Predicting return of fear following exposure therapy with an implicit measure of attitudes

doi:10.1016/j.brat.2012.08.007

Behaviour Research and Therapy

Volume 50, Issue 12, December 2012, Pages 767-774

https://doi.org/10.1016/j.brat.2012.08.007 Get rights and content

Abstract

We sought to advance understanding of the processes underlying the efficacy of exposure therapy and particularly the phenomenon of return of fear (ROF) following treatment by drawing on a social psychological view of phobias as attitudes. Specifically, a dual process theory of attitude-related behavior predicts that a positive response to exposure therapy may reflect change in either the automatic (the attitude representation itself) or controlled (skills and confidence at coping with the fear) responses to the phobic stimulus, or both. However, if the attitude representation remains negative following treatment, ROF should be more likely. We tested this hypothesis in a clinical sample of individuals with public speaking phobia using a single-session exposure therapy protocol previously shown to be efficacious but also associated with some ROF. Consistent with predictions, a post-treatment implicit measure of attitudes toward public speaking (the Personalized Implicit Association Test [PIAT]) predicted ROF at 1-month follow-up. These results suggest that change in the automatically activated attitude toward the phobic stimulus is an important goal of exposure therapy and that an implicit measure like the PIAT can provide a useful measure of such change by which to gauge the adequacy of exposure treatment and predict its long-term efficacy.

Highlights

► We applied a social psychological perspective on attitudes to understanding the effects of exposure therapy. ► Attitudes involve automatic and controlled processes and implicit measures tap the former. ► Return of fear (ROF) should be likely when automatically activated attitudes remain negative following treatment. ► As predicted, a Personalized Implicit Association Test following treatment predicted ROF at 1-month follow-up. ► Change in the automatic phobic attitude is an important goal of exposure therapy.

Section snippets

Participants

Participants were 40 adults (60% female) ranging in age from 18 to 46 years (M = 22.4, SD = 5.7). Most members of the sample self-identified as Caucasian (70%), with 17.5% Asian-American, 7.5% Hispanic, and 5% Bi- or Multi-Racial. Based on administration of the Structured Clinical Interview for DSM Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995), all participants met diagnostic criteria at minimum for Social Anxiety Disorder (SAD) in the context of public speaking, with 20% also

Did fear decline significantly following treatment?

Paired t-tests revealed significant improvement from pre- to post-treatment on all measures (Table 1). Most notably, PIAT scores were significantly reduced, indicating a less negative attitude representation following treatment.

Did ROF occur at follow-up?

ROF was assessed at both the average and the individual levels. As shown in Table 1, on average, significant increases from post-treatment to follow-up were seen in anticipatory STAI scores for BAT 2 but not BAT 1. A similar pattern emerged for pre-speech SUDs ratings

Discussion

In this study we sought to advance understanding of the processes underlying the efficacy of exposure therapy and particularly the phenomenon of ROF by drawing on a social psychological view of phobias as attitudes. Specifically, based on the MODE model (Fazio, 1990), we predicted that individuals completing exposure therapy would vary in the degree to which their attitude representation of the phobic situation was successfully modified as a result of the learning opportunities afforded by

Acknowledgments

This research was supported by Grant MH38832 from the National Institute of Mental Health to the first and last authors. The authors thank Dr. Joseph P. DeCola for providing clinical supervision for the study, Deborah Sharp for her assistance with the PIAT, and Andrew Brush, Greg Hilbert, Kaitlyn Fieseler, Marissa Mishne, and Jennifer Varela for their help with speech coding.

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Citation Excerpt :
First, we found emotional concordance patterns during exposure (reduced HR, subjective distress, negative valence, and arousal ratings), but not during spontaneous recovery and fear renewal tests. This may reflect random variation across response indices and is consistent with findings of similar studies (e.g., Craske et al., 2019; Vasey et al., 2012) and with the general fear conditioning literature (e.g., Mertens et al., 2018) in which subjective and physiological responses also substantially varied. One plausible explanation for this variation is that lab studies may not always evoke sufficient fear for full emotional concordance to occur (Hollenstein & Lanteigne, 2014).
Exposure-based therapy is an effective treatment for social anxiety, but some patients relapse. We used a novel virtual reality procedure to examine spontaneous recovery (i.e., a return of fear over time) and fear renewal (i.e., the return of fear after a context switch) in individuals with fear of public speaking. On Day 1, 32 participants received exposure training before a virtual audience. On Day 8, participants completed a spontaneous recovery phase, followed by a fear renewal test, in which they gave a presentation in front of a new (context switch) or the same audience (no context switch). After exposure, participants exhibited a lower heart rate, subjective distress, negative valence, and arousal. One week later, participants showed spontaneous recovery of heart rate, and the context switch group showed renewal of subjective distress, negative valence, and arousal. Future studies can use this procedure to test interventions aimed at improving long-term exposure effects in individuals with public speaking fear.

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Predicting return of fear following exposure therapy with an implicit measure of attitudes

Abstract

Highlights

Section snippets

Participants

Did fear decline significantly following treatment?

Did ROF occur at follow-up?

Discussion

Acknowledgments

Organizational Behavior and Human Decision Processes

Behaviour Research and Therapy

Clinical Psychology Review

Journal of Anxiety Disorders

Behaviour Research and Therapy

Journal of Experimental Social Psychology

Journal of Experimental Social Psychology

Behaviour Research and Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Clinical Psychology Review

Behaviour Research and Therapy

Clinical Psychology Review

Journal of Anxiety Disorders

Clinical Psychology Review

Behavior Therapy

Journal of Behavior Therapy and Experimental Psychiatry

Double dissociation between implicit and explicit personality self-concept: the case of shy behavior

Journal of Personality and Social Psychology

Counteracting the context-dependence of extinction: relapse and tests of some relapse prevention methods

Fear and learning: From basic processes to clinical implications