Inhibitory Learning Theory Research Articles

Opening the Black Box: The Underlying Working Mechanisms in Virtual-Reality Exposure Therapy for Anxiety Disorders

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.

Approach and Conquer: Optimizing Fear Extinction by Adding Approach?

Exposure treatment involves systematic confrontation with fear-inducing stimuli, effectively reducing fear and anxiety. However, a significant number of clients still experience a return of fear (ROF) after treatment. This study investigates whether incorporating an approach component during fear extinction, a laboratory exposure analog, could mitigate this return of fear. Furthermore, we explored the underlying mechanisms by drawing on predictions from the inhibitory learning theory and the reflective-impulsive model of behavior. In a within-subjects design, we compared instructed active approach of a stimulus during extinction to more passive non-avoidance. Contrary to expectations, our findings revealed that performing approach behavior during extinction did not reduce ROF when compared to non-avoidance. Furthermore, valence and action tendencies, which were potential mechanisms based on the reflective-impulsive model of behavior, remained unaltered. Still, a noteworthy discovery emerged in the form of increased threat expectancies for the approached stimulus during extinction, suggesting a heightened level of expectancy violation, as predicted on the basis of the inhibitory learning theory. These findings offer valuable insights into the intricate relationship between approach behavior, ROF, and underlying mechanisms, highlighting the need for further research to assess the potential benefits of emphasizing approach in exposure treatment.

Daily-life stress reactivity and recovery following virtual-reality-based cognitive behavioral therapy in patients with a psychotic disorder.

Studies have consistently demonstrated increased stress sensitivity in individuals with psychosis. Since stress sensitivity may play a role in the onset and maintenance of psychosis, this could potentially be a promising target for treatment. The current study was the first to investigate whether reactivity to and recovery from daily-life stressors in psychosis change in response to treatment, namely virtual-reality-based cognitive behavioral therapy (VR-CBT). 116 patients were randomized to either VR-CBT or the waiting list control group (WL). Pre-treatment and post-treatment participants completed a diary ten times a day during six to ten days. Multilevel analyses were used to model the time-lagged effects of daily stressful events on negative affect (NA) and paranoia symptoms to examine reactivity and recovery. There was a significant difference in NA reactivity. VR-CBT showed higher NA at post-treatment compared to pre-treatment than WL (bpre=0.14; bpost=0.19 vs bpre=0.18; bpost=0.14). There was a significant difference in NA recovery and paranoia recovery between the groups at lag 1: VR-CBT showed relatively lower negative affect (bpre=0.07; bpost=-0.06) and paranoia (bpre= 0.08; bpost=-0.10) at post-treatment compared to pre-treatment than WL (bpre=0.08; bpost=0.08; bpre=0.04; bpost=0.03). Negative affect and paranoia recovery improved in response to treatment. Increased NA reactivity may be explained by a decrease in safety behavior in the VR-CBT group. The discrepancy between reactivity and recovery findings may be explained by the inhibitory learning theory that suggests that an original threat reaction may not erase but can be inhibited as a consequence of exposure therapy.

Paradigms and Practice Shifts: A Topical Narrative Review of the Evolving Face of Exposure-Based Treatment for Youth

Abstract: Exposure therapy is the gold standard treatment for anxiety and obsessivecompulsive disorders in children, adolescents, and adults. Inhibitory Learning Theory offers a nuanced and advanced perspective on exposure treatment positing that violating threat expectancies is more important than habituation. This paper highlights the effectiveness of inhibitory learning theory-guided exposure procedures for youth with anxiety and OCD, chronic pain, and eating disorders. A topical review focusing on the theoretical foundations of inhibitory learning theory, crucial augmentations of the approach, and outcomes with pediatric patients diagnosed with anxiety, eating, and pain disorders is presented. The literature review indicated that inhibitory learning theory-driven exposure produced beneficent outcomes in the identified populations. Various limitations and future directions were discussed. Limitations notwithstanding, inhibitory learning theory-led exposure represents a viable treatment option for pediatric patients with anxiety, eating, and chronic pain disorders.

The Impact of Exposure Therapy on Cancer-Related Future Cognitions in Severe Health Anxiety

Individuals with illness anxiety disorder (IAD) experience a preoccupation with having or acquiring a serious illness despite having mild or absent physical symptoms. Formerly hypochondriasis, individuals with IAD experience high rates of disability, contribute to elevated annual health care costs, and experience multiple comorbidities. IAD has been historically difficult to treat for both medical and mental health providers. Research suggests cognitive behavior therapy has mixed results for individuals with IAD. In this fictitious case presentation, we describe a course of successful exposure therapy for IAD drawing on the principals of inhibitory learning theory. Thus, through this example we demonstrate how to overcome common obstacles to successful treatment for IAD, such as willingness to participation, comorbid depression, and therapeutic alliance.

Inhibitory Learning versus Habituation in an Experimental Exposure Intervention for People With Heightened Health Anxiety: Increase of Distress Tolerance as a Joint Mechanism of Change?

The Inhibitory Learning Theory (ILT; Craske et al., 2008) changed the focus of exposure-based treatment from erasing excitatory associations and fear reduction (habituation (HA)) to reinforcing inhibitory associations and fear toleration (inhibitory learning (IL)). Studies which directly compare both approaches, IL versus HA, are scarce. The present study aimed at implementing and comparing an IL-based ( n = 26; Age: M = 23.59, SD = 4.38) with a HA-based ( n = 28; Age: M = 25.46, SD = 6.22) experimental exposure approach (including in vivo, interoceptive, and in sensu exposure) in a sample of people with heightened health anxiety. A significant pre- to post-intervention reduction of state health anxiety ( p < .001), which was especially associated with an increase of distress tolerance (DT) pre- to post-exposure ( F (1, 50) = 12.2, p < .001, ηp2 = .20), was observed. A superiority of the IL-based over the HA-based exposure intervention was not detected in relation to major outcomes (e.g., state health anxiety), as well as in relation to a change of DT. The present study underlines the importance of strengthening DT (for heightened health anxiety) during an exposure-based intervention.

Expectancy violation during exposure therapy: A pilot randomized controlled trial

Despite empirical support for the efficacy of exposure-based therapy for anxiety-related disorders, many individuals do not respond to this intervention or else experience a return of fear after treatment. Inhibitory learning theory has informed novel approaches to exposure therapy delivery that aim to improve both short- and long-term outcomes. One exposure optimization strategy is to maximize expectancy violation (i.e., the difference between expected and actual outcomes), which is thought to strengthen inhibitory (i.e., non-threat) associations and enhance long-term fear extinction. In practice, exposure therapy is traditionally preceded by cognitive restructuring to lessen the magnitude of harm expectancies. Yet this technique may restrict the discrepancy between expected and actual outcomes, thus reducing the potency of exposure and limiting the durability of treatment gains. The present study examined the effects of manipulating the timing of cognitive techniques during exposure-based therapy by randomly assigning 45 participants with spider phobia to one of three conditions: (a) cognitive restructuring before exposure (CR-EXP; n = 15), (b) exposure before cognitive restructuring (EXP-CR; n = 15), and (c) stress management control (SM; n = 15). Although both CR-EXP and EXP-CR were more effective than SM, there were no significant differences between CR-EXP and EXP-CR on measures of fear, avoidance, spider-related cognitions, or change in harm expectancy. Clinical implications, study limitations, and future directions are discussed.

Merging Our Understanding of Anxiety and Exposure: Using Inhibitory Learning to Target Anxiety Sensitivity in Exposure Therapy.

Exposure-based therapies are the gold standard treatment for anxiety disorders, and recent advancements in basic and clinical research point to the need to update the implementation of exposure. Recent research has highlighted the importance of transdiagnostic factors such as anxiety sensitivity (AS), or fear of anxiety-related sensations. Elevated AS is common among all anxiety disorders and contains three dimensions, or expectancies, that can be used to guide treatment. Recently, treatments directly targeting AS have shown potential in reducing symptoms of anxiety. In addition, inhibitory learning theory (ILT) provides an alternative explanation of exposure processes based on basic learning research. ILT extends the current framework by accounting for renewal of fear, which is important given the substantial number of individuals who experience a return of symptoms following treatment. The current paper will provide an overview of ILT and discuss several ILT techniques that can be used to target AS. These two converging bodies of research hold strong potential for optimizing treatment for anxiety.

La thérapie par exposition en réalité virtuelle pour les états de stress post-traumatiques, les troubles obsessionnels compulsifs et les troubles anxieux : indications, plus-value et limites

The exposure in cognitive behavioral therapy (CBT) is a well-known intervention, widely investigated in scientific research. Several studies have shown the benefits of this intervention in the treatment of anxiety disorders, obsessive-compulsive disorders (OCD) and post-traumatic stress disorders (PTSD). The different exposure techniques are mainly based on the emotional processing of fear theory and use an emotional stimulation of fear, following by its habituation. However, new approaches have emerged and are based on the inhibitory learning theory. The virtual reality technology allows emotional involvement from patients and represents a complementary approach to the classical modalities of exposure therapy (e.g., mental or in vivo expositions). This modern approach presents specific features that need to be taken into account by the therapist. Firstly, the presence feeling, which is defined as the “be there” feeling. This feeling is dependent on immersive technical features and personality factors. Secondly, virtual reality sickness, similar to motion sickness, represents a limitation that might prejudice a virtual therapy. The main scientific investigations of Virtual Reality Exposure Therapy (VRET) for treating social phobia, specific phobia, PTSD, and panic disorders are encouraging and demonstrate a similar effectiveness between both in vivo and in virtuo exposures. The scarce investigations on generalized anxiety disorders and OCD also suggeste a similar effectiveness between these exposures. However, further scientific investigations are needed to support these preliminary findings. The attrition rates and deteriorating states are similar to classical CBT approaches. Nevertheless, scientific literature presents several limits: 1) much of the research on this topic has interest conflicts (e.g., developers are also authors of a large number of studies); 2) there is a high heterogeneity of materials and virtual environments used; 3) important measures are not always taken into account in scientific research (e.g., the presence feeling); and 4) a massive use of waiting lists as a control measure. Despite these limitations, the VRET have strong silver linings: 1) the easy access to exposure (less limited than standard exposure techniques) and a cost reduction; 2) highly guaranteed security; 3) the anonymization of exposures (i.e., the patients do not risk meeting someone they know during the exposure therapy); 4) the therapist has a greater control of exposures; 5) a standardization of the exposures; 6) a greater involvement in therapy for technophile patients. Virtual exposure also seems to be generally more accepted by patients.

Treating Taboo or Forbidden Thoughts: Integrating Mindfulness, Acceptance, and Emotion Regulation Into an Exposure-Based Intervention.

Individuals with obsessive compulsive disorder (OCD) who struggle with taboo or unacceptable obsessions (i.e., aggressive, sexual, or religious intrusions) tend to rely upon mental rituals to regulate their distress and possess difficulties labeling and regulating their affective state. Moreover, these individuals respond poorly to exposure with response prevention when the treatment is grounded in emotional processing theory. To improve patients' therapeutic outcomes, clinicians can consider integrating mindfulness- and acceptance-based skills into an exposure-based treatment to: facilitate the identification and acceptance of covert ritualistic urges, improve the accuracy of emotion labeling, and increase the efficiency of emotion regulation efforts. Additionally, in line with inhibitory learning theory, clinicians can design exposures to violate expectancies to promote the maintenance of long-term gains. Through a case vignette, the current article will demonstrate how to integrate these strategies into a standard exposure with response prevention intervention to meet the needs of a patient with taboo thoughts.

A randomized controlled trial of the judicious use of safety behaviors during exposure therapy

Safety behaviors—actions performed to prevent, escape from, or reduce the severity of perceived threat—are typically eliminated during exposure therapy for clinical anxiety. Yet some experts have called for the strategic and “judicious use” of safety behaviors during exposure to improve treatment acceptability/tolerability without diminishing its efficacy. Empirical findings regarding this debate are mixed and existing work is subject to several methodological limitations. The current randomized controlled trial incorporated longitudinal design and multimethod assessment to compare the efficacy of traditional exposure with the elimination of safety behaviors (E/ESB) and exposure with judiciously used safety behaviors (E/JU). Adults with clinically significant spider fear (N = 60) were randomized to four twice-weekly sessions of E/ESB or E/JU. Self-report and behavioral measures were administered at pretreatment, posttreatment, and 1-month follow-up. Participants exhibited large effects on all measures from pretreatment to posttreatment, with no change from posttreatment to follow-up. There were no significant group differences in treatment outcome or treatment acceptability/tolerability. Exploratory analyses were used to compare behavioral and inhibitory learning processes between conditions. Clinical implications, study limitations, and future directions are discussed in terms of inhibitory learning theory.

Efficacy of inhibitory learning theory-based exposure and response prevention and selective serotonin reuptake inhibitor in obsessive-compulsive disorder management: A treatment comparison.

Background:The majority of treatment research on obsessive-compulsive disorder (OCD) has focused on emotional processing theory (EPT)-based exposure-based interventions. Despite the outcomes of EPT-based exposure and response prevention (ERP), a sizeable percentage of patients do not respond whereas 50%–60% of those who respond experience at least partial relapse at follow-up assessments. Inhibitory learning theory (ILT) provides a novel foundation for understanding how exposure therapy can be maximized to overcome such deficits but has not been adequately studied and compared to other evidence-based management in OCD.Aim:The aim of this study was to compare ILT-based ERP plus selective serotonin reuptake inhibitor (SSRI) with only SSRI treatment in OCD patients.Materials and Methods:The present study is pretest/posttest control group design with single masking, where participants (n = 32) diagnosed with OCD were randomly assigned into two treatment groups, namely ILT-based ERP plus SSRI and SSRI alone. Yale-Brown obsessive-compulsive scale was primary outcome measure. Intervention was done for 3 months. Thereafter, the participants were followed up for 6 months.Results:ILT-based ERP and SSRI are both effective treatments. There was no significant difference in treatment effects between combined treatments of SSRI plus ILT-based ERP and SSRI alone in immediate post assessment. However, combined treatment of SSRI plus ILT-based ERP had significantly better treatment effects on follow-ups than SSRI alone.Conclusions:SSRI combined with ILT-based strategies to maximize ERP is significantly better than SSRI alone in the treatment of OCD.

Verbal Exposure for Irrational Fears: New Directions in Research and Applications

Exposure therapies are proven to be effective in irrational fears such as seen in Obsessive-Compulsive Disorder (OCD) and phobia [1-5]. Typically, an individual with irrational fears is exposed to the feared stimuli in imagination and/or in vivo along with prevention of avoidance response. The exposure in this manner initially leads to an increase in fear reaction which gradually begins to decline. The repeated exposure in this manner leads to habituation or elimination of fear reaction. For instance, in an individual with fear of lizards, imaginal exposure would involve repeated holding of imagery of lizard including feared consequences in the content of consciousness. For in vivo exposure, the patient would be encouraged being repeatedly in proximity of actual lizard and imagining feared consequences without avoidance response. Multiple theories have been put forth to explain the mechanisms of action involved in exposure therapies. Rachman [6] and Foa and McNally [7] proposed Emotional Processing Theory to explain the mechanisms of action in exposure therapy. Craske et al. [8] and Labordaan Miller [9] offered Inhibitory Learning Theory for the same

Testing the Habituation-Based Model of Exposures for Child and Adolescent Anxiety

Exposure has been identified as key to effective treatment of youth anxiety. However, the precise theoretical mechanisms of exposure are a matter of debate. Emotional processing theory emphasizes the need for fear activation during exposure and its habituation both within and across exposures. Despite the popularity of the theory to explain exposure, it has not been tested with anxious youth. To determine whether emotional processing theory parameters predict anxiety severity, coping abilities, and global functioning after cognitive-behavioral treatment. The present study examined 72 youth (Mage = 10.50 years; 45% female; 87.5% non-Hispanic Caucasian) diagnosed with an anxiety disorder and who received family or individual CBT. Three exposure habituation variables—initial fear activation (peak anxiety), within-session habituation, and between-session habituation—were assessed using Subjective Units of Distress and examined as predictors of outcome at posttreatment and at 1-year follow-up. Outcomes were measured using the Coping Questionnaire, Multidimensional Anxiety Scale for Children, Revised Children’s Manifest Anxiety Scale, Children’s Global Assessment Scale, and clinician severity ratings on the Anxiety Disorder Interview Schedule. Emotional processing theory variables did not predict any anxiety outcomes at posttreatment or follow-up with one exception: Initial fear activation predicted less anxiety at follow-up among youth without GAD. In addition, within- and between-session habituation were not associated with one another. Between-session habituation was not associated with initial fear activation. These findings suggest a limited role of habituation within cognitive-behavioral therapy for anxiety in youth. An alternative to emotional processing theory, inhibitory learning theory, is discussed.