Optimizing Exposure Therapy for Pathological Health Anxiety: Considerations From the Inhibitory Learning Approach

Exposure therapy has demonstrated its efficacy in the treatment of pathological health anxiety—however, psychotherapy research reveals that many patients do not show a clinically significant change. Therefore, improvements are necessary to optimize psychotherapy for pathological health anxiety. Most treatment rationales refer to habituation during exposure as the central mechanism of change. However, there is evidence that extinction learning is mediated by inhibitory learning processes. Targeting these processes may help to improve treatment outcomes in pathological health anxiety. The aim of this review was to adapt, from the inhibitory learning approach and empirical findings, the most promising strategies for the exposure-based treatment of pathological health anxiety. The exposure-optimizing strategies adapted are expectancy violation, combination, variability in contexts and stimuli, affect labeling, and removal of safety signals. A case example illustrates how to implement these methods for patients with pathological health anxiety.     

Clinical perspectives on the combination of D-cycloserine and cognitive-behavioral therapy for the treatment of anxiety disorders

In a particular success for translational research agendas, characterization of the neuronal circuits underlying fear extinction, and basic research in animal extinction paradigms, has led to intervention studies examining the use of D-cycloserine (DCS) to enhance therapeutic learning from exposure-based cognitive-behavioral therapy (CBT). In this article, we review these intervention studies, and discuss DCS augmentation of CBT relative to more traditional combination-treatment strategies in the treatment of anxiety disorders. We offer an accounting, based on evidence for internal context effects, of current limitations in the combination of antidepressant or benzodiazepine medications with CBT and discuss the advantages of isolated-dosing strategies with DCS relative to these limitations. This strategy is contrasted with the chronic-dosing applications of DCS for schizophrenia and Alzheimer's disease, and future directions for isolated-dosing strategies are discussed.     

Hope for the Worst: Occasional Reinforced Extinction and Expectancy Violation in the Treatment of OCD

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.     

Using Multiple Contexts and Retrieval Cues in Exposure-Based Therapy to Prevent Relapse in Anxiety Disorders

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.     

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive–Compulsive Disorder?

Clinical studies in adults and children with obsessive–compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.     

Addressing Barriers to Change in the Treatment of Childhood Obsessive Compulsive Disorder

Although considerable evidence supports the use of cognitive behavior therapy (CBT) for the treatment of childhood obsessive compulsive disorder, large numbers of youth fail to respond and clinical remission is often elusive. Poor family functioning frequently is implicated as an obstacle for youth undergoing CBT, with features such as symptom accommodation, family conflict, and blame known to attenuate outcomes. These features are common in child and adolescent obsessive compulsive disorder (OCD) and they may pose particular challenges for exposure-based treatments. Nonetheless, interventions that focus specifically on family functioning have, to date, been limited. This paper reviews the literature on family features associated with childhood OCD and discusses their links to treatment outcome. It then describes the development of a brief family intervention tailored to address the needs of highly distressed families of youth with OCD in the service of improving individual child CBT outcomes. Preliminary pilot data are presented and clinical implications are discussed.     

Optimierung expositionsbasierter Therapie

Exposure is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear. Research results suggest that anxious individuals show deficits in the mechanisms underlying exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure; however, 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, in ways that distinguish it from a fear habituation approach and a belief disconfirmation approach. 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.     

The Struggle of Behavioral Therapists With Exposure: Self-Reported Practicability,Negative Beliefs,and Therapist Distress About Exposure-Based Interventions

Exposure-based interventions are a core ingredient of evidence-based cognitive-behavioral treatment (CBT) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). However, previous research has documented that exposure is rarely utilized in routine care, highlighting an ongoing lack of dissemination. The present study examined barriers for the dissemination of exposure from the perspective of behavioral psychotherapists working in outpatient routine care (N = 684). A postal survey assessed three categories of barriers: (a) practicability of exposure-based intervention in an outpatient private practice setting, (b) negative beliefs about exposure, and (c) therapist distress related to the use of exposure. In addition, self-reported competence to conduct exposure for different anxiety disorders, PTSD, and OCD was assessed. High rates of agreement were found for single barriers within each of the three categories (e.g., unpredictable time management, risk of uncompensated absence of the patient, risk of decompensation of the patient, superficial effectiveness, or exposure being very strenuous for the therapist). Separately, average agreement to each category negatively correlated with self-reported utilization of exposure to a moderate degree (-.35 ≤ r ≤ -.27). In a multiple regression model, only average agreement to barriers of practicability and negative beliefs were significantly associated with utilization rates. Findings illustrate that a multilevel approach targeting individual, practical, and systemic barriers is necessary to optimize the dissemination of exposure-based interventions. Dissemination efforts may therefore benefit from incorporating strategies such as modifying negative beliefs, adaptive stress management for therapists, or increasing practicability of exposure-based interventions.     

Exposure-Based Cognitive-Behavioral Therapy for Disruptive Mood Dysregulation Disorder: An Evidence-Based Case Study

Severe, chronic irritability is one of the most frequently reported problems in youth referred for psychiatric care. Irritability predicts adult depressive and anxiety disorders, and long-term impairment. Reflecting this pressing public health need, severe, chronic, and impairing irritability is now codified by the DSM-5 diagnosis of disruptive mood dysregulation disorder (DMDD). Since DMDD has only recently been added as its own nosological class, efficacious treatments that specifically target severe irritability as it presents in DMDD are still being developed. In a recent pilot study, we described the general concept of exposure-based cognitive-behavioral therapy (CBT) for irritability. This mechanism-driven treatment is based on our pathophysiological model of irritability that postulates two underlying mechanisms, which potentiate each other: (1) heightened reactivity to frustrative nonreward, and (2) aberrant approach responses to threat. In this case report, we describe and illustrate the specific therapeutic techniques used to address severe irritability in an 11-year-old boy with a primary diagnosis of DMDD. Specific techniques within this CBT include motivational interviewing to build commitment and target oppositionality; creation of an anger hierarchy; in-session controlled, gradual exposure; and parent training focusing on contingency management to counteract the instrumental learning deficits in irritable youth. Parents learn to tolerate their own emotional responses to their youth’s irritability (e.g., parents engage in their own exposure) and increase their adaptive contingencies for their youth’s behavior (e.g., withdraw attention during unwanted behavior, praise desirable behavior). Future directions in the context of this CBT, such as leveraging technology, computational modeling, and pathophysiological targets, are discussed.     

Comorbidity of Pediatric Obsessive–Compulsive Disorder and Anxiety Disorders: Impact on Symptom Severity and Impairment

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

Lessons Learned From a Randomized Controlled Pilot Trial Testing an Inhibitory Learning Approach to Exposure in Anxious Youth

Accumulating evidence from basic and translational research indicates that fear extinction may be best explained by principles of “inhibitory learning,” by which prefrontal cortical structures inhibit activity in the amygdala. New guidelines for the clinical practice of exposure therapy have arisen from research on inhibitory learning, but these guidelines have received little empirical testing in clinical samples of youth receiving treatment for anxiety disorders. We investigated the acceptability, feasibility, and initial efficacy of conducting exposure therapy for anxiety disorders in youth according to clinical guidelines developed from basic research on inhibitory learning principles, using a pilot randomized controlled trial design. Thirteen youths (ages 7 to 16) were recruited from a university hospital-based pediatric outpatient clinic to participate in a 9-week treatment study and were randomized to either an inhibitory learning-based exposure condition or a standard exposure condition. Results supported the feasibility and acceptability of an inhibitory learning-based approach to exposure therapy in youth and, despite the small sample size, effect sizes were in favor of the inhibitory learning approach on several measures. Differences between the standard exposure and inhibitory learning conditions are discussed using two case examples. Discussion of results and lessons learned may contribute to changes in clinical guidelines for optimally effective practice of exposure.     

Inhibitory Learning for Anxiety-Related Disorders

This article reviews the articles in this issue that describe the strategies derived from the inhibitory learning model as applied to exposure therapy for anxiety disorders. The major principles of inhibitory learning are to create and strengthen nonthreat associations in memory (largely by engaging prefrontal cortical regions), and to effectively retrieve those nonthreat associations in the long term. Several case vignettes are provided that demonstrate how the principles of inhibitory learning (which include maximizing expectancy violations, limiting distraction, fear antagonistic actions, deepened extinction, elimination of safety behaviors, occasional reinforced extinction, increasing variability of exposures and offsetting reinstatement and context renewal effects) can be applied in clinical practice.     

Exposure-based cognitive behavior therapy for anxiety related to asthma: A feasibility study with multivariate baseline design

In the presence of asthma, the risk of having an anxiety disorder is increased twofold. The few trials conducted on cognitive behavior therapy (CBT) for anxiety and asthma have mainly targeted panic disorder, and with mixed results. Experimental laboratory research indicates that increased anxiety may lead to hypervigilance toward asthma. Hence, fear and avoidance associated with increased anxiety due to asthma may be an important treatment target. A treatment that learn participants to differentiate between anxiety and asthma through gradual exposure to situations that risk triggering anxiety for asthma may be a possible avenue. As a first step to investigate this issue further, we developed a 10-week exposure-based CBT protocol for anxiety related to asthma and tested it in six participants using multivariate baseline design with repeated assessments throughout treatment. All participants reported satisfaction with treatment, as well as subjective overall improvement after treatment. Visual analysis, using graphs over each individual's trajectory, as well as potential efficacy on group level analyzing standardized mean change, indicated improvements in important outcomes. We conclude that exposure-based CBT is feasible and may improve anxiety related to asthma. Further investigation under randomized controlled trial conditions is warranted.     

Videoconferencing-based cognitive-behavioral therapy for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a prevalent, chronic and disabling anxiety disorder. Despite the efficacy and strength of pharmacologic interventions for OCD, medications are not always well accepted or effective, making an efficacious psychosocial alternative especially attractive. Cognitive-behavioral therapy (CBT) has been established as an effective treatment for adult OCD, yet access to such treatment is limited, especially in rural areas. Technological advances allow for therapy to be provided in a real-time format over a videoconferencing network. This method allows therapists to provide state-of-the-art treatment to patients who would not otherwise have access to it. This paper presents three cases of OCD successfully treated via videoconferencing CBT. The presence of OCD was established via structured clinical interview and clinician-rated outcome measures were completed by evaluators blinded to the method of treatment. A multiple baseline across individuals design was used to support the internal validity of the CBT outcome data. Patient ratings of therapeutic alliance were high across all three cases. Information gathered from qualitative interviews post-treatment confirmed quantitative measures finding high levels of patient satisfaction. This pilot study suggests that videoconferencing-based CBT is a promising method to bring appropriate treatment to thousands who live far distances from well-trained therapists.     

Exposure Quality in Cognitive Behavioral Treatment for Youth Anxiety Disorders—Predictors and Associations with Outcomes

Journal of Child and Family Studies - To optimize cognitive behavioral therapy (CBT) outcomes for anxiety disorders in youth, more knowledge is needed about how specific CBT components work....     

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12–15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.     

Recalling safety: cooperative functions of the ventromedial prefrontal cortex and the hippocampus in extinction

Anxiety disorders are commonly treated with exposure-based therapies that rely on extinction of conditioned fear. Persistent fear and anxiety following exposure therapy could reflect a deficit in the recall of extinction learning. Animal models of fear learning have elucidated a neural circuit for extinction learning and recall that includes the amygdala, ventromedial prefrontal cortex (vmPFC), and hippocampus. Whereas the amygdala is important for extinction learning, the vmPFC is a site of neural plasticity that allows for the inhibition of fear during extinction recall. We suggest that the vmPFC receives convergent information from other brain regions, such as contextual information from the hippocampus, to determine the circumstances under which extinction or fear will be recalled. Imaging studies of human fear conditioning and extinction lend credence to this extinction network. Understanding the neural circuitry underlying extinction recall will lead to more effective therapies for disorders of fear and anxiety.     

Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.     

Introduction to the Special Series: Clinical Applications of the Inhibitory Learning Model

Exposure therapies (ETs) are treatments of choice for a number of mental health disorders, particularly anxiety and associated conditions, and problems due to avoidance. Exposure has received broad empirical support as a primary intervention. Recent efforts have focused on improving the efficacy and acceptability of exposure-based treatments. As proposed by Craske etal. (2014), strategies to improve ETs based on the inhibitory learning model have shown notable promise. However, surveys suggest that clinicians continue to avoid ETs, or implement them in a manner that interrupts their efficacy. In this special series, articles focus on specific inhibitory learning strategies in exposure, and their adaptation to multiple patient populations. The aim of the special series is to critically assess the research support for inhibitory learning approaches to exposure, and provide guidance for clinicians to implement these strategies in everyday practice.     

Antidepressant Medication: Is It a Viable and Valuable Adjunct to Cognitive-Behavioral Therapy for School Refusal?

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.