124 CHAPTER 4
Systematic desensitization
The behavioral technique of learning to relax
in the presence of a feared stimulus.
thereby making exposure (and habituation) unlikely. Patients in therapy can experi-
ence exposure in three ways:- imaginal exposure, which relies on forming mental images of the stimulus;
- virtual reality exposure, which consists of exposure to a computer-generated
(often very realistic) representation of the stimulus; and - in vivo exposure, which is exposure to the actual stimulus.
Leon’s social phobia could be treated in any or all of these ways: He could viv-
idly imagine interacting with others, he could use virtual reality software to have
the experience of interacting with others without actually doing so, or he could
interact with others in the fl esh.
Virtual reality exposure combines aspects of the other two
types of exposure: As with imaginal exposure, the patient isn’t
actually exposed to the fear- or anxiety-producing stimulus, and,
as with in vivo exposure, the patient experiences a vivid situation
that isn’t totally under his or her control—similar to a real situ-
ation. Virtual reality exposure has been used to treat a variety of
psychological disorders, including posttraumatic stress disorder
(Ready et al., 2006), even among active duty soldiers (Reger &
Gahm, 2008); fear of fl ying (Rothbaum et al., 2006); social pho-
bia (specifi cally, fear of public speaking, with a virtual audience;
Anderson et al., 2005); and fear of heights (Krijn et al., 2004).
Patients are less likely to refuse treatment with virtual reality
exposure than with in vivo exposure (Garcia-Palacios et al.,
2007). Moreover, virtual reality exposure may be more effec-
tive than in vivo exposure for some people and some disorders
(Powers & Emmelkamp, 2008).
Another technique for treating fear, anxiety and avoidance is systematic desen-
sitization, which is learning to become relaxed in the presence of a feared stim-
ulus. Whereas exposure relies on habituation, systematic desensitization relies on
the fact that a person cannot be relaxed and anxious at the same time. Systematic
desensitization is used less frequently than exposure because it is usually not as
effi cient or effective; however, it may be used to treat a fear or phobia when a patient
chooses not to try exposure or has tried it but was disappointed by the results.
The fi rst step of systematic desensitization is learning to become physically re-
laxed through progressive muscle relaxation, relaxing the muscles of the body in
sequence from feet to head. Once the patient has mastered this ability, the thera-
pist helps the patient construct a hierarchy of possible experiences relating to the
feared stimulus, ordering them from least to most feared, just as is done for expo-
sure (see Figure 4.1). Over multiple therapy sessions, the patient practices becoming
relaxed and then continuing to remain relaxed while imagining increasingly feared
experiences.
Although systematic desensitization and biofeedback both involve relaxation,
systematic desensitization uses relaxation as the fi rst step in reducing anxiety in re-
sponse to feared stimuli and does not utilize any equipment. In contrast, the goal of
biofeedback is learning to control what are generally involuntary responses.Treating Compulsive Behaviors In some cases, avoidance or fear of a specifi c stimulus
is not the primary maladaptive behavior. For people with OCD, the maladaptive
behavior is a compulsive, ritualistic action that patients feel they must perform in
response to some stimulus. After grocery shopping, for example, a person may feel
compelled to reorganize all the canned goods in the cupboard so that the contents
remain in alphabetical order. Similarly, some people with bulimia nervosa feel com-
pelled to make themselves throw up after eating even a bite of a dessert. These
compulsive behaviors temporarily serve to decrease anxiety that has become part of
a conditioned emotional response to a particular stimulus (e.g., randomly arranged
canned goods or the sensation of dessert in the mouth).Exposure—imaginal, in vivo, or virtual reality—
can be used successfully to treat people with
a variety of anxiety disorders, including a fear
of heights and posttraumatic stress disorder
(Krijn et al., 2004; Reger & Gahm, 2008).
AP Photo/Ted S. Warren