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 techniques within MDMA-assisted therapy (MDMA-AT) for social anxiety disorder (SAD). The treatment, conducted as part of a randomized controlled trial, consisted of three nondrug preparation sessions, two drug sessions, and six nondrug integration sessions. Exposure interventions included imaginal exposure to shame-related memories during MDMA sessions, in vivo social exposures during MDMA sessions, imagery rescripting exercises during integration sessions, and social activation homework between sessions. The participant, a man in his late 30s with generalized SAD, showed significant reduction in symptoms and functional impairment as measured by the Leibowitz Social Anxiety Scale and Sheehan Disability Scale. Qualitative reports indicated increased social engagement, reduced anxiety in social situations, and a shift towards more self-compassion. The participant found both imaginal and in vivo exposures during MDMA sessions particularly impactful, reporting they allowed him to access intrinsic desires for social connection and performance that were previously masked by anxiety. This case suggests MDMA-AT incorporating exposure techniques may be a promising treatment for SAD, warranting further research.