Exposure therapy is a technique in behavior therapy to treat anxiety disorders.
Exposure therapy involves exposing the 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] : 141–142 [2] Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, [3] post-traumatic stress disorder (PTSD), and specific phobias. [4]
As of 2024, focus is particularly on exposure and response prevention (ERP or ExRP) therapy, in which exposure is continued and the resolution to refrain from the escape response is maintained at all times (not just during specific therapy sessions). [5] [6] [7] [8]
Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction. [9] 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 fear-inducing stimuli. [10]
This may be done;
There are several types of exposure procedures.
All types of exposure may be used together or separately. [15] [16] [17] Discussion continues on how to best to carry out exposure therapy, including on whether safety behaviours should be discontinued. [18] [19]
In the exposure and response prevention (ERP or EX/RP) form of exposure therapy, the resolution to refrain from the escape response is to be maintained at all times (not just during specific practice sessions). [20] 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. [21]
While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms. [22] [23] : 103 [8]
The American Psychiatric Association recommends ERP for the treatment of OCD, citing that ERP has the richest empirical support. [24] As of 2019, ERP is considered a first-line psychotherapy for OCD. [20] [25]
Effectiveness is heterogeneous. Higher efficacy correlates with lower avoidance behaviours, and greater adherence to homework. Using SSRI meds whilst doing ERP does not appear to correlate with better outcomes. [26] [27] [28] Discussion continues on how to best conduct ERP. [29]
Generally, ERP incorporates a relapse prevention plan toward the end of the course of therapy. [20] This can include being ready to re-apply ERP if an anxiety does occur. [30]
Mechanism research has been limited in the field. [31]
Habituation was seen as a mechanism in the past, but is seen more recently as a model of therapeutic process. [32]
As of 2022, the inhibitory learning model is the most common conjecture of the mechanism which causes exposure therapy efficacy. This model posits that in exposure therapy the unpleasant reactions such as anxiety (that were previously learned during fear conditioning) remain intact - they are not expected to be eliminated - but that they are now inhibited or balanced or overcome by new learning about the situation (for instance that the feared result will not necessarily happen). [19] [33] [34] [35] More research is needed. [36]
This model posits that additional associative learning processes, such as counterconditioning and novelty-enhanced extinction may contribute to exposure therapy. [37] [38]
Exposure therapy is seen as under-used in relation to its efficacy. [39] Barriers to use of exposure therapy by psychologists include it appearing antithetical to mainline psychology, [39] lack of confidence, and negative beliefs about exposure therapy. [40]
Exposure therapy is the most successful known treatment for phobias. [41] 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. [14]
Agoraphobia and social anxiety disorder are examples of phobias that have been successfully treated by exposure therapy. [42]
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 (a.k.a. desensitisation). Exposure may involve: [17]
Forms include:
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. [45] [46]
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. [47] [ dubious ] Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.
In the area of PTSD, historic barriers to the use of exposure therapy include that clinicians may not understand it, are not confident in their own ability to use it, or more commonly, see significant contraindications for their client. [48] [49]
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. [24] [50]
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. [21] 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. [14] 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. [24] [50]
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. [50] 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. [51]
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), [14] 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. [52] Exposure is used to promote fear tolerance. [53]
Exposure therapy is also a preferred method for children who struggle with anxiety. [54]
Exposure therapy has been posited as potentially helpful for other uses, including substance abuse disorders, [55] overeating, binge eating, and obesity, [56] [57] [58] and depression. [59] [60] [ timestamp needed ] [61] [ timestamp needed ]
The 9th century Persian polymath Abu Zayd al-Balkhi wrote about 'tranquilizing fear' by 'forcing oneself to repeatedly expose one's hearing and sight to noxious things' and to 'moved again and again near the thing it is scared of until it becomes used to it and loses its fear.' [62]
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. [21]
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. [21] 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. [21]
Exposure and response prevention (ERP) traces its roots back to the work of psychologist Vic Meyer in the 1960s. Meyer devised this treatment from his analysis of fear extinguishment in animals via flooding and applied it to human cases in the psychiatric setting that, at the time, were considered intractable. [63] The success of ERP clinically and scientifically has been summarized as "spectacular" by prominent OCD researcher Stanley Rachman decades following Meyer's creation of the method. [64]
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." [65] 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. [65]
Eye movement desensitization and reprocessing (EMDR) includes an element of exposure therapy (desensitization), though whether this is an effective method or not, is controversial. [66]
Desensitization and extinction also involve exposure to a cause of disturbance.
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. [67] [68]
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. Cognitive behavioral therapy is one of the most effective means of treatment for substance abuse and co-occurring mental health disorders. CBT focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.
A phobia is an anxiety disorder, defined by an irrational, unrealistic, persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.
Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.
Hoarding disorder (HD) or Plyushkin's disorder, is a mental disorder characterised by persistent difficulty in parting with possessions and engaging in excessive acquisition of items that are not needed or for which no space is available. This results in severely cluttered living spaces, distress, and impairment in personal, family, social, educational, occupational, or other important areas of functioning. Excessive acquisition is characterized by repetitive urges or behaviours related to amassing or buying property. Difficulty discarding possessions is characterized by a perceived need to save items and distress associated with discarding them. Accumulation of possessions results in living spaces becoming cluttered to the point that their use or safety is compromised. It is recognised by the eleventh revision of the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).
Scrupulosity is the pathological guilt/anxiety about moral or religious issues. Although it can affect nonreligious people, it is usually related to religious beliefs. It is personally distressing, dysfunctional, and often accompanied by significant impairment in social functioning. It is typically conceptualized as a moral or religious form of obsessive–compulsive disorder (OCD). The term is derived from the Latin scrupus, a sharp stone, implying a stabbing pain on the conscience. Scrupulosity was formerly called scruples in religious contexts, but the word scruple now commonly refers to a troubling of the conscience rather than to the disorder.
An intrusive thought is an unwelcome, involuntary thought, image, or unpleasant idea that may become an obsession, is upsetting or distressing, and can feel difficult to manage or eliminate. When such thoughts are associated with obsessive-compulsive disorder (OCD), Tourette's syndrome (TS), depression, body dysmorphic disorder (BDD), and sometimes attention-deficit hyperactivity disorder (ADHD), the thoughts may become paralyzing, anxiety-provoking, or persistent. Intrusive thoughts may also be associated with episodic memory, unwanted worries or memories from OCD, post-traumatic stress disorder, other anxiety disorders, eating disorders, or psychosis. Intrusive thoughts, urges, and images are of inappropriate things at inappropriate times, and generally have aggressive, sexual, or blasphemous themes.
The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) is a test to rate the severity of obsessive–compulsive disorder (OCD) symptoms.
Edna Foa is an Israeli professor of clinical psychology at the University of Pennsylvania, where she serves as the director of the Center for the Treatment and Study of Anxiety. Foa is an internationally renowned authority in the field of psychopathology and treatment of anxiety. She approaches the understanding and treatment of mental disorders from a cognitive-behavioral perspective.
Primarily obsessional obsessive–compulsive disorder, also known as purely obsessional obsessive–compulsive disorder, is a lesser-known form or manifestation of OCD. It is not a diagnosis in the DSM-5. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD. While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination. Primarily obsessional OCD takes the form of intrusive thoughts often of a distressing, sexual, or violent nature.
Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.
Stanley Jack Rachman was a South African-born psychologist who worked primarily with obsessive-compulsive disorder (OCD) and other anxiety disorders. He spent much of his career based in the UK and Canada.
Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.
The effects of stress on memory include interference with a person's capacity to encode memory and the ability to retrieve information. Stimuli, like stress, improved memory when it was related to learning the subject. During times of stress, the body reacts by secreting stress hormones into the bloodstream. Stress can cause acute and chronic changes in certain brain areas which can cause long-term damage. Over-secretion of stress hormones most frequently impairs long-term delayed recall memory, but can enhance short-term, immediate recall memory. This enhancement is particularly relative in emotional memory. In particular, the hippocampus, prefrontal cortex and the amygdala are affected. One class of stress hormone responsible for negatively affecting long-term, delayed recall memory is the glucocorticoids (GCs), the most notable of which is cortisol. Glucocorticoids facilitate and impair the actions of stress in the brain memory process. Cortisol is a known biomarker for stress. Under normal circumstances, the hippocampus regulates the production of cortisol through negative feedback because it has many receptors that are sensitive to these stress hormones. However, an excess of cortisol can impair the ability of the hippocampus to both encode and recall memories. These stress hormones are also hindering the hippocampus from receiving enough energy by diverting glucose levels to surrounding muscles.
In psychology, relationship obsessive–compulsive disorder (ROCD) is a form of obsessive–compulsive disorder focusing on close or intimate relationships. Such obsessions can become extremely distressing and debilitating, having negative impacts on relationships functioning.
The delayed-maturation theory of obsessive–compulsive disorder suggests that obsessive–compulsive disorder (OCD) can be caused by delayed maturation of the frontal striatal circuitry or parts of the brain that make up the frontal cortex, striatum, or integrating circuits. Some researchers suspect that variations in the volume of specific brain structures can be observed in children that have OCD. It has not been determined if delayed-maturation of this frontal circuitry contributes to the development of OCD or if OCD is the ailment that inhibits normal growth of structures in the frontal striatal, frontal cortex, or striatum. However, the use of neuroimaging has equipped researchers with evidence of some brain structures that are consistently less adequate and less matured in patients diagnosed with OCD in comparison to brains without OCD. More specifically, structures such as the caudate nucleus, volumes of gray matter, white matter, and the cingulate have been identified as being less developed in people with OCD in comparison to individuals that do not have OCD. However, the cortex volume of the operculum (brain) is larger and OCD patients are also reported to have larger temporal lobe volumes; which has been identified in some women patients with OCD. Further research is needed to determine the effect of these structural size differences on the onset and degree of OCD and the maturation of specific brain structures.
The University of Florida Obsessive–Compulsive Disorder Program is a treatment and research clinic in the Department of Psychiatry at the University of Florida. The clinic is located in Gainesville, Florida.
Safety behaviors are coping behaviors used to reduce anxiety and fear when the user feels threatened. An example of a safety behavior in social anxiety is to think of excuses to escape a potentially uncomfortable situation. These safety behaviors, although useful for reducing anxiety in the short term, might become maladaptive over the long term by prolonging anxiety and fear of nonthreatening situations. This problem is commonly experienced in anxiety disorders. Treatments such as exposure and response prevention focus on eliminating safety behaviors due to the detrimental role safety behaviors have in mental disorders. There is a disputed claim that safety behaviors can be beneficial to use during the early stages of treatment.
Jonathan Stuart Abramowitz is an American clinical psychologist and Professor in the Department of Psychology and Neuroscience at the University of North Carolina at Chapel Hill (UNC-CH). He is an expert on obsessive-compulsive disorder (OCD) and anxiety disorders whose work is highly cited. He maintains a research lab and currently serves as the Director of the UNC-CH Clinical Psychology PhD Program. Abramowitz approaches the understanding and treatment of psychological problems from a cognitive-behavioral perspective.
Bunmi O. Olatunji is an American psychologist who is Gertrude Conaway Vanderbilt Chair in Social Sciences at Vanderbilt University. He is Director of the Emotion and Anxiety Research Laboratory and Associate Dean of Academic Affairs for the Vanderbilt University Graduate School. Olatunji studies the psychopathology of obsessive–compulsive disorder.
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