High intensity approaches to exposure and response prevention for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with multidetermined etiological and maintaining mechanisms. Cognitive behavioral therapy (CBT), specifically exposure and response prevention (ERP), is the first line behavioral intervention to treat OCD. ERP directly targets threat learning that characterizes OCD through processes of habituation (fear extinction) and inhibitory learning, in addition to eliciting neuronal changes implicated in OCD. Although ERP has a strong evidence base, not all OCD patients respond fully to standard, weekly or twice-weekly outpatient ERP. High intensity ERP-treatment delivered through more and/or longer sessions in a condensed manner-is a potential alternative approach that has also demonstrated efficacy for adults and youth with OCD. The goal of this review article is to describe the nature, rationale, and evidence for high intensity ERP for OCD treatment. We describe the foundations of ERP for OCD, various formats of intensive ERP, clinical research on the efficacy of this approach including neuronal changes, and potential pharmacological and neurosurgical augmentation strategies. We conclude with limitations of the current literature on intensive approaches and recommendations for future directions. While additional research is needed, high intensity ERP may be a promising approach for patients who have not responded to standard ERP or for patients requiring rapid symptom improvement.