Enhancing readiness for exposure and response prevention in obsessive compulsive disorder: ketogenic metabolic therapy as a candidate readiness adjunct

Exposure and response prevention (ERP) remains a first-line psychological treatment for obsessive compulsive disorder (OCD), yet a clinically meaningful subset of patients cannot initiate, tolerate, or complete an adequate ERP dose even after step up in format, frequency, pharmacotherapy augmentation, or level of care. These failures are often interpreted as noncompliance, but they more often reflect a persistent capacity gap that limits between-session exposure practice and response prevention. This conceptual analysis positions ketogenic metabolic therapy (KMT) as a candidate adjunct when low capacity prevents delivery of an adequate ERP trial or persists after nonresponse. OCD evidence for KMT remains limited to case level reports that include standardized symptom measures and describe remission during nutritional ketosis, including one report in which KMT preceded successful ERP completion. These observations support a narrower clinical question that centers on capacity restoration rather than direct symptom treatment. ERP readiness is conceptualized across clinical, functional, and psychosocial domains that shape distress tolerance, cognitive efficiency, daily feasibility, and accommodation. Measurement-based care anchors decision points using adherence to between session exposure practice, completion of an adequate ERP dose, and established response and remission thresholds on validated symptom and global severity measures. Stepped care and staging checkpoints define pragmatic windows to test whether KMT increases ERP engagement, reduces refusal and drop out, and improves symptom severity and functioning beyond usual escalation alone.