A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people

Background

Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny.

Aims

This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years.

Method

Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure.

Results

From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication.

Conclusions

A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.

Intensive Exposure and Response Prevention for Adolescent Body Dysmorphic Disorder With Comorbid Obsessive–Compulsive Disorder and Major Depressive Disorder

Body dysmorphic disorder (BDD) primarily onsets during adolescence, and symptoms typically worsen when left untreated. Although use of cognitive-behavioral therapy (CBT) has established efficacy for adults with BDD, there is limited research and few case studies to suggest the same for adolescents and children. The present case describes the implementation of intensive (daily) treatment for Erin (pseudonym), a 17-year-old Caucasian female with primary BDD, as well as comorbid obsessive–compulsive disorder (OCD) and major depressive disorder (MDD), who was initially nonresponsive to outpatient supportive psychotherapy and pharmacotherapy. Treatment consisted of exposure and response prevention (ERP), concurrent with behavioral activation (BA). At discharge, Erin’s total score on the Children’s Yale–Brown Obsessive Compulsive Scale–Self-Report version (CY-BOCS-SR) decreased from 32 ( extreme severity) at pretreatment to 11 ( mild severity), as well as demonstrating improvement on other self-report measures.

Despite significant reductions in ritual engagement, Erin’s symptoms never fully remitted. Based on telephone contact with her mother, Erin discontinued ERP upon returning home, where treatment gains were not maintained and symptoms returned to baseline severity. Thus, this case study demonstrates the effectiveness of intensive ERP for adolescent BDD, as well as demonstrating the lack of gain durability associated with withdrawing early from treatment. Furthermore, this case demonstrates that withdrawal from ERP prior to complete remission may lead to a resurgence of symptoms, thus making previous progress obsolete.

Five-day intensive treatment for adolescent OCD: a case series

This case series describes the use of an intensive 5-day treatment for obsessive-compulsive disorder (OCD) with three adolescents. The treatment is based on traditional cognitive-behavioral therapy consisting primarily of exposures and response prevention (ERP) and involves 10 sessions over 5 days. In addition, the treatment emphasizes instructing the adolescent and the parents on how to conduct ERP at home following the completion of the 5 days of therapy. The treatment is designed for adolescents who do not have local access to mental health practitioners with expertise in ERP for OCD. The three patients who participated in the experimental program each experienced substantial improvements in their OCD symptoms and overall functioning. The present study suggests that brief, 5-day intensive treatment may be an effective means of delivering CBT for adolescents with OCD and may be of use to mental health practitioners who provide services to large catchments.