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At first, all treatments appeared equally efficacious; however, at 6 months’ follow-up, 32% of patients in the CBT group continued to maintain their treatment gains compared with 20% in the imipramine group and 24% in the combined-treatment group.

Foa and colleagues randomized patients with OCD to receive in vivo exposure and response prevention, clomipramine, or a combination of both.

Exposure therapy is defined as any treatment that encourages the systematic confrontation of feared stimuli, which can be external (eg, feared objects, activities, situations) or internal (eg, feared thoughts, physical sensations).

The aim of exposure therapy is to reduce the person’s fearful reaction to the stimulus.

Internal vs external Exposures can target internal and/or external cues.

Exposures to external cues include a spider-phobic patient handling a spider, or a height-phobic patient systematically approaching increasing heights in a skyscraper.

Theoretical mechanisms of exposure therapy Biologically, the extinction of fear appears to be mediated by N-methyl-d-aspartate receptor activity in the basolateral amygdala, a finding that has led to the use of neuroplasticity compounds such as d-cycloserine to augment exposure.

For example, initial exposure to ocean water can be cold.

At posttreatment follow-up (after an average of 4 years), 90% of these patients still had significant reduction in fear, avoidance, and overall level of impairment and 65% no longer had a specific phobia.

Barlow and colleagues investigated the effects of interoceptive exposure with components of cognitive restructuring (cognitive-behavioral therapy [CBT]), imipramine, and a combination of the two in patients with panic disorder.

In clinical practice, exposure-based therapies for anxiety disorders are underutilized, which highlights the need for additional dissemination and training.

We hope the dissemination of the theoretical mechanisms, practical applications, and empirical support for exposure-based therapies in this article will encourage mental health practitioners to embrace this modality as a viable and easily accessible option in the treatment of anxiety disorders.

For example, in the Harvard/Brown Anxiety Research Project, only 23% of treated patients reported receiving even occasional imaginal exposure and only 19% had received even occasional in vivo exposure.

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