Question 1

How do I build an exposure hierarchy and decide between in-vivo vs imaginal exposure?

Accepted Answer

Exposure hierarchies rank feared stimuli by subjective distress (SUDS 0-100), typically 8-12 items, starting at moderate anxiety (SUDS 40-50) rather than the bottom. In-vivo exposure is the gold standard when the fear cue is accessible. Imaginal exposure is indicated when fear cues are inaccessible (future catastrophes in GAD), involve trauma memories, or are logistically impractical. Interoceptive exposure (deliberately inducing feared bodily sensations) is the most strongly supported active ingredient for panic disorder (Pompoli 2018; PMID 29368665; ch04/lesson-03, OR 7.69). VRET shows meta-analytic parity with in-vivo exposure for specific phobias and social anxiety. ILM principles apply across all modalities: maximize expectancy violation, vary contexts, remove safety behaviors.

Question 2

How many items should be on the hierarchy and how do I rank by SUDS?

Accepted Answer

Exposure hierarchies rank feared stimuli by subjective distress (SUDS 0-100), typically 8-12 items, starting at moderate anxiety (SUDS 40-50) rather than the bottom. In-vivo exposure is the gold standard when the fear cue is accessible. Imaginal exposure is indicated when fear cues are inaccessible (future catastrophes in GAD), involve trauma memories, or are logistically impractical. Interoceptive exposure (deliberately inducing feared bodily sensations) is the most strongly supported active ingredient for panic disorder (Pompoli 2018; PMID 29368665; ch04/lesson-03, OR 7.69). VRET shows meta-analytic parity with in-vivo exposure for specific phobias and social anxiety. ILM principles apply across all modalities: maximize expectancy violation, vary contexts, remove safety behaviors.

Question 3

When is imaginal exposure the better choice?

Accepted Answer

Exposure hierarchies rank feared stimuli by subjective distress (SUDS 0-100), typically 8-12 items, starting at moderate anxiety (SUDS 40-50) rather than the bottom. In-vivo exposure is the gold standard when the fear cue is accessible. Imaginal exposure is indicated when fear cues are inaccessible (future catastrophes in GAD), involve trauma memories, or are logistically impractical. Interoceptive exposure (deliberately inducing feared bodily sensations) is the most strongly supported active ingredient for panic disorder (Pompoli 2018; PMID 29368665; ch04/lesson-03, OR 7.69). VRET shows meta-analytic parity with in-vivo exposure for specific phobias and social anxiety. ILM principles apply across all modalities: maximize expectancy violation, vary contexts, remove safety behaviors.

Question 4

How do I prevent dropout when patients face high-anxiety exposures?

Accepted Answer

Exposure hierarchies rank feared stimuli by subjective distress (SUDS 0-100), typically 8-12 items, starting at moderate anxiety (SUDS 40-50) rather than the bottom. In-vivo exposure is the gold standard when the fear cue is accessible. Imaginal exposure is indicated when fear cues are inaccessible (future catastrophes in GAD), involve trauma memories, or are logistically impractical. Interoceptive exposure (deliberately inducing feared bodily sensations) is the most strongly supported active ingredient for panic disorder (Pompoli 2018; PMID 29368665; ch04/lesson-03, OR 7.69). VRET shows meta-analytic parity with in-vivo exposure for specific phobias and social anxiety. ILM principles apply across all modalities: maximize expectancy violation, vary contexts, remove safety behaviors.

Question 5

For social anxiety specifically, what does an in-vivo hierarchy look like?

Accepted Answer

Exposure hierarchies rank feared stimuli by subjective distress (SUDS 0-100), typically 8-12 items, starting at moderate anxiety (SUDS 40-50) rather than the bottom. In-vivo exposure is the gold standard when the fear cue is accessible. Imaginal exposure is indicated when fear cues are inaccessible (future catastrophes in GAD), involve trauma memories, or are logistically impractical. Interoceptive exposure (deliberately inducing feared bodily sensations) is the most strongly supported active ingredient for panic disorder (Pompoli 2018; PMID 29368665; ch04/lesson-03, OR 7.69). VRET shows meta-analytic parity with in-vivo exposure for specific phobias and social anxiety. ILM principles apply across all modalities: maximize expectancy violation, vary contexts, remove safety behaviors.

PsychHQ

Building Exposure Hierarchies: In-Vivo, Imaginal, Interoceptive, and Virtual Reality