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    Exposure and response prevention

    暴露与反应预防

    Therapy
    Also called
    ERP, EX/RP, exposure and ritual prevention, exposure with response prevention, exposure therapy for OCD

    What is exposure and response prevention (ERP)?

    Exposure and response prevention (ERP) is the first-line psychotherapy for obsessive-compulsive disorder (OCD): with a therapist, the person repeatedly faces situations that trigger obsessions, from easier to harder, without performing the compulsions that ease the anxiety.[1] UK NICE guidance includes it in the recommended treatment for adults at every level of severity.[2]

    The OCD cycle

    Negative reinforcement

    ERP breaks the cycle here

    How ERP proceeds

    Select a box or card for details.
    Schematic. At the top, the OCD cycle: obsessions bring anxiety, compulsions bring it down for a while, and the relief entrenches the ritual. Below, how ERP proceeds: assessment, an exposure ladder, graded exposure without rituals, a review afterward and practice between sessions. The ladder items and scores are illustrative only. Select a part for details. Select a part for details
    Schematic. At the top, the OCD cycle: obsessions bring anxiety, compulsions bring it down for a while, and the relief entrenches the ritual. Below, how ERP proceeds: assessment, an exposure ladder, graded exposure without rituals, a review afterward and practice between sessions. The ladder items and scores are illustrative only. Select a part for details. Save as image (PNG)

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    Key points

    • DSM-5 moved OCD out of the anxiety disorders.[4] Compulsions briefly relieve the anxiety obsessions cause, and that relief reinforces them, as in the avoidance cycle.[1]
    • Triggers are ranked by distress and faced step by step, in real life or in imagination.[1] For people without overt compulsions, NICE advises exposure to the obsessions while preventing mental rituals.[2]
    • On the inhibitory learning view, the aim is tolerating distress and uncertainty without rituals, not waiting for anxiety to fall; after each exposure, expectations are compared with what happened.[1]
    • In a meta-analysis of 36 randomized trials, ERP beat psychological placebo but not other active psychotherapies, and three quarters of the trials showed signs of researcher allegiance.[3]

    An example

    Jay goes back to check his door lock a dozen times before leaving. In therapy he starts low on his ladder: lock once, walk away, and don’t replay the locking in his head. The first few times he feels restless. Afterward he writes down that nothing happened at home and that he got through the unease.

    Misreadings and limits

    ERP is often pictured as forcing yourself to quit every ritual at once, something you can learn from an online guide. It is a graded treatment, and NICE expects those who deliver it to be trained and supervised.[2] Even so, 20–30% of people drop out and about half reach remission.[1] Whether symptoms amount to OCD also needs a professional assessment.

    Sources

    1. 1 Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian Journal of Psychiatry, 61(Suppl 1), S85–S92. doi:10.4103/psychiatry.IndianJPsychiatry_516_18
    2. 2 National Institute for Health and Care Excellence (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (CG31). NICE clinical guideline (presentational update May 2024). View source
    3. 3 Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., & Fineberg, N. A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Comprehensive Psychiatry, 106, 152223. doi:10.1016/j.comppsych.2021.152223
    4. 4 Fineberg, N. A., Apergis-Schoute, A. M., Vaghi, M. M., Banca, P., Gillan, C. M., Voon, V., Chamberlain, S. R., Cinosi, E., Reid, J., Shahper, S., Bullmore, E. T., Sahakian, B. J., & Robbins, T. W. (2018). Mapping compulsivity in the DSM-5 obsessive compulsive and related disorders: Cognitive domains, neural circuitry, and treatment. International Journal of Neuropsychopharmacology, 21(1), 42–58. doi:10.1093/ijnp/pyx088

    Last checked against sources: October 28, 2026