Exposure therapy

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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 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] 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, 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. [7]


Exposure therapy is the most successful known treatment for phobias. [8] 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. [9]

Agoraphobia and social anxiety disorder are examples of phobias that have been successfully treated by exposure therapy. [10]

Post-traumatic stress disorder

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. [11] [ dubious ] 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. [12] [13]

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. [14] 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. [12] [13]

The AACAP's practise 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. [13] 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. [15]


Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction. [16] 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. [17] 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. [18] 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. [19]

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. [20] [21]

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. [22] [23]

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. [24] 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. [25] The American Psychiatric Association recommends ERP for the treatment of OCD, citing that ERP has the richest empirical support. [26]

While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms. [27] [28] :103 Generally, ERP incorporates a relapse prevention plan toward the end of the course of therapy. [24]


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. [29]

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. [29] 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. [29]


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." [30] 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. [30]


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. [31] [32]

Related Research Articles

Anxiety disorder Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders also called anxious disorders are a group of mental disorders characterized by significant feelings of anxiety and fear. Anxiety is a worry about future events, while fear is a reaction to current events. These feelings may cause physical symptoms, such as increased heart rate and shakiness. There are several anxiety disorders, including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. The disorder differs by what results in the symptoms. It is possible for an individual to have more than one anxiety disorder.

Specific phobia is an anxiety disorder, characterized by an unreasonable fear associated with a specific object or situation. 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.

Compulsive hoarding

Compulsive hoarding, also known as hoarding disorder, is a behavioral pattern characterized by excessive acquisition of and an inability or unwillingness to discard large quantities of objects that cover the living areas of the home and cause significant distress or impairment. Compulsive hoarding behavior has been associated with health risks, impaired functioning, workplace impairment, economic burden, and adverse effects on friends and family members. When clinically significant enough to impair functioning, hoarding can prevent typical uses of space, enough so that it can limit activities such as cooking, cleaning, moving through the house, and sleeping. It can also put the individual and others at risk of fires, falling, poor sanitation, and other health concerns.

Scrupulosity is characterized by pathological guilt about moral or religious issues. It is personally distressing, objectively 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 scrupulum, 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), 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.

Sexual obsessions are persistent and unrelenting thoughts about sexual activity. In the context of obsessive-compulsive disorder (OCD), these are extremely common, and can become extremely debilitating, making the person ashamed of the symptoms and reluctant to seek help. A preoccupation with sexual matters, however, does not only occur as a symptom of OCD, they may be enjoyable in other contexts.

Edna B. Foa Israeli psychologist

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 on the psychopathology and treatment of anxiety. She approaches the understanding and treatment of mental disorders from a cognitive-behavioral perspective.

Social anxiety is nervousness in social situations. Some disorders associated with the social anxiety spectrum include anxiety disorders, mood disorders, autistic spectrum disorders, eating disorders, and substance use disorders. Individuals higher in social anxiety avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. They may exhibit irrational anxiety and fear in social interactions. This differs from shyness because it is a persistent disorder that could influence one’s capability to interact with peers and family throughout a long period of time. This disorder is commonly found in teenagers and can be persistent throughout life. Trait social anxiety, the stable tendency to experience this nervousness, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Nearly 90% of individuals, more of whom are women, report feeling symptoms of social anxiety at some point in their lives. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

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Obsessive–compulsive disorder Disorder that involves repeated thoughts (obsessions) that make a person feel driven to do something (compulsions)

Obsessive–compulsive disorder (OCD) is a mental disorder in which a person has certain thoughts repeatedly or feels the need to perform certain routines repeatedly to an extent that generates distress or impairs general functioning. The person is unable to control either the thoughts or activities for more than a short period of time. Common compulsions include hand washing, counting of things, and checking to see if a door is locked. These activities occur to such a degree that the person's daily life is negatively affected, often taking up more than an hour a day. Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide.

Stanley Jack Rachman is a psychologist and Professor Emeritus of the Department of Psychology at the University of British Columbia in Vancouver, British Columbia, 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.

Effects of stress on memory Overview of the effects of stress on memory

The effects of stress on memory include interference with a person's capacity to encode memory and the ability to retrieve information. 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.

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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.

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Jonathan Abramowitz American clinical psychologist

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 authority on obsessive-compulsive disorder (OCD) and anxiety disorders whose work is highly cited. He maintains a research lab and serves as the Director of the UNC-CH Anxiety and Stress Disorders Clinic. Abramowitz approaches the understanding and treatment of psychological problems from a cognitive-behavioral perspective.

Michelle Craske

Michelle G. Craske is a Professor of Psychology, Psychiatry, and Behavioral Sciences, Miller Endowed Chair, Director of the Anxiety and Depression Research Center, and Associate Director of the Staglin Family Music Center for Behavioral and Brain Health at the University of California, Los Angeles. She is known for her research on anxiety disorders, including phobia and panic disorder, and the use of fear extinction through exposure therapy as treatment. Other research focuses on anxiety and depression in childhood and adolescence and the use of cognitive behavioral therapy as treatment. Craske served as the past president of the Association for Behavioral and Cognitive Therapy. She was a member of the DSM-IV work group on Anxiety Disorders and the DSM-5 work group on Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders, while chairing the sub-work group on Anxiety Disorders. She is the editor-in-chief of Behaviour Research and Therapy.


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