Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears
Traditional models and methods of exposure therapy utilize a fear hierarchy, whereby patients complete sets of exposures in a graduated manner, with the goal of fear habituation within and between sessions. In the current experiment, we examined whether this typical exposure paradigm was necessary to achieve clinical improvement.
Fifty undergraduate participants scoring in the top quartile of a self-report measure of contamination fears were randomly assigned to one of two groups: blocked and constant exposure (BC Group) and random and variable exposure (RV Group). Both groups completed three weekly sessions of exposure treatment, with subjective and psychophysiological indices of fear recorded throughout. Subjective, behavioral, and psychophysiological dependent measures were evaluated by an independent assessor at pre-treatment (PRE), post-treatment (POST), and two-week follow-up (2WFU).
Both the BC Group and RV Group exhibited decreases in subjective fear from PRE to POST and 2WFU, with no significant differences between groups. Partialing group, greater variability in subjective fear during exposure predicted lower subjective fear at 2WFU.
Despite significant findings for subjective fear, behavioral and psychophysiological findings were limited. Follow-up studies should investigate questions regarding traditional exposure within a clinical group.
These results support the notion that traditional exposure is sufficient, but not necessary, to produce clinical improvement in contamination-related fears. There may be benefits to variability in fear level during exposure, and evaluation of emotion variability during exposure therapy for other anxiety disorders is warranted.
Available from: Dean Mckay
- "The findings of the current study suggest that, in lieu of directly targeting disgust, symptom reduction may be achieved by alternatively targeting anxiety or other manifest symptoms. While the specific mechanism of exposure therapy is currently under contention (Craske et al., 2008; Kircanski et al., 2012), a reduction of disgust propensity could potentially signify habituation to disgust sensitivity (i.e., how distressing one finds the emotion of disgust; van Overveld, de Jong, Peters, Cavanagh, & Davey, 2006), or inhibitory learning of disgust reactions by reinforcing differential behavior associated with the previously disgusting stimuli. While disgust propensity can be considered a higherorder factor for all anxiety disorders, it may be a more salient and critical treatment target when symptoms intersect with the core (e.g., blood-injection-injury phobias), animal-reminder (e.g., OCD with symptoms related to sex or bodily waste), and contamination (e.g., OCD with contamination symptoms, phobias of insects) domains (Olatunji, Ebesutani, Haidt, & Sawchuk, 2014; Olatunji et al., 2007). "
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ABSTRACT: La asco, además del miedo, es un estado emocional prominente asociado con la evitación de estímulos perturbadores. Aunque la mayoría de la investigación se ha llevado a cabo en relación con el trastorno obsesivo-compulsivo (TOC), datos recientes han implicado la asco en la etiología de trastornos de ansiedad en general. Se ha demostrado que la disminución de la asco es clave para la reducción de los síntomas en personas con TOC. Sin embargo, son escasos los trabajos que exploren si estas intervenciones son eficaces en trastornos de ansiedad en la infancia con componentes prominentes de asco. Este estudio examinó cómo la propensión a la asco en niños con trastornos de ansiedad responde a la terapia cognitivo-conductual (TCC) con énfasis en la exposición. Cuarenta y un niños de 7 a 17 años, con trastornos de ansiedad, fueron evaluados en la propensión a la asco y tratados semanalmente con TCC intensiva. Se encontró que los niveles de asco disminuyeron tras el tratamiento en todos los diagnósticos de trastorno de ansiedad, siendo los niños con TOC primario los que mostraron reducciones significativamente mayores. Se discuten las implicaciones clínicas y sugerencias para futuras investigaciones sobre el tratamiento de la asco en relación con los trastornos de ansiedad infantil.
Available from: Tomislav Zbozinek
- "Furthermore, Kircanski et al. (2012) found added benefits of affect labeling in a sample of individuals with spider phobias as they underwent exposure therapy. In comparison to cognitive reappraisal of thoughts, distraction, and exposure alone, affect labeling during exposure was found to reduce skin conductance and increase approach behavior at one week follow up in a context different than the exposure context (Kircanski et al., 2012). These data suggest that linguistic processing in the form of labeling, as opposed to more traditional cognitive therapy which attempts to change the content of appraisals, can improve outcomes from exposure. "
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ABSTRACT: Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a 'fear habituation' approach and 'belief disconfirmation' approach within standard cognitive-behavior therapy. Exposure optimization strategies include 1) expectancy violation, 2) deepened extinction, 3) occasional reinforced extinction, 4) removal of safety signals, 5) variability, 6) retrieval cues, 7) multiple contexts, and 8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.
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ABSTRACT: In traditional exposure therapy for phobias and anxiety disorders, reduction of fear responding is used as an index of learning. However, recent evidence in animal models suggests that sustained arousal and enhanced fear responding throughout exposure may actually predict better long-term outcomes (Rescorla, 2000).
The effects of sustained arousal during exposure were investigated in a clinical analog sample of 59 participants fearful of public speaking. Participants completed exposure with or without the presence of additional excitatory stimuli which were intended to enhance arousal and fear responding throughout exposure.
Group assignment (exposure versus exposure with additional excitatory stimuli) did not significantly predict outcome at 1-week follow-up testing, as measured physiologically, subjectively, and behaviorally. A set of regression analyses investigating whether any exposure process measures predicted outcome indicated that sustained arousal throughout exposure as well as variability in subjective fear responding throughout exposure (e.g., Kircanski et al., 2011) predicted lower levels of fear at follow-up testing (p < 0.05; p < 0.001) after controlling for demographic variables as well as pre-exposure fear levels.
The excitatory stimuli used failed to produce the intended effects. However, some participants did maintain elevated arousal throughout exposure and this predicted better outcomes at 1-week follow-up testing.
Sustained arousal throughout exposure as well as variability in subjective fear responding during exposure may be better predictors of long-term outcomes than habituation of fear across exposure.
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