Exposure with Response Prevention

ERP Graphics courtesy of HealioOpens in new window

Exposure with response prevention (ERP) is a cognitive-behavioral technique that is best known as a treatment for obsessive-compulsive disorder (OCD)Opens in new window.

ERP has also been used to treat Tourette’s syndromeOpens in new window, phobiasOpens in new window and anxietyOpens in new window, bulimiaOpens in new window, body dysmorphic disorderOpens in new window, drug and alcohol cravings, and hypochondriasisOpens in new window, with varying degrees of success (McKay et al., 1997; Mclean, Whittal, & Thordarson, 2001).

ERP generally starts with a person making a list of thoughts or situations that cause fearOpens in new window or anxietyOpens in new window as well as listing rituals or avoidance behaviors in which she engages to reduce her anxiety. Then she assigns each anxiety-provoking situation or behavior a value on the Subjective Units of Distress ScaleOpens in new window (SUDS; where 1 equals no anxiety at all and 10 equals maximum anxiety possible).

The person generates a fear hierarchy and exposes herself to a situation (trigger) she fears (starting with the least feared situation) for gradually increasing lengths of time each day without engaging in her typical rituals or avoidance behaviors (response prevention).

The idea behind regular, repeated exposures is that the person will become habituated to the trigger, reducing the SUDS level. Once the person experiences lower SUDS levels for one trigger, she starts exposure to a trigger higher up on her fear hierarchy.

Treatments other than ERP that have been used for OCD include cognitive therapy (CT)Opens in new window and cognitive-behavioral therapy (CBT)Opens in new window and some medications (e.g., antidepressantsOpens in new window). ERP has been shown to be a more effective treatment for OCD than progressive muscle relaxation, generic anxiety management techniques, and placebo pills and has been determined to have effectiveness greater than or equal to pharmacotherapies such as clomipramine (a tricyclic agent with antidepressant and antiobsessional properties).

A 2005 study showed that while both CT and CBT are more effective for OCD than to treatment at all, and both have a lower dropout rate than ERP, neither CT nor CBT (alone or combined with ERP) is more effective than ERP alone (Abramowitz, Taylor, & McKay, 2005).

Ideally, some of the exposure exercises should be done with the therapist (within-session ERP), with other exercises done as homework between therapy sessions (Abramowitz et al., 2005).

Authors of a study with 72 participants that compared telephone and face-to-face therapy claimed that ERP can be done effectively with minimal face-to-face contact between the therapists and the patient (Lovell et al., 2006). The study utilized a model where therapists helped clients design exposure tasks and reviewed ERP homework with clients, but each client practiced ERP on his own (as homework).

Average symptom reduction for OCD patients receiving ERP typically exceeds 50 to 60 percent but does not eliminate symptoms completely (Abramowitz et al., 2005). ERP is not an effective treatment for everyone with OCD—ERP has been shown to be less effective for those who have poor insight into the senselessness of their obsessions (overvalued ideation). Some people cannot tolerate the distress and anxiety associated with repeated exposure exercises, so ERP treatment has a high dropout rate.

Keep on learning:
  1. Hyman, B.M., & Pedrick, C. (2005). The OCD workbook: Your guide to breaking free from obsessive-compulsive disorder (2nd ed.). Oakland, CA: New Harbinger.
  2. Abramowitz, J.S., Taylor, S., & McKay, D. (2005). Potentials and limitations of cognitive treatments for obsessive-compulsive disorder. Cognitive Behavior Therapy, 34, 140 – 147.
  3. Lovell, K., Cox, D., Haddock, G., Jones, C., Raines, D., Garvey, R., et al. (2006). Telephone administered cognitive behavior therapy for treatment of obsessive compulsive disorder: Randomised controlled non-inferiority trial. British Medical Journal, 333, 883 – 886.
  4. McKay, D., Todaro, J., Neziroglu, F., Campisi, T., Moritz, E.K., Yaryura-Tobias, J.A. (1997). Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy, 35, 67 – 70.
  5. Mclean, P.D., Whittal, M.L., & Thordarson, D.S. (2001). Exposure and response prevention are marginally more effective than cognitive-behavioral treatment in obsessive-compulsive disorder. Clinician’s Research Digest, 19, 3.