Prolonged Exposure Therapy for PTSD among Individuals in a Residential Substance Use Treatment Program: A Case Series

Clients with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders present a unique challenge for clinicians in substance use treatment settings. Substance dependent individuals with PTSD tend to improve less during substance use treatment and relapse more quickly following abstinence attempts compared to those without PTSD. Recent scientific efforts have focused on understanding the potential benefit of providing PTSD treatment concurrent with substance use treatment. The current case study describes 4 individuals with PTSD in a residential substance use facility who received prolonged exposure therapy for treatment of PTSD, in addition to the substance use treatment. These individuals completed 9 bi-weekly 60-minute sessions of prolonged exposure, as well as in vivo and imaginal exposure homework between sessions. None of the clients met criteria for PTSD at the end of treatment, with these gains being maintained at 3- and 6-months post-treatment. Additionally, the clients did not relapse in response to undergoing exposure therapy. Implications for delivery of PTSD treatment in substance use treatment facilities are discussed.     

Resolving Ethical Dilemmas in a Tertiary Care Veterinary Specialty Hospital: Adaptation of the Human Clinical Consultation Committee Model

Technological advances in veterinary medicine have produced considerable progress in the diagnosis and treatment of numerous diseases in animals. At the same time, veterinarians, veterinary technicians, and owners of animals face increasingly complex situations that raise questions about goals of care and correct or reasonable courses of action. These dilemmas are frequently controversial and can generate conflicts between clients and health care providers. In many ways they resemble the ethical challenges confronted by human medicine and that spawned the creation of clinical ethics committees as a mechanism to analyze, discuss, and resolve disagreements. The staff of the North Carolina State University Veterinary Hospital, a specialty academic teaching institution, wanted to investigate whether similar success could be achieved in the tertiary care veterinary setting. We discuss the background and rationale for this method, as well as the approach that was taken to create a clinical ethics committee.     

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8–18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure—however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists’ use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.     

The Practice of Exposure Therapy: Relevance of Cognitive-Behavioral Theory and Extinction Theory

Exposure therapy is the most effective psychological intervention for people with anxiety disorders. While many therapists learn how to implement exposure techniques through clinical training programs or instructional workshops, not all of these educational efforts include a focus on the theory underlying this treatment. The availability of treatment manuals providing step-by-step instructions for how to implement exposure makes it easier for clinicians to use these techniques with less training than they might otherwise receive. This raises questions regarding whether it is necessary to understand the theory behind the use of exposure. This article argues that knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome. Specific ways in which theory is relevant to using exposure techniques are discussed.     

Using Multiple Contexts and Retrieval Cues in Exposure-Based Therapy to Prevent Relapse in Anxiety Disorders

The benefits of exposure-based interventions for anxiety disorders are substantial but not stable for everyone, given that these interventions are often followed by relapse of symptoms. A body of research provides a background on how to add certain strategies in exposure-based therapy to prevent relapse in anxiety disorders. This review summarizes some of these strategies and provides clear-cut clinical implications. Studies that provide support for two types of strategies to prevent relapse have been reviewed—the use of multiple contexts and the use of retrieval cues. The use of multiple contexts reduces context and stimulus specificity of extinction learning during exposure, while the use of retrieval cues enhances memory (re)consolidation and retrieval after exposure. The described strategies to enhance the accessibility and therefore the retrievability of exposure-based learning to prevent relapse in anxiety disorders can be summarized as advice to conduct exposure under variable conditions. This way, the generalizability of what is learned during exposure to the patients’ daily life after treatment improves. Therefore, adding these strategies in the course of exposure-based treatment of anxiety disorders seems beneficial. However, future replications and translational studies are needed to verify ecological validity.     

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.     

Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.     

Translating Empirically Supported Strategies Into Accessible Interventions: The Potential Utility of Exercise for the Treatment of Panic Disorder

Many patients suffering from panic disorder do not receive adequate care. Advances in the conceptualization and treatment of panic disorder encourage innovative strategies for targeting core fears (fears of anxiety sensations) that underlie this disorder. In this article, we discuss the use of exercise as a potential strategy for therapeutic exposure to these feared sensations, and the role that exercise may play as an acceptable intervention to aid the dissemination of exposure-based approaches to the treatment of panic disorder. Evidence for the efficacy of exercise for the treatment of anxiety and panic is presented; along with strategies to enhance the role exercise can play as an interoceptive (internal sensation) exposure procedure. Finally, issues of comorbidity and exercise acceptability are discussed. Our conclusion is that exercise-based interventions are promising strategies for improving the utilization of exposure-based interventions for panic disorder. Clinical guidelines and future research directions are discussed.     

Treatment of a Case Example With PTSD and Chronic Pain

This commentary reviews the case of GH, a survivor of a road traffic collision, who has chronic pain and posttraumatic stress disorder (PTSD). The case formulation, assessment strategy, and treatment plan are informed by the relevant experimental literature and empirically supported treatments using a cognitive behavioral perspective. Given this framework, the commentary includes a focus on the treatment of PTSD with an eye toward generalizing the therapeutic strategies to chronic pain problems. Psychoeducation, imaginal exposure to the traumatic event, in vivo exposure to avoided activities, and cognitive interventions including coping self-statements, correction of logical errors, decatastrophizing and developing alternative explanations are all included in the recommendations as part of a standard cognitive behavioral treatment for PTSD. Added to this standard PTSD protocol is the suggested use of interoceptive exposure to address GH’s feared bodily sensations. In the assessment domain, standard measures for pain and PTSD assessment are suggested along with tracking of depression and anxiety sensitivity. Some recognition of more recent approaches to cognitive behavioral therapy (e.g., Acceptance and Commitment Therapy) is given in considering potential obstacles to treatment.     

Enhancing Inhibitory Learning: The Utility of Variability in Exposure

Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.     

New Directions in the Cognitive-Behavioral Treatment of OCD: Theory,Research, and Practice

The beneficial effects of cognitive-behavioral interventions (particularly exposure and response prevention) for OCD are among the most consistent research findings in the mental health literature. Nevertheless, even after an adequate trial, many individuals experience residual symptoms, and others never receive adequate treatment due to limited access. These and other issues have prompted clinicians and researchers to search for ways to improve the conceptual and practical aspects of existing treatment approaches, as well as look for augmentation strategies. In the present article, we review a number of recent developments and new directions in the psychological treatment of OCD, including (a) the application of inhibitory learning approaches to exposure therapy, (b) the development of acceptance-based approaches, (c) involvement of caregivers (partners and parents) in treatment, (d) pharmacological cognitive enhancement of exposure therapy, and (e) the use of technology to disseminate effective treatment. We focus on both the conceptual/scientific and practical aspects of these topics so that clinicians and researchers alike can assess their relative merits and disadvantages.     

Targeting a niche market of pet owners: consumer evaluation of a mobile veterinarian's service concept

The veterinary care service industry in the USA is projected to continue its growth during the next decade, primarily due to increasing numbers of pets and rising consumer expenditure for pet medical care. The increasing demand for pet care has spawned a proliferation of traditional and non‐traditional veterinary services. There is a need to examine the market potential for new veterinary services. A concept test among 150 target consumers is used here to provide an evaluation of a non‐traditional veterinary service—mobile veterinary care for small companion animals. Although using a vet who makes house calls would require a change in consumer behaviour, the findings indicate that the service concept is appealing to a niche market of pet owners who desire more service convenience and are willing to pay for it. Educating more consumers about the service benefits may broaden its appeal. Copyright © 2002 Henry Stewart Publications Ltd.     

The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature

This article reviews research into the use of virtual reality in the study, assessment, and treatment of body image disturbances in eating disorders and nonclinical samples. During the last decade, virtual reality has emerged as a technology that is especially suitable not only for the assessment of body image disturbances but also for its treatment. Indeed, several virtual environment-based software systems have been developed for this purpose. Furthermore, virtual reality seems to be a good alternative to guided imagery and in vivo exposure, and is therefore very useful for studies that require exposure to life-like situations but which are difficult to conduct in the real world. Nevertheless, review highlights the lack of published controlled studies and the presence of methodological drawbacks that should be considered in future studies. This article also discusses the implications of the results obtained and proposes directions for future research.     

Prolonged Exposure Therapy With an Older Adult: An Extended Case Example

Prolonged exposure therapy (PE) has gained strong empirical support for posttraumatic stress disorder (PTSD) in the general population. However, some authors have suggested that exposure therapies may be less effective for the treatment of PTSD in older adults. There is a paucity of empirical treatment studies for older adults with PTSD. The extant studies are briefly reviewed. There are indications that exposure therapies can be feasible, safe, and efficacious for older adults. However, the degree and maintenance of gains may be reduced in older adults relative to younger adults. A case example is presented to provide a detailed illustration of PE conducted with an older adult. The treatment is presented in five phases, including standard treatment components and suggested modifications for older adults. The modifications include careful use of terminology, slowing down the presentation of some information, involvement of family members, and utilizing technology to minimize the negative effects of physical impairments and stigma.     

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.     

A Retrospective Examination of the Similarity Between Clinical Practice and Manualized Treatment for Childhood Anxiety Disorders

The objective of this study was to facilitate the bidirectional communication between researchers and clinicians about the treatment of childhood anxiety disorders, including obsessive-compulsive disorder. Forty-four children were assessed before and after cognitive behavioral treatment with the parent versions of the Spence Child Anxiety Scale and Child Sheehan Disability Scale. In this retrospective study, treatment sessions were coded for the presence of exposures, relaxation, anxiety management, and behavior management. Results showed improved functioning within the clinical sample and suggested that treatment could be shorter, with exposure exercises implemented earlier in the course of treatment than described in manuals. Moreover, improvements in functioning were positively related to the use of exposures, and negatively related to the use of other anxiety management strategies. These results are discussed in the context of efforts to increase the availability of evidence-based treatments and are interpreted as supporting the development of more flexible treatment manuals.     

Multimedia Field Test Thinking About Exposures? There’s an App for That!

Anxiety Coach is a smartphone application (“app”) for iOS devices that is billed as a self-help program for anxiety in youth and adults. The app is currently available in the iTunes store for a one-time fee of $4.99. Anxiety Coach is organized around three related content areas: (a) self-monitoring of anxiety symptoms, (b) learning about anxiety and its treatment, and (c) guiding users through the development of a fear hierarchy and completion of exposure tasks. Although the app includes psychoeducation about anxiety as well as information regarding specific skills individuals can use to cope with anxiety (e.g., cognitive restructuring), the primary focus of the app is on exposure tasks. As such, the app includes a large library of potential exposure tasks that are relevant to treating common fears and worries, making Anxiety Coach useful to clients and clinicians alike. Additionally, Anxiety Coach prompts users to provide fear ratings while they are carrying out an exposure task and displays a message instructing users to stop the exposure once fear ratings drop by half. These features work together to create an app that has the potential to greatly increase the reach of exposure-based cognitive behavioral therapy for anxiety.     

Safety Behaviors in Adults With Social Anxiety: Review and Future Directions

Safety behaviors are considered an important factor in the maintenance of social anxiety disorder (SAD). Safety behaviors are typically employed by socially anxious individuals to reduce anxiety in feared social situations. However, by preventing individuals with social anxiety from gathering evidence that would disconfirm their maladaptive beliefs about social situations, the use of safety behaviors ultimately maintains social anxiety over time. Twenty years ago, Wells and colleagues (1995) demonstrated that use of safety behaviors diminishes the efficacy of exposure treatment for SAD, suggesting that reduction in the use of safety behaviors during exposure can enhance treatment response. Research on safety behaviors has expanded considerably since Wells et al.’s seminal publication, and our understanding of the role safety behaviors may play in the maintenance of social anxiety has grown in breadth and depth. In this paper, we present a detailed review of the published research on safety behaviors relevant to social anxiety and social-anxiety-related processes. Finally, we evaluate the impact of safety behaviors on the outcome of treatment for SAD, and we look to the literature on safety behaviors in other anxiety disorders to inform our understanding of use of safety behaviors during exposure and to facilitate future research in SAD.     

Safety behaviour does not necessarily interfere with exposure therapy

There has been much recent controversy regarding whether or not the use of safety and other neutralizing behaviour interferes with exposure-based therapy. The aim of this study was to examine the role of safety behaviour in the treatment of specific phobia. Sixty-two snake-fearful participants were randomized to a 45-min exposure session with or without the use of safety gear, such as gloves and goggles. During the treatment, participants in the safety behaviour group were able to achieve a significantly closer initial distance of approach to the snake compared to controls. When tested post-treatment without any safety gear, both groups demonstrated comparable treatment gains involving significant reductions in fearful cognitions and subjective anxiety, as well as significant improvements in distance of approach. Results suggest that reliance on safety behaviour during exposure therapy for anxiety disorders may not interfere with treatment outcome.