Exposure therapy augmentation: A review and extension of techniques informed by an inhibitory learning approach

doi:10.1016/j.cpr.2017.10.010

Clinical Psychology Review

Volume 59, February 2018, Pages 41-51

https://doi.org/10.1016/j.cpr.2017.10.010 Get rights and content

Highlights

•
An inhibitory learning approach to exposure has begun to garner empirical support.
•
This framework generates predictions regarding factors that may enhance exposure.
•
Proposed exposure augmentation techniques following from this theory are reviewed.
•
Further strategies to enhance exposure therapy and future directions are discussed.

Abstract

Although exposure therapy is often considered a gold standard behavioral intervention for pathological anxiety, questions remain surrounding the mechanisms underlying exposure interventions, and some individuals are characterized by suboptimal treatment outcomes. Recently, a formulation known as the inhibitory learning theory, which is grounded in basic science principles of extinction learning and memory, has been proposed to provide a more parsimonious mechanistic explanation for the effects of exposure than previous, habituation-based models [Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. 2008. Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27; Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T., & Vervliet, B. 2014. Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23]. Strategies informed by this theory are proposed to maximize extinction learning by fostering the development of new, non-threat associations between stimuli in memory and enhancing the accessibility and retrieval of these safety-based associations. This comprehensive review serves as a critical examination of the empirical literature regarding major tenets of inhibitory learning theory and the potential for such techniques to augment exposure therapy for anxiety disorders. Limitations of the extant research, as well as potential future directions, are explored.

Section snippets

Maximizing mismatches with expectancies

It has long been proposed that the discrepancy between expectancy and outcome is a critical component of extinction learning (Rescorla & Wagner, 1972). Thus, if an individual has particular expectations regarding how often aversive events should occur in terms of duration or frequency, then exposures that clearly violate these expectancies should provide the strongest mismatches (Craske et al., 2008). Unfortunately, no studies of exposure have examined these issues in detail (e.g., by assessing

Increase variability during exposures

The first technique identified by Craske and colleagues (Craske et al., 2008, Craske et al., 2014) to increase retrieval of new, safety-based associations to previously-feared stimuli involves variation in exposure characteristics such as type or number of stimuli, trial duration, and level on the hierarchy (i.e., degree of overall difficulty or intensity). The proposed benefits of this method are derived from memory research showing that variation increases the storage strength of information

Integration and conclusions

Consistent with our evolving understanding of the processes underlying extinction learning, Craske and colleagues' inhibitory learning theory (Craske et al., 2008, Craske et al., 2014) was designed to enhance the efficacy of exposure therapy through a dual focus on developing new, non-threat associations and enhancing the accessibility and retrieval of these newly-learned associations over time and context. Of the exposure augmentation techniques reviewed above, the research literature most