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 Table of Contents  
Year : 2022  |  Volume : 38  |  Issue : 2  |  Page : 201-204

Brief flooding with exposure and response prevention In vivo in OCD

Department of Psychiatry, GMCH, Chandigarh, India

Date of Submission02-Apr-2020
Date of Decision01-May-2020
Date of Acceptance22-Jul-2020
Date of Web Publication08-Sep-2021

Correspondence Address:
Dr. Ira Domun
Department of Psychiatry GMCH, Sector 32, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_57_20

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Obsessive–compulsive disorder (OCD) is a commonly encountered psychiatric illness. Cognitive behavior therapy (CBT)/exposure and response prevention (ERP) is first-line treatment option for OCD. When facilities are available, CBT/ERP monotherapy may be recommended in mild to moderately ill patients. However, in severely ill patients, the management comprising CBT and pharmacotherapy is more efficacious than single treatment alone. Behaviorists practicing ERP recommend that exposure in real-life situations (vivo) is more effective than in imaginative situations (vitro). Here, we present a case of a middle-aged female with obsessions regarding contamination by menstrual blood and compulsions of checking and cleaning, causing marked sociooccupational deficit. The index patient who was suffering from debilitating form of OCD failed to respond to pharmacotherapy alone and later with combination of pharmacotherapy; brief in vivo flooding and ERP in vitro responded well; which is sustained at 6 months' follow-up.

Keywords: Brief flooding, erp, in-vivo, menstrual blood, ocd

How to cite this article:
Chavan BS, Domun I, Machal V. Brief flooding with exposure and response prevention In vivo in OCD. Indian J Soc Psychiatry 2022;38:201-4

How to cite this URL:
Chavan BS, Domun I, Machal V. Brief flooding with exposure and response prevention In vivo in OCD. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Aug 9];38:201-4. Available from: https://www.indjsp.org/text.asp?2022/38/2/201/325756

  Introduction Top

Obsessive–compulsive disorder (OCD) is a commonly encountered psychiatric illness with lifetime prevalence of 2.3%.[1],[2] OCD is associated with significant dysfunction and reduced quality of life.[3] Until the mid-20th century, OCD was considered to be untreatable, as both psychotherapy and medication had failed in reducing symptoms. Major innovation in management came in 1966 with the introduction of exposure and response prevention (ERP).[4] If untreated, OCD becomes a chronic illness with a waxing and waning course. Early diagnosis and appropriate treatment improve outcome.[5] Those who suffer from OCD tend to be cryptic about their symptoms which they fear to share. Less than a third of OCD patients receive appropriate and adequate pharmacotherapy and even much less receive evidence-based psychotherapy.[6] Consistently, Cognitive behavior therapy (CBT) and ERP have proven to be effective in the treatment of OCD.[4],[7] CBT/ERP is a first-line treatment option for OCD.

In severely ill patients, a combination of CBT and selective serotonin reuptake inhibitors is more efficacious than single arm management.[3],[8] Interventions to eliminate fear use conditioning principles, and elimination of maladaptive fears requires exposure (contact) with the feared object, event, or scenario, in some cases, it is difficult to produce real-life situations, this is when imaginative techniques come handy. Graduated procedures (i.e., desensitization or ERP alone) use hierarchical approach to exposure. However, both are different as desensitization is based on the principles of reciprocal inhibition, and ERP is based on the principles of extinction. Whereas flooding with ERP involves immediately exposing the patient to the most feared stimulus along with response prevention. Graduated approach may reduce patient dropout rate, noncompliance, and resistance faced. However, flooding achieves faster results, reducing distress under a quicker period.

The behaviorists practicing ERP recommend that exposure in real-life situations (vivo) is more effective than in imaginative situations (vitro). However, it may not always be possible to expose a person into real-life situations because the feared situations may be very personal to the person and also these might be specific to the place of living and working.[9]

Here, we present a case of a middle-aged female with obsessions regarding contamination by menstrual blood and compulsions of checking and cleaning, causing marked socio-occupational deficit. The treating team initially spent lot of time using ERP to create a feared situation as best as possible. However, the patient did not show any improvement. Since patient was staying 100 km away from the treating center, it was not possible to take her to the place of her residence and the school where she was working. However, when the pharmacotherapy and ERP in vitro did not work, it was decided to take her to the place of working and do brief flooding with ERP in vivo. The treating team was excited to see the degree of improvement with brief exposure in real-life situation.

  Case Top

Mrs. P/39-year-old married female, postgraduate, working as a laboratory teacher in a primary school belonging to Hindu extended family of LMSES. The patient presented with 3 years' history OCD. The illness had insidious onset, continuous course, and multiple precipitating factors (death of father; loss of job; separation from in-laws). Illness began when patient would remain worried and began to have recurrent; intrusive; distressing thoughts that her hands are contaminated with dirt. Without any treatment, the patient recovered from sadness and anxiety within 3–4 months However, the thoughts of contamination continued, and gradually patient began to modify her lifestyle to accommodate her excessive handwashing, ritualistic bathing, washing of clothes in a specific manner. The patient sought treatment from a tertiary care center in May, 2017, and was started on Tab Fluoxetine, dose optimized up to 60 mg and concurrent behavior therapy (BT) (ERP). However, maximum improvement was 20% in a span of 7 months, with irregular follow-ups. The patient was subsequently lost to follow-up. For next 1.5 years, the patient made few visits and compliance to pharmacotherapy was also irregular.

Around 9 months back, when the patient was at work, her periods started 10 days before due date and she had spotting in her clothes while sitting on a couch in the staff room. On reaching home, she thought of the spotting and this thought led to immense anxiety and patient instantly began to trace back all her activities of the day, i.e., she sat on a specific couch, she ate lunch, shook hands with colleagues/students. The thought that she has contaminated the washroom, furniture in the class room and staff room, the females colleagues, the students and all the other places which she had touched made her fearful and guilty.

After this incident in the school, the patient started having same fear at home also. She stopped touching her husband and children would not go to the kitchen and requested her sister-in-law to cook and wash her clothes, would spend lot of time in the bathroom. After entering the bathroom, she would clean the bucket, the soap, the mug, taps many times before taking bath, or use a hose-pipe. Even after spending 60–90 min in the bathroom, she would still continue to get the thoughts of contamination. Whatever article she would touch, she would wash it many times. With these symptoms, she had to make several changes in her daily routine to accommodate her obsessions and compulsions. She began to wake up at 3:30 am. Patient reduced drinking of water (<500 ml/day) so as to avoid going to the washroom, she would not eat lunch at work place as she would think that at least one of her colleagues must be menstruating and must has contaminated, and must have used the taps of the wash-basin of the staff room. Patient would never use school washrooms and on two occasions when she was unable to control her urine, she had to go home during work hours due to excessive bladder pressure. The symptoms would be present irrespective of her menstrual cycle phases. Her family members would ask her to seek treatment as it was causing distress to patient and family.

With these symptoms, the patient was admitted to start her on flooding with ERP along with pharmacotherapy.

At baseline, her Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) score was 39, putting her in extreme severity of OCD. Her WHOQOL BREF domain wise score at baseline was 25 in physical domain, 19 in psychological domain, 6 in social relationship domain, and 75 in environmental domain, depicting deficits in the first three domains. It was decided to start flooding with ERP from the highest anxiety provoking situation along with therapeutic management of Tablet fluoxetine 20 mg. Since the maximum fear was with the thoughts of contamination with menstrual blood, it was decided to start exposure with fear of contamination with menstrual blood. In order to create an identical situation, it was decided to use young patients as volunteers. These volunteers were told to go and sit with the patient and telling the patient that they are having menses. However, patient did not report much anxiety as she was able to rationalize that they must be telling a lie. Later, another session of flooding was planned, it was decided to use red ink and touch tap, her chair and hanger in the washroom with red ink and patient was told that one of the mentally ill patients has spoilt these articles with her menstrual blood. The patient was made to touch these articles, although there was initial hesitation, but she could touch these without much anxiety. She again convinced herself that the red color was not menstrual blood and it was red ink. When these two strategies did not work, it was decided by the treating team to buy sanitary pads and put red color on these pads in order to give a feel that these were used pads and were stained with menstrual blood. However, in this third trial of flooding, again the purpose could not be served and patient said that the stains on the pad were not menstrual blood. Tablet fluoxetine was increased to 60 mg in 2 weeks. Since the patient was already in the ward for several days and nothing was working, there was lot of pressure on the treating team. As an alternate option, sessions of implosive therapy (in which patient was asked to imagine that she was either at home or in school and she is menstruating and she had stained certain articles) was given. This evoked extreme distress and also gagging was noticed. Patient also began to cry. After three sessions of implosion, patient reported mild improvement. However, she started saying that she would face same symptoms once she goes back to her work place. The treating team reviewed her progress and it was felt that unless flooding with ERP is conducted in the real-life situation, patient may not show expected improvement.

Therefore, it was decided to depute the therapist to carry out in vivo flooding with ERP at her home and work place at least for 10 h (6.00 am to 4.00 pm). Separate informed consent was taken from patient regarding prolonged and intensive therapy in hospital, home and work place, since the patient was comfortable as she had informed the therapist that her staff and neighborhood knew about the illness, and were supportive, therapist went ahead. For this purpose one final year resident who was part of the treating team was deputed to conduct therapy at her home (6:00-am–8.00 am and 2.00–4.00 pm) and at her school (8.00–2.00 pm). As per the plan, continuous in-vivo flooding with ERP was done for 10 h. Patient was made to follow the same routine which she was following before the onset of illness. She was made to do all the activities within a stipulated period and not letting her to avoid and/or repeat it. Patient cooked food for the family, took bath in 15 min, reached school in time and was made to take class, sit in the staff room and eat her lunch with other staff members (ERP). She was also made to use the washroom and shake hands with other staff and students. Later, the patient was asked to give a lecture on menstrual hygiene to female students using real sanitary pads. She was made to shake hands with menstruating females (flooding) and not allowed to wash her hands (RP). Post this home based flooding session, patient reported 50% improvement, however quantitatively the improvement was 70%. This was the maximum improvement ever reported by the patient. Patient came back to the hospital on the same evening. Over the next 3 days, patient reported that she is more than 60% better and the degree of improvement on Y-BOCS was around 75%.WHOQOL BREF was re-applied and came out to be was 88 in physical domain, 88 in psychological domain, 81 in social relationship domain and 100 in environmental domain, showing significant improvement in all domains. She was discharged on 60 mg fluoxetine and was asked to visit after 7 days. On follow-up after 7 days, patient continued to show sustained improvement, and she reported that she is much better as she has been able to carry out all her routine activities without much anxiety and avoidance. With regular follow-ups till 6 months patient is still maintaining improvement. Patient is able to do household chores on time, is able to be satisfied in bathing within 15–20 min. Patient also has lunch and interacts well with staff and students.

  Discussion Top

There is a good research evidence that the combination of BT and pharmacotherapy is more effective than either alone.[10] Controlled trials have also reported greater efficacy with combined treatment.[11],[12] Among various BT techniques, flooding with ERP is the best proven BT technique.

Thus, in the present patient, it was decided to start flooding with ERP along with ongoing pharmacotherapy (fluoxetine 60 mg/day). Since, maximum distress was associated with contamination of menstrual blood leading to avoidance, it was decided to start flooding with ERP on maximum anxiety provoking situation. Although the distress and avoidance was associated with certain objects, persons and situations at home and in the school, the treating team tried to create similar situations (in vitro exposure) within the hospital setting using red ink and sanitary pads and asking patient to touch and use articles which were stained with red ink without her knowledge. However, even after 2 weeks of intensive therapy, there was no improvement. At this stage, it was planned to use flooding with ERP in vivo and for this purpose one therapist was allowed to conduct 10 h flooding with ERP at her home and her school. The 10 h intensive flooding with ERP in the real-life situations surprisingly led to excellent improvement as per patient's self-report as well as Y-BOCS score which decreased from 39 to 10 at discharge. This improvement is sustained even during follow-up at 6 months. At the last follow-up, patient's Y-BOCS score was 8.

Techniques such as imaginal exposure, exposure in vivo, home visits for therapy conduction have shown to be effective in patients in literature also.[12] A case, is reported in which a patient with severe OCD underwent complete remission following a single, massive, involuntary exposure to avoided stimuli.[4]

Although NICE guidelines as well as other research have shown flooding as an effective treatment for OCD, there are no guidelines regarding the duration of treatment. In order to increase patient's acceptance and minimize drop-out, many clinicians practice ERP where exposure is started from the minimum distressing situation. However, there is research evidence that flooding may be required in many cases for eliminating compulsions.[7] In the literature, we did not find any research article or case report on brief flooding with ERP leading to such an excellent and sustained improvement. Although there is research evidence that ERP in vivo is more effective than ERP in vitro and the improvement with vivo ERP is sustained at follow-up.[13] Thus, many behaviorists prefer flooding with ERP in vivo. Although flooding with ERP cannot be used in patients who don't have any rituals and also it may not be always be feasible to have vivo exposure.

  Conclusion Top

Brief flooding in vivo along with ERP has led to rapid and sustained results in index patient. Hence the authors would like to recommend tailormade approach for each patient and as close as possible to reality/in-vivo psychotherapeutic approach should be adopted to achieve success in patients with such disabling illness.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. Separate informed consent was taken from patient regarding prolonged and intensive therapy in hospital, home and work place. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and their clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Janardhan Reddy YC, Sundar AS, Narayanaswamy JC, Math SB. Clinical practice guidelines for Obsessive-Compulsive Disorder. Indian J Psychiatry 2017;59:S74-90.  Back to cited text no. 3
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Skapinakis P, Caldwell D, Hollingworth W, Bryden P, Fineberg N, Salkovskis P, et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive-compulsive disorder in children/adolescents and adults. Health Technology Assessment 2016;20:1-392.  Back to cited text no. 5
Manjula M, Sudhir PM. New-wave behavioral therapies in obsessive-compulsive disorder: Moving toward integrated behavioral therapies. Indian J Psychiatry 2019;61:S104-13.  Back to cited text no. 6
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