Obsessive compulsive disorder (OCD) is a psychiatric condition marked by the presence of obsessive thoughts, images, doubts, or urges, followed by compulsive behaviors or acts aimed at easing the distress caused by the obsession. While the content of the obsessions can take many forms, they are always repetitive, persistent, involuntary, and intrusive, and they often result in a great deal of anxiety for the person experiencing them.
Medical professionals view exposure and response prevention (ERP) as the most effective therapy for successfully treating individuals with OCD. But what is an intrusive thought, and how does ERP treat these thoughts so successfully? Read on to find out.
Intrusive thoughts are not unique to OCD and are probably more common than you may think. They are those fleeting, often scary thoughts, such as considering hurting yourself, a loved one, or a stranger. These thoughts can take on many forms, and for most of us they flow out of our minds almost as quickly as they entered. We can recognize the thought as just that — a thought, not a desire — without putting any emphasis or undue importance on it.
For people with OCD, though, these thoughts are stickier. They latch into your mind, fester, and grow. Maybe I really do want to hurt myself. Maybe I really will push that stranger in front of the train. The thoughts escalate to distressing levels as the person searches for ways to eradicate them. This is where compulsions come into play. Compulsions are the tools people use to attempt to ease the anxiety caused by these intrusive thoughts.
Compulsions can take many forms. For example, someone might clean for hours every day in an attempt to diminish fear or anxiety about contamination. Someone else might repeatedly check that the stove is turned off due to a fear of harming oneself or others by accidentally starting a fire. While these examples seem related to the feared outcomes, some compulsions may have no causal relationship to the intrusive thought at all. For instance, someone might engage in rearranging compulsions where they put items in symmetrical order to prevent harm to loved ones.
The issue is that acting out these compulsions does not solve the underlying issue, and in fact performing a compulsion can reinforce the obsession. An individual experiences the intrusive thought, and anxiety rises. The individual then engages in the compulsive act and the anxiety is temporarily alleviated, thereby reinforcing the compulsive behavior. Thus, the obsessive-compulsive cycle is formed.
So, how does ERP disrupt this pattern and help treat OCD? ERP is a form of cognitive behavioral therapy (CBT), in which the goal is for patients to confront their fears without compulsions to learn that they are able to tolerate anxiety and distress.
In ERP, someone with intrusive thoughts is purposefully exposed to situations that stimulate those thoughts — but then, instead of engaging in their compulsions, they are challenged to sit with the thoughts. The aim of ERP is to show the person that what they’re afraid might happen when they experience an intrusive thought is not likely to actually happen. For example, an individual may avoid or lock away knives or engage in compulsive behavior when in the vicinity of knives because of fear of stabbing someone. In an ERP course of treatment, the individual would be exposed to the feared stimulus (the knife). However, they would be asked to refrain from engaging in the compulsive acts that would usually follow their intrusive thought. Over time, as the outcome the individual feared continuously does not occur, both the fear of that outcome and the need to perform the compulsive or ritualistic act should begin to subside.
It is important to note that ERP can be challenging. Individuals are exposed to stimuli that trigger their intrusive thoughts, and they are asked to refrain from compulsive behaviors they would normally use to soothe their anxiety. Doing so is important because, as the feared outcomes are repeatedly challenged, the fear response to those thoughts begins to weaken. The unrealistic outcome expectations are slowly replaced with more realistic outcomes, which are absent the anxiety or fear response. The more a person is exposed to the stimulus while refraining from compulsive acts and experiencing non-threatening outcomes, the stronger the realistic memory structure becomes — e.g., they repeatedly see that they don’t hurt anyone with the knife — while the unrealistic fear response grows weaker and weaker.
The process of unlearning or disproving the feared response to a stimulus through repeated exposure is called habituation. Through exposure, pt’s engage in the process of unlearning or disproving the feared response to a stimulus. In other words, they learn that their fears do not come to fruition. Further, many pts may experience habituation, a decrease in anxiety over time, during or after exposure practice. While ERP may not completely eradicate intrusive thoughts, helping the person to learn how to respond to them differently is powerful. Through learning and habituation, a person’s reaction to an intrusive thought begins to shift and they feel less need to perform compulsive responses over time.
NOCD has a world-class team of clinicians who are ready to help you get started with ERP. I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment, our care team at NOCD can figure out the best path for you. We’re available in all 50 states, and our teletherapy is affordable. All NOCD therapists specialize in OCD and receive ERP-specific training. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP.