ED Therapy - Exposure and Response Prevention?

Corntney Modelewski, MA, LLPC, an active member of SMEDA and a Kalamazoo therapist that specializes in Cognitive Behavioral Therapy and DBT.  She has written this months blog article on Exposure and Response Prevention (ERP).  http://www.southwestmichiganeatingdisorders.org/directory/

     Exposure and Response Prevention (ERP) is a therapy for Obsessive Compulsive Disorder (OCD) that requires being in the presence of something that causes fear – exposure – and not avoiding the feared situation – response prevention. It can also be used during eating disorder treatment, with growing research to support its use in Anorexia Nervosa and Bulimia Nervosa. For example, in 2011 the International Journal of Eating Disorders published an article about data support ERP use to aid in weight restoration, fear of eating, learning to tolerate fear, and relapse prevention in those with Anorexia Nervosa when used as part of a treatment plan.

     With a licensed mental health therapist, a list called a hierarchy is made up of feared situations to be used as exposure tasks. Distress ratings on a scale of 0 – 100, called Subjective Units of Distress (SUD), are included on the hierarchy as well. The hierarchy gives the frame for treatment.

As an example...

Anorexia Hierarchy

Feared Situation                                                                    SUD (0-100)

Skip one day of exercise                                                                 55

Eat at a Chinese buffet restaurant                                                  95

Have friends over for dinner and eat in front of them                  100

Walk through a grocery store without buying anything                35

Fill pantry with canned food                                                           70

Eat apples with therapist                                                                 60

 

     It's common for individuals to have more than one mental health concern, especially anxiety or OCD. It helps to treat eating disorders and anxiety at the same time when doing ERP.  Kind of like killing two birds with one stone.

As an example...

Anorexia and OCD with Contamination Fear Hierarchy

Feared Situation                                                                                               SUD (0-100)

Eat sucker that has touched a grocery cart seat                                                     70

Hold a raw steak for five minutes before cooking                                                   75

Eat a bag of M&Ms off of therapist's office floor                                                     30

Eat an egg salad sandwich in the bathroom at home                                             45

Play with neighbor's dogs, eat meal without washing hands afterwards               80

 

Treatment structure will look like this:

  • One hour weekly appointments for 14 – 16 weeks.
  • Agreeing to one-half to two hours per day working on exposure tasks outside of session.
  • Getting hands-on help from the therapist to show how to complete the exposure tasks and prevent the person from trying to avoid fear.
  • Time to talk about feelings with the therapist after exposure tasks.
  • Exposure tasks outside of sessions may include help from friends, family, or members of the treatment team.
  • Tracking distress on a sheet of paper, including lessons learned from the activity, and other homework as assigned by the therapist and other treatment team members.
  • Repeating exposure tasks until SUDs go down.

     To sum it up, ERP is a process that addresses fears unique to the individual's needs. One of ERP's main goals is to help people learn skills to use when therapy is complete and encourage people to use their own ERP as needed. In other words, ERP is to help people with eating disorders to become their own ERP therapist.

Recommended YouTube video:

 

https://youtu.be/ZTwVb_3koCU

 

Sources:  (Many of these sources can be found in PubMed.)

Foa, Edna B., Elna Yadin, and Tracey K. Lichner. Exposure and Response (ritual) Prevention for Obsessive-compulsive Disorder: Therapist Guide. Oxford: Oxford UP, 2012. Print.


(Exposure and Response/Ritual Prevention for Obsessive-Compulsive Disorder: Therapist Guide, Edna Foa, Elna Yadin, and Tracey K Lichner, 2012)

Simpson, H. B., et al. (2013). Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cognitive Behaviour Therapy, 42(1), 64-76. doi:10.1080/16506073.2012.751124

(Treatment of Obsessive-Compulsive Disorder Complicated by Comorbid Eating Disorders, Cognitive Behaviour Therapy, 2013, Simpson, et al)

Steinglass, J. E., Sysko, R., Glasofer, D., Albano, A. M., Simpson, H. B. and Walsh, B. T. (2011), Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa. Int. J. Eat. Disord., 44: 134–141. doi:10.1002/eat.20784

(Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa, International Journal of Eating Disorders, 2011, Steinglass et al)

Toro, J., Cervera, M., Feliu, M., Garriga, N., Jou, M., Martinez, E., & Toro, E. (2003). Cue exposure in the treatment of resistant bulimia nervosa. International Journal of Eating Disorders, 34(2), 227-234. doi:10.1002/eat.10186

(Cue Exposure in the Treatment of Resistant Bulimia Nervosa, International Journal of Eating Disorders, 2003, Toro, et al)