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.This is also true in panic disorder/agoraphobia, because the essential fear of panicking has to do with the fear of fainting, having a heart attack or losing one’s mind, events that have not occurred even in the midst of their worst panic attacks.It is somewhat more difficult when the source of the perceived danger is external, particularly when tied to real possibilities, no matter how remote (e.g.in specific fears of thunderstorms).Social phobia also presents the same type of difficulty,because the dreaded consequence is also external to the patient in the form of being ridiculed or at the very least of being seen as anxious by others.In these cases a cognitive behavioural therapeutic approach is often needed to ensure that the patient differentiates between his fears and real dangerbefore proceeding with exposure.Application.The dismantling of escape/avoidance mechanisms need notbe complete or start with exposure to the most feared situation at first.The pace of treatment needs to be individualized depending on the readinessand tolerance of the patient for anxiety.It is a good principle to follow a hierarchy of contexts from least distressful to most distressful.Concomitant treatment with antidepressants and even benzodiazepines can be useful aslong as benzodiazepines are not taken contingently to decrease anxiety norgiven in large doses that could interfere with the ability to experience the process of habituation.Once patients experience this process they becomeconvinced of its therapeutic usefulness and they can and very often doapply the exposure principle at every occasion.A point comes in treatmentPSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: COMMENTARIES __ 219where they spontaneously take the initiative of abandoning the most tacit of avoidance and escape mechanisms such as mental distractions, appliedrelaxation or breathing techniques, the anxiolytic they carried in theirpockets for many months or years, praying etc.The goal of treatment is toapproximate a situation where the patient no longer takes precautionarymeasures to avoid experiencing anxiety/fear and where the only responseelicited by fear, less and less frequent and severe, is to simply acknowledge its neurotic nature.The approach is both therapeutic and prophylactic andmay underlie the lasting effects of behavioural treatment.Research questions.The empirical evidence shows lasting improvementwith behavioural treatments.Whether this is due to the enduring effects of acute treatment or to ongoing maintenance treatment warrants investigation.One way of addressing this question would be to monitor the use ofanxiety management strategies, in addition to symptom severity, over thefollow-up period.The evidence presented by Barlow et al.clearly suggests that the effect-iveness of exposure depends on self-exposure regardless of whetherinstructions are provided by a therapist or not.Questions have also beenraised regarding the specific role of cognitive therapy independent ofexposure.Given the importance of translating evidence into practicalexperience, it may be valuable therefore to ascertain the extent to whichpatients require a fully manualized cognitive behaviour approach aboveand beyond the simple formulation of therapeutic rationale and instructions for self-directed exposure in everyday clinical practice.REFERENCE1.Mavissakalian M.(1993) Combined behavioral and pharmacological treatmentof anxiety disorders.In American Psychiatric Press Annual Review of Psychiatry, vol.12 (Eds J.M.Oldham, M.B.Riba, A.Tasman), pp.565–584.AmericanPsychiatric Press, Washington, DC.220 __________________________________________________________________________________________ PHOBIAS4.4The Treatment of Phobic Disorders: Is Exposure stillthe Treatment of Choice?Paul M.G.Emmelkamp1The review by Barlow et al.provides a fair evaluation of the progress that has been achieved in the treatment of phobias, particularly in the pastdecade.As noted by these authors, exposure in vivo is consistently effective across the various phobic conditions.Exposure therapy is based on thenotion that anxiety subsides through a process of habituation after a person has been exposed to a fearful situation for a prolonged period of time,without trying to escape.Several studies [1] have provided supportiveevidence for the role of habituation in exposure therapy, with self-reported fear and physiological arousal showing a declining trend across exposures,consistent with habituation.The success of exposure in vivo has also been explained by the acquisitionof fresh, disconfirmatory evidence, which weakens the catastrophiccognitions.From this perspective, exposure is viewed as a critical inter-vention through which catastrophic cognitions may be tested.Results of astudy [2] showed that cognitive change (decrease in frequency of negativeself-statements) indeed was achieved by exposure in vivo therapy.However, cognitive change per se was not related to a positive treatmentoutcome.A recent development consists of exposure by using virtual reality (VR).VR integrates real-time computer graphics, body tracking devices, visualdisplays and other sensory inputs to immerse individuals in a computer-generated virtual environment.VR exposure has several advantages overexposure in vivo.The treatment can be conducted in the therapist’s officerather than the therapist and patient having to go outside to do theexposure exercises in real phobic situations.Hence, treatment may be morecost-effective than therapist-assisted exposure in vivo.Further, VR treatment can also be applied on patients who are too anxious to undergo real-lifeexposure in vivo.In a study at the University of Amsterdam [3], the effectiveness of twosessions of VR versus two sessions of exposure in vivo was investigated in a within-group design in individuals suffering from acrophobia.VR exposurewas found to be at least as effective as exposure in vivo on anxiety andavoidance.The aim of a following study [4] was to compare the effec-tiveness of exposure in vivo versus VR exposure in a between-group design1 Department of Clinical Psychology, University of Amsterdam, Roetersstraat 15, 1018 WBAmsterdam, The NetherlandsPSYCHOTHERAPEUTIC INTERVENTIONS FOR PHOBIAS: COMMENTARIES __ 221with acrophobic patients.In order to enhance the comparability of exposure environments, the locations used in the exposure in vivo programme wereexactly reproduced in virtual worlds that were used in VR exposure.VRexposure was found to be as effective as exposure in vivo on anxiety andavoidance and also reflected in a reduction of actual avoidance behaviour.Recently, we completed a study [5] in which the role of feelings of presence during VR was investigated.High presence (Computer Automatic VirtualEnvironment, CAVE) and low presence (Head Mounted Display, HMD)were compared.Both VR exposure conditions were more effective thanno-treatment, but high presence did not enhance treatment effectiveness [ Pobierz całość w 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