This document summarizes a webinar on the treatment of obsessive-compulsive symptoms using exposure and response prevention therapy. It begins by differentiating normal and abnormal anxiety, then discusses functional assessment of anxiety which involves understanding fear cues, misperceptions, safety behaviors, and feared consequences. Exposure therapy is described as involving prolonged, graduated exposure to fear cues while preventing safety behaviors. Response prevention refers to refraining from rituals meant to reduce anxiety. The effectiveness of this approach is supported by randomized controlled trials and meta-analyses.

1. Webinar
Treatment of Obsessive-Compulsive Symptoms
March 12, 2013
Erin McGinty, LPC, NCC
Program Director, Anxiety Services Coordinator, and Primary Therapist
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611, ext. 103
www.castlewoodtc.com

2. Normal vs. Abnormal Anxiety (Barlow, 2002)
Anxiety? Fear? Worry? Panic? Terminology…
Anxiety is a future-oriented mood state associated with
preparation for possible, upcoming negative events.
Fear is an alarm response to present or imminent
danger (real or perceived).

3. Normal vs. Abnormal Anxiety
The fight-or-flight response:
• Physiological: Changes in heart rate and breathing,
nausea
• Cognitive: Attention shifts to the perceived threat
• Behavioral: Actions intended to avoid or escape the
threat (e.g., fleeing, attacking)
“In times of danger, anxiety can be a person’s best
friend. (Abramowitz, 2011)”

4. Normal vs. Abnormal Anxiety
Abnormal anxiety: “When anxiety occurs in the
absence of danger or when it is out of proportion
relative to the actual threat. Such excessive and
pathological anxiety– stemming from the
misperception of a safe situation as dangerous
(Abramowitz, 2011).”
This leads to the development of safety behaviors and
strategies intended to detect, avoid, or escape
perceived danger… that may exacerbate symptoms.

5. Elements of Clinical Anxiety
Fear Cues: Stimuli and situations that elicit anxiety
Maladaptive Beliefs: Exaggerated estimates of threat
• Catastrophizing
• Probability Overestimation
Safety Behaviors: “Actions intended to detect, avoid,
or escape a negative or feared outcome”
(Abramowitz, 2011)

6. Anxiety Disorders (Abramowitz, 2011)
Anxiety Disorder Fear Cue(s) Misperception(s) Coping Responses
Obsessive- Intrusive thoughts, Thought-action Avoidance,
Compulsive situational cues fusion, inflated compulsive rituals,
Disorder (OCD) responsibility for reassurance seeking
preventing harm
Specific Phobia Snakes, heights, Overestimation of Avoidance, use of
injections, etc. the likelihood or drugs, distraction
severity of danger
Social Phobia Social situations Other people are Avoidance, in-
highly judgmental; situation safety
negative evaluation behaviors (e.g.,
is intolerable using alcohol at a
party)

7. Anxiety Disorders (Abramowitz, 2011)
Anxiety Disorder Fear Cue(s) Misperception(s) Coping Responses
Panic Disorder and Arousal-related Misinterpretation of Agoraphobic
Agoraphobia body sensations; arousal-related body avoidance, in-
situational cues sensations as situation safety
dangerous behaviors, safety
signals
Posttraumatic Stress Intrusive memories Nowhere is safe Avoidance of
Disorder (PTSD) of traumatic events reminders,
distraction, safety
signals
Generalized Thoughts/images of Intolerance of Reassurance
Anxiety Disorder low probability uncertainty; seeking, worrying
(GAD) events overestimation of as a form of
the likelihood and problem solving
severity of
outcomes

8. Functional Assessment of Anxiety
“Because exposure therapy targets the patient’s specific fears, it
is not enough to know that the individual has a diagnosis of
(an anxiety disorder). Developing an effective exposure
treatment plan requires the therapist to be cognizant of the
particular situations and stimuli that trigger fears, the feared
consequences of facing these fears, and the specific
maladaptive strategies the individual uses to manage these
fears” (Abramowitz, 2011).

9. Functional Assessment of Anxiety
Components of Functional Assessment of Anxiety (Abramowitz,
2011):
1. Problem list
2. Background and medical history
3. Historical course of the problem and significant events or
circumstances
– Personal and family history of anxiety
– Other events (e.g., media reports, illness outbreaks) that stand out as
possible triggers of the current problem
4. Fear cues
– External situations and stimuli
– Internal cues: body signs and sensations
– Intrusive thoughts, ideas, doubts, images, and memories

10. Functional Assessment of Anxiety
Feared Cues (Abramowitz, 2011):
What specific things are you afraid of? What situations do you avoid?
In what situations do you start to feel anxious or afraid? What are your
triggers?
In what situations do you have to use safety behaviors, such as _____?
What bodily symptoms are you concerned with?
What happens to your body that makes you feel afraid?
What symptoms set off concerns about your health?

11. Functional Assessment of Anxiety
Feared Cues (Abramowitz, 2011):
What upsetting thoughts or memories do you have that trigger anxiety?
What thoughts do you try to avoid, resist, or dismiss?
What is it that triggers these thoughts (or memories)?
Tell me about the form of these thoughts. Are they images? Are they
impulses to do something terrible?
What about these thoughts is scary for you?
What makes you feel that it is bad to have them?
What else can you tell me about the thoughts?

12. Functional Assessment of Anxiety
5. Feared consequences of exposure to fear cues
– Overestimates of the likelihood and severity of danger
– Intolerance for uncertainty
– Beliefs about experiencing anxiety

13. Functional Assessment of Anxiety
Feared Consequences (Abramowitz, 2011):
What is so frightening for you about flying on a plane?
What do you tell yourself if you experience tightness in your chest?
What makes it so bad for you to give public speeches?
What are you worried might happen if you went to a party where you
did not know anyone?
What is the worst-case scenario that could happen if used a public
bathroom?

14. Functional Assessment of Anxiety
6. Safety-seeking behaviors
– Passive avoidance
– Checking and reassurance seeking
– Compulsive rituals and covert, mini- (or mental) rituals
– Safety signals
– Beliefs about the power of safety behaviors to prevent
feared consequences

15. Safety Behaviors (Abramowitz, 2011)
Type of Safety Behavior Description & Examples
Passive Avoidance The deliberate failure to engage in a low-risk
activity associated with a feared cue.
Checking & Reassurance Seeking Subtle or overt behaviors aimed at confirming or
verifying what is usually already known about a
fear trigger or feared consequence.
•Checking locks, outlets, lights
•Information seeking
•Mental reviewing
Compulsive Rituals Repetitive behaviors, often performed according to
certain self-prescribed rules and aimed at reducing
anxiety, “undoing” or removing a perceived
danger, or preventing feared consequences.
Behavioral and mental.

16. Safety Behaviors (Abramowitz, 2011)
Type of Safety Behaviors Description & Examples
Compulsive Rituals, cont’d. •Compulsive, rule-driven handwashing
•Mental rehearsing
•Repeating simple behaviors
•Repetitive praying
•Needing to visualize a “good” outcome in
response to thoughts of a bad outcome
Brief, Covert (Mini) Rituals Nonritualistic attempts to reduce anxiety, remove or
escape from feared stimuli, and prevent disasters.
Behavioral or mental.
•Repeatedly replacing a “bad” word or image with
“good” one
•Trying to suppress upsetting thoughts, images, or
memories
•Attempting to distract oneself from a fear trigger

17. Safety Behaviors (Abramowitz, 2011)
Type of Safety Behavior Description & Examples
Safety Signals Stimuli associated with the absence (or reduced
likelihood) of feared outcomes. Even if these items
are not used, the mere presence can artificially
reduce anxiety and make the individual feel as if he
or she is safer than he or she would be if such items
were not present.
•Medications
•Cell phone
•Keys
•Safe person
•Hospital
•Water bottle

18. Functional Assessment of Anxiety
Safety Behaviors (Abramowitz, 2011):
“When assessing safety behaviors it is important to understand
not just the form or topography of the action, but the function
or purpose of the behavior– that is, why the individual
performs such behavior and in what situations it occurs.
In other words, what feared consequences does it prevent and
how does the patient believe the safety behavior works?”

19. Functional Assessment of Anxiety
Safety Behaviors (Abramowitz, 2011):
How do you avoid _____?
What do you avoid because of your fears of _____?
Do you check that (a feared consequence) will not happen or has not
happened?
Do you ask other people for assurances that something bad will not
happen?
Can you tell me exactly what you do when you do _____?
What gives you the feeling that you need to do _____? How do you
know when to stop?

20. Functional Assessment of Anxiety
Safety Signals (Abramowitz, 2011):
What might happen if you didn’t do _____?
Are there other things you do to protect yourself from (feared
consequence)?
Are there any objects or people that make you feel comfortable or
reduce your anxiety?
Do you carry anything with you to help you feel safe?
What precautions do you take so that you are prepared in case
something terrible happens such as (specify the feared
consequence)?

21. Treatment:
Exposure and Response
Prevention Therapy

22. Exposure and Response Prevention Therapy
Exposure
• Prolonged, graduated, repetitive, and consistent exposure to
situations and thoughts that provoke anxiety and distress
– Situational/In vivo exposure
– Imaginal exposure
– Interoceptive exposure (Panic Disorder)
• The “A to Z rule”
• Exposures are considered challenges by choice
• Hierarchies are developed with clients using a 7-point Likert
scale rating subjective units of distress
– Begin with exposures in the 3 to 4 range

23. Exposure and Response Prevention Therapy
ANXIETY RATING SCALE
0 1 2 3 4 5 6 7
TRY AS HARD AS POSSIBLE TO RESIST
HAVE TO RESIST
Difficult to resist
Challenging Challenging
“It bothers me” urges.
Anxiety is
Unsure if able to Extremely hard to
CALM “Don’t want to do bothersome, yet “Wish I didn’t
resist ritualizing. resist urges to
NO ANXIETY it but know it will manageable. have to do it, but Panicking
use safety Near panic
NO URGES TO be easier than I can do it. Glad
Very hard to behaviors.
RITUALIZE AT think.” A little bit harder when it’s over!” Fear of dying.
resist urges to
ALL to resist urges but
use safety Start feeling
A few urges to can still do it. Come close to
behaviors. symptoms of
use safety safety behaviors
panic.
behaviors. but can still
resist.
Can’t imagine making
A few weeks before Think about ‘faking it through the
EXAMPLE: Dreading going. Don’t know if I can
appointment. Think being sick.’ Trying to appointment. Think
Really don’t want to, make it. Feel some Refuse to go. PANIC
GOING TO about not wanting to make excuses. Go to about leaving in the
but know it will panic symptoms Feeling panicky. Fear of dying if I go.
THE DENTIST
go, but no it, but glad when it’s middle of the
be ok if I go. starting.
worries, really. over. appointment. Strong
relief when I make it.

24. INVIVO EXPOSURE HIERARCHY
4
______
(Anxiety Rating)
Exercise
1. Use public lotion.
2. Lay on bed wearing “contaminated” clothes.
3. Do not cover up body when sitting in community space.
4. Use toilet without barriers.
5. Cut meat into uneven pieces of varying sizes.
6. Do not make the bed.
7. Greet people and make eye contact.
8. Touch community keyboard.
9. Sit where “contaminated” peer sat.
10. Use colloquial expressions.
11. Go to group late.
12. Sit at the table in the “wrong” way.
13. Hold plastic bag that contains a “contaminated” bandage.
14. Walk flat footed in bathroom.
15. Hold sink faucet.
16. Put moisturizer on face with “contaminated” hands.
17. Put socks in shirt drawer with shirts.
18. Tell staff that you don’t like something they like.
19. Say 5 words in every single group.
20. Put butter on fingers without washing.
21. Shake the hands of staff.

25. Exposure and Response Prevention Therapy
Response Prevention
• Refraining from behaviors during exposure that are meant to
reduce anxiety
– Behavioral rituals
– Mental rituals
– Avoidance
• Needs to be clearly defined between client and the clinician
• Clients learn that feared consequences of exposure are
irrational

26. Exposure and Response Prevention Therapy
• While performing the exposure trial, the client imagines the feared
consequence(s) of the exposure
• The client remains exposed to the cue until the associated anxiety
decreases by 50% or more
• The client records his or her peak anxiety level, the amount of time
elapsed for the anxiety to reduce by 50%, and the end anxiety level
• The client usually engages in 3-5 trials per day, every day, until
habituation occurs

27. Exposure and Response Prevention Therapy
Peak Anxiety Final Anxiety
Trial # Date Time Elapsed Time
Rating Rating
1 4/27/2012 15:30 4 6 minutes 2
2 4/27/2012 15:40 4 3 minutes 2
3 4/27/2012 15:50 3 5 minutes 1
4 4/27/2012 15:59 3 3 minutes 1
5 4/27/2012 16:03 2 2 minutes 1
6
7
8
9
10

28. Exposure and Response Prevention Therapy
Habituation: The decrease in anxiety due only to the
passing of time
– Within-trial habituation: The decrease in the peak
anxiety experienced in one exposure trial
– Between-trial habituation: The decrease in peak anxiety
ratings as a result of repeated exposure trials
Between-trial habituation
is the treatment effect!

29. Exposure and Response Prevention Therapy

30. Exposure and Response Prevention Therapy
• Banning safety behaviors
– Bans represent the “response prevention” portion of ERP and
target the behaviors carried out to reduce anxiety.
• Why Ban behaviors?
– May likely result in greater impairment and reinforce
symptoms (Calvocoressi et al., 1999; de Abreu Ramos-
Cerqueira et al., 2008; Merlo et al., 2009; Peris et al., 2008;
Steketee & Van Noppen, 2003; Stewart et al., 2008; Storch et al.,
2007b; Storch et al., 2010a).
– May likely hinder treatment effectiveness (Amir et al., 2000).

31. Exposure and Response Prevention Therapy
Reassurance Seeking
Submit Resist
4/29 llll llll llll l
llll

32. Effectiveness of Exposure and Response
Prevention Therapy
• Randomized control trials
– (see De Haan, Hoogduin, Buitelaar, & Keijsers, 1998; Fisher &
Wells, 2005; Hodgson, Rachman, & Marks, 1972; Kozak,
Liebowitz, & Foa, 2000; Marks, Hodgson, & Rachman, 1975;
Rachman et al., 1979; Rachman, Hodgson, & Marks, 1971).
• Meta-analytic techniques
– (see Abromowitz, 1996; Kobak, Greist, Jefferson, Katzelnick, &
Henk, 1998).
• Nonrandomized samples
– (see Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000;
Rothbaum & Shahar, 2000).

33. Anxiety Services at Castlewood
• Anxiety Consults
• Individual Therapy
– Exposure and Response Prevention Therapy (ERP)
– Functional assessment
• Group Therapy
– Social Anxiety Group
– Improvisation Group
– Anxiety Management Group
– Awareness Cultivation Group
• Public Exposure
– Meal, snack, body image, and other exposures

34. Treatment Resources
Anxiety Disorders Association
of America
- www.adaa.org
International Obsessive
Compulsive Disorders
Foundation
- www.ocfoundation.org
Association for Behavioral and
Cognitive Therapies
- www.abct.org

35. Bibliotherapy Resources
Exposure and Response Prevention Therapy:
Abramowitz, J. S. (2011). Exposure therapy for anxiety: Principles and
practice. New York, NY: Guilford Publications, Inc.
Abramowitz, J. S. (2006). Obsessive-compulsive disorder: Advances in
psychotherapy- evidence based treatment. Cambridge, MA: Hogrefe
Publishing.

36. Bibliotherapy Resources
Obsessive-Compulsive Disorder:
Abramowitz, J. S. (2009). Getting over OCD: A 10-step workbook for taking
back your life. New York, NY: Guilford Publications, Inc.
Baer, L. (2001). The imp of the mind: Exploring the silent epidemic of
obsessive bad thoughts. New York, NY: Penguin Putnam, Inc.
Gross, J. J. (2007). Handbook of Emotion Regulation. New York, NY: The
Guilford Press.

37. Bibliotherapy Resources
Emotion Regulation:
Leahy, R. L. (2011). Emotion regulation in psychotherapy: A practitioner’s
guide. New York, NY: The Guilford Press.
Rapoport, J. L. (1989). The boy who couldn’t stop washing: The experience
and treatment of obsessive-compulsive disorder. New York, NY: Penguin
Putnam, Inc.
Weg, A. H. (2011). OCD treatment through storytelling: A strategy for
successful therapy. New York, NY: Oxford University Press.