Exposure and response prevention

Also known as ERP · EX/RP · Exposure and ritual prevention · Exposure with response prevention · OCD exposure therapy · Behavioural treatment of OCD

Exam-exhaustive fellowship reference on exposure and response prevention (ERP/EX/RP) — OCD maintenance cycle, habituation vs inhibitory learning, hierarchy design, ritual and safety-behaviour prevention, intensive vs outpatient dosing, landmark trials (Foa, Simpson, POTS), medication integration, pitfalls, youth adaptations, and CASC technique. FRANZCP-primary, globally tagged.

high19 referencesUpdated 26 July 202614 min readVerification in progress

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10 MCQs

Meet the patient

A 28-year-old nurse has spent four years hiding her cracked, bleeding hands from colleagues. She washes for forty minutes after every patient contact, sanitises her phone six times a shift, and asks her partner whether her hands are clean until he gives the answer that lets her stop. Her Y-BOCS is 28. Clomipramine took the edge off; the rituals did not move.^[1]^[14]

The registrar's referral reads "OCD, refractory, consider augmentation." The examiner's question is sharper: what was the actual behavioural treatment she received, and was it ever ERP? Nine times in ten the answer is no — and that is the whole topic.^[13]^[15]

References19Show

[1]Foa EB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder Am J Psychiatry, 2005.PMID 15625214
[2]Simpson HB, Foa EB, Liebowitz MR, et al. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder Am J Psychiatry, 2008.PMID 18316422
[3]Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial JAMA Psychiatry, 2013.PMID 24026523
[4]Foa EB, Simpson HB, Rosenfield D, et al. Six-month outcomes from a randomized trial augmenting serotonin reuptake inhibitors with exposure and response prevention or risperidone J Clin Psychiatry, 2015.PMID 25375780
[5]Abramowitz JS, Foa EB, Franklin ME Exposure and ritual prevention for obsessive-compulsive disorder: effects of intensive versus twice-weekly sessions J Consult Clin Psychol, 2003.PMID 12699033
[6]Pediatric OCD Treatment Study (POTS) Team Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial JAMA, 2004.PMID 15507582
[7]Franklin ME, Sapyta J, Freeman JB, et al. Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial JAMA, 2011.PMID 21934055
[8]Öst LG, Havnen A, Hansen B, Kvale G Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014 Clin Psychol Rev, 2015.PMID 26117062
[9]Eddy KT, Dutra L, Bradley R, Westen D A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder Clin Psychol Rev, 2004.PMID 15533282
[10]Song Y, Li D, Zhang S, et al. The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis Psychiatry Res, 2022.PMID 36179591
[11]Skapinakis P, Caldwell DM, Hollingworth W, et al. Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis Lancet Psychiatry, 2016.PMID 27318812
[12]Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B Maximizing exposure therapy: an inhibitory learning approach Behav Res Ther, 2014.PMID 24864005
[13]Hezel DM, Simpson HB Exposure and response prevention for obsessive-compulsive disorder: A review and new directions Indian J Psychiatry, 2019.PMID 30745681
[14]Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability Arch Gen Psychiatry, 1989.PMID 2684084
[15]Wheaton MG, Galfalvy H, Steinman SA, et al. Patient adherence and treatment outcome with exposure and response prevention for OCD: Which components of adherence matter and who becomes adherent? Behav Res Ther, 2016.PMID 27497840
[16]Wheaton MG, Gershkovich M, Gallagher T, Foa EB, Simpson HB Behavioral avoidance predicts treatment outcome with exposure and response prevention for obsessive-compulsive disorder Depress Anxiety, 2018.PMID 29394511
[17]Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB; American Psychiatric Association Practice guideline for the treatment of patients with obsessive-compulsive disorder Am J Psychiatry, 2007.PMID 17849776
[18]Ruscio AM, Stein DJ, Chiu WT, Kessler RC The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication Mol Psychiatry, 2010.PMID 18725912
[19]Fineberg NA, Hollander E, Pallanti S, et al. Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders Int Clin Psychopharmacol, 2020.PMID 32433254