Exposure and response prevention — structured clinical viva

Opening definition

ERP/EX/RP is structured treatment combining confrontation with obsession cues and systematic prevention of rituals and safety behaviours so that negative reinforcement of OCD is interrupted and new safety learning can form.[13]

Habituation vs inhibitory learning

Habituation models watch distress fall within and between sessions. Inhibitory learning (Craske) designs for expectancy violation, context variability, and removal of safety signals; full within-session calm is not mandatory for every successful trial.[12]

Technique sketch for harm OCD

• Inventory mental rituals (reviewing, praying-as-undoing, silent checking) and overt checking.
• Imaginal script of feared harm scene without undoing; in-vivo tasks that leave situations incompletely checked.
• Hard rule: no mental reviewing for a set period; no reassurance questions to partner/therapist.
• Rate prediction before and learning after; assign daily homework; track Y-BOCS.[12][13][14]

Evidence bundle

• Foa 2005: EX/RP greater than clomipramine alone; combination not clearly superior to EX/RP alone at 12 weeks.[1]
• Simpson 2008/2013: EX/RP beats stress management and beats risperidone as SRI augmentation.[2][3]
• POTS: CBT and sertraline active in youth; combination strongest overall pattern — name when asked about children.[6]

Pitfalls and accommodation

Therapist drift, reassurance collusion, exposure without response prevention, benzodiazepine blunting, family checking/reassurance undoing homework.[13]

Risk interface

Screen suicide/depression before and during therapy. Expected anxiety rise is not automatic crisis, but escalating SI, incapacity, or inability to keep safe requires pausing intensity and stepping up psychiatric care — ERP does not override duty of care.[13]

Examiner pushbacks