Journal of Psychotherapy Integration © 2019 American Psychological Association

2019, Vol. 29, No. 1, 6 –14 1053-0479/19/$12.00 http://dx.doi.org/10.1037/int0000109

Mechanisms of Change in Prolonged Exposure Therapy for PTSD:

Implications for Clinical Practice

Lily A. Brown, Laurie J. Zandberg, and Edna B. Foa

University of Pennsylvania

Prolonged exposure therapy (PE) is a highly efficacious and effective treatment for
posttraumatic stress disorder (PTSD). In addition to reducing PTSD symptoms, PE
ameliorates a wide-variety of related symptoms, including anxiety, depression, func-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tional impairment, mild suicidal ideation, and anger. Furthermore, PE is effective in

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patients with comorbid conditions, including dissociation, substance use, borderline

personality disorder and psychosis. How does PE achieve these outcomes? Emotional
processing theory (EPT) is the conceptual model from which PE was derived. Three
key concepts were originally proposed as indicators that emotional processing, the
mechanism underlying symptom reduction via exposure therapy, including PE, had
occurred. The three indicators are fear activation, within-session habituation, and
between-session habituation, all of which were proposed to reduce symptoms of PTSD.
In addition to these indicators, EPT posits that changes in cognitive evaluations about
the self and the world are also involved in successful emotional processing, the
mechanism underlying symptom reduction. Since its emergence in 1986, EPT has been
updated and modified to incorporate emerging empirical findings and conceptual
developments. We first review recent empirical support for, and refutation of, various
hypotheses derived from EPT, including the importance of fear activation, between-
session habituation, and cognitive change. We then provide a clinical case study to
highlight strategies to promote emotional processing and the resultant long-term
symptom reduction. This case example highlights three common obstacles to success
in PE: namely underengagement, insufficient homework compliance, and the presence
of PTSD-related negative cognitions.

Keywords: posttraumatic stress disorder, prolonged exposure therapy, emotional

processing theory, mechanisms, case example

Emotional Processing Theory
Emotional processing theory (EPT) explains
the development, maintenance and updating of
emotional structures, or networks of emotion-
ally salient associations (Foa & Kozak, 1986).
According to EPT and consistent with experi-
mental analogue studies of associative learning,
emotions such as fear indicate the activation of
an emotional structure, a cognitive network that
contains information about stimuli, responses,
and the meaning of stimuli and responses. Em-
Lily A. Brown, Laurie J. Zandberg, and Edna B. Foa,
Department of Psychiatry, Center for the Treatment and
Study of Anxiety, University of Pennsylvania.
Correspondence concerning this article should be addressed
to Lily A. Brown, Market Street Suite 600 North, Philadelphia,
PA 19104. E-mail: lilybr@mail.med.upenn.edu
6
bedded within the emotional structure are asso-
ciations between aversive unconditioned stimuli
(US) and neutral conditioned stimuli (CS).
Thus, pairing a dark alley (CS) and assault (US)
results in an association that is represented in
the emotional structure. The structure includes
CS elements (e.g., the gender or race of the
assailant, dark alleys, music heard in the back-
ground of the assault), US elements (e.g., the
physical assault itself), conditioned response el-
ements (CR; e.g., fear, shame, avoiding dark
alleys or people who resemble the assailant),
and unconditioned response elements (UR; e.g.,
the physical pain of the assault). Stimuli and
response elements, in turn, are associated with
new meaning (e.g., dark alleys mean “danger”).
Associations embedded in emotional struc-
tures can be either accurate or inaccurate. Ac-
cording to EPT, associations represented within
the emotional structure are maintained until
 MECHANISMS OF PROLONGED EXPOSURE
new, inconsistent information becomes avail-
able and is embedded in the structure. Thus, a
woman who has experienced an assault may
perceive individuals who resemble the perpetra-
tor as dangerous until she encounters neutral or
positive experiences with such individuals. Un-
fortunately, CRs (e.g., fear, avoidance) that are
evoked in response to CS maintain the errone-
ous predictions of “danger” in the face of safe
stimuli. For example, if the woman described
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above feels anxious around and therefore avoids
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men who resemble the perpetrator, she will not
have the opportunity to learn that these men are
not dangerous. Thus, fear of safe stimuli ele-
ments is maintained indefinitely through avoid-
ance.
Emotional structures are updated through the
presentation of information that is incompatible
with erroneous associations represented in the
structure. This information allows for the for-
mation of new associations (i.e., not all men
who resemble the perpetrator are dangerous).
For new information to become embedded in
and update an emotional structure, two con-
ditions are necessary. First, the emotional
structure must be activated so it becomes
available to incorporate new information.
Thus, fear activation is both a mechanism
through which an emotional structure is
primed for updating as well as an indicator
that emotional processing is taking place.
Second, information that directly competes
with the erroneous, pathological associations
must be available. For example, the trauma-
tized woman described above will eventually
learn that not all men who resemble the per-
petrator are dangerous if: (a) she encounters
men who resemble the perpetrator, initially
resulting in a fear response (fear activation),
during exposure therapy; and (b) she is not
assaulted by these men, thus promoting ex-
tinction learning. According to EPT, two ad-
ditional indicators of emotional processing
are (a) decreased emotional responding (e.g.,
fear) within an exposure (i.e., within-session
habituation) and (b) decreased emotional re-
sponding across sessions (i.e., between-
session habituation). These principles of EPT
form the basis of prolonged exposure therapy
(PE) for posttraumatic stress disorder
(PTSD).
7
Prolonged Exposure Therapy (PE)
PE is an evidence-based manualized treat-
ment for PTSD with numerous randomized con-
trolled trials supporting its efficacy and effec-
tiveness (Cusack et al., 2016). There are four
components of PE: (1) in vivo exposure; (2)
imaginal exposure/processing; (3) psychoedu-
cation; and (4) breathing retraining (Foa, Hem-
bree, & Rothbaum, 2007). In vivo exposure
involves the gradual confrontation of anxiety-
provoking but objectively safe trauma-remind-
ers, including people, places, objects and situa-
tions. In vivo exposure promotes: (a) reduction
in negative trauma-related cognitions; (b) learn-
ing that the feared situation is not dangerous; (c)
learning that fear and arousal do not last indef-
initely; and (d) learning about the ability to
tolerate anxiety. Imaginal exposure and pro-
cessing involve the revisiting of the trauma
memory aloud coupled with discussing core
cognitions and beliefs about the self, others and
the world related to the trauma. By repeatedly
confronting the memory of the trauma, pa-
tients can learn that: (a) the memory itself is
not dangerous; (b) the distress associated with
thinking about what happened declines over
time; and (c) some of the faulty perceptions
they may hold about their own and other’s
behavior are not accurate. Psychoeducation
involves the provision of didactic information
about PTSD, common reactions to trauma,
and the role of avoidance in maintaining
PTSD. In breathing retraining, patients learn
to slow their breathing to regulate distressing
emotions.
Mechanisms of Change in PE
EPT principles are embedded in PE for
PTSD. First, both in vivo exposure and imagi-
nal exposure exercises involve emotional acti-
vation. This emotional activation allows for the
incorporation of new information into the emo-
tion structure. Fear activation has been found to
predict treatment response for anxiety disorders
(e.g., Jaycox, Foa, & Morral, 1998; Norton,
Hayes-Skelton, & Klenck, 2011; Peterman,
Carper, & Kendall, 2016; Phelps, Delgado,
Nearing, & LeDoux, 2004), though some stud-
ies contradict these findings, including a recent
meta-analysis (e.g., Baker et al., 2010; Rupp,
Doebler, Ehring, & Vossbeck-Elsebusch,
 8 BROWN, ZANDBERG, AND FOA
2017). Additionally, within-session habituation
is encouraged in PE. Patients are commonly
encouraged to continue in vivo exposures until
their fear reduces by 50%. Similarly, patients
engage in extended imaginal exposure exer-
cises, often about 40 min in length, in part to
promote within-session habituation. However,
evidence about the relationship between within-
session habituation and symptom reduction is
mixed. Although a recent meta-analysis found
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that within-session habituation was associated
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with outcome of exposure therapy (Rupp et al.,
2017), several studies have not found a relation-
ship between within-session habituation and
outcome (Baker et al., 2010; Harned, Ruork,
Liu, & Tkachuck, 2015; Nacasch et al., 2015;
Peterman et al., 2016; Sripada & Rauch, 2015;
van Minnen & Foa, 2006). Finally, between-
session habituation, or the reduction of anxiety
from one session to the next, is promoted in PE
through exposure homework assignments. Most
studies have found that between-session habit-
uation is related to symptom reduction (e.g.,
Rupp et al., 2017; Sripada & Rauch, 2015; van
Minnen & Hagenaars, 2002), though some stud-
ies have not (Peterman et al., 2016).
Finally, changes in PTSD-related negative
cognitions are associated with symptom reduc-
tion. PE significantly reduces negative cogni-
tions (Foa & Rauch, 2004; McLean, Yeh,
Rosenfield, & Foa, 2015; Nacasch et al., 2015;
Zalta et al., 2014). Furthermore, reductions in
negative cognitions precede reductions in PTSD
symptoms in adults (Kumpula et al., 2017) and
adolescents (McLean et al., 2015). Thus,
changes in negative cognitions are a mechanism
of symptom improvement for PE.
Enhancing PE per EPT Principles of
Change
To illustrate the use of these putative mech-
anisms to enhance PE outcomes, we present the
case of Alice. We focus herein on fear activa-
tion, between-session habitation, and cognitive
change. We do not emphasize within-session
habituation because it is not related to treatment
outcome.
Alice is a 40-year old Latina female who presented to
treatment with longstanding PTSD symptoms related
to the traumatic death of her mother. Alice’s mother
developed an addiction to opiates following a knee
injury during Alice’s adolescent years. In the decade
following, Alice endured countless episodes of emo-
tional abuse from her mother, particularly when her
mother needed assistance in obtaining additional med-
ications. Alice found her mother’s dead body on a day
when Alice had chosen to stay at work, rather than
rushing home when her mother had called her to re-
quest medications. The exact cause of her mother’s
death remains unknown. Many years after her mother’s
passing, Alice continued to experience nightmares, in-
trusive memories, and (occasional) dissociative flash-
backs about finding her mother’s body. Whenever pos-
sible, she avoided talking about her mother or about the
general topic of drug use; similarly, she had not visited
her mother’s grave since the funeral. Alice endorsed
beliefs that she was responsible for her mother’s death,
that she was a bad and uncaring daughter, and—in her
worst moments—that she “killed her mother.” Her
heightened anxiety, hypervigilance, and intermittent
panic attacks compromised her daily functioning.
Thus, she made the difficult decision to take a medical
leave of absence to obtain PE treatment.
Enhancing Initial Activation of the
Emotional Structure: Addressing Under
Engagement
Imaginal exposure is designed to help pa-
tients systematically approach their trauma
memory—to narrate in detail what occurred and
emotionally process the trauma. To improve
symptoms of PTSD, it is necessary to activate
the emotional network related to PTSD symp-
toms. During imaginal exposure for PE, patients
revisit the memory for approximately 40 min
per session. To enhance activation, patients are
instructed to close their eyes and recall the
memory in present tense, describing what they
were thinking, feeling, and doing at the time of
the trauma. In the following text, we describe
Alice’s difficulty in initially achieving appropri-
ate activation of the trauma emotional structure
in imaginal exposure.
In her first few imaginal exposures, Alice exhibited
“under-engagement.” She complied with the instruc-
tions for exposure, but retold the events of the trauma
in an unemotional and detached manner. The therapist
made several notes: (1) Alice narrated logistical details
very specifically, as if she were reading a police report,
but did not comment on her personal thoughts and
feelings; (2) The moments where Alice discovered her
mother’s body were recounted very quickly, with lim-
ited detail; and (3) Alice frequently lapsed into tangen-
tial or reflective commentary (e.g., “see that’s the kind
of thing that happens when a family member is an
addict”). While pertinent to the processing of the ex-
perience following the imaginal exposure, it was pos-
ited that this kind of editing during the imaginal expo-
sure served to distance Alice from the trauma imagery.
Each of these observations suggested that Alice may be
 MECHANISMS OF PROLONGED EXPOSURE
titrating her experience by engaging in subtle forms of
protective avoidance.
Alice’s therapist made several modifications to en-
hance activation and emotional engagement. First, she
revisited the imaginal exposure rationale (originally
presented in Session 3). She emphasized the impor-
tance of emotional engagement with the trauma mem-
ory to promote Alice’s processing of her feelings.
Second, she used open-ended questioning to explore
whether Alice might have concerns about engaging
with the memory. These questions revealed that Alice
was quite concerned that if she envisioned all the
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trauma details, she might get so upset that she would
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“lose it.” She felt like she was “on the brink of falling
apart as it was,” and was not sure she could afford to
take this risk. Alice’s therapist provided reassurance
that her distress will likely decrease rather than in-
crease if she allows herself to stick with her feelings.
Additionally, the therapist reminded Alice that fully
experiencing her emotions will allow her to digest and
process the trauma and gain control over the memory.
The therapist validated that the experience may be
distressing in the first few sessions while also high-
lighting that this short-term pain may be necessary for
healing.
During imaginal exposure, the therapist facilitated
greater engagement by asking prompting questions to
draw out detail about the trauma, especially about
Alice’s thoughts and feelings. Prompts were brief and
delivered in the present tense, such as “what do you
feel in your body?” and “what’s going through your
mind?” When Alice reached the part of the memory
where she found her mother’s body, the therapist
prompted her to “stay here—what are you seeing?” In
so doing, Alice described details she had been avoid-
ing, and her emotions broke through to the surface. She
was appropriately tearful during subsequent exposures,
and her body showed signs of heightened anxiety (e.g.,
sweating, shaky voice). As predicted by EPT, however,
the more Alice retold the memory in this connected
way, the easier she could speak about it. Alice realized
that she did not “lose it,” and was in fact stronger than
she had predicted.
Enhancing Between-Session Habituation:
Homework Compliance
As noted earlier, between-session habituation
is a well-established marker of long-term main-
tenance of gains in exposure therapy for anxiety
disorders (Rupp et al., 2017). Mechanisms driv-
ing between-session habituation are currently
unknown, but homework compliance may pro-
mote between-session habituation. Indeed,
higher compliance with imaginal exposure
homework is associated with greater reductions
in PTSD symptom severity (Cooper et al.,
2017). How should clinicians manage issues
related to homework compliance to optimize
9
outcomes in PE? We revisit the case of Alice to
demonstrate.
Alice presented to her fourth session of PE appearing
forlorn and anxious. When her therapist asked how she
was doing, she reported feeling guilty that she had not
listened to her imaginal exposure tape. While she had
agreed to complete an in vivo exposure exercise daily,
she had only completed one in vivo exposure exercise
in the past week.
When the therapist inquired about the completed in
vivo assignment, Alice revealed that she went to the
grocery store after work once. She reported that she
remained at the store for about 30 min despite feeling
quite anxious (pre-SUDS: 60, post-SUDS: 70, peak
SUDS: 85). The therapist praised Alice’s effort and
asked her “How did you convince yourself to go to the
store in the first place?” Alice revealed that she was
worried about breaking her commitment to her thera-
pist. The therapist then asked Alice “Was there any-
thing that you said to yourself as you were driving to
the store or walking inside?” Alice had reminded her-
self about the rationale for PE; she remembered that if
she avoided the store, she would continue to feel anx-
ious. The therapist praised Alice and agreed with the
utility of this strategy.
The therapist then asked, “How were you able to stay
in the store even though you were very anxious?” Alice
reported that when she was at the store, she reminded
herself that if she left right away, she would be giving
into her anxiety. She reported thinking that if she left
right away, it might even make her anxiety worse.
Again, the therapist praised Alice for having the cour-
age to fight through her anxiety.
Once the therapist felt that she had thoroughly praised
Alice for the completed assignment, she turned her
attention briefly to the incomplete assignment. The
therapist said, “I think it’s wonderful that you were
able to complete that first exposure this week. It’s
going to be important for us to collaboratively choose
assignments that you can repeat. Repetition is a critical
component for success in PE. The more that you repeat
the exposures, the less anxiety that you will feel. Do
you have any questions about that? At the end of the
session, we’ll make sure to spend time on planning for
the week for in vivo exposures.”
Then, the therapist explored noncompliance with ima-
ginal exposure homework. “What do you think got in
the way of imaginal exposure homework this week?
I’m really worried about this. We’ve found that listen-
ing to the tape helps to relieve suffering. I’m worried
that if you don’t listen to the tape, you’re not going to
get the most out of this treatment. Does that make
sense? At the end of the session, we’ll spend some time
trouble-shooting ways to overcome urges to avoid lis-
tening to the tape this week. For right now, I think we
should start another imaginal exposure.”
After the patient completed the imaginal exposure and
processing, the therapist opened another conversation
about homework compliance concerns. “Alice, you
 10 BROWN, ZANDBERG, AND FOA
have done an exceptional job with your imaginal ex-
posure and processing today. You should be very
proud of yourself. It’s going to be extremely important
for you to listen to the tape this week—you discussed
important information and it’s essential for you to hear
it repeatedly. Would you be willing to commit to
listening to the tape at least three times this week?
Could I call you at a scheduled time, perhaps right after
you listen to the tape for the first time this week? In
terms of the in vivo exposure homework for this week,
let’s build on momentum from last week. Can you
foresee any difficulties in completing these assign-
ments in the coming week? Is there anything that we
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can do to make them more likely to be accomplished?
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Would you be willing to commit to doing these assign-
ments this week? Just remember, the more that you do
this now, the faster your symptoms are going to
improve.”
Note that the therapist used several strate-
gies throughout this example to maintain rap-
port, improve Alice’s sense of mastery and
self-efficacy, and improve homework compli-
ance. First, she praised Alice for completing
one homework component. Second, she reit-
erated the rationale for repetition of exposure
practice. Third, she expressed care and con-
cern for the patient, as well as described re-
search suggesting the link between homework
compliance and improvement. Fourth, she en-
gaged in problem solving with the patient to
enhance compliance by planning for midweek
check-in calls and helping the patient antici-
pate obstacles. Fifth, she used scaffolding to
gradually increase homework compliance; the
therapist may have assumed that listening to
the imaginal exposure tape daily was too
overwhelming for the patient and therefore
decreased the frequency to three times. Fi-
nally, she used the power of public commit-
ment to encourage the patient to vocalize her
commitment to the assignments.
Enhancing Cognitive Change: Techniques
Used in Processing of Imaginal Exposure
Many patients with PTSD harbor exagger-
ated or distorted perceptions of their respon-
sibility for the trauma. Excessive guilt or self-
blame is common. Avoidance of the trauma
memory prevents direct confrontation of the
details of the trauma. As a result, these neg-
ative perceptions go unchallenged. Imaginal
exposure promotes cognitive change by high-
lighting the context in which the trauma oc-
curred. In many cases, imaginal exposure
alone leads to changes in perception of cul-
pability. In other cases, processing of the ima-
ginal exposure allows for in depth discussion
of these beliefs, and facilitates change in neg-
ative cognitions.
Alice reported strong beliefs that she was a disgusting
and unfeeling person who was responsible for her
mother’s death. She believed that if only she had
returned home earlier, when her mom first called her,
her mother might still be alive. To Alice, the fact that
she had chosen to ignore her mother’s pleas demon-
strated that she was “no good”, and that she may have
wanted her mom to die. She was, after all, very angry
with her mom at this point in her life because of the
culmination of years of verbal abuse.
To better evaluate these cognitions, Alice’s therapist
probed the “choice point” driving her shame and guilt:
When Alice’s mother called and decided to stay at
work instead of returning home immediately. The goal
was to reveal influential contextual details. What did
Alice’s mom say? How did she sound? What was Alice
thinking? Alice verbalized her anguish at the time of
the event. Rather than being cold and unfeeling, she
had gone to the break-room and cried. There was
nothing in the phone message that was different than
the hundreds of prior calls her mom had made. This
time, Alice decided she could not afford to lose her job,
and delayed checking on her mom until after her shift.
During processing, the therapist helped Alice reevalu-
ate her reasons for making the difficult decision of
staying at work on the day her mother died. This
reevaluation was facilitated by questioning, but with-
out any formal cognitive exercises (as you might see in
other PTSD treatments, such as Cognitive Processing
Therapy). Questions were posed to help Alice explore
inconsistencies between her stated beliefs and the de-
tails that emerged in the imaginal exposure. For exam-
ple, “Help me understand: you think that you should
have known your mother really needed you that day.
How did her voicemail compare to her other mes-
sages?” Alice could think of no differences. Her ther-
apist replied, “So it sounds like there was no way to tell
a difference from the voicemail. What usually hap-
pened when you got home?” Alice recognized that all
her previous experiences suggested her mom would be
sick from withdrawal, but otherwise fine. The therapist
wondered “What do you make of that?” Alice realized
that there was no real difference between that day and
the many other times when her mother asked Alice to
leave her work.
Over 15 sessions of PE, Alice’s beliefs about her
direct responsibility for her mom’s death softened
greatly. She still wished that she had gone home that
day, but did not view herself as responsible for her
mother’s death. Instead, she understood the com-
plexity of the circumstances that led her to stay at
work, and the lack of certainty that her mother
would have survived even if she had gone home
immediately.
 MECHANISMS OF PROLONGED EXPOSURE
Managing Treatment Refusal, Nonresponse,
and Symptom Exacerbation
Unfortunately, not all patients who are of-
fered PE respond as well as Alice. A full
discussion of strategies to manage treatment
refusal, nonresponse, and symptom exacerba-
tion is beyond the scope of this article. In
brief, common strategies include exploring
and validating ambivalence about exposures,
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revisiting the treatment rationale, altering the
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intensity of exposures, and increasing thera-
pist support by engaging in check-in phone-
calls between sessions. When these and other
strategies have not increased treatment en-
gagement or response, several considerations
may be appropriate.
First, some patients may refuse to engage
in PE. After the rationale is revisited and
general motivational enhancement strategies
have been engaged, potentially borrowing
from the motivational interviewing literature
(Miller & Rollnick, 2013), some patients may
refuse PE in part or whole. For example, one
study reported that about 17% of patients
refused to engage in imaginal exposure exer-
cises (Schottenbauer, Glass, Arnkoff, Ten-
dick, & Gray, 2008). There is no evidence to
support the efficacy of delivering piecemeal
components of PE in the absence of the full
package. In fact, a few studies have demon-
strated that in vivo or imaginal exposures
alone are not sufficient to reduce symptoms of
PTSD (Bryant et al., 2008). Therefore, rather
than agreeing to continue with one treatment
component in the absence of the full PE pack-
age, it is recommended that the therapist and
patient make a clear transition toward another
treatment package or modality altogether in
the event of patient refusal.
Second, patients may not benefit from PE, as
approximately 50% of patients do not respond
clinically to empirically supported treatments
for PTSD (Schottenbauer et al., 2008). The full
PE treatment package should be continued at
least for several sessions even in the event of
initial nonresponse. In fact, prior research has
suggested differential patterns of response, such
that some participants respond more quickly
than others (Clapp, Kemp, Cox, & Tuerk, 2016;
Foa, Zoellner, Feeny, Hembree, & Alvarez-
Conrad, 2002). Therefore, nonresponse early in
treatment should not be cause for alarm. If a
11
participant continues the treatment for several
sessions without responding, changing the treat-
ment plan may be warranted. Rather than sup-
plementing PE with alternative treatment pro-
cedures in PE sessions, one option is for the
therapist and patient to consciously shift to an
alternate evidence-based treatment modality
(e.g., Cognitive Processing Therapy; Interper-
sonal Psychotherapy). A thorough evaluation of
the impediments to success may guide the se-
lection of alternative treatments. For instance, a
patient who has panic attacks that interfere with
PE engagement may benefit from panic disorder
treatment prior to returning to PE. A second
option is to supplement PE with attendance in a
complementary therapy. For example, patients
with symptoms of borderline personality disor-
der may benefit from attendance in dialectical
behavior therapy (DBT; Linehan, 1993) group
sessions in addition to individual PE sessions.
However, therapists should be cautious about
this approach, as there is limited data to support
its efficacy (for an example, see Harned et al.,
2014). While the concurrent delivery of two
empirically supported treatments may improve
treatment outcome, it may also dilute treatment
effects (Foa et al., 1999). A third option is to
deliver additional treatment sessions beyond the
traditional recommendation of 12 sessions. This
may be a useful approach when patients have
shown some improvement but have not reached
full treatment response. However, we are not
aware of any research on this topic in PTSD.
Third, some patients receiving PE experience
symptom exacerbation. Approximately 3–15%
of patients report a reliable exacerbation in
symptoms (Foa et al., 2002). This exacerbation
has been detected most commonly between Ses-
sions 3 and 4, following the introduction of
imaginal exposure. Fortunately, symptom exac-
erbation is not associated with worsened treat-
ment outcome (Foa et al., 2002). Therefore, in
the absence of acute safety concerns, clinicians
should not deviate from the PE protocol despite
symptom exacerbation. Indeed, the possibility
of symptom exacerbation is frequently dis-
cussed as part of preparation for PE. This facil-
itates appropriate expectations for the treatment
and mitigates demoralization following symp-
tom exacerbation. If symptom exacerbation
continues for several weeks, the therapist may
consider many of the options described
for nonresponse. Many of the listed options for
 12 BROWN, ZANDBERG, AND FOA
treatment nonresponse are also relevant for
symptom exacerbation. Specifically, therapists
should consider stopping treatment and initiat-
ing a new treatment modality or supplementing
treatment with a concurrent treatment option
(e.g., group therapy).
Conclusion
In summary, PE is a very effective treatment
for PTSD. When the therapist bases treatment
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decision in EPT, outcomes are enhanced, as
demonstrated by the evidence in support of fear
activation, between-session habituation, and
cognitive change. In PE, therapists should en-
sure that fear is appropriately activated, home-
work is completed, and negative cognitions are
identified and modified. We have described sev-
eral strategies for promoting each of these
mechanisms in clinical practice.
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a0034735

Mecanismos de cambio en la terapia de exposición prolongada para el TEPT: implicaciones para la

práctica clínica

La terapia de exposición prolongada (EP) es un tratamiento altamente eficaz y eficaz para el trastorno de estrés
postraumático (TEPT). Además de reducir los síntomas de trastorno de estrés postraumático, la EP mejora una amplia
variedad de síntomas relacionados, que incluyen ansiedad, depresión, deterioro funcional, ideación suicida leve y enojo.
Además, la EP es efectiva en pacientes con condiciones comórbidas, que incluyen disociación, uso de sustancias, trastorno
límite de la personalidad y psicosis. ¿Cómo logra la EP estos resultados? La teoría del procesamiento emocional (EPT por
sus siglas en inglés) es el modelo conceptual del cual se derivó la EP. Tres conceptos clave se propusieron originalmente
como indicadores de que el procesamiento emocional, el mecanismo subyacente a la reducción de los síntomas mediante
la terapia de exposición, incluida la EP, había ocurrido. Los tres indicadores son la activación del miedo, la habituación
dentro de la sesión y la habituación entre sesiones, todos los cuales se propusieron para reducir los síntomas del TEPT.
Además de estos indicadores, EPT postula que los cambios en las evaluaciones cognitivas sobre el yo y el mundo también
están involucrados en el procesamiento emocional exitoso, el mecanismo subyacente en la reducción de los síntomas. Desde
su aparición en 1986, el EPT se ha actualizado y modificado para incorporar hallazgos empíricos emergentes y desarrollos
conceptuales. Primero, revisamos el apoyo empírico reciente y la refutación de varias hipótesis derivadas del EPT, incluida
la importancia de la activación del miedo, entre la habituación de la sesión y el cambio cognitivo. Luego proporcionamos
un estudio de caso clínico para resaltar estrategias para promover el procesamiento emocional y la reducción de síntomas
a largo plazo resultante. Este ejemplo de caso destaca tres obstáculos comunes para el éxito en la educación física: la falta
de participación, el cumplimiento insuficiente de la tarea y la presencia de cogniciones negativas relacionadas con el
trastorno de estrés postraumático.
 14 BROWN, ZANDBERG, AND FOA

trastorno de estrés postraumático, terapia de exposición prolongada, teoría del procesamiento emocional, mecanismos,
ejemplo de caso

针对创伤性应激障碍的延迟暴露疗法中的改变机制：临床实践的意义
延迟暴露疗法（PE）是一项针对创伤性应激障碍（PTSD）具有高度实验效力和临床功效的治疗方式。并且，为
了减少创伤性应激障碍的症状（PTSD），延迟暴露疗法（PE）缓解了多种相关症状，包括：焦虑，抑郁，功能性
失调，轻度自杀意念和愤怒。并且，延迟暴露疗法（PE）对于有并发症的病人非常有效，包括解离（症状），药
物成瘾，边缘型人格障碍以及精神病。那么延迟暴露疗法（PE）是怎样获得这些效果的呢？情绪处理理论（EPT）
作为一种核心模型，延迟暴露疗法即由此发展而来。三个核心概念作为指标最先被提出来， 即：情绪处理作
为通过暴露疗法获得症状缓解的机制（包括：长期暴露疗法 PE）已然发生。这三个指标就是恐惧的触发，治
疗中的习惯化，以及治疗期间的习惯化，这三个指标都被视为能够够缓解创伤性应激障碍（PTSD）的症状。连同
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

这些指标一起，情绪处理理论（EPT）认为在关于自我及世界的认知评断上发生的改变都伴随着成功的情绪处理
This document is copyrighted by the American Psychological Association or one of its allied publishers.

----即让症状获得缓解的机制。自从1986年情绪处理理论（EPT）产生至今，它有数次更新和调整，以便引进不
断更新的实证发现和概念发展。我们首先回顾了最近的实证支持，以及对从情绪处理理论（EPT）发展而来的许
多假设的驳斥，包括恐惧触发、治疗期间的习惯化、还有认知的改变的重要性。我们接下来再提供临川实例研究
去强调一些策略，以便能够推进情绪处理理论（EPT）（的发展）并带来长期症状减缓的结果。这些案例突出了三
个阻碍延迟暴露疗法（PE）成功的因素，即：低参与度、不充分的作业遵从，以及存在创伤应激障碍相关的负面
认知。

创伤性应激障碍, 延迟暴露疗法, 情绪处理理论, 机制, 案例

Received August 4, 2017

Revision received December 14, 2017
Accepted December 17, 2017 !