Inhibitory Learning Model Research Articles

Feeling more confident to encounter negative emotions: The mediating role of distress tolerance on the relationship between self-efficacy and outcomes of exposure and response prevention for OCD

BackgroundWhile exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond. In an effort to better understand the mechanisms behind ERP, the inhibitory learning model emphasizes the roles of increasing perceived self-efficacy and distress tolerance. While self-efficacy and distress tolerance have separately been shown to predict OCD symptoms and treatment outcomes, no studies have assessed their joint effects in ERP. The current study examined distress tolerance as a mediator of the relationship between self-efficacy and ERP outcomes. MethodsPatients in an intensive ERP-based treatment program (N = 116) completed weekly self-report measures. ResultsOver the course of treatment, as OCD symptoms reduced, self-efficacy and distress tolerance both significantly increased. Importantly, increases in self-efficacy and distress tolerance mediated each other in explaining symptom reduction, suggesting a possible bi-directional effect. LimitationsThe temporal relationship between changes in self-efficacy and distress tolerance is worthy of further investigation. In addition, the current sample had limited racial diversity and might not be representative of patients receiving lower levels of care. Findings merit replication to be ascertained of their reliability. ConclusionsFindings suggest that during ERP, patients gain confidence in their abilities both to cope with general challenges and to withstand distress, potentially helping them engage with exposures and overcome initial fears. These findings provide support for the inhibitory learning model and highlight the mechanistic roles of self-efficacy and distress tolerance in ERP. Clinical implications to target both in treatment are discussed.

The Role of Expectancy Violation in Extinction Learning: A Two-Day Online Fear Conditioning Study.

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

Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide.

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

Fidelity to the Inhibitory Learning Model, Functionality, and Availability of Free Anxiety Treatment Apps

Fidelity to the Inhibitory Learning Model, Functionality, and Availability of Free Anxiety Treatment Apps

An Experimental Analogue Study on the "Dose-Response Relationship" of Different Therapeutic Instructions for Pain Exposures: The More, The Better?

ObjectiveNovel suggestions derived from the inhibitory learning model on how to optimize exposure therapy have been debated with enthusiasm in the last few years, particularly with respect to the focus on expectancy violations. However, little is known about how this new approach directly compares to the traditional habituation rationale of exposure therapy. In the present study, we examined these two competing therapeutic instructions among healthy female participants in an experimental heat pain paradigm.Design and MethodsParticipants (N= 116) received a therapeutic instruction derived from either a habituation-based approach or the inhibitory learning model (expectation violation). Participants were repeatedly exposed to painful thermal stimulations until a predefined exposure goal was reached.ResultsThe expectation violation instruction led to faster goal attainment and higher response rates than the habituation instruction. Both instructions led to increased pain tolerance in the short and long term (one-week follow-up).ConclusionOur results suggest that exposure treatments using an expectation violation instruction are especially time-effective. Although the findings from this analogue design cannot be directly generalized to populations with clinically relevant levels of chronic pain, they do point to some important theoretical and clinical implications for the treatment of pain.

A longitudinal investigation of the efficacy of online expressive writing interventions for Hispanic students exposed to traumatic events: competing theories of action

Objective: Although expressive writing (EW) appears efficacious for treating a range of posttraumatic stress (PTS) symptoms including diagnosed PTSD, little is known about its efficacy when offered online and for ethnic/cultural minority populations such as Hispanic individuals. The current study examined the longitudinal effects of two online EW tasks for treating PTS symptoms in a Hispanic student sample. Design: Seventy-one participants who had experienced a traumatic event were randomly assigned to either an emotion-focused (EM) writing group or a fact-focused (FC) writing group and completed online writing sessions for three consecutive days. Participants completed online assessments at 1-week, 1-month, and 3-month follow-ups. The PTSD Checklist–DSM-5 version was used to assess PTS symptoms. Results: Both groups reported statistically significant reductions in severity of PTS symptoms at 1-week follow-up with the EM group demonstrating statistically significantly greater symptom reductions than the FC group. Differential longitudinal effects over the 3-month follow-up periods were found for some PTS domains, with the EM group showing superior improvements relative to the FC group. Conclusion: EW delivered online can be useful for Hispanic individuals with PTS symptoms following traumatic life events. Further, the current findings align with an inhibitory learning model for explaining EW’s mechanism of action.

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

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

Inhibitory Learning for Anxiety-Related Disorders

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

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

Recent findings have led to a reconceptualization of the mechanisms that account for the efficacy of exposure-based treatments. Termed the “inhibitory learning model,” this approach emphasizes new learning when confronted with previously avoided stimuli rather than merely the cessation of fear or aversive emotional responding. In this paper, we propose the applicability of the inhibitory learning model for conditions and contexts in which simple exposure does not produce habituation. We illustrate this application from an in-progress randomized controlled treatment trial for adults with misophonia. Misophonia is a condition marked by strong aversive reactions to specific sounds. It is a difficult to treat and understudied syndrome. All participants in the trial received exposure, either before or after a stress management module of treatment. Exposure treatment emphasized altered expectancies for the target sounds as well as deliberate practice in hearing sounds on the individually developed hierarchy. Inhibitory learning strategies were employed to increase treatment adherence and commitment, shape patient behavior during exposures, manufacture negative prediction errors, increase perceived control over reactions, and promote learning that generalized to functional improvements. The findings are discussed in the context of future applications of the inhibitory learning model for psychopathology associated with avoidance.

Dropping Safety Aids and Maximizing Retrieval Cues: Two Keys to Optimizing Inhibitory Learning During Exposure Therapy

The inhibitory learning model of exposure therapy posits that clinical anxiety is most effectively treated when clinicians employ strategies that maximize the (a) violation of negative expectancies and (b) generalization of nonthreat associations. Translation of basic learning research to exposure therapy via this explanatory model underscores two keys to optimizing inhibitory learning during exposure: dropping safety aids and maximizing retrieval cues. Although topographically similar, safety aids and retrieval cues are functionally distinct as well as therapeutically incompatible. In the present article, we delineate safety aids and retrieval cues in the context of exposure therapy from an inhibitory learning perspective, providing illustrative case examples of how clinicians may address the two when treating patients with clinical anxiety.

Enhancing Inhibitory Learning: The Utility of Variability in Exposure

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

The credibility of exposure therapy: Does the theoretical rationale matter?

ObjectiveLittle is understood about how the public perceives exposure-based therapy (ET) for treating anxiety and trauma-related disorders or how ET rationales affect treatment credibility. Distinct approaches to framing ET are practiced, including those emphasized in traditional cognitive behavioral therapy, acceptance and commitment therapy, and the more recent inhibitory learning model. However, their relative effect on ET's credibility remains unknown. MethodA final sample of 964 U.S. adults provided baseline views of ET. Participants rated ET treatment credibility following a simple ET definition (pre-rationale) and following randomization to rationale modules addressing ET goals, fear, and cognitive strategies from distinct theoretical perspectives (post-rationale). Baseline ET views, symptoms, and sociodemographic characteristics were examined as putative moderators and predictors. ResultsAt baseline, the majority had never heard of ET. From pre- to post-rationale, ET treatment credibility significantly increased but the rationales' theoretical perspective had little impact. More negative baseline ET views, specific ethnic/racial minority group status, and lower education moderated or predicted greater increases in treatment credibility following the rationale. ConclusionsET remains relatively unknown as a treatment for anxiety or trauma, supporting the need for direct-to-consumer marketing. Diverse theory-driven rationales similarly increased ET credibility, particularly among those less likely to use ET.

Maximizing exposure therapy: An inhibitory learning approach

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

Effect of nitric oxide synthase inhibitor l-NAME on fear extinction in rats: A task-dependent effect

There is increasing evidence that nitric oxide may be involved in learning and memory. However, there remain comparatively few studies that have explored the relationship between nitric oxide signaling and fear extinction, an inhibitory learning model. In the present study, we tested the effects of nitric oxide synthase inhibitor l-NAME on three tone fear extinction tasks in rats. In task 1, rats received fear conditioning, extinction training and extinction test in the same context (AAA design). In task 2, rats received fear conditioning in context A, extinction training in context B and extinction test in context A (ABA design). In task 3, rats received fear conditioning in context A, extinction training and extinction test in context B (ABB design). l-NAME (10, 20 and 40mg/kg) was injected intraperitoneally 30min prior to extinction training in each task. Percent of time spent freezing was used to measure conditioned fear response. We found that l-NAME administrations had no effect on freezing in task 1 and 2 but produced a dose-dependent increase in task 3. Further results indicated that the increased freezing in task 3 was not attributed to state-dependency effects or nonspecific changes of locomotor activity that followed l-NAME injection. These results showed that l-NAME produced a task-dependent impairment of fear extinction, and implied that nitric oxide signaling was involved in memory process of certain extinction tasks.

P.2.g.006 Comparison of bipolar patients with and without comorbid dissociative disorder

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