Exposure therapy is a technique in behavior therapy to treat anxiety disorders.

Exposure therapy involves exposing the patient to the anxiety source or its context (without the intention to cause any danger). Doing so is thought to help them overcome their anxiety or distress.[1]: 141–142 [2] Procedurally, it is similar to the fear extinction paradigm developed for studying laboratory rodents.[3][1] Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder,[4] post-traumatic stress disorder (PTSD), and specific phobias.[5]

As of 2024, focus is particularly on Exposure and response prevention (ERP or ExRP) therapy, in which exposure is continued and the resolution to refrain from the escape response is maintained at all times (not just during specific therapy sessions).[6][7][8][9]

Techniques

Exposure therapy is based on the principle of respondent conditioning often termed Pavlovian extinction.[10] The exposure therapist identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus and then tries to break the pattern of escape that maintains the fear. This is done by exposing the patient to fear-inducing stimuli.[11]

This may be done;

  • using progressively stronger stimulii. Fear is minimized at each of a series of steadily escalating steps or challenges (a hierarchy), which can be explicit ("static") or implicit ("dynamic" — see Method of Factors) until the fear is finally gone.[12] The patient is able to terminate the procedure at any time.
  • using flooding therapy, which exposes the patient to feared stimuli starting at the most feared item in a fear hierarchy.[13][14]

There are several types of exposure procedures.

  • in vivo or "real life."[15] This type exposes the patient to actual fear-inducing situations. For example, if someone fears public speaking, the person may be asked to give a speech to a small group of people.
  • virtual reality, in which technology is used to simulate in vivo exposure.
  • imaginal, where patients are asked to imagine a situation that they are afraid of. This procedure is helpful for people who need to confront feared thoughts and memories.
  • interoceptive, in which patients confront feared bodily symptoms such as increased heart rate and shortness of breath. This may be used for more specific disorders such as panic or post-traumatic stress disorder.

All types of exposure may be used together or separately.[16][17][18]

Exposure and response prevention (ERP)

In the exposure and response prevention (ERP or EX/RP) form of exposure therapy, the resolution to refrain from the escape response is to be maintained at all times (not just during specific practice sessions).[19] Thus, not only does the subject experience habituation to the feared stimulus, but they also practice a fear-incompatible behavioral response to the stimulus. The distinctive feature is that individuals confront their fears and discontinue their escape response.[20]

While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms.[21][22]: 103 [9]

The American Psychiatric Association recommends ERP for the treatment of OCD, citing that ERP has the richest empirical support.[23] As of 2019, ERP is considered a first-line psychotherapy for OCD.[19][24]

Effectiveness is heterogeneous. Higher efficacy correlates with lower avoidance behaviours, and greater adherence to homework. Using SSRI meds whilst doing ERP does not appear to correlate with better outcomes.[25][26][27] Discussion continues on how to best conduct ERP.[28]

Generally, ERP incorporates a relapse prevention plan toward the end of the course of therapy.[19] This can include being ready to re-apply ERP if an anxiety does occur.[29]

Mechanism

As of 2022, the inhibitory learning model of extinction is the most common conjectured mechanism causing exposure therapy efficacy. This posits that after exposure therapy the conditional stimulus may not cause the previous effects.[30] [31][32][31] Mechanism research has been limited in the field.[33]

Under-use and barriers to use

Exposure therapy is seen as under-used in relation to its efficacy.[34] Barriers to use of exposure therapy by psychologists include it appearing antithetical to mainline psychology,[34] lack of confidence, and negative beliefs about exposure therapy.[35]

Uses

Generalized anxiety disorder

There is empirical evidence that exposure therapy can be an effective treatment for people with generalized anxiety disorder, citing specifically in vivo exposure therapy (exposure through a real-life situation),[15] which has greater effectiveness than imaginal exposure in regards to generalized anxiety disorder. The aim of in vivo exposure treatment is to promote emotional regulation using systematic and controlled therapeutic exposure to traumatic stimuli.[36] Exposure is used to promote fear tolerance.[37]

Exposure therapy is also a preferred method for children who struggle with anxiety.[38]

Phobia

Exposure therapy is the most successful known treatment for phobias.[39] Several published meta-analyses included studies of one-to-three-hour single-session treatments of phobias, using imaginal exposure. At a post-treatment follow-up four years later 90% of people retained a considerable reduction in fear, avoidance, and overall level of impairment, while 65% no longer experienced any symptoms of a specific phobia.[15]

Agoraphobia and social anxiety disorder are examples of phobias that have been successfully treated by exposure therapy.[40]

Post-traumatic stress disorder

Exposure therapy in PTSD involves exposing the patient to PTSD-anxiety triggering stimuli, with the aim of weakening the neural connections between triggers and trauma memories (a.k.a. desensitisation). Exposure may involve:[18]

Forms include:

  • Flooding – exposing the patient directly to a triggering stimulus, while simultaneously making them not feel afraid.
  • Systematic desensitisation (a.k.a. "graduated exposure") – gradually exposing the patient to increasingly vivid experiences that are related to the trauma, but do not trigger post-traumatic stress.
  • Narrative exposure therapy - creates a written account of the traumatic experiences of a patient or group of patients, in a way that serves to recapture their self-respect and acknowledges their value. Under this name it is used mainly with refugees, in groups.[41] It also forms an important part of cognitive processing therapy and is conditionally recommended for treatment of PTSD by the American Psychological Association.[41]
  • Prolonged exposure therapy (PE) - a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder, characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is a repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous (despite being objectively safe). Additional procedures include processing of the trauma memory and breathing retraining. The American Psychological Association strongly recommends PE as a first-line psychotherapy treatment for PTSD.[42]

Researchers began experimenting with Virtual reality exposure (VRE) therapy in PTSD exposure therapy in 1997 with the advent of the "Virtual Vietnam" scenario. Virtual Vietnam was used as a graduated exposure therapy treatment for Vietnam veterans meeting the qualification criteria for PTSD. A 50-year-old Caucasian male was the first veteran studied. The preliminary results concluded improvement post-treatment across all measures of PTSD and maintenance of the gains at the six-month follow up. Subsequent open clinical trial of Virtual Vietnam using 16 veterans, showed a reduction in PTSD symptoms.[43]

This method was also tested on several active duty Army soldiers, using an immersive computer simulation of military settings over six sessions. Self-reported PTSD symptoms of these soldiers were greatly diminished following the treatment.[44] Exposure therapy has shown promise in the treatment of co-morbid PTSD and substance abuse.

In the area of PTSD, historic barriers to the use of exposure therapy include that clinicians may not understand it, are not confident in their own ability to use it, or more commonly, see significant contraindications for their client.[45][46]

Obsessive compulsive disorder

Exposure and response prevention (also known as exposure and ritual prevention; ERP or EX/RP) is a variant of exposure therapy that is recommended by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the Mayo Clinic as first-line treatment of obsessive compulsive disorder (OCD) citing that it has the richest empirical support for both youth and adolescent outcomes.[23][47]

ERP is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears, but refrain from engaging in the escape response or ritual that delays or eliminates distress.[20] In the case of individuals with OCD or an anxiety disorder, there is a thought or situation that causes distress. Individuals usually combat this distress through specific behaviors that include avoidance or rituals. However, ERP involves purposefully evoking fear, anxiety, and or distress in the individual by exposing him/her to the feared stimulus.[15] The response prevention then involves having the individual refrain from the ritualistic or otherwise compulsive behavior that functions to decrease distress. The patient is then taught to tolerate distress until it fades away on its own, thereby learning that rituals are not always necessary to decrease distress or anxiety. Over repeated practice of ERP, patients with OCD expect to find that they can have obsessive thoughts and images but not have the need to engage in compulsive rituals to decrease distress.[23][47]

The AACAP's practice parameters for OCD recommends cognitive behavioral therapy, and more specifically ERP, as first line treatment for youth with mild to moderate severity OCD and combination psychotherapy and pharmacotherapy for severe OCD.[47] The Cochrane Review's examinations of different randomized control trials echoes repeated findings of the superiority of ERP over waitlist control or pill-placebos, the superiority of combination ERP and pharmacotherapy, but similar effect sizes of efficacy between ERP or pharmacotherapy alone.[48]

Other possible uses of exposure therapy

Exposure therapy has been posited as potentially helpful for other uses, including substance abuse disorders,[49] overeating, binge eating, and obesity,[50] and depression.[51][52][53]

History

The use of exposure as a mode of therapy began in the 1950s, at a time when psychodynamic views dominated Western clinical practice and behavioral therapy was first emerging. South African psychologists and psychiatrists first used exposure as a way to reduce pathological fears, such as phobias and anxiety-related problems, and they brought their methods to England in the Maudsley Hospital training program.[20]

Joseph Wolpe (1915–1997) was one of the first psychiatrists to spark interest in treating psychiatric problems as behavioral issues. He sought consultation with other behavioral psychologists, among them James G. Taylor (1897–1973), who worked in the psychology department of the University of Cape Town in South Africa. Although most of his work went unpublished, Taylor was the first psychologist known to use exposure therapy treatment for anxiety, including methods of situational exposure with response prevention—a common exposure therapy technique still being used.[20] Since the 1950s, several sorts of exposure therapy have been developed, including systematic desensitization, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.[20]

Exposure and response prevention (ERP) traces its roots back to the work of psychologist Vic Meyer in the 1960s. Meyer devised this treatment from his analysis of fear extinguishment in animals via flooding and applied it to human cases in the psychiatric setting that, at the time, were considered intractable.[54] The success of ERP clinically and scientifically has been summarized as "spectacular" by prominent OCD researcher Stanley Rachman decades following Meyer's creation of the method.[55]

Mindfulness

A 2015 review pointed out parallels between exposure therapy and mindfulness, stating that mindful meditation "resembles an exposure situation because [mindfulness] practitioners 'turn towards their emotional experience', bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it."[56] Imaging studies have shown that the ventromedial prefrontal cortex, hippocampus, and the amygdala are all affected by exposure therapy; imaging studies have shown similar activity in these regions with mindfulness training.[56]

EMDR

Eye movement desensitization and reprocessing (EMDR) includes an element of exposure therapy (desensitization), though whether this is an effective method or not, is controversial.[57]

Other

Desensitization and extinction also involve exposure to a cause of disturbance.

Research

Exposure therapy can be investigated in the laboratory using Pavlovian extinction paradigms. Using rodents such as rats or mice to study extinction allows for the investigation of underlying neurobiological mechanisms involved, as well as testing of pharmacological adjuncts to improve extinction learning.[58][59]

See also

Explanatory footnotes

  1. ↑ For example, a person with panic disorder may be told to run in place, causing their heart to race, so that they can see that this feeling is not dangerous.

References

  1. 1 2 Myers KM, Davis M (February 2007). "Mechanisms of fear extinction". Molecular Psychiatry. 12 (2): 120–150. doi:10.1038/sj.mp.4001939. PMID 17160066.
  2. ↑ Joseph JS, Gray MJ (2008). "Exposure Therapy for Posttraumatic Stress Disorder". Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention. 1 (4): 69–80. doi:10.1037/h0100457.
  3. ↑ Marks I (February 1979). "Exposure therapy for phobias and obsessive-compulsive disorders". Hospital Practice. 14 (2): 101–108. doi:10.1080/21548331.1979.11707486. PMID 34562.
  4. ↑ Huppert JD, Roth DA (2003). "Treating Obsessive–Compulsive Disorder with Exposure and Response Prevention" (PDF). The Behavior Analyst Today. 4 (1): 66–70. doi:10.1037/h0100012. Archived from the original (PDF) on 2012-10-30. Retrieved 2013-01-12.
  5. ↑ Böhnlein J, Altegoer L, Muck NK, Roesmann K, Redlich R, Dannlowski U, Leehr EJ (January 2020). "Factors influencing the success of exposure therapy for specific phobia: A systematic review". Neuroscience and Biobehavioral Reviews. 108: 796–820. doi:10.1016/j.neubiorev.2019.12.009. PMID 31830494.
  6. ↑ Himle JA, Grogan-Kaylor A, Hiller MA, Mannella KA, Norman LJ, Abelson JL, Prout A, Shunnarah AA, Becker HC, Russman Block SR, Taylor SF, Fitzgerald KD (January 1, 2024). "Exposure and response prevention versus stress management training for adults and adolescents with obsessive compulsive disorder: A randomized clinical trial". Behaviour Research and Therapy. 172: 104458. doi:10.1016/j.brat.2023.104458. PMID 38103359. S2CID 266285353 – via ScienceDirect.
  7. ↑ Song Y, Li D, Zhang S, Jin Z, Zhen Y, Su Y, Zhang M, Lu L, Xue X, Luo J, Liang M, Li X (November 1, 2022). "The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis". Psychiatry Research. 317: 114861. doi:10.1016/j.psychres.2022.114861. PMID 36179591. S2CID 252530334 – via ScienceDirect.
  8. ↑ Wynn GH, Ursano RJ (January 1, 2017). "Posttraumatic Stress Disorder☆". Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier. doi:10.1016/B978-0-12-809324-5.05378-5. ISBN 9780128093245 – via ScienceDirect.
  9. 1 2 "International OCD Foundation | Exposure and Response Prevention (ERP)".
  10. ↑ Marks IM (1981). Cure and care of neuroses: theory and practice of behavioral psychotherapy. New York: Wiley. ISBN 978-0-471-08808-0.
  11. ↑ De Silva P, Rachman S (1981). "Is exposure a necessary condition for fear-reduction?". Behaviour Research and Therapy. 19 (3): 227–232. doi:10.1016/0005-7967(81)90006-1. PMID 6117277.
  12. ↑ Miltenberger RG (2008). Behavioral Modification: Principles and Procedures (4th ed.). Thomson/Wadsworth. p. 552.
  13. ↑ de Silva P, Rachman S (1983). "Exposure and fear-reduction". Behaviour Research and Therapy. 21 (2): 151–152. doi:10.1016/0005-7967(83)90160-2. PMID 6838470.
  14. ↑ Cobb J (1983). "Behaviour therapy in phobic and obsessional disorders". Psychiatric Developments. 1 (4): 351–365. PMID 6144099.
  15. 1 2 3 4 Kaplan JS, Tolin DF (6 September 2011). "Exposure Therapy for Anxiety Disorders". Psychiatric Times. 28 (9). Retrieved 2021-09-22.
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  17. ↑ "Exposure therapy". Cleveland Clinic.
  18. 1 2 "What Is Exposure Therapy?". American Pyschological Association (APA).
  19. 1 2 3 Hezel DM, Simpson HB (January 2019). "Exposure and response prevention for obsessive-compulsive disorder: A review and new directions". Indian Journal of Psychiatry. 61 (Suppl 1): S85–S92. doi:10.4103/psychiatry.IndianJPsychiatry_516_18. PMC 6343408. PMID 30745681.
  20. 1 2 3 4 5 Abramowitz JS, Deacon BJ, Whiteside SP (2011-03-14). Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 9781609180171.
  21. ↑ "Ten Things You Need To Know To Overcome OCD". Beyond OCD. Retrieved 2020-08-17.
  22. ↑ Abramowitz JS, Deacon BJ, Whiteside SP (2011-03-14). "Treatment Planning II: Hierarchy Development and Treatment Engagement". Exposure Therapy for Anxiety: Principles and Practice. Guilford Press. ISBN 978-1-60918-017-1.
  23. 1 2 3 Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB (July 2007). "Practice guideline for the treatment of patients with obsessive-compulsive disorder" (PDF). The American Journal of Psychiatry. 164 (7 Suppl): 5–53. PMID 17849776.
  24. ↑ "The best treatment for OCD is CBT which typically includes exposure and response prevention (ERP) and some degree of more cognitive interventions." "Relapse Prevention in the Treatment of OCD".
  25. ↑ Kim H, Wheaton MG, Foa EB, Simpson HB (May 1, 2023). "Identifying trajectories of symptom change in adults with obsessive compulsive disorder receiving exposure and response prevention therapy". Journal of Anxiety Disorders. 96: 102711. doi:10.1016/j.janxdis.2023.102711. PMC 10209477. PMID 37148799 – via ScienceDirect.
  26. ↑ Wheaton MG, Rosenfield B, Rosenfield D, Marsh R, Foa EB, Simpson HB (October 1, 2023). "Predictors of EX/RP alone versus EX/RP with medication for adults with OCD: Does medication status moderate outcomes?". Journal of Obsessive-Compulsive and Related Disorders. 39: 100850. doi:10.1016/j.jocrd.2023.100850. PMC 10695351. PMID 38054078 – via ScienceDirect.
  27. ↑ Simpson HB, Maher M, Page JR, Gibbons CJ, Franklin ME, Foa EB (March 10, 2010). "Development of a Patient Adherence Scale for Exposure and Response Prevention Therapy". Behavior Therapy. 41 (1): 30–37. doi:10.1016/j.beth.2008.12.002. PMC 3949512. PMID 20171325.
  28. ↑ Ong CW, Petersen JM, Terry CL, Krafft J, Barney JL, Abramowitz JS, Twohig MP (April 1, 2022). "The "how" of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder". Journal of Contextual Behavioral Science. 24: 87–95. doi:10.1016/j.jcbs.2022.03.009. S2CID 247802575 – via ScienceDirect.
  29. ↑ "Relapse Prevention in the Treatment of OCD".
  30. ↑ Craske MG, Treanor M, Zbozinek TD, Vervliet B (May 2022). "Optimizing exposure therapy with an inhibitory retrieval approach and the OptEx Nexus". Behaviour Research and Therapy. 152: 104069. doi:10.1016/j.brat.2022.104069. PMID 35325683. S2CID 247487555.
  31. 1 2 Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B (July 2014). "Maximizing exposure therapy: an inhibitory learning approach". Behaviour Research and Therapy. 58: 10–23. doi:10.1016/j.brat.2014.04.006. PMC 4114726. PMID 24864005.
  32. ↑ Sewart AR, Craske MG. "Inhibitory learning.". In Abramowitz JS, Blakey SM (eds.). Clinical handbook of fear and anxiety: Maintenance processes and treatment mechanisms. American Psychological Association. pp. 265–285.
  33. ↑ Tolin DF, McKay D, Olatunji BO, Abramowitz JS, Otto MW (November 2023). "On the importance of identifying mechanisms and active ingredients of psychological treatments". Behaviour Research and Therapy. 170: 104425. doi:10.1016/j.brat.2023.104425. PMID 37913558. S2CID 264571425.
  34. 1 2 Becker-Haimes EM, Stewart RE, Frank HE (June 2022). "It's all in the name: why exposure therapy could benefit from a new one". Current Psychology. 42 (25): 21641–21647. doi:10.1007/s12144-022-03286-6. PMC 9161762. PMID 35669210.
  35. ↑ Moses K, Gonsalvez CJ, Meade T (April 2023). "Barriers to the use of exposure therapy by psychologists treating anxiety, obsessive-compuslive disorder, and posttraumatic stress disorder in an Australian sample". Journal of Clinical Psychology. 79 (4): 1156–1165. doi:10.1002/jclp.23470. PMID 36449416. S2CID 254093759.
  36. ↑ Parsons TD, Rizzo AA (September 2008). "Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis". Journal of Behavior Therapy and Experimental Psychiatry. 39 (3): 250–261. doi:10.1016/j.jbtep.2007.07.007. PMID 17720136. S2CID 6688068.
  37. ↑ "Instead of teaching patients to resist, control or "fix" their fear or anxiety, exposure is used to promote 'fear tolerance' given that fear and anxiety are universal, inevitable and safe." Exposure Therapy for Anxiety, Second Edition (2019), p18, Abramowitz, Deacon and Whiteside
  38. ↑ Whiteside SP, Deacon BJ, Benito K, Stewart E (May 2016). "Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders". Journal of Anxiety Disorders. 40: 29–36. doi:10.1016/j.janxdis.2016.04.001. PMC 4868775. PMID 27085463.
  39. ↑ Chambless DL, Ollendick TH (2001). "Empirically supported psychological interventions: controversies and evidence". Annual Review of Psychology. 52 (1): 685–716. doi:10.1146/annurev.psych.52.1.685. PMID 11148322. S2CID 9487499.
  40. ↑ Vögele C, Ehlers A, Meyer AH, Frank M, Hahlweg K, Margraf J (March 2010). "Cognitive mediation of clinical improvement after intensive exposure therapy of agoraphobia and social phobia". Depression and Anxiety. 27 (3): 294–301. doi:10.1002/da.20651. PMID 20037922. S2CID 21915062.
  41. 1 2 "Narrative Exposure Therapy (NET)". American Psychological Association.
  42. ↑ Courtois CA, Sonis J, Brown LS, Cook J, Fairbank JA, Friedman M, Schulz P (2017). "Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults" (PDF). Washington, D.C.: American Psychological Association.
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  47. 1 2 3 Geller DA, March J (January 2012). "Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder". Journal of the American Academy of Child and Adolescent Psychiatry. 51 (1): 98–113. doi:10.1016/j.jaac.2011.09.019. PMID 22176943.
  48. ↑ O'Kearney RT, Anstey KJ, von Sanden C (October 2006). "Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents". The Cochrane Database of Systematic Reviews. 2006 (4): CD004856. doi:10.1002/14651858.CD004856.pub2. hdl:1885/50872. PMC 8855344. PMID 17054218.
  49. ↑ McHugh RK, Kosiba JD, Chase AR (January 9, 2022). "Exposure Therapy in the Treatment of Substance Use Disorders". In Smits JA, Jacquart J, Abramowitz J, Arch J, Margraf J (eds.). Clinical Guide to Exposure Therapy: Beyond Phobia. Springer International Publishing. pp. 261–276. doi:10.1007/978-3-031-04927-9_14. ISBN 978-3-031-04926-2 – via Springer Link.
  50. ↑ Boutelle KN, Eichen DM, Virzi NE (January 9, 2022). "Exposure Exercises for Overeating, Binge Eating, and Obesity". In Smits JA, Jacquart J, Abramowitz J, Arch J, Margraf J (eds.). Clinical Guide to Exposure Therapy: Beyond Phobias. Springer International Publishing. pp. 299–316. doi:10.1007/978-3-031-04927-9_16. ISBN 978-3-031-04926-2 – via Springer Link.
  51. ↑ Hayes AM, Yasinski C, Alpert E (January 9, 2022). "The Application of Exposure Principles to the Treatment of Depression". In Smits JA, Jacquart J, Abramowitz J, Arch J, Margraf J (eds.). Clinical Guide to Exposure Therapy: Beyond Phobias. Springer International Publishing. pp. 317–345. doi:10.1007/978-3-031-04927-9_17. ISBN 978-3-031-04926-2 – via Springer Link.
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  53. ↑ Richard DC, Lauterbach D (2006). Handbook of Exposure Therapies Hardcover. Elsevier. ISBN 978-0-08-046781-8.
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  55. ↑ "The history of obsessive-compulsive disorder". www.ocdhistory.net.
  56. 1 2 Tang YY, Hölzel BK, Posner MI (April 2015). "The neuroscience of mindfulness meditation". Nature Reviews. Neuroscience. 16 (4): 213–225. doi:10.1038/nrn3916. PMID 25783612. S2CID 54521922.
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  59. ↑ Milad MR, Quirk GJ (2011-11-30). "Fear extinction as a model for translational neuroscience: ten years of progress". Annual Review of Psychology. 63 (1): 129–151. doi:10.1146/annurev.psych.121208.131631. PMC 4942586. PMID 22129456.
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