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Cited by 161Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesPosttraumatic Stress Disorder ResearchPsychotherapy Techniques and Applications

Does habituation matter? Emotional processing theory and exposure therapy for acrophobia

Open access
Baker, Aaron, Mystkowski, Jayson, Culver, Najwa, Yi, Rena, Mortazavi, Arezou, Craske, Michelle G.·2010·Behaviour Research and Therapy
DOI 10.1016/j.brat.2010.07.009PMC PMC2956764
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Abstract

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.

Integrity signals

Registry

Crossref · 10.1016/j.brat.2010.07.009

Cites

21 of 21 references verified0 citation errors · 0 not checkable

Statistics

3 tests recomputed · 0 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

2 of 16 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Findingown data

    Participants did not show significant decreases in average heart rate during BAT.

    “Though participants did not show significant decreases in average heart rate during the BAT (F (1,2) < 1, p = .58).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
  • Findingown data

    No relationship was found between WSH and BSH.

    “In addition, no relationship was found between WSH and BSH.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.
  • Findingown data

    WSH did not significantly predict any outcome change measure from baseline to immediate or baseline to post.

    “Again, neither HR-WSH nor SUDS-WSH significantly predicted any outcome change measure, in either baseline-immediate or baseline-post.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.
    • Rests on an assumption: The operationalization of IFA, WSH, and BSH using peak or quartile differences in HR and SUDS adequately captures the theoretical constructs.
  • Findingown data

    IFA did not significantly predict any outcome change measure from baseline to immediate or baseline to post.

    “Neither SUDS-IFA nor HR-IFA significantly predicted any outcome change measure, across baseline-immediate or baseline-post.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.
    • Rests on an assumption: The operationalization of IFA, WSH, and BSH using peak or quartile differences in HR and SUDS adequately captures the theoretical constructs.
  • Findingown data

    In this study, no EPT variable consistently predicted treatment outcome.

    “Results indicated that no EPT variables were consistently predictive of treatment outcome.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.
    • Rests on an assumption: The operationalization of IFA, WSH, and BSH using peak or quartile differences in HR and SUDS adequately captures the theoretical constructs.
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 11

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    BSH is purported to form the basis for long-term learning and to be mediated by changes in the meaning proposition, including lowered probability of harm and lessened negativity.

    “BSH is purported to form the basis for long term learning, and to be mediated by changes in the meaning proposition, in the form of lowered probability of harm (i.e., risk) and lessened negativity (i.e., valence) of the stimulus.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Foa & Kozak, 1986 source
      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    WSH is considered a necessary prerequisite for BSH.

    “WSH is considered a necessary pre-requisite for the second piece of incompatible information, which derives from between-session habituation (BSH) over repeated occasions of exposure.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Foa & Kozak, 1986 source
      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    SUDS-BSH predicted change in AQ scores from baseline to immediate but not from baseline to post.

    “SUDS-BSH predicted change in AQ scores from baseline to immediate (ΔR2 = .151, p = .009), but not from baseline to post (ΔR2 = .039, p = .199).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • May combine two claims.

    Findingown data

    HR-BSH predicted change in HR during BAT from baseline to immediate but not from baseline to post.

    “HR-BSH predicted change in HR during BAT from baseline to immediate (ΔR2 = .307, p = .000), but not baseline to post (ΔR2 = .001, p = .854).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    SUDS-IFA correlated significantly with SUDS-WSH.

    “SUDS-IFA correlated significantly with SUDS-WSH (r = .528, p =.000).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    HR-IFA correlated significantly with HR-WSH.

    “HR-IFA correlated significantly with HR-WSH (r = .462, p =.003)”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • May combine two claims.

    Findingown data

    SUDS-BSH predicted change in SUDS-maximum during BAT from baseline to immediate and from baseline to post.

    “SUDS-BSH predicted change in SUDS-maximum during BAT from baseline to immediate (ΔR2 = .273, p = .000) and from baseline to post (ΔR2 = .187, p = .002).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Mean AQ fear score was 62.63 (SD 13.33), comparable to a clinical sample.

    “The mean acrophobia fear score on the AQ was 62.63 (SD = 13.33) (maximum score = 120), which is comparable to a clinical sample (61.30, SD = 15.85; Cohen, 1977).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Cohen, 1977 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    The treatment was effective overall: participants showed significant change in AQ and SUDS during BAT.

    “Overall the treatment was found to be effective, with participants showing significant change in the subjective outcome variables of AQ (F (1,2) = 62.32, p <.001) and SUDS during the BAT (F (1,2) = 64.46, p <.001).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Average exposure duration across both sessions was 21.27 minutes (SD 17.25).

    “The average exposure duration across both sessions was 21.27 minutes (SD = 17.25), though there was a large range in total exposure time, so it was used as a covariate in all analyses.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    EPT holds that exposure therapy is most effective when fear is activated during exposure.

    “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).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Foa & Kozak, 1986 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    A fear structure is a memory-stored set of propositions about a stimulus, response, and their meaning.

    “A ‘fear structure’, as first put forth by Lang (1971), is a set of propositions about a stimulus (e.g., spider), response (e.g., racing heart) and their meaning (e.g., “I will be poisoned”) that are stored in memory.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Lang, 1971

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    EPT posits that exposure therapy works by activating a fear structure and integrating incompatible information, producing a non-fear structure that replaces or competes with the original.

    “EPT purports that the effects of exposure therapy derive from activation of a ‘fear structure’ and integration of information that is incompatible with it, resulting in the development of a non-fear structure that replaces (Foa & Kozak, 1986) or competes with (Foa & McNally, 1996) the original one.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Foa & Kozak, 1986 source

      Not checked in the free run.

    • cites Foa & McNally, 1996

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    EPT holds that exposure therapy is most effective when fear subsides within sessions.

    “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).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Foa & Kozak, 1986 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    EPT holds that exposure therapy is most effective when fear subsides between sessions.

    “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).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Foa & Kozak, 1986 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    These results raise serious doubts about WSH as a mechanism of change, and while BSH may have limited immediate effects, other factors are more important for long-term exposure outcomes.

    “These results raise serious doubts about the role of within-session habituation as a mechanism of change, and while between-session habituation may have some limited effects immediately, there appear to be other more important factors that play into long-term results of exposure therapy.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.
    • Rests on an assumption: SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.
    • Rests on an assumption: The operationalization of IFA, WSH, and BSH using peak or quartile differences in HR and SUDS adequately captures the theoretical constructs.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Differential autonomic conditioning is strongly associated with verbal measures of contingency knowledge.

    “Differential autonomic conditioning in particular is strongly associated with verbal measures of contingency knowledge (e.g., Purkis & Lipp, 2001).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Purkis & Lipp, 2001

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Extinction is posited to follow from a mismatch between expectancy of an aversive event and its absence, or from perception of negative change in rate of aversive events associated with CS.

    “Expectancies also are important for extinction; extinction is posited to follow from a mismatch between the expectancy of an aversive event and the absence of its occurrence (Rescorla & Wagner, 1972), or from the perception of a negative change in the rate at which aversive events are associated with the CS (Gallistel & Gibbon, 2000).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Rescorla & Wagner, 1972

      Not checked in the free run.

    • cites Gallistel & Gibbon, 2000

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The lack of relationship between WSH and BSH is problematic for EPT because WSH is presumed necessary for BSH.

    “This is especially problematic for EPT, as WSH is presumed to be a necessary prerequisite for BSH.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Contingency awareness is a strong correlate of conditioned responding.

    “For example, contingency awareness (i.e., knowledge that a specific CS predicts a US), although of debatable necessity for conditioned responding (e.g., Lovibond & Shanks, 2002, versus Ohman & Mineka, 2001) is a strong correlate of conditioned responding.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Lovibond & Shanks, 2002

      Not checked in the free run.

    • cites Ohman & Mineka, 2001 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    These data suggest that continuous CS durations during extinction exceeding acquisition CS length induce extinction by violating temporal expectancy of US, and once induced, extinction learning is best consolidated with spaced training.

    “These data have been interpreted to suggest that durations of a continuous CS presentation during extinction that exceed the length of the CS during acquisition induces extinction learning most effectively by violating the temporal expectancy of the US, and that once induced, extinction learning is best consolidated with spaced training.”
    Quote in the paperSubstantial claim
21 of 21

  • The paper relies on this without support.

    Heart rate is a valid index of fear responding during exposure and the behavioral avoidance test.

    “Heart rate data were collected continuously throughout the 2-minute anticipatory phase and the BAT using a Polar Vantage NV that provides wireless heart-rate monitoring with ECG-accurate continuous measurement, sampling once every five seconds.”

  • The paper relies on this without support.

    SUDS ratings are a valid measure of subjective fear during exposure and the behavioral avoidance test.

    “Subjective Units of Distress (SUDS; 0–100) and self efficacy (0–100) (confidence in being able to complete the task successfully) were each rated after a 2-minute anticipatory period and before initiating the BAT.”

  • The paper relies on this without support.

    The operationalization of IFA, WSH, and BSH using peak or quartile differences in HR and SUDS adequately captures the theoretical constructs.

    “IFA was operationalized as the peak in HR or SUDS score in the first quartile, or minute whichever was longer, of the first exposure session.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Other studies have found no effect of within-session or between-session distress reduction on anxiety changes after exposure therapy.

    “Other studies have demonstrated no effect of within- or between-session distress reduction on changes in anxiety following exposure therapy (Baker et al., 2010; Peterman et al., 2019).”

    From Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders (2024) · cites this paper as Baker et al., 2010

    The Discussion reports no relationship between within-session habituation and treatment outcomes. But the Results report that between-session reductions in distress predicted some anxiety improvements, including changes measured immediately after exposure, although the findings were inconsistent at the later assessment. The claim's unqualified 'no effect' for between-session distress reduction is therefore not supported. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

  • There is considerable debate over whether between-session habituation is necessary in exposure therapy.

    “Recently, there has been considerable debate over the necessity of between-session habituation in individuals undergoing exposure therapy (Baker et al., 2010; Craske et al., 2008).”

    From Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD (2014) · cites this paper as Baker et al., 2010

  • In VRET, presence is likely a moderator of intervention effects; an adequate sense of presence could arguably be considered a prerequisite for evoking a fear response that can then be attenuated through the same mechanisms as in traditional exposure therapy.

    “In VRET, presence is likely a moderator of intervention effects: an adequate sense of presence could arguably be considered a prerequisite for evoking a fear response that can then be attenuated through the same mechanisms as in traditional exposure therapy [37].”

    From Experiences of gamified and automated virtual reality exposure therapy for spider phobia: qualitative study (2020) · cites this paper as [37]

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value: F (1,2) = 64.46, p < .001

    Minor

    The paper reports p < .001 here; recomputing from the test statistic and its degrees of freedom gives p = .015. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p < .001 · recomputed p = .015

  • Inconsistent p-value: F (1,2) = 62.32, p < .001

    Minor

    The paper reports p < .001 here; recomputing from the test statistic and its degrees of freedom gives p = .016. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p < .001 · recomputed p = .016

2 of 2

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upF(1, 2) = 62.32reported p < .001 · recomputed p = .016

    “F (1,2) = 62.32, p < .001”

  • Doesn’t add upF(1, 2) = 64.46reported p < .001 · recomputed p = .015

    “F (1,2) = 64.46, p < .001”

  • ConsistentF(1, 2) < 1reported p = .58 · recomputed p = .423

    “F (1,2) < 1, p = .58”

3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract denies relationships that the results report

    Minor

    The abstract says the EPT variables are not related to one another, but the results report significant correlations between initial fear activation and within-session habituation for both heart rate and distress ratings.

1 of 1

Cites

Flagged first, then by citations

2 of the 23 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G.
Affiliations
  • University of California, Los Angeles (US)
  • Claremont Graduate University (US)
Corresponding author
Baker, Aaron
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2010-11
Volume
48
Issue
11
Pages
1139-1143
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2010.07.009
PMC
PMC2956764
OpenAlex
W2093146307
Cited by
161
References
23
Citations by year
2026: 9 · 2025: 11 · 2024: 11 · 2023: 9 · 2022: 17 · 2021: 10 · 2020: 12 · 2019: 13 · 2018: 12 · 2017: 13 · 2016: 10 · 2015: 10 · 2014: 8 · 2013: 4 · 2012: 6
FWCI
5.77
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Behaviour Research and Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (R21MH072259)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
emotional processing theory, exposure therapy, acrophobia, fear extinction, in vivo exposure, treatment outcome prediction
MeSH terms
Adolescent, Desensitization, Psychologic, Emotions, Female, Habituation, Psychophysiologic, Humans, Implosive Therapy, Male, Phobic Disorders, Surveys and Questionnaires, Severity of Illness Index, Treatment Outcome, Young Adult

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

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