Exposure is a general term for various procedures that have in common that patients are exposed to situations that elicit tension and anxiety and that they are inclined to avoid or flee the situation (Van Hout & Emmelkamp, 2002). Traditionally there were two principal ways in which exposure might take place:

• in vitro, or in imagination, in which the patient imagines himself in the anxiety-eliciting situation (also referred to as imaginal exposure);

• in vivo, or in reality, in which the patient is in effect exposed to the anxiety-eliciting situation.

It is often difficult to motivate the patient to confront the feared situation. When this happens, the therapist may employ modelling procedures: i.e. the therapist (or another person) may demonstrate the desired approach behaviours in the feared situation. Two procedural forms of exposure-based treatments can be distinguished:

• Gradual or self-guided exposure. The patient controls the exposure by determining when s/he progresses to the next situation of a higher (threat or anxiety) level.

• Flooding and prolonged exposure in vivo. The therapist controls the extent and duration of the exposure.

A short vignette of a dog-phobic patient may clarify the above distinctions. In gradual exposure, therapist and patient collaboratively construct a hierarchy of fear-eliciting situations that the patient usually avoids. These situations are ranked from easy/not challenging to (very) difficult/challenging. An example of an easy item might be 'watching a picture of a puppy' whereas an example of a difficult item might be 'being alone in a room with a Rottweiler'. When the first situation is successfully mastered - the patient experiences no fear - the next step in the hierarchy is confronted, until finally the entire fear hierarchy is completed.

During flooding, the therapist confronts the patient with the most challenging (fear-provoking) situations right away. In our case, this means that the patient is required to be in a room alone with the Rottweiler. The objective is to have the patient habituate to the fear, which allows for the extinction of the fear response.

Flooding in vivo is sometimes also referred to as 'prolonged exposure in vivo', where 'prolonged' refers to the extended time interval required to achieve habituation. The exposure interval, during which no escape or avoidance is allowed, can last up to two hours. Prolonged exposure in vivo is generally the most successful exposure treatment.

However, it can be difficult or impossible to conduct exposure in vivo sessions for individuals with some complaints. Imaginal exposure and to some extent virtual-reality exposure (VRE) can then be useful alternatives. Virtual-reality exposure integrates real-time computer graphics, body tracking devices, visual displays, and other sensory inputs to immerse individuals in a computer-generated virtual environment. A number of VR case studies have reported on fear of flying, acrophobia, claustrophobia, spider phobia, and agoraphobia. Moreover, recent controlled studies provide substantial empirical support that VR exposure is at least as effective as exposure in vivo treatment for patients with acrophobia (Emmelkamp et al., 2001; Emmelkamp et al., 2002; Krijn et al., 2004) and fear of flying (Krijn, Emmelkamp & Olafsson, 2004).

A modification of the basic principle of exposure is the exposure with response prevention paradigm. This mode of exposure is regularly applied in the treatment of problem behaviours in which certain stimuli elicit maladaptive coping behaviours (for example, drinking/drug use in substance use disorders, vomiting and excessive exercising in bulimia nervosa, and compulsions in obsessive-compulsive disorders).

Exposure is also the underlying principle of behaviour therapies that are focused on the processing of negative experiences, such as those used in post-traumatic stress and complicated bereavement. As a hierarchical presentation of salient stimuli is often not feasible, flooding is most typically used with these problems. Although exposure in vivo can be an important component of the treatment, imaginary exposure is typically most central to the treatment of these problems. The efficacy of exposure-based treatments among war veterans and victims of other trauma (such as rape) has been adequately documented (Emmelkamp, 2004; Rothbaum et al., 2000). Exposure for post-traumatic stress can also be conducted by means of writing assignments and treatment may even be applied through the Internet (Lange et al., 2003). The effects of exposure-based bereavement therapy are less convincing as yet (Sireling & Cohen, 1988).

Drug-taking and drinking behaviour are strongly cue and context specific and cue-exposure treatment (CET) is regarded as 'probably efficacious' by Chambless & Ollendick (2001). However, Conklin & Tiffany (2002) are less optimistic and conclude in their metaanalyses that there is no consistent evidence for the efficacy of cue exposure in the treatment of substance-use disorders. When the treatment goal is moderation of drinking rather than abstinence, results are also inconclusive. Sirtarthan et al. (2001) compared a moderation goal-orientated CET with cognitive-behaviour therapy in a population of non-dependent alcohol-abusing patients and found a significant decrease in alcohol consumption at post-treatment and at follow-up. Heather et al. (2000) found moderation goal oriented CET as effective as behavioural self-control training.

Conquering Fear In The 21th Century

Conquering Fear In The 21th Century

The Ultimate Guide To Overcoming Fear And Getting Breakthroughs. Fear is without doubt among the strongest and most influential emotional responses we have, and it may act as both a protective and destructive force depending upon the situation.

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