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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.

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.

Another factor may be that many health care professionals do not understand the principles of exposure or may even hold (usually unfounded) negative beliefs about this form of treatment.

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.

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.

Surveys of psychologists who treat patients with PTSD show that the majority do not use exposure therapy and most believe that exposure therapy is likely to exacerbate symptoms.

The available research literature suggests that exposure-based therapy should be considered the first-line treatment for a variety of anxiety disorders.

Sometimes, in vivo exposure is not feasible (eg, it would be both difficult and hazardous for someone with combat-related PTSD to experience the sights, sounds, and smells of combat in real life).

In such cases, imaginal exposure can be a useful alternative.

In clinical practice, these approaches appear equally effective; however, most patients and clinicians choose a graded approach because of the personal comfort level.

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