Skip to main content Accessibility help

Sleep enhances exposure therapy

  • B. Kleim (a1), F. H. Wilhelm (a2), L. Temp (a3), J. Margraf (a4), B. K. Wiederhold (a5) (a6) and B. Rasch (a7)...



Sleep benefits memory consolidation. Here, we tested the beneficial effect of sleep on memory consolidation following exposure psychotherapy of phobic anxiety.


A total of 40 individuals afflicted with spider phobia according to DSM-IV underwent a one-session virtual reality exposure treatment and either slept for 90 min or stayed awake afterwards.


Sleep following exposure therapy compared with wakefulness led to better reductions in self-reported fear (p = 0.045, d = 0.47) and catastrophic spider-related cognitions (p = 0.026, d = 0.53) during approaching a live spider, both tested after 1 week. Both reductions were associated with greater percentages of stage 2 sleep.


Our results indicate that sleep following successful psychotherapy, such as exposure therapy, improves therapeutic effectiveness, possibly by strengthening new non-fearful memory traces established during therapy. These findings offer an important non-invasive alternative to recent attempts to facilitate therapeutic memory extinction and consolidation processes with pharmacological or behavioral interventions.


Corresponding author

* Address for correspondence: B. Kleim, Ph.D., Department of Clinical Psychology and Psychotherapy, University of Zurich, Binzmühlestrasse 14, Box 26, CH-8050 Zurich, Switzerland. (Email:


Hide All
Anderer, P, Moreau, A, Woertz, M, Ross, M, Gruber, G, Parapatics, S, Loretz, E, Heller, E, Schmidt, A, Boeck, M, Moser, D, Kloesch, G, Saletu, B, Saletu-Zyhlarz, GM, Danker-Hopfe, H, Zeitlhofer, J, Dorffner, G (2010). Computer-assisted sleep classification according to the standard of the American Academy of Sleep Medicine: validation study of the AASM version of the Somnolyzer 24 × 7. Neuropsychobiology 62, 250264.
APA (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn, revised. American Psychiatric Association: Washington, DC.
Arntz, A, Lavy, E, Van den Berg, G, Van Rijsoort, S (1993). Negative beliefs of spider phobics: a psychometric evaluation of the Spider Phobia Beliefs Questionnaire. Advances in Behaviour Research and Therapy 15, 257277.
Baran, B, Pace-Schott, EF, Ericson, C, Spencer, RMC (2012). Processing of emotional reactivity and emotional memory over sleep. Journal of Neuroscience 32, 10351042.
Beck, AT, Steer, RA (1987). Beck Depression Inventory: Manual. Psychological Corporation: San Antonio, TX.
Buysse, DJ, Reynolds, CF, Monk, TH, Berman, SR, Kupfer, DJ (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Research 28, 193213.
Choy, Y, Fyer, AJ, Lipsitz, JD (2007). Treatment of specific phobia in adults. Clinical Psychology Review 27, 266286.
Craske, MG, Mystkowski, JL (2006). Exposure therapy and extinction: clinical studies. In Fear and Learning: Basic Science to Clinical Application (ed. Craske, D. H. M. G. and Vansteenwegen, D.), pp. 217234. American Psychological Association: Washington, DC.
De Quervain, DJF, Bentz, D, Michael, T, Bolt, OC, Wiederhold, BK, Margraf, J, Wilhelm, FH (2011). Glucocorticoids enhance extinction-based psychotherapy. Proceedings of the National Academy of Sciences USA 108, 66216625.
Diekelmann, S, Biggel, S, Rasch, B, Born, J (2012). Offline consolidation of memory varies with time in slow wave sleep and can be accelerated by cuing memory reactivations. Neurobiology of Learning and Memory 98, 103111.
Diekelmann, S, Born, J (2010). The memory function of sleep. Nature Reviews Neuroscience 11, 114126.
Diekelmann, S, Wilhelm, I, Born, J (2009). The whats and whens of sleep-dependent memory consolidation. Sleep Medicine Review 13, 309321.
Emmelkamp, PM, Bruynzeel, M, Drost, L, van der Mast, CA (2001). Virtual reality treatment in acrophobia: a comparison with exposure in vivo . Cyberpsychology and Behavior 4, 335339.
Horne, JA, Ostberg, O (1976). A self-assessment questionnaire to determine morningness–eveningness in human circadian rhythms. International Journal of Chronobiology 4, 97110.
Hussaini, SA, Bogusch, L, Landgraf, T, Menzel, R (2009). Sleep deprivation affects extinction but not acquisition memory in honeybees. Learning and Memory 16, 698705.
Johns, MW (1994). Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep 17, 703710.
Lahl, O, Wispel, C, Willigens, B, Pietrowsky, R (2008). An ultra short episode of sleep is sufficient to promote declarative memory performance. Journal of Sleep Research 17, 310.
Magee, WJ, Eaton, WW, Wittchen, HU, McGonagle, KA, Kessler, RC (1996). Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Archives of General Psychiatry 53, 159168.
McNally, RJ (2007). Mechanisms of exposure therapy: how neuroscience can improve psychological treatments of anxiety disorders. Clinical Psychology Review 27, 750759.
Mednick, S, Nakayama, K, Stickgold, R (2003). Sleep-dependent learning: a nap is as good as a night. Nature Neuroscience 6, 697698.
Mölle, M, Born, J (2011). Slow oscillations orchestrating fast oscillations and memory consolidation. Progress in Brain Research 193, 93110.
Mystkowski, JL, Craske, MG, Echiverri, AM (2002). Treatment context and return of fear in spider phobia. Behavior Therapy 33, 399416.
Mystkowski, JL, Craske, MG, Echiverri, AM, Labus, JS (2006). Mental reinstatement of context and return of fear in spider-fearful participants. Behavior Therapy 37, 4960.
Nishida, M, Pearsall, J, Buckner, RL, Walker, MP (2009). REM sleep, prefrontal theta, and the consolidation of human emotional memory. Cerebral Cortex 19, 11581166.
Norton, PJ, Price, EC (2007). A meta-analytic review of adult cognitive–behavioral treatment outcome across the anxiety disorders. Journal of Nervous and Mental Disease 195, 521531.
Ost, LG (1996). One-session group treatment of spider phobia. Behavior Research and Therapy 34, 707715.
Ost, LG, Brandberg, M, Alm, T (1997). One versus five sessions of exposure in the treatment of flying phobia. Behavior Research and Therapy 35, 987996.
Pace-Schott, E, Verga, PW, Bennett, TS, Spencer, RM (2012). Sleep promoted consolidation and generalizaton of extinction learning in simulated exposure therapy for spider fear. Journal of Psychiatric Research 46, 10361044.
Pace-Schott, EF, Milad, MR, Orr, SP, Rauch, SL, Stickgold, R, Pitman, RK (2009). Sleep promotes generalization of extinction of conditioned fear. Sleep 32, 1926.
Pace-Schott, EF, Shepherd, E, Spencer, RM, Marcello, M, Tucker, M, Propper, RE, Stickgold, R (2011). Napping promotes inter-session habituation to emotional stimuli. Neurobiology of Learning and Memory 95, 2436.
Payne, JD, Stickgold, R, Swanberg, K, Kensinger, EA (2008). Sleep preferentially enhances memory for emotional components of scenes. Psychological Science 19, 781788.
Powers, MB, Emmelkamp, PM (2008). Virtual reality exposure therapy for anxiety disorders: a meta-analysis. Journal of Anxiety Disorders 22, 561569.
Price, M, Mehta, N, Tone, EB, Anderson, PL (2011). Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia. Journal of Anxiety Disorders 25, 763770.
Rasch, B, Buchel, C, Gais, S, Born, J (2007). Odor cues during slow-wave sleep prompt declarative memory consolidation. Science 315, 14261429.
Ressler, KJ, Rothbaum, BO, Tannenbaum, L, Anderson, P, Graap, K, Zimand, E, Hodges, L, Davis, M (2004). Cognitive enhancers as adjuncts to psychotherapy: use of d-cycloserine in phobic individuals to facilitate extinction of fear. Archives of General Psychiatry 61, 11361144.
Ruhmland, M, Margraf, J (2001). Effectiveness of psychological therapies for specific phobia and obssessive–compulsive disorder: disorder-specific meta-analyses. Verhaltenstherapie 11, 12.
Scheuchenpflug, R (2001). Measuring presence in virtual environments. In HCI International (ed. Smith, M. J., Salvendy, G. and Kasdorf, M. R.), pp. 5658. Lawrence Erlbaum: Mahwah, NJ.
Schneider, S, Margraf, J (2006). Diagnostic Interview for Mental Disorders (DIPS). Springer: Berlin.
Silvestri, AJ, Root, DH (2008). Effects of REM deprivation and an NMDA agonist on the extinction of conditioned fear. Physiology and Behavior 93, 274281.
Silvestri, R, Pace-Schott, EF, Gersh, T, Stickgold, R, Salzman, C, Hobson, JA (2001). Effects of fluvoxamine and paroxetine on sleep structure in normal subjects: a home-based Nightcap evaluation during drug administration and withdrawal. Journal of Clinical Psychiatry 62, 642652.
Smith, CT, Aubrey, JB, Peters, KR (2004). Different roles for REM and stage 2 sleep in motor learning: a proposed model. Psychologica Belgica 44, 81104.
Spoormaker, VI, Schröter, MS, Andrade, KC, Dresler, M, Kiem, SA, Goya-Maldonado, R, Wetter, TC, Holsboer, F, Sämann, PG, Czisch, M (2011). Effects of rapid eye movement sleep deprivation on fear extinction recall and prediction error signaling. Human Brain Mapping 33, 23622376.
Spoormaker, VI, Sturm, A, Andrade, KC, Schroter, MS, Goya-Maldonado, R, Holsboer, F, Wetter, TC, Samann, PG, Czisch, M (2010). The neural correlates and temporal sequence of the relationship between shock exposure, disturbed sleep and impaired consolidation of fear extinction. Journal of Psychiatric Research 44, 11211128.
Stickgold, R (2009). How do I remember? Let me count the ways. Sleep Medicine Review 13, 305308.
Suppiger, A, In-Albon, T, Herren, C, Bader, K, Schneider, S, Margraf, J (2008). Reliabilität des Diagnostischen Interviews bei psychischen Störungen (DIPS für DSM-IV-TR). [Reliability of the Diagnostic Interview for Mental Disorders (DIPS for DSM-IV-TR).]. Verhaltenstherapie 18, 237244.
van der Helm, E, Gujar, N, Nishida, M, Walker, MP (2011 a). Sleep-dependent facilitation of episodic memory details. PLoS ONE 6, e27421.
van der Helm, E, Walker, MP (2011). Sleep and emotional memory processing. Sleep Medicine Clinics 6, 3143.
van der Helm, E, Yao, J, Dutt, S, Rao, V, Saletin, JM, Walker, MP (2011 b). REM sleep depotentiates amygdala activity to previous emotional experiences. Current Biology 21, 20292032.
Wagner, U, Gais, S, Born, J (2001). Emotional memory formation is enhanced across sleep intervals with high amounts of rapid eye movement sleep. Learning and Memory 8, 112119.
Wagner, U, Hallschmid, M, Rasch, B, Born, J (2006). Brief sleep after learning keeps emotional memories alive for years. Biological Psychiatry 60, 788790.
Walker, MP (2008). Sleep-dependent memory processing. Harvard Review of Psychiatry 16, 287298.
Walker, MP (2009). The role of sleep in cognition and emotion. Annals of New York Academy of Science 1156, 168197.
Walker, MP, Brakefield, T, Morgan, A, Hobson, JA, Stickgold, R (2002). Practice with sleep makes perfect: sleep-dependent motor skill learning. Neuron 35, 205211.
Walker, MP, Brakefield, T, Seidman, J, Morgan, A, Hobson, JA, Stickgold, R (2003). Sleep and the time course of motor skill learning. Learning and Memory 10, 275284.
Walker, MP, van der Helm, E (2009). Overnight therapy? The role of sleep in emotional brain processing. Psychological Bulletin 135, 731748.
Wamsley, EJ, Stickgold, R (2010). Dreaming and offline memory processing. Current Biology 20, R1010R1013.
Wertz, AT, Wright, KP, Ronda, J M, Czeisler, CA (2006). Effects of sleep inertia on cognition. Journal of the American Medical Association 295, 163164.
Wolpe, J, Lazarus, AA (1966). Behavior Therapy Techniques. Pergamon Press: Oxford.


Sleep enhances exposure therapy

  • B. Kleim (a1), F. H. Wilhelm (a2), L. Temp (a3), J. Margraf (a4), B. K. Wiederhold (a5) (a6) and B. Rasch (a7)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed