Exposure therapy

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Exposure therapy is a technique in behavior therapy used 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 and/or distress.[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 disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, PTSD, and specific phobias.[5]

Background[edit]

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.[6]

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 Although most of his work went unpublished, Taylor was the first psychologist known to use exposure therapy treatment for anxiety, including methods of situational exposure with response prevention—a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.[6] 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.[6]

Techniques[edit]

Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction.[7] 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.[8] 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.[9] 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.” 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.[10]

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.[11][12]

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.[13][14]

In the "exposure and response prevention" 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. Thus, not only does the subject experience habituation to the feared stimulus, they also practice a fear-incompatible behavioral response to the stimulus. While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms.[15]:103

Applications[edit]

Generalized anxiety disorder[edit]

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[edit]

Exposure therapy is the most successful known treatment for phobias.[17] 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 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]

Agoraphobia is an example of a phobia that has been successfully treated by exposure therapy. Agoraphobia is an irrational fear of crowded space, originating from the Ancient Greek term "Agora" or Marketplace. Such fears can be very debilitating in themselves, and in addition patients often worry about showing anxiety and losing control in public.[19]

Post-traumatic stress disorder[edit]

Virtual reality exposure (VRE) therapy is a modern but effective treatment of post-traumatic stress disorder (PTSD). This method was 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.,[20] Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.

Obsessive compulsive disorder[edit]

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.[21][22]

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.[23] 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. 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.[21][22]

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.[22] 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. [24]

Mindfulness[edit]

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."[25] 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.[25]

Organizations and certification[edit]

There are a number of organizations of behavior therapists around the world. The Association for Behavior Analysis International (ABA) offers a certification in behavior therapy[26] to therapists who demonstrate competence in exposure therapy.

Research[edit]

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.[27]

See also[edit]

References[edit]

  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. 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. ^ a b c 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. 
  7. ^ Marks, Isaac Meyer (1981). Cure and care of neuroses: theory and practice of behavioral psychotherapy. New York: Wiley. ISBN 0-471-08808-0. 
  8. ^ 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. 
  9. ^ Miltenberger, R. G. “Behavioral Modification: Principles and Procedures”. Thomson/Wadsworth, 2008. p. 552.
  10. ^ Foa, E. B. (2011). "Prolonged exposure therapy: present, and future". Depression and Anxiety. 28: 1034–1047. 
  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 3337146Freely accessible. 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. ^ 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. 
  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.; Tolin, D. F. (2011). "Exposure therapy for anxiety disorders: Theoretical mechanisms of exposure and treatment strategies". Psychiatric Times. 28 (9): 33–37. 
  19. ^ 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. 
  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. ^ a b 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. 
  22. ^ a b c "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. January 2012. doi:10.1016/j.jaac.2011.09.019. PMID 22176943. 
  23. ^ Abramowitz, Jonathan S.; Deacon, Brett J.; Whiteside, Stephen P. H. (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781609180171. 
  24. ^ O'Kearney RT, Anstey K, von Sanden C, Hunt A. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004856. DOI: 10.1002/14651858.CD004856.pub2
  25. ^ a b 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. 
  26. ^ [1]
  27. ^ 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 4942586Freely accessible. PMID 22129456.