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Maximizing Exposure Therapy: An Inhibitory Learning Approach
... Effective treatment, according to this theory, requires modification of the pathological features and incorporation of new elements in a fear structure in memory [42,86]. Second, inhibitory learning theory has more recently gained attention [29,30]. It is rooted in associative learning models, focuses on creating new inhibitory associations to override existing fear associations, which is presumably driven by expectancy violation. ...
... In line with recommendations by Craske et al. [29,30], before each exercise, the trainer and participants will identify the participants' feared outcome expectancy (e.g., what do you fear the most will happen?). Pre-and post-exposure Visual Analogue Scales (VASs; on a scale from 0 to 100) adapted from Craske et al. [29,30] and [81] will be used to measure violation and change of threat expectancies. ...
... In line with recommendations by Craske et al. [29,30], before each exercise, the trainer and participants will identify the participants' feared outcome expectancy (e.g., what do you fear the most will happen?). Pre-and post-exposure Visual Analogue Scales (VASs; on a scale from 0 to 100) adapted from Craske et al. [29,30] and [81] will be used to measure violation and change of threat expectancies. To operationalize expectancy violation, we will measure threat expectancy likelihood (How likely is it that your greatest worry will come true on a scale from 0 ...
While virtual reality exposure (VRE) has shown effectiveness in treating social anxiety in adults, research on its efficacy for adolescents remains limited. Given that adolescence is a critical period for early intervention, this study aims to address this gap by evaluating the efficacy and acceptability of VRE compared to in vivo exposure (IVE) in a non-referred sample of socially anxious adolescents. Additionally, we seek to identify mechanisms of change—such as expectancy violation, habituation, and self-efficacy—as well as predictors of treatment response, including clinical, personality, and VR-related factors. Using a randomized controlled trial (RCT), 120 adolescents (ages 12–16) with subclinical to moderate social anxiety will be assigned to one of three conditions: VRE, IVE, or a waitlist control (WL). Participants in the active conditions will undergo a seven-session exposure-based intervention (either in VR or in vivo). Primary (SPAI-18, LSAS-avoidance) and secondary (SPWSS) measures of social anxiety, along with general well-being indicators (e.g., resilience, depression, psychosocial functioning), will be assessed at baseline, post-treatment, and 3- and 6-month follow-ups. A series of linear mixed model (LMM) analyses will be used to examine and compare the effects of the interventions. We hypothesize that both VRE and IVE will significantly reduce social anxiety symptoms compared to WL at post-assessment, with comparable long-term efficacy between the two exposure methods. Additionally, thematic analyses will be conducted to explore participants’ experiences and acceptance of VRE and IVE through qualitative interviews. The findings of this study aim to advance digital mental health research by evaluating the potential of VRE as an early intervention and identifying mechanisms and predictors to inform personalized treatments for socially anxious youth.
Trial registration
Clinicaltrials.gov: NCT06379633, registered on April, 23, 2024.
... ERP disrupts this cycle by shifting the focus from thought analysis to direct experiential learning, leading to cognitive changes. Inhibitory Learning Theory (Craske et al. 2014(Craske et al. , 2022 posits that exposure is most efficacious when it fosters the establishment of novel, non-fear-based associations instead of merely mitigating distress through habituation. Nevertheless, given the inherent difficulty and discomfort associated with ERP, clients may resist exposure tasks. ...
... The ERP treatment was adapted to address Aaron's cognitive compulsions by orienting the intervention towards exposure to uncertainty rather than the specific feared stimuli. This approach aligns with the inhibitory learning model, which posits that tolerating fear instead of habituation alone is pivotal to long-term change (Craske et al. 2014(Craske et al. , 2022. Sessions with the senior therapist began similarly to those with the novice therapist. ...
... The conversation around IMs is a way of naturally increasing the possibility of inhibiting a response to fear. The deeper and more complex the elaboration is, helped by therapists guiding dialogue and facilitating the elaboration of details of the events that are incongruent with the responses of fear, the more consolidated the new response would be (in terms of inhibitory learning theory, this represents the retrieval of the new response to fear, Craske et al. 2014Craske et al. , 2022 and the stronger the possibility of inhibiting the fear response. Identifying the presence of IMs during ERP, reflecting them to the client, and asking about what is different from the past (contrast) and what allowed this positive change to occur (process) fits naturally with the therapeutic conversation. ...
Exposure and response prevention (ERP) constitutes the first‐line treatment for obsessive‐compulsive disorder (OCD). Despite robust empirical evidence supporting its efficacy, ERP has challenges, including high attrition rates and difficulty sustaining engagement. Research suggests that focusing on clients' strengths while addressing their difficulties can enhance therapy effectiveness. The present article details the case of a young adult with OCD characterized by sexual obsessions and mental compulsions, who initially underwent 12 sessions of cognitive‐behavioral therapy (CBT) with limited progress. A subsequent transition to ERP throughout nine sessions resulted in positive treatment outcomes. The article illustrates how ERP may be coupled with a framework that capitalizes change using Innovative Moments (IMs)—changes in clients' discourse that reflect progress in therapy as manifested by new and adaptive ways of acting, feeling, or thinking. Therapists can be attentive, detect, and explore these moments to expand and promote further change. By attuning to and reinforcing IMs during ERP, the therapist assisted the client in disengaging from compulsions, increasing exposure tolerance, and consolidating therapeutic gains. This case underscores a practical strategy for clinicians: therapists can leverage naturally occurring change markers to enhance motivation and deepen learning in ERP rather than solely correcting dysfunctional patterns. The recognition and expansion of IMs have the potential to assist clients in maintaining engagement, tolerating distress, and cultivating more flexible responses to intrusive thoughts, which are all pivotal factors in the effective treatment of OCD.
... Excessive fear and associated avoidance of perceived threat cues represent cardinal symptoms of anxiety disorders, constituting one of the largest groups of mental disorders and a leading cause of sustained disability [1][2][3]. The repeated exposure to feareliciting stimuli invokes a profound inhibition of these symptoms and has thus become a central strategy in anxiety disorder's firstline treatment, cognitive behavioral therapy (CBT) [1,4,5]. Despite its efficacy, CBT nonetheless faces high rates of non-responders (~50%) and relapses (~14%), calling for therapeutic adjuncts that support a persistent inhibition of fear [6][7][8]. ...
... For instance, when rodents are repeatedly exposed to a previously threat-signaling stimulus that is now no longer associated with aversive consequences (extinction), fear responses decline due to increased transmission in the basolateral amygdala, which invokes an inhibition of the central amygdala that orchestrates multi-level fear responses [9,10]. Such fear extinction is considered to be the core mechanism of exposure-based treatments [4,8,11,12], and can even persist over longer time periods, if the medial prefrontal cortex activates the basolateral amygdala during future encounters of the previous threat cue [13,14]. Preclinical functional imaging research suggested, that the human amygdala and medial prefrontal cortex exhibit similar functions during fear extinction as in rodents [12,[15][16][17][18]. Accordingly, a technique that taps into these neural circuits might be a promising adjunct to facilitate responding to exposure-based treatments. ...
... Thus, the current study not only refines our concept of the mechanisms underlying taVNS, but also allows a critical evaluation of its capacity to inhibit excessive fear responses, finally highlighting its potential use as an adjunct to exposure therapy. In fact, exposure-based treatment of anxiety disorders majorly builds upon extinction processes [4,8,11,12] and deficient fear extinction is prevalent in patients with anxiety disorders [99], possibly contributing to high rates of non-responders and relapses [6,7]. Extending previous evidence [20][21][22][23][24][30][31][32][33], our results suggest that taVNS may help to overcome these deficits by noradrenergically tapping into fear extinction circuitry, ultimately facilitating responding to such treatment. ...
Recent laboratory research showed that vagus nerve stimulation promotes fear extinction, the inhibitory core mechanism of exposure treatment, presumably via activation of the noradrenergic brain system. However, a translation of this stimulation technique to clinical practice is lacking. We therefore investigated the potential of vagal stimulation to inhibit excessive fear responses and facilitate responding to in-vivo and laboratory exposure in individuals with specific phobia. Spider-phobic participants were subjected to three standardized in-vivo exposures towards a living tarantula, complemented by an exposure in vitro (between exposure in vivo I and II). Transcutaneous auricular vagus nerve stimulation (taVNS) was applied during in-vitro exposure, presenting pictures of the exposed tarantula, other spiders and neutral tools in the laboratory. Fear was assessed by self-reports and behavioral avoidance (in-vivo exposures), and amygdala-mediated autonomic and behavioral fear components (exposure in vitro). Vagal stimulation facilitated the reduction of behavioral avoidance across repeated in-vivo exposures. During laboratory exposure, taVNS inhibited fear tachycardia and corrugator muscle activity specifically in response to pictures of the previously exposed tarantula – an effect that became stronger with increasing stimulation duration. Psychophysiological indices of noradrenergic transmission in the basolateral amygdala were elevated during taVNS and correlated to subsequent attenuation of behavioral avoidance. Our results suggest, that taVNS exerts stimulus-specific and dose-dependent inhibition of multiple automatic response components of excessive fear, highlighting taVNS as a valuable adjunct to exposure-based treatment. A translational mechanism of action is supported, proposing that taVNS exhibits its effects by noradrenergic activation of fear extinction circuitry, particularly targeting the basolateral amygdala.
... The second factor is intensive exposure based on the inhibitory learning principle. Craske et al. (2008Craske et al. ( , 2014 argued that in anxiety treatment, the conventional approach of aiming to immediately reduce the anxiety itself has no theoretical basis, and patients should aim to "tolerate" the anxiety for effective treatment [15,16]. Inhibitory-learningbased exposure, therefore, lets patients learn that the fear is tolerable and the feared outcomes are less likely to occur than expected [14,16]. ...
... The second factor is intensive exposure based on the inhibitory learning principle. Craske et al. (2008Craske et al. ( , 2014 argued that in anxiety treatment, the conventional approach of aiming to immediately reduce the anxiety itself has no theoretical basis, and patients should aim to "tolerate" the anxiety for effective treatment [15,16]. Inhibitory-learningbased exposure, therefore, lets patients learn that the fear is tolerable and the feared outcomes are less likely to occur than expected [14,16]. ...
... Craske et al. (2008Craske et al. ( , 2014 argued that in anxiety treatment, the conventional approach of aiming to immediately reduce the anxiety itself has no theoretical basis, and patients should aim to "tolerate" the anxiety for effective treatment [15,16]. Inhibitory-learningbased exposure, therefore, lets patients learn that the fear is tolerable and the feared outcomes are less likely to occur than expected [14,16]. Despite being a recently supported concept, inhibitory learning is remarkably effective for anxiety treatment. ...
Background: Although digital cognitive behavioral therapy (dCBT) is considered effective for anxiety disorders, there is considerable heterogeneity in its efficacy across studies, and its varied treatment content and clinical components may explain such heterogeneity. Objective: This review aimed to identify the efficacy of digital cognitive behavioral therapy for panic disorder and agoraphobia, and examine whether applying relevant clinical components of interoceptive exposure, inhibitory-learning-based exposure, and personalization of treatment enhances its efficacy. Methods: Randomized controlled trials of dCBT for panic disorder and agoraphobia with passive or active controls were identified from OVID Medline, Embase, Cochrane Library, and PsycINFO. The overall effect sizes for dCBT groups (interventions through digital platforms based on the internet, mobile, computers, VR, etc.) were aggregated against passive control (placebo/sham) and active control (traditional CBT) groups. For subgroup analysis, key intervention components such as interoceptive exposure, inhibitory learning, and personalization were assessed dichotomously (0 or 1) along with other study characteristics. The stepwise meta-regression models were applied with traditional and Bayesian statistical testing. The risk of bias and publication bias of included studies were assessed. Results: Among the 31 selected studies, dCBT had an overall effect size of g = 0.70 against passive control and g = −0.05 against active control. In subgroup analysis, interoceptive exposure improved the clinical effects for both controls, and inhibitory learning and personalization increased the clinical effects for passive control along with therapist guide/support and the length of sessions. Many studies were vulnerable to therapist bias and attrition bias. No publication bias was detected. Conclusions: The heterogeneity in clinical effects of dCBT for panic and agoraphobia can be explained by the different intervention factors they include. For effective dCBT, therapists should consider the clinical components relevant to the treatment.
... In what follows, I will describe work suggesting that emotional engagement is necessary for lasting change in stimulus processing. Moreover, I will show how emotional disengagement may play a role in worsening anxiety and depression, potentially because it limits deeper processing necessary to adapt to emotional challenges (Wilson and Gilbert 2008) and learn from new information (Craske et al. 2014;Foa and Kozak 1986). To begin, I will briefly review prominent models of emotion regulation. ...
... Chronic use of emotion regulation strategies that work well in the moment but preserve or even increase the emotional salience of stimuli over time may lead to shifts in emotion processing that could underlie psychopathology (Craske et al. 2014;Foa and Kozak 1986). Although a great deal of research has focused on heightened neurobiological response to negative stimuli in the internalizing disorders (Ball et al. 2012;Etkin and Wager 2007;Hattingh et al. 2013;Hayes, Hayes, and Mikedis 2012;Killgore et al. 2013;Kinney, Burkhouse, and Klumpp 2019;Kujawa et al. 2015;Sartory et al. 2013), emotional disengagement-that is, blunted electrocortical response to negative stimuli-has also been reported (Foti et al. 2010;MacNamara et al. 2013;MacNamara, Kotov, and Hajcak 2016;Weinberg and Hajcak 2011), most often among patients with more severe and/or more comorbid psychopathology. ...
... In line with this notion, prominent models of anxiety suggest that to reduce fear, sustained engagement with threatening stimuli is necessary (Foa and Kozak 1986). By continuing to sit with and process the meaning of threatening stimuli throughout the duration of stimulus presentation (and potentially beyond), it may be possible for individuals to assimilate new information that is at odds with the "fear structure" underlying an anxiety disorder (Craske et al. 2014;Foa and Kozak 1986). Without this-that is, for individuals with greater disengagement, as evident in blunted LPPs, the threat value of stimuli may be maintained, and might worsen over time. ...
Emotion regulation strategies vary in depth of processing. For instance, reappraisal requires greater engagement than distraction. This affects short‐term and long‐term response to stimuli. In this review, I describe how the “engagement‐disengagement dimension” improves understanding of emotion regulation in normative contexts and in internalizing psychopathology. Part 1 reviews work from my laboratory and others, suggesting that relatively disengaged emotion regulation strategies (e.g., distraction), may have short‐term benefits (e.g., faster implementation), but may come with long‐term costs (e.g., increased processing of stimuli at subsequent encounter). Therefore, depending on the desired outcome, the adaptive selection of an emotion regulation strategy will be determined by extent of emotional engagement–disengagement. In Part 2, I describe how individuals with more comorbid internalizing psychopathology (e.g., multiple anxiety and depressive diagnoses) are characterized by disengagement from negative stimuli as measured by the late positive potential (LPP). In addition, I introduce a brain profile I have termed, HARM‐A (heightened “alarm” and reduced motivated attention), which is characterized by a combination of heightened “alarm” (i.e., increased amygdala) and emotional disengagement (i.e., blunted LPPs) in response to negative stimuli. HARM‐A prospectively predicts worse outcomes over 2 years in a mixed internalizing sample. As such, chronic disengagement from negative stimuli appears to contribute to more comorbid and more severe internalizing psychopathology. Overall, emotional disengagement can be beneficial in the short term but may be poorly suited to emotional coping in the longer term.
... Yet, a metaanalysis Rupp et al. (2017) came to the conclusion that there is no clear evidence that emotional activation is actually positively related to treatment outcome. Further studies provided similar evidence, that the within-session strength of initial emotional activation does not necessarily predict therapeutic treatment outcome (Baker et al. 2010;Craske et al. 2014;Jaycox, Foa, and Morral 1998;Mota et al. 2015;Rauch et al. 2004). Similarly, it has not been clarified whether the effectiveness of imaginal exposure is based on mental imagery, particularly the emotional engagement studied by means of the vividness of the mental image, or whether propositional engagement leads to similar results. ...
... In reality testing, extinction has the goal of correcting distorted or erroneous assumptions regarding the fear-inducing situation or stimulus (Rupp et al. 2017). The focus is not on a subjectively perceived reduction of fear during exposure trials (as in the case of habituation-based models of exposure therapy), but on changing the dysfunctional interpretation of the fear-inducing situation (Craske et al. 2014). The aim is to expose oneself to the feared situation for as long as necessary to invalidate the truth of the dysfunctional expectations, which in turn promotes an adaptive or realistic approach to the feared situation, i.e. relying less on safety-seeking behavior, and thus reduces the fear response. ...
... This mechanism is supported by the concept of inhibitory learning, according to which extinction aims to establish newly learned, secondary associations to replace the original pathological fear memory (Bouton 2002;Miller and Matzel 1988;Myers and Davis 2007). Thus, highly emotional arousal may not be decisive, but rather the omission of avoidance and safety strategies that previously prevented the examination of erroneous beliefs (Craske et al. 2014). Consequently, emotion-triggering mental imagery (see Wicken, Keogh, and Pearson 2021) that is associated with higher levels of subjective distress in patients (Hoppe, Holmes, and Agren 2021;Mota et al. 2015;Rauch et al. 2004) would not be necessary for the effectiveness of imaginal exposure, which in turn would prevent therapy dropout (Coombs, Coleman, and Jones 2002;Eftekhari et al. 2020;Najavits 2015;Pascual-Leone and Greenberg 2007). ...
Imaginal exposure is a standard procedure of cognitive behavioral therapy for the treatment of anxiety and panic disorders. It is often used when in vivo exposure is not possible, too stressful for patients, or would be too expensive. The Bio-Informational Theory implies that imaginal exposure is effective because of the perceptual proximity of mental imagery to real events, whereas empirical findings suggest that propositional thought of fear stimuli (i.e., thinking about the stimuli without seeing them in the mind's eye) could be sufficient. To investigate whether mental imagery or propositional thought is crucial for the success of imag-inal exposure, participants with the rare state of aphantasia (= absence of sensory mental imagery) and two control groups were subjected to a fear conditioning paradigm followed by imaginal exposure and a reinstatement procedure. During imaginal exposure , a control group (N = 30) stared at a bright screen to disrupt visual imagery by incoming luminance (=simulated aphantasia), while a second control group (N = 30) and participants with actual aphantasia (N = 30) kept their eyes closed. Results showed successful extinction in all groups, thus demonstrating that imaginal extinction is possible using propositional thought. Moreover, exploratory analyses revealed less subjective fear in people with aphantasia during the fear conditioning procedure, potentially due to similar mechanisms as in alexithymia, that is, a decoupling between physiological arousal and emotional experience.
... Exposure and response prevention (ERP) therapy is the gold standard for treating OCD [18], but about 30% of individuals show little to no improvement with ERP [1]. One reason for this lack of succesful treatment might be, that exposure therapy is based on inhibitory learning of fearful associations [8]. However, research of the last 20 years has identified disgust as an important aspect regarding the development and maintainance of OCD [31,25] and thus presumably an important part of succesful treatment [32,30,40]. ...
... While such an experience may result in the development of an aversive association with -for example -the location where it was encountered through classical conditioning [37], subsequent visits to the againclean bus stop are likely to diminish this negative feeling as inhibitory learning overwrites the aversive association [8]. However, coming back to how disgust and OCD might be related, disruptions in inhibitory learning -due to e.g. ...
Exposure-based interventions rely on inhibitory learning, often studied through Pavlovian conditioning. While disgust conditioning is increasingly linked to psychiatric disorders, it has been less researched than fear conditioning. In this study, we applied a categorical Pavlovian disgust conditioning paradigm with two CS categories (animals and tools) and disgusting images as US (e.g., feces). During categorization, acquisition, and extinction phases, we measured eye movements and pupil responses in 44 participants. Consistent with previous results, subjective disgust and US expectancy increased from categorization to acquisition for CS+, along with greater pupil dilation for CS+ than CS-. Higher disgust sensitivity was associated with more generalized and longer lasting disgust experiences, as well as higher expectancy for disgusting images. Pupil response during acquisition and extinction depended on disgust sensitivity: Participants with lower disgust sensitivity showed greater pupil dilation. These findings suggest that individuals with high disgust sensitivity and prolonged expectancy may exhibit physiological differences from less sensitive individuals as early as the acquisition phase. This could inform contamination-based OCD treatments by integrating interventions which focus on attentional deployment or physiological reactions. To our knowledge, this is the first study using pupillometry and eye tracking in categorical disgust conditioning.
... Influenced by translational neuroscience research in animals and healthy volunteers focused on fear extinction, Craske et al. posit that this 'inhibitory learning' underpins successful exposure therapy [39]. This involves the encoding and long-term retention of newly learned, non-threatening associations to suppress existing fear memory engrams [39]. ...
... Influenced by translational neuroscience research in animals and healthy volunteers focused on fear extinction, Craske et al. posit that this 'inhibitory learning' underpins successful exposure therapy [39]. This involves the encoding and long-term retention of newly learned, non-threatening associations to suppress existing fear memory engrams [39]. Mechanistically, it appears that the amygdala and the medial prefrontal cortex (mPFC) play a key role in this active learning process [34]. ...
Background: Obsessive-compulsive disorder (OCD) is a complex condition marked by persistent distressing thoughts and repetitive behaviours. Despite its prevalence, the mechanisms behind OCD remain elusive, and current treatments are limited. This protocol outlines an investigative study for individuals with OCD, exploring the potential of psilocybin to improve key components of cognition implicated in the disorder. The PsilOCD study strives to assess the effects of low-moderate psilocybin treatment (10 mg) alongside non-interventional therapy on several facets of OCD. The main focus points of PsilOCD are cognitive flexibility, measured with cognitive tests, and neuroplasticity, assessed through electroencephalography (EEG).
Methods: 20 blinded participants with OCD will complete two dosing sessions, separated by four weeks, where they will receive 1 mg of psilocybin on the first and 10 mg on the second. The first dose serves as an active placebo, and the latter is a low-moderate dose that induces relatively mild-moderate emotional and perceptual effects. Participants will be supported by trained psychedelic therapists, who will sit with them during each dosing session and provide virtual preparation and integration sessions over the 12-week study period. Therapeutic support will be the same for both the 1 mg and 10 mg sessions. PsilOCD’s primary outcomes include scores in the intradimensional-extradimensional (ID-ED) shift task, which is an established measure of cognitive flexibility, and neuroplasticity as quantified by a visual long-term potentiation (vLTP) task. This task is delivered as part of an EEG paradigm and measures acute quantified changes in neuroplasticity in the brain’s visual system. The ID-ED task will be conducted twice, two days after each dosing session, and the EEG recordings will also be taken twice, immediately after each session. Secondary outcome assessments will include OCD and affective symptom severity, as well as an array of patient-reported outcome measures (PROMs), in the form of questionnaires designed to assess well-being, dissociable and well-established mood-related (affective) measures, and participants’ subjective experience of the psilocybin experience.
Discussion: This study’s results are expected to offer critical insights into the neural mechanisms underlying the effects of psilocybin-assisted therapy in treating OCD, and whether these correlate with changes in the cognitive features of the condition. As a secondary aim, it will ascertain whether a low, tolerable dose is a feasible and efficacious clinical treatment, and will provide crucial data to guide the design of a potential follow-up randomised control trial (RCT).
... To further enhance the effectiveness of treatment and retention, a growing number of adult intensive treatment programmes combine prolonged exposure (PE) therapy and EMDR therapy, sometimes complemented by physical activity and psychoeducation (Auren et al., 2022;Matthijssen et al., 2024;Van Woudenberg et al., 2018). Prolonged exposure involves continuous controlled exposure to traumatic memories to reach extinction through the disconfirmation of harm expectancy, based on the inhibitory learning theory (Craske et al., 2014;Foa et al., 2007). On the other hand, EMDR therapy facilitates the processing of traumatic memories by taxing patients' working memory, which reduces the emotional intensity of memories (De Jongh et al., 2024). ...
... Where helpful, in vivo material collected by therapists and patients based on the case conceptualisation was used to cue trauma memories and facilitate deepened extinction. This technique involves combining multiple fear-provoking stimuli to enhance inhibitory learning and improve its long-term retrieval (Craske et al., 2014). Owing to the intensity of the programme, patients did not receive homework, although they were encouraged to practice with in vivo material. ...
Background: Psychotherapeutic interventions aimed at treating posttraumatic stress disorder (PTSD) in adolescents and young adults are hampered by high dropout rates. Looking at the results from adult treatments, short, intensive, outpatient treatment programmes may offer a promising alternative, but it has yet to be tested in this young population.
Objective: To assess the results of a six-day intensive outpatient trauma-focused treatment programme for young individuals (12-25 years) with PTSD. The treatment combined prolonged exposure and EMDR therapy, supplemented with physical activity and the participation of relatives and/or friends. Treatment was performed by a rotating team of therapists.
Methods: Seventy-four adolescents and young adults (89% women, mean age = 18.6 years, 36 patients aged 12–17 and 38 patients aged 18-25; SD = 3.1) with PTSD and a minimum of four memories of A-criterion traumatic events participated in the programme. PTSD symptoms, depressive symptoms, and the perceived burden of trauma symptoms were assessed before treatment, at the start and one month after treatment.
Results: Patients showed a significant reduction in PTSD symptoms from pre-treatment to one month after treatment (Cohen’s d = 1.66). Of all patients, 52 (70%) showed a clinically meaningful response, and 48 (65%) no longer met the diagnostic criteria for PTSD one month after treatment. Depressive symptoms also decreased significantly (Cohen’s d = 1.02). The dropout rate was 4% (N = 3). None of the patients experienced an adverse event or worsening of symptoms.
Conclusions: Results suggest that a short, intensive, outpatient therapy programme combining prolonged exposure, EMDR therapy, physical activity, and participation of relatives and friends, is well-tolerated, and an effective and safe treatment alternative for adolescents and young adults with PTSD due to multiple traumatization.
... Inhibitory learning shifts the focus of ERP to tolerating distressing emotional experiences (e.g., anxiety, disgust, shame, guilt, and fear) rather than habituating or experiencing a reduction in distress. Intervention focuses on strengthening this new learning, augmenting exposure with strategies such as increasing surprise from the exposure, conducting exposures in multiple settings and with varying fear levels, and emphasizing tolerance of distressing emotions rather than experiencing minimal distress or proving that the worst-case scenario did not come to pass [29,30]. One component of inhibitory learning is expectancy violations, which highlight the differences in the frequency and intensity of aversive outcomes from what was anticipated. ...
Background/Objectives: Residential treatment represents an important level of care for adolescents with severe and/or treatment-refractory obsessive–compulsive disorder (OCD). Despite accumulating evidence supporting the treatment efficacy and cost-effectiveness of insurance-based intensive OCD treatment in residential settings, few data exist that characterize the population of adolescent patients utilizing this level of care. As a result, residential treatment may be poorly understood by patients, their families, and referring providers, which may delay appropriate treatment for adolescents with OCD. Here, we characterize the patient population at an intensive residential treatment center (RTC) and partial hospitalization program (PHP) for adolescents (Mage = 15.23) with a primary diagnosis of OCD. Methods: We examine quantitative data collected from 168 adolescents admitted to the McLean OCD Institute for Children and Adolescents for the treatment of primary OCD or a related disorder over a three-year period. We also conduct analyses on a subset of patients (n = 120) who participated in the Child and Adolescent Routine Evaluation (CARE) Initiative (McLean Child Division-Wide Measurement-Based Care Program) to further characterize this patient population with a lens toward additional comorbidities and factors impacting prognosis. Results: The current paper describes the severity of symptom presentation, comorbidities, psychotropic medication profiles, and disruption to personal and family functioning. Analyses also include the prevalence of OCD subtypes and co-occurrence among varied presentations. Conclusions: In addition to identifying common clinical presentations in an RTC/PHP, this paper further aims to detail best practices and clinical rationale guiding a specialty RTC/PHP to inform families, providers, and payors about the individuals that most benefit from this level of care.
... The last activity showed a trend towards improvement, although only one comparison reached statistical significance after Bonferroni adjustment. These findings support the idea that repeated practice and gradual exposure helped participants improve their performance, likely reflecting reduced aversion or fear that initially hindered their performance [34,[73][74][75][76][77] Furthermore, the application of gamification in this framework amplifies the effectiveness of therapy. By integrating elements such as rewards, progressive challenges, and real-time feedback, gamification transforms the therapeutic process into an engaging and motivating experience. ...
Citation: Lopes, I.; Simões de Almeida, R.; Veloso Gomes, P.; Marques, A. A Gamified Virtual Reality Exposure Therapy for Individuals with Arachnophobia: A Pilot Study. Virtual Worlds 2025, 4, 15. Abstract: Arachnophobia is a specific phobia characterized by an intense and persistent fear of spiders, often leading to avoidance behaviors that can significantly impact daily life. Virtual Reality Exposure Therapy (VRET) offers a controlled, adaptable, and immersive therapeutic environment, allowing for greater personalization, flexibility, and the real-time modulation of exposure parameters. This pilot study employed a quasi-experimental design without a control group to evaluate the efficacy of a gamified VRET intervention for treating arachnophobia. A sample of 25 participants underwent the intervention, with outcomes assessed through a Behavioral Approach Test (BAT) and self-report measures, including the Fear of Spiders Questionnaire (FSQ) and the Spider Phobia Questionnaire (SPQ-15), administered pre-intervention, post-intervention, and at a two-week follow-up. Findings indicate that gamified VRET led to significant reductions in self-reported fear and avoidance behaviors, suggesting its potential as an effective therapeutic tool for arachno-phobia. Although some results were not entirely conclusive, the overall improvements observed support further investigation in larger, controlled trials.
... Exposure therapy, the first-line treatment for anxiety disorders, relies on processes related to extinction learning (Craske et al., 2014;Graham & Milad, 2011;Zlomuzica et al., 4 2020). While the effectiveness of exposure therapy in reducing fear is well-established, its impact on reducing disgust appears to be less convincing (Mason & Richardson, 2012;Olatunji, Smits, et al., 2007;Preusser et al., 2017;Smits et al., 2002). ...
Introduction: Understanding differences in conditioning with stimuli evoking fear and/or disgust is valuable to develop meaningful interventions for phobias, anxiety disorders, and obsessive-compulsive disorders (OCD). We investigated possible differences in the acquisition and extinction of conditioned responses using unconditioned stimuli (UCS) which elicit fear, disgust, or both emotions simultaneously.
Methods: Participants underwent a sequential conditioning paradigm over three consecutive days (acquisition, extinction, and extinction retrieval) and were randomly assigned to fear (F), disgust (D), or mixed (FD) conditioning. Pictorial stimuli (UCS) and neutral faces (as conditioned stimuli; CS) were used, with CS-UCS contingency, valence, fear, and disgust ratings as readout measures.
Results: The D and FD groups showed higher valence and disgust ratings after acquisition than the F group, with no group differences in CS-UCS contingency or fear ratings. During extinction, the F group had the greatest reduction in CS-UCS contingency ratings, and the D group showed the largest decrease in disgust ratings for CS+. At extinction retrieval, disgust ratings decreased most in the D group, while fear ratings dropped most in the F and FD groups for CS-. No significant group differences were found for valence during extinction and extinction retrieval.
Conclusion: Conditioning with UCS evoking disgust or disgust and fear simultaneously led to stronger negative valence and disgust responses compared to conditioning with fear-evoking stimuli. Extinction was most effective in the F group (highest reduction of CS-UCS contingency ratings), offering some support for the idea that disgust may be more resistant to extinction than fear.
... Craighead and Dunlop (2014) pointed out that dissemination of evidence-based psychotherapies is still limited, with some clinicians practicing these interventions without formal training. To enhance the focus on evidence-based psychotherapies, all therapists have the opportunity to participate in training workshops on a variety of evidence-based approaches for mood, anxiety, and trauma-related disorders, including behavioral activation (Martell et al., 2001), cognitive approaches for depression and anxiety (Barlow et al., 2010;Beck, 1979;Clark & Beck, 2011), short-term relationship focused approaches (Connolly Gibbons et al., 2016;Luborsky, 1984), prolonged exposure therapy for post-traumatic stress disorder (Foa et al., 2019;Hembree et al., 2003), cognitive processing therapy for post-traumatic stress disorder (Resick et al., 2016), exposure and response prevention for obsessive-compulsive disorder (Meyer, 1966;Whittal et al., 2005), and general exposure therapy for anxiety disorders (Abramowitz et al., 2019;Craske et al., 2014). In the naturalistic setting, there is no formal assessment of fidelity to evidence-based psychotherapies. ...
Despite the availability of evidence-based psychosocial and pharmacologic interventions for mental health concerns, access to care remains suboptimal. We present a time-efficient mental health treatment program designed to improve overall community access to evidence-based care. Quality of care within the time-efficient model was prioritized by focusing on a multifaceted program of evidence-based interventions and facilitating connections to long-term care when needed. We present the results of a proof-of-concept open trial that indicates that access to care can be improved while maintaining quality mental health services. The Time-Efficient, Evidence-Based, Accessible, Multidisciplinary approach includes time-limited care provided by a team of psychotherapists, psychiatrists, nurse practitioners, and case managers working in pods, supported by measurement-based care, to develop individualized treatment plans. We used data from the electronic health record to evaluate (a) access to care, (b) engagement, and (c) treatment outcomes for an initial sample of 1,726 patients. Patients waited on average 17 days to see a therapist and 20 days to see a psychopharmacologist. Patients received on average 10 sessions of psychotherapy and four medication management sessions. Fifty-seven percent remained in treatment for at least 3 months. Patients demonstrated large improvements in depression (d = 1.18) and anxiety (d = 1.20) with small to moderate effects for improvements in functioning (d = 0.40). By capitalizing on a package of evidence-based interventions delivered with equitable time limits, the Time-Efficient, Evidence-Based, Accessible, Multidisciplinary clinic demonstrates initial access while yielding good engagement in services and moderate to large treatment effects.
... Exposure-based cognitive behaviour therapy (CBT) targets the cycle of anxiety, avoidance behaviour, and associated impairments 13 and has been shown to effectively alleviate psychological distress related to somatic disorders. 14,15 CBT can be effectively administered online, achieving treatment outcomes that are similar to those of traditional face-to-face therapy, while also increasing scalability. ...
Aims
Cardiac anxiety, which is cardiac-related fear and avoidance behaviours, is common following myocardial infarction (MI) and has been associated with increased risk for cardiovascular events. However, there are currently no treatments specifically designed to target cardiac anxiety. The aim of the two pilot studies was to evaluate an exposure-based cognitive behavioural therapy protocol (MI-CBT) targeting cardiac anxiety following MI, assessing feasibility, acceptability, and the intervention's potential for reducing cardiac anxiety and improving health-related quality of life (QoL).
Methods and results
A series of two sequential, uncontrolled pilot studies were conducted. In Pilot Study 1 (n = 15), MI-CBT was delivered via face-to-face videoconference, while Pilot Study 2 (n = 23) was delivered online. Patients with a history of MI (≥6 months before assessment, type 1 ST- or non-ST-segment elevation MI, and elevated cardiac anxiety as per clinical interview) were included. The interventions lasted 8 weeks and were therapist-led, with key components including exposure to cardiac-related symptoms and reduction of avoidance behaviours. Participants completed self-rated assessments, including the Cardiac Anxiety Questionnaire (CAQ) and the 12-Item Short Form Health Survey (SF-12), at baseline, post-treatment, and 6-month follow-up. Treatment adherence and satisfaction were high. Cognitive behavioural therapy led to a large reduction in cardiac anxiety, as measured by the CAQ (P < 0.001), and significant improvements in health-related QoL, as measured by the SF-12 (P < 0.001), in both pilot studies.
Conclusion
These studies suggest that exposure-based CBT is a feasible, acceptable, and promising approach to reduce cardiac anxiety and improve QoL following MI. A randomized controlled trial should be conducted to evaluate the efficacy of the intervention.
... On the other hand, Pavlovian threat extinction models the gradual weakening or persistence of conditioned defensive responses when the conditioned stimulus is subsequently presented in safe contexts (i.e., in the absence of the unconditioned stimulus; Dunsmoor et al., 2015;Laing et al., 2024). Extinction (or safety) learning is notably a core principle of exposure therapy that is leveraged to reduce maladaptive defensive responses (Craske et al., 2014(Craske et al., , 2022. Elucidating the mechanisms that modulate how conditioned defensive responses are acquired and extinguished thus holds high translational value across basic and clinical research, as well as clinical practice (Kredlow et al., 2018;Milad & Quirk, 2012;Zuj & Norrholm, 2019). ...
Pavlovian threat acquisition and extinction are fundamental processes by which individualslearn about threat and safety in their environment. Research has shown that humans learnmore rapidly and persistently to associate threatening and—somewhat counterintuitively—positive rewarding stimuli with aversive events, supporting predictions derived fromappraisal theories of emotion (Stussi et al., 2018; Stussi, Pourtois, et al., 2021). Here, thepresent study aimed to provide a confirmatory analysis of these findings and furthercharacterize their algorithmic bases. Data from the four original experiments (N = 247) usinga differential Pavlovian threat conditioning paradigm were combined and reanalyzed. In thisparadigm, threat-relevant (angry faces, snakes), positive-relevant (baby faces, happy faces,erotic images), and neutral (neutral faces, colored squares) stimuli were used as conditionedstimuli, and skin conductance response was measured as an index of learning. Computationalmodeling was applied to identify signatures of learning biases in Pavlovian threat acquisitionand extinction. An expanded model comparison indicated that a reinforcement-learningmodel differentiating between excitatory (learning from reinforcement) and inhibitory(learning from the absence of reinforcement) learning best explained the observed data.Although no evidence for differences in excitatory learning rates was found between stimuluscategories, both threat- and positive-relevant stimuli exhibited a lower inhibitory learning ratecompared to neutral stimuli, contributing to the persistence of the conditioned responseduring extinction. These results confirm the robustness of the original findings and furthervalidate the appraisal-based approach, thereby informing the affective and computationaldeterminants of Pavlovian threat extinction biases and their translational relevance.
... This phenomenon allows for a quicker response to potential threats, but it can also lead to undue anxiety in situations that may not pose an actual threat (Dymond et al., 2015). In contrast, fear extinction entails an inhibitory learning process, where individuals learn that a previously fear-associated stimulus no longer signals danger or threat, by repeatedly presenting the CS+ without the US (Bouton, 1993;Craske et al., 2014;Hermans et al., 2006). Differential fear conditioning in humans is commonly examined using various outcomes. ...
Fear learning processes are often considered underlying mechanisms in the development and maintenance of various anxiety- and stress-related disorders. However, limited attention has been paid to whether these changes are shared across disorders or certain symptoms. In this context, transdiagnostic research on symptom dimensions is especially relevant, as it addresses the significant symptom overlap and heterogeneity observed in anxiety disorders and obsessive-compulsive disorder (OCD). In the current study, we investigated attentional processes (late positive potential), defensive responding (fear-potentiated startle), and subjective ratings (US-expectancy) in a transdiagnostic sample of participants with OCD (n=38), social phobia (n=39), specific phobia (n=40), and control participants (n=39). We focused on two transdiagnostic anxiety dimensions: anxious arousal and anxious apprehension. A differential fear learning paradigm using geometrical forms was employed, including a habituation, acquisition, generalization, and extinction phase. We observed successful fear acquisition across all outcomes, which generalized to the stimulus most similar to the CS+. While fear responses to the CS+ decreased during extinction, they remained significantly elevated compared to the CS-. The results revealed no differences between the diagnostic groups for neither phase, stimulus nor outcome measure. On a dimensional level, anxious arousal was associated with an increased shock expectancy to the CS+ during acquisition, while depressive symptoms were associated with a higher shock expectancy for both CS+ and CS- during extinction. The unexpected absence of differences between diagnostic groups, along with the modulating dimensional effects, supports the utility of these transdiagnostic symptom dimensions in unraveling altered fear learning processes in internalizing disorders.
... Therefore, exploring ways to circumvent direct confrontation with each feared object is crucial for improving treatment efficacy. One potential approach is the use of imagination, which not only introduces variability through a different modality (Craske et al., 2014 but also has the potential to directly target the fear network (Cuthbert et al., 2003;Ji et al., 2016;P. J. Lang et al., 1980), and provides an opportunity for extinction learning (Hoppe et al., 2021(Hoppe et al., , 2022Jiang & Greening, 2021;Mitra & Asthana, 2024;Reddan et al., 2018). ...
A challenge in exposure-based treatments is the effective generalization of extinction learning, as it tends to be highly specific to stimuli or situations used during exposure. This study takes a first step toward enhancing extinction generalization by promoting the updating of extinction memory. 35 participants underwent a three-day, within-subject, category-based fear conditioning paradigm. Two conditioned stimulus (CS) categories were paired with an electric shock during acquisition training (CS+1; CS+2), while one CS category was not (CS-). On day two, extinction training was followed by a prompt to retrieve the inhibitory learning association and to imagine the same experience with multiple novel stimuli for the CS+1 category in order to promote extinction memory updating. Importantly, these stimuli were not directly presented but solely imagined based on a two-word description. On day three, participants were tested for initial fear recall. We observed a pronounced return of fear for new stimuli from the CS+2 category. However, skin conductance response (SCR), fear-potentiated startle (FPS), shock expectancy and fear ratings were decreased for imagined stimuli of the category with extinction memory updating (CS+1) compared to the other category (CS+2). Moreover, extinction memory updating led to a diminished fear response for new CS+1 stimuli as indexed by SCR as well as for previously seen images during acquisition as indexed by FPS and subjective measures. These findings suggest that mental imagery involving novel stimuli may help to facilitate extinction generalization. Further research is needed to explore the underlying mechanisms and the potential to be clinically applicable to improve treatment outcomes.
... In the past decade, the Inhibitory Learning Model (Craske et al. 2014(Craske et al. , 2022 has become the dominant model of explaining the effects of exposure. According to this model, the emphasis is not on habituation to the anxiety-provoking stimulus but rather on disconfirming the relationship between a trigger and the expected catastrophe and learning a new association of the trigger and "no catastrophe" (inhibitory meaning). ...
In anxiety and related disorders, Virtual Reality Exposure Therapy (VRET) was one of the first steps toward integrating technology into psychological treatments. In this article, we discuss crucial therapeutical skills and provide a case conceptualisation for the treatment of social anxiety disorder with VRET. The case conceptualisation is based on evidence‐based cognitive‐behavioural treatment approaches. Social anxiety can be very challenging to treat with exposure in vivo, and virtual reality exposure offers the added benefit of being able to create social situations and real‐time interactions within the therapeutic context. The case conceptualisation presented is worked out for a 23‐year‐old female with social anxiety disorder who is increasingly hindered by her anxiety in her professional and personal life. The treatment rationale of VRET, homework assignments, and progress of therapy are presented. Additionally, this paper discusses what steps to take if the first exposure experiences are not successful and how to progress in such cases. Therapeutic pitfalls are illustrated within this case and potential solutions on how to avoid these pitfalls are addressed.
... This adaptive process, called extinction, is the basis of exposure therapy to treat anxiety disorders by gradually diminishing maladaptive fear responses [2]. Thus, understanding the neural basis of these processes can advance therapeutic strategies for anxiety disorders [3,4]. ...
Animals adaptively regulate aversive memories in safe environments through extinction, a process central to exposure therapy for anxiety disorders. The limbic thalamus controls cognitive function in concert with interconnected cortical and limbic structures. Though medial prefrontal (mPFC) afferents to the limbic thalamus regulate aversive memory, the functional role of limbic thalamus efferents to mPFC is unclear. Here, we investigated the roles of thalamic nuclei, the reuniens (RE) and mediodorsal (MD) thalamus, projecting to the medial prefrontal cortex (mPFC) in aversive memory conditioning and extinction in male mice. Using retrograde tracing, we demonstrated that ventromedial PFC (vmPFC)- and dorsomedial PFC (dmPFC)-projecting neurons are topologically segregated within the RE and MD. Fiber photometry revealed that both RE→vmPFC and MD→vmPFC neurons respond to aversive stimuli. Notably, RE→vmPFC neurons develop shock-associated cue (CS+) response during aversive conditioning. During extinction, RE→vmPFC neurons exhibited a biphasic response to CS+, while MD→vmPFC neurons showed no cue-evoked activity. Neither optogenetic activation nor inactivation of these populations altered freezing behavior during extinction compared to controls. Collectively, these findings indicate that RE→vmPFC neurons encode aversive cue information during extinction but are dispensable for behavioral modulation. This study highlights the distinct contributions of limbic thalamus-PFC circuits to aversive memory processing.
... In IE, patients relive the traumatic memory repeatedly in their imagination until the distress gradually declines. IE is assumed to create a new, less distressing memory representation that competes with the original memory during retrieval without altering the original memory itself (Brewin et al., 1996(Brewin et al., , 2010Cooper et al., 2017;Craske et al., 2014). In ImRs, patients reactivate their memory and are then instructed to change the course of events in their imagination so that the outcome is experienced as less distressing (e.g., the perpetrator is confronted and the victim's needs are taken care of, e.g., Arntz & Weertman, 1999). ...
Eye Movement Desensitization and Reprocessing (EMDR), Imaginal Exposure (IE), and Imagery Rescripting (ImRs) are trauma-focused interventions aimed at reducing trauma-associated psychopathology. Despite their clinical effectiveness, concerns remain about the potential impact of these interventions on the accuracy of memories addressed in treatment. This study therefore examined the effects of EMDR, IE and ImRs on memory accuracy.Two hundred sixty-five healthy participants underwent the Trier Social Stress Test and received one of the three interventions or no intervention (NIC) on the following day. Memory accuracy was assessed one week later using a cued recall task.Contrary to expectations, the interventions showed no differences in their effects on memory accuracy; thus, the three interventions led to neither an improvement nor an impairment in memory compared to NIC. This aligns with recent findings indicating that ImRs and IE do not distort memory. Although there are studies suggesting that EMDR impairs memory accuracy, this could not be confirmed in our study. The findings challenge the notion that trauma-focused psychological treatments such as EMDR, ImRs, and IE cause memory alterations, which is particularly reassuring in legal contexts where accurate memory recall by trauma survivors is crucial. However, further research is needed to ensure that the results generalize to risk constellations and more complex, emotionally charged events in clinical samples.
... Thus, there is a need for developing treatment augmentations and alternatives to enhance the efficacy, efficiency, and tolerability of exposure therapy. Efforts to enhance exposure have involved behavioral (Wolitzky & Telch, 2008), cognitive (Julian, Beard, Schmidt, Powers, & Smits, 2012;Kamphuis & Telch, 2000;Sloan & Telch, 2002), biological (Telch et al., 2014;Zaizar, Gonzalez-Lima, & Telch, 2018;Zoellner et al., 2017), and procedural strategies (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014;Telch, York, Lancaster, & Monfils, 2017), all aiming to augment the underlying mechanisms of extinction learning. ...
... While both people could benefit from ERP focusing on shower reduction and exposure to triggers, the mechanisms targeted may differ. For example, Person 1 might benefit from testing their expectancy that not showering will cause illness (e.g., Inhibitory Learning Craske et al., 2008Craske et al., , 2014, whereas Person 2 might benefit from distress habituation over time (e.g., Emotion Processing Theory; Foa & Kozak, 1986). While untested, the motivational model may offer clinicians more direction on how to frame ERP rationale and guide post-exposure processing. ...
Purpose
Content-based models, which focus on observable symptom content, have dominated much of the literature on heterogeneity in OCD. However, alternate models emphasize the motivations underlying different symptom presentations, including harm avoidance (HA) and incompleteness (INC). To promote understanding of these motivations, we examined their associations with various content-based symptom dimensions, obsessive belief patterns, and other clinical characteristics.
Methods
We examined a large set of demographic and clinical characteristics and their associations with HA and/or INC among individuals (N = 218) receiving treatment for OCD and related disorders in a partial hospital/residential program. We also examined the extent to which HA and INC mapped onto dimensions in prevailing symptom content and obsessive belief models.
Results
Results showed that women reported more HA than men, and INC was associated with an earlier age of onset. HA and INC were not differentially associated with sexual orientation, self-view, quality of life, depression, or suicidality. HA and INC mapped onto symptom content and obsessive belief models in some, but not all the ways we expected. Notably, contamination/washing in our sample was associated with INC, but not HA.
Conclusions
Understanding motivations underlying OCD symptoms may lead to personalized care and improvement in treatment outcomes. We suggest that future research should continue to examine the motivational model, as well as ways in which presentations of each motivation may differ.
Background: Obsessive–compulsive disorder (OCD) in youth commonly co-occurs with other affective disorders (e.g., anxiety, depression). Exposure and response prevention (ERP) is the front-line treatment for OCD but may require significant adaptation to treat co-occurring symptoms or complex comorbidity patterns. Preliminary evidence suggests that the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A) are effective in reducing OCD symptoms. Still, it is not yet known if the UP-C/A are comparably effective to treat OCD as they are for anxiety and depression, the disorders for which there is the most robust empirical support. Methods: This study compared trajectories of OCD, anxiety, and depression symptom change among 388 youth who received UP-C/A treatment (M = 15 sessions) at a university-based research clinic. We also examined whether youth with (n = 60) and without (n = 328) an OCD diagnosis demonstrated comparable improvements in anxiety, depression, and transdiagnostic treatment targets (i.e., anxiety sensitivity, cognitive flexibility, and distress tolerance). Results: OCD symptoms improved at a slower rate than anxiety and depression symptoms during the first half of UP-C/A treatment but at a comparable rate to anxiety and depression symptoms during the second half of treatment. Youth with and without OCD exhibited comparable improvements in anxiety, depression, anxiety sensitivity, cognitive flexibility, and distress tolerance across the treatment course. Conclusions: Findings support the efficacy of UP-C/A treatment for co-occurring OCD and affective disorders but suggest that initiating exposure earlier in the treatment course may confer additional benefits.
In this randomized, double-blind, controlled trial, we examined whether combining transcranial direct current stimulation (tDCS) with exposure–response prevention (ERP) (tDCS + ERP) enhances obsessive–compulsive disorder (OCD) treatment efficacy compared to ERP alone. Fifty-three patients with OCD with contamination-related symptoms were enrolled and randomly assigned to receive either active or sham anodal tDCS targeting the prefrontal cortex during ERP treatment, with the intervention comprising ten sessions over an eight-week primary endpoint. An electroencephalogram (EEG) was administered at baseline and after tDCS + ERP treatments 1 and 8, and magnetic resonance imaging was conducted at baseline. The primary outcome was the percent reduction in Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) scores. We found a significantly larger percent reduction in Y-BOCS scores in the active group compared with the sham group after tDCS + ERP treatment 4 (active, 25.3 ± 2.2%; sham, 18.0 ± 2.2%, 95% confidence interval (CI), 1.1–13.5%, F = 5.681, Bonferroni-corrected P = 0.021) and treatment 8 (active, 38.1 ± 3.0%; sham, 28.2 ± 3.0%, 95% CI, 1.3–18.4%, F = 5.406, Bonferroni-corrected P = 0.024). The secondary outcome measure was the response rate, defined as a reduction of ≥35% in the Y-BOCS score, which was 16/26 for patients treated with active tDCS and 8/27 for sham tDCS (active versus sham: 61.5% versus 29.6%, χ2 = 5.443, P = 0.020). No moderate or severe adverse effects were reported. An exploratory analysis of EEG-based brain state showed a marginally significant correlation (false discovery rate-corrected P = 0.08) between the final treatment outcome and tDCS-induced changes in microstate class A occurrence after the first active tDCS session. Concurrent tDCS could significantly enhance ERP’s therapeutic efficacy for contamination-related OCD. ClinicalTrials.gov registration: NCT04527302.
Intolerance of uncertainty (IU), the tendency to find uncertainty negative, is a fundamental transdiagnostic dimension across anxiety-related disorders. Over the past two decades, there has been an increase in both clinical and experimental research on the role of IU in the maintenance and treatment of anxiety-related disorders. However, there has been a lack of integration of research findings from a mechanistic perspective, which has slowed progress in translational research. This review seeks to fill this gap by synthesising the clinical (e.g. randomised controlled trials) and experimental (e.g. lab-based) literature on the psychological mechanisms that drive change in IU across anxiety-related disorders. The review highlighted that: (1) cognitive restructuring, supported by mechanisms such as cognitive appraisal, modify IU-related cognitions, (2) behavioural exposures, supported by mechanisms such as inhibitory learning, alter IU-related cognitions and physiological arousal, and (3) mindfulness techniques underpinned by mechanisms such as attentional monitoring, decentering, and acceptance, change IU-related cognitions. Across the different therapeutic techniques reviewed, there was a lack of evidence for how different mechanisms change IU-related emotions and behaviours. Directions for further research include directly comparing the effectiveness of different mechanisms that produce change in IU across anxiety disorders and other mental health disorders, and examining the specificity of change in IU over other anxious traits. Overall, the findings provide a foundation for future translational research efforts to build upon maximising existing treatment interventions and/or to develop novel treatment interventions to target dispositional IU and situational uncertainty-related distress in anxiety-related disorders and beyond.
Subjective relief from threat omission is emerging as a proxy index of reward Prediction Error signaling during safety learning. Yet, the relation between relief and prediction error signaling remains poorly understood, limiting translational research. Here, we complemented our previous research in this field by providing further evidence of similarities between the emotion of relief and prediction error signaling. To this end, we enrolled fifty-one healthy participants, and applied a Temporal Difference Learning approach to subjective relief ratings collected during a classical fear extinction learning paradigm. If relief is a reliable index of reward Prediction Error signal then it should display the classical backpropagation from unexpected reward delivery (unexpected threat omission) to conditioned cue presentation, as the large literature in reward learning clearly demonstrated across species. We found that a TD model largely fits subjective relief ratings. Future studies could thereby use this TD model to understand if and how relief-PE drive fear extinction and its potential deficit.
Zusammenfassung
Zwangsstörungen gehen häufig mit großem Leid für Betroffene und deren Angehörigen einher. Behandlung der ersten Wahl ist eine kognitive Verhaltenstherapie (KVT) mit Exposition und Reaktionsverhinderung. Bei der in Norwegen konzipierten 4-Tages-Behandlung („Bergen 4-Day Treatment“, B4DT) werden diese Expositionen konzentriert und im Kurzformat angeboten. Der Beitrag stellt das Rationale der Expositionsbehandlung vor und geht in diesem Zusammenhang auch auf den Ablauf und die Wirksamkeit dieser Kompaktbehandlung ein.
Background
Sudden gains are significant symptom improvements occurring between therapy sessions. Approximately 20% of individuals with generalized anxiety disorder (GAD) experience sudden gains during psychotherapy (Deschênes and Dugas in Cogn Ther Res 37:805–811, 2013. https://doi.org/10.1007/s10608-012-9504-1; Flückiger et al. in J Consult Clin Psychol 89(5):454, 2021. https://doi.org/10.1037/ccp0000639). This study explores the frequency and impact of sudden gains during a novel cognitive-behavioral treatment (CBT) for GAD—Behavioral Experiments for Intolerance of Uncertainty (Dugas et al. in Behav Ther 53(6):1147–1160, 2022. https://doi.org/10.1016/j.beth.2022.05.003)—a treatment designed to reduce intolerance of uncertainty via behavioral experiments that expose individuals to uncertainty-inducing situations and help them develop more adaptive beliefs and emotional reactions toward uncertainty (Robichaud et al. in Cognitive behavioral treatment for generalized anxiety disorder: from science to practice, Routledge, London, 2019).
Methods
The study tested three hypotheses: (1) at least 20% of participants would experience a sudden gain, (2) participants with sudden gains would demonstrate greater progress during treatment, and (3) these improvements would persist at 6-month follow-up. Forty-eight (48) adults with primary GAD completed 12 sessions of CBT. Sudden gains were identified using the Penn State Worry Questionnaire—Past Week (PSWQ-PW; Stöber and Bittencourt in Behav Res Ther 36(6):645–656, 1998. https://doi.org/10.1016/S0005-7967(98)00031-X), which was administered weekly during treatment. GAD symptoms were assessed with the Worry and Anxiety Questionnaire (WAQ; Dugas et al. in Journal de Thérapie Comportementale et Cognitive 11:31–36, 2001) administered at baseline, post-treatment, and 6-month follow-up to track symptom changes over time.
Results
Fifteen participants (31.25%) experienced a sudden gain. Mixed ANOVAs revealed that participants with sudden gains achieved significantly greater symptom reductions from pre- to post-treatment (WAQ [F(1,46) = 4.51, p =.039, partial η² =.09]). These improvements were sustained at 6-month follow-up (WAQ [F(2,82) = 4.91, p =.01, partial η² =.11]).
Conclusions
Sudden gains during CBT for GAD are both frequent and impactful. In the context of Behavioral Experiments for Intolerance of Uncertainty, these gains contribute to superior outcomes observed at post-treatment and sustained over the long term. Their mechanisms of action and implications for enhancing treatment efficacy warrant further investigation.
Nicotinic receptor signaling is influential in modulating appropriate responses to salient stimuli within a complex environment. The cholinergic neurotransmitter system drives attention to salient stimuli such as stressors, and aids in orchestrating the proper neural and behavioral responses. Dysregulation of this system, however, has been implicated in altered anxiety regulation and mood disorders. Among the multiple layers of regulation are protein modulators such as Lynx2/Lypd1, which provides negative nicotinic acetylcholine receptor regulation within anxiety-related circuits, such as the amygdala and medial prefrontal cortex, among other brain regions. Mice null for Lynx2/Lypd1 (Lynx2 KO) show elevated basal anxiety-like behavior in tests such as elevated plus maze, light-dark box and social interaction assays. Here, we queried how a line predisposed to basal anxiety-like behavior would respond to specific stressors, using validated models of experiential-based affective disorders such as fear extinction, acute and chronic social defeat stress assays. We discovered that Lynx2 KO mice demonstrate an inability to extinguish learned fear during fear extinction tests even during milder stress conditions. In social defeat studies, contrary to our predictions, the Lynx2 KO mice switched from a socially avoidant phenotype (which could be considered susceptible) before defeat to a social approach/resilient phenotype after defeat. Consistent with reports of the inverse relationship between resilience and BDNF levels, we observed reduced BDNF levels in the VTA of Lynx2 KO mice. Furthermore, we provide evidence for the functional role of α7 nicotinic receptor subtypes by phenotypic rescue of fear extinction and social defeat phenotypes by MLA antagonism of α7 nicotinic acetylcholine receptors, or by crossing with α7 nicotinic acetylcholine receptor null mutant mice. A stable physical interaction between LYNX2 and α7 nAChRs was observed by co-immunoprecipitation of complexes from mouse amygdalae extracts. Together, these data indicate that responses to specific stressors can become aberrant when baseline genetic factors predispose animals to anxiety dysregulation. These studies underscore the critical nature of well-regulated nicotinic receptor function in the adaptive response to environmental stressors.
Obsessive–compulsive disorder (OCD) is a serious and debilitating psychiatric condition. It has historically been associated with anxiety. Recent analyses have identified a specific role for disgust as well. A clinical vignette underscores the relevant understanding of disgust in the context of OCD. While contemporary evidence-based treatment emphasizes exposure with response prevention (ERP) for OCD, there are special considerations for addressing symptoms that are a result of disgust reactions. The review provides greater insight into the recent research on disgust and how it differs from the emotion of fear. In addition to highlighting the complexity of treatment for contamination fears, evidence-based assessment and practice considerations are discussed, as well as the ethical challenges of exposure and response prevention (ERP). Future research targeting disgust symptomatology is warranted.
Partial reinforcement schedules, wherein a conditioned stimulus (CS) is intermittently paired with an unconditioned stimulus (US) during associative learning, have been widely studied and found to affect the extinction and recall of learned behaviors. Notably, behaviors conditioned under partial (as opposed to consistent) reinforcement are more resistant to extinction, an effect known as the partial reinforcement extinction effect (PREE). The present study initially aimed to examine the effects of partial reinforcement on the acquisition and recall of fear extinction (FE) when altering the contextual environment. However, our systematic investigation of partial reinforcement using C57BL/6J mice challenges the well-established PREE within the domain of FE learning. Across multiple experimental setups altering CS duration, US intensity, and reinforcement schedules, we consistently found no significant impact of partial reinforcement on the acquisition, consolidation, or recall of FE. Mice exhibited similar patterns of extinction and spontaneous recovery of conditioned fear responses regardless of reinforcement schedule. These findings suggest that partial reinforcement during fear acquisition may not confer resistance to extinction of conditioned freezing, challenging the established understanding of the PREE and prompting a reexamination of how reinforcement schedules affect learning and memory of fear-related behaviors.
Purpose
Dysfunctional threat appraisal plays a key role in both the development and treatment of PTSD. It is unclear how these appraisals can best be measured. This study aimed to explore the specific negative outcome predictions held by patients with PTSD and to develop and validate the Threat Appraisal in PTSD Scale (TAPS).
Methods
We used data from a non-clinical (N = 309) and clinical sample (N = 125) to assess the psychometric properties of the TAPS.
Results
The TAPS had excellent internal consistency and test-retest reliability, and convergent and discriminative validity were adequate. The TAPS showed to be sensitive to change following treatment. The TAPS demonstrated incremental validity beyond general cognitions in predicting PTSD symptoms in the combined sample, but not in the patient sample. An exploratory factor analysis suggested three factors: ‘losing control’, ‘externalizing reactions’, and ‘physical reactions’, and patients seemed most concerned about outcomes related to ‘losing control’.
Conclusions
These findings imply that the TAPS could be clinically beneficial, enabling patients and therapists to recognize dysfunctional expectancies and tailor therapeutic interventions accordingly.
Latent inhibition refers to the retardation in learning an association between a target stimulus and an outcome when the target stimulus has been pre-exposed in the absence of consequences. The inhibitory properties of latent inhibitors have been the subject of controversy, as standard latent inhibition training—consisting of pre-exposure to the target stimulus alone—does not provide the latent inhibitor with the ability to pass a summation test, a key criterion for demonstrating genuine inhibition. However, previous research with animals has shown that a specific pre-exposure procedure, in which the target stimulus (A) is presented in compound with successive novel stimuli (An1, An2, An3…), can endow the target with sufficient inhibitory properties to pass both retardation and summation tests. To examine whether this phenomenon generalizes to humans, we conducted two experiments using a video game-based conditioning paradigm. Experiment 1 demonstrated that this compound pre-exposure schedule enhanced the retardation effect compared to standard pre-exposure or control conditions. Experiment 2 revealed that the target stimulus pre-exposed with novel stimuli significantly reduced responding when tested in compound with an excitatory conditioned stimulus, thus passing the summation test. These results suggest that compound pre-exposure facilitates the acquisition of inhibitory properties in humans, consistent with findings from animal studies. The findings are discussed within the framework of Hall-Rodríguez model, emphasizing the role of expectancy violation during pre-exposure in strengthening inhibitory associations. Implications for clinical applications, particularly in enhancing exposure therapy for anxiety disorders, are also considered.
This is the first book to analyze empirically supported treatments by using the newest criteria from the American Psychological Association's Society of Clinical Psychology, Division 12. Clinicians, scholars, and students all need to stay updated on the treatment research, and this book goes beyond providing updated treatment information by pointing readers to other useful treatment manuals and websites for continuing to stay up-to-date. The chapters, all written by prominent experts, highlight the best available evidence for specific disorders by breaking treatments down into credible components. With an emphasis on treatments for adults, chapters also share information about treatments for youth. Other variables that influence treatment are discussed, including assessment, comorbidity, demographics, and medication. Each chapter also corresponds with a chapter in the companion book, Pseudoscience in Therapy, presenting a full picture of the evidence base for common treatments.
This is the first book to analyze empirically supported treatments by using the newest criteria from the American Psychological Association's Society of Clinical Psychology, Division 12. Clinicians, scholars, and students all need to stay updated on the treatment research, and this book goes beyond providing updated treatment information by pointing readers to other useful treatment manuals and websites for continuing to stay up-to-date. The chapters, all written by prominent experts, highlight the best available evidence for specific disorders by breaking treatments down into credible components. With an emphasis on treatments for adults, chapters also share information about treatments for youth. Other variables that influence treatment are discussed, including assessment, comorbidity, demographics, and medication. Each chapter also corresponds with a chapter in the companion book, Pseudoscience in Therapy, presenting a full picture of the evidence base for common treatments.
Exposure therapy is an efficacious treatment for anxiety-related disorders. Yet, fear often returns after treatment. Occasional reinforcement, in which the feared stimulus is intermittently presented during extinction, increases safety learning and slows fear renewal in conditioning paradigms and analogue samples, but no studies to date have examined this strategy in clinical samples. The present study examined the effects of vicarious occasional reinforcement on fear renewal in a snake-phobic sample across multiple levels of analysis. Fear was intermittently reinforced by providing reminders of the feared outcome (a snake bite) throughout a two-session analogue video exposure manipulation. Snake-phobic adults were randomized to one of three conditions: a single-cue [S], multiple-cue [M], or multiple-cue+fear-outcome [M+FO] exposure group. Results showed the three groups did not significantly differ in threat expectancy or attentional bias for threat at follow-up. Despite sustained anxiety, however, the M+FO condition completed significantly more steps on a visual avoidance task at follow-up than the M and S conditions and heightened mean distress during exposure mediated this effect. The M and S groups did not significantly differ in visual avoidance at follow-up. These findings suggest incorporating reminders of the feared outcome into exposure may be an effective strategy for increasing inhibitory retrieval.
Although research on virtual-reality (VR) exposure therapy (VRET) in anxiety disorders has primarily focused on effectiveness and acceptability, the underlying working mechanisms have received scant attention. To fill this knowledge gap, we discuss potential theoretical underpinnings of VRET based on three dominant theoretical accounts on exposure: inhibitory-learning theory (expectancy violation), emotional-processing theory (habituation), and self-efficacy theory. Whereas theoretically speaking, habituation and self-efficacy seem plausible candidate mechanisms to explain the effects of VRET, the role of expectancy violation is less straightforward. Because of the simulated nature of VR, some feared outcomes cannot occur, and therefore, possibilities to violate expectancies about their occurrence may be compromised. Empirical evidence on the working mechanisms of VRET is scarce and has important limitations. Avenues for future research are provided. Insights into the mechanisms of VRET not only are of theoretical importance but also can provide theory-based directions to optimize the application of VRET.
Treatment of specific fears and phobias is sometimes followed by a return of fear. Work with rats has provided evidence that a greater return of fear occurs when a conditioned stimulus extinguished in 1 context is later presented in a different context than if presented in the same context in which it was originally extinguished. In the present study, 36 human participants who were highly afraid of spiders received 1 session of exposure therapy (with participant modeling) and were then tested for return of fear 1 week later in either the same or a different context. It was hypothesized that there would be a greater return of fear in those participants treated and followed up in different contexts than in those treated and followed up in the same context. Participants tested in a novel context at follow-up showed a greater return of fear than participants tested in the same context. Limitations and areas for future study are discussed.
72 college students learned 3 motor tasks under a blocked (low interference) or random (high interference) sequence of presentation. Retention was measured after a 10-min or 10-day delay under blocked and random sequences of presentation. Subsequent transfer to a task of either the same complexity or greater complexity than the originally learned tasks was also investigated. Results showed that retention was greater following random acquisition than under changed contextual interference conditions. Likewise, transfer was greater for random acquisition groups than for blocked acquisition groups. This effect was most notable when transfer was measured for the transfer task of greatest complexity. Results are considered as support for W. F. Battig's (1978) conceptualization of contextual interference effects on retention and transfer. (13 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
While many researchers have largely focused on principles of systematic desensitization and habituation
in explaining fear extinction, these processes have mixed evidence at best. In particular, these models
do not account for spontaneous recovery or reinstatement of fear, nor do they explain the context
dependency of extinction or rapid reacquisition. This may in part account for the significant number of
patients who fail to respond to our available treatments which rely on these principles in designing
exposure sessions. However, recent research is converging to suggest that an inhibitory model of fear
reduction, in which the original feared association (CS-US) remains but is inhibited by a newly formed
association (CS-noUS) representing safety, holds promise in explaining the long-term attenuation of fear
and anxiety. This paper reviews research in a number of areas, including neuroimaging,
psychophysiology, and psychopharmacology that all provide support for the inhibition model of anxiety.
Limitations to this body of research are discussed, along with recommendations for future research and
suggestions for improving exposure therapy for fear and anxiety disorders. Clinical implications
discussed in this paper include incorporating random and variable practice in exposure sessions,
multiple contexts, and pharmacological aides, among others.
Over the last 30years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g=1.010/g=1.128) and exposure was spread over the course of multiple sessions (g=1.527/g=1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.
Adolescent rats exhibit impaired extinction retention compared to pre-adolescent and adult rats. A single nonreinforced exposure to the conditioned stimulus (CS; a retrieval trial) given shortly before extinction has been shown in some circumstances to reduce the recovery of fear after extinction in adult animals. This study investigated whether a retrieval-extinction procedure would reduce the recovery of extinguished fear in adolescent rats. Furthermore, the effect of the retrieval-extinction sequence on fear recovery was examined by presenting the retrieval trial following extinction to some animals. In Experiment 1 adolescent rats received one nonreinforced CS presentation (a retrieval trial) or equivalent context exposure (no retrieval) 10 min before fear extinction. A retrieval trial shortly before extinction reduced overall levels of fear in both test contexts (i.e., it improved extinction retention and reduced renewal). In Experiment 2 a weakening of renewal was observed with a retrieval-extinction manipulation, regardless of whether the retrieval trial occurred in the training or extinction context. A key result was that a retrieval trial 10 min, but not 6 h, after extinction led to reduced overall levels of fear similar to that observed if the retrieval trial was given before extinction (Experiments 3 and 4), inconsistent with the current interpretation of the reduction in relapse being due to a disruption of reconsolidation. Together, these findings show that the impaired extinction retention observed in adolescents can be ameliorated by a very simple behavioral manipulation, but also raise some questions about the mechanisms underlying the retrieval-extinction effect.
This paper is an attempt to consider classical conditioning models of human fears and phobias in a contemporary context, and to consider how conditioning models might be of some theoretical help in this area. The paper covers (i) a contemporary review of the basic phenomena of human conditioning, (ii) a comparison of conditioning processes in humans and animals, (iii) a description of a contemporary model of human conditioning designed to accommodate recent research findings, (iv) a re-examination of the traditional criticisms of conditioning accounts of phobias in the light of this contemporary model, (v) a discussion of some of the features of fears and phobias that this model can address, and (vi) a brief discussion of the scope of this model and some implications for the treatment of clinical fears and phobias.
We argue herein that typical training procedures are far from optimal. The goat of training in real-world settings is, or should be, to support two aspects of posttraining performance: (a) the level of performance in the long term and (b) the capability to transfer that training to related tasks and altered contexts. The implicit or explicit assumption of those persons responsible for training is that the procedures that enhance performance and speed improvement during training will necessarily achieve these two goals. However, a variety of experiments on motor and verbal learning indicate that this assumption is often incorrect. Manipulations that maximize performance during training can be detrimental in the long term; conversely, manipulations that degrade the speed of acquisition can support the long-term goals of training. The fact that there are parallel findings in the motor and verbal domains suggests that principles of considerable generality can be deduced to upgrade training procedures.
In this article I review research and theory on the "interference paradigms" in Pavlovian learning. In these situations (e.g., extinction, counterconditioning, and latent inhibition), a conditioned stimulus (CS) is associated with different unconditioned stimuli (USs) or outcomes in different phases of the experiment; retroactive interference, proactive interference, or both are often observed. In all of the paradigms, contextual stimuli influence performance, and when information is available, so does the passage of time. Memories of both phases are retained, and performance may depend on which is retrieved. Despite the similarity of the paradigms, conditioning theories tend to explain them with separate mechanisms. They also do not provide an adequate account of the context's role, fail to predict the effects of time, and overemphasize the role of learning or storage deficits. By accepting 4 propositions about animal memory (i.e., contextual stimuli guide retrieval, time is a context, different memories are differentially dependent on context, and interference occurs at performance output), a memory retrieval framework can provide an integrated account of context, time, and performance in the various paradigms.
Exposure-based treatments for clinical anxiety generally are very effective, but relapse is not uncommon. Likewise, laboratory studies have shown that conditioned fears are easy to extinguish, but they recover easily. This analogy is striking, and numerous fear extinction studies have been published that highlight the processes responsible for the extinction and return of acquired fears. This review examines and integrates the most important results from animal and human work. Overall, the results suggest that fear extinction is relatively easy to "learn" but difficult to "remember." It follows that treatments will benefit from an enhanced focus on the long-term retrieval of fear extinction. We review the available studies on the prevention of return of fear and the prospects of weakening fear memories forever. We show that the behavioral principles outlined in learning theory provide a continuous inspiration for preclinical (neurobiological) and clinical research on the extinction and return of fear.
Review of the literature indicates that, according to theories of selective attention, learning about a stimulus depends on attending to that stimulus; this is represented in 2-stage models by saying that Ss switch in analyzers as well as learning stimulus-response associations. It is argued that this assumption, however, is equally well represented in a formal model by the incorporation of a stimulus-specific learning-rate parameter, a, into the equations describing changes in the associative strength of stimuli. Previous theories of selective attention have also assumed that (a) Ss learn to attend to and ignore relevant and irrelevant stimuli (i.e., that a may increase or decrease depending on the correlation of a stimulus with reinforcement); and (b) there is an inverse relationship between the probabilities of attending to different stimuli (i.e., that an increase in a to one stimulus is accompanied by a decrease in a to others). The first assumption has been used to explain the phenomena of acquired distinctiveness and dimensional transfer, the second to explain those of overshadowing and blocking. It is argued that although the first assumption is justified by the data, the second is not: Overshadowing and blocking are better explained by the choice of an appropriate rule for changing a, such that a decreases to stimuli that signal no change from the probability of reinforcement predicted by other stimuli. (65 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Memories become labile when recalled. In humans and rodents alike, reactivated fear memories can be attenuated by disrupting
reconsolidation with extinction training. Using functional brain imaging, we found that, after a conditioned fear memory was
formed, reactivation and reconsolidation left a memory trace in the basolateral amygdala that predicted subsequent fear expression
and was tightly coupled to activity in the fear circuit of the brain. In contrast, reactivation followed by disrupted reconsolidation
suppressed fear, abolished the memory trace, and attenuated fear-circuit connectivity. Thus, as previously demonstrated in
rodents, fear memory suppression resulting from behavioral disruption of reconsolidation is amygdala-dependent also in humans,
which supports an evolutionarily conserved memory-update mechanism.
Renewal has been implicated as one of the underlying mechanisms in return of fear following exposure therapy. ABC renewal is clinically more relevant than ABA renewal and yet it is a weaker form of renewal, suggesting that conducting extinction treatment in multiple contexts may be sufficient to attenuate ABC renewal. Using self-reported expectancy of shock and startle blink responses the current study examined the effects of conducting extinction treatment in multiple contexts on ABC fear renewal. Participants (N = 68) received conditional stimulus (CS) and unconditional stimulus (US) pairings in one context (A) followed by extinction treatment (CS presentations alone) in either one other context (B) or three other contexts (BCD). Non-reinforced test trials in a novel context (E) resulted in renewal of extinguished conditioned behaviour for those who received extinction in only one context. However, renewal was attenuated for those who received extinction treatment in three contexts. No renewal was found for the control group that received the test trial in the same context as during extinction. Suggestions are provided for clinicians seeking to prevent or attenuate return of fear following exposure therapy.
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
The contextual interference effect is a learning phenomenon where interference during practice is beneficial to skill learning. That is, higher levels of contextual interference lead to poorer practice performance than lower levels while yielding superior retention and transfer performance. This rather counterintuitive effect, first demonstrated by Battig (1966) for verbal materials and later shown to be relevant to motor skill learning by Shea and Morgan (1979), has led to a considerable amount of research. In this article, we review the motor skills literature related to this effect by focusing on two research directions. First, evidence related to the generalizability of the effect is considered to identify possible parameters of the contextual interference effect. It is apparent that this effect is not applicable for learning all types of tasks and for all types of learners. Thus, task and individual characteristics are given particular consideration. Second, the explanations offered to establish what learning processes account for this effect are considered. Here, the different views proposed to explain the contextual interference are discussed along with research addressing this issue. Also, the relationship between the contextual interference effect and the practice variability hypothesis of Schmidt's schema theory is explored. Finally, future research directions are suggested with the goal of providing guidelines for research to enhance our present knowledge of the contextual interference effect and its relationship to motor skill learning.
Fear conditioning is one of the prime paradigms of behavioural neuroscience and a source of tremendous insight in the fundamentals of learning and memory and the psychology and neurobiology of emotion. It is also widely regarded as a model for the pathogenesis of anxiety disorders in a diathesis-stress model of psychopathology. Starting from the apparent paradox between the adaptive nature of fear conditioning and the dysfunctional nature of pathological anxiety, we present a critique of the human fear conditioning paradigm as an experimental model for psychopathology. We discuss the potential benefits of expanding the human fear conditioning paradigm by (1) including action tendencies as an important index of fear and (2) paying more attention to "weak" (i.e., ambiguous) rather than "strong" fear learning situations (Lissek et al., 2006), such as contained in selective learning procedures. We present preliminary data that illustrate these ideas and discuss the importance of response systems divergence in understanding individual differences in vulnerability for the development of pathological anxiety.
Memory loss in retrograde amnesia has long been held to be larger for recent periods than for remote periods, a pattern usually referred to as the Ribot gradient. One explanation for this gradient is consolidation of long-term memories. Several computational models of such a process have shown how consolidation can explain characteristics of amnesia, but they have not elucidated how consolidation must be envisaged. Here findings are reviewed that shed light on how consolidation may be implemented in the brain. Moreover, consolidation is contrasted with alternative theories of the Ribot gradient. Consolidation theory, multiple trace theory, and semantization can all handle some findings well but not others. Conclusive evidence for or against consolidation thus remains to be found.
Investigations of fear conditioning in rodents and humans have illuminated the neural mechanisms underlying cued and contextual fear. A critical question is how personality dimensions such as trait anxiety act through these mechanisms to confer vulnerability to anxiety disorders, and whether humans' ability to overcome acquired fears depends on regulatory skills not characterized in animal models. In a neuroimaging study of fear conditioning in humans, we found evidence for two independent dimensions of neurocognitive function associated with trait vulnerability to anxiety. The first entailed increased amygdala responsivity to phasic fear cues. The second involved impoverished ventral prefrontal cortical (vPFC) recruitment to downregulate both cued and contextual fear prior to omission (extinction) of the aversive unconditioned stimulus. These two dimensions may contribute to symptomatology differences across anxiety disorders; the amygdala mechanism affecting the development of phobic fear and the frontal mechanism influencing the maintenance of both specific fears and generalized anxiety.
Four conditioned suppression experiments examined the influence of contextual stimuli on the rat's fear of an extinguished conditioned stimulus (CS). When rats received pairings of a CS with shock in one context and then extinction of the CS in another context, fear of the CS was renewed when the CS was returned to and tested in the original context (Experiments 1 and 3). No such renewal was obtained when the CS was tested in a second context after extinction had occurred in the conditioning context (Experiment 4). In Experiment 2, shocks presented following extinction reinstated fear of the CS, but only if they were presented in the context in which the CS was tested. In each experiment, the associative properties of the contexts were independently assessed. Contextual excitation was assessed primarily with context-preference tests in which the rats chose to sit in either the target context or an adjoining side compartment. Contextual inhibition was assessed with summation tests. Although reinstatement was correlated with demonstrable contextual excitation present during testing, the renewal effect was not. Moreover, there was no evidence that contextual inhibition developed during extinction. The results suggest that fear of an extinguished CS can be affected by the excitatory strength of the context but that independently demonstrable contextual excitation or inhibition is not necessary for contexts to control that fear.
When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism.
In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned stimulus or a 'rest' control group that received only exposure to the apparatus in the first two phases. However, reacquisition was impaired relative to acquisition in a 'learning-experienced' group that had previously received conditioning and extinction with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls. The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced trials signal other reinforced trials.
The ABA renewal procedure involves pairing a conditional stimulus (CS) and an unconditional stimulus (US) in one context (A), presenting extinction trials of the CS alone in a second context (B), and nonreinforced test trials of the CS in the acquisition context (A). The renewal of extinguished conditioned behaviour is observed during test. The current study tested the effects of multiple extinction contexts and context similarity in attenuating renewal. Participants (N=99) took part in a fear conditioning ABA renewal procedure. Using a measure of self-reported expectancy of the US, ABA renewal was observed when a single extinction context that was dissimilar to the test context was used. Renewal was attenuated, though still present, when extinction occurred in multiple dissimilar extinction contexts or in a single extinction context that was similar to the test context. Renewal was completely abolished when multiple extinction contexts that were similar to the test context were combined. Multiple extinction contexts and context similarity act additively in their effect on attenuating renewal. The results are discussed in relation to the design of exposure therapy programs that seek to reduce relapse that can occur via renewal.
Importance Obsessive-compulsive disorder (OCD) may be characterized by impaired self-regulation and behavioral inhibition. Elevated fear and anxiety are common characteristics of this disorder. The neurobiology of fear regulation and consolidation of safety memories have not been examined in this patient population.
Objective To examine the psychophysiological and neurobiological correlates of conditioned fear extinction in patients with OCD.
Design Cross-sectional, case-control, functional magnetic resonance imaging study.
Setting Academic medical center.
Participants Twenty-one patients with OCD and 21 healthy participants.
Main Outcomes and Measures Skin conductance responses and blood oxygenation level–dependent responses.
Results The between-group difference noted in our psychophysiological measure (skin conductance responses) was during extinction recall: patients with OCD showed impaired extinction recall relative to control subjects. Regarding the functional magnetic resonance imaging data, patients with OCD showed significantly reduced activation in the ventromedial prefrontal cortex across training phases. Moreover, reduced activation in the patients with OCD was noted in the caudate and hippocampus during fear conditioning, as well as in the cerebellum, posterior cingulate cortex, and putamen during extinction recall. Contrary to our prediction, OCD symptom severity was positively correlated with the magnitude of extinction memory recall. Also contrary to our prediction, functional responses of the ventromedial prefrontal cortex were positively correlated with symptom severity, and functional responses of the dorsal anterior cingulate cortex were inversely correlated with symptom severity.
Conclusions and Relevance As expected, our study showed that fear extinction and its neural substrates are impaired in patients with OCD. However, this study also yielded some surprising and unexpected results regarding the correlates between extinction capacity and its neural substrates and the severity of symptoms expressed in this disorder. Thus, our data report neural correlates of deficient fear extinction in patients with OCD. The negative correlations between fear extinction deficits and Yale-Brown Obsessive-Compulsive Scale symptoms in OCD suggest that there may be other factors, in addition to fear extinction deficiency, that contribute to the psychopathology of OCD.
primarily concerned with the generation of conditioned responses
contingency theory of learning
timing theories of learning and performance
comparator hypothesis of performance (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.
In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to
occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned
and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned
stimulus or a “rest” control group that received only exposure to the apparatus in the first two phases. However, reacquisition
was impaired relative to acquisition in a “learning-experienced” group that had previously received conditioning and extinction
with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition
was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial
conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls.
The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced
trials signal other reinforced trials.
Recent research indicates that return of fear occurs when spider-fearful individuals are confronted with the phobic stimulus in a context different than the one used during exposure therapy (Mineka, Mystkowski, Hladek, & Rodriguez, 1999; Rodriguez, Craske, Mineka, & Hladek, 1999). However, limitations regarding fear measurement, lack of real-world context manipulations and statistical power suggest that further investigation is warranted. With these concerns in mind, 46 spider-fearful individuals received a 1-session exposure-based therapy in one of two contexts, and were followed-up 1 week later for fear assessment in the treatment context, as well as in a new context, in a counterbalanced order. Self-report data confirmed the hypothesis that return of fear will appear when individuals are tested for fear in a context different than the treatment context. In addition, changes in perceptions of safety, danger, control, and predictability did not mediate and/or moderate a contextually based return of fear. Limitations of the current study and directions for future study are discussed.
Although exposure treatment has been shown to be highly effective in ameliorating phobias, the return of fear (ROF) is often evidenced (see Rachman, 1989). The present study compared the effects of massed (single session), uniform-spaced (5, 5, 5 intervening days), and expanding-spaced (1, 4, 10 intervening days) schedules on fear reduction and ROF in an analog sample with self-reported public-speaking anxiety. Treatment utilized a standardized speech exposure task. It was predicted that although massed treatment would produce the greatest fear reduction by posttreatment, it would yield the greatest ROF at 1-month follow-up. The uniform schedule was expected to produce intermediate fear reduction by posttreatment and at follow-up, whereas the expanding schedule was predicted to generate the lowest fear reduction by posttreatment, but the least ROF at follow-up. All groups unexpectedly demonstrated comparable fear reduction by posttreatment, but, as predicted, massed treatment produced the greatest ROF at follow-up — fear ratings in this group no longer differed from pretreatment levels. Expanding and uniform treatments showed an impressive lack of ROF at follow-up; possible explanations for the unexpectedly robust performance of the uniform group are discussed. Given the high rates of attrition for the uniform schedule (50%), results provide preliminary support for the utility of an expanding schedule. Limitations of the present study, and theoretical and practical issues regarding spacing of treatment, are discussed.
Two appetitive conditioning experiments with rats examined reacquisition after conditioned responding was eliminated by either extinction or by a partial reinforcement procedure in which reinforced trials were occasionally presented among many nonreinforced trials. In Experiment 1, reacquisition to a conditional stimulus (CS) that had been conditioned and extinguished was more rapid than acquisition in a group that had received no prior conditioning. However, the addition of occasional reinforced trials to extinction slowed this rapid reacquisition effect. Experiment 2 replicated the result and showed that a procedure in which the CS and the unconditional stimulus (US) were unpaired in extinction interfered even further with reacquisition. The results suggest that rapid reacquisition is ordinarily produced when reinforced trials provide a contextual cue that can renew responding by signaling other acquisition trials (Ricker & Bouton, 1996). The effects of partial reinforcement in extinction are surprising from several theoretical perspectives and have useful clinical implications.
Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.
A differential fear conditioning paradigm was used with 107 healthy undergraduate participants to evaluate the effect of conditioned stimulus (CS) temporal properties on fear acquisition and extinction. Two minute duration CSs were used for Day 1 fear acquisition. Participants were randomized to receive either 1, 2, or 4min CS durations during Day 2 extinction. Extinction re-test was examined on Day 3 using the original acquisition CS duration (2min). Findings indicated that participants who were aware of the CS+/unconditioned stimulus (US) contingency (n=52) develop a temporal expectation about when the unconditioned stimulus will be delivered. Although the shorter duration CS resulted in greater fear reduction during extinction, cessation of fear responding at re-test was the same for CS extinction durations ranging from half the CS acquisition duration to twice the CS acquisition duration. Thus, extinction performance did not predict extinction at re-test, which could have important implications for optimizing exposure therapy for anxiety disorders.
In traditional exposure therapy for phobias and anxiety disorders, reduction of fear responding is used as an index of learning. However, recent evidence in animal models suggests that sustained arousal and enhanced fear responding throughout exposure may actually predict better long-term outcomes (Rescorla, 2000).
The effects of sustained arousal during exposure were investigated in a clinical analog sample of 59 participants fearful of public speaking. Participants completed exposure with or without the presence of additional excitatory stimuli which were intended to enhance arousal and fear responding throughout exposure.
Group assignment (exposure versus exposure with additional excitatory stimuli) did not significantly predict outcome at 1-week follow-up testing, as measured physiologically, subjectively, and behaviorally. A set of regression analyses investigating whether any exposure process measures predicted outcome indicated that sustained arousal throughout exposure as well as variability in subjective fear responding throughout exposure (e.g., Kircanski et al., 2011) predicted lower levels of fear at follow-up testing (p < 0.05; p < 0.001) after controlling for demographic variables as well as pre-exposure fear levels.
The excitatory stimuli used failed to produce the intended effects. However, some participants did maintain elevated arousal throughout exposure and this predicted better outcomes at 1-week follow-up testing.
Sustained arousal throughout exposure as well as variability in subjective fear responding during exposure may be better predictors of long-term outcomes than habituation of fear across exposure.
Traditional models and methods of exposure therapy utilize a fear hierarchy, whereby patients complete sets of exposures in a graduated manner, with the goal of fear habituation within and between sessions. In the current experiment, we examined whether this typical exposure paradigm was necessary to achieve clinical improvement.
Fifty undergraduate participants scoring in the top quartile of a self-report measure of contamination fears were randomly assigned to one of two groups: blocked and constant exposure (BC Group) and random and variable exposure (RV Group). Both groups completed three weekly sessions of exposure treatment, with subjective and psychophysiological indices of fear recorded throughout. Subjective, behavioral, and psychophysiological dependent measures were evaluated by an independent assessor at pre-treatment (PRE), post-treatment (POST), and two-week follow-up (2WFU).
Both the BC Group and RV Group exhibited decreases in subjective fear from PRE to POST and 2WFU, with no significant differences between groups. Partialing group, greater variability in subjective fear during exposure predicted lower subjective fear at 2WFU.
Despite significant findings for subjective fear, behavioral and psychophysiological findings were limited. Follow-up studies should investigate questions regarding traditional exposure within a clinical group.
These results support the notion that traditional exposure is sufficient, but not necessary, to produce clinical improvement in contamination-related fears. There may be benefits to variability in fear level during exposure, and evaluation of emotion variability during exposure therapy for other anxiety disorders is warranted.
It has been proposed that the judicious use of safety behaviour can facilitate improvements in the acceptability of cognitive behaviour therapy (CBT). It was decided to explore the possibility of facilitating CBT by introducing a form of safety behaviour. We sought to assess the degree to which Exposure plus Safety Behaviour (E + SB) is an effective intervention for contamination fears.
A comparison was made between the effects of a control condition (Exposure and Response Prevention; ERP) and an experimental condition (Exposure plus Safety Behaviour; E + SB) in which each exposure to a contaminant was followed by the use of a hygienic wipe in a sample of (n = 80) undergraduate students. In session one, each participant touched a confirmed contaminant 20 times. After each exposure participants were asked to report their feelings of contamination, fear, disgust, and danger. In the second session, two weeks later, the same procedure was carried out for a further 16 trials.
The ERP and the E + SB conditions both produced large, significant and stable reductions in contamination. Significant reductions in fear, danger and disgust were also reported in both conditions.
The treatment was provided to an analogue sample and over two sessions.
The use of hygienic wipes, the safety behaviour used in this experiment, did not preclude significant reductions in contamination, disgust, fear and danger. If it is replicated and extended over a longer time-frame, this finding may enable practitioners to enhance the acceptability of cognitive behavioural treatments and boost their effectiveness.
The present studies investigated if retrieval cues (reminder objects) can attenuate context renewal of fear. In Study 1, 32 participants completed exposure in one of two contexts; 1-week follow-up testing occurred in a novel or the same context. Results indicated significant renewal of fear for those tested in a novel context. In Study 2, 40 participants completed exposure in one of these contexts; half were presented with cues. One week later, all were tested in a novel context with or without cues. Results indicated weak attenuation of context renewal for participants re-presented with cues. In Study 3, 18 participants completed exposure in one of two maximally distinct contexts; all with cues. One week later, participants were tested in a novel context with or without cues. Results indicated no group differences. These findings suggest that clinical relevance of this set of cues for attenuating context renewal may be limited.
In six experiments we studied the effects of a single re-exposure to a conditioned stimulus (CS; "retrieval trial") prior to extinction training (extinction-reconsolidation boundary) on the development of and recovery from fear extinction. A single retrieval trial prior to extinction training significantly augmented the renewal and reinstatement of extinguished responding. Augmentation of recovery was not observed if the retrieval and extinction training occurred in different contexts. These results contrast with those reported in earlier papers by Monfils and coworkers in rats and by Schiller and coworkers in humans. We suggest that these contrasting results could depend on the contrasting influences of either: (1) occasion-setting contextual associations vs. direct context-CS associations formed as a consequence of the retrieval trial or (2) discrimination vs. generalization between the circumstances of conditioning and extinction.
Clinically, there is wide subscription to emotional processing theory (EPT; Foa & Kozak, 1986) as a model of therapeutic effectiveness of exposure therapy: EPT purports that exposure is maximal when (1) fear is activated (IFA), (2) fear subsides within sessions (WSH), and (3) fear subsides between sessions (BSH). This study examined these assumptions, using in vivo exposure therapy for 44 students scoring high on acrophobia measures. Results indicated that no EPT variables were consistently predictive of treatment outcome. No support was found for IFA or WSH; measures of BSH were predictive of short-term change, but these effects were attenuated at follow-up. Furthermore, EPT variables were not predictive of each other as previously hypothesized, indicating the variables are not functionally related.