is an emotion associated with a sense of uneasiness and apprehension.
It is a future orientated emotional response in reaction to the perception
of threat of some kind. Anxiety, fear and panic tend to revolve around
the perception of threat toward one's physical well-being and safety,
one's acceptability in social situations or one's emotional state.
The thought processes associated with anxiety tend to be future orientated.
Thinking is often repetitive and rumination is often present. Anxiety
tends to be accompanied by behavioural responses that are orientated
toward avoidance of the anxiety-provoking stimulus.
A diversity of physical symptoms of varying intensities associated
with autonomic nervous system arousal may develop. These would include:
- Heart palpitations or accelerated heart rate
- Trembling or shaking
- Sensations of shortness of breath or an elevated respiratory
- Chest pain or discomfort or a sense of pressure on the chest
- Nausea or abdominal distress
- Feelings of dizziness or light-headedness
- Derealization (feelings of unreality) or depresonalization (feeling
detached from oneself)
- Feelings of numbness or tingling
- Cold chills or hot flushes
- Impaired attention and concentration
FEAR is seen as a response
to a known, external, definite threat (e.g. a snake or a gun being
pointed at you) as oppose to anxiety that is often experienced in
response to an unknown or more vague and less definite threat that
is often not immediately present.
PANIC on the other hand is
defined as an intense episode of intense dread or fear. Panic tends
to have an abrupt onset as oppose to gradually building anxious
arousal. It is associated with an intense urge to escape and less
often with urges to fight. The tendency to flee or escape is supported
by strong autonomic nervous system arousal and includes intense
symptoms such as those listed above. The perception of threat is
imminent with panic, whereas with anxiety the threat is seen as
more future orientated.
Figure 1: Representation of the cognitive-biological-behavioural
nature of anxiety
HEALTHY vs UNHEALTHY ANXIETY
Many "negative" or unpleasant emotional reactions may be
seen as either healthy and functional or unhealthy and dysfunctional.
For instance, if someone feels extreme fear during the course of an
armed robbery or symptoms of anxiety before or during an oral examination
then this may be unpleasant and uncomfortable but it may not necessarily
be unhealthy or dysfunctional. In fact, fear and anxiety may actually
be extremely helpful. If humans (and animals) did not have the ability
to fear, then we would all have been extinct by now! Fear and anxiety
really does help keep us alive! Certain scenarios really do require
fear as a protective mechanism, such as swimming with sharks in deep
water, falling from a dangerous height, walking down a dangerous alley
at night or sleeping with your doors unlocked. If we did not fear
these scenarios or feel some concern or anxiety about them, then none
of us would behave in such a manner so as to prevent these realistically
dangerous situations from occurring.
Unhealthy or dysfunctional anxiety on the other hand can generally
be defined by the following criteria:
- The perception of threat is seen to be greater than the objective
degree of threat
- The anxiety tends to impair an individual's ability to function
within their respective roles and their environment
- The anxiety is perceived as distressing and unwanted
- The anxiety and its associated symptoms are experienced over
an extended period of time which is not objectively necessary.
WHAT IS AN ANXIETY DISORDER?
Anxiety disorders are probably the most common of all psychiatric
and psychological disorders. They are however also probably one
of the most responsive groups of psychological disorders to treatment
from a CBT perspective.
In order for a diagnosis of an anxiety disorder to be made, a thorough
clinical assessment is required and such an assessment would need
to reveal the following:
- That prominent symptoms of anxiety are present and that those
symptoms are experienced as distressing.
- That the symptoms have been present for a significant period
of time (that meets the minimum time period criteria for that
- That the symptoms cause a sufficient amount of disturbance or
impairment in an individual's ability to function at work or school,
within social settings and in other important areas of functioning
While some individuals may experience
what is referred to as sub-clinical or "less severe and disabling"
symptoms of anxiety, most anxiety symptoms fall into one of the
Professionals trained in the diagnosis of anxiety disorders would
include psychiatrists, psychologists and general practitioners.
For an accurate diagnosis to be made, a mental health professional
well trained in the assessment, diagnosis and treatment of anxiety
disorders is often required. Making an accurate diagnosis is of
extreme importance. The reason for this is that CBT-based treatments
for anxiety disorders are becoming more disorder specific. This
is as a result of ongoing theoretical and treatment developments
that inform more specific treatment planning. As a result, successful
treatment is generally highly dependent upon an accurate diagnosis
being made. Knowing that someone has anxiety is insufficient for
disorder specific treatment planning.
WHAT IS THE COGNITIVE-BEHAVIOURAL
PERSPECTIVE ON THE DEVELOPMENT OF ANXIETY DISORDERS?
Cognitive-behavioural theory for anxiety disorders has grown rather
significantly over the last few decades. More recent additions to
our understanding of the development and treatment of anxiety disorders
have taken place as a result of significant advances in neuroscience
(McNally, 2007). See our LINKS
PAGE to the very interesting Le Doux Laboratory website
in this regard. These developments together with pre-existing cognitive
and behavioural theory have assisted in informing our theoretical
understanding and treatment approaches within modern day clinical
The development, maintenance and successful treatment of anxiety
disorders is seen as being related to a number of factors.
PREDISPOSING DEVELOPMENTAL FACTORS are
factors that are present from early on in childhood, that tend to
increase the risk of the development of an anxiety disorder. These
would include factors such as:
- Family history of anxiety (genetic predisposition)
- Temperamental style associated with anxiousness and greater
physiological reactivity and
a particular thinking style that may predispose one toward
- Early trauma, early parental separation or unstable living conditions
PRECIPITATING DEVELOPMENTAL FACTORS are
factors that contribute greatly toward the onset of a first episode
of anxiety or an experience during which fear conditioning (see
below) may take place. These may vary across the different anxiety
disorders. They may include a variety of factors such as:
- A traumatic event (motor vehicle accident or mugging)
- An unpleasant and uncomfortable encounter with an animal (e.g.
a bird or a dog) especially during childhood
- Unpleasant and uncomfortable physical symptoms associated with
a medical condition (e.g. feelings of shortness of breath related
- Experience of someone else suffering a serious medical condition
(e.g. parent having a heart attack)
- Unremitting pressure and stress at work
- Some other uncomfortable experience during which one responds
with a significant amount of anxiety.
Precipitating developmental factors may also include a number of
other internal physiological factors that may "set one up"
with high levels of physiological arousal such as intoxication,
illness, sleep deprivation or caffeine intoxication or physiological
factors such as thyroid problems, intense headache or migraine,
a heart attack or changes in other biological variables such as
blood carbon dioxide levels.
FEAR CONDITIONING is the process during
which all of the above factors come together. During fear conditioning,
neutral or "non dangerous" stimuli are strongly associated
with "dangerous" stimuli or the perception of threat and
the fear response (Mc Nally, 2007).
Figure 2: A diagrammatic illustration of the way in which
a non-dangerous stimulus (memory of a traumatic event) becomes a
conditioned stimulus for the perception of threat and the fear response.
The example relates to an individual suffering from PTSD
These neutral stimuli may be internal. For example:
- Elevated heart rate or light-headedness in the case
of people suffering from panic disorder
- The thought that one's hands are dirty and must be washed
in the case of people suffering with OCD - contamination type
- A memory of a past traumatic event in the case of someone
suffering from PTSD
These stimuli are however often also external. For example:
- Driving on the N1 in the case of people suffering from
post-traumatic stress disorder after a motor vehicle accident
- Standing on a ladder in the case of someone with a phobia
- Being the last one to enter a room full of people in
the case of someone suffering with social phobia
The brain learns that these "previously neutral" stimuli
are dangerous and should be feared and avoided. Fear conditioning
may occur during a single event or over a period of time as a result
of repeated experiences.
This learning tends to however be inaccurate in the case of anxiety
disorders where the degree of threat associated with these stimuli
tends to be overestimated and the fear response is thus exaggerated.
There are a number of different learning systems within the brain.
The anatomical structure most central to fear condition is the amygdala,
a tiny pea shaped structure that lies alongside the hippocampus
(also involved in learning, memory and anxiety) in an anatomical
cluster of nuclei referred to as the limbic system. Other structures
within the limbic system have however also been implicated as being
highly involved with anxiety disorders.
Once fear conditioning has taken place, the anxiety disorder and
fear response that goes along with that tends to be rather resistant
to change. The amygdala learns what "should be feared"
very quickly and it remembers those fear stimuli very well but it's
not all that good at later learning that those stimuli are not actually
dangerous. This is a much slower, more resistant process that relies
on the strengthening of inhibitory pathways from the medial pre-frontal
cortex that shut the amygdala's fear response down (Davis, 2002).
The amygdala is a structure lower down in the brain and it is what
we would refer to as a more primal structure. Without it we would
have no fear response and thus be extremely vulnerable to danger,
death and extinction. The problem with the overly-sensitive or overly-reactive
amygdala is that it is not very good at distinguishing between various
contexts. An overly sensitive and reactive amygdala is also not
very good at distinguishing more subtle differences between stimuli
involved during fear conditioning vs. non-dangerous stimuli that
are encountered after fear conditioning has taken place. As a result,
it sees anything that resembles the feared stimulus as signalling
danger. This is why an individual with a snake phobia will have
a phobic response to a picture of a snake in a magazine, two metres
away. The non-dangerous stimulus (picture of snake in magazine)
is present and this is all the amygdala needs to react. It does
not distinguish between contexts and therefore does not realize
that this stimulus and this context is non-dangerous.
The other problem with the amygdala is that it is extremely quick
in its perception of threat and its reaction to it. The primal nature
of this structure allows it to receive incoming sensory information
and react to it before the conscious brain is even aware of it (Harvey,
Bryant & Tarrier, 2003). This is why people with anxiety disorders
will often report that they started to feel anxious before they
have even had any thoughts going through their mind. The amygdala
is a protective structure that will initiate the fear response before
we are consciously aware of the stimulus. It's similar to the automatic
response that you have to placing your hand on a hot object. The
brain and spinal cord have automatic reflex mechanisms that perceive
the danger of the hot object and allow you to immediately remove
your hand from the object before you have necessarily consciously
realized that your hand is burning. If we had to wait for the thinking
part of the brain (the cortex) to first realize that there is some
threat then we would take too long to react to it. This is also
why it is difficult to "think your way out of anxiety",
because the fear response is often initiated before conscious cognition
is present, so the anxiety has a head start. This is also why traditional
"talk therapy" is rather unhelpful in treating anxiety
disorders and why reconditioning or prolonged exposure is so important.
Figure 3: A diagrammatic illustration of the neural pathways
involved in the perception of threat and the fear response. Note
how the amygdala would tend to react to a stimulus before the "thinking
brain" can challenge the reaction!
DYSFUNCTIONAL THINKING is associated
with the development and maintenance of anxiety disorders (Beck
& Emery, 1985). It is possible that dysfunctional ways of thinking
may sometimes cause anxiety on their own but dysfunctional thinking
is often the conscious brain's reaction during fear conditioning.
Dysfunctional thinking may however also develop in response to anxiety.
We call this secondary disturbance (Walen, DiGiuseppe & Dryden,
1992) and much of the initial stages of cognitive therapy is orientated
toward reducing anxiety about anxiety. Exactly when during the development
of anxiety, thinking plays its role, is less important than the
fact that we know that it contributes toward maintaining it and
that it's helpful to challenge dysfunctional thinking as a critical
component to treatment.
The dysfunctional thinking styles that people with anxiety disorders
present with tend to revolve around multiple themes. Some examples
of dysfunctional thinking would include the following:
- Overestimation of the degree of
threat of a particular situation
Snake Phobia "if I walk on
the mountain then I will be bitten by a snake (and die)"
Panic Disorder "if I have
a panic attack, then I will have a heart attack (and die)"
PTSD "if I drive on the N1
again then I will end up in an accident"
OCD "If I have a blasphemous
thought again like this, then something terrible will happen
Confusing low probability with
PTSD "there is a 50%
chance that I will be sexually assaulted again"
Flying Phobia "there's
a fifty-fifty chance that the plane could crash"
Catastrophising or Awfulizing or
regularly predicting the worst-case scenario
Social Phobia "they'll
think I'm crazy if they see that I'm anxious and that would
GAD "it would be horrible
if I don't get the job, and then I may never get another one"
Panic Disorder "it would
be awful if I had another panic attack"
Underestimating one's ability to
cope with an adverse situation also referred to as Low Frustration/Discomfort
Panic Disorder "I can't
handle the panic attacks"
All Anxiety "I can't
handle those feelings of anxiety"
OCD "I can't stand the
urge to wash my hands, it's too much"
OCD/GAD "The uncertainty
is just too much to bare, I must know for certain"
that if something bad had happened once, that it will always
PTSD "I'll never be
able to drive on the N1 without having an accident again"
PTSD "All men are
thinking of sexually assaulting me when they look at me"
Social Phobia "I'll
always be anxious in front of strangers"
or "Must" statements or imperatives that tend to increase
Agoraphobia "I must
not be anxious"
Social Phobia "Other people
must not have a negative opinion of me or judge me"
GAD/Performance Anxiety "I
have to get an A for my exam"
Panic Disorder and Agoraphobia
"I should have total control at all times over my
Negative Self-Rating, where one
judges the whole of oneself as bad, inadequate, worthless or
Social Phobia "Getting
so anxious makes me a weak person and other people will
think this of me "
GAD/Performance Anxiety "I'm
such a failure for having failed at that task"
Anxiety within Relationships
"If I do all these things and I still can't get John to
love me then I must be unlovable"
Misinterpretation of the meaning
or danger of physical symptoms
All Anxiety "If I allow
myself to get so anxious then It might become totally out
Panic Disorder "I'll have
a stroke if these panic attacks continue"
Claustrophobia "I won't
be able to breath and I'll end up suffocating"
As previously mentioned, there are at least two parallel systems
involved in fear conditioning. The one is involved in more sub-concious
fear conditioning and reaction to sensory cues and the other involves
more conscious sensory perception and thought (Brewin, 2001; Dalgleish,
Anxiety provoking or anxiety maintaining beliefs may be the result
of years of repetitive dysfunctional thinking patters which may
be driven by what is referred to as underlying dysfunctional cognitive
schema's or core beliefs, which often develop out of experience.
For example, a child that grows up experiencing numerous unexpected
and traumatic or difficult events may develop certain beliefs about
the probability of "something bad happening". This may
later on lead to an intolerance of uncertainty and an associated
tendency to catastrophize and predict the worst-case scenario. This
may function as one of the thinking or cognitive mechanisms that
underlies generalized anxiety disorder or chronic worry.
Dysfunctional beliefs may however also develop in conjunction with
or in reaction to more automatic fear conditioning. For example,
people with panic disorder may not have any particular dysfunctional
thinking styles that result in their initial panic attack. Further
panic attacks may however be initiated by dysfunctional thinking
about the nature of panic.
Figure 4: Using the example of John suffering with Panic Disorder
and Agoraphobia, the cognitive model would explain the influence
of dysfunctional cognitions or thinking in the following way:
John becomes aware of some slight symptoms of anxiety
or thinks about the possibility of having a panic attack
I must be able to control my anxiety
If I can't stop it now, then it will become totally
out of control
I'm going to have a heart attack and die
I cant cope with this anymore
I'm such a weak person, what's wrong with me
I must avoid these places where It's difficult to escape
if I become anxious
I'll never get over this
UNHEALTHY EMOTIONAL REACTIONS
Anxiety (about anxiety)
Insomnia (worry about panic in sleep)
UNHEALTHY BEHAVIOURAL REACTIONS
Avoidant coping mechanisms
Avoid physical exercise
Use of alcohol and tranquillisers to relax
Avoid places where the panic is more prevalent
tend to revolve around avoidance behaviour. Avoidance behaviours
tend to actually exacerbate or maintain anxiety. Avoidance always
seems like a good solution (because in the short term it is anxiety-reducing)
but it's actually a symptom of an anxiety disorder and tends to
make things worse.
The brain falsely learns during fear conditioning that certain "non-dangerous"
stimuli "are dangerous" and should be feared and avoided".
There is really only one way in which the brain is able to learn
that this is in fact untrue and that the "feared stimulus"
is in fact quite safe and does not need to be feared or avoided.
This is through a technique referred to as prolonged exposure or
extinction training (Rothbaum & Foa, 1992). During prolonged
exposure the brain learns that the "non-dangerous" feared
stimulus is in fact not dangerous and as a result the brain stops
reacting to it with fear and the behavioural tendency to avoid.
Avoidance prevents the brain from learning that the non-dangerous
feared stimulus is in fact not actually threatening and does not
need to be feared or avoided.
Figure 5: The exacerbation and maintenance of anxiety as a result
of escape or avoidance
Avoidance thus ensures that the fear stimulus is either never encountered
or is only encountered for short periods of time before escape is
initiated, as illustrated in the graph above. As a result, prolonged
exposure cannot occur if the feared stimulus is never encountered
for significant periods of time. Avoidance thus ensures that the
association between non-dangerous stimuli and the perception of
danger and fear remains, which obviously keeps the fear response
intact and the anxiety disorder in place.
Avoidance may include basic behavioural avoidance and more subtle
avoidance behaviours such as alcohol abuse or the use of prescription
medication such as tranquilizers or benzodiazepine medication, that
all assist in reducing the symptoms of anxiety (whilst the substance
is in ones body) but seldom lead to sustained symptom reduction.
This is because the association between the feared stimulus and
the fear reaction remains and is merely avoided.
WHAT ARE THE COMPONENTS TO COGNITIVE-BEHAVIOURAL THERAPY FOR ANXIETY
The cognitive behavioural therapy approach toward the understanding
and treatment of anxiety disorders differs somewhat between each
of the disorders. There are however a number of concepts and treatment
approaches that are central to most treatment approaches for all
anxiety disorders. These are outlined below. Please refer to the
sections on each of the respective anxiety disorders for a short
summary of what CBT-based treatment entails for each of the respective
The purpose of cognitive-behavioural therapy is to assist individuals
in altering their emotional distress and dysfunctional behavioural
patterns. This is no different to most other psychotherapy approaches.
The ways of understanding anxiety and the methods employed in treating
it are however very specific and rather unique to CBT. From a cognitive-behavioural
therapy perspective, anxiety disorders are seen as the result of
inappropriate fear conditioning and dysfunctional ways of evaluating
the degree of threat of the feared stimulus.
THE COGNITIVE MODEL proposes that it is
not merely a potential adverse situation that leads to panic, fear,
anxiety and worry but the way in which we think about it (Beck &Emery,
1985; Ellis & Harper, 1961). Cognitive theory proposes that
irrational or dysfunctional ways of thinking about a particular
stimulus or event would result in unhealthy fear and anxiety about
that stimulus or event.
Cognitive therapy is thus aimed at identifying those thoughts, attitudes
and assumptions that create, exacerbate or maintain unnecessary
fear and anxiety. Some of these thinking patterns may be very obvious
and conscious whilst others may sit a little below conscious awareness,
but easily elicited and identifiable with the correct interviewing
techniques. Once identified, these thoughts, assumptions and attitudes
are assessed in a scientific manner with regards to the following:
- Whether they follow logical reasoning
- Whether or not they are based on any objective evidence
- Whether they are helpful or self-defeating and anxiety provoking.
A variety of different types of irrational ways of thinking may
be identified as shown in the section above on Dysfunctional Thinking.
Once identified these thoughts, attitudes and assumptions are disputed
or challenged and ultimately replaced by healthier, more evidence
based, logical cognitions or way of thinking. These healthier thinking
styles are then practiced repeatedly and with different methods
that enable people to develop a stronger level of conviction for
these healthier ways of thinking (Walen, DiGiuseppe & Dryden,
1992). This tends to assist in reducing anxiety and reducing avoidance.
However, as previously mentioned, it is very difficult to "think
your way out of anxiety". This is because the pre-frontal cortex
or thinking part of the brain is quite good at activating the amygdala
but not all that good at shutting it down. This is where the behavioural
model comes into play.
Figure 6: An example is provided below of how someone suffering
with panic disorder may be thinking and how their thoughts are identified,
disputed and changed to healthier ways of thinking using the cognitive
John becomes aware of some slight symptoms of anxiety
or thinks about the possibility of having a panic attack
I cannot have absolute control over my anxiety and trying
to gain absolute control will only make it worse, I'll
have greater control if I don't try to have total control
Trying to stop it now is like trying to have total control
of it, I can rather work on tolerating it while it temporarily
The anxiety is a physical symptom but it is not a dangerous
physical symptom and I can't have a heart attack or
experience any other harmful consequence as a result
I can cope with it while its lasts (because I have always
survived it in the past), I just don't like coping with
I have many strengths and weaknesses, but I am neither
completely strong nor weak, even though I'm battling
with anxiety. My amygdala may be overly sensitive though!
I would prefer to avoid the anxiety, but avoidance is
not a must and it will only make me fear the anxiety
for longer. Tolerating it while it lasts in the short
term will help to reduce it in the long term
I'll be the first one if I never get over this (and
perhaps be famous for it!). It will temporarily last
for sometime until it goes
UNHEALTHY EMOTIONAL REACTIONS
Less intense Anxiety (about anxiety)
Reduced tendency to develop Panic
Reduced worry about panic
Reduced risk of Depression
UNHEALTHY BEHAVIOURAL REACTIONS
Less avoidant coping mechanisms
Less avoidant coping mechanisms
Participation in physical exercise
Reduced use of alcohol and tranquillisers
Greater Tolerance of anxiety
Greater preparedness to participate in exposure
therapy (in vivo and interoceptive)
THE BEHAVIOURAL MODEL proposes that anxiety
disorders result from inappropriate fear conditioning. This means
that the brain inaccurately associates non-dangerous stimuli in
non-dangerous contexts with the perception of threat and the fear
response. The behavioural model is now substantiated and further
informed by significant advances in neuroscience (McNally, 2007).
The behavioural model proposes that avoidant coping responses only
serve to exacerbate and maintain the inaccurate association between
non-dangerous stimuli in non-dangerous contexts with the perception
of danger and the fear response.
It proposes prolonged exposure or extinction training as the solution
to this inaccurate association and suggests this as the only way
in which non-dangerous stimuli in non-dangerous contexts can be
accurately associated with the perception of safety and a non-anxious
response. The problem with exposure is that anyone with an anxiety
disorder will initially respond with the fear response and with
significant symptoms of anxiety. As a result, most people tend to
leave the situation and escape or avoid it. This does not give the
brain sufficient time to learn that the feared consequences do not
actually occur or that the anxiety is tolerable or does eventually
reduce. This is why exposure must be prolonged. It needs to be long
enough for the brain to have the opportunity to realize how these
stimuli do not need to be feared. Exposure also needs to be long
enough for the brain to begin rewiring itself and developing inhibitory
pathways from the medial pre-frontal cortex to the central nucleus
of the amygdala, that shut the fear response down.
Figure 7: The eventual reduction in symptoms of anxiety during
prolonged exposure (without avoidance) over a 20 to 60 minute period.
There are four types of prolonged exposure that are used with varying
degrees according to the anxiety disorder that is being treated
(Choy, Fyer, Lipsitz, 2007).
PROLONGED IN-VIVO EXPOSURE
Prolonged in-vivo exposure is a technique that is used with individuals
who are suffering from anxiety disorders where the feared stimulus
is external. Prolonged exposure is done to the feared stimulus that
has previously been avoided in response to the anxiety. Prolonged
in-vivo exposure is used with most anxiety disorders but most often
forms a significant component to treatment planning with specific
phobias, social phobia, agoraphobia, obsessive-compulsive disorder
and post-traumatic stress disorder.
PROLONGED IMAGINAL EXPOSURE
Prolonged imaginal exposure is a technique that is primarily used
with individuals who are suffering from post-traumatic stress disorder.
Imaginal exposure is used with anxiety disorders where the feared
stimulus is imaginal (an image). Memories of traumatic experiences
trigger a great deal of anxiety and panic in individuals suffering
from PTSD. The memories and all that triggers them are seen as the
non-dangerous stimuli, which trigger the perception of threat and
the fear response in PTSD. Exposure is thus done to the images and
memories of the traumatic event until the brain no longer reacts
to them as dangerous (because they aren't, even though they may
remain unpleasant). Imaginal exposure may also be used in the treatment
of other anxiety disorders as a preparatory step before in-vivo
exposure. Imaginal exposure to images relating to the content of
worry, may also be done with people with generalized anxiety disorder.
Interoceptive exposure is a technique during which individuals are
exposed to the internal physical sensations that they react to with
fear, panic, anxiety or worry. Interoceptive exposure is used primarily
with people suffering from panic disorder, agoraphobia or claustrophobia.
It is however often also helpful as an adjunct to in-vivo exposure
for phobias, especially when people are extremely anxious and fearful
of their anxiety.
Virtual exposure is a technique that is used using virtual reality
computer software that assists individuals with exposure exercises
that would difficult to create in-vivo (real life). Virtual exposure
is most often used with people who have a phobia of flying. This
is because it is often difficult and very expensive to do in-vivo
exposure with aircraft.
Figure 8: A diagrammatic illustration of the way in which
a non-dangerous stimulus (memory of a traumatic event) becomes associated
with the perception of safety and a calmer response as a result
of prolonged imaginal exposure. As with figure 2 above, the example
relates to an individual suffering from PTSD
Each of these exposure techniques are ultimately aimed at assisting
the brain to build stronger associations between the non-dangerous
stimulus and the perception of safety that tend to overpower associations
between the non-dangerous stimulus and the perception of danger
and the fear response. Prolonged exposure is a very powerful and
extremely successful technique that assist in reducing symptoms
of many anxiety disorders. Our clinical experience would suggest
that prolonged exposure is most useful after an initial cognitive
therapy intervention and a significant amount of psycho-education.