Obsessive Compulsive Disorder / Exposure and Response Prevention

I began my supervised clinical training in the treatment of OCD with Dr. Steven Phillipson (world renowned OCD expert) in 2006.

Obsessive Compulsive Disorder (OCD) is a disorder which can be debilitating in its more extreme form. It can manifest in many different ways and two people who are both diagnosed with OCD can have very different symptomology.

People suffering with OCD may have various compulsions or rituals which they feel they have to engage in, in order to mitigate or eliminate anxiety, “bad” thoughts, or feelings. These compulsions can be in the form of various behaviors such as hand washing, checking, saying certain words, etc. Compulsions can also be in the form of thoughts. This form of OCD is called the “Purely Obsessional” or “Pure-O” form of OCD and can also manifest itself in many ways. For example, someone with Pure-O OCD may have thoughts or images enter their minds which cause extremely heightened anxiety. These thoughts or images can range from harming others (sexually or physically) to ones that are less violent or disturbing but whose mere presence is just bothersome. For these people, it is not the content of the thoughts which disturbs them, but the presence of the thoughts themselves. People who are bothered by solely the presence of various thoughts are usually uncomfortable with having an “imperfect” state of mind. Their compulsions usually entail attempting to clear their minds by pushing thoughts out or attempting to prevent thoughts from coming on, therefore circumventing anxiety. Other forms of perfectionism are also common among those with OCD and can sometimes reach clinical levels and may be labeled as Obsessive Compulsive Personality Disorder. OCPD can sometimes overlap with OCD and treatment may vary depending on the presenting issues.

Other people may feel anxiety brought on by the actual thought content rather than an image or the simple presence of thoughts. For example, some people may face heightened anxiety when certain thoughts/questions are triggered such as:
• “Am I gay?”
• “Is my partner the right one for me?”
• “Do I want to harm that person?”
• “Did I commit a crime?”
• “Did I commit a sin?”

Patients struggling with this form of OCD feel overwhelming anxiety at the idea that these thoughts/questions may be true and are compelled to “problem solve” or “figure out” the answers to these thoughts/questions. Problem solving and ‘figuring it out’ is also a compulsion in and of itself as having answers temporarily relieves anxiety as well. However, it is engaging in compulsions such as problem solving (or hand washing in the more traditional forms of OCD) that propel the OCD and keep it alive. The thoughts are not limited to the above examples and can literally take ANY form.

Exposure and Response Prevention (ERP) is the treatment of choice for OCD. A very basic explanation of ERP is that it involves exposing the patient to the thought content, thought presence, object, or image that causes them anxiety in a systematic way. The patient is also asked to refrain from engaging in the rituals/compulsions (the response) using various techniques. After continued and repetitive exposure, the patient is expected to habituate to the presence of the thought, image, or object and the anxiety decreases over time.