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Practice Makes Perfect: How Exposure and Response Prevention Helps OCD Patients Confront Their Fears

January 10, 2019

When many people think of Obsessive Compulsive Disorder (OCD), the fear of contamination and the compulsion to sanitize or hand wash comes to mind. However, OCD often presents with repeated intrusive thoughts, urges or mental images that could easily be mistake as psychosis; therefore, proper diagnosis is key.

It’s important to realize that these thoughts and compulsions can be about anything, and they don’t have simple roots. The fear of contamination may derive from intrusive thoughts of, “I will become sick, if I touch this,” or, “I will die, if I touch this.” These compulsions can become ritualistic. When a person develops multiple rituals, it can become incredibly time consuming and debilitating without treatment.

For the parents of a child with OCD, a major concern is how to treat the disorder without medication, so they may retain the skills needed to lead a normal life.

Stephanie Ferroni, Psychiatric Nurse Practitioner at Jefferson Health – New Jersey, has experienced this firsthand – and not just through treating patients. Her 17-year-old daughter, Sydney, was diagnosed with OCD when she was 5. A couple of years later, she received a type of cognitive behavioral therapy (CBT) called exposure and response prevention (ERP) for the first time.

ERP gradually exposes patients to their fears and prevents their response. Because compulsions act as safety mechanisms to decrease anxiety, during ERP, a patient’s anxiety will initially increase drastically, but over time will decrease until the fear becomes “boring.”

“The patient must understand that they will be uncomfortable – they’re facing their biggest fears,” Ferroni explained. “They must learn that the reason they didn’t get sick and die is not because they washed their hands. The truth is, they wouldn’t have gotten sick and died anyway.”

ERP is based on a hierarchy. The patient ranks their fears according to level of severity, and begins exposure with the least scary thought. A patient may visit their therapist twice a week for eight weeks for ERP sessions.

“A patient who fears contamination is okay touching their own belongings. To expose them, they may be asked to touch a door knob, and eventually they may be asked to hold onto an escalator,” Ferroni said. “The more you act, the more your anxiety will habituate on its own. The thought loses its power.”

When Sydney was younger, she had intrusive thoughts with mental compulsions to confess and seek reassurance that she was still a good girl.

“This is common in younger children,” Ferroni said. “If she had a mean thought about somebody, she’d tell me. I would then ask her, ‘If you think you’re a bad person, what does that mean?’”

This common CBT technique attempts to disprove the correlation between the thought and the compulsion.

 “As a parent, your instinct is to give your kid reassurance and make them feel confident,” Ferroni continued. “With OCD, you have to withhold reassurance, and instead challenge the thought with honesty. They have to learn to tolerate uncertainty.”

Ferroni, who previously worked in the ER, Interventional Radiology, and Critical Care, was inspired to make the transfer to Behavioral and Mental Health after watching her daughter grow up with OCD.

“ERP and CBT truly work,” Ferroni said. “Professionally, I’ve watched patients become empowered. As a mother, I’ve watched my daughter learn exposure skills that she can use throughout her life.”