of Florida. About one third of patients appear to partially respond to neurosurgical strategies.2 In some cases, OCD symptoms can be reduced enough to allow the patient to benefit from ERP therapy.
Most patients with OCD benefit from the inclusion of cognitive therapy in their treatment program. As mentioned earlier, the general balance sought in our programs is 85% ERP and 15% cognitive restructuring.
During cognitive restructuring, the therapist tries to identify and correct errors in the patient’s thinking that generate anxiety. Patients with OCD usually have 2 types of erroneous thinking. One is a probability overestimation error, in which they overestimate the probability of a bad event, such as becoming infected with HIV by touching a doorknob. The second is a catastrophe error, in which the patient magnifies the severity of a likely event, such as observing someone using the toilet and not washing his hands. Persons with OCD can best learn to identify and self-correct these errors in thought by going through a series of steps that we call thought challenging. The steps include evidence identification and completion of worksheets to correct both types of errors.
ERP in perspective
ERP treatment has been proved effective in clinical studies. Foa and colleagues4 performed a meta-analysis of 12 studies involving 330 patients with OCD who were treated with ERP therapy. In all, 83% of these patients were greatly improved.
Greist5 performed a different metaanalysis, examining behavioral therapy and Y-BOCS scores in 294 patients enrolled in 18 studies. Y-BOCS scores were compared before and after treatment with a serotonin reuptake inhibitor (SRI). The average decrease in scores on the Y-BOCS from pre- to post-therapy in persons treated with behavior therapy alone was 11.8, a decrease that is statistically significant and significantly greater than the average reduction on the Y-BOCS achieved with an SRI, which was 7.5.
Relapse rates are very low with ERP therapy. In reporting on 16 studies involving 376 patients, Foa and Kozak6 found that 76% had improved at followup. We have found that patients’ completion of their exposure hierarchy is key to a low relapse rate.
ERP is an effective and robust treatment. Patients respond quickly, with many noting improvement after the first week. The only adverse effect is an increase in anxiety during treatment, which can be managed by graduating the exposure to the fearful stimulus appropriately. The disadvantages are that ERP is hard work and time-consuming for patients and therapists alike. However, the hours a day we ask patients to commit to treatment are hours they are already spending ritualizing. It can also be difficult to find therapists who are qualified in this kind of treatment. Based on its efficacy and low relapse rate, however, ERP is currently considered to be the first-line treatment for OCD.7
Treatment steps in exposure and ritual prevention
Initial evaluation (1 hour)
(4 - 5 hours)*
|Patient completes Y-BOCS checklist
and severity rating scale†
Generate exposure exercises
Patient rates each exercise on a scale of
0 to 7, depending on perceived difficulty
Create exposure hierarchy
Decide how intensively to deliver BT
|Mild to moderate cases can usually be
managed in a weekly outpatient setting
(little need for therapist-aided exposure)
Moderate to severe cases typically need
more intensive treatment (need more
Multiple visits per week, each lasting
several hours, for 3 weeks (for
moderate to severe OCD)
Homework for the patient to complete
outside of office visits
|OCD, obsessive-compulsive disorder; Y-BOCS, Yale-Brown Obsessive Compulsive Scale; BT, behavior therapy.
*Detailed assessment is performed over several office visits.
†Severity rating scale can be completed before, after, and every 2 weeks during treatment.
|For more information on obsessive-compulsive disorder, visit www.ocfoundation.org and www.rogershospital.org. For information on treatment scholarships, visit www.anxietydisordersfoundation.org.|
Dr Riemann is clinical director of the Obsessive-Compulsive Disorder Center at Rogers Memorial Hospital, Oconomowoc, Wis, and is on the scientific advisory board of the Obsessive Compulsive Foundation. He reports no conflicts of interest regarding the subject matter of this article.
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