User:Jjk016/sandbox

Obsessive compulsive disorder (OCD)

Exposure and response prevention (also known as exposure and ritual prevention; ERP or EX/RP) is a variant of exposure therapy that is recommended by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the Mayo Clinic as first-one treatment of OCD citing that it has the richest empirical support for both youth and adolescent outcomes.

ERP is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears, but refrain from engaging in the escape response or ritual that delays or eliminates distress. In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviors that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus. The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behavior that functions to decrease distress. The patient is then taught to tolerate distress until it fades away on its own, thereby learning that rituals are not always necessary to decrease distress or anxiety. Over repeated practice of ERP, patients with OCD expect to find that they can have obsessive thoughts and images but not have the need to engage in compulsive rituals to decrease distress.

The AACAP's practice parameters for OCD recommends cognitive behavioral therapy, and more specifically ERP, as first line treatment for youth with mild to moderate severity OCD and combination psychotherapy and pharmacotherapy for severe OCD. The Cochrane Review's examinations of different randomized control trials echoes repeated findings of the superiority of ERP over waitlist control or pill-placebos, the superiority of combination ERP and pharmacotherapy, but similar effect sizes of efficacy between ERP or pharmacotherapy alone.

Exposure and response prevention (ERP or EX/RP) also called exposure and ritual is a treatment method available from behavioral psychologists and cognitive-behavioral therapists for a variety of anxiety disorders but used especially to treat obsessive–compulsive disorder (OCD) and specific phobias. ERP, also referred to as exposures and ritual prevention, is a variant of cognitive behavioral therapy that has the strongest empirical evidence for treating OCD in youth and adults. British psychologist Victor Meyer is credited as the first clinical to report the successful treatment of OCD using an exposure-based predecessor of ERP. The American Academic of Child and Adolescent Psychiatry (AACAP) recommends cognitive behavioral therapy, and more specifically ERP, as first line treatment for youth with mild to moderate severity OCD and combination psychotherapy and pharmacotherapy for severe OCD. For adults, the American Psychiatric Association recommends ERP as for the treatment of OCD citing that ERP has the richest empirical support.

Theory and rationale

The method is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears and discontinue their escape response. In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviors that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus. The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behavior that functions to decrease distress.

For example, a person with great fear of contamination and/or germs, will often engage in frequent hand washing that may be impairing and disruptive if their fear and anxiety surrounding contamination and/or germs is severe.

An example of how this process works: Imagine a person who repeatedly checks light switches to ensure they're in the off position, even when entering a clearly unlit room. The person would be exposed to their feared stimulus (leaving lights switched on), and would refuse to respond with any safety behaviors.

The results of the 1997 treatment guidelines, the 2004 POTS study and the AACAP recommendations clearly support the effectiveness of Cognitive Behavior Therapy.  CBT makes use of two techniques: Exposure and Response Prevention (ERP) -- sometimes called "ritual prevention" -- and Cognitive Therapy.  Not every psychologist or psychiatrist is trained in the use of CBT, and not every doctor or mental health professional trained in CBT has experience treating children or young adults.  Sometimes finding a cognitive behavior therapist with this experience is challenging.

In Exposure and Response Prevention therapy, the therapist develops, together with the child, a hierarchy of all the child’s fears and rituals (from least to most disruptive) as well as situations in which these symptoms are likely to be triggered.  The therapist then conducts a series of controlled ERP sessions, beginning with tasks that are lower on the list (i.e., they produce less fear).  The child is systematically placed into feared situations (exposure) and instructed to refrain from performing his or her usual compulsions or rituals for a period of time (response prevention).  During repeated exposure exercises, the child may be asked to delay the rituals for increasingly greater periods of time.

ERP differs from exposure therapy for phobia in that the resolution to refrain from the escape response is to be maintained at all times and not just during specific practice sessions. Thus, not only does the subject experience habituation to the feared stimulus, they also practice a fear-incompatible behavioral response to the stimulus. While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms.

However, more recent work suggests that habituation is not a necessary condition for successful long-term outcome with exposure therapy. Instead, it has been suggested that clinical levels of fear and anxiety are combated through inhibitory learning wherein the exposure to anxiety itself is an important factor in long-term fear extinction.

Recent results indicate that ERP can be carried out effectively with minimal face-to-face contact between the therapist and the subject.

Treatment and implementation

OCD

Meta-analysis

Other disorders

Alcohol abuse

Bulimia nervosa

Body dysmorphic disorder

Augmentation with medication and other treatments

Combination therapies that can compensate for treatment resistance are being explored and many appear to be promising.

Serotonin reuptake inhibitors

Serotonin reuptake inhibitors (SRIs) have long been prescribed for individuals with OCD. Serotonergic medications have been found to be superior to placebo for treating OCD symptoms. However,

Clomipramine

D-cycloserine

More recently, D-cycloserine has been gaining attention among researchers as an option for combination therapy with ERP. Several studies indicate that simultaneous administration of d-cycloserine with ERP substantially improves treatment outcomes for individuals suffering from OCD. Results have been mixed, however, with other studies suggesting that d-cycloserine does not impact the outcome of ERP.

Transcranial magnetic stimulation

Another study conducted in 2014 at the Medical University of South Carolina also suggests that ERP effectiveness may be enhanced by administering transcranial magnetic stimulation (TMS) to the pre-supplementary motor area before ERP sessions.

Mindfulness

Recent reviews and research have pointed out parallels between exposure therapy and mindfulness, stating that mindful meditation "resembles an exposure situation because [mindfulness] practitioners 'turn towards their emotional experience', bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it." This largely echoes strategies within exposure therapy in which individuals are encouraged to "sit with" and tolerate their distress instead of suppressing and ignoring distress.

Neuroscience findings also appear to follow this similarities. The same brain regions identified as crucial in fear conditioning and extinction have been implicated as areas of functional and structural change following mindfulness meditation training. These regions include the ventromedial prefrontal cortex (associated with signaling contextual safety), the amygdala (crucial to acquisition and expression of fear), subgenual anterior cingulate cortex, and the hippocampus. A review of the recent literature has found an overlap of these same brain regions implicated for both mindfulness and exposure therapy thereby suggesting that mindfulness training may enhance the ability to extinguish conditioned fear.

Organizations

Exposure and response prevention is a behavior therapy technique. Many organizations exist for behavior therapists around the world. The World Association for Behavior Analysis offers a certification in behavior therapy. Their exam tests knowledge of this technique.

The Association for Behavioral and Cognitive Therapies (ABCT) is the world's largest organization dedicated to disseminating behavioral therapies.

Additionally, the International Obsessive Compulsive Disorder Foundation provides training and recognition for training in Exposure and Response Prevention for Obsessive Compulsive Disorder.

See also

• Obsessive–compulsive disorder
• Exposure therapy
• Behavior therapy
• Cognitive behavioral therapy

Further reading

• Stop Obsessing, by Foa, Edna
• Marks I (1981) Cure and Care of Neuroses John Wiley & Sons Inc, ISBN 0-471-08808-0
• Marks I. (1997) Behaviour therapy for obsessive-compulsive disorder: a decade of progress. Can J Psychiatry. Dec;42(10):1021-7.
• Lovell K, Cox D, Haddock G, Jones C, Raines D, Garvey R, Roberts C, Hadley S. (2006) Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non-inferiority trial. BMJ. Oct 28;333(7574):883
• Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781609180171.