How to Deliver Concurrent ERP and PE for Comorbid OCD and PTSD
How should clinicians structure concurrent exposure and response prevention and prolonged exposure for adults with comorbid obsessive-compulsive disorder and posttraumatic stress disorder?
Adults with comorbid obsessive-compulsive disorder and posttraumatic stress disorder often have interacting symptoms that can make single-disorder treatment insufficient. This guide summarizes the concurrent video-therapy model used in Exposure-Based Video Therapy for Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder: Clinical Outcomes From a Large Real-World Sample of Adults for delivering both exposure-based treatments within one course of care.
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Confirm both diagnoses early in care
Establish obsessive-compulsive disorder and posttraumatic stress disorder diagnoses using the DIAMOND semistructured diagnostic interview during the initial intake session. In the study, DIAMOND completion occasionally extended into subsequent sessions, but baseline symptom measurement for both conditions had to occur within the first 2 sessions.
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Obtain baseline symptom measures for both disorders
Measure PTSD symptoms with the PCL-5 and OCD symptoms with the DOCS at baseline. The study defined valid baseline assessment as completion of both scales within the first 2 treatment sessions so that both symptom domains could be tracked during the same treatment episode.
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Ensure active treatment in both protocols
Provide at least 4 sessions of ERP and at least 4 sessions of PE if you are implementing this concurrent model. The article used this minimum because early sessions typically focus on assessment, psychoeducation, and hierarchy development, with active exposure beginning around session 4.
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Use one therapist across the full episode
Have the same therapist deliver both OCD- and PTSD-focused care across the treatment episode. In the study, all treatment was delivered by a single therapist who had training in both ERP and PE, allowing session focus to shift as symptoms interacted.
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Alternate the primary session focus based on current clinical need
Deliver ERP for OCD and PE for PTSD concurrently within the same treatment episode, choosing whether a given session is primarily OCD-focused or PTSD-focused according to the patient's clinical presentation. Therapists could still address both conditions within a single session when symptoms interacted, but the primary target alternated rather than treating one disorder to completion before starting the other.
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Match session frequency to the condition being prioritized
When OCD is the primary focus, the study's therapists recommended two 60-minute ERP sessions per week until clinically significant symptom reduction. When PTSD is the primary focus, they encouraged one 60-minute PE session per week until clinically significant symptom reduction; these frequencies were not additive, and the observed median overall pace was 1.1 sessions per week.
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Deliver therapy by video from private locations
Conduct sessions by therapist-delivered video, with both therapist and patient on camera throughout the session. In the study, patients joined from home or another private location using an internet-connected device, and all care was delivered through a HIPAA-compliant Zoom platform.
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Stay flexible when one disorder activates the other
Expect symptoms to interact and shift the session focus accordingly. The authors noted that response prevention for OCD could intensify traumatic memories and that clinicians often alternated between ERP and PE across sessions when compulsions also functioned to manage trauma-related distress.
Clinical Considerations
- This was an observational retrospective analysis, so the article does not prove that concurrent ERP and PE is superior to sequential or single-protocol treatment.
- No formal treatment fidelity checks such as session video reviews were conducted, although therapists had standardized training and biweekly consultation.
- The treatment model included additional supports such as therapist messaging, support groups, and online community access, and the independent effect of those components could not be separated.
- The sample included adults treated on a specialty teletherapy platform, so generalizability to other settings and populations is uncertain.
Bottom Line
For adults with comorbid obsessive-compulsive disorder and posttraumatic stress disorder, the article supports using one trained therapist to alternate ERP and PE within the same video-based treatment episode rather than treating the disorders sequentially.
