Maximizing exposure therapy: An inhibitory learning approach

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Highlights

  • We summarize the research related to an inhibitory model of exposure therapy.

  • Includes strategies for the acquisition, consolidation and retrieval of extinction.

  • Case studies provide useful guides for implementing these strategies with patients.

Abstract

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.

Section snippets

Inhibitory learning model of extinction

In a Pavlovian conditioning model, a neutral stimulus (the conditional stimulus, CS, such as a neutral picture) is followed by an aversive stimulus (the unconditional stimulus, US, such as an electric shock). After a number of such pairings, the neutral CS will come to elicit anticipatory fear reactions (or a conditional response, CR). The CR is presumed to depend upon the CS becoming a reliable predictor of the US. An association is posited between the memory representations of the CS and the

Deficits in inhibition and anxiety disorders

A substantial number of individuals fail to achieve clinically significant symptom relief from exposure-based therapies (Arch & Craske, 2009) or experience a return of fear following exposure therapy (see Craske & Mystkowski, 2006). This may derive in part from the deficits in extinction learning (Craske et al., 2008, Lissek et al., 2005) and more specifically, deficits in inhibitory learning and inhibitory neural regulation during extinction, that characterize individuals with anxiety

Inhibitory learning versus habituation and behavioral testing approaches to exposure

Notably, the strategies listed below are not always consistent with an habituation-based model of exposure therapy, which rests upon fear reduction during exposure trials as a critical index of therapeutic change (e.g., Foa and Kozak, 1986, Foa and McNally, 1996, Lader and Mathews, 1968). Habituation models posit that fear reduction during an exposure trial is a necessary precursor to subsequent, longer lasting cognitive changes in the perceived harm associated with the phobic stimulus. The

Therapeutic strategies for enhancing inhibitory learning and its retrieval

(1) Expectancy violation. The first strategy is to design exposures that maximally violate expectancies regarding the frequency or intensity of aversive outcomes (Davey, 1992, Gallistel and Gibbon, 2000, Rescorla and Wagner, 1972). This strategy derives from the premise that the mismatch between expectancy and outcome is critical for new learning (Rescorla & Wagner, 1972) and for the development of inhibitory expectancies that will compete with excitatory expectancies. The more the expectancy

Therapeutic strategy for enhancing inhibitory regulation

Social neuroscience has identified another strategy for enhancing inhibitory regulation that involves linguistic processing, or affect labeling. Affect labeling may work to augment associative inhibitory processes within extinction or may work in an independent but complementary manner to extinction learning. A number of studies have shown that linguistic processing activates a region of the cortex, the right ventrolateral prefrontal cortex, that reduces activity in the amygdala, thereby

Case studies

In the following section, we present case examples of implementing an inhibitory learning based model of exposure therapy for a variety of anxiety disorders. This is not intended to be exhaustive but rather exemplary.

Summary

The translation from extinction learning to exposure therapy for fear and anxiety disorders involves directly targeting the initial acquisition, consolidation, and later retrieval of new learning. While the focus of the exposure may differ depending on the psychological condition being treated, in each case exposure therapy will generally contain the following elements. First is the specific goal of the exposure therapy: together, the therapist and client decide on the specific goal of the

Acknowledgments

The authors wish to acknowledge the very helpful comments from Katharina Kircanski in the manuscript preparation phase.

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