Treatment for OCD & Related Disorders

What is Exposure and Response Prevention (ERP)?

ERP is a very specific type of Cognitive Behavioral Therapy (CBT) that research has shown to be the most effective way of treating OCD. CBT is a form of therapy that addresses one's thinking and behaviors. The idea is that when one is able to change the way they think and behave through new awareness and insight, the way they feel will also begin to change providing for increased satisfaction. Some treatment providers may use the terms ERP and CBT interchangeably, but it is important to specifically use ERP when treating OCD.

The Steps of ERP

Step one is to get a better picture of your OCD symptoms and how it impacts your life. We do this by using the Yale-Brown Obsessive Compulsive (YBOCS) checklist and scale. This will not only indicate the types of obsessions and/or compulsions you struggle with, but also how much it impacts your daily life. This also provides the opportunity for us to discuss other OCD-related disorders.

Step two is to review and consider a number of factors that may be contributing to your OCD symptoms and/or general anxiety. These include but are not limited to

  • stress management
  • diet and exercise
  • family influence (or lack thereof)
  • sleep habits
  • distorted thinking (often related to depressed mood)
  • relaxation techniques
  • influence of medications/medical conditions (if any)

Step three is to begin developing the hierarchy. We call this the "road map" in therapy. It's a graduated list of all the things that you do that make you anxious, that you think make you anxious, or that you avoid because they make you anxious. This is a list of all the exposures and response preventions that you will work on while in therapy. This will also include a subjective unit of distress (SUDs) number that indicates how difficult performing any given task will be. The hierarchy is always changing, so it is a critical part of therapy during the entire therapy process.

Step four is to begin developing and working on weekly homework assignments. Homework assignments will first begin with working on developing your hierarchy. All homework assignments after this will involve doing one or more of the tasks listed on your hierarchy. You will be encouraged to face your fears one at a time without doing the safety maneuver (ritual/compulsion). You will begin with the easiest things on your list and when doing an "exposure" you will have to make sure to "prevent your typical response or ritual" that would ordinarily relieve the anxiety temporarily. You will slowly work up to the harder items on your hierarchy finding that the more easy things you do, the easier the more difficult items will become. The important piece about doing homework each is week is to make sure it's an assignment that you can do every day with some anxiety but not so overwhelming that the anxiety lasts more than an hour or is impossible to complete some days.

During this process listed above, we will also consider who you are without your OCD. We could call this the "post-OCD" vision for your life. Additionally, at the end, it will be important to discuss ways in which you can maintain your gains on your ow

Major Differences Between Treatment for OCD and Hoarding

While both OCD and hoarding are generally treated with CBT/ERP treatment, there are some significant differences between the two. First, individuals with hoarding often struggle with things like procrastination, decision making, scheduling, and organizing, so a few weeks of therapy are specifically dedicated to what we call "cognitive rehabilitation". This will address how to be better organized both with items and time.

The second major difference between the two is the importance of some home visits for hoarding. With hoarding there is often a great deal of shame that comes with one's home (we call this "CHAOS" - Can't Have Anyone Over Syndrome), so while this may be very difficult for the client, it provides for a great deal of understanding and insight on the therapist's part when working with the client.

The third most common difference is the way ERP is approached with a hierarchy. While a hierarchy is still used in hoarding treatment, it is often used to describe various areas within/around the home that would be difficult to clear rather than specific items. Additionally, depending on whether there are any safety concerns in the home, the client may be asked to work on areas that are not the easiest item on his/her hierarchy to address safety issues first. See hoarding brochure for additional information.

Habit Reversal Training (HRT)

Habit Reversal Training is a form of therapy used to treat Body-Focused Repetitive Behaviors (BFRBs), impulse control disorders, and tics/Tourette's. It includes learning to increase awareness of the unwanted behavior, create a competing response, utilize relaxation techniques or focusing techniques, and incorporate positive social reinforcement. The first step is to become aware of when these behaviors are most and least frequent. Steps are then taken to create a competing response while utilizing relaxation and/or focusing techniques to get work through the impulse. Then lastly we want to positively reinforce the use of  both the tools and the reduction of the behavior.

Treatment for Tics/Tourrette's

Comprehensive Behavioral Intervention for Tics (CBIT) is a type of therapy consisting of three important components:

  • Awareness training of his/her tics and the urge to tic.
  • Teaching one how to use a competing behavior when they feel the urge to tic. The competing response is a special behavior or movement that makes the tic more difficult to accomplish.
  • Making changes to day to day activities/environments in ways that can help reduce tics. 

CBIT combines elements of habit reversal training with psycho-education and function-based behavioral interventions. In 2010 results of a child study was published in the Journal of the American Medical Association and showed that 52.5% of the children who received CBIT experienced significant symptom improvement compared to 18.5% receiving the control treatment. In 2012 an adult study was published in the Journal Archives of General Psychiatry and showed that 38% of those receiving CBIT experienced significant improvement compared to just 7% who did not receive CBIT treatment. In both studies improvement was maintained for at least six months after the end of the study.

Treatment for Body Dysmorphic Disorder (BDD)

For many years studies have show that the best treatment for treating BDD is Cognitive Behavioral Therapy (CBT). Similarly to OCD it has also been treated using ERP; however, it is often the case that the use of CBT/ERP alone is not enough. The use of Psychodynamic therapy, Family Systems therapy, and Interpersonal therapy have also proven to be an important part of the treatment for those struggling with BDD. 

Medication has also shown to be a very effective and important part of treatment when an individual is struggling with BDD. Clients are encouraged to seek out medication management with a Psychiatrist if they feel that this is a direction they would like to go with their treatment.