An Update Model of OCD Treatment

If you or a loved one struggles with Obsessive Compulsive Disorder (OCD), you’ve likely heard of Exposure and Response Prevention (ERP). This treatment is known as the gold standard and has been shown through ample research to be a highly effective treatment (e.g. Song et al., 2022). What you may be unaware of, however, is that there has been an innovation in the application of ERP that may enhance its effectiveness. In this article we’ll compare this innovation, called the Inhibitory Learning Theory (ILT), to the older model of ERP, namely Emotion Processing Theory (EPT).

Is Habituation Central to ERP?

Initially, ERP was thought to work through a process called habituation. Habituation is a process in which repeated exposure to a stimulus decreases a subject’s responses to that stimulus.. A model called the Emotion Processing Theory (EPT) claimed that habituation is the central component to ERP: that repeatedly exposing a patient to their fear, while preventing the client from escaping that fear, would gradually reduce the patient’s physiological responses to said fear (Foa & Kozak, 1986). However, much research since then has questioned whether habituation is actually central to successful outcomes in exposure therapy. Many researchers have found no relationship between habituation within a given session and treatment outcomes (Baker et al., 2010, Jaycox, Foa, & Morral, 1998; Kozak, Foa, & Steketee, 1988; Meuret, Seidel, Rosenfield, Hofmann, & Rosenfield, 2012). Researchers have also discovered that treatment results can be gained in the absence of habituation (e.g., Rachman, Craske, Tallman, & Solyom, 1986; Rowe & Craske, 1998b; Tsao & Craske, 2000).

Introducing Inhibitory Learning Theory (ILT)

This leaves us with an important question. If habituation is not a central component of ERP, but ERP is still effective, what is actually causing the change? Inhibitory learning theory (ILT) offers a new and perhaps more accurate perspective on ERP. Rather than focusing solely on reducing anxiety during exposures, ILT emphasizes creating new learning experiences that override old fear-based associations. When a client has OCD, they often have expectations that facing their fear without protective measures such as reassurance or other compulsions will result in disaster: either literally or in the form of intolerable heightened anxiety. When we utilize an ILT approach, we challenge these expectations in a variety of ways, to help the client learn that they can handle their anxiety much better than they might have anticipated (Kim et al., 2020, Jacoby & Abramowitz, 2016).

What are the strengths of an ILT approach?

One central issue with the EPT ERP is that patients often relapse (e.g., Franklin & Foa, 1998). Researchers have begun to propose that ILT ERP may be more effective in providing lasting results. For example, a study by Elsner et al. (2022) found that habituation (reduction in fear during exposure) predicted short-term improvement, but something called “expectancy violation” (a key component of ILT) was more predictive of long-term success after treatment. Similarly, Bautista and Teng (2022) argue that an ILT approach utilizes tools that can prevent relapse more effectively than the traditional habituation method. This may be because through an ILT model, clients learn a generalizable set of skills to handle anxiety which can help them even if their OCD switches themes. Conversely, habituating to one OCD theme may not help clients to the same extent later on if their OCD takes on a different theme.

It is important to note, as can be seen from a quick glance at the dates of the studies referenced here, that this research is still very new. However, in our clinic at OCD and Anxiety Specialists, we can attest to a bevy of anecdotal data. We frequently treat folks who report having had been to therapy before or even seen an OCD specialist before and did not receive the results they were looking for. Perhaps during therapy, the client struggled to habituate to their theme, and each exposure was as challenging and unhelpful as the one before it. Perhaps the client developed “meta-OCD” and began obsessing about the treatment itself, which interfered with treatment results. Perhaps in the moment they felt that therapy was “working,” or the therapy helped them achieve relief from their current OCD theme, but the results did not last over time. Perhaps the client did achieve enduring results for their specific OCD theme, but when the theme switched after therapy was over, the client had no idea how to manage it. In these situations and more, we have frequently found the ILT approach to be helpful where the EPT approach fell short.

Conclusion

Whether you are just learning about OCD or have been in treatment for a while, understanding these different approaches can provide valuable insight into your treatment. Both the habituation model and ILT offer powerful tools for treating anxiety and OCD, and knowing how they work can help you feel more confident and engaged in your treatment journey. We believe that there are many advantages to undergoing treatment based on a more modern and updated understanding of the processes of ERP. If you agree, consider working with us at OCD and Anxiety Specialists to get the treatment outcomes you deserve.

References:

Adams, T. G., Cisler, J. M., Kelmendi, B., George, J. R., Kichuk, S. A., Averill, C. L., ... & Pittenger, C. (2021). Transcranial direct current stimulation (tDCS) targeting the medial prefrontal cortex (mPFC) modulates functional connectivity and enhances inhibitory safety learning in obsessive-compulsive disorder (OCD). medRxiv, 2021-02.

Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour research and therapy, 48(11), 1139-1143.

Bautista, C. L., & Teng, E. J. (2022). Merging our understanding of anxiety and exposure: Using inhibitory learning to target anxiety sensitivity in exposure therapy. Behavior Modification, 46(4), 819-833.Elsner, B., Jacobi, T., Kischkel, E., Schulze, D., & Reuter, B. (2022). Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy. BMC psychiatry, 22(1), 66.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological bulletin, 99(1), 20.

Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.

Kim, J. W., Kang, H. J., Lee, J. Y., Kim, S. W., Shin, I. S., & Kim, J. M. (2020). Advanced cognitive-behavioral treatment model with exposure-response prevention for treating obsessive-compulsive disorder. Psychiatry Investigation, 17(11), 1060.