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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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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
“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
Experimental — accuracy not yet measured
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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
The cited source says what the claim attributes to it.
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
The cited source says what the claim attributes to it.
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]
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
“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
The cited source says what the claim attributes to it.
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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Fear as a translational mechanism in the psychopathology of anorexia nervosa
Murray, S. B., Strober, M., Craske, M. G., Griffiths, S., Levinson, C. A., & Strigo, I. A. (2018) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2018.10.013 · Cited by 75
Self-citationTaylor, C. T., Pearlstein, S. L., Kakaria, S., Lyubomirsky, S., & Stein, M. B. (2020) · Cognitive Therapy and Research · doi:10.1007/s10608-020-10102-7 · Cited by 81
Levinson, C. A., Christian, C., Ram, S. S., Vanzhula, I., Brosof, L. C., Michelson, L. P., & Williams, B. M. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.07.075 · Cited by 79
Panitz, C., Endres, D., Buchholz, M., Khosrowtaj, Z., Sperl, M. F. J., Mueller, E. M., Schubö, A., Schütz, A. C., Teige‐Mocigemba, S., & Pinquart, M. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.726432 · Cited by 86
Anticipatory Threat Responding: Associations With Anxiety, Development, and Brain Structure
Abend, R., Gold, A. L., Britton, J. C., Michalska, K. J., Shechner, T., Sachs, J. F., Winkler, A. M., Leibenluft, E., Averbeck, B. B., & Pine, D. S. (2019) · Biological Psychiatry · doi:10.1016/j.biopsych.2019.11.006 · Cited by 83
Wheaton, M. G., Galfalvy, H., Steinman, S. A., Wall, M. M., Foa, E. B., & Simpson, H. B. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.07.010 · Cited by 79
“However, evaluating other aspects of exposures, such as violating expectancies, learning something new, and practicing in a new context (as emphasized by Abramowitz & Arch, 2014; Craske et al., 2008; 2014) might reveal a stronger relationship between homework exposure quality and treatment outcome.”
BackgroundFrom lab to clinic: Extinction of cued cravings to reduce overeating
Jansen, A. T. M., Schyns, G., Bongers, P., & van den Akker, K. (2016) · Physiology & Behavior · doi:10.1016/j.physbeh.2016.03.018 · Cited by 83
“The length of an exposure session can be determined by the time needed for US expectancies to be violated (instead of waiting for the craving to decrease) [18].”
BackgroundInfluentialFear conditioning and extinction in obsessive-compulsive disorder: A systematic review
Cooper, S. E., & Dunsmoor, J. E. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.07.026 · Cited by 83
Benito, K. G., Machan, J., Freeman, J. B., Garcia, A. M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., et al. (2018) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000315 · Cited by 73
“Future studies should also examine the rate and predictive value of this metric among adults, for whom anxiety disorders and OCD are associated with deficits in extinction learning (e.g., Craske et al., 2014; McLaughlin et al., 2015).”
BackgroundInfluentialAVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets
Ward, T., Rus‐Calafell, M., Ramadhan, Z., Soumelidou, O., Fornells‐Ambrojo, M., Garety, P. A., & Craig, T. (2020) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaa061 · Cited by 78
Lindner, P., Dagöö, J., Hamilton, W., Miloff, A., Andersson, G., Schill, A., & Carlbring, P. (2020) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2020.1795240 · Cited by 84
“The treatment protocol targets specific catastrophic beliefs (Hofmann, 2007) through exposure exercises that emphasize inhibitory learning (Craske et al., 2014) over physiological habituation (A. Baker et al., 2010).”
BackgroundMethodResultSjouwerman, R., Scharfenort, R., & Lonsdorf, T. B. (2020) · Scientific Reports · doi:10.1038/s41598-020-72007-5 · Cited by 82
Are Fear and Anxiety Truly Distinct?
Daniel‐Watanabe, L., & Fletcher, P. C. (2021) · Biological Psychiatry Global Open Science · doi:10.1016/j.bpsgos.2021.09.006 · Cited by 95
“Psychiatric approaches have been informed by findings from rodent models, which have inspired therapies (8) and elucidated causal factors and mechanisms [e.”
BackgroundThe surprising subtleties of changing fear memory: a challenge for translational science
Kindt, M. (2018) · Philosophical Transactions of the Royal Society B Biological Sciences · doi:10.1098/rstb.2017.0033 · Cited by 78
Expanding exposure‐based interventions for eating disorders
Reilly, E. E., Anderson, L. M., Gorrell, S., Schaumberg, K., & Anderson, D. A. (2017) · International Journal of Eating Disorders · doi:10.1002/eat.22761 · Cited by 77
“, spontaneous recovery of extinguished behavior (Craske et al., 2014)].”
Matheve, T., Hodges, P. W., & Danneels, L. A. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12175510 · Cited by 78
Rupp, C., Doebler, P., Ehring, T., & Vossbeck‐Elsebusch, A. N. (2017) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2039 · Cited by 76
Kerns, C. E., Pincus, D. B., McLaughlin, K. A., & Comer, J. S. (2017) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.05.002 · Cited by 77
Cardi, V., Leppanen, J., Mataix‐Cols, D., Campbell, I. C., & Treasure, J. (2019) · European Eating Disorders Review · doi:10.1002/erv.2639 · Cited by 72
Turner, C., O'Gorman, B., Nair, A., & O'Kearney, R. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2017.12.034 · Cited by 73
Brief intensive CBT for pediatric OCD with E-therapy maintenance
Farrell, L. J., Oar, E. L., Waters, A. M., McConnell, H. W., Tiralongo, E., Garbharran, V., & Ollendick, T. H. (2016) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2016.06.005 · Cited by 76
“…adequate arousal during ERP for OCD, it often requires finding more natural contexts; and (2) more recent evidence from adult studies across various anxiety disorders suggests that exposure therapy outcomes may be enhanced when conducted across multiple contexts (see Craske et al, 2008; 2014).”
BackgroundCore Mechanisms of Cognitive Behavioral Therapy for Anxiety and Depression
Powers, M. B., de Kleine, R. A., & Smits, J. A. J. (2017) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2017.08.010 · Cited by 83
Intolerance of Uncertainty Predicts Anxiety Outcomes Following CBT in Youth with ASD.
Keefer, A., Kreiser, N. L., Singh, V., Blakeley-Smith, A., Duncan, A., Johnson, C., Klinger, L., Meyer, A., Reaven, J., & Vasa, R. A. (2017) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-016-2852-z · Cited by 72
“Additionally, the use of ‘‘exposure optimizing strategies’’ which are based in inhibitory learning models of anxiety (Craske et al. 2014) may enhance treatment response.”
BackgroundLindner, P., Rozental, A., Jurell, A., Reuterskiöld, L., Andersson, G., Hamilton, W., Miloff, A., & Carlbring, P. (2020) · JMIR Serious Games · doi:10.2196/17807 · Cited by 71
“(VRET) for the treatment of anxiety disorders [4-6], in which phobic stimuli are replaced with virtual equivalents to perform otherwise typical exposure therapy (ie, graded, systematic exposure under controlled conditions until the fear response habituates or inhibitory learning occurs) [7].”
BackgroundMarin, M.-F., Song, H., VanElzakker, M. B., Staples-Bradley, L. K., Linnman, C., Pace-Schott, E. F., Lasko, N. B., Shin, L. M., & Milad, M. R. (2016) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2015.14111460 · Cited by 74
“Hence, further examination of the brain network underlying fear extinction could improve our understanding of PTSD and contribute to improved PTSD therapies (9).”
Tackling maladaptive memories through reconsolidation: From neural to clinical science
Elsey, J. W. B., & Kindt, M. (2017) · Neurobiology of Learning and Memory · doi:10.1016/j.nlm.2017.03.007 · Cited by 83
Dissecting the Core Fear in Anorexia Nervosa: Can We Optimize Treatment Mechanisms?
Murray, S. B., Loeb, K. L., & Le Grange, D. (2016) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2016.1623 · Cited by 73
Lange, I., Goossens, L., Michielse, S., Bakker, J. M., Vervliet, B., Marcelis, M. C., Wichers, M., van Os, J., van Amelsvoort, T., & Schruers, K. R. J. (2019) · Neuropsychopharmacology · doi:10.1038/s41386-019-0467-8 · Cited by 74
“Extinction learning has been regarded as the core principle underlying exposure therapy [6].”
BackgroundResultInfluentialSelf-citationA meta-analytic review of the relationship between family accommodation and OCD symptom severity
Strauss, C., Hale, L. S., & Stobie, B. (2015) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2015.05.006 · Cited by 74
Farrell, N. R., Kemp, J. J., Blakey, S. M., Meyer, J. M., & Deacon, B. J. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.011 · Cited by 71
Common neurocircuitry mediating drug and fear relapse in preclinical models
Goode, T. D., & Maren, S. (2018) · Psychopharmacology · doi:10.1007/s00213-018-5024-3 · Cited by 77
Using expectation violation models to improve the outcome of psychological treatments
Rief, W., Sperl, M. F. J., Braun-Koch, K., Khosrowtaj, Z., Kirchner, L., Schäfer, L. N., Schwarting, R. K. W., Teige‐Mocigemba, S., & Panitz, C. (2022) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102212 · Cited by 78
Dopamine: from prediction error to psychotherapy
Papalini, S., Beckers, T., & Vervliet, B. (2020) · Translational Psychiatry · doi:10.1038/s41398-020-0814-x · Cited by 75
Self-citationAlfei, J. M., Ferrer Monti, R. I., Molina, V. A., Bueno, A. M., & Urcelay, G. P. (2015) · Learning & Memory · doi:10.1101/lm.038513.115 · Cited by 71
“It is unclear whether the reduction of fear during extinction predicts fear expressed during subsequent tests (for review, see Craske et al. 2014).”
BackgroundInfluentialThe role of expectations in mental disorders and their treatment
Rief, W., & Glombiewski, J. A. (2017) · World Psychiatry · doi:10.1002/wps.20427 · Cited by 72
Mercado, D., Schmidt, U., O'Daly, O., Campbell, I., & Werthmann, J. (2020) · Journal of Eating Disorders · doi:10.1186/s40337-019-0276-9 · Cited by 44
Lindner, P., Miloff, A., Bergman, C., Andersson, G., Hamilton, W., & Carlbring, P. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00116 · Cited by 66
“…is consistent with the extant literature on the mechanisms of exposure therapy in general, which suggest that factors such as inhibitory learning processes (not measured in the current study) are a stronger predictor of treatment outcomes than simple emotional evocation and processing (2, 41).”
BackgroundResultAn experimental test of the role of control in spider fear.
Healey, A., Mansell, W., & Tai, S. (2017) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.03.005 · Cited by 63
Can Psychological Expectation Models Be Adapted for Placebo Research?
Rief, W., & Petrie, K. J. (2016) · Frontiers in Psychology · doi:10.3389/fpsyg.2016.01876 · Cited by 72
“Several treatment approaches actually set out to induce expectation violations (e.g., exposure therapy in anxiety disorders; Craske et al., 2014; Craske, 2015).”
BackgroundTuerk, P. W., Wangelin, B. C., Powers, M. B., Smits, J. A. J., Acierno, R. E., Myers, U. S., Orr, S. P., Foa, E. B., & Hamner, M. B. (2018) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1432679 · Cited by 70
“Moreover, sustained subject distress throughout exposure via experimentally interfering with habituation has been shown to improve inhibitory learning outcomes (Craske et al., 2014; Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012; Lang & Craske, 2000).”
BackgroundResultEnhancing Inhibitory Learning: The Utility of Variability in Exposure
Knowles, K. A., & Olatunji, B. O. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2017.12.001 · Cited by 60
Rief, W., Barsky, A. J., Bingel, U., Doering, B. K., Schwarting, R., Wöhr, M., & Schweiger, U. (2016) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2015.11.008 · Cited by 67
A randomized clinical trial of cue exposure treatment through virtual reality for smoking cessation
Pericot‐Valverde, I., Secades‐Villa, R., & Gutiérrez‐Maldonado, J. (2018) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2018.10.003 · Cited by 67
McGuire, J. F., Orr, S. P., Essoe, J. K.-Y., McCracken, J. T., Storch, E. A., & Piacentini, J. (2016) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2016.1199276 · Cited by 67
“Following each exposure trial, the clinician will ask the youth about the learning that occurred regarding the nonoccurrence of the feared outcome and discrepancies between initial predictions and actual outcomes [27].”
InfluentialΚube, T., D’Astolfo, L., Glombiewski, J. A., Doering, B. K., & Rief, W. (2016) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12114 · Cited by 65
Κube, T., Glombiewski, J. A., Gall, J., Touissant, L., Gärtner, T., & Rief, W. (2019) · Journal of Affective Disorders · doi:10.1016/j.jad.2019.03.027 · Cited by 67
Frank, B., & McKay, D. (2019) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.04.003 · Cited by 64
Raber, J., Arzy, S., Bertolus, J. B., Depue, B., Haas, H. E., Hofmann, S. G., Kangas, M., Kensinger, E., Lowry, C. A., Marusak, H. A., et al. (2019) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2019.03.015 · Cited by 62
A memory-based theory of emotional disorders.
Cohen, R. T., & Kahana, M. J. (2022) · Psychological Review · doi:10.1037/rev0000334 · Cited by 75
Ten misconceptions about trauma-focused CBT for PTSD
Murray, H., Grey, N., Warnock‐Parkes, E., Kerr, A., Wild, J., Clark, D. M., & Ehlers, A. (2022) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x22000307 · Cited by 65
“Incidentally, the importance of testing feared predictions has also been highlighted in contemporary exposure therapies for PTSD as well (e.g. Craske et al., 2014).”
BackgroundOdriozola, P., & Gee, D. G. (2021) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2020.20020232 · Cited by 62
Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms
Murray, S. B., Treanor, M., Liao, B., Loeb, K. L., Griffiths, S., & Le Grange, D. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.08.017 · Cited by 60
Self-citationVeale, D. M., Naismith, I., Miles, S., Gledhill, L. J., Stewart, G. D., & Hodsoll, J. P. (2015) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2015.11.005 · Cited by 63
“This is consistent with the modern principles of exposure and testing the predicted consequences in a behavioral experiment (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
ResultDavis, M. L., Witcraft, S. M., Baird, S. O., & Smits, J. A. J. (2017) · Elsevier eBooks · doi:10.1016/b978-0-12-803457-6.00003-9 · Cited by 73
Can Exposure-Based CBT Extend the Effects of Intravenous Ketamine in Obsessive-Compulsive Disorder?
Rodríguez, C. I., Wheaton, M. G., Zwerling, J., Steinman, S. A., Sonnenfeld, D., Galfalvy, H., & Simpson, H. B. (2016) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.15l10138 · Cited by 63
Elsey, J. W. B., & Kindt, M. (2016) · AJOB Neuroscience · doi:10.1080/21507740.2016.1218377 · Cited by 66
“…of extinction learning (which provides the experimental basis for exposure therapy) propose that exposure to feared stimuli reduces anxiety by creating new memories that inhibit the old memory trace (Bouton and Swartzentruber 1991; Bouton, Westbrook, Corcoran, and Maren 2006; Craske et al. 2014).”
Kube, T., Glombiewski, J. A., & Rief, W. (2018) · Psychosomatic Medicine · doi:10.1097/psy.0000000000000596 · Cited by 62
Boutelle, K. N., Manzano, M. A., & Eichen, D. M. (2020) · Physiology & Behavior · doi:10.1016/j.physbeh.2020.113018 · Cited by 61
From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain
Cañeiro, J. P., Smith, A. J., Bunzli, S., Linton, S. J., Moseley, G. L., & O’Sullivan, P. (2021) · Physical Therapy · doi:10.1093/ptj/pzab271 · Cited by 71
Särnholm, J., Skúladóttir, H., Rück, C., Axelsson, E., Bonnert, M., Bragesjö, M., Venkateshvaran, A., Ólafsdóttir, E., Pedersen, S. S., Ljótsson, B., et al. (2023) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2023.04.044 · Cited by 62
Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders
Reid, A. M., Bolshakova, M. I., Guzick, A. G., Fernandez, A. G., Striley, C. W., Geffken, G. R., & McNamara, J. P. (2017) · Community Mental Health Journal · doi:10.1007/s10597-017-0108-9 · Cited by 60
Zbozinek, T. D., & Craske, M. G. (2017) · Journal of Experimental Psychopathology · doi:10.5127/jep.052615 · Cited by 61
“Translation of these principles to exposure therapy highlights the value in rehearsing the non-occurrence of the aversive event (i.e., the new inhibitory learning) immediately after completion of an exposure practice (Craske et al., 2014).”
BackgroundMethodInfluentialSelf-citationNovelty-facilitated extinction and the reinstatement of conditional human fear
Lucas, K., Luck, C. C., & Lipp, O. V. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.08.002 · Cited by 61
Odor-induced recall of emotional memories in PTSD–Review and new paradigm for research
Daniels, J. K., & Vermetten, E. H. G. J. M. (2016) · Experimental Neurology · doi:10.1016/j.expneurol.2016.08.001 · Cited by 74
“As recent research on exposure therapy for anxiety disorders indicates, the inclusion of many diverse sensory elements in the exposure setting might boost the effect of exposure treatment and delay return of fear (Craske et al., 2008, 2014, Janak and Corbit, 2011, Rescorla, 2006).”
BackgroundRattel, J., Miedl, S., Blechert, J., & Wilhelm, F. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.12.010 · Cited by 57
From avoidance to approach: The influence of threat-of-shock on reward-based decision making
Bublatzky, F., Alpers, G. W., & Pittig, A. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.01.003 · Cited by 67
Thabrew, H., Stasiak, K., Hetrick, S. E., Donkin, L., Huss, J. H., Highlander, A., Wong, S., & Merry, S. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012488.pub2 · Cited by 67
“Recent advances have identified optimal methods of delivering exposure work such as affect labelling, using retrieval cues and undertaking exposure in multiple contexts (Craske 2014).”
BackgroundMethodInfluentialAlex Brake, C., Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Farchione, T. J., & Barlow, D. H. (2016) · Behavior Therapy · doi:10.1016/j.beth.2015.10.008 · Cited by 58
“These findings coincide with previous evidence suggesting nonjudgmental awareness is well suited to maximizing key factors for effective exposure (Boswell et al., 2014; Craske et al., 2014; Wahl et al., 2013).”
ResultLaforest, M., Bouchard, S., Crétu, A.-M., & Mesly, O. (2016) · Frontiers in ICT · doi:10.3389/fict.2016.00018 · Cited by 60
“Further research is needed to document whether presence allows for, or is associated with, virtual stimuli to be perceived and processed as real, which then leads to the core process associated with treatment success, namely “developing new associations with lack of threat” (Bouchard et al., 2012; Craske et al., 2014).”
BackgroundWharton, E., Edwards, K. S., Juhasz, K., & Walser, R. D. (2019) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2019.09.006 · Cited by 60
On the Maintenance of Expectations in Major Depression – Investigating a Neglected Phenomenon
Κube, T., Rief, W., & Glombiewski, J. A. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.00009 · Cited by 62
“That is, behavioral experiments can serve as expectation-violating situations insofar as patients can gain experiences that are contrary to their expectations (Craske et al., 2014).”
BackgroundInfluentialA translational perspective on neural circuits of fear extinction: Current promises and challenges
Sevenster, D., Visser, R. M., & D’Hooge, R. (2018) · Neurobiology of Learning and Memory · doi:10.1016/j.nlm.2018.07.002 · Cited by 64
“This is not only relevant in the context of maximizing PE as a route to enhance the effectiveness of exposure therapy (Craske, 2015; Craske et al., 2014; Culver et al., 2015), but also to demarcate the transition from reconsolidation to extinction processes.”
BackgroundCognitive Behavioral Therapy for Childhood Anxiety Disorders: A Review of Recent Advances
Banneyer, K. N., Bonin, L., Price, K., Goodman, W. K., & Storch, E. A. (2018) · Current Psychiatry Reports · doi:10.1007/s11920-018-0924-9 · Cited by 59
Dugas, M. J., Sexton, K. A., Hebert, E. A., Bouchard, S., Gouin, J.-P., & Shafran, R. (2022) · Behavior Therapy · doi:10.1016/j.beth.2022.05.003 · Cited by 58
Impaired hippocampus-dependent associative learning as a mechanism underlying PTSD: A meta-analysis
Lambert, H. K., & McLaughlin, K. A. (2019) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2019.09.024 · Cited by 71
Genheimer, H., Andreatta, M., Asan, E., & Pauli, P. (2017) · Scientific Reports · doi:10.1038/s41598-017-18183-3 · Cited by 65
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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