Exposure therapy

Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the target patient to the anxiety source or its context without the intention to cause any danger. Doing so is thought to help them overcome their anxiety or distress.[1][2] Procedurally, it is similar to the fear extinction paradigm developed for studying laboratory rodents.[3][4] Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder,[5] post-traumatic stress disorder (PTSD), and specific phobias.[6]

Medical uses

Generalized anxiety disorder

There is empirical evidence that exposure therapy can be an effective treatment for people with generalized anxiety disorder, citing specifically in vivo exposure therapy, (exposure through a real life situation),[7] which has greater effectiveness than imaginal exposure in regards to generalized anxiety disorder. The aim of in vivo exposure treatment is to promote emotional regulation using systematic and controlled therapeutic exposure to traumatic stimuli.[8] Exposure therapy is also a preferred method for children who struggle with anxiety.[9]

Phobia

Exposure therapy is the most successful known treatment for phobias.[10] Several published meta-analyses included studies of one-to-three hour single-session treatments of phobias, using imaginal exposure. At a post-treatment follow-up four years later 90% of people retained a considerable reduction in fear, avoidance, and overall level of impairment, while 65% no longer experienced any symptoms of a specific phobia.[11]

Agoraphobia and social anxiety disorder are examples of phobias that have been successfully treated by exposure therapy.[12]

Post-traumatic stress disorder

Exposure therapy in PTSD involves exposing the patient to PTSD-anxiety triggering stimuli, with the aim of weakening the neural connections between triggers and trauma memories (aka desensitisation). Exposure may involve:[13]

Forms include:

  • Flooding – exposing the patient directly to a triggering stimulus, while simultaneously making them not feel afraid.
  • Systematic desensitisation (aka "graduated exposure") – gradually exposing the patient to increasingly vivid experiences that are related to the trauma, but do not trigger post-traumatic stress.
  • Narrative exposure therapy - creates a written account of the traumatic experiences of a patient or group of patients, in a way that serves to recapture their self-respect and acknowledges their value. Under this name it is used mainly with refugees, in groups.[14] It also forms an important part of cognitive processing therapy and is conditionally recommended for treatment of PTSD by the American Psychological Association.[14]
  • Prolonged exposure therapy (PE) - a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder, characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous (despite being objectively safe). Additional procedures include processing of the trauma memory and breathing retraining. The American Psychological Association strongly recommends PE as a first-line psychotherapy treatment for PTSD.[15]

Researchers began experimenting with Virtual reality exposure (VRE) therapy in PTSD exposure therapy in 1997 with the advent of the "Virtual Vietnam" scenario. Virtual Vietnam was used as a graduated exposure therapy treatment for Vietnam veterans meeting the qualification criteria for PTSD. A 50-year-old Caucasian male was the first veteran studied. The preliminary results concluded improvement post-treatment across all measures of PTSD and maintenance of the gains at the six-month follow up. Subsequent open clinical trial of Virtual Vietnam using 16 veterans, showed a reduction in PTSD symptoms.[16]

This method was also tested on several active duty Army soldiers, using an immersive computer simulation of military settings over six sessions. Self-reported PTSD symptoms of these soldiers were greatly diminished following the treatment.[17] Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.

Obsessive compulsive disorder

Exposure and response prevention (also known as exposure and ritual prevention; ERP or EX/RP) is a variant of exposure therapy that is recommended by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the Mayo Clinic as first-line treatment of obsessive compulsive disorder (OCD) citing that it has the richest empirical support for both youth and adolescent outcomes.[18][19]

ERP is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears, but refrain from engaging in the escape response or ritual that delays or eliminates distress.[20] In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviors that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus.[21] The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behavior that functions to decrease distress. The patient is then taught to tolerate distress until it fades away on its own, thereby learning that rituals are not always necessary to decrease distress or anxiety. Over repeated practice of ERP, patients with OCD expect to find that they can have obsessive thoughts and images but not have the need to engage in compulsive rituals to decrease distress.[18][19]

The AACAP's practice parameters for OCD recommends cognitive behavioral therapy, and more specifically ERP, as first line treatment for youth with mild to moderate severity OCD and combination psychotherapy and pharmacotherapy for severe OCD.[19] The Cochrane Review's examinations of different randomized control trials echoes repeated findings of the superiority of ERP over waitlist control or pill-placebos, the superiority of combination ERP and pharmacotherapy, but similar effect sizes of efficacy between ERP or pharmacotherapy alone.[22]

Techniques

Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction.[23] The exposure therapist identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus and then tries to break the pattern of escape that maintains the fear. This is done by exposing the patient to progressively stronger fear-inducing stimuli.[24] Fear is minimized at each of a series of steadily escalating steps or challenges (a hierarchy), which can be explicit ("static") or implicit ("dynamic" — see Method of Factors) until the fear is finally gone.[25] The patient is able to terminate the procedure at any time.

There are three types of exposure procedures. The first is in vivo or "real life."[26] This type exposes the patient to actual fear-inducing situations. For example, if someone fears public speaking, the person may be asked to give a speech to a small group of people. The second type of exposure is imaginal, where patients are asked to imagine a situation that they are afraid of. This procedure is helpful for people who need to confront feared thoughts and memories. The third type of exposure is interoceptive, which may be used for more specific disorders such as panic or post-traumatic stress disorder. Patients confront feared bodily symptoms such as increased heart rate and shortness of breath. All types of exposure may be used together or separately.[27]

While evidence clearly supports the effectiveness of exposure therapy, some clinicians are uncomfortable using imaginal exposure therapy, especially in cases of PTSD. They may not understand it, are not confident in their own ability to use it, or more commonly, they see significant contraindications for their client.[28][29]

Flooding therapy also exposes the patient to feared stimuli, but it is quite distinct in that flooding starts at the most feared item in a fear hierarchy, while exposure starts at the least fear-inducing.[30][31]

Exposure and response prevention

In the exposure and response prevention (ERP or EX/RP) variation of exposure therapy, the resolution to refrain from the escape response is to be maintained at all times and not just during specific practice sessions.[32] Thus, not only does the subject experience habituation to the feared stimulus, but they also practice a fear-incompatible behavioral response to the stimulus. The distinctive feature is that individuals confront their fears and discontinue their escape response.[33] The American Psychiatric Association recommends ERP for the treatment of OCD, citing that ERP has the richest empirical support.[34]

While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms.[35][36]: 103  Generally, ERP incorporates a relapse prevention plan toward the end of the course of therapy.[32]

History

The use of exposure as a mode of therapy began in the 1950s, at a time when psychodynamic views dominated Western clinical practice and behavioral therapy was first emerging. South African psychologists and psychiatrists first used exposure as a way to reduce pathological fears, such as phobias and anxiety-related problems, and they brought their methods to England in the Maudsley Hospital training program.[37]

Joseph Wolpe (1915–1997) was one of the first psychiatrists to spark interest in treating psychiatric problems as behavioral issues. He sought consultation with other behavioral psychologists, among them James G. Taylor (1897–1973), who worked in the psychology department of the University of Cape Town in South Africa. Although most of his work went unpublished, Taylor was the first psychologist known to use exposure therapy treatment for anxiety, including methods of situational exposure with response prevention—a common exposure therapy technique still being used.[37] Since the 1950s, several sorts of exposure therapy have been developed, including systematic desensitization, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.[37]

Mindfulness

A 2015 review pointed out parallels between exposure therapy and mindfulness, stating that mindful meditation "resembles an exposure situation because [mindfulness] practitioners 'turn towards their emotional experience', bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it."[38] Imaging studies have shown that the ventromedial prefrontal cortex, hippocampus, and the amygdala are all affected by exposure therapy; imaging studies have shown similar activity in these regions with mindfulness training.[38]

EMDR

Eye movement desensitization and reprocessing (EMDR) includes an element of exposure therapy (desensitization), though whether this is an effective method or not, is controversial.[39]

Research

Exposure therapy can be investigated in the laboratory using Pavlovian extinction paradigms. Using rodents such as rats or mice to study extinction allows for the investigation of underlying neurobiological mechanisms involved, as well as testing of pharmacological adjuncts to improve extinction learning.[40][41]

See also

  • Catharsis

Explanatory footnotes

  1. ↑ For example, a person with Panic Disorder may be told to run in place, causing their heart to race, so that they can see that this feeling is not dangerous).

References

  1. ↑ Myers & Davis 2007, pp. 141–2
  2. ↑ Joseph, J.S.; Gray, M.J. (2008). "Exposure Therapy for Posttraumatic Stress Disorder". Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention. 1 (4): 69–80. doi:10.1037/h0100457.
  3. ↑ Marks, I. (1979). "Exposure therapy for phobias and obsessive-compulsive disorders". Hosp Pract. 14 (2): 101–8. doi:10.1080/21548331.1979.11707486. PMID 34562.
  4. ↑ Myers, K.M.; Davis, M. (2007). "Mechanisms of Fear Extinction". Molecular Psychiatry. 12 (2): 120–50. doi:10.1038/sj.mp.4001939. PMID 17160066.
  5. ↑ Huppert; Roth (2003). "Treating Obsessive–Compulsive Disorder with Exposure and Response Prevention" (PDF). The Behavior Analyst Today. 4 (1): 66–70. doi:10.1037/h0100012. Archived from the original (PDF) on 2012-10-30. Retrieved 2013-01-12.
  6. ↑ Böhnlein, Joscha; Altegoer, Luisa; Muck, Nina Kristin; Roesmann, Kati; Redlich, Ronny; Dannlowski, Udo; Leehr, Elisabeth J. (January 2020). "Factors influencing the success of exposure therapy for specific phobia: A systematic review". Neuroscience & Biobehavioral Reviews. 108: 796–820. doi:10.1016/j.neubiorev.2019.12.009. PMID 31830494.
  7. ↑ "Exposure Therapy for Anxiety Disorders". Psychiatric Times. Retrieved 2021-09-21.
  8. ↑ Parsons, T.D.; Rizzo, A.A. (2008). "Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis". Journal of Behavior Therapy and Experimental Psychiatry. 39 (3): 250–261. doi:10.1016/j.jbtep.2007.07.007. PMID 17720136.
  9. ↑ Whiteside, Stephen P.H.; Deacon, Brett J.; Benito, Kristen; Stewart, Elyse (2016-05-01). "Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders". Journal of Anxiety Disorders. 40: 29–36. doi:10.1016/j.janxdis.2016.04.001. ISSN 0887-6185. PMC 4868775. PMID 27085463.
  10. ↑ Chambless, D.L.; Ollendick, T.H. (2001). "Empirically supported psychological interventions: Controversies and Evidence". Annual Review of Psychology. 52 (1): 685–716. doi:10.1146/annurev.psych.52.1.685. PMID 11148322.
  11. ↑ Kaplan, J. S.; Tolin, D. F. (2011). "Exposure therapy for anxiety disorders: Theoretical mechanisms of exposure and treatment strategies". Psychiatric Times. 28 (9): 33–37.
  12. ↑ Vögele, Claus; Ehlers, Anke; Meyer, Andrea H.; Frank, Monika; Hahlweg, Kurt; Margraf, Jürgen (2010). "Cognitive mediation of clinical improvement after intensive exposure therapy of agoraphobia and social phobia". Depression and Anxiety. 27 (3): 294–301. doi:10.1002/da.20651. PMID 20037922. S2CID 21915062.
  13. ↑ "What Is Exposure Therapy?".
  14. 1 2 "Narrative Exposure Therapy (NET)". American Psychological Association.
  15. ↑ Courtois CA, Sonis J, Brown LS, Cook J, Fairbank JA, Friedman M, Schulz P (2017). "Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults" (PDF). Washington, D.C.: American Psychological Association.
  16. ↑ Rizzo AA, Rothbaum BO, Graap K. Virtual reality applications for combat-related posttraumatic stress disorder. In: Figley CR, Nash WP, editors. Combat stress injury: Theory, research and management. New York: Routledge; 2007. pp. 420–425
  17. ↑ Reger, G.M.; Gahm, G.A. (2008). "Virtual reality exposure therapy for active duty soldiers". Journal of Clinical Psychology: In Session. 64 (8): 940–6. doi:10.1002/jclp.20512. PMID 18612993.
  18. 1 2 Koran, LM; Hanna, GL; Hollander, E; Nestadt, G; Simpson, HB; American Psychiatric, Association. (July 2007). "Practice guideline for the treatment of patients with obsessive-compulsive disorder" (PDF). The American Journal of Psychiatry. 164 (7 Suppl): 5–53. PMID 17849776.
  19. 1 2 3 Geller, Daniel A.; March, John (January 2012). "Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder". Journal of the American Academy of Child and Adolescent Psychiatry. 51 (1): 98–113. doi:10.1016/j.jaac.2011.09.019. PMID 22176943.
  20. ↑ Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781609180171.
  21. ↑ "Exposure Therapy for Anxiety Disorders". Psychiatric Times. Retrieved 2021-09-22.
  22. ↑ O'Kearney, RT; Anstey, K; von Sanden, C; Hunt, A (2006). "Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents". Cochrane Database of Systematic Reviews. 2006 (4): CD004856. doi:10.1002/14651858.CD004856.pub2. hdl:1885/50872. PMID 17054218.
  23. ↑ Marks, Isaac Meyer (1981). Cure and care of neuroses: theory and practice of behavioral psychotherapy. New York: Wiley. ISBN 978-0-471-08808-0.
  24. ↑ De Silva, P.; Rachman, S. (1981). "Is exposure a necessary condition for fear-reduction?". Behav Res Ther. 19 (3): 227–32. doi:10.1016/0005-7967(81)90006-1. PMID 6117277.
  25. ↑ Miltenberger, R. G. "Behavioral Modification: Principles and Procedures". Thomson/Wadsworth, 2008. p. 552.
  26. ↑ "Exposure Therapy for Anxiety Disorders". Psychiatric Times. Retrieved 2021-09-22.
  27. ↑ Foa, E. B. (2011). "Prolonged exposure therapy: present, and future". Depression and Anxiety. 28 (12): 1043–1047. doi:10.1002/da.20907. PMID 22134957. S2CID 28115857.
  28. ↑ C. Becker; C. Zayfert; E. Anderson (2004). "A Survey of Psychologists' Attitudes Towards and Utilization of Exposure Therapy for PTSD". Behaviour Research and Therapy. Digital Commons @ Trinity. 42 (3): 277–92. doi:10.1016/S0005-7967(03)00138-4. PMID 14975770. Retrieved 13 June 2011.
  29. ↑ Jaeger, J.A.; Echiverri, A.; Zoellner, L.A.; Post, L.; Feeny, N.C. (2009). "Factors Associated with Choice of Exposure Therapy for PTSD" (PDF). International Journal of Behavioral Consultation and Therapy. 5 (2): 294–310. doi:10.1037/h0100890. PMC 3337146. PMID 22545029. Archived from the original (PDF) on 2013-02-26. Retrieved 2013-01-12.
  30. ↑ de Silva, P.; Rachman, S. (1983). "Exposure and fear-reduction". Behav Res Ther. 21 (2): 151–2. doi:10.1016/0005-7967(83)90160-2. PMID 6838470.
  31. ↑ Cobb, J. (1983). "Behaviour therapy in phobic and obsessional disorders". Psychiatr Dev. 1 (4): 351–65. PMID 6144099.
  32. 1 2 Hezel, Dianne M.; Simpson, H. Blair (January 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. ISSN 0019-5545. PMC 6343408. PMID 30745681.
  33. ↑ Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781609180171.
  34. ↑ Koran, LM; Hanna, GL; Hollander, E; Nestadt, G; Simpson, HB; American Psychiatric, Association. (July 2007). "Practice guideline for the treatment of patients with obsessive-compulsive disorder" (PDF). The American Journal of Psychiatry. 164 (7 Suppl): 5–53. PMID 17849776.
  35. ↑ "Ten Things You Need To Know To Overcome OCD". Beyond OCD. Retrieved 2020-08-17.
  36. ↑ Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 978-1-60918-017-1.
  37. 1 2 3 Abramowitz, Jonathan S.; Deacon, Brett Jason; Whiteside, Stephen P. H. (2010). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 978-1-60918-016-4.
  38. 1 2 Tang, YY; Hölzel, BK; Posner, MI (April 2015). "The neuroscience of mindfulness meditation". Nature Reviews. Neuroscience. 16 (4): 213–25. doi:10.1038/nrn3916. PMID 25783612. S2CID 54521922.
  39. ↑ "Eye Movement Desensitization and Reprocessing for Post-Traumatic Stress Disorder | Society of Clinical Psychology". www.div12.org. 6 March 2017.
  40. ↑ Singewald, N; Schmuckermair, C; Whittle, N; Holmes, A; Ressler, K.J. (2015). "Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders". Pharmacology & Therapeutics. 149: 150–190. doi:10.1016/j.pharmthera.2014.12.004. PMC 4380664. PMID 25550231.
  41. ↑ Milad, Mohammed R.; Quirk, Gregory J. (2011-11-30). "Fear Extinction as a Model for Translational Neuroscience: Ten Years of Progress". Annual Review of Psychology. 63 (1): 129–151. doi:10.1146/annurev.psych.121208.131631. ISSN 0066-4308. PMC 4942586. PMID 22129456.
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