Exposures For Fear Of Appearing Anxious
Concerns about appearing anxious in front of others plays a central role in social anxiety. Exposure is an effective treatment for tackling these fears. Clients sometimes find it difficult to develop appropriate exposure tasks or identify manageable ‘steps’ between behavioral experiments. The Exposures For Fear of Appearing Anxious information handout is designed to help clients and therapists identify feared stimuli, develop exposure hierarchies, and plan appropriate exposure exercises and behavioral experiments. It also contains information about safety-seeking behaviors which may need to be addressed during exposure.
The fears that people struggle with can be organized according to their focus. Tolin (2012) suggests that the most common sources of fear relate to:
- Specific situations or objects (e.g., fear of dogs, fear of crowded places)
- Bodily sensations (e.g., heart palpitations, dizziness)
- Social and performance situations
- Obsessive fears
- Excessive worries
- Post-traumatic fears (e.g., beliefs that one is still in danger even after the threat has passed, or memories of trauma which are accompanied by high levels of fear)
Exposure is one of the most effective interventions for overcoming fear (Hofmann & Smits, 2008). It involves individuals repeatedly facing their fears to reduce their fearful responses and reverse the patterns of avoidance that perpetuate them (Springer & Tolin, 2020). Exposure is a first-line intervention for some conditions (such as phobias), and is an essential treatment component for many others (such as panic, social anxiety, OCD, and PTSD).
Exposure methods share the common feature of confrontation with frightening, yet realistically safe, stimuli.
Rothbaum & Schwartz, 2002
Exposure-based interventions have been incorporated into several therapies, most notably cognitive behavioral therapy (CBT), and can take various forms:
- In-vivo exposure. The client confronts their fear in real life. These fears may include objects, situations, bodily sensations (‘interoceptive exposure’), and thoughts.
- Imaginal exposure. The client confronts their fear using their imagination or a narrative (e.g., re-reading a written description of their fear). Imaginal exposure is often used when exposure is impractical or impossible (e.g., the client’s fear relates to a traumatic event or potential disaster).
- Virtual reality exposure. This client faces their fear using virtual reality (e.g., giving a presentation to a computer-generated crowd of strangers). Like imaginal exposure, virtual reality is often useful when in-vivo exposure is difficult to facilitate.
Theoretical accounts of exposure-based treatments have developed over the past century. Two of the currently most influential accounts are derived from emotional processing theory and inhibitory learning theory:
- Emotional processing theory proposes that fear is represented by associative networks that maintain information about the feared stimulus, behavioral fear responses, physiological fear responses, and their meaning (Foa & Kozak, 1986). When an individual encounters a stimulus that resembles the feared stimulus, the fear representation is activated. Kaczkirkin and Foa (2022) propose that a fear structure is pathological when “the relationship among stimuli, responses, and their meaning do not match reality, such as when it is activated for safe stimuli”, and that the fear structure is maintained by avoidance behaviors, which prevent new learning. Exposure modifies this pathological fear structure by first activating it, and then providing new information that disconfirms inaccurate or pathological associations in the fear structure. Emotional processing theory suggests that habituation within sessions leads to habituation between sessions, and subsequently longer-term change, although more recent research suggests that habituation is not a strong predictor of treatment effectiveness.
- Inhibitory learning theory (ILT) proposes that the threat association learned during fear acquisition is not erased, replaced, or modified by new learning during exposure (Craske et al, 2008; Tolin, 2016). Instead, the fear-inducing stimulus becomes ambiguous, with two meanings that both live in memory and compete for retrieval. Craske describes how a client might “enter therapy with a threat expectancy, such as ‘If I panic, I might die’ or ‘If I am socially rejected, it would be unbearable’. As a result of exposure therapy, a competing non-threat expectancy develops, such as ‘If I panic, I am unlikely to die’ or ‘If I am socially rejected, I will survive’. After completion of exposure therapy, the level of fear that is experienced when the stimulus is re-encountered is dependent upon which expectancy is activated. Activation of the original threat expectancy will enhance the expression of fear, whereas activation of the exposure-based non-threat expectancy will lessen fear expression”. Inhibitory learning theory helps to explain why fear can return easily, even in people who have successfully completed treatment, and why habituation does not seem to be important for exposure therapy to be effective.
While the mechanisms underlying exposure are debatable, the stages of exposure are relatively consistent:
- The client identifies a fear stimulus they are willing to confront.
- The client describes what they expect will happen when they face the stimulus.
- The client exposes themselves to the stimulus for a prolonged period, without distraction.
- Changes in the client’s fear levels are monitored.
- After exposure, the client and therapist reflect on what has been learned (e.g., whether the stimulus is as dangerous as the client initially thought).
- The client repeats the exposure.
Exposure is usually preceded by the development of a fear ladder (sometimes referred to as an “exposure hierarchy”) (Beck et al., 1985). Fear ladders are an idiographic list of stimuli (such as activities, situations, or sensations) that generate fear for the client and are avoided. Once the list is generated, items are ranked and ordered according to the level of fear they generate.
The Exposures for Fear of Appearing Anxious information handout is designed for clients who struggle with social or performance anxiety. Social anxiety is one of the most common anxiety disorders, with a lifetime prevalence of up to 12% in the US (Kessler et al., 2005). Research suggests that fear of appearing anxious and socially inept often plays a central role in these difficulties (Turner et al., 2003). These concerns are maintained by cognitive appraisals, attentional processes, avoidance, and ‘safety behaviors’ such as apologetic behaviors, avoiding eye contact, and the use of beta-adrenergic medications (Springer & Tolin, 2020).
This handout provides examples of exposure exercises for addressing these concerns. Therapists can use this tool to:
- Identify feared stimuli that are relevant to the client.
- Inform case conceptualizations and formulations.
- Normalize fear-related triggers.
- Discuss what exposure is likely to entail.
- Develop idiographic items for fear or exposure hierarchies.
- Inform exposure exercises and behavioral experiments.
- Identify safety behaviors the client should refrain from using during exposure.
We’ve talked about how exposure can help people overcome fear. I’d like to show you some examples of how other people have used it to address difficulties like yours. We can use these examples to think about which exposure exercises you might find helpful. Can we look at it together?
Useful questions to support this tool include:
- Which items on this list would make you feel afraid or anxious?
- Which items would you usually avoid because of your fear?
- Which items would you endure with distress or discomfort?
- Can you think of any other scenarios that would make you feel afraid?
- Which safety behaviors do you use to cope with your fear?
- Can you think of any other safety behaviors or coping strategies you sometimes use?
- Does the process of facing your fears make sense? How might you start exposure?
- How could you enhance the exposure(s) you are planning to do?
Other resources that supplement this handout include:
- Facing Your Fears and Phobias (Guide)
- Fear Ladder (Worksheet)
- Exposure Session Record (Worksheet)
- Maximizing the Effectiveness of Exposure Therapy (Information handout)
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. Basic Books.
Craske, M. (2015). Optimizing exposure therapy for anxiety disorders: an inhibitory learning and inhibitory regulation approach. Verhaltenstherapie, 25, 134-143. DOI: 10.1159/000381574.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35, https://doi.org/10.1037/0033-2909.99.1.20
Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry, 69(4), 621.
Katerelos, M., Hawley, L. L., Antony, M. M., & McCabe, R. E. (2008). The exposure hierarchy as a measure of progress and efficacy in the treatment of social anxiety disorder. Behavior Modification, 32, 504-518. DOI: 10.1177/0145445507309302.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. DOI: 10.1001/archpsyc.62.6.593.
Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745-751. DOI: 10.1016/j.jbtep.2011.10.010.
Knowles, K. A., & Olatunji, B. O. (2019). Enhancing inhibitory learning: The utility of variability in exposure. Cognitive and Behavioral Practice, 26, 186-200. DOI: 10.1016/j.cbpra.2017.12.001.
Springer, K. S., & Tolin, D. F. (2020). The Big Book of Exposures: Innovative, Creative and Effective CBT-Based Exposures for Treating Anxiety-Related Disorders. New Harbinger Publications.
Tolin, D. F. (2012). Face Your fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions. John Wiley and Sons.
Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts, and emotions. Guilford Press.
Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N. A., & Lydiard, R. B. (2003). The Social Thoughts and Beliefs Scale: a new inventory for assessing cognitions in social phobia. Psychological Assessment, 15, 384-391. DOI: 10.1037/1040-3522.214.171.1244.
Watts, F. (1971). Desensitization as an habituation phenomenon: I. Stimulus intensity as determinant of the effects of stimulus lengths. Behaviour Research and Therapy, 9, 209–217, https://doi.org/ 10.1016/0005-7967(71)90006-4
Wolpe, J. (1990). The practice of behavior therapy (4th ed.). Plenum.