Exposure and Response Prevention (ERP) Therapy is a top treatment for Obsessive-Compulsive Disorder (OCD). It helps people face their fears and feel anxiety, discomfort, and uncertainty without using compulsive behaviors. This process is key to helping individuals learn to handle distress and reduce OCD symptoms over time, giving them hope and control. 

Exposure and Response Prevention 

ERP has two main parts: exposure and response prevention. Exposure means facing the thoughts, images, objects, or situations that cause anxiety or discomfort. This can be done by directly facing the feared situation (real-life exposure), imagining the feared situation (imaginal exposure), or experiencing feared physical sensations (interoceptive exposure). Response prevention means not doing compulsive behaviors or mental rituals in response to the exposure. The goal is to stop the cycle of compulsion and reduce dependence on these behaviors for relief. Successful ERP involves not doing any compulsion while feeling anxiety and discomfort. 

Working with an ERP-trained therapist is very important. The therapist helps the client identify specific obsessions and fears, understand what triggers their anxiety, and recognize unique compulsions and rituals. This support reassures both the person with OCD and their families by identifying both obvious and hidden compulsions and providing a plan for recovery. Compulsions can include behaviors like checking, arranging, cleaning, tapping, or repeating, or mental compulsions like mental reassurance, thought suppression, rumination, mental checking, and mentally repeating words or phrases. Identifying compulsions is crucial as they are not always obvious, with mental compulsions being very hard to recognize and address. 

One challenge in doing ERP successfully is identifying and stopping compulsions and making sure that one compulsion is not replaced with another. For example, a client might stop a behavioral compulsion but start a mental compulsion instead. The main idea of ERP is learning to handle discomfort without trying to escape it through compulsions. This involves being aware of one’s responses to triggers and learning to live with anxiety and uncertainty without using compulsions. 

Exposures and OCD 

Exposures are crucial to recovering from OCD because the disorder makes people think they cannot handle the distress they feel when facing their fears. Also, OCD makes people believe that certain bad things will happen if they do not do specific compulsions. The purpose of exposure is to help individuals repeatedly see that their feared consequence does not happen even when they do not give in to their compulsion. This is the only way to break the OCD cycle because safety behaviors are the only part of the cycle that people can control. They cannot control their unpleasant thoughts, feelings, or sensations, but they can choose to react in a way that does not reinforce them. The more a person with OCD does exposure and response prevention, the more their brain learns that the initial trigger was not dangerous to begin with, reducing obsessions over time. 

Clients often ask what they should do during an exposure if not their compulsion. The answer is to stay present. For the exposure to work, the person must not do anything to reduce discomfort. Instead, they are encouraged to stay in the moment, feel uncomfortable, and notice their unpleasant thoughts, feelings, and sensations with curiosity and without judgment. This approach lets the individual see that anxiety decreases over time without the need to do anything about it. Trying to escape the discomfort only provides temporary relief and keeps the cycle going. 

Break free from the cycle of OCD

It is important to note that the goal of ERP is not to get rid of unpleasant thoughts, feelings, or sensations but to learn how to tolerate them without using compulsions. By facing their fears and not doing compulsions, individuals can see that their anxiety decreases over time and that they can handle the distress without using compulsive behaviors. This empowers them to break free from the cycle of OCD and regain control over their lives. ERP is a structured and systematic approach to treating OCD designed to build confidence in mental health professionals and help individuals regain control over their lives by reducing the power of obsessions and compulsions. Through the guidance of an ERP-trained therapist, clients can learn to face their fears, tolerate discomfort, and achieve lasting relief from OCD symptoms, showing how effective this approach is. Exposure and Response Prevention Therapy is a powerful tool in treating OCD, leading to lasting relief and a renewed sense of hope and empowerment. 

  

References 

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. 

Abramowitz, J. S., McKay, D., & Storch, E. A. (Eds.). (2017). Obsessive-compulsive disorder: Contemporary issues in treatment. Wiley-Blackwell. 

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press. 

Franklin, M. E., & Foa, E. B. (2011). Treatment of obsessive-compulsive disorder. Annual Review of Clinical Psychology, 7(1), 229-243. https://doi.org/10.1146/annurev-clinpsy-032210-104533 

March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. Guilford Press. 

Salkovskis, P. M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(Suppl 1), S29-S52. https://doi.org/10.1016/S0005-7967(99)00049-2 

What Does OCD Look Like?

• Are you frequently late because you must check the stove eight or nine times to ensure it’s off before leaving your house? 
• Do you wash your hands often, trying to get them clean, but never really feel they are? 
• Are you unable to throw anything away because you think it may be helpful in the future? 
• Do you become worried that you will somehow lose control of your behavior and hurt someone, even though you never have? 
• Do you perform a verbal or physical ritual that you feel helps ensure that people you are close to stay healthy and safe?
• Do you find it hard to let go of specific thoughts, finding them so intrusive and persistent that you cannot get other important tasks done?

If you answered yes to any of these questions, you may suffer from OCD – or obsessive-compulsive disorder. This illness is not rare; it affects at least four million adults in the United States and is the fourth most common psychiatric illness.

OCD is a disorder that is often progressive and can become crippling. Some OCD sufferers never leave their homes because of the various rituals they need to perform. Others can’t function at work because they spend so much time secretly engaged in various rituals. Many obsessive thoughts and practices are entirely mental, not physical, so the illness can be almost invisible to everyone close to the person affected.

As the name suggests, OCD has two parts: obsessions and compulsions. Many people suffer from obsessions only, but a good number eventually develop compulsions. 

Obsessions and Compulsions: What Are They?

Obsessions are the thoughts, ideas, or impulses that repeatedly well up in the mind of the person with OCD. They may feel a need to do things almost too perfectly, an unreasonable concern about becoming contaminated by germs, or a persistent fear that harm may come to themselves or loved ones. Compulsions are the behaviors that are done in reaction to this thinking, usually to try to gain some control over the uncontrollable. Following a behavioral routine gives the sufferer temporary relief through a false belief that the ritual can ensure that something unwanted will not happen. Usually, the person with OCD is fully aware that their thinking is irrational, but this does little to stop the behavior. The obsessions and compulsions often lead to an unbreakable cycle, including severe anxiety.

Most people experience obsessive thoughts or compulsive behaviors at one time or another. Still, the disorder of OCD is not present until the ideas and rituals have become dominant features in their lives and some aspect of the person’s work, family, or social life is affected. Once someone meets the entire criterion, OCD will often not go away, and therapy is needed before there are irreversible effects on a person’s social, academic, or work life. 

Overcoming OCD 

The good news about OCD is that it has a very favorable prognosis – OCD is straightforward to overcome through therapy. Most therapists use cognitive behavioral therapy to bring about relief from OCD symptoms. Clients learn to monitor their thoughts and recognize the connection between their thinking, feeling, and behavior. The therapist acts as a “behavioral coach” and often gives a lot of homework between sessions. Progress can be slow, but gradually clients learn to separate their thoughts from their behaviors. Once behavior changes, there is a strong likelihood that things will get much better sooner than later. You’ll come away with a toolbox to manage your symptoms in real time!

The bad news is that the isolation, embarrassment, and self-loathing caused by OCD can prevent some people from seeking help. They may be afraid that their thoughts or compulsions are so “crazy” that they’ll get laughed at or labeled as strange. 

Next Steps

If you suspect you are suffering from OCD, consider finding a therapist. Be confident that they know that this problem is unpreventable and biological, just like an allergy or sight impairment. You don’t have to be a prisoner of OCD. The combination of therapy, sometimes along with medication, usually provides effective treatment. You can make a life-changing decision by recognizing the problem and having the courage to seek help.

You are not alone if you suffer from OCD, even though you may suffer in silence. Therapy can genuinely help and give you the resources to stave off relapses should they begin to come on in the future. Cognitive behavioral therapy often provides tips and techniques you can use to manage many kinds of anxiety, so it can often have lasting effects beyond OCD.

Dr. Alan Jacobson is a Licensed Psychologist who has been in practice for over 20 years. He has helped many adolescents and adults who suffer from OCD and other challenges with anxiety.  

The GoodTherapy registry might be helpful to you to find a therapist if you have struggled with OCD. There are thousands of therapists listed who would love to walk with you on your journey. Find the support you need today.

By Gary Trosclair, DMA, Licensed Clinical Social Worker

Do you really have OCD? Or is it OCPD?

OCD has become a household term we casually use to refer to anyone who needs to have things a certain way. As a casual term, it works well. It gives us a general sense of what’s being described. But if it’s used as an actual diagnosis to determine therapeutic treatment, it can cause problems. People who we might casually say have OCD may actually have a different condition, and the differences between these conditions call for a different approach to treatment.  

OCD, Obsessive-Compulsive Disorder, may look similar at first to a different condition, OCPD, Obsessive-Compulsive Personality Disorder, which is often overlooked and even misdiagnosed by clinicians. But OCD is an anxiety disorder, while OCPD is a personality disorder.

Diagnostic Difficulties

Far fewer people have OCD than have OCPD: 1.2% of the population has OCD,[1] while as much as 7.9% has OCPD.[2]   

About 20% of the people who have OCD also have OCPD,[3] making it difficult to distinguish between the two. And both diagnoses can be either severe or less-debilitating. Many people have some traits of Obsessive-Compulsive Personality Disorder but do not meet the full diagnostic criteria. These individuals can be very productive and fairly well-adapted socially.

Proper diagnosis should be completed by a licensed mental health professional. But following are some fundamental differences that may help you to better understand yourself in either case.

Symptoms: Specific vs. Generalized

People with OCD have specific obsessions (thoughts that are intrusive, involuntary, repetitive, irrational, and anxiety-provoking) and specific ritualistic compulsions (repetitive behaviors they can’t stop, such as checking and washing). On the other hand, the entire personality of someone with OCPD is affected by an overwhelming need to prioritize control, perfectionism, and order.

While people with OCD may try to control very particular things in order to quiet their obsessions, people with OCPD tend to be controlling universally. It’s as if the space they need to control is much larger. It’s not just the cupboards, it’s their entire world, and they can become very rigid about it.

Emotional Differences

People with OCD are more likely to feel anxious when specific things aren’t the way they want them to be. People with OCPD are more likely to feel angry if things aren’t the way they believe they should be.  

For instance, Angie, who suffers from OCD, is concerned about how the dishes get washed because she feels anxious if they aren’t absolutely clean.

But Arthur, who suffers from OCPD, insists that the correct thing is to have the entire house in order all the time. People with OCPD may justify their efforts to control by trying to prove that their way is the right way. They feel that they are trying to do the right thing to make life better for everyone, and their efforts can be helpful. But in many cases, they may become rigid in their actions, and, contrary to their motivations, they can make things more difficult for others.

People with OCD don’t necessarily restrict their emotions. However, they do try to control their thoughts (which can range from mildly uncomfortable to very disturbing) by doing compulsive things, such as repetitive and ritualistic cleaning and checking. 

But people with OCPD often try to control their emotions as well as their environment. They’re known for delaying gratification. They often give priority to their work, neglecting relationships and their own wellbeing. The emotions they are most aware of are anger, frustration, and resentment. They are more reluctant to be vulnerable than those with OCD, and may not even be aware of any underlying anxiety.

Angie gets anxious if the top is off the toothpaste tube because she fears germs. Arthur gets angry because it’s wrong to leave it off.

Shame or Pride about Their Condition

People with OCD don’t like their obsessions and compulsions and willingly seek help.

People with full-blown OCPD, because they try so hard to live their lives according to moral principles, are very proud of the way they live and don’t understand that they have a disorder. They tend to seek help only when forced to do so by a partner or when they become so depressed from trying to live with such demanding standards that they can’t go on that way any longer.

Motivations

People who have OCD are motivated to stay safe and to prevent catastrophes. People with OCPD are more motivated by rules and perfectionism. While they may justify their control by pointing to possible catastrophes, their underlying motivation often has more to do with wanting to avoid chastisement, blame, or failing to fulfill their responsibilities.

People with OCD are more clearly motivated to relieve their anxiety. While people with OCPD may also have underlying anxiety or a fear of being abandoned, their conscious concern is that they want to be respected rather than criticized.  

Behavioral Differences

While people with OCD may often behave in an insecure way because of their obsessions and compulsions, people with OCPD may become domineering, trying to hide their insecurities from themselves and others.  

People who have OCD spend much of their time in compulsive rituals such as cleaning and organizing. People with OCPD spend more time planning and working.

OCD efforts are usually maladaptive, except insofar as it helps them to maintain good hygiene. In contrast, some OCPD traits can be adaptive in a practical way, allowing them to succeed in the outer world, even if it makes them very unhappy. Because they are very conscientious, meticulous, energetic, and committed, they can make significant contributions in many fields, from art to public service to accounting. Most successful performers and athletes are compulsive to some degree.

Differences Among Compulsive Personalities

There are wide variations in the degree of unhealthiness among people with compulsive personalities, based on how controlling, perfectionistic, and rigid they are. Some, who don’t technically have OCPD but only have some compulsive traits, have very few maladaptive symptoms and can be very helpful in planning, organizing, and getting things done.

And there are wide variations in the style of compulsive personality: some are domineering, some are workaholics, some are compulsive people-pleasers, and others are so obsessive about getting things just right that they can’t get anything done.

Treatment

There is significant research to demonstrate that targeting the specific symptoms of OCD, as short-term Cognitive Behavioral Therapy (CBT) does,[4] can be effective for treating OCD.

There is far less research regarding the treatment of OCPD. In fact, according to psychologist and researcher Anthony Pinto, “there is no empirically validated gold standard treatment for OCPD.”[5]

However, there is reason to believe that approaching OCPD treatment by targeting specific symptoms may not be as effective as it is for OCD because of the pervasive nature of personality disorders. OCPD may benefit from a longer course of treatment in psychodynamic or expressive therapy.[6] This approach can help the individual to understand the possible benefits of their inherent personality style and to understand how those same traits can turn destructive when taken to extremes. Psychodynamic therapy can help them develop a better relationship with their emotions and use their need for control and perfectionism in a healthier way.

Getting to the Root Causes of OCPD

The causes of OCPD include genetic, environmental, and dynamic factors. These dynamic factors include the strategy the individual unconsciously adopted to cope with their particular combination of inherited traits and family situation. We can refer to these dynamic factors as old tapes, triggers, complexes, schemas, or patterns that they play out unwittingly, as if they were still living in the past with their families.

Attempting to treat the systemic, unconscious, and underlying character organization of OCPD by targeting just its external manifestations may not shift the underlying causes.

For example, some compulsives cope with their anxiety by externalizing, by getting those around them to do what they think should be done so that they feel safer. Other compulsives cope by internalizing, by taking too much responsibility on themselves and becoming people-pleasers to avoid a feared abandonment.

In most cases, people with OCPD feel a great need to prove themselves, and they attempt to do so with perfection, order, and control.  

Whatever the underlying dynamic, a therapeutic experience that gives the individual a chance to identify their specific coping strategy by seeing their old tapes play out in session with a therapist can be very effective. Does the client try to control the therapist? Does the client try to control his own emotions in session? Do they try to prove to the therapist that they are ethically good? This process often requires patiently developing awareness of emotions and the capacity to tolerate them in session, rather than reacting to them by trying to control themselves or the therapist.

The Potential Benefits of Compulsive Personality

If your basic character style is compulsive by nature, you won’t be able to change that. But you can begin to use your natural meticulousness, conscientiousness, and tendency to plan in a healthier, more conscious way that works well for you and the people around you. This can’t happen if efforts to change includes only trying to eradicate symptoms.  

I have referred to anxiety and a need for respect as motivations for the individual with OCPD. But on an even deeper level, they are motivated by a desire to help, plan, and repair in ways that can benefit everyone. Finding that original motivation can equip the OCPD sufferer with insight and direction, which can help them to heal and to be more helpful to those around them.

Footnotes

[1] National Institute of Mental Health website. Obsessive-Compulsive Disorder. https://www.nimh.nih.gov/health/statistics/obsessive-compulsive-disorder-ocd.shtml. Retrieved 12.23.20.

[2] Burkauskas, J. F., Naomi. (2020). History and Epidemiology of OCPD. In J. E. Grant, Anthony Pinto, Samuel Chamberlain (Ed.), Obsessive-Compulsive Personality Disorder (pp. 1-16). Washington, D.C.: American Psychiatric Association Publishing.

[3] Mancebo, M. C., Jane L Eisen, Jon E. Grant, Steven A. Rasmussen (2005). Obsessive Compulsive Personality Disorder and Obsessive Compulsive Disorder: Clinical Characteristics, Diagnostic Difficulties, and Treatment. Annals of Clinical Psychiatry, 17(4), 197-204. doi:10.3109/10401230500295305

[4] Foa, Edna B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience. Jun; 12(2): 199–207.

[5] Pinto, A. (2020). Psychotherapy for OCPD. In A. P. Grant JE, Samuel R. Chamberlain (Ed.), Obsessive-Compulsive Personality Disorder (pp. 143-178). Washington, D.C.: American Psychiatric Publishing.

[6] Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. doi:10.1037/a0018378

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