In vivo flooding for anxiety disorders: Proposing its utility in the treatment posttraumatic stress disorder

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Abstract

Exposure techniques have now been used in the treatment of anxiety disorders for several decades. Although such techniques are a dominant feature of current therapies for disorders such as posttraumatic stress disorder and acute stress disorder, examination of their relative merits has been less studied. The purpose of this review is to suggest the usefulness of in vivo flooding in the treatment of posttraumatic stress. We discuss the relevant exposure literature by briefly examining the efficacy of these techniques in the treatment of anxiety. The theoretical and methodological limitations of investigations to date of exposure methods that have been used in posttraumatic stress treatment studies are then reviewed. We highlight the fact that in vivo flooding, an exposure technique that has been used to treat some anxiety-based disorders, has received scant clinical and research attention as a treatment for posttraumatic stress. A case is made for further study of in vivo flooding in the treatment of posttraumatic stress.

Section snippets

Graded in vivo exposure versus in vivo flooding

Historically, exposure treatments for anxiety employed imaginal methods (Gelder et al., 1973, Hussain, 1971; Marks, Boulougouris, & Marset, 1971; Stampfl & Levis, 1967; Wolpe, 1958, Wolpe, 1961). Subsequent investigation compared the relative efficacy of imaginal versus real life exposure techniques for a range of anxiety conditions of varying levels of severity (e.g., Everaerd, Rijken, & Emmelkamp, 1973; Mathews et al., 1976). Overall the superiority of in vivo exposure techniques to imaginal

Treatments for posttraumatic stress disorder (PTSD)

Posttraumatic stress disorder is a traumatic stress response diagnosed following exposure to significant trauma such as physical and sexual assault, war or combat-related trauma, motor vehicle accidents and natural disasters (American Psychiatric Association, 1994). It is characterized by re-experiencing symptoms (e.g., nightmares, intrusive and distressing memories of the traumatic event), avoidance symptoms (e.g., avoiding situations that represent the trauma, not talking about the trauma,

Can in vivo flooding be used in the treatment of PTSD?

As emphasized by the above literature, when the separate effects of exposure has been examined in PTSD treatment studies it has been in reference to imaginal versus in vivo exposure, and has not examined in vivo exposure in its own right. Indeed, this has generally been the case with the anxiety field as a whole as discussed earlier in this review. For example, in reviewing the literature in the context of treating clinical fear, James (1986) examined whether in vivo flooding was superior to

The need for empirical investigation of in vivo flooding

What might be the advantages of in vivo flooding? Some literature suggests that in vivo flooding in the treatment of other anxiety disorders might have faster therapeutic effects than in vivo graded exposure (or for that matter, imaginal flooding) (Mannion & Levine, 1984), thus it is possible that such procedures could result in accelerated treatment outcome. Consistent with this notion, Yuksel et al. (1984) reported comparable treatment outcome in rapid and slow therapist-aided in vivo

The role of cognition (beliefs) in the treatment of PTSD

Although the present review has focused upon behavioral components of therapies for PTSD, this should not be taken to reflect that cognition is considered unimportant in the development and maintenance of the posttraumatic response. Indeed, in addition to the necessary component of fear activation and habituation in the treatment of posttraumatic stress, Foa and Kozak's (1986) ‘fear network’ model also requires that new, corrective information be introduced which is incompatible with the

Scientist-practitioner model

An additional reason for the study of in vivo flooding lies in the need to provide clinicians with practical yet empirical information regarding the efficacy (or non-efficacy) of varying therapeutic techniques. There is some preliminary evidence to suggest that imaginal or prolonged exposure, a validated treatment technique for PTSD (Foa, Keane, & Friedman, 2000) may not be used widely by therapists in the treatment of PTSD (Becker, Zayfert, & Anderson, 2004; Gillock, Zayfert, & Hayes, 2001).

Summary

In conclusion, studies need to examine the effectiveness (or lack of) of in vivo flooding in its own right. Saigh (1989) recommends that exposure treatments be dismantled to understand the active components. In vivo flooding needs to be compared with in vivo graded exposure, and finally, given the importance of cognitions in posttraumatic stress, the efficacy of in vivo flooding in conjunction with cognitive therapy techniques should also be investigated. Similarly, in line with recommendations

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