Edna Foa on Exposure and Prolonged Exposure
For Anxiety Disorders
By Lynn Mollick
On Sunday March 16, Edna Foa presented NJ-ACT’s 20th annual Master Lecture to a sold-out audience of 115. In the morning Dr. Foa explained her emotional processing theory and its application to OCD, Social Anxiety Disorder, Panic Disorder, and PTSD. In the afternoon she described how to use prolonged exposure to treat PTSD.
Emotional Processing Theory
A fear structure includes information about: a feared situation and the meaning of that situation to the patient. The meaning that an individual places on a situation determines the individual’s behavior, thoughts, and emotions.
In the anxiety disorders, safe stimuli acquire dangerous meaning and therefore elicit unrealistic fear and avoidance. Cognitive Behavior Therapy enables patients to disconfirm pathological elements of their fear structure. At the end of successful treatment, patients believe that:
a) The previously-feared situation is not dangerous;
b) The patient’s anxiety will not last forever; and
c) Anxiety will not destroy the patient.
Successful treatment for the anxiety disorders includes both behavioral and cognitive interventions. Because each anxiety disorder has a specific fear structure, each disorder requires a specific treatment.
Obsessive-Compulsive Disorder (OCD)
OCD patients hold exaggerated beliefs about the danger of specific situations. These situations elicit anxiety and patients believe they can relieve their anxiety only by performing rituals. Exposure and response prevention for OCD has four components:
1. In vivo exposure – prolonged experiencing of fear-producing situations.
2. Imaginal exposure – prolonged imaginal experiencing of feared situations. Imaginal exposure must be utilized for feared situations that cannot be experienced in vivo, e.g. burning in hell.
3. Ritual prevention – not performing any rituals to reduce anxiety.
4. Cognitive processing – “what did you learn?” - discussion after exposure about erroneous beliefs that were disconfirmed.
EX/RP is about twice as effective as the best antidepressant (clomipramine/Anafranil). But adding an antidepressant to EX/RP does not improve its efficacy. Antipsychotics (risperidone) are no better than placebos.
Panic Disorder (PD)
Panic Disorder patients believe that sensations in their body are dangerous because they lead to heart attacks, fainting, or “going crazy.” Panic patients avoid situations that elicit feared body sensations.
Barlow’s Panic Control Treatment corrects erroneous beliefs and avoidance behaviors. The treatment has 3 components:
1. Information that body sensations are normal rather than dangerous.
2. Interoceptive exposure: intentionally provoking the feared body sensations.
3. In vivo exposure to situations that evoke feared body sensations.
Alprazolam (Xanax) interferes with cognitive behavioral treatment for PD because it prevents patients from experiencing sensations of anxiety and learning that the symptoms are not dangerous.
Social Anxiety Disorder (SAD)
SAD patients hold misconceptions about their social performance:
1. People will criticize imperfect behavior.
2. People can tell if I am anxious and anxious people are disrespected.
3. I am dull and boring.
In social interaction SAD patients focus on themselves instead of on the other person. SAD patients develop safety behaviors, subtle ways to avoid social anxiety. Safety behaviors interfere with effective social behavior. Rehearsing answers to questions and avoiding eye contact are common safety behaviors.
Providing experiences that disconfirm SAD patients’ dysfunctional beliefs is difficult because SAD patients are often socially isolated and because SAD patients don’t believe friends who tell them that their social behavior is fine.
Although SAD patients improve with CBT, they often remain symptomatic. For example. Group therapy that includes cognitive restructuring, exposure to simulated social situations, and homework is an empirically supported treatment. However, medication is more effective than CBT and adding medication to CBT improves outcome.
Group CBT for SAD includes instructions to focus on the other person, to omit safety behaviors, and videotaped feedback to demonstrate that patients’ social behavior is much more effective than they believe. (Note: In September 2011, Richard Heimberg presented NJ-ACT members with a more optimistic view of CBT’s effectiveness for SAD. (See: http://nj-act.org/heimberg.html )
Post Traumatic Stress Disorder (PTSD)
80 to 90% of traumatized individuals recover without treatment. However, if symptoms persist for two to four weeks, you can conduct CBT for PTSD. If symptoms persist for a year, they become chronic. Patients with chronic PTSD present to mental health professionals with depression and anxiety -- you almost always must inquire about trauma to discover it.
In PTSD, the fear structure contains the trauma memory. The fear structure also includes representations of physiological and behavioral responses to the trauma and the meaning of the trauma. Patients avoid situations that evoke the trauma memory and the fear structure.
PTSD patients endorse the following erroneous beliefs:
1. The world is extremely dangerous.
2. People are untrustworthy.
3. My PTSD symptoms are a sign that I am weak/crazy.
4. Other people would have prevented the traumatic event.
Dr. Foa developed prolonged exposure (PE) as a treatment for PTSD. This protocol is effective for patients with personality disorders and works equally well for patients with high state anger and for those with low state anger. It has been studied around the world with different traumas, and it has been proven to be effective regardless of the particular trauma or population addressed.
The Prolonged Exposure Protocol
The protocol consists of ten 90-minute sessions and has five components:
1. In vivo exposure. Build a hierarchy of specific situations that the patient avoids. As long as these situations are safe, you want patients to stop avoiding them. Ask patients to confront a situation that is moderately distressing and to remain in the situation until anxiety diminishes by half. Avoidance maintains fear and depression.
2. Imaginal exposure to the trauma memory. During a therapy session patients record their memory of the trauma in detail from beginning to end. Between sessions patients listen to the recording without distractions every day. (Dr. Foa said that 3 times a week is good enough.)
Each week, patients are asked to retell the story and to include more details about the thoughts, emotions and sensations they experienced during the trauma. To justify the repetition, you can say: “No one remembers everything. This will help you get a new perspective on what happened.”
During initial imaginal exposures, the therapist encourages the patient to tell the story and does not ask questions. At session 6, the therapist begins to focus on “hot spots,” places in the narrative where patients’ recitation of events moves too quickly and they are clearly leaving details out.
Dr. Foa recommends taking suds ratings every 5 minutes. This helps patients see that they are progressing. It also alerts the therapist to problems in the treatment.
The goal of imaginal exposure is to tell a coherent narrative about the traumatic experience. At the final session, patients are able to tell the entire story of the trauma from beginning to end. They talk about the trauma as something unfortunate that happened in the past and they no longer experience it as if it is still happening.
Dismantling studies have shown that imaginal exposure is superior to in vivo exposure, and the combination of the two is better than either alone.
3. Cognitive processing – When patients finish imaginal exposure in the session, engage them in conversation about what they learned. Cognitive processing is just as effective as Cognitive Therapy and it’s easier to implement.
4. Pychoeducation – Tell PTSD patients about common reactions to trauma and give them handouts to read and refer to at home.
Explain PE to patients and tell them what to expect. “Right now your trauma memory controls you, but you will learn that what you thought was dangerous is not. You will be in control of yourself and of your memory of the trauma.” Have a positive attitude and tell patients you think they can do PE. “You will only feel upset for a little while and then you will get used to it.”
5. Breathing re-training – In the first session, teach patients diaphragmatic breathing to help them approach situations and memories they avoid. Dr. Foa is skeptical about the value of breathing re-training, but patients and therapists like it and it is part of her protocol.
A complete description of Dr. Foa’s PE protocol can be found in “Prolonged Exposure for PTSD” by E. B. Foa, E. A. Hembree, and B. O. Rothbaum, Oxford University Press.
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