Exposure with response prevention in OCD

Exposure with response prevention is currently one of the treatments with the greatest empirical support in the treatment of OCD. We talk about its therapeutic advantages and its drawbacks.

Obsessive-compulsive disorder could be defined as a psychological disorder in which we find, on the one hand, obsessions (thoughts, images or impulses that burst into our mind without us wanting them) and on the other, compulsions (mental or motor acts whose purpose is to neutralize the anxiety caused by obsessions and prevent a supposed threat).

Everyone, to a lesser or greater extent, can experience obsessions from time to time.. As people with the ability to think, sometimes our minds create absurd, unrealistic or exaggerated mental products. When this happens, we usually don’t give it much importance or value. We let them pass and continue our daily lives without merging with them. We are aware that they are thoughts and nothing more, that they do not have to have anything to do with reality.

In the case of obsessive-compulsive disorder, reasoning does not occur this way. Unlike people who have thoughts of any kind, but do not value them, People with OCD worry a lot about the thoughts that appear in their mind and give them excessive power.

These generate a lot of anxiety and although they do not identify with them and find them annoying, they believe them. Therefore, they feel the need to do something that neutralizes that annoying feeling and that prevents, in some way, the threat that, according to their mind, is about to come.

When a patient with OCD performs the compulsion, he or she feels a refreshing relief. Finally the anxiety and the obsession with it disappear and therefore, a catastrophe that could have been devastating has been “avoided.” As we can see, despite being extremely intelligent people in most cases, their way of reasoning is biased.

We know that a thought alone cannot generate a real threat. But this is the thought pattern that exists in their mind and the one they follow to the letter. Therefore, patients with OCD end up worn out, extremely exhausted and without any hopesince they never quite get rid of the obsession.

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Faced with this, Exposure with response prevention is perhaps the most successful intervention in this area. However, this same effectiveness implies a series of drawbacks such as dropouts.

The importance of exposing yourself to obsessions

In general, Exposure is usually the treatment of choice in disorders that involve a high anxiety component.. Anxiety is a normal emotional response that arises when the individual interprets an event, situation or stimulus as threatening and believes that something may happen that compromises their survival or that of other people. In this sense, anxiety is an ally that helps us face the problems inherent to life.

When the same anxiety that benefits us appears in circumstances that do not entail any type of risk, it stops having functionality and meaning. It is at this point where anxiety becomes a problem, since it does not respond to reality as we can perceive it with our senses, but rather to an expectation.

When a person manifests obsessions, they mistakenly think that something is going to happen that could cause harm, that is immoral or that reflects a lack of responsibility. These obsessions are not realistic, there is no evidence to support them in any way, but the patient with OCD cannot get them out of his head without another illusory solution other than the one offered by the compulsion.

It is for this reason that it is necessary to expose the patient to that stimulus that he believes can bring him some harm, even to his obsessions, and to verify for himself, without performing neutralization, that what he fears never happens.

The idea of response prevention is that, through habituation, the person reaches a point where can tolerate, control and manage the obsession without giving way to a compulsion.

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It is about experiencing that nothing really happens after touching the buttons of an elevator, about allowing reality to throw away your expectations again and again, until somehow they stop being expectations.

Let’s think that If the compulsion is carried out, it is impossible for the person to disconfirm his unrealistic thoughts.. He will believe, mistakenly, that thanks to compulsion what he fears has not happened, but the truth is that it has not happened because it has no realistic basis.

Exposure with response prevention as a treatment for OCD

Exposure with response prevention, as we have indicated, is the treatment that has shown the best results against OCD. It works especially with patients who carry out ritualsbeing difficult to apply against pure obsessions.

Exposure with response prevention It has the disadvantage that patients perceive it as very aversive because their anxiety levels usually increase at first. of the treatment. This is an indicator that the treatment is being carried out correctly, since the patient is exposing himself and is not covering up his anxiety.

It is extremely necessary to explain to the patient how the technique works so that they realize the great importance of exposing themselves to what they fear and how their rituals are ultimately responsible for the problem not ending.

First of all, A hierarchy of anxiety-producing stimuli must be created, which will vary depending on the case.. This hierarchy must be made by the therapist; If the patient performs it, we run the risk of him being too self-indulgent and not exposing himself to the stimuli that really cause anxiety. The stimuli that cause discomfort are evaluated by the patient according to Subjective Anxiety Units (USAS), which can range from 0 to 100.

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The ideal is to start exposing yourself with intermediate USAS levels (40-50). It is important that anxiety is reduced to at least 50% within the consultation and, if this is not the case, we should not move on to the next item in the hierarchy, as we could cause the person to become sensitized rather than habituated. Besides, It is not advisable to carry out the exposure outside the consultation if the first steps of habituation have not been taken inside and it is on track..

Sessions should be as long as possible. In some cases, the patient can even be exposed to it for 24 hours, modifying certain stimuli in their own home, for example. This greatly facilitates habituation.

Although effective, the technique exposure with response prevention has the disadvantage of therapeutic abandonment. Tolerating the anxiety caused by obsessions, without starting the ritual, is very aversive for the person with OCD.

The key is to offer quality psychoeducation, establish a good and solid therapeutic alliance so that the patient trusts in the treatment, trying as much as possible for the person to commit to their recovery and perform the tasks correctly, both inside and outside the session.

It is also advisable to work with the family, the couple or some other co-therapist. to ensure that they do not reinforce their obsessive-compulsive behavior. Having a co-therapist closer to the patient’s life helps in the patient’s recovery, motivating the person to avoid rituals and favoring exposure in the prescribed manner and measure.