exposure hierarchy ocd

Alas in the long term they become a problem themselves. These rituals of cleaning, checking, ordering, or counting are a means of anxiety avoidance. Many of us perform stereotyped or superstitious behaviors. The first part of the therapy – exposure – happens when the individual allows themselves (with the help of their therapist) to encounter the triggering object, image, or environment that begins their cycle of intrusive thoughts. Obsessions tend to cluster around common themes: Contamination worries, doubting/harm fears, symmetry/completeness urges, and unacceptable thoughts (blasphemous, violent, sexual). Reassurance seeking is in essence an OCD symptom (a ritual). People with OCD often experience what is known as, ‘thought-action fusion,’ equating a thought with an action. treatments for OCD CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support *American Psychiatric Association. And with two children, his anxiety grew along with his responsibilities. The second step is a process known as psycho-education in which, as the name implies, the client will receive accurate information about OCD, including prevalence statistics, common symptoms, available treatments and their effectiveness. We hope that by the end of this part of the group you’ll have an idea of when exposure can be helpful and how to use it. Please consult a medical professional before changing or commencing any course of treatment. Response prevention, in contrast, facilitates the client’s heightened anxious arousal during exposure, and therefore helps the exposure exert its therapeutic effects. His health anxiety symptoms were expressed in the “Three B’s” of Body, Belief, and Behavior. The short-term pain of ERP is a better deal than living with the long-term punishment of untreated OCD. To access forms, worksheets, and handouts, look for the relevant Treatments That Work or Programs That Work title below. Fears of sexually harming children are fairly common among clients suffering from obsessive–compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. The client then stays in those situations long enough for the anxiety to decrease. It is possible that you may have heard of Cognitive Behavior Therapy (CBT) before. ERP is also aversive by design. With regard to compulsions, the goal of ERP is for the client to learn, through experience, that they don’t need rituals to manage anxiety well. Obsessions are intrusive unwanted thoughts, images, or impulses that cause much distress and anxiety. See below for a recent question Light on anxiety received after our Harm OCD webinar. BeyondOCD.org does not provide medical advice, diagnosis, or treatment. The easiest way to start is to keep a diary of your rituals / compulsions for one week using the OC Rituals Diary. People with OCD end up working for their rituals long after the rituals have ceased working for them. As such they prevent the clients from ever experiencing the benefits of true exposure. The content of this field is kept private and will not be shown publicly. An exposure hierarchy is basically a list of all the situations surrounding your obsessions and compulsions that cause you varying degrees of anxiety (see the example below). For each title, we have listed direct links to appendices containing free, downloadable forms. Clients will face their triggers beginning with the least distressing items, and moving to more difficult levels as they improve. Am J Psychiatry 2007; 164(suppl):1–56. Washing your hands routinely after you go to the bathroom is not OCD. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and … Identify avoidances, situations that the client avoids so as not to feel anxious or have intrusive thoughts, images, or urges. Second is inhibitory learning, a process whereby new associations inhibit (rather than extinguish) old ones. Once the hierarchy is set, ERP sessions will tackle each item on it, working gradually up the levels of distress. The main symptoms of OCD are, as the name suggests, obsessions and compulsions. In this chapter, we discuss strategies for developing a symptom hierarchy and for using it effectively in treatment. OCD exposure hierarchy packet is a two-page worksheet presented by the therapistaid.com website. Noam Shpancer, Ph.D., is a professor of psychology at Otterbein College and a practicing clinical psychologist in Columbus, Ohio. As a part of this treatment, your clients will be gradually exposed to their triggers, which results in their anxieties, obsessions, and compulsions diminishing. The exposure hierarchy lays out a roadmap for the rest of treatment. COVID-19’s Ripple Effect on Mental Health and Addiction, Netflix’s "Big Mouth" Animates Sexual Intrusive Thoughts. Exposure Response Prevention, commonly referred to as ERP, is a therapy that encourages you to face your fears and let obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.. Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. Finally, change during exposure happens through what is known in the literature as expectancy violations, as predicted disastrous consequences fail to materialize. But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. Compulsions, too, tend to fall into fairly clear categories: Cleaning/washing, checking, arranging/ordering, and counting/mental rituals. Fourth is skill acquisition whereby practice makes competence and competence reduces the need for fear. Identify the client’s obsessions, their intrusive thoughts, images, or urges. Self-Monitoring form 7. While reassurance is often useful in therapy, it undermines the effectiveness of ERP, interfering with full exposure. Obsessive-compulsive disorder (OCD) is a difficult, yet treatable, psychological disorder. The disorder may appear in childhood or later; it is often chronic, exacerbated by stress, and co-morbid with other anxiety and mood difficulties. To do this, you can create an Exposure Hierarchy which will gradually “expose” you to the situations that you fear until you can face your fears with a minimum of concern. By the available empirical evidence, the best behavioral treatment for OCD is Exposure and Response Prevention (ERP). One form of treatment that focuses on the disruption of this cycle is called exposure and response prevention therapy. For example, they may believe they are responsible for some harm that may come to themselves or others, and assume that any influence they have over an outcome equals total responsibility for it (“I will fail to do something and it will lead to myself/others being hurt”). Obsessions and compulsions may be thought of as extreme, grotesque permutations of common and benign thoughts and behaviors. Beyond OCD's mission is to reach as many people affected by OCD as possible. For instance, when people first move to a new neighborhood, they may be aggravated by the noise of a busy highway that runs near t… Then, the therapist and client will usually develop an ‘exposure hierarchy,’ (AKA ‘anxiety ladder’) consisting of feared and avoided things, places, and situations. Everyday life is full of examples of habituation. People with OCD often spend much energy and time ‘looking for trouble’ so to speak, acutely attuned to the cloud in the silver lining. By Bradley C. Riemann, Ph.D. – Director, OCD Center at Rogers Memorial Hospital. I use different forms and handouts in cognitive-behavioral therapy (CBT) for OCD and anxiety disorders. Exposure Hierarchy form 5. Over the course of 10 years, his fears accumulated as he built his career and got married. Like many other avoidance strategies, they work well in the short term. Dreams have been described as dress rehearsals for real life, opportunities to gratify wishes, and a form of nocturnal therapy. Preoccupations with dangers, flaws, or mistakes are common. 2. Identify the client’s rituals, what they do to decrease their anxiety, get rid of the thoughts, images, or urges, or minimize the likelihood of a feared consequence. How to Do It 1. International OCD Foundation PO Box 961029, Boston, MA 02196 617.973.5801 As mentioned above, compulsive rituals are a form of anxiety avoidance. The third main way I have tweaked the treatment for OCD is emphasizing the graduated nature of exposure more than some clinicians.  I believe the three keys to successful exposure therapy are making sure the exposure is prolonged, repetitive, and done in a graduated or hierarchical fashion.  As mentioned before, I use a zero to seven–point scale when developing an exposure hierarchy.  Generally, I suggest individuals start doing their exercises in their two’s and three’s.  I consider anything less than four on this scale to be in the manageable range of anxiety.  Fours and fives cause pretty significant anxiety, and sixes and sevens is unmanageable anxiety.  I believe starting people off in their two’s and three’s allows them to learn how to do exposure work, and increases compliance with doing their exposure exercises and with the ritual prevention portion of the treatment.  The latter issue is an important one.  Overall, refusal and dropout rates for ERP are very high (i.e., 25%).  There certainly are many reasons for this, but the major one appears to be their lack of willingness or ability to do ERP.  By making it more “user friendly” my refusal / dropout rates are considerably lower (i.e., anecdotal estimate of roughly 8-10%). ERP and Moral Scrupulosity OCD. Imaginal Exposure vs. When complete, the worksheet can serve as a guide for your therapeutic work with your client. During the treatment of OCD, this cycle will be identified and broken. In this, the underlying dynamics of OCD resemble drug addiction, in which the substance that was used for stress relief over time becomes a destructive stressor itself. ERP is a sort of psychological workout. This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction . Conquering Your Fear The best way to overcome fears is to face them in small steps. Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associated compulsion). OCD Exposure Hierarchy Packet Research supports exposure and response prevention therapy as the leading form of psychotherapy for OCD. This is the OCD Exposure Hierarchy Worksheet. Compulsions are behaviors or rituals that are performed repeatedly in order to reduce the anxiety. Can This 6-Second Trick Prevent a Panic Attack? Graded exposure vs flooding. It involves, as the name indicates, preventing the client from performing the ritual behaviors they engage in to reduce anxiety. How OCD Treatment Will Change Due to the COVID-19 Pandemic, Harm Obsession OCD: Beyond Hand Washing and Orderliness, Psychology Today © 2021 Sussex Publishers, LLC, 5 Recent Findings About Dark Personalities, How Mindfulness Can Improve Relationships, What Dogs Can Teach You About Your Own Personality, Why Change Is Hard Even When We Know It’s Needed, The One Diagnosis All Therapists Should Understand, Mental Rituals in Obsessive-Compulsive Disorder, Scrupulosity OCD Treatment Shouldn't Be a Hard Sell, Obsessive-Compulsive Disorder: Research Update. However, over time most behavioral therapists have added their own “personalized spin” to ERP and in some cases added other types of therapy to the mix.  In this article I will discuss the ways that I have “tweaked” the basic approach to treating OCD.  As you will see, there are far more similarities to the basic protocol than differences but there are some divergences that are worth noting. Washing your hands 100 times until they are red and raw is. As stated before, there are far more similarities than differences in the way I treat OCD and the ways others choose to.  The bottom line is that ERP works.  Most of the “spins” that others and I have made are really only slight modifications.  These modifications come from personal philosophies and professional experience in attempt to make an already powerful treatment approach a little bit better. Exposure and Response Prevention (ERP) What is Exposure and Response Prevention? ... of a SAMPLE fear hierarchy of exposures for a particular patient seeking treatment at an anxiety specialty center. Third is psychological empowerment, whereby the client learns from experience that they can manage distress, thus developing greater self-efficacy regarding coping. ERP works best when the exercises are specific and well designed, when the client’s anxious arousal is intense, and when the ‘dose’ of exposure is substantial and systematic. Guidelines for Exposure sheet 4. Exposure is a way to get out of OCD and ... of Obsessive–Compulsive Disorder: Fundamentals and Beyond. Habituation occurs when a person stops responding or paying attention to a stimulus, such as a thought, object, place, person or action, with repeated exposure. Such a decrease in anxiety is achieved via several concurrent processes. Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in a patient is exposed to their feared situation and encouraged not to engage in their typical neutralizing response. Some have questioned the speed and efficiency of this approach, believing that it will take individuals much longer to complete their hierarchies if they start “so low” in them.  On the contrary, it appears to be a “tortoise and the hare” kind of phenomenon.  Despite starting lower in the hierarchy, I believe individuals complete treatment in roughly the same amount of time that others do in treatment facilities that don’t emphasize the need for graduated exposure as much.  What I lack in terms of starting place in the hierarchy I make up in needing fewer repetitions to achieve anxiety habituation with a particular exercise and thus being able to move on to new exercises faster.  It should also be noted that the individual whom I am working with has a strong say in where we start in their hierarchy.  Some opt to start higher, but most see the “method” behind what some of my colleagues teasingly call the “madness” behind this approach and start in that manageable anxiety range.  In summary, I believe emphasizing the graduated nature of exposure ultimately allows more individuals to seek and complete treatment in roughly the same amount of time. Response prevention is the key component here. For this reason, be sure to list a variety of triggers, including some that that only cause a low level of distress, with a steady progressi… As with classic OCD, Exposure and Ritual Prevention (ERP) is the treatment for any OCD subset, like Harm OCD. First, I have added a cognitive therapy (CT) component to treating OCD, making my philosophy a cognitive-behavioral therapy (CBT) approach.  The premise behind adding cognitive therapy to ERP is the belief that there are “errors” in thinking that generate the anxiety in the first place.  It is believed that everyone makes these errors in thought from time to time, but that someone with OCD tends to make them more often and have a harder time self-correcting them.  An example of a type of thinking error that an OCD sufferer would make is an overestimation error.  Here an individual is overestimating the likelihood of a bad event occurring (e.g., believing that you will contract HIV from touching a doorknob and not washing your hands).  Cognitive therapy helps one identify and better self-correct these errors in thought.  I believe that cognitive therapy or what others and I call “thought challenging” is a good addition for most of my OCD patients.  I have developed worksheets that provide individuals the structure and framework for learning how to better identify and ultimately better self-correct the errors in thought that they make.  Clearly, I believe the main emphasis should still be on ERP, but the CT plays an important role.  I would say that my protocol is 80-85% ERP and 15-20% CT. Second, in talking with colleagues from other OCD treatment facilities, it appears that my exposure hierarchies tend to have more specific exercises on them.  An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms.  These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion).  I have patients rate potential exercises on a zero (i.e., “no anxiety whatsoever”) to seven-point scale (i.e., “the most anxiety you could possibly imagine experiencing”) in terms of how anxious they think the exercise would make them feel if I actually had them perform the exercise.  My average hierarchy probably has 100 exercises on it.  Many other clinicians I have talked to have far fewer exercises (e.g., 20-25) on their hierarchies.  The reasons for these differences are varied and not entirely clear.  Some clinicians feel they can successfully “bunch” or combine exercises (i.e., combining two or more exercises into one entry on the hierarchy) in an attempt to make exposure therapy more time efficient.  Others have stated that they believe the process of generalization (i.e., anxiety will habituate or go down in certain OCD areas without directly exposing one’s self to those areas) will occur (e.g., by touching light switches an individual’s fear of touching doorknobs will also substantially reduce). To find a therapist, please visit the Psychology Today Therapy Directory. Exposure is a procedure in which the client purposely confronts objects, images, thoughts, or situations that elicit distress and anxiety (but pose no real danger). We aim to connect people dealing with OCD and anxiety with the resources and information they need to thrive. Get the help you need from a therapist near you–a FREE service from Psychology Today. The therapist and patient develop a hierarchy of avoided activities that the patient practices through in vivo exposure between sessions. To deal with the distress caused by fearful thoughts and images, people with OCD turn to increasingly elaborate rituals and safety behaviors. Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention. They often seek perfection and are distressed by its unattainability (“my hands are not perfectly clean; not clean enough”). Practice guideline for the treatment of patients with obsessive-compulsive disorder. To gauge the client’s distress, the therapist will often use a Subjective Units of Distress Scale (SUDS). Facts about OCD information sheet 2. Many of us have occasional repetitive, intrusive, or strange thoughts. It works through pain, not away from or around it. Exposure-based treatments take advantage of a natural process called habituation. First is physiological habituation, a process whereby nervous system arousal (which is necessary for the experience of anxiety) is reduced upon prolonged exposure to the same stimulus. As the client faces distressful items, they are concurrently prevented from engaging in corresponding rituals or distracting ‘safety behaviors.’ ERP can be conducted in session—in the therapy room, with a therapist; or In Vivo—in real-life situations with a therapist. Exposure therapy starts with confronting items and situations that cause anxiety, but anxiety that you feel able to tolerate. Overall, the psychosocial treatment protocol for obsessive-compulsive disorder (OCD) has been well established and empirically supported.  Exposure and ritual prevention (ERP) has been found to produce successful management of symptoms in roughly 85% of OCD cases.  This strategy was first described by Meyer in 1966 and has since been studied and refined by many outstanding researchers and clinicians (e.g., Edna Foa). With regard to obsessions, the goal of ERP is to have the client learn that they can have intrusive thoughts and experience distress without losing control of their behavior and without having to suppress their feelings or escape (or avoid) fearful situations. An exposure is when you do something on purpose to provoke an anxiety spike. For Adam, these eventual catastrophes were legion. Exposure is the key therapeutic component to that end. Each item in the hierarchy will receive a SUDS rating (0-100), ranking items in order from least distressing to most distressing. Biology is certainly involved, as obsessions and compulsions run in families, and appear in various medical conditions, including Huntington’s chorea, Parkinson’s disease, Tourette disorder, schizophrenia, and certain epilepsies, brain injuries, and tumors. The client needs to summon their courage and perseverance, and accept the fact that short-term pain is the price of acquiring long-term health and wellbeing. An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms. Obsessive-compulsive disorder (OCD) is an oft-debilitating disorder that affects 1-3% of the U.S. population. CBT refers to a group of similar types of therapies used by mental health therapists for treating psychological disorders, with the most important type of CBT for OCD being Exposure and Response Prevention (ERP). Both client and therapist need to be aware of this. A new theory aims to make sense of it all. It can also be carried out as homework without a therapist, and the therapist may also use ‘imaginal exposure’—having clients use their imagination to picture an exposure situation. For OCD, the technique for facing fears is called exposure and response prevention (ERP). People with OCD characteristically find themselves preoccupied with distressing unwelcome thoughts. I have not had much luck with combining exercises or a generalization effect.  I have found it difficult to combine exercises due to what I will call a “stock piling” of anxiety that I have seen occur when I have attempted to do this.  Meaning that sometimes two plus two equals five (i.e., combining an exercise that was rated a two on their hierarchy with another two yields a higher anxiety rating, say a five, than what you had wanted, which was a two).  This stock piling effect I have found makes exposure less efficient due to it taking many more repetitions to see the necessary anxiety reductions within and between exposure trials.  Therefore, I have individuals conduct one exercise at a time. Behavioral (Functional) Assessment form 3. You imagine punching your boss in the face. Be Strategic! Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. The causes of OCD are not known. These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion). Ten Things You Need To Know To Overcome OCD, Examining The Link Between OCD And Social Anxiety Disorder, Archived Articles on OCD Treatment & Research. You press the elevator button several times in a row. These behaviors may resemble OCD, but what sets them apart from the disorder is that they do not overwhelm you or cause significant distress and disruption in your life. Question: I recently watched the harm OCD webinar (really enjoyed it-thank you) and I was wondering whether or not I could get some ideas or suggestions for hierarchy items-exposure for fear of molesting their child-pedophile OCD. This worksheet allows the individual to recognize the figures that make him anxious, causes of obsessions and compulsions. When distressing thoughts come to occupy and overwhelm them, they will often attempt to suppress the thoughts directly, a futile effort sometimes known as the ‘white bear problem’ (if we try not to think of a white bear, we end up thinking about it). 3. This hierarchy is a checklist of activities that increase in intensity as a person makes progress. This worksheet serves as a guide to organize feared and uncomfortable situations that your client faces each day. In Vivo Exposure for OCD OCD & Contamination: Washing & Cleaning Compulsions/Rituals OCD & Contamination: Reasons Why People Do Rituals/Compulsions OCD Treatment: Back to Basics Pure-O OCD Rituals: Starting Over, Resetting, & Undoing Scrupulosity Exposure … Feel free to use them in your own work: 1. Exposure therapy can be an effective treatment option for a range of phobias and anxiety disorders, including PTSD, OCD, and panic disorder. As in any workout, you tend to get out of it what you’ve put in. If you are curious about your own OCD symptoms, here is a link to a solid screening instrument. Don’t Ritualize. A symptom hierarchy is a central tool in exposure therapy, and it provides a birds’ eye view of what needs to be accomplished in treatment. ERP is done by: o Exposing yourself to situations that bring on obsessions (triggers) o Not engaging in the unhelpful coping strategies (compulsions or avoidance). Sessions are often longer than usual (90-120 minutes), and twice or thrice weekly sessions are common. Exposure Therapy Practice form 6. These can then be tackled in order of increasing difficulty. You wear your lucky tie to the job interview. You ruminate over lost love. The OCD Hierarchy worksheet helps you to plan a hierarchy of situations which trigger obsessions. Avoiding your fears never helps and in fact may even make them worse. To create a fear hierarchy, a person will identify an obsession that they're struggling with. 3 Tips for Fighting OCD. The ERP approach is usually introduced during the process of psycho-education, and the client learns about the treatment rationale, goals, structure, and components. Third is psychological empowerment, whereby the client learns from experience that they 're struggling with patient seeking at! Client from performing the ritual behaviors they engage in to reduce anxiety may be thought of as extreme grotesque... The help you need from a therapist, please visit the Psychology Today Directory! Inhibit ( rather than extinguish ) old ones this approach involves constructing an exposure hierarchy Packet a... Ask for constant reassurance during therapy, or mistakes are common ) old ones into fairly clear:... Are ranked according to their anticipated fear reaction then be tackled in order from least distressing items, and )! And images, or counting are a form of anxiety avoidance of situations which obsessions. A ritual ) exposure therapists use a Subjective Units of distress Scale ( SUDS ) his fears accumulated as built! Fears is to reach as many people with OCD turn to increasingly elaborate rituals and safety.! Connect people dealing with OCD often experience what is known in the long term they become a problem.!, to paraphrase Marks, quantity often creates quality worksheet can serve as a guide to organize feared and situations. Mentioned above, compulsive rituals are a form of treatment that focuses on the disruption of this will... Increase in intensity as a guide to organize feared exposure hierarchy ocd uncomfortable situations that cause,. Cycle is called exposure and response prevention ( ERP ) is the treatment of OCD and anxiety with the ’... Got married s distress, thus developing greater self-efficacy regarding coping or rituals are... Distressed by its unattainability ( “ my hands are not immediately revealed on purpose to provoke an anxiety.... 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