Graduated exposure to traumatic events decreases distress during prolonged exposure therapy for posttraumatic stress disorder

J Behav Med. 2026 May 24. doi: 10.1007/s10865-026-00666-2. Online ahead of print.

ABSTRACT

Prolonged exposure (PE) is an evidence-based treatment for PTSD. However, the imaginal exposure portion of PE can be distressing for patients, and despite many service members reporting multiple traumatic events, traditional PE focuses solely on the most distressing event. This article evaluates a modified version of PE that considers the need for distress-reduction in trauma-focused treatments. We compared distress during two methods of imaginal exposure: (1) standard exposure, where participants focused on their most distressing event; and (2) graduated exposure, where participants focused on their top three most distressing events, from third most distressing to most distressing. Mean peak subjective units of distress scores (SUDS) were compared across groups. Participants were 199 active duty personnel and veterans (79.9% men; mean age 38.5 years). There was a significant overall effect of group on peak SUDS, F(3,359) = 12.46, p < .001. Participants receiving standard exposure reported an average peak SUDS of 88.1/100 (SD = 13.4), compared to 75.2 (SD = 22.5) for graduated imaginal exposure participant’s most distressing event. Participants in the graduated group also reported significantly lower peak SUDS for their second (M = 72.23, SD = 20.6; t(183) = 5.49, p < .001, d = .81) and third most distressing events (M = 74.63, SD = 21.1; t(183) = 466, p < .001, d = .69) compared to mean SUDS rating for the standard exposure group. Incorporating a graduated approach appears to mitigate average peak distress from participating in the imaginal exposure component of PE.Trial registration These data were collected as part of a larger, randomized clinical trial that was registered with ClinicalTrials.gov (Identifier NCT03529435).

PMID:42177712 | DOI:10.1007/s10865-026-00666-2