Exposure With Response Prevention Research Articles

Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder – A non-inferiority randomized controlled trial

ObjectiveExposure with response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD). However, refusals, dropouts and the required high time and logistic effort constitute barriers to the use of ERP. In a non-inferiority randomized controlled trial, we compared metacognitive therapy (MCT) to exposure with response prevention (ERP) as treatments for OCD. Method74 outpatients received 12 weekly sessions of either manualized MCT or ERP, with primary outcomes assessed by blinded assessors using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at pre-treatment, mid-treatment, post-treatment, and 6-month follow-up. Secondary outcomes included measures of depression and anxiety. Non-inferiority margin was specified at no less than d = 0.38 below the improvement reached by ERP, corresponding to a difference of about 3 points on the Y-BOCS. ResultsDrop-out rates were low (<14%) and similar in both groups. Linear models indicated non-inferiority of MCT to ERP at post-treatment, but not at 6-month follow-up. While both groups showed comparable Y-BOCS improvements, the MCT group demonstrated a significantly greater reduction in state anxiety scores at post-treatment and follow-up. ConclusionsOverall, MCT was not inferior to ERP, especially at post-treatment, suggesting it could be a treatment alternative. However, further research is needed to explore differential treatment indications.

Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive–compulsive disorder: a study protocol for a randomized controlled trial

BackgroundPatients with obsessive–compulsive disorder (OCD) suffer from repetitive fearful intrusions which they try to neutralize by performing compulsions. OCD is considered to be the most resistant anxiety disorder with a remission rate of only 53% after a year of an evidence-based treatment. Therefore, it remains an obligation to develop and investigate more effective treatment interventions. This study aims to compare personalized exposure with response prevention (ERP) using experience sampling methodology-based feedback to ERP as usual in patients with OCD. Personalized exposure will be provided screen-to-screen in an ecologically valid (real time and real place) context by means of a smartphone application. This app will also be used to collect both objective and subjective data by means of experience sampling methodology (ESM). This ESM data will be used to identify triggers and protective factors for symptom severity, provide personalized feedback and optimize the effect of ERP. The primary goal of this RCT is to compare the effectiveness of personalized ERP to ERP as usual in the traditional context of a therapist’s room in patients with OCD in OCD symptom severity, as well as differences in quality of life, depressive symptoms and anxiety states. Since both self-efficacy and experiential avoidance are known to influence symptom severity in OCS, a secondary goal is to examine if a possible treatment effect is mediated by self-efficacy or experiential avoidance.MethodsThis study involves a randomized controlled trial with 20 weekly sessions by 2 groups (ERP as usual versus personalized ERP), repeated measurements at baseline (T0), 5 weeks of treatment (T1), 10 weeks of treatment (T2), 15 weeks of treatment (T3), posttest at 20 weeks (T4), 6 weeks follow-up (T5), 3 months follow-up (T6), 6 months follow-up (T7) and a year follow-up (T8). A hundred and sixty patients with an OCD diagnosis according to DSM-5 criteria will participate. Half of the group will receive exposure with response prevention as usual, the other half will receive personalized exposure with response prevention with a smartphone application and personalized feedback sessions based on experience sampling data. Multilevel mixed modelling analysis will be used to investigate differences in treatment effect, as well as differences in quality of life, depressive symptoms and anxiety states. We will use the macro of Preacher and Hayes and apply bootstrapping methods to assess the possible mediating effect of changes in self-efficacy and experiential avoidance on subsequent treatment effects.DiscussionThis randomized controlled trial is the first to assess the influence of delivering ERP through video-calling and the use of an ESM intervention on the symptom severity of OCD. Since the global pandemic COVID-19, the use of video-calling to deliver psychological treatments has become more common, increasing the relevance of this study.Trial registrationICTRP Trial NL8254. Registered on 2019–12-24.

Pediatric anxiety disorders: Basic concepts for primary care.

Anxiety disorders in children and adolescents often present in primary care, and many clinicians will need to guide families on treatment. The purpose of this article is to give a brief overview of assessment and treatment principles for clinicians in primary care. Anxiety and its expression are heavily influenced by children's developmental progression and capabilities. Anxiety disorders have multiple underlying etiologies including temperament, environmental exposure to stressors, and childhood trauma. All anxiety disorders are strengthened by an operant process known as escape conditioning. The most effective treatments for child and adolescent anxiety begin with behavioral-based interventions including exposure with response prevention (ERP) and cognitive behavioral therapy (CBT). Medication can be effective in combination with CBT and ERP, or as a standalone treatment when behavioral interventions are not available. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors have been evaluated by randomized clinical trials for the treatment of childhood anxiety, but most are not approved by the Food and Drug Administration. When anxiety is severe and functional impairment is high, referral for psychiatric care and multimodal treatment reduces the likelihood of poor outcomes.

A Randomized Controlled Trial of OC-Go for Childhood Obsessive–Compulsive Disorder: Augmenting Homework Compliance in Exposure With Response Prevention Treatment

The current study investigates a novel digital tool designed to address barriers to out-of-session homework adherence in exposure with response prevention (ERP) for child obsessive-compulsive disorder (OCD). The OC-Go platform allows clinicians to create and push tailored interactive protocol- or symptom-specific assignments to patients on their mobile devices, providing in-the-moment step-by-step directions, encouragement, accountability, and a sense of therapeutic presence for patients during out-of-office exposures. The platform also facilitates objective measurement of homework and allows providers to support one another through a shared and searchable crowdsourced library with hundreds of assignable exposures and psychoeducation activities for specific OCD symptoms. The current study tested the usability and feasibility of the OC-Go platform with ERP stakeholders (OCD therapists, patients, and parents; N = 172) using the System Usability Scale (SUS). The study also tested the efficacy of OC-Go for augmenting homework adherence and clinical response using a randomized controlled, crossover design in a sample of 28 treatment-seeking youth with OCD. Participants randomized to standard ERP exhibited a homework adherence rate of 68.4% (95% CI [65.6, 71.0]), those randomized to ERP with OC-Go exhibited a greater adherence rate of 83.3% (95% CI [80.8, 85.6], p < .001). Both groups experienced large declines in Children’s Yale–Brown Obsessive–Compulsive Scale-rated OCD (d = 1.31, p < .001), though participants randomized to begin ERP with OC-Go exhibited clinically significant greater improvement (p = .05), translating into an additional augmented treatment response at the Week 6 primary end point (d = 0.36) and the Week 12 treatment end point (d = 0.72). Stakeholders rated OC-Go in the 90th percentile for usability on the SUS, indicative of a highly usable and easy-to-learn technology. Initial evidence supports OC-Go as a feasible and effective adjunct to improve out-of-office exposure measurement, adherence, and treatment response in ERP for child OCD.

The effectiveness of metacognitive therapy in comparison to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial

BackgroundThe recommended psychological treatment of choice for obsessive-compulsive disorder (OCD) is exposure with response prevention (ERP). Although this treatment is quite effective, recovery rates are modest and attrition rate is relatively high. Also, ERP treatment requires amounts of therapist time. A possible way to improve OCD treatment is by taking into account key cognitive processes involved in the development and maintenance of the disorder. The metacognitive model is such an account and pilot findings suggest that the associated metacognitive therapy (MCT) might be an effective treatment for OCD. MethodsIn the present study, a randomized controlled trial (RCT) is used to assess the effectiveness of MCT in comparison to ERP in an outpatient clinical sample of patients with OCD. ResultsBoth MCT and ERP produced significant pre-treatment to post-treatment decreases in obsessive-compulsive, comorbid psychological symptoms and metacognitive beliefs, both with moderate to large within-group effect sizes and high proportions of significant clinical change. Drop-out rates were low and treatment gains were maintained at six-month follow-up. There were no differences in efficacy observed between MCT and ERP treatments. ConclusionsMCT proves to be a promising treatment of OCD.

Extended treatment of multimodal cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder improves symptom reduction: a within-subject design.

Based on the current state of research regarding the treatment in pediatric obsessive-compulsive disorder (OCD), cognitive behavioral therapy (CBT) (in severe cases with additional pharmacotherapy) is considered as the first-line treatment according to internationally recognized guidelines. Research is mostly based on randomized controlled trials (RCTs; efficacy research). Thus, examined treatment conditions, especially the treatment duration, and patients' characteristics do not necessarily correspond to those found within routine care. Studies showed CBT packages as a whole to be efficacious, but less is known about the effects of individual CBT components. Furthermore, effects on comorbid symptoms or psychosocial impairment have been often neglected and different rater perspectives have been hardly considered in previous research. This effectiveness study aimed to examine the effects of multimodal CBT in children, adolescents, and young adults (age 6-20years) with OCD (n = 38) within routine care. Effects on obsessive-compulsive and co-existing symptoms were evaluated in a within-subject design by comparing changes during the assessment phase with 12-week standard treatment and with individually tailored extended treatment. Additionally, within the standard treatment, non-exposure treatment was compared to exposure treatment. Multi-informant assessment was applied, and the analyses included multilevel modeling and t-tests for pre-post comparisons. During the standard treatment and extended treatment, obsessive-compulsive symptoms, strain, and functional impairment significantly decreased. Moreover, a significant reduction of overall comorbid symptoms emerged, particularly regarding internalizing symptoms, including anxiety and depression. Comparisons of treatment components indicated that adding exposure with response prevention (ERP) has an additional positive effect. Clinical improvement and remission rates increased considerably when more treatment sessions were provided. These results suggest that improvement after an initial 12-week course of treatment may not allow for the prediction of non-responders/non-remitters and for the termination of treatment. Overall, the findings show that results from randomized controlled trials are transferrable to routine care. Trial registration number This study was registered retrospectively at the German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00030050 ).

Treating pediatric hoarding behaviors with an exposure response prevention model: A case study

With TV shows such as Hoarding buried alive, mainstream media depictions of hoarding disorder are presented mostly in the context of adults. Interestingly, however, studies have found that the onset of hoarding disorder often occurs in childhood between the ages of 8 and 10 (Morris et al., 2016). Since hoarding can onset at a young age, early intervention could help decrease the long‐term impairment of the disorder. According to the Diagnostic and statistical manual of mental disorders hoarding disorder is characterized as tending to collect items, difficulty in throwing items away despite the items' value or significance, and possessing an excessive number of items, leading to clutter (5th ed.; DSM–5; American Psychiatric Association, 2013). Despite a typical onset in childhood, most hoarding treatment and research has focused on adults because hoarding behaviors in youth can be challenging to identify due to family accommodation (Morris et al., 2016). In this article, we will review the prevalence of pediatric hoarding and provide a case example to describe clinical considerations for treating pediatric hoarding with exposure with response prevention (ERP).

The impact of COVID-19 on the treatment of obsessive-compulsive disorder.

The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.

A brief course of digitally delivered cognitive behavioural therapy for the treatment of blood contamination-based obsessive-compulsive disorder: a structured case report

Abstract The lifetime prevalence of OCD in the UK is estimated to be between 1 in 100 and 1 in every 50 people. It is therefore necessary to explore innovations in practice to expand the reach of the gold standard therapeutic approaches of exposure with response prevention (ERP) and cognitive behavioural therapy (CBT). The COVID-19 pandemic has facilitated such innovations with several services accommodating changes to routine practice by utilising digital platforms to provide videoconference-delivered therapy. Despite a growing evidence base demonstrating efficacy and scope for the use of videoconference-delivered CBT for obsessive-compulsive disorder (OCD), there remains qualitative research collated from clinicians which suggests that a lack of practitioner confidence and a low belief in positive outcomes are barriers to adopting remote therapy practices for clinicians. Therefore, this structured case report describes the assessment, formulation, intervention and outcome of an 11-week videoconference-delivered therapeutic intervention. Reflections are made regarding the use of the digital platform throughout the intervention, alongside the strengths and difficulties of applying videoconference-delivered CBT for OCD. Key learning aims (1) To illustrate a digital treatment of OCD through flexible application of the current evidence base. (2) To gain an understanding of the strengths and weaknesses of delivering digital out-patient CBT for OCD. (3) To consider the utility of structured case reports in routine practice when delivering digital therapy.

Forming a Doctor-Patient Alliance During COVID-19 to Enhance Treatment Outcomes for Obsessive-Compulsive Disorder.

Forming a Doctor-Patient Alliance During COVID-19 to Enhance Treatment Outcomes for Obsessive-Compulsive Disorder.

The impact of COVID-19 on the treatment of obsessive-compulsive disorder.

The COVID-19 pandemic has led to challenges in providing cognitive-behavioral therapy for patients with obsessive-compulsive disorder (OCD). Despite the presence of the pandemic and the risk of contracting illness, therapists can continue to utilize exposure with response prevention (ERP), which is the gold standard psychotherapy treatment for OCD. Therapists can ethically implement ERP by focusing on core treatment tenets while incorporating guidelines recommended by the Centers for Disease Control and Prevention to mitigate risk for COVID-19 exposure. The pandemic has also provided an opportunity to more widely implement ERP through virtual telehealth appointments, which have notable benefits as well as some drawbacks.

Technology supported mindfulness for obsessive compulsive disorder: Self-reported mindfulness and EEG correlates of mind wandering

Cognitive Behavior Therapy (CBT) incorporating Exposure with Response Prevention (ERP) is the most efficacious treatment intervention for Obsessive Compulsive Disorder (OCD); however, there is a growing literature indicating that mindfulness based approaches can be beneficial in terms of managing OCD symptoms. The current study examined the potential benefits of using a consumer grade EEG-based biofeedback device (called “Muse”) that permits individuals to engage in mindfulness meditation practices while at home. In this randomized controlled study, participants with a principal DSM-5 diagnosis of OCD (N = 71) were randomly assigned to eight weeks of: 1) a meditation program involving daily use of the “Muse” device, or 2) waitlist control. At weeks 1, 4, and 8, participants completed a five minute “open monitoring” practice while EEG data was recorded, and they completed self-report measures of mindfulness (FFMQ: Five Factor Mindfulness Questionnaire) and OCD symptoms (YBOCS: Yale-Brown Obsessive Compulsive Scale). Latent Difference Score (LDS) models demonstrated that the FFMQ “Non-Reactivity” facet and EEG-derived correlates of “Mind Wandering” (i.e., alpha, beta, but not delta or theta band power) were temporally associated with subsequent changes in YBOCS symptom scores. Participants in the Muse group (in comparison to the control group) experienced increased FFMQ “Non-Reactivity” and decreased mind wandering (increased alpha and beta band power), and in each case, these variables were associated with subsequent OCD symptom improvement. These results suggest that technology supported mindfulness training for OCD is associated with improvements in OCD symptoms, mindfulness and decreased mind wandering.

Cortisol, DHEA and DHEA-S during exposure therapy in patients with obsessive-compulsive disorder – secretion patterns and prediction of treatment response

The cortisol response in patients with obsessive-compulsive disorder (OCD) during exposure with response prevention (ERP), a stressful but very effective psychotherapeutic treatment, has shown contradictory findings in three prior studies with low sample sizes. In a larger cohort of 51 patients with OCD we repeatedly measured subjective units of distress (SUD) and the adrenocortical stress hormones cortisol, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA-S) in saliva during the very first session of ERP and on the day before. Expectedly, SUD were increased on the ERP day before the session and further rose during ERP, but salivary cortisol and DHEA were statistically indistinguishable from the comparison condition. Interestingly, DHEA-S was significantly elevated throughout the ERP versus the comparison day, but did not further increase in acute response to ERP. According to an explorative analysis in a subsample, hormone levels on the comparison or the ERP day did not predict anti-OCD treatment response one month later. These results corroborate our prior findings of cortisol non-response despite considerable subjective stress in ERP. The role of DHEA-S in anticipatory anxiety and the effects of augmentative cortisol therapy in ERP need further study.

Prolonged avoidance training exacerbates OCD-like behaviors in a rodent model

Obsessive-compulsive disorder (OCD) is characterized by compulsive behaviors that often resemble avoidance of perceived danger. OCD can be treated with exposure-with-response prevention (ERP) therapy in which patients are exposed to triggers but are encouraged to refrain from compulsions, to extinguish compulsive responses. The compulsions of OCD are strengthened by many repeated exposures to triggers, but little is known about the effects of extended repetition of avoidance behaviors on extinction. Here we assessed the extent to which overtraining of active avoidance affects subsequent extinction-with-response prevention (Ext-RP) as a rodent model of ERP, in which rats are extinguished to triggers, while the avoidance option is prevented. Male rats conditioned for 8d or 20d produced similar avoidance behavior to a tone paired with a shock, however, the 20d group showed a severe impairment of extinction during Ext-RP, as well as heightened anxiety. Furthermore, the majority of overtrained (20d) rats (75%) exhibited persistent avoidance following Ext-RP. In the 8d group, only a minority of rats (37%) exhibited persistent avoidance, and this was associated with elevated activity (c-Fos) in the prelimbic cortex and nucleus accumbens. In the 20d group, the minority of non-persistent rats (25%) showed elevated activity in the insular-orbital cortex and paraventricular thalamus. Lastly, extending the duration of Ext-RP prevented the deleterious effects of overtraining on extinction and avoidance. These rodent findings suggest that repeated expression of compulsion-like behaviors biases individuals toward persistent avoidance and alters avoidance circuits, thereby reducing the effectiveness of current extinction-based therapies.

A meta‐analysis of dropout rates from exposure with response prevention and pharmacological treatment for youth with obsessive compulsive disorder

Beliefs that exposure with response prevention (ERP) is excessively distressing and will result in client dropout from treatment are commonly-cited reasons for clinicians not providing evidence-based treatment. This meta-analysis examined treatment attrition for ERP for youth with obsessive compulsive disorder (OCD) compared with other treatment modalities. A systematic literature search identified 11 randomized controlled trials (RCTs) comparing ERP to active or waitlist control conditions, 9 comparing pharmacotherapy to control, and 3 comparing ERP to pharmacotherapy for youth with OCD. Attrition rates were low for ERP (10.24%) compared to pharmacotherapy (17.29%), active control (e.g., relaxation, metacognitive therapy; 20.63%), and pill placebo (23.49%). ERP had lower risk of attrition compared to active control conditions (RR = 0.60; p = .02), and was not significantly different to waitlist (RR = 0.80; p = .59). In head-to-head trials, there was no difference between the risk of attrition from ERP and pharmacotherapy (RR = 1.26; p = .74). Of the pharmacotherapy trials, risk of attrition from serotonin reuptake inhibitors treatment was not significantly different compared to placebo (RR = 0.94; p = .76), with no difference between antidepressants and clomipramine (p = .19). Attrition from ERP was primarily for logistical reasons, compared to lack of efficacy for relaxation and/or adverse reactions from pharmacotherapy. Attrition from ERP is low, and is generally lower than non-ERP interventions. Given favorable attrition and efficacy data, there is little justification for appropriately-trained clinicians not to offer ERP as a first-line treatment for youth with OCD.

Clinician-reported barriers to using exposure with response prevention in the treatment of paediatric obsessive-compulsive disorder

Exposure techniques are underutilised in the treatment of anxiety disorders in routine practice, but little is known about the use of exposure with response prevention (ERP) for OCD, particularly in youth. The current study aimed to examine the utilisation of ERP for paediatric OCD via an anonymous online survey completed by clinicians (N = 107). Specifically, we explored the association of clinician characteristics and OCD symptom subtypes with ERP use, as well as clinician-reported barriers to ERP implementation. The majority of clinicians reported commonly using ERP when treating youth with OCD, and rates of ERP use were highest among clinical psychologists. Clinician-held negative beliefs about exposure were significantly associated with lower ERP use. Additionally, clinicians reported being less likely to use ERP to treat hoarding symptoms and taboo obsessions, compared to other OCD symptom subtypes. The most commonly endorsed barriers to successful ERP implementation were aspects of the phenomenology of OCD (e.g. covert compulsions, frequently changing rituals) as opposed to general barriers (e.g. insufficient time during sessions). Overall, our findings suggest that OCD presents unique challenges for clinicians delivering exposure-based therapy. Training should address these OCD-specific obstacles in order to promote dissemination of ERP for youth with OCD.

Individual Versus Group Exposure With Response Prevention (ERP) for the Treatment of Obsessive Compulsive Disorder (OCD)

Individual Versus Group Exposure With Response Prevention (ERP) for the Treatment of Obsessive Compulsive Disorder (OCD)

9.2 Community-Based Delivery to Enhance Accessibility and Effectiveness of Exposure With Response Prevention: Conceptual Rationale and Practical Implementation at Bradley Hospital

Exposure with response prevention (ERP) is effective for youth with OCD and anxiety disorders, but access to the treatment is poor, and not all recipients respond. This presentation will describe the rationale for community-based, rather than office-based, delivery of ERP as a means of improving treatment accessibility and effectiveness and for the implementation of community-based ERP in partial hospital and outpatient services at the Bradley Hospital Pediatric Anxiety Research Center (PARC).

“Phobie à deux” and other reasons why clinicians do not apply exposure with response prevention in patients with obsessive–compulsive disorder

ABSTRACTMeta-analyses suggest that exposure with response prevention (ERP) is the most efficacious treatment for obsessive–compulsive disorder (OCD) and treatment guidelines for the disorder accordingly recommend ERP. Despite this, many therapists, including those with a cognitive-behavioral therapeutic background, do not perform ERP in patients with OCD. The present study aimed to elucidate the reasons why. German therapists (N = 216) completed an anonymous online survey, the newly developed Reasons for Not Performing Exposure in OCD Scale (REPEX), that inquired whether, to what extent, and how they perform ERP in the treatment of OCD. We also asked their reasons for not applying ERP in the past. Most therapists considered ERP an efficient treatment for OCD. Marked differences emerged between physicians and psychologists, however. The former used exposure less often and for a shorter period, preferred in sensu to in vivo exposure, and conducted exposure less often in the personal environment of the patient than did psychologists. Both groups were familiar with clinical guidelines to a similar extent. A factor analysis of the REPEX scale revealed five factors. Patient lack of motivation, preference for exposure to be self-help as well as alleged organizational difficulties were endorsed most often. The latter was correlated with the age of the therapist and was far more often affirmed by physicians. Fear of side effects was named by a subgroup of clinicians; in the context of patient ambivalence, this may foster “phobie à deux”. Unlike prior research, lack of expertise was rarely identified as a reason not to use ERP. Recommendations for improving adherence to guidelines are discussed.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study.

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats.Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD.Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse.Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 – 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.