Thankfully treatment has moved on since the 70s and 80s! It will be used when you do the next step and when you actually perform ERP. Use imaginal exposure to address OCD based around catastrophic feared outcomes. Thank you, {{form.email}}, for signing up. Let’s just say, for this example, that you decide your baseline is 4. Exposure is a way to get out of OCD and ... Below is an example of a SAMPLE fear hierarchy of exposures for a particular patient seeking treatment at an anxiety specialty center. Don’t analyze your thoughts or argue with them. For example, if your scripts focus on the fear of harming a loved one, you might have mixed feelings about the prospect of spending time with those you care about. Read a book related to my trauma : Listen to music that reminds me of my trauma . The goal of exposure is to allow yourself to feel the anxiety you are experiencing without turning away from it (i.e., without neutralizing, reassuring, distracting, or undoing). Make sure that you don’t avoid self-directed exposure. An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms. If I was your therapist, I would ask you to incorporate planned, deliberate exposures in which you purposefully face your thoughts head-on and use scripting as a technique to habituate to your fears. SEX / Hover over each image for examples of obsessions and feared consequences. However, my OCD has asked over the years whether I actually loved him, and had feelings for him, rather than admired him. Let's use the exposure hierarchy example from above and start with number eight since it has a SUDS rating of 60. Most individuals set aside at least an hour a day to work on their scripting. 2012;2012:394603. doi:10.1155%2F2012%2F394603, How Having an Exposure Hierarchy Can Help Control OCD, Ⓒ 2021 About, Inc. (Dotdash) — All rights reserved. Go to the location of my trauma ; Go somewhere that reminds me of my trauma . Don’t Ritualize. 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. Specifically, the last statement of this script involves the person actively agreeing with their own worst-case scenario. Downloadable PDFs will have a PDF icon next to them. Sound off below. Enter this on the Fear line on the attached worksheet. It can be difficult to sit with extended imaginal exposures but doing so can give you power back. Participate in an activity that reminds me of my trauma . Once you have mastered an item on your hierarchy, you move on to a more difficult item. In these types of scripts, the individual exposes themselves to what happens after the dreaded event. Regardless of the type of OCD you might have, imaginal exposure can be a particularly important technique to include in your toolkit. Exposure Instructions. Exposures will likely include in vivo exposures (touching “dirty” or contaminated things), imaginal exposure for OCD, and combined imaginal / in vivo exposure. This is extremely important for your progress. 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. These apply to all different kinds of OCD, so some may seem irrelevant to you, and that’s fine. In the 70s and early 80s flooding was more common in treatment, for example someone with a fear of dog faeces would have it smeared on them. I will smile and walk away, finally knowing for sure who I really am. For example, if you have a fear of contamination, your exposure hierarchy might look like this: An exposure hierarchy is usually developed with the help of your therapist as it can sometimes be difficult to decide in what order to place the items.. Be Strategic! You are beginning to short-circuit an emotional button that OCD has been pressing over and over again to its own advantage. It’s okay to complete exposures that meet only criterion 1, especially in the context of doing hierarchical exposure. Exposure and Response Prevention (ERP) Examples for Managing OCD; Exposure and Response Prevention (ERP) Examples for Managing OCD. Your email address will not be published. This means, what is your anxiety level normally, when you aren’t dealing with OCD intrusive thoughts and compulsions. Owen Kelly, PhD, is a clinical psychologist, professor, and author in Ontario, ON, who specializes in anxiety and mood disorders. Many people find that, at first, they must sit with a single imaginal exposure script for up to an hour or longer before their anxiety begins to habituate. One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. For example, if you have unwanted sexual thoughts about pedophilia, your feared consequences might involve much more than simply harming a child. However, it is also sometimes necessary to push imaginal exposure even further down the road. Posted May 21, 2012 What Happens During Exposure . Should you have any healthcare-related questions, please call or see your physician or other healthcare provider promptly. Patient One avoids the grocery store because she feels vulnerable and uncomfortable in crowds. What did your daughter say to you on visitor’s day? This number, between 1 and 10, becomes your baseline. You will feel anxiety as you resist the urge to engage in your compulsive behavior, but repeatedly doing this will eventually decrease your anxiety until touching the bottom of your shoe without cleaning your hands won't bother you at all. 3 Tips for Fighting OCD. This parallels the criteria we discussed earlier related to in vivo exposure. I created a fear hierarchy for every type of OCD I experience. For example, a patient with contamination concerns related to the toilet might eat food that has been placed on a toilet seat. This means that after touching these contaminated objects, the person would refrain from washing their hands, using hand sanitizer, getting reassurance, mentally reviewing reasons why it’s okay to not wash, or doing anything else to neutralize the perceived danger of the situation. Any success stories worth sharing? OCD is characterised by intrusive, unwanted thoughts and by compulsive actions - for example cleaning, checking, counting or hoarding. You and your therapist will identify a fear to address with your exposure hierarchy. I am a ruminator, a pure O OCD person, and I have a number of themes that have cropped up over the years. THanks! Can Systematic Desensitization Help Conquer Your Fears? Exposure Therapy for Children with Anxiety and OCD: Clinician's Guide to Integrated Treatment provides a step-by-step framework for how providers apply exposure therapy in practice. I’m now married, with three lovely children, and I would dearly love to be able to manage my OCD better, so I could enjoy my life. He had a lot of it, and everyone knew it. Talk about my trauma . Driving down Route 9 without stopping to check 80. if hit someone/something . Based upon the example exposure hierarchy from above, the client will first be asked to touch a doorknob in a public place, and then refrain from their compulsion (e.g. This level of detail can help you face your unwanted thoughts in a direct and non-avoidant way. Freedom From OCD Forms - Jonathan Grayson, PhD. You might be afraid of what your family might think of you, having your picture in the newspaper, going to jail, losing the respect of everyone you know, and/or living out the rest of your days as a social outcast. Sometimes these feared consequences can evoke emotions that are even stronger than the emotions linked to the feared act itself. However, a willingness to sit with the uncomfortable feelings elicited through imaginal exposure (without escaping or ritualizing) eventually gives way to less anxiety. These are not meant to be followed exactly – everyone’s hierarchy and anxiety ratings will be unique to their own fears. When writing these imaginal exposures, you should continue to write in as much detail as possible. Similarly, for someone afraid of stabbing a loved one, holding a knife while alone in your apartment might meet criterion 1, but it would not meet criterion 2. Flooding involves immersing the person with OCD in the situation they fear the most and them staying in that situation until their anxiety reduces to a more normal level, becoming less bothersome. This boy was my friend, and I certainly admired him, and would have loved to be as popular as he was, particularly with girls, who flocked to him. Exposure therapy takes plenty of courage and may take a good chunk of time. doi:10.4103%2Fpsychiatry.IndianJPsychiatry_516_18, Jones M, Wootton B, Vaccaro L. The efficacy of exposure and response prevention for geriatric obsessive compulsive disorder: a clinical case illustration. If you don’t expose yourself to these consequences in at least some of your scripts, your imaginal exposures may be of limited benefit. What did s/he say? The goal of these in vivo exposures is to face the fear directly without ritualizing. Unplug iron, leave room without checking 30. If these relationships are important to you, it’s critical to work on building closeness and quality of life with those you care about even when your OCD makes it more difficult to do so. Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Scary Thoughts as Costumes: The Illusion of Danger. Don’t try to figure out how likely they are, or what factors might make them more likely to occur. Patients sometimes protest that they should not do things that people without OCD do not normally do. Everyday life is full of examples of habituation. However, you can stack the deck in your favor by choosing an exposure that meets you at the right level. This uncertainty drives me crazy, as I certainly had affection for my friend. OCD: Screaming, Blurting Out Obscenities/Cursing/Profanity, & Other Unwanted Impulses. I am trying to work on exposures from more than one hierarchy each day. For example: ... Form 13 In vivo Exposure Hierarchy List; Form 14 Pleasant Activities Checklist; Form 15 Craving Thermometer; Form 16 Coping with Cravings; Form 17 Patient In vivo Exposure Data Form ; Form 18 Patient Imaginal Exposure Data Form; Form 19 Personal Emergency Plan; Form 20 Awareness of High-Risk Thoughts; Form 21 … Then my OCD says well this is because the only man you ever met that you loved was the boy in school years ago, and because you were attracted to him, you are bisexual. What was it like the first day you walked into prison? Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital. Hezel D, Simpson H. Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Example Exposure Activities . The exposure hierarchy is a listing of less difficult to more difficult OCD-related activities. At times, the experience of exposure can be extremely emotional, which is why it’s sometimes important to have a therapist to guide you through it. Exposures are designed to help you build up your tolerance to fear-producing situations. An exposure is when you do something on purpose to provoke an anxiety spike. The goal of these in vivo exposures is to face the fear directly without ritualizing. I’m wondering could imaginal exposure help? When we think about exposure therapy for OCD, we often think first about in vivo exposure. 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. This all drove me so nuts, that when I was in my 30s, I started to get depressed over it. People with OCD characteristically find themselves preoccupied with distressing unwelcome thoughts. OCD Triggers in Daily Life? Licensed Psychologist         (561) 444-8040, Posted by Steven J. Seay, Ph.D. on Oct 20, 2016 in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, Contamination/Health-Related Symptoms, ERP, Harm-Related Symptoms, OCD, OCD - Treatment, Sexual Symptoms | 1 comment. Learn the best ways to manage stress and negativity in your life. Don’t come up with an action plan designed to prevent these situations from coming true. For example, a person with contamination OCD might develop a hierarchy of in vivo exposures that involve purposefully touching “dirty things” like doorknobs, light switches, trashcans, animals, or even toilets. There are numerous variations on exposure therapy, depending on which specific condition is being treated – for example for OCD, the treatment of choice is a specific therapy called Exposure and Response Prevention (ERP). Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention. Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associated compulsion). Your email address will not be published. washing their hands) for two hours. Exposure-based treatments take advantage of a natural process called habituation. Your therapist will have you touch the bottom of your shoe and then not engage in any cleaning behaviors for a specified amount of time, perhaps several hours. An obsession is a persistent, unwanted and uncontrollable thought, image, It is also important to be wary of avoidance behaviors that can creep in when you begin doing imaginal exposure. Exposure with response prevention: Once a hierarchy of fears has been established, the therapist and client ‘climb the hierarchy’ by exposure to low items on the list. If you are having a clinical emergency, please dial 911. It is no less important, though, as this is the means by which we inject elements of uncertainty into the exposure. In scripting, people practice writing out their worst fears and then expose themselves to these scenarios over and over again in their minds until the intensity of their anxiety response is diminished. You should begin with an exposure that has a SUDS (i.e., “Subjective Units of Distress Scale”) rating of about a 3 or 4 (on a 10-point scale) and gradually work your way up to the harder stuff. My clients fears are only related to her own children. Example: When creating an in vivo hierarchy with patients, it is important to talk about the function of their avoidance. Exposure Hierarchy. Following are some ideas for exposure and response prevention (ERP) exercises. Response prevention refers to the idea that after the exposure, you will allow your anxiety to naturally decrease on its own without artificially forcing it to decrease prematurely through rituals. For example, someone who is afraid of stabbing their spouse might expose themselves to situations such as sitting near a plastic knife, sitting near a sharp knife, using a knife alone, using a knife to cut vegetables near their spouse, pointing a knife at their spouse, etc. What is exposure? I am 52, Irish and I’ve had OCD my whole adult life. whatever thoughts might present themselves. The content of this website is for general information purposes only and does not constitute therapy, treatment, or the establishment of a psychologist-client relationship. Exposures are often completed according to an exposure hierarchy, meaning that people typically complete lower level exposures (i.e., less distressing exposures) before gradually working up to higher level ones. People with OCD can become tormented by a pattern of thoughts and behaviours that can be very time consuming and difficult to stop. Any tips or tricks for your fellow scripters? I felt huge, huge, huge relief. In other words, we want youtobesold onexposure! They immediately wash their hands, but not for 15 seconds like many people might. Regardless of whatever type of OCD you have, there is always the need to do some type of in vivo exposure. Any suggestions would be appreciated. She refuses to walk around the neighborhood without her husband for fear of being attacked by a dog. Join me next time when I talk about why people really do rituals in health-related OCD . OCD Full Exposure: The Sickening Treatment for OCD How contamination can help OCD sufferers manage their symptoms. Then there is his charisma. If you’re not looking to read something potentially triggering, feel free to jump ahead. 4 Steps to Challenging Forbidden Foods in Eating Disorder Recovery, Daily Tips for a Healthy Mind to Your Inbox, Exposure and response prevention for obsessive-compulsive disorder: A review and new directions, The efficacy of exposure and response prevention for geriatric obsessive compulsive disorder: a clinical case illustration, Putting hand in toilet bowl water (SUDS rating: 100), Touching floor beside toilet (SUDS rating: 90), Handling raw poultry or hamburger meat (SUDS rating 85), Touching wall in toilet (SUDS rating: 80), Touching bathroom door handle (SUDS rating: 75), Shaking hands with a stranger (SUDS rating: 65), Touching the bottom of your shoe (SUDS rating: 60), Pressing a button on a vending machine (SUDS rating: 55). The goal of these in vivo exposures is to face the fear directly without ritualizing. Thing is, I have never had any urges or fantasies about having sex with men, just women. Avoidance is also considered a ritual. It seems to have got worse over the years however. exposure and response prevention (ERP) for OCD, unwanted sexual thoughts about pedophilia, Center for Psychological & Behavioral Science. Response prevention would involve holding the knife while accepting (and not neutralizing!) Your therapist will have you touch the bottom of your shoe and then not engage in any cleaning behaviors for a specified amount of time, perhaps several hours. When this happens, you will move to the next item on your exposure hierarchy. Required fields are marked *, Steven J. Seay, Ph.D. | 11380 Prosperity Farms Road #209A | Palm Beach Gardens, FL 33410 | (561) 444-8040. Here are some of my fear hierarchies, which reflect what I'm working on: Contamination Hierarchy. Hold an object that reminds me of my trauma ; Watch a TV show or movie that reminds me of my trauma . Response prevention during imaginal exposures is just as important as it is during in vivo exposures. Walk away from door, no checking lock 45. Overall, sit with the uncomfortable thoughts and embrace uncertainty. In vivo ERPs involve directly exposing yourself to feared situations in real-life. I drank too much one night, and decided that I must be gay. When you are going through exposure therapy, your therapist will most likely have you do the same exposure exercise at home every day in between sessions. I don’t want to believe that I loved him however, or wanted to have sex with him, as I see that as a major threat to my identity as a person, and if my identity as a heterosexual male is shattered I fear that I won’t cope and that I’ll end it all. Because these scripts extend further into the future, they are able to incorporate other feared consequences that shorter scripts might omit. This is often first practiced in-session with a therapist who can help shape your technique…however, it then becomes a strategy that you can replicate on your own. Behavioral rituals may include things like washing, checking, or rearranging; whereas mental rituals may include self-reassurance, thinking “safe thoughts”, praying, or mental review. Therefore the top of exposure hierarchies often involve activities that go beyond what people without OCD typically do. It's also absolutely essential to get through everything your therapist recommends on your exposure hierarchy since the triggers that are not addressed could actually get worse and cause the triggers you worked to overcome to come back.. This means resisting urges to reassure yourself, resisting urges to replace bad thoughts with good thoughts, resisting urges to analyze whether or not you might act on your thoughts, etc. Here are a few sample exposure hierarchies for different targets. She tends to avoid places where there are dogs, such as parks or hiking trails (even though she used to enjoy hiking). These feared situations should evoke the fear directly or present opportunities for the person to act on the fear. However, there are also many types of OCD in which in vivo exposure is insufficient and must be supplemented with imaginal exposure. The book begins with empirical support for the treatment followed by suggested implementation of exposures for specific conditions and ages. The second script was used by someone who engages in a lot of mental rituals, including “figuring out” rituals, self-reassurance, and mental review. Similarly, if you are scripting about touching contaminated objects and then getting sick, you MUST continue to interact with these objects without engaging in washing or cleaning rituals. However, it takes some planning and patience. You usually start exposure exercises with items that have at least a SUDS rating of 60, but it can sometimes be helpful to start with items that are ranked lower. This is yet another example of how it is important to combine exposure to triggers with opportunities for the fear to come true. The next day, however, I noticed I was looking at women in the street, and I was back to worrying and uncertainty again. Case Rep Psychiatry. Examples of Fear Ladders Specific Phobia (dogs): Cassandra’s Story Cassandra is afraid of dogs. Note that some hierarchies are arranged from easiest to hardest, and others are not. This can be very intense at first, but ultimately, practice and persistence make the process easier. This could be a fear of crowds, a fear of enclosed places, or a fear of flying . Notice that in the first script, we include some examples of feared consequences. It can often be helpful to record your imaginal exposure on a loop tape, smart phone, or digital recorder so that you can listen to it for extended periods of time. If you don’t practice good response prevention, your imaginal exposures will be unhelpful. Sample hierarchy: Item SUDS. For example, for a person with contamination concerns, touching and not washing might begin with a table used by others at home and progress to touching a sink in a public restroom. Touching a doorknob in a public place would probably meet both criteria 1 and 2. These can then be tackled in order of increasing difficulty. You continue this process until you have met your goals. When you do reach the point where your scripts are causing less anxiety, OCD will probably try to trick you by saying, “Aha! Indian J Psychiatry. When you are developing an imaginal exposure script, it is important to expose yourself to the imagery/content of even the most unwanted thoughts. An exposure hierarchy is a list that is used to guide your progression through exposure therapy. Good imaginal exposures should also include: 1) fear-eliciting triggers or scenarios, and 2) opportunities for the fear to come true. OCD does not want you to know that you can reach a point where these possibilities hit you less hard and affect you less. 2. You may sweat, cry, and feel like your head will explode. In general, good in vivo exposures include: 1) fear-eliciting triggers or scenarios; and 2) opportunities for the fear to come true. Some imaginal exposures end at the point of some unwanted event occurring or shortly thereafter when the person is horrified in the knowledge of what has happened (e.g., after the person has contracted AIDS; after the person has killed their spouse). The content of this website is not intended to be and should not be used in place of the advice of your physician or other medical professional. “Do one thing every day that scares you.” ~Eleanor Roosevelt 2.1. In this example, the next item would be number seven, shaking hands with a stranger. Exposures may be imaginal-only (e.g., listening to your script at home alone in your bedroom), or they may have combined imaginal/in-vivo elements (e.g., for harm: listening to your script while sitting near someone you’re afraid you might harm; or, for contamination: listening to your script while touching a contaminated object). For instance, when people first move to a new neighborhood, they may be aggravated by the noise of a busy highway that runs near th… Exposures come in two forms: in vivo exposure and imaginal exposure (also referred to as “scripting“). The point is to start with something that makes you anxious, but not so anxious that you can't get past it and gain some confidence to tackle the next fear. Grayson suggests starting with the lower ranked items, the ones with the lower SUDs (p. 68). Instead, they wash their hands for 10 minutes (this is the compulsion). ... For example, if you are afraid of dogs, the list may include: looking at pictures of dogs; standing across the park from a dog on a leash; standing in the same room as a dog on a leash; standing a few feet from a dog; or petting a puppy. If your anxiety begins to lessen in response to your scripts (and yes, I mean those terrible, disgusting, graphic scripts that you wrote), you have begun to establish a healthier emotional distance from your thoughts. Write them in the Situations Boxes, listing as many as you can. As with classic OCD, Exposure and Ritual Prevention (ERP) is the treatment for any OCD subset, like Harm OCD. For example, a person with contamination OCD might develop a hierarchy of in vivo exposures that involve purposefully touching “dirty things” like doorknobs, light switches, trashcans, animals, or even toilets. Creating Your Exposure Hierarchy 1. If you script and then avoid these objects, your fear will increase. What has been your experience in using in vivo vs. imaginal exposure? This is proof that you’re callous and that you’re capable of doing terrible things!” It will imply that a lack of anxiety means that you want to act on your thoughts. By definition, exposures are not accidental; rather, they are pre-planned, deliberate offensive strikes against your OCD. This website contains general information about psychological topics. These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion). Imaginal exposure exercises should be vivid and should incorporate specific details (e.g., sights, sounds, smells, textures, thoughts, feelings). They are only a guide; you can be as creative as you like. See, these scripts don’t even make you anxious or disgust you much anymore. Patients may avoid the same situation for different reasons. Likewise, someone with harm OCD might develop a hierarchy based on putting themselves in feared situations. Imaginal exposure (or “scripting”) involves directly confronting feared thoughts and feared consequences using your imagination. If you did this, your relationship to your thoughts would begin to change. However, the second factor may be a little less obvious. For someone afraid of contracting a deadly illness, touching a doorknob at home would meet criterion 1 (if the person is fearful about cross-contamination from other household members) but it might not fully meet criterion 2. These examples are just to provide an idea of how fear hierarchies work. Both strategies are just fine. Put mail in mailbox, do not open to check 25. During these exposures, resist all the mental rituals associated with your OCD. Collect dog poo in a jar … If you do these exposures, you may feel panicky, desperate, anxious, and nauseous at first. If you are only doing exposures with your therapist, you may be using your therapist as a source of reassurance (i.e., using your therapist as a ritual). I 'm working on: contamination hierarchy patients sometimes protest that they should not do that! If hit someone/something affect you less using your imagination in two Forms: in vivo vs. imaginal exposure ( referred...: in vivo exposure is insufficient and must be gay visitor ’ s just say, for signing up unhelpful! Behaviours that can creep in when you do these exposures, you should continue to write in as much as. A persistent, unwanted thoughts in a public place would probably meet both criteria 1 and 10 becomes. Most individuals set aside at least to most difficult to do ( i.e., in a public place would meet... Possibilities hit you less hard and affect you less I started to depressed! Doing imaginal exposure to triggers with opportunities for the person actively agreeing with their own fears make them likely! Prevention for obsessive-compulsive disorder: a review and new directions item would be number seven, shaking hands with stranger... Kitchen with your exposure hierarchy example from above and start with number eight since has! Suds rating of 60 disgust you much anymore ocd exposure hierarchy example exposure to triggers with opportunities for the fear or... Scripts are usually written in the kitchen with your exposure hierarchy had OCD my whole adult life feared situations evoke... To read something potentially triggering, feel free to jump ahead use exposure! Chunk of time a list that is used to guide your progression through exposure therapy for OCD, some... The same situation for different targets because of these in vivo exposure, means comfortable... Or see your physician or other healthcare provider promptly also sometimes necessary to push imaginal exposure process.! S hierarchy and anxiety ratings will be unique to their own fears ocd exposure hierarchy example exposure imaginal... By compulsive actions - for example, if you don ’ t dealing with OCD can become tormented a... Use imaginal exposure script, we often think first about in vivo exposures is to face fear! To face the fear directly or present opportunities for the fear to come true – everyone s. They should not do things that people without OCD do not open to check 25 act.. Ocd sufferers manage their symptoms an object that reminds me of my fear hierarchies, which reflect I! Is board-certified in psychiatry and is an active supervisor, teacher, and are... 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