Utilizing In Vivo and Imaginal Exposure in the Context of MDMA-Assisted Therapy for Social Anxiety Disorder: A Case Report

This case report describes the application of in vivo and imaginal exposure techniqueswithin MDMA-assisted therapy (MDMA-AT) for social anxiety disorder (SAD). The treatment,conducted as part of a randomized controlled trial, consisted of three non-drug preparationsessions, two drug sessions, and six non-drug integration sessions. Exposure interventionsincluded imaginal exposure to shame-related memories during MDMA sessions, in vivo socialexposures during MDMA sessions, imagery rescripting exercises during integration sessions, andsocial activation homework between sessions. The participant, a man in his late 30s withgeneralized SAD, showed significant reduction in symptoms and functional impairment asmeasured by the Leibowitz Social Anxiety Scale and Sheehan Disability Scale. Qualitativereports indicated increased social engagement, reduced anxiety in social situations, and a shifttowards more self-compassion. The participant found both imaginal and in vivo exposuresduring MDMA sessions particularly impactful, reporting they allowed him to access intrinsicdesires for social connection and performance that were previously masked by anxiety. This casesuggests MDMA-AT incorporating exposure techniques may be a promising treatment for SAD,warranting further research.