clinical conditions. As might be expected, research
suggeststhatitismosteffectivewhenusedtotreat
anxiety disorders, particularly specific phobias,
social anxiety, public speaking anxiety, and gener-
alized anxiety disorder (Chambless et al., 1998;
Chambless & Ollendick, 2001; Emmelkamp,
1994, 2004).
Exposure Therapy
The termexposure therapydescribes a behavior ther-
apy technique that is a refinement of a set of
procedures originally known as flooding or implo-
sion. The roots of exposure therapy can be traced to
Masserman (1943), who studied anxiety reactions
and avoidance behaviors in cats. Masserman’s studies
involved inducing“neurotic behaviors”in cats by
administering shock under certain environmental
conditions. He subsequently discovered that the
avoidance behavior could be extinguished if the
cats were forced to remain in the situation in
which they had previously been shocked (i.e., no
escape or avoidance was possible). These findings
were the basis for developing anxiety treatments
for humans. There is empirical support for the
efficacy of exposure treatments for specific phobias,
panic disorder, agoraphobia, social phobia, post-
traumatic stress disorder, and obsessive-compulsive
disorder (Chambless et al., 1998; Chambless &
Ollendick, 2001; Emmelkamp, 1994, 2004;
Powers, Halpern, Ferenschak, Gillihan, & Foa,
2010; Rosa-Alcazar, Sanchez-Meca, Gomez-
Conesa, & Marin-Martinez, 2008; Sanchez-Meca,
Rosa-Alcazar, Marin-Martinez, & Gomez-Conesa,
2010; Wolitzky-Taylor, Hororwitz, Powers, &
Telch, 2008).
In exposure therapy, patients expose them-
selves to stimuli or situations that were previously
feared and avoided. The“exposure”can be in real
life (in vivo) or in fantasy (in imagino). In the latter
version, patients are asked to imagine themselves in
the presence of the feared stimulus (e.g., a spider) or
in the anxiety-provoking situation (e.g., speaking in
front of an audience). Several researchers suggest
that certain features must be present in exposure
treatments for the patient to achieve maximum
benefit (Barlow & Cerny, 1988):- Exposure should be of long rather than short
duration. - Exposure should be repeated until all fear/
anxiety is eliminated. - Exposure should be graduated, starting with
low-anxiety stimuli/situations and progressing
to high-anxiety stimuli/situations. - Patients must attend to the feared stimulus and
interact with it as much as possible. - Exposure must provoke anxiety.
Like other behavioral therapies we describe in
this chapter, exposure treatment can be used as a
self-contained treatment or as one component of a
multimodal treatment. For example, Barlow and
Cerny (1988) describe a psychological treatment
for panic disorder that includes relaxation, cogni-
tive restructuring, and exposure components.
What is especially ingenious about their version
of exposure treatment is that they have patients
expose themselves to interoceptive cues—internal
physiological stimuli such as rapid breathing and
dizziness. This modification was necessary because
individuals suffering from panic disorder typically
report that their panic attacks are unpredictable
and“come out of the blue.”In such cases, no
external anxiety-provoking stimulus or situation
is apparent. In contrast, individuals with other
non-panic anxiety disorders report acute anxiety
primarily in the face of certain external stimuli or
situations.
How do clinicians convince patients that com-
pleting tasks that increase levels of anxiety will ulti-
mately be helpful? To illustrate the rationale that is
presented for exposure treatment, Box 14-2 pro-
vides the introduction that is used in Barlow and
Cerny’s (1988) psychological treatment for panic
disorder.
Craske, Rowe, Lewin, and Noriega-Dimitri
(1997) compared the effectiveness of two forms of
treatment for panic disorder with agoraphobia—one
that included interoceptive exposure and one that
406 CHAPTER 14