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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
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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
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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]
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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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“inhibitory learning impairments noted above, inhibitory learning may be a key therapeutic component for future CBT protocols for youth with OCD to improve treatment outcomes.[47, 48] Along with inhibitory learning impairments in late extinction, youth with OCD displayed an initial reversal of SCRs to the CS+ and CS− d…”
BackgroundInfluentialPharmacologically induced amnesia for learned fear is time and sleep dependent
Kindt, M., & Soeter, M. (2018) · Nature Communications · doi:10.1038/s41467-018-03659-1 · Cited by 61
The effects of imagery rescripting on memory outcomes in social anxiety disorder
Romano, M., Moscovitch, D. A., Huppert, J. D., Reimer, S. G., & Moscovitch, M. (2019) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2019.102169 · Cited by 58
Sülter, R. E., Ketelaar, P. E., & Lange, W.-G. (2022) · Computers & Education · doi:10.1016/j.compedu.2021.104384 · Cited by 52
Raeder, F., Merz, C. J., Margraf, J., & Zlomuzica, A. (2020) · Scientific Reports · doi:10.1038/s41598-020-61004-3 · Cited by 53
Bonnert, M., Olén, O., Bjureberg, J., Lalouni, M., Hedman-Lagerlöf, E., Serlachius, E., & Ljótsson, B. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.03.006 · Cited by 53
Schyns, G., Roefs, A., Mulkens, S., & Jansen, A. T. M. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.11.007 · Cited by 53
Schepers, S. T., & Bouton, M. E. (2015) · Journal of Experimental Psychology Animal Learning and Cognition · doi:10.1037/xan0000061 · Cited by 53
The Role of Disgust in Eating Disorders
Anderson, L. M., Berg, H. E., Brown, T. A., Menzel, J. E., & Reilly, E. E. (2021) · Current Psychiatry Reports · doi:10.1007/s11920-020-01217-5 · Cited by 56
Armstrong, T., & Olatunji, B. O. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.03.009 · Cited by 52
“Several methods for augmenting extinction learning during exposure therapy have been proposed (see Craske, Treanor, Conway, Zbozinek,& Vervliet, 2014), all of which aim to enhance expectations that the US will not follow the CS (i.e., inhibitory learning; Craske et al., 2014).”
MethodHeinig, I., Pittig, A., Richter, J., Hummel, K., Alt, I., Dickhöver, K., Gamer, J., Hollandt, M., Koelkebeck, K., Maenz, A., et al. (2017) · International Journal of Methods in Psychiatric Research · doi:10.1002/mpr.1560 · Cited by 57
Cooper, A. A., Zoellner, L. A., Roy‐Byrne, P., MAVISSAKALIAN, M. R., & Feeny, N. C. (2017) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000220 · Cited by 57
A randomized controlled trial comparing EMDR and CBT for obsessive–compulsive disorder
Marsden, Z., Lovell, K., Blore, D. C., Ali, S., & Delgadillo, J. (2017) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2120 · Cited by 62
Reduced return of threat expectancy after counterconditioning versus extinction
Kang, S., Vervliet, B., Engelhard, I. M., van Dis, E. A. M., & Hagenaars, M. A. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.06.009 · Cited by 52
Self-citationWijnhoven, L. A. M. W., Creemers, D. H. M., Vermulst, A. A., Lindauer, R., Otten, R., Engels, R. C. M. E., & Granic, I. (2020) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2020.101548 · Cited by 53
Elements of the therapeutic relationship in CBT for anxiety disorders: A systematic review
Luong, H. K., Drummond, S. P. A., & Norton, P. J. (2020) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2020.102322 · Cited by 60
Álvarez‐Pérez, Y., Rivero, F., Herrero, M., Viña, C. M., Fumero, A., Betancort, M., & Castro, W. P. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10163505 · Cited by 58
“From a therapeutic perspective, the results coincide with the inhibitory learning model [79,80] more than with the emotional processing model of fear [81,82], because even though a significant decrease in anxiety levels was observed, in the brain, the person would continue to feel afraid.”
ResultA Meta-Analysis of d-Cycloserine in Exposure-Based Treatment
Mcguire, J. F., Wu, M. S., Piacentini, J. C., McCracken, J. T., & Storch, E. A. (2016) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.15r10334 · Cited by 52
Partial reinforcement of avoidance and resistance to extinction in humans
Xia, W., Dymond, S., Lloyd, K. R., & Vervliet, B. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.04.002 · Cited by 56
Self-citationWahlund, T., Andersson, E., Jolstedt, M., Perrin, S., Vigerland, S., & Serlachius, E. (2020) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2019.06.002 · Cited by 49
Brown, M. L., & Levinson, C. A. (2022) · International Journal of Eating Disorders · doi:10.1002/eat.23728 · Cited by 47
Wang, P., Wang, Z., & Qiu, S. (2024) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/s13034-024-00735-x · Cited by 66
“By addressing the overestimation of potential risks and dangers associated with these stimuli, exposure practice aims to facilitate fear habituation, disconfir-mation of fear beliefs, and promote inhibitory learning [32].”
BackgroundLearned Overeating: Applying Principles of Pavlovian Conditioning to Explain and Treat Overeating
van den Akker, K., Schyns, G., & Jansen, A. T. M. (2018) · Current Addiction Reports · doi:10.1007/s40429-018-0207-x · Cited by 50
Ghiţă, A., Teixidor, L., Monràs, M., Ortega, L., Mondón, S., Gual, A., Paredes, S. M., Urgell, L. V., Porras-García, B., Ferrer‐García, M., et al. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.00074 · Cited by 51
Pittig, A., Alpers, G. W., Niles, A. N., & Craske, M. G. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.08.003 · Cited by 47
Self-citationModerators of Outcome for Youth Anxiety Treatments: Current Findings and Future Directions
Norris, L. A., & Kendall, P. C. (2021) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2020.1833337 · Cited by 46
“For example, the theory of inhibitory learning posits that exposure efficacy rests in part on expectancy violations (Craske et al., 2014).”
BackgroundBrown, T., Nauman Vogel, E., Adler, S., Bohon, C., Bullock, K., Nameth, K., Riva, G., Safer, D. L., & Runfola, C. D. (2020) · Journal of Medical Internet Research · doi:10.2196/16386 · Cited by 49
“In CET, the main objective is to weaken the bond between the cues (conditioned stimuli) and the maladaptive responses (conditioned responses), which may mask or inhibit initial learning [32].”
BackgroundMorriss, J., & van Reekum, C. M. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.03.004 · Cited by 46
Trentowska, M., Svaldi, J., Jens Blechert, A., & Tuschen‐Caffier, B. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2016.12.006 · Cited by 49
“For example, within the inhibitory learning approach strategies such as expectancy violation, variation of stimuli, spaced exposure, multiple contexts and affect labeling (Craske et al., 2014) seem to optimize long term treatment outcome.”
BackgroundInfluentialWhy expectations do or do not change after expectation violation: A comparison of seven models
Pinquart, M., Endres, D., Teige‐Mocigemba, S., Panitz, C., & Schütz, A. C. (2021) · Consciousness and Cognition · doi:10.1016/j.concog.2021.103086 · Cited by 52
Maisto, D., Barca, L., den Bergh, O. V., & Pezzulo, G. (2021) · Psychological Review · doi:10.1037/rev0000290 · Cited by 60
Sharpe, L., Todd, J., Scott, A. J., Gatzounis, R., Menzies, R. E., & Meulders, A. (2022) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102126 · Cited by 59
A Learning Theory Approach to Attachment Theory: Exploring Clinical Applications
Bosmans, G., Vlierberghe, L. V., Bakermans‐Kranenburg, M. J., Kobak, R., Hermans, D., & van IJzendoorn, M. H. (2022) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-021-00377-x · Cited by 66
“If negative expectations and fear are more strongly activated, rule-violations get better encoded and more likely result in changed expectations and new behavioral strategies (Craske et al., 2014).”
BackgroundInfluentialKwee, C., Baas, J. M. P., van der Flier, F. E., Groenink, L., Duits, P., Eikelenboom, M., van der Veen, D. C., Moerbeek, M., Batelaan, N. M., van Balkom, A. J. L. M., et al. (2022) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2022.04.003 · Cited by 50
Thorsen, A. L., Kvale, G., Hansen, B. K. A., & van den Heuvel, O. A. (2018) · Current Treatment Options in Psychiatry · doi:10.1007/s40501-018-0142-4 · Cited by 51
Strauss, C., Lea, L., Hayward, M., Forrester, E., Leeuwerik, T., Bibby-Jones, A.-M., & Rosten, C. (2018) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2018.04.007 · Cited by 50
“Frequent, repeated exposure tasks are required for both these processes to occur, with inhibitory learning theory emphasising the context-specific nature of new learning (Craske et al., 2014).”
BackgroundLipp, O. V., Waters, A. M., Luck, C. C., Ryan, K. M., & Craske, M. G. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103529 · Cited by 50
Self-citationThe credibility of exposure therapy: Does the theoretical rationale matter?
Arch, J. J., Twohig, M. P., Deacon, B. J., Landy, L. N., & Bluett, E. J. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.05.008 · Cited by 47
Bentley, J. A., Feeny, N. C., Dolezal, M. L., Klein, A. B., Marks, L. H., Graham, B., & Zoellner, L. A. (2020) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2020.10.005 · Cited by 71
Blackwell, S. E. (2021) · International Journal of Cognitive Therapy · doi:10.1007/s41811-021-00102-0 · Cited by 52
Crombie, K. M., Sartin‐Tarm, A., Sellnow, K. A., Ahrenholtz, R., Lee, S., Matalamaki, M., Adams, T. G., & Cisler, J. M. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103867 · Cited by 48
Elsner, B., Jacobi, T., Kischkel, E., Schulze, D., & Reuter, B. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-03701-z · Cited by 52
“Second, we chose to focus on distress-related expectancy violation, although theoretical conceptions primarily suggest measuring the discrepancy between feared and actually occurring events [25, 28].”
BackgroundInfluentialGoetz, A. R., Davine, T. P., Siwiec, S. G., & Lee, H. (2015) · Clinical Psychology Review · doi:10.1016/j.cpr.2015.12.005 · Cited by 54
Associability-modulated loss learning is increased in posttraumatic stress disorder
Brown, V. M., Zhu, L., Wang, J. M., Frueh, B. C., King‐Casas, B., & Chiu, P. H. (2018) · eLife · doi:10.7554/elife.30150 · Cited by 50
“…attention, learning, and the amygdala have all been behavioral and neural targets of promising new therapies for PTSD (Badura- Brack et al., 2015; Craske et al., 2014; Langevin et al., 2016); elucidating the component neuro- behavioral mechanisms associated with learning in PTSD may refine…”
Kunze, A. E., Lancee, J., Nexhmedin Morina, B., Kindt, M., & Arntz, A. R. (2019) · Behavior Therapy · doi:10.1016/j.beth.2019.03.003 · Cited by 50
“…with modern accounts of exposure therapy, which state that increasing patients ’ ability to tolerate fear may be critical for treatment outcome (Craske et al., 2014), as the tolerability of negative emotions such as fear may promote the formation of new inhibitory associations (Arch & Craske,…”
Khan, A. N., Bilek, E. L., Tomlinson, R. C., & Becker‐Haimes, E. M. (2021) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2020.12.002 · Cited by 54
Wheaton, M. G., & Chen, S. R. (2021) · Cognitive Therapy and Research · doi:10.1007/s10608-020-10125-0 · Cited by 47
“For example, current homework assessment measures do not directly measure whether homework is being practiced in new or repeated contexts and do not include other features hypothesized to be important by inhibitory learning approaches (Craske et al. 2014).”
BackgroundResultDeveloping an automated VR cognitive treatment for psychosis: gameChange VR therapy
Lambe, S., Knight, I., Kabir, T., West, J., Patel, R., Lister, R., Rosebrock, L., Rovira, A., Garnish, B., Freeman, J., et al. (2020) · Journal of Behavioral and Cognitive Therapy · doi:10.1016/j.jbct.2019.12.001 · Cited by 48
Acceptance-based interoceptive exposure for young children with functional abdominal pain
Zucker, N., Mauro, C., Craske, M., Wagner, H. R., Datta, N., Hopkins, H., Caldwell, K., Kiridly, A., Marsan, S., Maslow, G., et al. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.07.009 · Cited by 47
Self-citationvan Dis, E. A. M., Hagenaars, M. A., Bockting, C., & Engelhard, I. M. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2019.103416 · Cited by 48
The role of context in persistent avoidance and the predictive value of relief
Papalini, S., Ashoori, M., Zaman, J., Beckers, T., & Vervliet, B. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103816 · Cited by 47
Self-citationLaing, P. A. F., & Harrison, B. J. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.05.014 · Cited by 68
Sewart, A. R., Niles, A. N., Burklund, L. J., Saxbe, D. E., Lieberman, M. D., & Craske, M. G. (2019) · Behavior Therapy · doi:10.1016/j.beth.2019.07.001 · Cited by 46
Self-citationSmith, N. B., Doran, J. M., Sippel, L. M., & Harpaz-Rotem, I. (2017) · Neuroscience Letters · doi:10.1016/j.neulet.2017.01.006 · Cited by 46
Moving from tradition-based to competence-based psychotherapy
Rief, W. (2021) · Evidence-Based Mental Health · doi:10.1136/ebmental-2020-300219 · Cited by 46
Adams, T. G., Cisler, J. M., Kelmendi, B., George, J. R., Kichuk, S. A., Averill, C. L., Anticevic, A., Abdallah, C. G., & Pittenger, C. (2021) · Depression and Anxiety · doi:10.1002/da.23212 · Cited by 46
“Exposure therapies depend on safety learning, particularly fear extinction (Singewald et al., 2015), a process whereby fear is inhibited through the acquisition of new safety learning that is promoted by therapeutic exposure (Craske et al., 2014; Peters et al., 2009).”
BackgroundInfluentialDymond, S., Bennett, M., Boyle, S., Roche, B., & Schlund, M. (2018) · Perspectives on Behavior Science · doi:10.1007/s40614-017-0133-6 · Cited by 46
“Ultimately, further research is needed to develop and optimize evidence-based fear reduction techniques involving AARR processes (Craske et al., 2014).”
BackgroundRyan, K. M., Zimmer‐Gembeck, M. J., Neumann, D. L., & Waters, A. M. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.11.009 · Cited by 44
Pulcu, E., Shkreli, L., Holst, C. G., Woud, M. L., Craske, M. G., Browning, M. D., & Reinecke, A. (2019) · Biological Psychiatry · doi:10.1016/j.biopsych.2019.04.010 · Cited by 46
Self-citationİnözü, M., Çelikcan, U., Akın-Sarı, B., & Çıçek, N. M. (2020) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2020.100518 · Cited by 52
Zimmer, A., Wang, N., Ibach, M. K., Fehlmann, B., Schicktanz, N., Bentz, D., Michael, T., Papassotiropoulos, A., & de Quervain, D. D. (2021) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2021.102442 · Cited by 44
Ma, L., Mor, S., Anderson, P. L., Baños, R., Botella, C., Bouchard, S., Cárdenas‐López, G., Donker, T., Fernández‐Álvarez, J., Lindner, P., et al. (2021) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2021.1939410 · Cited by 49
“Furthermore, the extensive control offered by virtual technologies can help implement and deliver the therapy using recommended techniques (Craske et al., 2014) in a consistent manner, maximising the effect of treatment.”
MethodTrait anxiety is associated with hidden state inference during aversive reversal learning
Zika, O., Wiech, K., Reinecke, A., Browning, M. D., & Schuck, N. W. (2023) · Nature Communications · doi:10.1038/s41467-023-39825-3 · Cited by 45
“While this procedure can lead to a decrease in fear responding, this reduction sometimes remains speci fi c to the therapeutic context, and fails to generalize to the outside world 1,2 .”
Influentialvan den Akker, K., Havermans, R. C., & Jansen, A. T. M. (2015) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2015.02.001 · Cited by 45
Concentrated ERP Delivered in a Group Setting: A Replication Study
Havnen, A., Hansen, B. K. A., Öst, L., & Kvale, G. (2017) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465817000091 · Cited by 45
“Research implies that therapeutic outcome is not predicted by the degree to which fear decreases during exposure or the fear level at the end of the session, but rather the degree of inhibitory learning, which is argued to be central to fear extinction (Craske et al., 2014).”
BackgroundCasey, B. M., & Ganley, C. M. (2021) · Developmental Review · doi:10.1016/j.dr.2021.100963 · Cited by 65
Schyns, G., van den Akker, K., Roefs, A., Houben, K., & Jansen, A. (2020) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2019.01.005 · Cited by 44
Selles, R. R., Franklin, M., Sapyta, J., Compton, S. N., Tommet, D., Jones, R. N., Garcia, A., & Freeman, J. (2018) · Child Psychiatry & Human Development · doi:10.1007/s10578-017-0748-6 · Cited by 44
“It is also possible that distress tolerance interacts with the other hypothesized mechanisms of exposure therapy such as habituation [36] and inhibitory learning [37].”
Smith, R. S., Moutoussis, M., & Bilek, E. (2021) · Scientific Reports · doi:10.1038/s41598-021-89047-0 · Cited by 46
“…to subsequently decrease after behavioral change has occurred—highlighting the need to also reinforce confidence in what has been learned during therapy (e.g., solidifying learning by helping a patient maintain attention to, and linguistically process, unexpected outcomes during exposure 24,27 ).”
BackgroundManaging Social Anxiety, Therapist Guide
Hope, D. A., Heimberg, R. G., & Turk, C. L. (2019) · doi:10.1093/med-psych/9780190247591.001.0001 · Cited by 46
D’Astolfo, L., & Rief, W. (2017) · Frontiers in Psychology · doi:10.3389/fpsyg.2017.01253 · Cited by 46
“In alignment with the approach by Craske et al. (2014) to maximize inhibitory learning by actively testing the expectation, we hypothesize a different cognitive processing of “active” paradigms, which encourage a behavioral adaptation and Frontiers in Psychology | www.frontiersin.org 3 July 2017 |…”
MethodLearning to feel tired: A learning trajectory towards chronic fatigue
Lenaert, B., Boddez, Y., Vlaeyen, J. W. S., & Heugten, C. M. V. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.11.004 · Cited by 46
“To our knowledge, there has been no research on the extinction of conditioned fatigue or fear of fatigue, in strong contrast to the rich literature on this topic in pain and anxiety research (Craske et al., 2014; den Hollander et al., 2010).”
BackgroundResultThabrew, H., Stasiak, K., Hetrick, S. E., Wong, S., Huss, J. H., & Merry, S. (2017) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012488 · Cited by 46
The revolting body: Self-disgust as a key factor in anorexia nervosa
Glashouwer, K. A., & de Jong, P. J. (2021) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2021.03.008 · Cited by 51
Virtual Reality Exposure Therapy for the Treatment of Dental Phobia: A Controlled Feasibility Study
Gujjar, K. R., van Wijk, A., Sharma, R., & de Jongh, A. (2018) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465817000534 · Cited by 43
“…VRET facilitates emotional processing by activation of people’s underlying fear structure through controlled confrontations with their fearful stimuli without aversive outcomes, and that one learns that the fear is unfounded, thereby adjusting negative, irrational predictions (Craske et al., 2014).”
BackgroundHow can neurobiology of fear extinction inform treatment?
Craske, M. G., Sandman, C. F., & Stein, M. B. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104923 · Cited by 43
Self-citationMoscovitch, D. A., Moscovitch, M., & Sheldon, S. (2023) · Perspectives on Psychological Science · doi:10.1177/17456916221141351 · Cited by 48
Bruce, S. L., Ching, T. H. W., & Williams, M. T. (2017) · Archives of Sexual Behavior · doi:10.1007/s10508-017-1031-4 · Cited by 48
Safety Behavior After Extinction Triggers a Return of Threat Expectancy
van Uijen, S. L., Leer, A., & Engelhard, I. M. (2017) · Behavior Therapy · doi:10.1016/j.beth.2017.08.005 · Cited by 46
“…safety behaviors can prevent fear extinction, clinical guidelines recommend to motivate patients to drop all safety behaviors during exposure-based therapy (e.g., Abramowitz, Deacon, & Whiteside, 2011; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014; Keijsers, van Minnen, & Hoogduin, 2011).”
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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