Behavioral Therapies for Anxiety DisordersMatthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.Exposure Therapy: The effectiveness of exposure therapy relies upon the behavioral concept called habituation. Habituation is the process by which a person's behavioral and sensory response diminishes over time after repeated exposure to a particular stimulus. Habituation is an experience we can all relate to. Have you ever visited friends who lived nearby an airport, busy highway, or a train station and wondered how they could possibly concentrate or sleep with all that noise? Your friends may have felt the same way when they first moved in, but after living there for a while, their sensory neurons just stopped reacting to the noise. They will probably tell you that they are so accustomed to the noise they no longer even hear it anymore. They've become habituated to it. Or have you ever jumped into an ice cold swimming pool only to feel comfortable after a few minutes? That's habituation at work.
Exposure therapy simply means repeated exposure to the feared stimulus, so that habituation occurs. This is usually accomplished in gradually increasing levels of intensity. For instance, individuals with a phobia of needles might first be shown a photograph of a syringe. They allow themselves to experience the fear until habituation occurs, and the fear eventually subsides. Next, they might be shown a film of an injection, experience the fear until habituation occurs and the fear subsides, and finally they may view an actual injection. Often times, relaxation training and breath training are utilized to facilitate the reduction of fear.
Exposure therapy may be conducted using in vivo exposure (meaning real live exposure to the feared stimulus), or it may be conducted using imagination, or both. The use of imagination is particularly useful in cases of trauma, or other occasions when in vivo exposure is not practical. When imagination is used, the therapy is most effective when all five senses are included in the guided therapeutic exercises. For example, in the case of a violent attack or rape, the therapy participant may be asked to recall the smell of their attacker, and to recall what sounds they heard, etc. So whether by in vivo exposure or by imaginal exposure, individuals are encouraged to repeatedly face the anxiety-producing stimulus until habituation occurs so that they no longer experience the same degree of anxiety and distress.
Once habituation occurs, the fearful behavior will eventually be extinguished. This concept is based on the classical conditioning evidence that suggests individuals learn to become afraid of neutral stimuli (needles, doorknobs, rats, etc.) as a result of the paired association between a neutral, conditioned stimulus (CS) and fear-inducing stimuli (UCS). A behavior will be extinguished, (i.e., the fear is eliminated), by simply the reversing that process; i.e., unlearning, or un-pairing the association between the CS and UCS. For example, a person with germ contamination may have formed an association between fear and doorknobs (CS). As a result, he or she may avoid touching doorknobs directly. Through exposure therapy, the person would repeatedly touch doorknobs until habituation occurs. Because the doorknobs (CS) are no longer producing a fearful response (due to habituation), the association between the CS and fear is broken, and the feared response is gradually eliminated or extinguished. Through repeated practice, the person realizes that nothing terrible happens as a result of touching the doorknob. Or, in the case of social anxiety, a person may associate parties with the dread of excruciating embarrassment, but by repeatedly facing social situations, the fear will be extinguished.
Response Prevention: A second component frequently coupled with exposure therapy is called "response prevention," also known as "ritual prevention." This component of treatment is particularly important for people who have developed ritualized, repetitive behaviors (compulsions) that serve to "undo" or neutralize their anxiety when faced with their anxiety-provoking situation. Response prevention is based on operant conditioning principle that suggests that if a behavior is no longer rewarded (reinforced) it becomes extinct; meaning the behavior gradually fades away. For instance, washing one's hands after contact with a doorknob serves to "undo," or negate the effect of touching the door knob. Because these rituals are reinforcing and serve the same function as escape and avoidance behavior, extinction cannot not occur unless these behaviors are prevented. Response prevention is a necessary component of behavioral therapy in the treatment of Obsessive- Compulsive Disorder. The combination of exposure to feared stimuli, along with the prevention of rituals, leads to the most effective treatment response.
Exposure and response prevention is an extremely effective treatment for anxiety disorders and relies on scientific principles tested in laboratory research (Deacon & Abramowitz, 2004; Norton & Price, 2007; Stewart & Chamblass, 2009). More specific examples of these treatment methods can be found in the Treatment of Anxiety Disorders Section.
Very recently, emerging research has forced researchers to rethink the classical learning theory model so as to accommodate new insights into how memory functions. It used to be thought that once a memory was established, that memory was more or less permanent. Based on the assumption that memories were more or less permanent structures, learning theory based psychotherapies explored ways of creating and then suppressing, competing with, or starving to death troubling memories. It turns out that memories are not very permanent structures at all, but rather structures that can be edited and changed under certain circumstances. This process of editing established memories has been termed "memory reconsolidation" in recognition of the fact that when a memory is first established, that process of establishment is known as "consolidation". As understanding of how to manipulate the reconsolidation process has grown, researchers have developed experimental forms of memory reconsolidation therapy that appear to be able to effectively and quickly delete emotional memories including those troubling memories associated with PTSD. More information on these experimental therapies is provided here.
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