The Exposure Therapy Evidence Map.
What we know about exposure-based therapy, what we're still figuring out, and what the data can't tell us.
Exposure-based therapy is the closest thing anxiety treatment has to a settled answer. The effect sizes for specific phobia and panic are unusually large. The mechanism keeps getting refined. The original model (habituation, anxiety drops with repeated exposure) has been substantially replaced by the inhibitory learning model (the old fear association doesn't disappear, a new safety association is built alongside it that competes with it). That changes how protocols are designed. The map below shows the evidence by condition, by exposure modality, and by what the field calls the dissemination gap, which is the difference between what works in trials and what actually reaches patients.
Evidence nodes
What the map shows
The effect sizes for exposure-based therapy in specific phobia and panic disorder are larger than almost anything else in outpatient psychiatry. Single-session exposure for specific phobia can produce sustained remission. Inhibitory learning principles (variable exposure, multiple contexts, no safety behaviors) have replaced habituation as the operative model and changed protocol design. In vivo exposure outperforms imaginal exposure when in vivo is feasible. VR exposure is comparable to in vivo for some phobias and is closing the access gap for others. The map calls those threads out and points to the relevant evidence summary for each.
What the map doesn't show
- ·The dissemination gap is the part of the picture that statistics on effect size don't capture. Most patients with conditions exposure could treat never get exposure. That's a clinician availability problem, not a treatment efficacy problem.
- ·Effect sizes vary by exposure dose. A few sessions don't get the same result as a full protocol, and most non-specialist outpatient care delivers a partial dose.
- ·VR exposure trials are mostly conducted with engaged researchers running the protocols. Real-world VR deployment doesn't always carry the same fidelity.
- ·Pediatric exposure is well-studied but the parent involvement piece is the part most providers get wrong, which is a fidelity issue more than an evidence issue.
Sources
How to cite this map
The Exposure Therapy Evidence Map, AnxietyResearch.org. Built from exposure therapy meta-analyses across specific phobia, panic, and social anxiety, the inhibitory learning literature, virtual reality exposure trials, and the implementation science literature on dissemination. Accessed [date]. https://anxietyresearch.org/evidence-maps/exposure-therapy/
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