Exposure With Response Prevention Research Articles

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.

Post-treatment predictors of follow-up status for obsessive-compulsive disorder treated with concentrated exposure therapy

Recommended psychological treatment for obsessive-compulsive disorder (OCD) is cognitive behavioral therapy (CBT) including exposure with response prevention (ERP). Previous studies have identified...

A case report of the treatment of obsessive compulsive disorder in a patient with Cystic Fibrosis: Potential protective role of contamination fears

•This report describes the unique case of an individual with a DSM-5 diagnosis of obsessive compulsive disorder (OCD) who also had a general medical diagnosis of cystic fibrosis (CF).•Delivery of evidence-based treatment to individuals with OCD and CF presents a challenge for clinicians, as they need to consider the necessary contact precautions to reduce the risk for respiratory infection and exacerbations of symptoms of CF.•Contamination fears are common in OCD and require careful attention within the application of cognitive behavior therapy (CBT) with exposure with response prevention (ERP) for individuals with CF as the accompanying cleaning rituals may play a protective role.•Therapists providing CBT with ERP can work collaboratively with other professionals and individuals (who are themselves experts in the day-to-day management CF) to cipher out the actual versus anxiety driven obsessions and compulsions, and higher versus lower risk contexts.

Exposure with response prevention (ERP) for body dissatisfaction in a group therapy format: an exploratory study.

The aim of this exploratory study was to examine patient satisfaction and outcomes from exposure with response prevention (ERP) delivered in a group therapy format. The group was aimed at addressing eating disorder symptoms associated with body dissatisfaction in the later stages of outpatient treatment. 33 adults with a DSM-5 diagnosis of an eating disorder participated in the ERP group. Participants completed pre- and post-ERP group measures of depression, anxiety, self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, upward and downward appearance comparisons, and patient satisfaction. Involvement in the ERP group was associated with significant decreases in self-evaluation based on body image, restraint, eating concern, weight concern, shape concern, and upward physical appearance comparisons post-group treatment. This adjunct treatment group was well received and viewed as being helpful by participants. ERP in a group therapy format for addressing body dissatisfaction may represent a complimentary approach to current evidence-based treatments for an eating disorder, and warrant further investigation.

Online computer-aided vicarious exposure for OCD symptoms: A pilot study

Background and objectivesComputer-aided vicarious exposure (CAVE) for obsessive-compulsive disorder (OCD) is an intervention in which participants learn and rehearse exposure with response prevention (ERP) by directing a character around a virtual world. This study aimed to pilot an online CAVE program for OCD in a community sample with high OCD symptomatology. MethodsParticipants (n = 78) were allocated to an intervention group (three 45-min weekly CAVE sessions) or to a waitlist control group. The treatment group were asked to complete three 45-min sessions over a four week period. ResultsThose who completed at least one CAVE session showed greater improvement on measures of OCD symptomatology at one-month post-treatment (d = 0.49–0.81) compared to waitlist (d = 0.01–0.1). Older age, past treatment and higher symptom severity were associated with non-adherence. LimitationsThese findings should be considered preliminary due to sample size limitations and an absence of an active control group. However, the findings suggest that further development and evaluation of the program is warranted. ConclusionsPreliminary findings suggest that online CAVE programs have potential to bridge treatment gaps among those reluctant to attend treatment or engage with in vivo exposure exercises. These programs may also have potential applications as an adjunct to face-to-face or online cognitive behavioural therapy.

An Avoidance-Based Rodent Model of Exposure With Response Prevention Therapy for Obsessive-Compulsive Disorder

BackgroundObsessive-compulsive disorder is treated with exposure with response prevention (ERP) therapy, in which patients are repeatedly exposed to compulsive triggers but prevented from expressing their compulsions. Many compulsions are an attempt to avoid perceived dangers, and the intent of ERP is to extinguish compulsions. Patients failing ERP therapy are candidates for deep brain stimulation (DBS) of the ventral capsule/ventral striatum, which facilitates patients’ response to ERP therapy. An animal model of ERP would be useful for understanding the neural mechanisms of extinction in obsessive-compulsive disorder. MethodsUsing a platform-mediated signaled avoidance task, we developed a rodent model of ERP called extinction with response prevention (Ext-RP), in which avoidance-conditioned rats are given extinction trials while blocking access to the avoidance platform. Following 3 days of Ext-RP, rats were tested with the platform unblocked to evaluate persistent avoidance. We then assessed if pharmacologic inactivation of lateral orbitofrontal cortex (lOFC) or DBS of the ventral striatum reduced persistent avoidance. ResultsFollowing Ext-RP training, most rats showed reduced avoidance at test (Ext-RP success), but a subset persisted in their avoidance (Ext-RP failure). Pharmacologic inactivation of lOFC eliminated persistent avoidance, as did DBS applied to the ventral striatum during Ext-RP. ConclusionsDBS of ventral striatum has been previously shown to inhibit lOFC activity. Thus, activity in lOFC, which is known to be hyperactive in obsessive-compulsive disorder, may be responsible for impairing patients’ response to ERP therapy.

Does time-intensive ERP attenuate the negative impact of comorbid personality disorders on the outcome of treatment-resistant OCD?

Background and objectivesThere is growing interest regarding patients with obsessive-compulsive disorder (OCD) who do not fully respond to cognitive-behavioural therapy (CBT). Limited data are available on the role of Comorbid Personality Disorders (CPDs) in the outcome of treatment-resistant obsessive-compulsive disorder (OCD), despite the fact that CPDs are considered a predictor of a poorer outcome. This study investigated whether a time-intensive scheduling of treatment could be an effective strategy aimed at attenuating the negative influence of CPDs on outcome in a sample of 49 inpatients with a primary diagnosis of treatment-resistant OCD. Method38 inpatients completed the five-week individual treatment consisting of daily and prolonged sessions of exposure with response prevention (ERP) delivered for 2 h in the morning and 2 h in the afternoon. 44% of the sample received a full diagnosis of one or more CPDs. Following a pre-post-test design, outcome measures included the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). ResultsData showed that the treatment was effective and indicated that CPDs were not a significant predictor of treatment failure. LimitationsFuture larger studies should evaluate the role of specific clusters of CPDs on the outcome of resistant OCD. ConclusionsThese findings suggest that an intensive treatment could be effective for severely ill patients who have not responded to weekly outpatient sessions and could also attenuate the negative impact of CPDs on outcome, evidencing the importance of a tailored therapeutic approach for patients who need a rapid reduction in OCD-related impairment.

ERP, Medication, and Brief Hospitalization in the Treatment of an Adolescent With Severe BDD

This article describes the 2-year treatment of a 14-year-old girl suffering from severe body dysmorphic disorder (BDD) and comorbid major depressive disorder (MDD). Treatment consisted of twice-weekly sessions of exposure with response prevention (ERP), medication (fluoxetine), and a brief hospitalization for crisis stabilization. Continual (weekly) monitoring indicated significant reductions in daily obsessions and time spent in ritual. In addition, school attendance increased and scores on the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), Body Dysmorphic Disorder Examination (BDDE), and Children’s Depression Inventory (CDI) decreased. Gains were maintained at follow-up. At termination, the client met criteria for partial remission status as defined by Phillips, Pagano, Menard, and Stout. This case adds to the BDD treatment literature by evaluating the long-term effectiveness of a multicomponent intervention, as implemented in a naturalistic setting with an adolescent, and suggests that combination treatment may be required to reduce distress and to produce lasting changes in functioning.

Non-response of cortisol during stressful exposure therapy in patients with obsessive-compulsive disorder—Preliminary results

Exposure with response prevention (ERP) is an established treatment for patients with obsessive-compulsive disorder (OCD) and also an interesting model to characterize neuroendocrine response to psychological stress. However, so far few studies have assessed hypothalamic–pituitary–adrenocortical (HPA) function during ERP and results are inconsistent. In 15 patients with OCD we repeatedly measured salivary cortisol and subjective units of distress (SUD) on two consecutive afternoons. The first day served as a comparison condition; on the second day the very first session of ERP took place. While SUD were significantly increased during ERP versus the comparison day, salivary cortisol was statistically indistinguishable between ERP and comparison conditions before, during and after ERP. Thus, despite considerable psychological stress no increase of cortisol was observed. This response pattern to ERP in OCD patients needs further research.

Technology and Obsessive Compulsive Disorder: An Interactive Self-Help Website for OCD

Obsessive Compulsive Disorder (OCD) is a neurobiological illness characterized by unwanted thoughts and/or images followed by repetitive rituals. About 5 million Americans live with Obsessive Compulsive Disorder. OCD is a manageable illness when proper interventions are utilized. Treatment for OCD is limited due to the lack of adequately trained professionals and the high costs of treatment. Cognitive behavioral therapy (CBT) in conjunction with exposure with response prevention (ERP) is the most effective intervention modality available for OCD. To address the treatment gap, an online, interactive self-help website was developed for those living with OCD without access to an effective intervention. This report will explore development of the OCD Challenge website and future implications of its use.

Absent cortisol response during stressful exposure therapy in patients with obsessive-compulsive disorder

Exposure with response prevention (ERP) is the most effective treatment for patients with obsessive-compulsive disorder (OCD), but associated with considerable temporary stress during initial therapy sessions. Thus, it may serve as an interesting model to characterize neuroendocrine response to a psychological stimulus in these patients. However, so far only few studies have assessed hypothalamic-pituitary-adrenocortical function during ERP and results are inconsistent. In a pilot stuy we repeatedly measured salivary cortisol and subjective units of distress (SUD) on two consecutive afternoons in 15 patients with OCD during the first session of ERP and on a prior comparison day. Expectedly, SUD were significantly higher before and during ERP versus the comparison day (means 49.8 vs. 31.4 and 72.6 vs. 34.0, resp.). However, salivary cortisol concentrations were statistically indistinguishable between ERP and comparison condition before, as well as during and after ERP. This response pattern to ERP in OCD patients is not sufficiently explicable and needs further research. Our findings resemble congruent results in patients with panic disorder. Hypotheses on psychological and neurobiological backgrounds of this unexpected regulatory pattern will be discussed. The possible impact of cortisol response on extinction learning during ERP will be be speculated on and investigated more closely in this ongoing study.

European clinical guidelines for Tourette Syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

This clinical guideline provides recommendations for the behavioural and psychosocial interventions (BPI) of children and adolescents with tic disorders prepared by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain an update on the efficacy of BPI for tics. Relevant studies were identified using computerised searches of the Medline and PsycINFO databases and the Cochrane Library for the years 1950-2010. The search identified no meta-analyses, yet twelve (systematic) reviews and eight randomised controlled trials provided evidence for the current review. Most evidence was found for habit reversal training (HRT) and the available but smaller evidence also supports the efficacy of exposure with response prevention (ERP). Both interventions are considered first line behavioural treatments for tics for both children and adults and should be offered to a patient, taking into account his preference. Treatments that are considered second line or add-on behavioural treatments are contingency management, function based interventions and relaxation training. Neurofeedback is still experimental. Almost no research was identified that examined the efficacy of psychosocial interventions, e.g., psychoeducation and group work. Based on clinical practice, this guideline recommends behavioural treatment as first line offer to patients in most cases. It should be embedded within a psychoeducational and supportive context and can be combined with drug treatment.

Five-year outcome of cognitive behavioral therapy and exposure with response prevention for bulimia nervosa

Few data exist examining the longer-term outcome of bulimia nervosa (BN) following treatment with cognitive behavioral therapy (CBT) and exposure with response prevention (ERP). One hundred and thirty-five women with purging BN received eight sessions of individual CBT and were then randomly assigned to either relaxation training (RELAX) or one of two ERP treatments, pre-binge (B-ERP) or pre-purge cues (P-ERP). Participants were assessed yearly following treatment and follow-up data were recorded. Eighty-one per cent of the total sample attended long-term follow-up. At 5 years, abstinence rates from binging were significantly higher for the two exposure treatments (43% and 54%) than for relaxation (27%), with no difference between the two forms of exposure. Over 5 years, the frequency of purging was lower for the exposure treatments than for relaxation training. Rates of recovery varied according to definition of recovery. Recovery continued to increase to 5 years. At 5 years, 83% no longer met DSM-III-R criteria for BN, 65% received no eating disorder diagnosis, but only 36% had been abstinent from bulimic behaviors for the past year. This study provides possible evidence of a conditioned inoculation from exposure treatment compared with relaxation training in long-term abstinence from binge eating at 5 years, and the frequency of purging over 5 years, but not for other features of BN. Differences among the groups were not found prior to 5 years. CBT is effective for BN, yet a substantial group remains unwell in the long term. Definition of recovery impacts markedly on recovery rates.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II: rationale, design and methods.

This paper presents the rationale, design, and methods of the Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II), which investigates two different cognitive-behavior therapy (CBT) augmentation approaches in children and adolescents who have experienced a partial response to pharmacotherapy with a serotonin reuptake inhibitor for OCD. The two CBT approaches test a "single doctor" versus "dual doctor" model of service delivery. A specific goal was to develop and test an easily disseminated protocol whereby child psychiatrists would provide instructions in core CBT procedures recommended for pediatric OCD (e.g., hierarchy development, in vivo exposure homework) during routine medical management of OCD (I-CBT). The conventional "dual doctor" CBT protocol consists of 14 visits over 12 weeks involving: (1) psychoeducation, (2), cognitive training, (3) mapping OCD, and (4) exposure with response prevention (EX/RP). I-CBT is a 7-session version of CBT that does not include imaginal exposure or therapist-assisted EX/RP. In this study, we compared 12 weeks of medication management (MM) provided by a study psychiatrist (MM only) with two types of CBT augmentation: (1) the dual doctor model (MM+CBT); and (2) the single doctor model (MM+I-CBT). The design balanced elements of an efficacy study (e.g., random assignment, independent ratings) with effectiveness research aims (e.g., differences in specific SRI medications, dosages, treatment providers). The study is wrapping up recruitment of 140 youth ages 7–17 with a primary diagnosis of OCD. Independent evaluators (IEs) rated participants at weeks 0,4,8, and 12 during acute treatment and at 3,6, and 12 month follow-up visits.NCT00074815

Influence of Co‐Morbid Generalized Anxiety Disorder, Panic Disorder and Personality Disorders on the Outcome of Cognitive Behavioural Treatment of Obsessive‐Compulsive Disorder

This study examined co‐morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive‐compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co‐morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention‐to‐treat criteria, patients with generalized anxiety disorder and/or panic disorder co‐morbidity showed less treatment gains at post‐treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post‐treatment and the 12‐month follow‐up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co‐morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12‐month follow‐up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post‐treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.

Exposition aux substances addictogènes, réponses conditionnées et traitements d’exposition avec prévention de la réponse

Exposure to drugs or related cues is associated with psycho-physiological reactivity. These responses are conditioned during periods of active consumption. Exposure with response prevention (EPR) is a treatment established for anxiety disorder and aims to reduce anxiety by an extinction of previously conditioned responses. The conditioning recognized in additive processes has led to research into EPR's therapeutic potential for treating addiction. This paper is a review of the main studies on reactivity to cues, and EPR, particularly with respect to addiction to alcohol, opiates, cocaine and tobacco.This review is based on information from the Medline database, dealing with cue reactivity, attentional bias during exposure to cues and exposure treatment for addiction in general and, in particular, for each of the aforementioned substances.Exposure to drug-related cues is clearly associated with psycho-physiological reactivity and with attentional bias. Those phenomena are associated with craving and more difficulty in maintaining abstinence. The subject's attention is thus held by a large number of drug-related environmental stimuli. These observations are linked with conditioning phenomena and suggest the possibility of treatment by EPR conditioning extinction procedures. EPR has been most widely studied for abuse and alcohol addiction. Case reports give favourable outcomes. Results from controlled studies are less clear. Studies on patients addicted to cocaine or heroine are still limited and not conclusive. Different controlled studies on EPR for nicotine addiction have not produced conclusions in favour of this treatment. Generally, the EPR procedures used vary among studies. Studies focussing particularly on the evolution of physiological responses in a laboratory setting after EPR have demonstrated reduced autonomic nervous system activity. These results do not consistently lead to a reduction in consumption behaviour and in craving when the patient is in his/her natural environment. The difficulties encountered in the development of EPR treatments, despite the appealing reasoning behind them, could be explained by the tendency of conditional stimuli to re-occur spontaneously. However, it is clear from the studies reviewed that by selecting EPR conditions more rigorously, more efficient procedures might be developed at least for some patients. It seems that the place and the conditions of exposure are factors essential to the success of these therapeutic procedures. Exposure in vivo is better than exposure in imagination. Prolonged exposure over an hour is more effective than exposure lasting 10 minutes. Exposures in close succession are also associated with a better extinction of conditioned responses. The moment that the stimulus occurs, how appropriate it is and its proximity with potential reinforcement are also essential elements for the conditioning procedures. Improving the conditions in which EPR is applied could then enhance the therapeutic potential of this approach.

Office-based vs. home-based behavioral treatment for obsessive-compulsive disorder: A preliminary study

The current study investigated whether exposure with response prevention (ERP) for obsessive compulsive disorder (OCD) is more effective when administered in a participant's home or other natural environments where symptoms tend to occur, than in a therapist's office. Twenty-eight outpatients with a principal diagnosis of OCD were randomly assigned to receive ERP in their therapist's office vs. wherever their symptoms usually occur (e.g., at home, at work, in public places, in the car, etc.). Participants received 14, 90-min sessions of ERP with an individual therapist. Participants were assessed at pretreatment, post-treatment, and at 3- and 6-month follow-up. Assessments included both self-report as well as clinician-rated indicators of OCD symptom severity, depression, and functional impairment. Results suggested that participants improved significantly, regardless of where treatment occurred. There were no differences in efficacy between the home-based and office-based treatment for OCD. Implications of these findings are discussed.

A Psychodynamic Clinician’s Foray into Cognitive-Behavioral Therapy Utilizing Exposure-Response Prevention for Obsessive-Compulsive Disorder

Research suggests that, by itself or as an adjunct to pharmacotherapy, cognitive-behavioral therapy (CBT) involving exposure with response prevention (ERP) is an effective treatment for Obsessive-Compulsive Disorder (OCD). However, there is a shortage of clinicians trained in this form of therapy. Although many psychodynamic clinicians treat individuals with OCD using traditional therapy that may assist them with their relationships, there is little evidence that such treatment is effective in ameliorating the OCD symptoms. As there is a clear need for more clinicians trained in CBT for OCD, it may be possible for practitioners trained in psychodynamic or other modalities to learn ERP. Such cross-theoretical training involves a number of challenges. These include the therapist's own anxiety about ERP, understanding resistance, and reconsidering therapeutic boundaries. The first author describes his experiences as a psychodynamically-trained psychologist venturing into ERP in an attempt to demonstrate that although there are barriers they are not insurmountable.

Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: A Review of the Treatment Literature

Once considered a rare and largely untreatable condition, obsessive-compulsive disorder (OCD) is now known to be the fourth most common psychiatric disorder. Obsessive thoughts are intrusive, repugnant, and distress and anxiety provoking, whereas compulsive rituals often lead to significant impairment in many areas of life. In this article, the authors present an empirically based review of the treatment outcome literature on cognitive-behavioral therapy for OCD. Specifically, treatment by exposure with response prevention (EX/RP) has been demonstrated to be effective in reducing OCD symptoms. The effectiveness of different variations of EX/RP and comparisons between this and other psychosocial therapies (e.g., cognitive therapy) are also discussed. Finally, the authors consider studies that have examined variables thought to influence the effectiveness of treatment.

Effects of comorbid depression on response to treatment for obsessive-compulsive disorder

We examined the effects of comorbid depression on response to treatment for obsessive-compulsive disorder (OCD) using cognitive-behavioral therapy with and without medication. Eighty-seven OCD patients were divided into nondepressed and mildly, moderately, and severely depressed groups on the basis of their pretreatment Beck Depression Inventory (BDI) scores. Each received an intensive cognitive-behavioral treatment program involving exposure with response prevention (EX/RP); 59 (68%) were also taking medication for OCD. Patients with severe initial depression (BDI ≥30) showed significantly less improvement compared to those less depressed or nondepressed; yet, even highly depressed patients showed moderate treatment gains. Failure to habituate to anxiety-evoking stimuli during exposure and a lack of motivation for therapy are considered possible causes of attenuated outcome.