Exposure therapy

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Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders. It involves the exposure of the patient to the feared object or context without any danger, in order to overcome their anxiety.[1][2] Procedurally it is similar to the fear extinction paradigm in rodent work.[3][4] Numerous studies have demonstrated its effectiveness in the treatment of anxiety disorders such as PTSD and specific phobias.[5]

Exposure-based therapy may be effective in preventing the progression from acute stress disorder to post-traumatic stress disorder, according to a report in the June 2008 issue of Archives of General Psychiatry.[6]

It is also very closely related to exposure and response prevention, a method widely used for the treatment of obsessive–compulsive disorder.

Background

The use of exposure as a mode of therapy began in the 1950s during the behavior therapy movement, a time when the psychoanalytic view dominated Western psychology and behavioral therapists first emerged. South African psychologists and psychiatrists, who brought their methods to England and the Maudsley Hospital training program, first used exposure as a mode of therapy to reduce pathological fears, such as phobias and anxiety-related problems.[7]

One of the first psychologists to spark interest in resolving clinical problems from a behavioral point of view, Joseph Wolpe (1915–1997) sought consultation with other behavioral psychologists similar in methodology. James G. Taylor (1897–1973), working in the psychology department of the University of Cape Town in South Africa, was among the psychologists Wolpe sought discussion with. Although most of his work went unpublished, Taylor was the first recorded psychologist to use an exposure therapy treatment for anxiety, including methods of situational exposure with response prevention—a common exposure therapy technique still being utilized.[7] Since the 1950s and the behavior therapy movement, several modes of exposure therapy have proliferated, including systematic desensitization, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.[7]

Techniques

Exposure therapy is based on the principles of respondent conditioning often termed Pavlovian extinction.[8] The exposure therapist identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus, and attempts to break the pattern of escape that strengthens the fear response, through measured exposure to progressively stronger stimuli until habituation is reached.[9] The technique involves the creation of a program of steadily escalating steps or challenges (a hierarchy), which can be explicit ("static") or implicit ("dynamic" — see Method of Factors), that work towards a final goal representing a "non-phobic" response.[10] The patient then voluntarily moves through the steps, with a means of terminating each step which is under voluntary control.

While therapeutic exposure has a strong evidence base, some clinicians are uncomfortable using Imaginal Exposure therapy, specifically in cases of PTSD, because they do not understand it or are not confident in their own ability to utilize it, or more commonly, see significant contraindications for their client.[11][12]

Exposure and flooding differ in that flooding starts at the most extreme item in a fear hierarchy, while exposure does not.[13][14]

The exposure procedures are divided into three types. The first is in vivo or “real life.” This type of procedure uses a direct approach with activities in different situations. For example, if someone fears public speaking the person may be asked to give a speech to a small group of people just to channel that fear directly. 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 of different types of exposure can be used together or they can be used separately.[15]

Common 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, 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.[16]

Specific Phobias

Exposure based therapies have also been found to be successful in treating specific phobias and are the most validated treatment known for phobias.[17] Several published meta-analyses observed the success of a single-session of exposure therapy—specifically imaginal exposure, a one to three hour treatment session—in treating patients with specific phobias. Four years later at the post-treatment follow-up, 90% of patients retained a considerable reduction in fear, avoidance, and overall level of impairment, while 65% no longer experienced any symptoms of a specific phobia.[18]

For example, one disorder treated using exposure therapy is agoraphobia. Agoraphobia is a disorder of overwhelming anxiety that makes someone avoid situations that may cause him or her to panic, such as being alone, leaving the home, avoiding feeling trapped or being embarrassed or helpless. This disorder is a problem because it can be very debilitating to be so anxious that you do not want to leave your house or you don’t want to be alone. Additionally, patients are overly concerned about the social consequences of showing anxiety symptoms in public. They are afraid of losing control in front of everyone.[19]

Post-Traumatic Stress Disorder

A type of exposure therapy has recently found efficacy in treating disorders extending further into the anxiety spectrum. Virtual reality exposure (VRE) therapy is a modern but effective treatment of posttraumatic stress disorder (PTSD), and has been tested on several active duty Army soldiers using an immersive computer simulation of military settings over six sessions. Self-reported PTSD symptoms of the active duty Army soldiers were greatly diminished compared to pretreatment reports, thus advocating exposure therapy's effectiveness in reducing PTSD.[20] Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.[21]

Organizations

Exposure therapy is a behavior therapy technique. Many organizations exist for behavior therapists around the world. The Association for Behavior Analysis International (ABA) offers a certification in behavior therapy . This certification allows for the demonstration of knowledge regarding exposure therapy.

See also

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. 
  3. ↑ Marks, I. (1979). "Exposure therapy for phobias and obsessive-compulsive disorders". Hosp Pract 14 (2): 101–8. 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. 
  6. ↑ Newswise: Exposure Therapy May Help Prevent Post-Traumatic Stress Disorder
  7. ↑ 7.0 7.1 7.2 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. 
  8. ↑ Marks, Isaac Meyer (1981). Cure and care of neuroses: theory and practice of behavioral psychotherapy. New York: Wiley. ISBN 0-471-08808-0. 
  9. ↑ 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. 
  10. ↑ Miltenberger, R. G. “Behavioral Modification: Principles and Procedures”. Thomson/Wadsworth, 2008. p. 552.
  11. ↑ C. Becker, C. Zayfert, E. Anderson. "A Survey of Psychologists' Attitudes Towards and Utilization of Exposure Therapy for PTSD". Digital Commons @ Trinity. Retrieved 13 June 2011. 
  12. ↑ 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. PMC 3337146. PMID 22545029. 
  13. ↑ 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. 
  14. ↑ Cobb, J. (1983). "Behaviour therapy in phobic and obsessional disorders". Psychiatr Dev 1 (4): 351–65. PMID 6144099. 
  15. ↑ Foa, E. B. (2011). Prolonged exposure therapy: present, and future. Depression and Anxiety, 28, 1034-1047.
  16. ↑ 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. 
  17. ↑ 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. 
  18. ↑ Kaplan, J. S.; PhD; PhD; Tolin, D. F. (2011). "Exposure therapy for anxiety disorders: Theoretical mechanisms of exposure and treatment strategies". Psychiatric Times 28 (9): 33–37. 
  19. ↑ Vogele, C., Ehlers, A., Meyer, H. A., Frank, M., Hahlweg, K., & Margraf, J. (2010).Cognitive mediation of clinical improvement after intensive exposure therapy Of agoraphobia and social phobia. Depression and Anxiety, 27, 294-301
  20. ↑ 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. 
  21. ↑ Baschnagel, J.S.; Coffey, S.F.; Rash, C.J. (2006). "The Treatment of Co-Occurring PTSD and Substance Use Disorders Using Trauma-Focused Exposure Therapy" (PDF). IJBCT 2 (4): 498–508. 
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