Is Exposure Practice More Effective in the Morning?

Some studies have looked at enhancing exposure therapy by administering glucocorticoids, steroid hormones that increase levels of cortisol in the body. The exact mechanisms are not quite understood but studies have found that participants given glucocorticoids show better outcomes in exposure therapy for people with spider phobia (Soravia et al., 2014) and fear of heights (de Quervain et al., 2011). It is speculated that higher levels of cortisol enhance learning during exposure.

Rather than rely on drug administration, a new study researcher Dr. Alicia Meuret and colleagues studied a more naturalistic means to harness the exposure-enhancing effects of higher cortisol. People naturally have higher levels of cortisol in the mornings upon awakening.

In a blog post about the study, Dr. Meuret is quoted:

“The hormone cortisol is thought to facilitate fear extinction in certain therapeutic situations,” said Meuret, lead author on the research. “Drugs to enhance fear extinction are being investigated, but they can be difficult to administer and have yielded mixed results. The findings of our study promote taking advantage of two simple and naturally occurring agents – our own cortisol and time of day.”

Study

In this new study by Dr. Meuret and colleagues, 26 people with panic disorder were treated with 3 sessions of weekly exposure therapy followed by a fourth session 2 months later. Participants collected saliva samples at set points during the day which the researchers tested for cortisol levels.

Findings

Consistent with prior studies, the researchers found that higher cortisol levels were associated with a quicker response to treatment.

Moreover, participants who had morning sessions—when natural cortisol levels are higher—showed greater improvements at the end of treatment and 3 months later than participants who attended evening sessions, when cortisol levels are lower.

Some final thoughts

It’s important to keep these results in context. This was a pilot study showing a large effect in a small sample. Results in smaller samples are more prone to being influenced by outliers or other factors, and this study needs replication in order to be more confident about the findings. In particular, it’s possible that therapist expectancy may have had an effect here, as it doesn’t appear the therapists were blinded to the study hypotheses. Nevertheless, this is an intriguing and interesting study.

Limitations aside this study does suggest that—all things being equal—it might be advantageous to schedule exposure sessions earlier in the morning when cortisol levels are higher. The mechanism is not quite clear, but there is evidence that cortisol may enhance learning associated with exposure.

You can read the original blog post about the study on the Southern Methodist University website.

If you’d like to download a copy of the journal article, it is currently available on the authors’ ResearchGate page.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

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