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Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample. • Examined mechanisms of change in exposures for OCD using network analysis • Engagement with exposure was consistently the most central node • Engagement was related to understanding rationale, willingness, and ritualizing • Clarifying rationale and practicing willingness may be important for engagement [ABSTRACT FROM AUTHOR]

Background: Misophonia, a disorder of decreased sound tolerance, can cause significant distress and impairment. Cognitive behavioural therapy (CBT) may be helpful for improving symptoms of misophonia, but the key mechanisms of the disorder are not yet known. Aims: This case series aimed to evaluate individual, formulation-driven CBT for patients with misophonia in a UK psychology service. Method: A service evaluation of one-to-one therapy for patients with misophonia (n =19) was conducted in a specialist psychology service. Patients completed an average of 13 hours of therapy with a focus on the meaning applied to their reactions to sounds and associated behaviours. Primary outcome measures were the Misophonia Questionnaire (MQ) and the Amsterdam Misophonia Scale (A-MISO-S). Repeated measures t -tests were used to compare scores from pre-treatment to follow-up, and reliable and clinically significant change on the MQ was calculated. Results: Scores significantly improved on both misophonia measures, with an average of 38% change on the MQ and 40% change on the A-MISO-S. From pre-treatment to follow-up, 78% of patients showed reliable improvement on the MQ and 61% made clinically significant change. Conclusions: Limitations included a lack of control group, small sample size, and the use of an outcome measure that had not been thoroughly validated for a treatment-seeking sample. These results suggest that one-to-one, formulation-driven CBT for misophonia is worth exploring further using experimental design. Potential mechanisms to explore further include feared consequences of escalating reactions, the role of safety-seeking behaviours and the impact of early memories associated with reactions to sounds. [ABSTRACT FROM AUTHOR]

• Inhibitory learning applicable to exposure therapy of pathological health anxiety (HA) • Sig. reduction of HA during an inhibitory learning-based exposure intervention. • Reduction of HA sig. associated with increase of tolerance for aversive states. Exposure to illness-related stimuli is a crucial component of CBT for pathological health anxiety. Modern exposure approaches focus on forming inhibitory associations and provide promising results. An implementation in the treatment of pathological health anxiety is still missing. The present single case series study investigated the applicability and effects of an inhibitory learning-based exposure approach (12 sessions) on health anxiety, safety behavior, and tolerance for aversive states in n = 7 outpatients (age: M = 35.14, SD = 8.43) with a DSM-5 Illness Anxiety Disorder or Somatic Symptom Disorder with predominant health worries in multilevel models. A high intervention satisfaction and little adverse effects were reported. A significant(ly) (steepened) reduction of health anxiety (b = −0.10, p baseline <.001, p pre-intervention =.003), and body checking behavior (b = −0.14, p baseline/pre-intervention <.001), and a significant increase in distress tolerance (b = 0.07, p baseline =.02, p pre-intervention =.004), discomfort tolerance (b = 0.11, p baseline/pre-intervention <.001), and insecurity tolerance (b = 0.13, p baseline/pre-intervention <.001) were observed during the intervention in comparison to the baseline and pre-intervention phase. The present study provided first evidence that the principles of inhibitory learning can be effectively applied to the exposure-based treatment of pathological health anxiety. [ABSTRACT FROM AUTHOR]

In the last two decades, progress in the areas of learning and fear extinction have led to the formulation of a new conceptual model, based on exposure therapy, according to which the extinction of fear (which represents its clinical application) would occur through the creation of a new inhibiting memory rather than through the habituation process. This has led to the development of specific changes in the procedure, which aim to maximise exposure therapy, particularly in terms of diminished fear return. To date, the new «modus operandi» of therapy is being applied to patients by exposing them directly to what they fear, in other words, «in vivo». Virtual Reality environments (VR) are excellent for implementing the potential of inhibitory expository learning, although they are in need of a fully implemented protocol. To this purpose, we are rethinking current technology, modelled towards the process of habituation, in favour of a tool capable of facilitating the learning process through inhibitory learning, and even using the Flow mechanism. This paper makes some considerations on these innovations and proposes the hardware and software changes needed to shape innovative virtual reality psychotherapy. [ABSTRACT FROM AUTHOR]

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors. [ABSTRACT FROM AUTHOR]

[Background] Exposure therapy is at the core of the treatment of pathological anxiety. While the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. Therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning. [Method] In total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. To experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. Consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively. [Results] We found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. On Day 2, inhibitory CS-noUS associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings. [Conclusion] These findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety.

Inhibitory Learning Theory (ILT) framework implies that in-session distress variability may promote extinction learning and thereby enhance exposure therapy efficacy. Thus far, research has mainly focused on in-session distress reduction. The aim of the current study was to assess whether in-session distress variability predicts next session PTSD symptom decline in PTSD patients receiving prolonged exposure (PE). Eighty-six patients with PTSD received 14 to 16 sessions of PE. Using dynamic panel models, we assessed the temporal relation (i.e., within-persons) between in-session distress variability and PTSD symptom decline. Moreover, we assessed the averaged relation (i.e., between-persons) between in-session distress variability and PTSD symptom decline. Temporal analyses showed that in-session distress variability did not precede PTSD symptom improvement. Averaged analyses showed that distress variability was related to PTSD symptom improvement. The operationalization of distress variability appeared to deviate from its theoretical conceptualization. In absence of distress reduction, distress variability can vary. However, our findings suggest that in-session distress variability does not drive symptom reduction during PE. In contrast, averaged over participants, distress variability was related to symptom improvement, suggesting that those with a more variable distress pattern across sessions show better treatment response. More empirical work is needed to shed light on the effect of distress variability during exposure sessions on treatment outcome and to offer grounds for clinical recommendations. • Distress variability and distress reduction are related, but can diverge from each other. • In-session distress variability did not predict subsequent PTSD symptom improvement. • The average level of distress variability was related to better treatment outcome. • Distress variability is hard to control and operationalize in clinical settings. [ABSTRACT FROM AUTHOR]

Abstract Background Exposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome. Method In a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions. Results In a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings. Conclusions The results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.

In Experiment 1, rats received 16 nonreinforced trials of exposure to a flavor (A) that was subsequently used as the conditioned stimulus in flavor-aversion conditioning. In the critical condition, Flavor A was presented in compound with a different novel flavor on each of the eight daily trials. This treatment produced latent inhibition, in that this preexposure retarded conditioning just as did 16 trials with A alone. Rats in the control conditions, given no preexposure or exposure just to the sequence of novel flavors, learned readily. Experiment 2 examined the effects of these forms of preexposure on performance on a summation test, in which Flavor A was presented in compound with a separately conditioned flavor (X). The preexposure procedure in which A was presented along with novel flavors rendered A effective in inhibiting the response conditioned to X on that test. The conclusion, that this form of training can establish the target stimulus as a conditioned inhibitor, is predicted by the account of latent inhibition put forward by Hall and Rodríguez (2010) which proposes that the latent inhibition effect is a consequence both of a reduction in the associability of the stimulus and of a process of inhibitory associative learning that opposes the initial expectation that a novel event will be followed by some consequence. [ABSTRACT FROM AUTHOR]

Purpose of Review: Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness. Recent Findings: Recent studies have examined mechanisms of exposure-based interventions across multiple levels of analysis, from cognitive and behavioral changes that occur during treatment to the neurobiological mechanisms underlying fear extinction. Summary: Belief change and reductions in safety behaviors and avoidance mediate symptom improvements during exposure therapy, suggesting plausible cognitive and behavioral mechanisms. On the neural level, increased activation of prefrontal regions during extinction learning is a likely mechanism of exposure. Improved understanding of the biological mechanisms of exposure have led to exciting developments in clinical research, including pharmacological augmentation, though clinical translation of basic research has produced mixed results. Though still in development, such translational research is a promising future direction for exposure-based interventions. [ABSTRACT FROM AUTHOR]

The Inhibitory Learning Theory (ILT; Craske et al., 2008) changed the focus of exposure-based treatment from erasing excitatory associations and fear reduction (habituation (HA)) to reinforcing inhibitory associations and fear toleration (inhibitory learning (IL)). Studies which directly compare both approaches, IL versus HA, are scarce. The present study aimed at implementing and comparing an IL-based (n = 26; Age: M = 23.59, SD = 4.38) with a HA-based (n = 28; Age: M = 25.46, SD = 6.22) experimental exposure approach (including in vivo, interoceptive, and in sensu exposure) in a sample of people with heightened health anxiety. A significant pre- to post-intervention reduction of state health anxiety (p <.001), which was especially associated with an increase of distress tolerance (DT) pre- to post-exposure (F (1, 50) = 12.2, p <.001, ηp2 =.20), was observed. A superiority of the IL-based over the HA-based exposure intervention was not detected in relation to major outcomes (e.g., state health anxiety), as well as in relation to a change of DT. The present study underlines the importance of strengthening DT (for heightened health anxiety) during an exposure-based intervention. [ABSTRACT FROM AUTHOR]

Exposure therapy is an efficient treatment for pathological anxiety, yet its underlying mechanisms are not fully understood. Prediction error models suggest that optimizing the violation of threat-related expectancies improves treatment outcomes, however, causal evidence is still sparse. The aim of the current study was therefore to provide causal evidence for the influence of the extent of expectancy violations on extinction retention using a novel virtual reality fear conditioning paradigm. In total, 100 participants completed a two-day fear conditioning paradigm in which the approach behavior of an animated stimulus was differentially reinforced with an electrical stimulus (i.e., closer distances were associated with a higher probability for receiving the aversive stimulation). To experimentally manipulate the extent of expectancy violations during fear extinction, participants were presented only with distances to the conditioned stimulus that either weakly (i.e., far distances) or strongly predicted the aversive outcome (i.e., close distances), resulting in low vs. high expectancy violations. We found successful fear acquisition and extinction, as well as an influence of the extent of expectancy violations on US-expectancy and threat ratings after extinction on day 1. On the second day, at a spontaneous recovery and reinstatement test, however, there was only weak evidence for improved extinction retention in the high expectancy violation condition. Optimizing expectancy violations might be a necessary but not sufficient condition for improved extinction retention. Future research needs to address the conditions under which expectancy violations lead to robust expectancy adjustments and how these conditions can be met in exposure therapy for anxiety disorders., Competing Interests: Declaration of Competing Interest none, (Copyright © 2024. Published by Elsevier B.V.)

The Inhibitory Retrieval Approach to exposure therapy for fears and anxiety emphasizes prediction error as one of several strategies for improving outcomes. Prediction error depends on disconfirmation of expectancies for the feared outcome, and thus exposure strategies that derive from inhibitory retrieval approaches emphasize expectancy violation during exposure. However, research studies examining expectancy violation in exposure therapy have treated expectancy as a stable characteristic, assuming that expectancy following an exposure exercise remains constant over time. This brief report outlines two different uses of a methodology for using ecological momentary assessment (EMA) to assess between-session expectancy following exposure during treatment for anxiety, and reports on pilot trial results. Adults with social anxiety disorder (N = 12) and spider phobia (N = 31) taking part in larger trials investigating exposure therapy completed EMA questionnaires assessing expectancy for their feared outcome for 2–4 days following each of two exposure sessions. Expectancy ratings decreased from pre-to post-exposure and remained stable for 2–4 days following exposure. This pilot study used a very limited sample size and should be replicated in a larger sample. Expectancy for feared outcome may be assessed using EMA following exposure sessions. Pilot results suggest that expectancy decreases immediately following exposures and remains stable afterwards. • This is the first paper to study expectancy for feared outcome after exposure therapy using ecological momentary assessment. • Expectancy ratings decreased from pre-to post-exposure within session. • Lowered expectancy ratings remained stable for 2–4 days following exposure therapy. • Results suggest that expectancy for feared outcome may be assessed using EMA following exposure sessions. [ABSTRACT FROM AUTHOR]

Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.

The cerebellum is involved in the acquisition and consolidation of learned fear responses. Knowledge about its contribution to extinction learning, however, is sparse. Extinction processes likely involve erasure of memories, but there is ample evidence that at least part of the original memory remains. We asked the question whether memory persists within the cerebellum following extinction training. The renewal effect, that is the reoccurrence of the extinguished fear memory during recall in a context different from the extinction context, constitutes one of the phenomena indicating that memory of extinguished learned fear responses is not fully erased during extinction training. We performed a differential AB-A/B fear conditioning paradigm in a 7-Tesla (7T) MRI system in 31 young and healthy men. On day 1, fear acquisition training was performed in context A and extinction training in context B. On day 2, recall was tested in contexts A and B. As expected, participants learned to predict that the CS+ was followed by an aversive electric shock during fear acquisition training. Skin conductance responses (SCRs) were significantly higher to the CS+ compared to the CS- at the end of acquisition. Differences in SCRs vanished in extinction and reoccurred in the acquisition context during recall indicating renewal. Fitting SCR data, a deep neural network model was trained to predict the correct shock value for a given stimulus and context. Event-related fMRI analysis with model-derived prediction values as parametric modulations showed significant effects on activation of the posterolateral cerebellum (lobules VI and Crus I) during recall. Since the prediction values differ based on stimulus (CS+ and CS-) and context during recall, data provide support that the cerebellum is involved in context-related recall of learned fear associations. Likewise, mean β values were highest in lobules VI and Crus I bilaterally related to the CS+ in the acquisition context during early recall. A similar pattern was seen in the vermis, but only on a trend level. Thus, part of the original memory likely remains within the cerebellum following extinction training. We found cerebellar activations related to the CS+ and CS- during fear acquisition training which likely reflect associative and non-associative aspects of the task. Cerebellar activations, however, were not significantly different for CS+ and CS-. Since the CS- was never followed by an electric shock, the cerebellum may contribute to associative learning related to the CS, for example as a safety cue.

Abstract Background Many children and adolescents suffer from problematic levels of anxiety, but the multitude of these children do not receive an intervention. It is of importance to increase the accessibility and availability of child anxiety interventions, as to identify and treat anxious children early and successfully. Online platforms that include information, assessments and intervention can contribute to this goal. Interventions for child anxiety are frequently based on Cognitive Behavioral Therapy, because of its strong theoretical and empirical basis. However, the working mechanisms of Cognitive Behavioral Therapy in children are poorly studied. To our knowledge, mediation studies on child anxiety are non-existent regarding online Cognitive Behavioral Therapy. Methods We will aim at children aged 8–13 years with problematic anxiety. We recruit these children via the community setting, and refer them to our online platform ‘Learn to Dare!’ (in Dutch: ‘Leer te Durven!’), https://leertedurven.ou.nl , where information about child anxiety and our research is freely accessible. After an active informed consent procedure, the participants can access the screening procedure, which will select the children with problematic anxiety levels. Thereafter, these children will be randomized to an online intervention based on Cognitive Behavioral Therapy (n = 120) or to a waitlist control (WL, n = 120). The intervention consists of 8 sessions with minimal therapist support and contains psycho-education, exposure (based on inhibitory learning), cognitive restructuring and relapse prevention. Child anxiety symptoms and diagnoses, cognitions, avoidance behavior and level of abstract reasoning are measured. Assessments are the same for both groups and are performed before and after the proposed working mechanisms are offered during the intervention. A follow-up assessment takes place 3 months after the final session, after which children in the waitlist control group are offered to take part in the intervention. Discussion This protocol paper describes the development of the online platform ‘Learn to Dare!’, which includes information about child anxiety, the screening procedure, anxiety assessments, and the online intervention. We describe the development of the online intervention. Offering easy accessible interventions and providing insight into the working mechanisms of Cognitive Behavioral Therapy contributes to optimizing Cognitive Behavioral Therapy for anxious youth.

Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent thoughts and repetitive behaviors causing stress and anxiety. In the associative learning model of OCD, mechanisms of fear extinction are supposed to partly underlie symptom development, maintenance and treatment of OCD, proposing that OCD patients suffer from rigid memory associations and inhibitory learning deficits. To test these assumptions, previous studies have used skin conductance and subjective ratings as readouts in fear conditioning paradigms, finding impaired fear extinction learning, impaired fear extinction recall or no differences between individuals with OCD and healthy controls. Against this heterogeneous background, we tested fear acquisition and extinction in 37 OCD patients and 56 healthy controls, employing skin conductance as well as pupillometry and startle electromyography. Extinction recall was also included in a subsample. We did not observe differences between groups in any of the task phases, except a trend toward higher startle amplitudes during extinction for OCD. Overall, sensitive readouts such as pupillometry and startle responses did not provide evidence for moderate-to-large inhibitory learning deficits using classical fear conditioning, challenging the assumption of generically impaired extinction learning and memory in OCD. [ABSTRACT FROM AUTHOR]

Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent thoughts and repetitive behaviors causing stress and anxiety. In the associative learning model of OCD, mechanisms of fear extinction are supposed to partly underlie symptom development, maintenance and treatment of OCD, proposing that OCD patients suffer from rigid memory associations and inhibitory learning deficits. To test these assumptions, previous studies have used skin conductance and subjective ratings as readouts in fear conditioning paradigms, finding impaired fear extinction learning, impaired fear extinction recall or no differences between individuals with OCD and healthy controls. Against this heterogeneous background, we tested fear acquisition and extinction in 37 OCD patients and 56 healthy controls, employing skin conductance as well as pupillometry and startle electromyography. Extinction recall was also included in a subsample. We did not observe differences between groups in any of the task phases, except a trend toward higher startle amplitudes during extinction for OCD. Overall, sensitive readouts such as pupillometry and startle responses did not provide evidence for moderate-to-large inhibitory learning deficits using classical fear conditioning, challenging the assumption of generically impaired extinction learning and memory in OCD.

Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a 'fear habituation' approach and 'belief disconfirmation' approach within standard cognitive-behavior therapy. Exposure optimization strategies include (1) expectancy violation, (2) deepened extinction, (3) occasional reinforced extinction, (4) removal of safety signals, (5) variability, (6) retrieval cues, (7) multiple contexts, and (8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.

Abstract Background Public Speaking Anxiety (PSA) is a common anxiety with onset in adolescence and early adulthood. With the advent of consumer virtual reality (VR) technology, VR-delivered exposure therapy is now a scalable and practical treatment option and has previously been shown to be efficacious with adults. In this non-randomized feasibility and pilot trial, we explore the effect of one-session (90 min) VR-delivered exposure therapy for adolescents (aged 13–16) with PSA. Methods A total of 27 adolescents were recruited from Norwegian high schools and completed self-report measures of PSA twice prior to treatment, 1 week after treatment, and at 1 and 3 month follow-up. Heart rate was recorded during the treatment session. A low-cost head-mounted VR display with a custom-built VR stimuli material depicting a cultural and age appropriate classroom and audience were used when a series of speech (exposure exercises) were performed. Results Linear mixed effects model revealed a significant decrease in PSA symptoms (Cohen’s d = 1.53) pre-post treatment, and improvements were maintained at follow-ups. Physiological data revealed a small increase in heart rate during exposure tasks. Based on feedback from the adolescents, the feasibility of the intervention was increased during the trial. Conclusions The results show that low-cost, consumer VR hardware can be used to deliver efficacious treatment for PSA in adolescents, in a feasible one-session format.

Background: Alongside depression, anxiety disorders are the most frequent reason for consulting a psychotherapist. Objective: This article describes the recent progress in understanding basic learning processes in anxiety treatment, the resulting therapeutic procedures, the current state of knowledge on the efficacy of the various psychotherapeutic procedures and on the moderators of the success of treatment. Material and methods: The English and German language literature was reviewed and compiled, with an emphasis on the last 10 years. Results: Cognitive-behavioral therapy (CBT) achieves the best and broadest level of evidence across all anxiety disorders. Initial studies have also provided emerging evidence for the efficacy of manualized short-term psychodynamic treatment. The most discussed mechanism of action is that of inhibitory learning. Augmentation strategies and personalized treatment approaches are gaining in relevance. Conclusion: Current models of inhibitory learning are rooted in basic research and foster a deeper understanding of the underlying neurobiological mechanisms. In order to optimize success of exposure treatment in vulnerable subgroups of patients, many procedural, device-based and pharmacological augmentation strategies are currently under investigation, whereby the latter are mostly still in the stage of (pre)clinical testing. [ABSTRACT FROM AUTHOR]

Incompleteness (INC) and Harm Avoidance (HA) are known core dimensions of obsessive-compulsive disorder (OCD). Emotional processing and inhibitory learning (IL) have both been proposed as viable mechanisms of exposure for the alleviation of HA, yet the relationship with INC remains unclear. This study evaluated differential manipulation responses to induced INC. The authors specifically tested whether targeting the key component of IL, expectancy violation generated by the discrepancy between an articulated prediction and the actual exposure experience, would lead to improved outcomes. A sample of undergraduates (N = 68) completed a series of behavioral tasks to induce INC, followed by manipulations (exposure with or without articulated predictions) to reduce INC reactions. Results show that modest changes were observed following reduction manipulations following INC induction. Furthermore, heightened HA predicted the changes of induced sensations. Mediation tests showed that articulation of predicted sensations mediated pre- to postreduction ratings. Clinical and research implications are discussed. [ABSTRACT FROM AUTHOR]

Violating expectancies during exposure therapy is proposed to promote inhibitory learning and improved treatment outcomes. Because people tend to overestimate how distressing emotionally challenging situations will be, violating expectations of distress may be an intuitive way to promote treatment outcome during exposure-based cognitive-behavioral therapy (CBT). This study evaluated overpredictions of distress during exposure tasks in 33 youth with obsessive-compulsive disorder (OCD; ages 8-17) participating in CBT. Youth with more variable prediction accuracy and a higher proportion of overpredictions experienced more rapid symptom reduction, b = −0.29, p =.002. Underpredictions were less common toward the end of therapy as youth experienced less severe OCD, b = 0.12, p=.001. Findings suggest that although youth often accurately predict the intensity of exposure, overpredictions are common as well. The frequency of these overpredictions promoted treatment outcome, supporting expectancy violations as one indicator of inhibitory learning during exposure therapy. [ABSTRACT FROM AUTHOR]

Background: Many children and adolescents suffer from problematic levels of anxiety, but the multitude of these children do not receive an intervention. It is of importance to increase the accessibility and availability of child anxiety interventions, as to identify and treat anxious children early and successfully. Online platforms that include information, assessments and intervention can contribute to this goal. Interventions for child anxiety are frequently based on Cognitive Behavioral Therapy, because of its strong theoretical and empirical basis. However, the working mechanisms of Cognitive Behavioral Therapy in children are poorly studied. To our knowledge, mediation studies on child anxiety are non-existent regarding online Cognitive Behavioral Therapy. Methods: We will aim at children aged 8–13 years with problematic anxiety. We recruit these children via the community setting, and refer them to our online platform 'Learn to Dare!' (in Dutch: 'Leer te Durven!'), https://leertedurven.ou.nl, where information about child anxiety and our research is freely accessible. After an active informed consent procedure, the participants can access the screening procedure, which will select the children with problematic anxiety levels. Thereafter, these children will be randomized to an online intervention based on Cognitive Behavioral Therapy (n = 120) or to a waitlist control (WL, n = 120). The intervention consists of 8 sessions with minimal therapist support and contains psycho-education, exposure (based on inhibitory learning), cognitive restructuring and relapse prevention. Child anxiety symptoms and diagnoses, cognitions, avoidance behavior and level of abstract reasoning are measured. Assessments are the same for both groups and are performed before and after the proposed working mechanisms are offered during the intervention. A follow-up assessment takes place 3 months after the final session, after which children in the waitlist control group are offered to take part in the intervention. Discussion: This protocol paper describes the development of the online platform 'Learn to Dare!', which includes information about child anxiety, the screening procedure, anxiety assessments, and the online intervention. We describe the development of the online intervention. Offering easy accessible interventions and providing insight into the working mechanisms of Cognitive Behavioral Therapy contributes to optimizing Cognitive Behavioral Therapy for anxious youth. [ABSTRACT FROM AUTHOR]

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders. • Meta-analysis comparing extinction of conditioned disgust and fear in laboratory paradigms. • Disgust significantly more resistant to extinction than fear. • Degree of extinction not influenced by study characteristics. [ABSTRACT FROM AUTHOR]

Background: Public Speaking Anxiety (PSA) is a common anxiety with onset in adolescence and early adulthood. With the advent of consumer virtual reality (VR) technology, VR-delivered exposure therapy is now a scalable and practical treatment option and has previously been shown to be efficacious with adults. In this non-randomized feasibility and pilot trial, we explore the effect of one-session (90 min) VR-delivered exposure therapy for adolescents (aged 13–16) with PSA. Methods: A total of 27 adolescents were recruited from Norwegian high schools and completed self-report measures of PSA twice prior to treatment, 1 week after treatment, and at 1 and 3 month follow-up. Heart rate was recorded during the treatment session. A low-cost head-mounted VR display with a custom-built VR stimuli material depicting a cultural and age appropriate classroom and audience were used when a series of speech (exposure exercises) were performed. Results: Linear mixed effects model revealed a significant decrease in PSA symptoms (Cohen's d = 1.53) pre-post treatment, and improvements were maintained at follow-ups. Physiological data revealed a small increase in heart rate during exposure tasks. Based on feedback from the adolescents, the feasibility of the intervention was increased during the trial. Conclusions: The results show that low-cost, consumer VR hardware can be used to deliver efficacious treatment for PSA in adolescents, in a feasible one-session format. [ABSTRACT FROM AUTHOR]

Standard fear extinction relies on the ventromedial prefrontal cortex (vmPFC) to form a new memory given the omission of threat. Using fMRI in humans, we investigated whether replacing threat with novel neutral outcomes (instead of just omitting threat) facilitates extinction by engaging the vmPFC more effectively than standard extinction. Computational modeling of associability (indexing surprise strength and dynamically modulating learning rates) characterized skin conductance responses and vmPFC activity during novelty-facilitated but not standard extinction. Subjects who showed faster within-session updating of associability during novelty-facilitated extinction also expressed better extinction retention the next day, as expressed through skin conductance responses. Finally, separable patterns of connectivity between the amygdala and ventral versus dorsal mPFC characterized retrieval of novelty-facilitated versus standard extinction memories, respectively. These results indicate that replacing threat with novel outcomes stimulates vmPFC involvement on extinction trials, leading to a more durable long-term extinction memory. [ABSTRACT FROM AUTHOR]

Abstract The benefits of exposure-based interventions for anxiety disorders are substantial but not stable for everyone, given that these interventions are often followed by relapse of symptoms. A body of research provides a background on how to add certain strategies in exposure-based therapy to prevent relapse in anxiety disorders. This review summarizes some of these strategies and provides clear-cut clinical implications. Studies that provide support for two types of strategies to prevent relapse have been reviewed—the use of multiple contexts and the use of retrieval cues. The use of multiple contexts reduces context and stimulus specificity of extinction learning during exposure, while the use of retrieval cues enhances memory (re)consolidation and retrieval after exposure. The described strategies to enhance the accessibility and therefore the retrievability of exposure-based learning to prevent relapse in anxiety disorders can be summarized as advice to conduct exposure under variable conditions. This way, the generalizability of what is learned during exposure to the patients' daily life after treatment improves. Therefore, adding these strategies in the course of exposure-based treatment of anxiety disorders seems beneficial. However, future replications and translational studies are needed to verify ecological validity. Highlights • The use of multiple contexts reduces context and stimulus specificity of extinction. • The use of retrieval cues enhances memory retrieval of extinction learning. • Optimizing the generalizability of exposure-based extinction learning prevents relapse. [ABSTRACT FROM AUTHOR]

Abstract Recent findings have led to a reconceptualization of the mechanisms that account for the efficacy of exposure-based treatments. Termed the "inhibitory learning model," this approach emphasizes new learning when confronted with previously avoided stimuli rather than merely the cessation of fear or aversive emotional responding. In this paper, we propose the applicability of the inhibitory learning model for conditions and contexts in which simple exposure does not produce habituation. We illustrate this application from an in-progress randomized controlled treatment trial for adults with misophonia. Misophonia is a condition marked by strong aversive reactions to specific sounds. It is a difficult to treat and understudied syndrome. All participants in the trial received exposure, either before or after a stress management module of treatment. Exposure treatment emphasized altered expectancies for the target sounds as well as deliberate practice in hearing sounds on the individually developed hierarchy. Inhibitory learning strategies were employed to increase treatment adherence and commitment, shape patient behavior during exposures, manufacture negative prediction errors, increase perceived control over reactions, and promote learning that generalized to functional improvements. The findings are discussed in the context of future applications of the inhibitory learning model for psychopathology associated with avoidance. Highlights • Clinicians may be inclined to discontinue exposure therapies when habituation does not occur. • Inhibitory learning model can foster process-oriented modifications to exposure methodology. • Techniques can precipitate between-session changes without the aid of habituation. [ABSTRACT FROM AUTHOR]

Abstract Exposure-based treatments known to be effective for a wide range of psychopathology are thought to work via inhibitory learning, where new learning acquired during exposure exercises inhibits previously learned fear and avoidance responses. One way in which this inhibitory learning may be enhanced is through affect labeling, during which clients verbalize their internal emotional experiences. Theoretically, affect labeling may be a subtle, implicit form of emotion regulation and may facilitate more explicit forms of extinction learning. Experimental research suggests that affect labeling may lead to attenuated fear responses to emotionally evocative stimuli in healthy samples and may be a helpful strategy in reducing physiological arousal experienced during exposure tasks, particularly for clients with inhibitory deficits. Research with clinical samples is limited and mixed, at best. Case examples illustrate how affective labeling may help get a client "unstuck" from unproductive processing loops, can contribute to shifts in perspective and meaning making, and may modulate distress and promote distress tolerance. We argue that routine use of affect labeling in clinical care is premature. When used, it should be employed strategically within a broader case conceptualization and may be of a limited benefit beyond what is already employed in quality exposure therapy. Highlights • Affect labeling is when clients verbalize their internal emotional experience. • Affective labeling may work as a subtle, implicit form of emotion regulation. • Evidence is mixed, but affect labeling may benefit clients with inhibitory deficits. • Clinical case examples show how affect labeling promotes more explicit extinction processes. [ABSTRACT FROM AUTHOR]

Abstract The inhibitory learning model of exposure therapy posits that clinical anxiety is most effectively treated when clinicians employ strategies that maximize the (a) violation of negative expectancies and (b) generalization of nonthreat associations. Translation of basic learning research to exposure therapy via this explanatory model underscores two keys to optimizing inhibitory learning during exposure: dropping safety aids and maximizing retrieval cues. Although topographically similar, safety aids and retrieval cues are functionally distinct as well as therapeutically incompatible. In the present article, we delineate safety aids and retrieval cues in the context of exposure therapy from an inhibitory learning perspective, providing illustrative case examples of how clinicians may address the two when treating patients with clinical anxiety. Highlights • Emerging research supports the inhibitory learning model of exposure therapy. • The availability of certain stimuli during exposure may enhance or impede outcomes. • Patients' unnecessary safety aids hamper inhibitory learning and should be dropped. • Research suggests maximizing retrieval cues optimizes exposure's effectiveness. • Clinical examples demonstrate how to drop safety aids and maximize retrieval cues. [ABSTRACT FROM AUTHOR]

Abstract An inhibitory learning conceptualization of treatment mechanisms in exposure-based therapy appears to better account for durability of symptom reduction and index overall learning. Presented here is an overview of two core elements of inhibitory learning, expectancy violation and occasional reinforced extinction, as they are thought to function in exposure and response prevention (ERP) for OCD. The overview is then followed by case examples illustrating these processes at work in a naturalistic clinical setting. Implications for treatment are broadly discussed. Highlights • Occasional reinforced extinction and expectancy violation are thought to serve as key learning mechanisms in the treatment of OCD • In two cases, we find that these mechanisms appear to play a role in dictating outcome • Incidents approaching feared outcomes occurred but expectancies were violated in that patients were able to better navigate them than expected • Clinicians might encourage patients to seek out instances of "fear confirmation" rather than approach treatment in order to disconfirm OCD thoughts [ABSTRACT FROM AUTHOR]

Abstract Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered. Highlights • Inhibitory learning theory offers new insights for optimizing exposure therapy. • Increasing variability in exposure may improve inhibitory learning. • Variable exposure may increase tolerance of uncertainty. [ABSTRACT FROM AUTHOR]

Abstract Safety behaviors—actions performed to prevent, escape from, or reduce the severity of perceived threat—are typically eliminated during exposure therapy for clinical anxiety. Yet some experts have called for the strategic and "judicious use" of safety behaviors during exposure to improve treatment acceptability/tolerability without diminishing its efficacy. Empirical findings regarding this debate are mixed and existing work is subject to several methodological limitations. The current randomized controlled trial incorporated longitudinal design and multimethod assessment to compare the efficacy of traditional exposure with the elimination of safety behaviors (E/ESB) and exposure with judiciously used safety behaviors (E/JU). Adults with clinically significant spider fear (N = 60) were randomized to four twice-weekly sessions of E/ESB or E/JU. Self-report and behavioral measures were administered at pretreatment, posttreatment, and 1-month follow-up. Participants exhibited large effects on all measures from pretreatment to posttreatment, with no change from posttreatment to follow-up. There were no significant group differences in treatment outcome or treatment acceptability/tolerability. Exploratory analyses were used to compare behavioral and inhibitory learning processes between conditions. Clinical implications, study limitations, and future directions are discussed in terms of inhibitory learning theory. Highlights • Some patients refuse or relapse after exposure with elimination of safety behaviors (E/ESB). • Exposure with judiciously used safety behaviors (E/JU) might facilitate exposure. • Inhibitory learning (IL) suggests safety behaviors interfere with long-term outcome. • E/ESB and E/JU were equally acceptable/tolerable and efficacious for spider phobia. • E/JU facilitates behavioral approach but interferes with IL-related processes. [ABSTRACT FROM AUTHOR]

Background: While exposure therapy effectively reduces anxiety associated with specific phobias, not all individuals respond to treatment and some will experience a return of fear after treatment ceases. Aims: This study aimed to test the potential benefit of increasing the intensity of exposure therapy by adding an extra step that challenged uncontrollability (Step 15: allowing a spider to walk freely over one's body) to the standard fear hierarchy. Method: Fifty-one participants who had a severe fear of spiders completed two 60-min exposure sessions 1 week apart in a context that was either the same or different from the baseline and follow-up assessment context. Participants were categorized into groups based on the last hierarchy step they completed during treatment (Step 14 or fewer, or Step 15). Results: Those who completed Step 15 had greater reductions in fear and beliefs about the probability of harm from baseline to post-treatment than those who completed fewer steps. Although completing Step 15 did not prevent fear from returning after a context change, it allowed people to maintain their ability to tolerate their fear, which earlier steps did not. Despite some fear returning after a context change, individuals who completed Step 15 tended to report greater reductions in fear from baseline to the follow-up assessment than participants who completed 14 or fewer steps. Conclusions: Overall, these results suggest that more intensive exposure that directly challenges harm beliefs may lead to greater changes in fear and fear beliefs than less intensive exposure. [ABSTRACT FROM AUTHOR]

The beneficial effects of cognitive-behavioral interventions (particularly exposure and response prevention) for OCD are among the most consistent research findings in the mental health literature. Nevertheless, even after an adequate trial, many individuals experience residual symptoms, and others never receive adequate treatment due to limited access. These and other issues have prompted clinicians and researchers to search for ways to improve the conceptual and practical aspects of existing treatment approaches, as well as look for augmentation strategies. In the present article, we review a number of recent developments and new directions in the psychological treatment of OCD, including (a) the application of inhibitory learning approaches to exposure therapy, (b) the development of acceptance-based approaches, (c) involvement of caregivers (partners and parents) in treatment, (d) pharmacological cognitive enhancement of exposure therapy, and (e) the use of technology to disseminate effective treatment. We focus on both the conceptual/scientific and practical aspects of these topics so that clinicians and researchers alike can assess their relative merits and disadvantages. [ABSTRACT FROM AUTHOR]

Even after successful exposure, relapse is not uncommon. Based on the retrieval model of fear extinction (e.g., Vervliet, Craske, & Hermans, 2013), return of fear can occur after exposure due to an elapse of time (spontaneous recovery) or change in context (contextual renewal). The use of external salient stimuli presented throughout extinction (i.e., retrieval cues [RCs]) has been suggested as a potential solution to this problem (Bouton, 2002). The current study examined whether RCs attenuated return of fear in individuals with public speaking anxiety. Sixty-five participants completed a brief exposure while presented with two RC stimuli aimed at a variety of senses (visual, tactile, olfactory, and auditory). Later, half the participants were tested for return of fear in a context different from the exposure context, and the other half in the same context. Half of each context group were presented with the same cues as in exposure, while the other half were not. Return of fear due to an elapse of time, change in context, and effects of RCs were evaluated on subjective, behavioral, and physiological measures of anxiety. Although contextual renewal was not observed, results supported effects of RCs in reducing spontaneous recovery on behavioral and physiological measures of anxiety. There was also evidence that participants who were reminded of feeling anxious during exposure by the RCs benefited more from using them at follow-up, whereas those who perceived the cues as comforting (safety signals) benefited less. Clinical implications of the findings are discussed. [ABSTRACT FROM AUTHOR]

Objective This study tested the role of habituation of eating desires and violation of overeating expectancies during food cue exposure in obese women. Method 52 obese females were randomised into a two-session exposure condition aimed at habituation, a two-session exposure condition aimed at expectancy violation, or a no-treatment control condition. Eating in the absence of hunger of foods included during cue exposure (i.e., exposed foods) and foods not included during cue exposure (i.e., non-exposed foods), and duration of exposure were measured. Results Both cue exposure conditions ate significantly less of the exposed foods compared to the control condition, though there were no differences between both types of exposure. No differences were found between conditions regarding the eating of non-exposed foods. In addition, the duration of exposure was not different between both cue exposure conditions. Conclusions While food cue exposure in obese women led to less eating of exposed foods, focusing on either habituation of eating desires or expectancy violation did not matter. It is discussed why exposure works. [ABSTRACT FROM AUTHOR]

Although exposure therapy is often considered a gold standard behavioral intervention for pathological anxiety, questions remain surrounding the mechanisms underlying exposure interventions, and some individuals are characterized by suboptimal treatment outcomes. Recently, a formulation known as the inhibitory learning theory, which is grounded in basic science principles of extinction learning and memory, has been proposed to provide a more parsimonious mechanistic explanation for the effects of exposure than previous, habituation-based models [Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. 2008. Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy , 46 , 5–27; Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T., & Vervliet, B. 2014. Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy , 58 , 10–23]. Strategies informed by this theory are proposed to maximize extinction learning by fostering the development of new, non-threat associations between stimuli in memory and enhancing the accessibility and retrieval of these safety-based associations. This comprehensive review serves as a critical examination of the empirical literature regarding major tenets of inhibitory learning theory and the potential for such techniques to augment exposure therapy for anxiety disorders. Limitations of the extant research, as well as potential future directions, are explored. [ABSTRACT FROM AUTHOR]