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Maximizing exposure therapy: An inhibitory learning approach
Open accessAbstract
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.
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“According to this rationale, both unlearning old catastrophic interpretations and learning a wide range of new associations form the key to therapeutic change.”
From Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive–compulsive disorder: a study protocol for a randomized controlled trial (2024) · cites this paper as [24]
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In the citing paper
“However, the mechanisms of change in exposure therapy are still not well understood, especially in exposure therapy for EDs”
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 Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Emotional states are strong retrieval cues, and variation in fear may increase the salience of the association between a previously feared object or situation and a lack of extreme negative consequences (Bjork & Bjork, 1992, 2006; Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Variability in the exposure hierarchy may also enhance expectancy violation, which is proposed to maximize exposure therapy outcomes (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Instead of starting exposure with the premise of random progression through the exposure hierarchy, variability might be introduced after a few graded exposures of lower difficulty once the client has gained confidence in his or her ability to stay in the distressing situation (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
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In the citing paper
“SUDS are not typically part of the inhibitory learning model, as there is no emphasis on habituation (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“While the precise mechanisms supporting novelty-facilitated extinction remain unclear, the strategic incorporation of novelty into extinction may leverage effects of surprise that are central to inhibitory learning (1,3).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Exposure is hypothesized to be effective when the new association becomes stronger than the old association.”
From Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive–compulsive disorder: a study protocol for a randomized controlled trial (2024) · cites this paper as [24]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Furthermore, the meta-analyses primarily used data from same-day or next-day uninstructed threat extinction training with only one session, limiting the generalizability of the results to real-world exposure-based therapies (i.e., which typically involve instructions about assessing the likelihood of aversive events and often comprise more than one session) (8).”
From I Doubt It Is Safe: A Meta-analysis of Self-reported Intolerance of Uncertainty and Threat Extinction Training (2021) · cites this paper as [8]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“To this end, it is important to detect patients’ specific expectancies and to record the belief in these expectancies before exposure starts. This technique can help to reduce catastrophic thinking (Craske et al., 2014; Schyns et al., 2016; Schyns, Roefs, et al., 2018; Schyns, van den Akker, Roefs, Hilberath & Jansen, 2018).”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“One of the main strengths of the current study is that the treatment intervention (behavioral experiments) and treatment target (intolerance of uncertainty) are solidly grounded in the anxiety disorders literature.”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“This exposure generates new learning of safety-based associations that inhibit former fear response associations to the feared stimulus [77, 78, 118], thereby either extinguishing the fear response or enabling a level of fear tolerance that reduces anxious distress.”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Two factors are generally considered unique to CBT, “exposure” and “coping efficacy”, or skill building [77, 78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“These findings add to the growing literature suggesting that, instead, change can occur during exposure therapy without within-session reduction in distress via inhibitory learning processes (Craske et al., 2014; Essayli et al., 2023).”
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 Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“The inhibitory learning model is applicable to a wide spectrum of anxiety content.”
From Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic (2022) · cites this paper as Craske et al., 2014
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In the citing paper
“The degree to which these exposures more closely replicate the avoided experience (e.g., provoking a strong sensation) and create an expectancy violation (i.e., helping the individual to learn that outcomes differ from expectations), the more effective the interoceptive exposure.”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske et al., 2014
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In the citing paper
“One hypothesis whereby interoceptive exposure treatments exert their influence is via inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
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In the citing paper
“According to this model, exposures that intentionally provoke interoceptive sensations should be designed to disconfirm underlying expectancies of negative outcomes (e.g., I can’t handle pain; Craske et al., 2014).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Context and stimulus variability appear to be key in the generalization of learning, which allows clients to apply what they have learned to new contexts and new stimuli that were not encountered during exposure therapy (Craske et al., 2014; Kircanski et al., 2012).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Increasing variability is one potential modification to the delivery of exposure therapy that could maximize inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
The cited source says what the claim attributes to it.
In the citing paper
“For example, exposure therapy works to lessen negative affect through a mechanism principal to the defensive system – fear extinction (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Examining Positive and Negative Affect as Outcomes and Moderators of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy for Social Anxiety Disorder. (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
The cited source says what the claim attributes to it.
In the citing paper
“Difficulty learning about safety via extinction can arise in anxiety disorders and following trauma, and principles of extinction form the basis of exposure-based therapies (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Difficulty learning about safety via extinction can arise in anxiety disorders and following trauma, and principles of extinction form the basis of exposure-based therapies (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Instead, exposure therapy may be best optimized through strategies that enhance inhibitory learning, such as expectancy violation and variability in exposure (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Importantly, conceptualizations of the mechanisms supporting the effects of exposure therapy have increasingly shifted to emphasize inhibitory learning.”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“While habituation likely plays a role in extinction and while fear often decreases over the course of an exposure, the extent to which fear declines does not predict clinical outcomes (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Several studies have shown that learning is context-dependent and that exposure in multiple contexts appears to counteract a return of fear [6, 24].”
The cited source says what the claim attributes to it.
In the citing paper
“A promising intervention that aims at breaking such self-reinforcing circles of anxiety and safety behaviours is exposure therapy [30, 33, 34].”
From Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa (2024) · cites this paper as [30]
The cited source says what the claim attributes to it.
In the citing paper
“Recent research suggests that exposure therapy should be based on inhibitory learning principles, such as expectancy violation [30, 45].”
From Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa (2024) · cites this paper as [30]
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In the citing paper
“behavioral experiments, which require clients to formulate specific predictions and to compare their predictions to actual outcomes following an exposure-type situation, are directly in line with contemporary learning theories of fear reduction (e.g., Craske et al., 2014).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“IU-CBT is also influenced by current approaches to exposure that are based on findings that habituation within and between sessions is not necessary in order to achieve functional improvement (Craske et al., 2008;Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014;Jacoby & Abramowitz, 2016).”
From Intolerance of Uncertainty–Focused Treatment for Adolescents With Excessive Worry: A Pilot Feasibility Study (2020) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“These studies are in line with the work carried out by Craske et al. [81], focused on optimizing exposure therapy based on the inhibitory learning approach, because VR/AR can maximize some strategies reported by Craske.”
From In Vivo versus augmented reality exposure in the treatment of small animal phobia: A randomized controlled trial (2016) · cites this paper as Craske et al. [81]
The cited source says what the claim attributes to it.
In the citing paper
“Consolidation of this “safety” learning is essential for the success of exposure therapy (Craske et al., 2014).”
From Using sleep to enhance exposure treatment for anxious children: A pilot study. (2026) · cites this paper as Craske et al., 2014
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In the citing paper
“Within an inhibitory learning framework of understanding (Craske et al., 2014), the new learning of safety will constrain and dampen the old learning that others intend harm.”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Exposure therapy, which involves repeatedly exposing oneself to stimuli that cause fear, is an integral part of cognitive behavioral therapy for anxiety disorders (Craske et al., 2014).”
From Speaking face-to-face with a virtual avatar to reduce anxiety in students who stutter: Tool development and pilot study results. (2026) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Craske, Treanor, Conway, Zbozinek, and Vervliet (2014) suggest that exposure therapy works through inhibitory learning, indicating that expectancy violation (and not fear decrease) should be its main objective.”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Whereas some presentations of ARFID are clearly anxiety‐driven (e.g., specific phobia of choking/vomiting), and appear to suit Craske's et al. (Craske et al., 2014) theory quite well, not all presentations appear to be primarily characterized by anxiety.”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Nowadays it is believed that exposure in vivo sets off a process of inhibition in which the association of the conditioned stimulus (CS) (social situations) and the feared unconditioned stimulus (US) (humiliation) is inhibited by the forming of new associations around the CS, of which the association with ‘no-US’ (no rejection) is probably the most important [34].”
The cited source says what the claim attributes to it.
In the citing paper
“behavioral experiments, which require clients to formulate specific predictions and to compare their predictions to actual outcomes following an exposure-type situation, are directly in line with contemporary learning theories of fear reduction (e.g., Craske et al., 2014).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Tolerance of exposure, with inhibition of an associated avoidance response, is considered the key element in the cognitive behavioral therapy of anxiety disorders [77, 78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
The cited source says what the claim attributes to it.
In the citing paper
“Practicing these skills in different fear-inducing contexts supports generalization of inhibitory learning and stronger extinction of fear responses [78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
In the citing paper
“CBT, focusing on exposure to feared cues to promote extinction learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014), continues to be the most widely used and most strongly validated psychotherapeutic treatment for both youth and adult anxiety disorders (Barry, Yeung, & Lau, 2018;Kodal et al., 2018).”
From Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
In the citing paper
“Existing interventions for anxiety and depression emphasize negative affect reduction as the central treatment goal.”
From Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention: Taylor et al. (2017) · cites this paper as [17]
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Learning to Let Go: A Cognitive-Behavioral Model of How Psychedelic Therapy Promotes Acceptance
Wolff, M., Evens, R., Mertens, L. J., Koslowski, M., Betzler, F., Gründer, G., & Jungaberle, H. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00005 · Cited by 205
“It is well established that extinction learning in exposure treatments is most effective when negative expectancies regarding the outcomes of exposure are maximally violated (33).”
BackgroundLindner, P., Miloff, A., Hamilton, W., Reuterskiöld, L., Andersson, G., Powers, M. B., & Carlbring, P. (2017) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2017.1280843 · Cited by 187
“…varying the stimuli (e.g. having many different spiders) and context (e.g. a virtual living room, shed, outdoors etc.) has been shown to improve generalizability of extinction learning, decreasing the risk of return of fear outside the therapy session (Craske et al., 2014; Vervliet et al., 2013).”
BackgroundOptimizing exposure therapy with an inhibitory retrieval approach and the OptEx Nexus
Craske, M. G., Treanor, M., Zbozinek, T. D., & Vervliet, B. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2022.104069 · Cited by 195
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“To fully decontextualize inhibitory associations, however, exposure variations should eventually be completed without safety behaviors (Craske et al., 2014; Rachman et al., 2008).”
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“Clinical applications could include augmenting exposure therapy to increase surprise using novel but unremarkable outcomes, in line with clinical models that highlight the critical role for belief disconfirmation for the success of exposure treatments (46, 47).”
Fear in the context of pain: Lessons learned from 100 years of fear conditioning research
Meulders, A. (2020) · Behaviour Research and Therapy · doi:10.1016/j.brat.2020.103635 · Cited by 191
Lindner, P., Miloff, A., Fagernäs, S., Andersen, J., Sigeman, M., Andersson, G., Furmark, T., & Carlbring, P. (2019) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2018.07.003 · Cited by 175
Memory editing from science fiction to clinical practice
Phelps, E. A., & Hofmann, S. G. (2019) · Nature · doi:10.1038/s41586-019-1433-7 · Cited by 170
An enactive approach to pain: beyond the biopsychosocial model
Stilwell, P., & Harman, K. (2019) · Phenomenology and the Cognitive Sciences · doi:10.1007/s11097-019-09624-7 · Cited by 195
Hebert, E. A., & Dugas, M. J. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.07.007 · Cited by 165
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“10 In two previous studies in patients with psychosis, therapists have successfully conducted behavioural experiments using VR simulations of anxiety-provoking situations to reduce fears.”
The Hierarchical Taxonomy of Psychopathology (HiTOP) in psychiatric practice and research
Kotov, R., Cicero, D. C., Conway, C., DeYoung, C. G., Dombrovski, A. Y., Eaton, N. R., First, M. B., Forbes, M. K., Hyman, S. E., Jonas, K. G., et al. (2022) · Psychological Medicine · doi:10.1017/s0033291722001301 · Cited by 179
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Embodiment in Virtual Reality Intensifies Emotional Responses to Virtual Stimuli
Gall, D., Roth, D., Stauffert, J.-P., Zarges, J., & Latoschik, M. E. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.674179 · Cited by 185
“This hypothesis is consistent with the theory of depersonalization, a body function that decreases intense emotional reactions in highly threatening situations (Simeon et al., 2000; Sierra and David, 2011; Dewe et al., 2016, 2018).”
ResultA complex systems approach to the study of change in psychotherapy
Hayes, A. M., & Andrews, L. A. (2020) · BMC Medicine · doi:10.1186/s12916-020-01662-2 · Cited by 149
Monfils, M., & Holmes, E. A. (2018) · The Lancet Psychiatry · doi:10.1016/s2215-0366(18)30270-0 · Cited by 150
Pittig, A., Wong, A. H. K., Glück, V. M., & Boschet, J. M. (2020) · Behaviour Research and Therapy · doi:10.1016/j.brat.2020.103550 · Cited by 148
Behavioral Conceptualization and Treatment of Chronic Pain
Vlaeyen, J. W. S., & Crombez, G. (2019) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-050718-095744 · Cited by 158
Exposure therapy for eating disorders: A systematic review
Butler, R. M., & Heimberg, R. G. (2020) · Clinical Psychology Review · doi:10.1016/j.cpr.2020.101851 · Cited by 143
Shiban, Y., Schelhorn, I., Pauli, P., & Mühlberger, A. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.05.014 · Cited by 141
Miloff, A., Lindner, P., Hamilton, W., Reuterskiöld, L., Andersson, G., & Carlbring, P. (2016) · Trials · doi:10.1186/s13063-016-1171-1 · Cited by 141
“Recent evidence indicates that treatment benefits of exposure therapy accrue as a result of new inhibitory learning and not habituation of the conditioned response to phobic stimuli [55].”
BackgroundPractitioner Review: Anxiety disorders in children and young people – assessment and treatment
Creswell, C., Waite, P., & Hudson, J. (2020) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.13186 · Cited by 140
The role of attention control in complex real-world tasks
Draheim, C., Pak, R., Draheim, A. A., & Engle, R. W. (2022) · Psychonomic Bulletin & Review · doi:10.3758/s13423-021-02052-2 · Cited by 172
Thabrew, H., Stasiak, K., Hetrick, S. E., Wong, S., Huss, J. H., & Merry, S. N. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012489.pub2 · Cited by 141
“[DOI: 10.1002/14651858.CD008324.pub3] Craske 2014 Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B. Maximizing exposure therapy: an inhibitory learning approach.”
InfluentialExposure and response prevention for obsessive-compulsive disorder: A review and new directions
Simpson, H., & Hezel, D. (2019) · Indian Journal of Psychiatry · doi:10.4103/psychiatry.indianjpsychiatry_516_18 · Cited by 161
“Craske et al.[39] have proposed a number of ways to enhance extinction learning based on the aforementioned inhibitory learning perspective.”
BackgroundInfluentialChu, B. C., Crocco, S. T., Esseling, P. G., Areizaga, M. J., Lindner, A. M., & Skriner, L. C. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.11.005 · Cited by 138
“The mechanism by which exposures work is hotly contested (Craske et al., 2014; Foa & Mcnally, 1996), but exposures might best be seen as a context in which a therapist can enact multiple behavioral principles (e.g., extinction, differential reinforcement, shaping) to encourage new…”
BackgroundScheveneels, S., Boddez, Y., Vervliet, B., & Hermans, D. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.015 · Cited by 152
Self-citationvan Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., Lee, C. W., van Minnen, A., & de Jongh, A. (2018) · European Journal of Psychotraumatology · doi:10.1080/20008198.2018.1487225 · Cited by 146
An empirical review of potential mediators and mechanisms of prolonged exposure therapy
Cooper, A. A., Clifton, E. G., & Feeny, N. C. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.07.003 · Cited by 133
“For instance, animal research on fear inhibition can yield concrete, testable strategies to enhance impact of individual exposures (Craske et al., 2014).”
BackgroundInfluentialSchaumberg, K., Reilly, E. E., Gorrell, S., Levinson, C. A., Farrell, N. R., Brown, T. A., Smith, K. M., Schaefer, L. M., Essayli, J. H., Haynos, A. F., et al. (2021) · Clinical Psychology Review · doi:10.1016/j.cpr.2020.101952 · Cited by 121
“As etiological and treatment models of ADs have evolved in recent years (L. A. Brown et al., 2017; Craske et al., 2014; Craske et al., 2018), the time is ripe to reevaluate the conceptual overlap between anxiety and EDs, incorporating updated literature.”
BackgroundResultInfluentialWeisman, J. S., & Rodebaugh, T. L. (2018) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.10.010 · Cited by 143
Botella, C., Pérez-Ara, M. Á., Bretón-López, J., Quero, S., García-Palacios, A., & Baños, R. M. (2016) · PLoS ONE · doi:10.1371/journal.pone.0148237 · Cited by 124
“These studies are in line with the work carried out by Craske et al. [81], focused PLOS ONE | DOI:10.1371/journal.pone.0148237 February 17, 2016 16 / 22 on optimizing exposure therapy based on the inhibitory learning approach, because VR/AR can maximize some strategies reported by Craske.”
BackgroundInfluentialOrigins and outlook of interoceptive exposure
Boettcher, H., Brake, C. A., & Barlow, D. H. (2016) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2015.10.009 · Cited by 124
“…patients was establishing the utility of exposure to feared situational stimuli (e.g., tunnels, animals, water; Sherman, 1972), now understood to weaken the fear response by enabling new learning that competes with initial, fearful associations (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
BackgroundThe key role of extinction learning in anxiety disorders
Pittig, A., van den Berg, L., & Vervliet, B. (2015) · Current Opinion in Psychiatry · doi:10.1097/yco.0000000000000220 · Cited by 132
“Spanish translation of clinical case formulations and research findings for different behavioral strategies was adapted from [69].”
Self-citationCraske, M. (2015) · Verhaltenstherapie · doi:10.1159/000381574 · Cited by 124
Self-citationMcGovern, R. A., & Sheth, S. A. (2017) · Journal of Neurosurgery · doi:10.3171/2016.1.jns15601 · Cited by 117
Idiopathic Environmental Intolerance: A Comprehensive Model
Van den Bergh, O., Brown, R. J., Petersen, S., & Witthöft, M. (2017) · Clinical Psychological Science · doi:10.1177/2167702617693327 · Cited by 121
Hendriks, L., Kleine, R. A. D., Broekman, T. G., Hendriks, G.-J., & Minnen, A. V. (2018) · European Journal of Psychotraumatology · doi:10.1080/20008198.2018.1425574 · Cited by 121
Transdiagnostic dimensions of anxiety: Neural mechanisms, executive functions, and new directions
Sharp, P. B., Miller, G. A., & Heller, W. (2015) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2015.07.001 · Cited by 140
“Habituation to fearful stimuli is a key aspect of exposure therapy (e.g., Craske et al., 2014; Foa and Kozak, 1986; Fanselow and Sterlace, 2014), an empirically-supported and efficacious treatment for many anxiety disorders.”
BackgroundMeyer, H. C., Odriozola, P., Cohodes, E. M., Mandell, J. D., Li, A., Yang, R., Hall, B. S., Haberman, J. T., Zacharek, S. J., Liston, C. M., et al. (2019) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1910481116 · Cited by 121
Attenuating Neural Threat Expression with Imagination
Reddan, M. C., Wager, T. D., & Schiller, D. (2018) · Neuron · doi:10.1016/j.neuron.2018.10.047 · Cited by 110
Olatunji, B. O., Armstrong, T., & Elwood, L. S. (2017) · Perspectives on Psychological Science · doi:10.1177/1745691616688879 · Cited by 119
Kindt, M., & van Emmerik, A. (2016) · Therapeutic Advances in Psychopharmacology · doi:10.1177/2045125316644541 · Cited by 107
“Although the memory reactivation seems procedurally similar to imaginal exposure, including a violation of threat expectation [Craske et al. 2014], it should be much shorter than traditional exposure techniques in order to prevent the formation of a new inhibitory memory [Bos et al.”
BackgroundCatastrophic Thinking: A Transdiagnostic Process Across Psychiatric Disorders
Gellatly, R., & Beck, A. T. (2016) · Cognitive Therapy and Research · doi:10.1007/s10608-016-9763-3 · Cited by 128
“By utilizing exposures that maximally violate the client’s expectancies about aversive outcomes, deeper inhibitory learning takes place, facilitating memory consolidation (Craske et al. 2014).”
BackgroundMorriss, J., Zuj, D. V., & Mertens, G. (2021) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2021.05.011 · Cited by 116
“…behaviours are a natural response to threat, however maladaptive avoidance is considered a significant barrier to effective treatment by preserving conditioned threat relationships before, during, and after prolonged exposure-based therapies (Craske et al., 2014; Dymond, 2019; Pittig et al., 2018).”
BackgroundGujjar, K. R., van Wijk, A., Kumar, R., & de Jongh, A. (2019) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2018.12.001 · Cited by 111
Resilience training that can change the brain.
Tabibnia, G., & Radecki, D. (2018) · Consulting psychology journal · doi:10.1037/cpb0000110 · Cited by 124
The impact of social skills training for social anxiety disorder: A randomized controlled trial
Beidel, D. C., Alfano, C. A., Kofler, M. J., Rao, P. A., Scharfstein, L. A., & Sarver, N. W. (2014) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2014.09.016 · Cited by 118
Translating Across Circuits and Genetics Toward Progress in Fear- and Anxiety-Related Disorders
Ressler, K. J. (2020) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2020.20010055 · Cited by 104
“Such preclinical work has recently influenced novel approaches to behavioral exposure therapy as well, by actively bringing reward systems online at the culmination of threat exposures, which appears to enhance the efficacy of extinction and exposure for anxiety- and fear-related disorders (104, 105).”
BackgroundPhobia Exposure Therapy Using Virtual and Augmented Reality: A Systematic Review
Albakri, G., Bouaziz, R., Alharthi, W. J., Kammoun, S., Al-Sarem, M., Saeed, F., & Hadwan, M. (2022) · Applied Sciences · doi:10.3390/app12031672 · Cited by 113
“Exposure takes various forms, including graduated versus intense (or flooding therapy), brief versus prolonged, with and without various cognitive and somatic coping strategies, and imaginal, interceptive, or in vivo (or in real life) [20].”
BackgroundBurton, C. L., Wang, K., & Pachankis, J. E. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.05.001 · Cited by 105
Role of Human Ventromedial Prefrontal Cortex in Learning and Recall of Enhanced Extinction
Dunsmoor, J. E., Kroes, M. C. W., Li, J., Daw, N. D., Simpson, H. B., & Phelps, E. A. (2019) · Journal of Neuroscience · doi:10.1523/jneurosci.2713-18.2019 · Cited by 110
“…form the basis for exposure therapy (Foa and Kozak, 1986; Milad and Quirk, 2012; Vervliet et al., 2013; Ball et al., 2017), there is motivation to develop behavioral strategies that more effectively prevent the relapse of maladaptive behavior (Craske et al., 2008, 2014; Dunsmoor et al., 2015a).”
BackgroundFactors influencing the success of exposure therapy for specific phobia: a systematic review
Böhnlein, J., Altegoer, L., Muck, N. K., Roesmann, K., Redlich, R., Dannlowski, U., & Leehr, E. J. (2020) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2019.12.009 · Cited by 98
Jansen, A. T. M., Voorwinde, V., Hoebink, Y., Rekkers, M. E., Martijn, C., & Mulkens, S. (2015) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2015.06.002 · Cited by 104
The validity of human avoidance paradigms.
Krypotos, A.-M., Vervliet, B., & Engelhard, I. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.10.011 · Cited by 95
Self-citationAn affective neuroscience model of boosting resilience in adults
Tabibnia, G. (2020) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2020.05.005 · Cited by 115
Pittig, A., Heinig, I., Goerigk, S. A., Richter, J., Hollandt, M., Lueken, U., Pauli, P., Deckert, J., Kircher, T. T. J., Straube, B., et al. (2022) · Clinical Psychological Science · doi:10.1177/21677026221101379 · Cited by 105
“In line with previous research, absolute EV was calculated as the average mismatch between threat expectancy and threat occurrence (i.e., threat expectancy – threat occurrence averaged across exposure exercises of an individual patient; Craske et al., 2014; de Kleine et al., 2017).”
BackgroundResultInfluentialSelf-citationA behavioural neuroscience perspective on the aetiology and treatment of anxiety disorders
Kindt, M. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.08.012 · Cited by 103
Gloster, A. T., Klotsche, J., Ciarrochi, J., Eifert, G., Sonntag, R., Wittchen, H.-U., & Hoyer, J. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.01.013 · Cited by 101
Rodent models of impaired fear extinction
Singewald, N., & Holmes, A. (2018) · Psychopharmacology · doi:10.1007/s00213-018-5054-x · Cited by 110
“build fear inhibitory associations can explain the high rates of fear relapse in anxiety disorder patients (Craske et al. 2014).”
BackgroundDumont, E., Jansen, A., Kroes, D., de Haan, E., & Mulkens, S. (2019) · International Journal of Eating Disorders · doi:10.1002/eat.23053 · Cited by 98
Behavioral and neural processes in counterconditioning: Past and future directions
Keller, N. E., Hennings, A. C., & Dunsmoor, J. E. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103532 · Cited by 104
“Likewise, in real world scenarios the absence of a feared outcome is oftentimes insufficient to disconfirm threat expectancy, nor do encounters with a phobic stimulus itself constitute effective exposure treatment (Craske et al., 2014).”
BackgroundAvoidance behavior in chronic pain research: a cold case revisited
Volders, S., Boddez, Y., De Peuter, S., Meulders, A., & Vlaeyen, J. W. S. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.11.003 · Cited by 97
Gillett, C. B., Bilek, E. L., Hanna, G. L., & Fitzgerald, K. D. (2018) · Clinical Psychology Review · doi:10.1016/j.cpr.2018.01.007 · Cited by 99
Exposure therapy for obsessive-compulsive disorder: an optimizing inhibitory learning approach
Arch, J. J., & Abramowitz, J. S. (2015) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2014.12.002 · Cited by 96
“However, OCD along with most other anxiety disorders can be explained by fear conditioning models (see Craske et al. (2014)).”
Enkema, M. C., McClain, L., Bird, E. R., Halvorson, M. A., & Larimer, M. E. (2020) · Mindfulness · doi:10.1007/s12671-020-01442-2 · Cited by 97
Norrholm, S. D., Jovanović, T., Gerardi, M. A., Breazeale, K. G., Price, M., Davis, M., Duncan, E., Ressler, K. J., Bradley, B., Rizzo, A., et al. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.05.002 · Cited by 96
“Furthermore, a number of human studies have shown that greater expectancy violation may be among the most important variables involved in exposure therapy (reviewed in Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
BackgroundDopamine-dependent prefrontal reactivations explain long-term benefit of fear extinction
Gerlicher, A. M. V., Tüscher, O., & Kalisch, R. (2018) · Nature Communications · doi:10.1038/s41467-018-06785-y · Cited by 103
Revisiting the Cognitive Model of Depression: The Role of Expectations
Rief, W., & Joormann, J. (2019) · Clinical Psychology in Europe · doi:10.32872/cpe.v1i1.32605 · Cited by 100
“Exposure therapy in anxiety disorders has been reformulated as a therapy to disconfirm negative expectations, and to increase inhibition of avoidance behavior (Craske, 2015; Craske et al., 2014).”
BackgroundUnderstanding the Etiology of Chronic Pain From a Psychological Perspective
Linton, S. J., Flink, I. K., & Vlaeyen, J. W. S. (2018) · Physical Therapy · doi:10.1093/ptj/pzy027 · Cited by 106
Augmentation of Extinction and Inhibitory Learning in Anxiety and Trauma-Related Disorders
Lebois, L. A. M., Seligowski, A. V., Wolff, J. D., Hill, S. B., & Ressler, K. J. (2019) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-050718-095634 · Cited by 97
Metadata
- Authors
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B.
- Affiliations
- University of California, Los Angeles (US)
- KU Leuven (BE)
- Corresponding author
- Craske, Michelle G.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2014-07
- Volume
- 58
- Pages
- 10-23
- ISSN
- 0005-7967 (ISSN-L)
- PMC
- PMC4114726
- OpenAlex
- W2057906075
- Semantic Scholar
- 0d5de00a9991db7a0f004d29efca3e1c6f367c0f
- Cited by
- 2,339
- References
- 108
- Citations by year
- 2026: 304 · 2025: 247 · 2024: 265 · 2023: 196 · 2022: 233 · 2021: 245 · 2020: 213 · 2019: 175 · 2018: 156 · 2017: 124 · 2016: 107 · 2015: 59 · 2014: 12
- FWCI
- 139.66
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Lirias (submittedVersion, other-oa)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute of Mental Health (R34MH101359, R21MH081299, R01MH065651)
- National Human Genome Research Institute (T32HG002536)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Life Sciences › Neuroscience › Cognitive Neuroscience › Memory and Neural Mechanisms
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- exposure therapy, inhibitory learning, extinction learning, anxiety disorders, treatment optimization, expectancy violation, safety signals, retrieval cues, affect labeling, obsessive-compulsive disorder, post-traumatic stress disorder, social anxiety disorder, specific phobia, panic disorder
- MeSH terms
- Adult, Anxiety Disorders, Extinction, Psychological, Female, Humans, Implosive Therapy, Inhibition, Psychological, Learning, Male
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