Noam Shpancer, Ph.D., is a professor of psychology at Otterbein College and a practicing clinical psychologist in Columbus, Ohio. Obsessions tend to cluster around common themes: Contamination worries, doubting/harm fears, symmetry/completeness urges, and unacceptable thoughts (blasphemous, violent, sexual). When distressing thoughts come to occupy and overwhelm them, they will often attempt to suppress the thoughts directly, a futile effort sometimes known as the ‘white bear problem’ (if we try not to think of a white bear, we end up thinking about it). But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. Once those are established, they'll work together to create something called a "fear" or "exposure" hierarchy. ERP is also aversive by design. Ten Things You Need To Know To Overcome OCD, Examining The Link Between OCD And Social Anxiety Disorder, Archived Articles on OCD Treatment & Research. The main symptoms of OCD are, as the name suggests, obsessions and compulsions. Obsessive-compulsive disorder (OCD) is a difficult, yet treatable, psychological disorder. And with two children, his anxiety grew along with his responsibilities. To access forms, worksheets, and handouts, look for the relevant Treatments That Work or Programs That Work title below. People with OCD often spend much energy and time ‘looking for trouble’ so to speak, acutely attuned to the cloud in the silver lining. Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. 2. As such they prevent the clients from ever experiencing the benefits of true exposure. It is possible that you may have heard of Cognitive Behavior Therapy (CBT) before. People with OCD end up working for their rituals long after the rituals have ceased working for them. The client then stays in those situations long enough for the anxiety to decrease. ... of a SAMPLE fear hierarchy of exposures for a particular patient seeking treatment at an anxiety specialty center. How OCD Treatment Will Change Due to the COVID-19 Pandemic, Harm Obsession OCD: Beyond Hand Washing and Orderliness, Psychology Today © 2021 Sussex Publishers, LLC, 5 Recent Findings About Dark Personalities, How Mindfulness Can Improve Relationships, What Dogs Can Teach You About Your Own Personality, Why Change Is Hard Even When We Know It’s Needed, The One Diagnosis All Therapists Should Understand, Mental Rituals in Obsessive-Compulsive Disorder, Scrupulosity OCD Treatment Shouldn't Be a Hard Sell, Obsessive-Compulsive Disorder: Research Update. As mentioned above, compulsive rituals are a form of anxiety avoidance. To deal with the distress caused by fearful thoughts and images, people with OCD turn to increasingly elaborate rituals and safety behaviors. ERP is done by: o Exposing yourself to situations that bring on obsessions (triggers) o Not engaging in the unhelpful coping strategies (compulsions or avoidance). Exposure therapy can be an effective treatment option for a range of phobias and anxiety disorders, including PTSD, OCD, and panic disorder. Exposure therapy starts with confronting items and situations that cause anxiety, but anxiety that you feel able to tolerate. Imaginal Exposure vs. Avoiding your fears never helps and in fact may even make them worse. Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associated compulsion). Can This 6-Second Trick Prevent a Panic Attack? treatments for OCD CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support *American Psychiatric Association. Second is inhibitory learning, a process whereby new associations inhibit (rather than extinguish) old ones. Such a decrease in anxiety is achieved via several concurrent processes. It involves, as the name indicates, preventing the client from performing the ritual behaviors they engage in to reduce anxiety. This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction . Behavioral (Functional) Assessment form 3. The therapist and patient develop a hierarchy of avoided activities that the patient practices through in vivo exposure between sessions. The third main way I have tweaked the treatment for OCD is emphasizing the graduated nature of exposure more than some clinicians.  I believe the three keys to successful exposure therapy are making sure the exposure is prolonged, repetitive, and done in a graduated or hierarchical fashion.  As mentioned before, I use a zero to seven–point scale when developing an exposure hierarchy.  Generally, I suggest individuals start doing their exercises in their two’s and three’s.  I consider anything less than four on this scale to be in the manageable range of anxiety.  Fours and fives cause pretty significant anxiety, and sixes and sevens is unmanageable anxiety.  I believe starting people off in their two’s and three’s allows them to learn how to do exposure work, and increases compliance with doing their exposure exercises and with the ritual prevention portion of the treatment.  The latter issue is an important one.  Overall, refusal and dropout rates for ERP are very high (i.e., 25%).  There certainly are many reasons for this, but the major one appears to be their lack of willingness or ability to do ERP.  By making it more “user friendly” my refusal / dropout rates are considerably lower (i.e., anecdotal estimate of roughly 8-10%). This is the OCD Exposure Hierarchy Worksheet. A new theory aims to make sense of it all. Both client and therapist need to be aware of this. The exposure hierarchy lays out a roadmap for the rest of treatment. The short-term pain of ERP is a better deal than living with the long-term punishment of untreated OCD. These can then be tackled in order of increasing difficulty. This worksheet serves as a guide to organize feared and uncomfortable situations that your client faces each day. The ERP approach is usually introduced during the process of psycho-education, and the client learns about the treatment rationale, goals, structure, and components. They often seek perfection and are distressed by its unattainability (“my hands are not perfectly clean; not clean enough”). Please consult a medical professional before changing or commencing any course of treatment. However, over time most behavioral therapists have added their own “personalized spin” to ERP and in some cases added other types of therapy to the mix.  In this article I will discuss the ways that I have “tweaked” the basic approach to treating OCD.  As you will see, there are far more similarities to the basic protocol than differences but there are some divergences that are worth noting. Exposure doesn’t work for all types of anxiety, and there are things we want to know before starting to use it. As the client faces distressful items, they are concurrently prevented from engaging in corresponding rituals or distracting ‘safety behaviors.’ ERP can be conducted in session—in the therapy room, with a therapist; or In Vivo—in real-life situations with a therapist. Conquering Your Fear The best way to overcome fears is to face them in small steps. Be Strategic! These rituals of cleaning, checking, ordering, or counting are a means of anxiety avoidance. For example, they may believe they are responsible for some harm that may come to themselves or others, and assume that any influence they have over an outcome equals total responsibility for it (“I will fail to do something and it will lead to myself/others being hurt”). The client needs to summon their courage and perseverance, and accept the fact that short-term pain is the price of acquiring long-term health and wellbeing. You imagine punching your boss in the face. ERP is designed to break the two maladaptive associations that reside at the core of OCD: The association between sensations of distress and the objects, situations, or thoughts that produce the distress, and the association between performing ritualistic behaviors and decreasing the distress. Exposure is a way to get out of OCD and ... of Obsessive–Compulsive Disorder: Fundamentals and Beyond. Exposure is a procedure in which the client purposely confronts objects, images, thoughts, or situations that elicit distress and anxiety (but pose no real danger). These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion). Preoccupations with dangers, flaws, or mistakes are common. The OCD Hierarchy worksheet helps you to plan a hierarchy of situations which trigger obsessions. OCD Exposure Hierarchy Packet Research supports exposure and response prevention therapy as the leading form of psychotherapy for OCD. The easiest way to start is to keep a diary of your rituals / compulsions for one week using the OC Rituals Diary. You ruminate over lost love. The second step is a process known as psycho-education in which, as the name implies, the client will receive accurate information about OCD, including prevalence statistics, common symptoms, available treatments and their effectiveness. To gauge the client’s distress, the therapist will often use a Subjective Units of Distress Scale (SUDS). Many of us have occasional repetitive, intrusive, or strange thoughts. First is physiological habituation, a process whereby nervous system arousal (which is necessary for the experience of anxiety) is reduced upon prolonged exposure to the same stimulus. You wear your lucky tie to the job interview. Each item in the hierarchy will receive a SUDS rating (0-100), ranking items in order from least distressing to most distressing. Compulsions are behaviors or rituals that are performed repeatedly in order to reduce the anxiety. The therapist will work with the client to 1. Exposure-based treatments take advantage of a natural process called habituation. Alas in the long term they become a problem themselves. An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms. You press the elevator button several times in a row. If you are curious about your own OCD symptoms, here is a link to a solid screening instrument. Reassurance seeking is in essence an OCD symptom (a ritual). Obsessive-compulsive disorder (OCD) is an oft-debilitating disorder that affects 1-3% of the U.S. population. To create a fear hierarchy, a person will identify an obsession that they're struggling with. Exposure is the key therapeutic component to that end. Fears of sexually harming children are fairly common among clients suffering from obsessive–compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. It can also be carried out as homework without a therapist, and the therapist may also use ‘imaginal exposure’—having clients use their imagination to picture an exposure situation. Obsessions are intrusive unwanted thoughts, images, or impulses that cause much distress and anxiety. An exposure is when you do something on purpose to provoke an anxiety spike. Although some generalization does take place in exposure therapy, in my experience it is rarely enough to completely eliminate the need to work on an entire OCD area (e.g., light switches completely generalizing to doorknobs and thus eliminating the need to address).  Thankfully, generalization is present to an extent but I see it usually within an OCD area (i.e., there is no need to touch every light switch to overcome a fear of them) not as much between them.  I have individuals demonstrate their mastery over every OCD area.  Despite the observed generalization effect in my patients, I also tend to develop separate exposure exercises within each area (e.g., light switches) to address the differences most patients perceive between certain circumstances (e.g., differences between light switches in bedrooms and ones in bathrooms).  In summary, I believe these are the reasons my hierarchies are larger in terms of number of items than most behavioral therapists.  I believe that the more specific the exposure exercises are the more functional (i.e., anxiety reducing) they will be in the long run.  Obviously, this is a bit of a balancing act and too big of a hierarchy can really slow someone’s progress.  It also does not help an individual’s confidence to give them a hierarchy the size of a phone book! Identify the client’s obsessions, their intrusive thoughts, images, or urges. People with OCD characteristically find themselves preoccupied with distressing unwelcome thoughts. Over the course of 10 years, his fears accumulated as he built his career and got married. With regard to compulsions, the goal of ERP is for the client to learn, through experience, that they don’t need rituals to manage anxiety well. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and … Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in a patient is exposed to their feared situation and encouraged not to engage in their typical neutralizing response. Overall, the psychosocial treatment protocol for obsessive-compulsive disorder (OCD) has been well established and empirically supported.  Exposure and ritual prevention (ERP) has been found to produce successful management of symptoms in roughly 85% of OCD cases.  This strategy was first described by Meyer in 1966 and has since been studied and refined by many outstanding researchers and clinicians (e.g., Edna Foa). Biology is certainly involved, as obsessions and compulsions run in families, and appear in various medical conditions, including Huntington’s chorea, Parkinson’s disease, Tourette disorder, schizophrenia, and certain epilepsies, brain injuries, and tumors. The causes of OCD are not known. When complete, the worksheet can serve as a guide for your therapeutic work with your client. By Bradley C. Riemann, Ph.D. – Director, OCD Center at Rogers Memorial Hospital. First, I have added a cognitive therapy (CT) component to treating OCD, making my philosophy a cognitive-behavioral therapy (CBT) approach.  The premise behind adding cognitive therapy to ERP is the belief that there are “errors” in thinking that generate the anxiety in the first place.  It is believed that everyone makes these errors in thought from time to time, but that someone with OCD tends to make them more often and have a harder time self-correcting them.  An example of a type of thinking error that an OCD sufferer would make is an overestimation error.  Here an individual is overestimating the likelihood of a bad event occurring (e.g., believing that you will contract HIV from touching a doorknob and not washing your hands).  Cognitive therapy helps one identify and better self-correct these errors in thought.  I believe that cognitive therapy or what others and I call “thought challenging” is a good addition for most of my OCD patients.  I have developed worksheets that provide individuals the structure and framework for learning how to better identify and ultimately better self-correct the errors in thought that they make.  Clearly, I believe the main emphasis should still be on ERP, but the CT plays an important role.  I would say that my protocol is 80-85% ERP and 15-20% CT. Second, in talking with colleagues from other OCD treatment facilities, it appears that my exposure hierarchies tend to have more specific exercises on them.  An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms.  These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion).  I have patients rate potential exercises on a zero (i.e., “no anxiety whatsoever”) to seven-point scale (i.e., “the most anxiety you could possibly imagine experiencing”) in terms of how anxious they think the exercise would make them feel if I actually had them perform the exercise.  My average hierarchy probably has 100 exercises on it.  Many other clinicians I have talked to have far fewer exercises (e.g., 20-25) on their hierarchies.  The reasons for these differences are varied and not entirely clear.  Some clinicians feel they can successfully “bunch” or combine exercises (i.e., combining two or more exercises into one entry on the hierarchy) in an attempt to make exposure therapy more time efficient.  Others have stated that they believe the process of generalization (i.e., anxiety will habituate or go down in certain OCD areas without directly exposing one’s self to those areas) will occur (e.g., by touching light switches an individual’s fear of touching doorknobs will also substantially reduce). 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