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.     

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.     

Enhancing Inhibitory Learning: The Utility of Variability in Exposure

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.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

The Suitability of an Inhibitory Learning Approach in Exposure When Habituation Fails: A Clinical Application to Misophonia

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.     

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.     

Affect Labeling to Facilitate Inhibitory Learning: Clinical Considerations

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.     

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.     

The Practice of Exposure Therapy: Relevance of Cognitive-Behavioral Theory and Extinction Theory

Exposure therapy is the most effective psychological intervention for people with anxiety disorders. While many therapists learn how to implement exposure techniques through clinical training programs or instructional workshops, not all of these educational efforts include a focus on the theory underlying this treatment. The availability of treatment manuals providing step-by-step instructions for how to implement exposure makes it easier for clinicians to use these techniques with less training than they might otherwise receive. This raises questions regarding whether it is necessary to understand the theory behind the use of exposure. This article argues that knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome. Specific ways in which theory is relevant to using exposure techniques are discussed.     

Using Retrieval Cues to Attenuate Return of Fear in Individuals With Public Speaking Anxiety

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.     

焦虑障碍的虚拟现实暴露疗法研究述评

虚拟现实暴露疗法(VRET)是传统的行为疗法的一种转换形式, 也是经典的现实情境暴露疗法的替代性治疗形式。虚拟现实整合了即时计算机图形学、身体感觉传感、视觉成像技术, 给来访者提供近似真实的、可以沉浸(immersion)和交互作用的虚拟环境。研究者采用虚拟现实暴露疗法治疗幽闭恐怖症、恐高症、飞行恐怖症、创伤后应激障碍、惊恐障碍等焦虑障碍, 并且关注虚拟现实暴露疗法的认知机制以及心理生理机制。实验研究表明, 虚拟现实暴露疗法在治疗焦虑障碍时是有效的。被试经过治疗之后, 对情境的控制感和自我效能感提升, 消极自我评价降低, 对创伤事件的容忍力提高, 重新获得对情境的控制感。与心率指标相比, 皮肤电是预测虚拟现实暴露疗法治疗效果更好的指标。虚拟现实暴露疗法还处于实验验证阶段, 并没有应用到实际临床中, 需要更加规范的实验设计验证该疗法的认知机制以及心理生理机制。虚拟现实暴露疗法结合功能磁共振成像(FMRI)用于心理治疗, 会是未来发展的新方向。     

Eating Disorder Symptom and Fear Change Trajectories During Imaginal Exposure Therapy: A Slope Network Analysis

Eating disorders (EDs) are characterized by fears related to food, body image, and social evaluation. Exposure-based interventions hold promise for targeting a range of ED fears and reducing ED psychopathology. We investigated change mechanisms and optimal fear targets in imaginal exposure therapy for EDs using a novel approach to network analysis. Individuals with an ED (N = 143) completed up to four online imaginal exposure sessions. Participants reported ED symptoms and fears at pretreatment, posttreatment, and 6-month follow-up. We constructed networks of symptoms (Model 1), fears (Model 2), and combined symptoms and fears (Model 3). Change trajectory networks from the slopes of symptoms/fears across timepoints were estimated to identify how change in specific ED symptoms/fears related to change in other ED symptoms/fears. The most central changing symptoms and fears were feeling fat, fear of weight gain, guilt about one’s weight/shape, and feared concerns about consequences of eating. In Model 3, change in ED fears bridged to change in desire to lose weight, desiring a flat stomach, following food rules, concern about eating with others, and guilt. As slope networks present averages of symptom/fear change slopes over the course of imaginal exposure therapy, further studies are needed to examine causal relationships between symptom changes and heterogeneity of change trajectories. Fears of weight gain and consequences of eating may be optimal targets for ED exposure therapy, as changes in these fears were associated with maximal change in ED pathology. Slope networks may elucidate change mechanisms for EDs and other psychiatric illnesses.     

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.     

Exposure Therapy for Posttraumatic Stress Disorder: A Meta-Analysis

This meta-analysis compares the findings of empirical studies that employ either a traditional form of cognitive–behavioral-based exposure therapy or virtual reality exposure therapy (VRET) for the treatment of posttraumatic stress disorder (PTSD) to determine which is more viable and effective. Statistical analyses were performed on 26 studies to determine pre- to posttreatment effect sizes and interactions. Results demonstrated a trend toward significance in favor of traditional exposure therapy showing lower posttreatment PTSD. Limitations included a restricted number of relevant studies; future research on VRET for PTSD should orient more to experimental designs, larger samples, and increased use of control groups.     

Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19

The novel coronavirus (COVID-19) pandemic has caused widespread disruption to our traditional way of life and mental health therapy has not been spared. A combination of increased anxiety, diminished social opportunities, and the shift to telehealth service provision presents particular challenges for the treatment of social anxiety in youth, which relies heavily on exposures to social situations with peers, adults, or other feared social stimuli. The objective of this commentary is to provide guidance to clinicians working with youth with social anxiety on how to maintain ethical, evidence-informed provision of exposure therapy in light of these unusual circumstances. We first present an overview of how COVID-19 may uniquely impact youth with social anxiety and highlight the importance of continuing to provide exposure-based treatments during this time. We then discuss guiding principles for delivering exposure therapy during COVID-19. We focus on providing practical examples of how common social anxiety exposures can be adapted and delivered successfully through telehealth while abiding by COVID-19 social distancing guidelines. Finally, we discuss key recommendations to assist clinicians in moving treatment forward while considering changing safety guidelines pertaining to COVID-19.     

Using Prolonged Exposure and Cognitive Processing Therapy to Treat Veterans With Moral Injury-Based PTSD: Two Case Examples

Moral injury refers to acts of commission or omission that violate individuals’ moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations—thus, morally injurious events are often implicated in the development of posttraumatic stress disorder (PTSD) for military service members and veterans. Although prolonged exposure (PE) and cognitive processing therapy (CPT) have been well established as effective treatments for veterans who are struggling with PTSD, it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this paper is to detail how the underlying theories of PE and CPT can account for moral injury-based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The paper concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.     

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants’ written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.     

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8–18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure—however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists’ use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.     

Anxiety Sensitivity and Interoceptive Exposure: A Transdiagnostic Construct and Change Strategy

Recent findings support the relevance of anxiety sensitivity (AS) and interoceptive exposure (IE) across emotional disorders. This study (a) evaluated levels of AS across different anxiety disorders, (b) examined change in AS over the course of transdiagnostic psychological intervention, and its relationship with outcome, and (c) described the implementation of IE to address AS with patients with different anxiety disorders. Participants (N = 54) were patients who received treatment with the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) in two consecutive treatment trials. Participants completed a measure of AS at pre- and posttreatment, and multiple occasions during treatment. Symptom severity was assessed at pre- and posttreatment, and clinical information related to physical symptoms and IE were collected as part of routine clinical practice. Elevated AS was observed at pretreatment across diagnoses and decreases in AS were observed from pre- to posttreatment. Similar changes occurred across the diagnostic categories, notably coinciding with the introduction of IE. Change in AS was correlated with reduced symptom levels at posttreatment and 6-month follow-up. Patients with different anxiety disorders endorsed similar physical symptoms and practiced similar IE exercises with similar effects. Results provide preliminary support for the usefulness of IE as a treatment strategy across the spectrum of anxiety disorders, and additional support for the transdiagnostic relevance of AS.     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.