Adapting and integrating exposure therapies for obsessive–compulsive disorder and posttraumatic stress disorder: Translating research into clinical implementation.

Abstract

Despite a growing literature on co-occurring obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), and the interesting etiological, phenotypic, and functional intersections of OCD and PTSD, formal treatment recommendations are lacking. Currently, no robust, controlled treatment outcomes research exists to inform clinician delivery of treatment for OCD and PTSD; however, extant research and theory may help guide assessment, case conceptualization, and treatment for these co-occurring conditions. This article translates extant research and theory into clinically useful, concrete, and accessible suggestions for case conceptualization and treatment adaptation and offers several case examples to further illustrate use of these approaches. In particular, this article reviews research and theory regarding differential diagnosis, connections between OCD and trauma, outcomes for OCD and PTSD exposure therapies, the purported theoretical underpinnings of these exposure-based treatments, reassurance seeking and intolerance of uncertainty, working with disgust during exposures, and treating stressful life events that may impact symptoms but do not meet the definition for trauma. Public Health Significance StatementExtant literature on differential diagnosis, OCD and trauma conceptualization, exposure therapy, intolerance of uncertainty and reassurance seeking, disgust, and stressful life events is reviewed, and findings are interpreted and synthesized into concrete, accessible treatment recommendations. Despite an absence of robust treatment outcomes research, existing literature can provide guidance for treating co-occurring OCD and PTSD with exposure therapy.

Disclosure of traumatic details and obsessive-compulsive contamination symptoms in sexual assault survivors.

“…If issues with habituation to imaginal and in vivo exposures arise, clinicians may consider employing other techniques to address disgust, such as utilizing an inhibitory learning approach (Craske et al, 2008), which focuses on learning to inhibit urges to engage in safety behaviors when experiencing disgust by repeatedly choosing to engage with other approach behaviors during repeated exposures in different contexts (Viar-Paxton & Olatunji, 2012). When eliciting subjective units of distress (SUDS) during imaginal exposure, clinicians may consider assessing SUDS related to both distress and disgust/contamination and use both measures as indicators of potential hot spots and treatment progress (Pinciotti, in press). Survivors may feel uncertain as to how long they will continue to feel contaminated during recall but through repeated recall with a supportive provider, they can build self-efficacy around tolerating contamination when it arises.…”

A commentary on “Adapting and integrating exposure therapies for obsessive–compulsive disorder and post-traumatic stress disorder: Translating research into clinical implementation”.

“…Much has already been written about the potential advantages of UP in terms of ease of dissemination and implementation, which we will not repeat here. Pinciotti's (2023) exclusive focus on PE and ExRP is well justified, as these are the two most well-researched treatments for PTSD and OCD. However, there is value in broadening our focus to consider other evidence-based approaches, such as the UP or process-based cognitive behavioral treatment approaches (Hayes & Hofmann, 2018) for treating comorbid OCD and PTSD.…”

“…The discussion of inhibitory learning theory in this article brings to focus the goals of exposure that are common across PE and ExRP, which is particularly useful for considering ways to integrating the two protocols. Pinciotti (2023) points out that ExRP emphasizes learning to tolerate uncertainty, whereas PE emphasizes improving safety discrimination. However, in both PE and ExRP, exposures can emphasize learning to tolerate uncertainty.…”

“…Trauma Is an Experience, Not a Treatment Target An important concern that Pinciotti (2023) addresses is the distinction between exposure to trauma and PTSD. Trauma has recently become a popular topic in social media, where it is presented as the singular answer to the etiological question of a broad range of personality traits and cognitive and behavioral patterns.…”

“…In cases where PTSD is absent, but the content of OCD obsessions is clearly related to a past trauma, Pinciotti (2023) suggests that providers consider incorporating aspects of PE. For instance, the therapist may encourage in vivo exposures to target trauma-related triggers for obsessions.…”