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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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“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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“Based on recent studies describing the mechanisms of exposure therapy as inhibitory learning, the exposure to feared stimuli without coping skills may maximize the mismatch between expectations and experience and may enhance the learning effect rather than the exposure with coping skills [70].”
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Thompson, A., & Lipp, O. V. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.01.017 · Cited by 44
Skin Conductance Reactivity to Standardized Virtual Reality Combat Scenes in Veterans with PTSD
Wout‐Frank, M. V. ‘., Spofford, C. M., Unger, W. S., Sevin, E., & Shea, M. T. (2017) · Applied Psychophysiology and Biofeedback · doi:10.1007/s10484-017-9366-0 · Cited by 41
Khan, A. J., Pedrelli, P., Shapero, B. G., Fisher, L. B., Nyer, M., Farabaugh, A. H., & MacPherson, L. (2018) · Substance Use & Misuse · doi:10.1080/10826084.2018.1464027 · Cited by 41
“ABBTs also include experiential learning opportunities designed to teach skills to remain in contact with distress in pursuit of a larger purpose (i.e., values, goals), which also provides the opportunity for expectancy violation (Craske et al., 2014).”
BackgroundCahill, E. N., Wood, M. A., Everitt, B. J., & Milton, A. L. (2019) · Neuropsychopharmacology · doi:10.1038/s41386-018-0299-y · Cited by 40
Contextual reinstatement promotes extinction generalization in healthy adults but not PTSD
Hennings, A. C., McClay, M., Lewis‐Peacock, J. A., & Dunsmoor, J. E. (2020) · Neuropsychologia · doi:10.1016/j.neuropsychologia.2020.107573 · Cited by 41
Schröder, J., Werkle, N., Cludius, B., Jelinek, L., Moritz, S., & Westermann, S. (2020) · Depression and Anxiety · doi:10.1002/da.23105 · Cited by 40
“(5) Exposition and Reaction Prevention (ERP) The module on ERP educates users on the background of ERP and ways to perform repeated gradual exposure to the situations (including thoughts) that trigger obsessions and compulsions while discontinuing performing compulsive behavior to relearn helpful behavior through fear…”
BackgroundWong, A. H. K., & Pittig, A. (2020) · Psychological Research · doi:10.1007/s00426-021-01490-w · Cited by 33
L-DOPA improves extinction memory retrieval after successful fear extinction
Gerlicher, A. M. V., Tüscher, O., & Kalisch, R. (2019) · Psychopharmacology · doi:10.1007/s00213-019-05301-4 · Cited by 39
Baljé, A., Greeven, A., van Giezen, A., Korrelboom, K., Arntz, A., & Spinhoven, P. (2016) · Trials · doi:10.1186/s13063-016-1605-9 · Cited by 39
“…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].”
Vicarious extinction learning during reconsolidation neutralizes fear memory
Golkar, A., Tjaden, C., & Kindt, M. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.02.004 · Cited by 38
“One way to counteract the return of fear is by identifying therapeutic strategies for enhancing inhibitory learning, either pharmacologically or behaviorally, given that this type of learning forms the basis of exposure interventions (Craske et al., 2014).”
BackgroundGrados, M. A., Atkins, E., Kovacikova, G. I., & McVicar, E. L. (2015) · Psychology Research and Behavior Management · doi:10.2147/prbm.s58601 · Cited by 41
In Pursuit of Generalization: An Updated Review
Swan, A. J., Carper, M. M., & Kendall, P. C. (2015) · Behavior Therapy · doi:10.1016/j.beth.2015.11.006 · Cited by 39
de Jong, R., Lommen, M. J. J., de Jong, P. J., & Nauta, M. H. (2018) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.05.002 · Cited by 40
The role of threat level and intolerance of uncertainty in extinction
Morriss, J., Saldarini, F., & van Reekum, C. M. (2019) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2019.05.013 · Cited by 39
“From a clinical perspective, these findings are particularly interesting, as associative learning principles underlie exposure-based therapies (Bouton, 1988; Craske et al., 2014).”
BackgroundDeCross, S. N., Sambrook, K., Sheridan, M. A., Tottenham, N., & McLaughlin, K. A. (2021) · Biological Psychiatry · doi:10.1016/j.biopsych.2021.09.013 · Cited by 42
Salloum, A., Lu, Y., Chen, H., Quast, T. C., Cohen, J. A., Scheeringa, M. S., Salomon, K., & Storch, E. A. (2022) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2021.12.013 · Cited by 39
Reappraisal facilitates extinction in healthy and socially anxious individuals
Blechert, J., Wilhelm, F. H., Williams, H., Braams, B. R., Jou, J., & Gross, J. J. (2014) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2014.10.001 · Cited by 42
David, J., Crone, C. L., & Norberg, M. M. (2021) · Clinical Psychology and Psychotherapy · doi:10.1002/cpp.2660 · Cited by 34
Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms
Mitchell, B. J., Coifman, K. G., & Olatunji, B. O. (2024) · Behaviour Research and Therapy · doi:10.1016/j.brat.2024.104479 · Cited by 39
Deppermann, S., Vennewald, N., Diemer, J., Sickinger, S., Haeussinger, F. B., Dresler, T., Notzon, S., Laeger, I., Arolt, V., Ehlis, A., et al. (2017) · NeuroImage Clinical · doi:10.1016/j.nicl.2017.09.013 · Cited by 38
“Since CBT works by changing problematic cognitions and prompting inhibitory learning (Craske et al., 2014), hypothetically, on a neurobiological basis, these effects of CBT should be associated with increased prefrontal activation which has in fact been shown in a number of studies (for a review see Clark and Beck, 20…”
BackgroundResultInfluentialAngiotensin Regulation of Amygdala Response to Threat in High-Trait-Anxiety Individuals
Reinecke, A., Browning, M. D., Breteler, J. K., Kappelmann, N., Ressler, K. J., Harmer, C. J., & Craske, M. G. (2018) · Biological Psychiatry Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2018.05.007 · Cited by 35
“Such findings suggest that successful exposure depends on strong inhibitory learning, and that individuals with anxiety disorders are in need of strategies to enhance such processes (21).”
BackgroundInfluentialSelf-citationThompson, A., McEvoy, P. M., & Lipp, O. V. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.07.001 · Cited by 40
Maximizing the generalization of fear extinction: Exposures to a peak generalization stimulus
Struyf, D., Hermans, D., & Vervliet, B. (2018) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.09.005 · Cited by 36
Self-citationWake, S. J., Morriss, J., Johnstone, T., van Reekum, C. M., & Dodd, H. F. (2021) · Behaviour Research and Therapy · doi:10.1016/j.brat.2021.103818 · Cited by 33
Avoidance in Anorexia Nervosa: Towards a research agenda
Melles, H., Spix, M., & Jansen, A. (2021) · Physiology & Behavior · doi:10.1016/j.physbeh.2021.113478 · Cited by 37
“course of treatment, it should be achieved that exposures can be completed without any sort of safety behaviors in order to maximize inhibitory learning [21].”
BackgroundInfluentialA randomized controlled trial of the judicious use of safety behaviors during exposure therapy
Blakey, S. M., Abramowitz, J. S., Buchholz, J. L., Jessup, S. C., Jacoby, R. J., Reuman, L., & Pentel, K. Z. (2019) · Behaviour Research and Therapy · doi:10.1016/j.brat.2018.11.010 · Cited by 37
How stress hormones shape memories of fear and anxiety in humans
Merz, C. J., & Wolf, O. T. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104901 · Cited by 47
Duits, P., Richter, J., Baas, J. M. P., Engelhard, I. M., Limberg, A., Heitland, I., Hamm, A. O., & Cath, D. C. (2017) · Journal of Abnormal Psychology · doi:10.1037/abn0000266 · Cited by 37
“Those behavioral experiments during exposure therapy are hypothesized to be most effective when expectancies with regard to the feared outcome are maximally violated by the actual outcome of the behavioral experiment (Craske, 2015; Craske, Liao, Brown, & Vervliet, 2012; Craske et al., 2014).”
Lane‐Loney, S. E., Zickgraf, H. F., Ornstein, R. M., Mahr, F., & Essayli, J. H. (2020) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2020.06.010 · Cited by 37
Linke, J. O., Abend, R., Kircanski, K., Clayton, M., Stavish, C. M., Benson, B. E., Brotman, M. A., Renaud, O., Smith, S. M., Nichols, T. E., et al. (2020) · Biological Psychiatry · doi:10.1016/j.biopsych.2020.10.018 · Cited by 37
The effects of aversive-to-appetitive counterconditioning on implicit and explicit fear memoryPreprint
Keller, N. E., & Dunsmoor, J. E. (2019) · Learning & Memory · doi:10.1101/lm.050740.119 · Cited by 42
“Consequently, there is interest in approaches besides standard extinction to persistently reduce maladaptive behavior (Craske et al. 2014; Dunsmoor et al. 2015b).”
BackgroundMorriss, J., Wake, S., Lindner, M., McSorley, E., & Dodd, H. (2020) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2020.04.012 · Cited by 33
Mechanisms of Change in Exposure Therapy for Anxiety and Related Disorders: A Research Agenda
Benito, K., Pittig, A., Abramowitz, J. S., Arch, J. J., Chavira, D. A., de Kleine, R. A., Nadai, A. S. D., Hermans, D., Hofmann, S. G., Hoyer, J., et al. (2024) · Clinical Psychological Science · doi:10.1177/21677026241240727 · Cited by 37
“This remains problematic even when variable task selection is an explicit goal (Craske et al., 2014) because many patients become more willing to try challenging exposures later in treatment.”
Movement towards transdiagnostic psychotherapeutic practices for the affective disorders
Grös, D. F., Allan, N. P., & Szafranski, D. D. (2016) · Evidence-Based Mental Health · doi:10.1136/eb-2015-102286 · Cited by 36
“In addition, T-GCBT includes a large cognitive therapy component prior to exposure therapy, an approach that has received criticism in the more recent literature.(14) More specifically, use of cognitive therapy prior to exposure therapy is said to reduce the efficacy of exposure practices, which are the most efficacio…”
MethodCue exposure therapy reduces overeating of exposed and non-exposed foods in obese adolescents
Schyns, G., Roefs, A., Smulders, F. T. Y., & Jansen, A. T. M. (2017) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2017.09.002 · Cited by 36
“As suggested in the anxiety literature, exposure should aim at increasing associative strength of the inhibitory CS-noUS association, for example by violating CS-US expectancies (Craske et al., 2014).”
BackgroundExpectation-Focused Psychotherapy to Improve Clinical Outcomes
Doering, B. K., Glombiewski, J. A., & Rief, W. (2018) · International review of neurobiology · doi:10.1016/bs.irn.2018.02.004 · Cited by 37
0Phobia – towards a virtual cure for acrophobia: study protocol for a randomized controlled trial
Donker, T., van Esveld, S., Fischer, N., & van Straten, A. (2018) · Trials · doi:10.1186/s13063-018-2704-6 · Cited by 36
Inhibitory Learning for Anxiety-Related Disorders
Tolin, D. F. (2018) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.07.008 · Cited by 35
Conditioned inhibition: Historical critiques and controversies in the light of recent advances.
Sosa, R., & Ramírez, M. (2019) · Journal of Experimental Psychology: Animal Learning and Cognition · doi:10.1037/xan0000193 · Cited by 32
Thompson, B. L., Twohig, M. P., & Luoma, J. B. (2020) · Behavior Therapy · doi:10.1016/j.beth.2020.04.011 · Cited by 37
Bilek, E. L., Tomlinson, R. C., Whiteman, A., Johnson, T. D., Benedict, C., Phan, K. L., Monk, C. S., & Fitzgerald, K. D. (2021) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2021.1901230 · Cited by 36
“Remaining sessions (5–12) focused on completing exposures of increasing difficulty while also incorporating inhibitory learning techniques (Craske et al., 2014).”
BackgroundEhring, T. W., Limburg, K., Kunze, A. E., Wittekind, C. E., Werner, G. G., Wolkenstein, L., Guzey, M., & Cludius, B. (2022) · Clinical Psychology Review · doi:10.1016/j.cpr.2022.102163 · Cited by 43
Ryan, S. M., Strege, M. V., Oar, E. L., & Ollendick, T. H. (2016) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2016.07.011 · Cited by 36
Leveraging cognitive neuroscience for making and breaking real-world habits
Buabang, E. K., Donegan, K. R., Rafei, P., & Gillan, C. M. (2025) · Trends in Cognitive Sciences · doi:10.1016/j.tics.2024.10.006 · Cited by 34
“…capacities capacities Goal-directed inhibition is also clinically recognized: inhibition constitutes a core component of exposure therapy for anxiety disorders and OCD where individuals are systematically exposed to triggering stimuli and tasked with refraining from habitual responses [164,165].”
BackgroundOdgers, K., Kershaw, K. A., Li, S. H., & Graham, B. M. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2022.104203 · Cited by 35
Ollendick, T. H., & Muris, P. (2015) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2015.1020543 · Cited by 35
Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review
Knaust, T., Felnhofer, A., Kothgassner, O. D., Höllmer, H., Gorzka, R.-J., & Schulz, H. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.562506 · Cited by 40
The costs of distraction: The effect of distraction during repeated picture processing on the LPP
Paul, S., Kathmann, N., & Riesel, A. (2016) · Biological Psychology · doi:10.1016/j.biopsycho.2016.04.002 · Cited by 35
Ohst, B., & Tuschen‐Caffier, B. (2018) · PLoS ONE · doi:10.1371/journal.pone.0194493 · Cited by 35
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Byrne, S., Haber, P., Baillie, A., Giannopolous, V., & Morley, K. C. (2019) · Substance Use & Misuse · doi:10.1080/10826084.2019.1618328 · Cited by 37
Sherrill, A. M., Wiese, C. W., Abdullah, S., & Arriaga, R. I. (2022) · Journal of Technology in Behavioral Science · doi:10.1007/s41347-022-00273-3 · Cited by 31
Intensive Treatment of Pediatric OCD: The Case of Sarah.
Farrell, L. J., Sluis, R., & Waters, A. (2016) · Journal of Clinical Psychology · doi:10.1002/jclp.22397 · Cited by 11
Targeted Memory Reactivation During REM Sleep in Patients With Social Anxiety Disorder
Borghese, F., Henckaerts, P., Guy, F., Mayo, C., Delplanque, S., Schwartz, S., & Perogamvros, L. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.904704 · Cited by 33
“Inhibitory learning is central to extinction and deficit in this process could contribute to the development of anxiety disorders (Craske et al., 2014; Graham & Milad, 2011).”
Backgroundde Kleine, R. A., Hutschemaekers, M. H. M., Hendriks, G., Kampman, M., Papalini, S., van Minnen, A., & Vervliet, B. (2023) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2023.102698 · Cited by 38
Self-citationSchyns, G., van den Akker, K., Roefs, A., Hilberath, R., & Jansen, A. T. M. (2017) · Behaviour Research and Therapy · doi:10.1016/j.brat.2017.12.001 · Cited by 34
Identifying active ingredients in cognitive-behavioral therapies: What if we didn't?Preprint
Lorenzo‐Luaces, L. (2022) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104365 · Cited by 33
Christian, C., & Levinson, C. A. (2022) · New Ideas in Psychology · doi:10.1016/j.newideapsych.2022.100964 · Cited by 33
A Cognitive Behavioral Model Proposing That Clinical Burnout May Maintain Itself
Almén, N. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18073446 · Cited by 36
“For the change of phobic behaviors, exposure interventions may be motivated [4,66] and behavior activation may be considered for depression [133].”
BackgroundLockwood, J., Williams, L., Martin, J. L., Rathee, M., & Hill, C. (2022) · JMIR Mental Health · doi:10.2196/29008 · Cited by 34
“Negative expectancies associated with a perceived aversive outcome are countered by emphasizing the mismatch between what is expected to occur and what actually occurs [48].”
BackgroundNaim, R., Dombek, K., German, R. E., Haller, S. P., Kircanski, K., & Brotman, M. A. (2023) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2023.2264385 · Cited by 33
“Exposure is a behavioral technique extensively used in the treatment of anxiety disorders (Craske et al., 2008, 2014); patients confront and tolerate subjectively threatening stimuli while learning that expected adverse outcomes do not occur.”
MethodDrug memory reconsolidation: from molecular mechanisms to the clinical context
Milton, A. L. (2023) · Translational Psychiatry · doi:10.1038/s41398-023-02666-1 · Cited by 35
“[48] for methods to minimise the impact of contextual in fl uences).”
MethodCognitive behavioral therapy techniques and strategies.
Wenzel, A. E., Dobson, K. S., & Hays, P. A. (2016) · American Psychological Association eBooks · doi:10.1037/14936-000 · Cited by 36
Comparing musical and psychological emotion theories.
Warrenburg, L. (2019) · Psychomusicology Music Mind and Brain · doi:10.1037/pmu0000247 · Cited by 40
Behrens, S. C., Tesch, J., Sun, P. J. B., Starke, S., Black, M. J., Schneider, H., Pruccoli, J., Zipfel, S., & Giel, K. E. (2023) · Psychotherapy and Psychosomatics · doi:10.1159/000530932 · Cited by 41
Richter, J., Pittig, A., Hollandt, M., & Lueken, U. (2017) · Zeitschrift für Psychologie · doi:10.1027/2151-2604/a000309 · Cited by 37
“In a similar vein, numerous recommendations are already derived from the inhibitory model of fear reduction (Craske et al., 2014; Pittig et al., 2015; Pittig, van den Berg, & Vervliet, 2016).”
Internet-Based Extinction Therapy for Worry: A Randomized Controlled Trial
Andersson, E., Hedman, E., Wadström, O., Boberg, J., Andersson, E. Y., Axelsson, E., Bjureberg, J., Hursti, T., & Ljótsson, B. (2017) · Behavior Therapy · doi:10.1016/j.beth.2016.07.003 · Cited by 30
Scheveneels, S., Boddez, Y., Van Daele, T., & Hermans, D. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02849 · Cited by 33
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Associative learning versus fear habituation as predictors of long-term extinction retention
Brown, L. A., LeBeau, R. T., Chat, I. K.-Y., & Craske, M. G. (2016) · Cognition & Emotion · doi:10.1080/02699931.2016.1158695 · Cited by 32
“For more specific clinical recommendations for enhancing expectation violation, see Craske et al. (2012, 2014).”
BackgroundSelf-citationBennett, J., & Maynard, I. W. (2016) · Journal of Sport Psychology in Action · doi:10.1080/21520704.2016.1227414 · Cited by 32
Harm expectancy violation during exposure therapy for posttraumatic stress disorder
de Kleine, R. A., Hendriks, L., Becker, E. S., Broekman, T. G., & van Minnen, A. (2017) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2017.03.008 · Cited by 32
Woodruff, E. R., Chun, L. E., Hinds, L. R., Varra, N. M., Tirado, D., Morton, S. J., McClung, C. A., & Spencer, R. L. (2018) · eNeuro · doi:10.1523/eneuro.0455-18.2018 · Cited by 32
“Unfortunately, partial or negligible response to treatment occurs in 20–60% of PTSD patients (van Minnen et al., 2002; Schottenbauer et al., 2008; Craske et al., 2014), emphasizing the need for research in this area.”
BackgroundReactivation and Evaluation of Mastery Experiences Promotes Exposure Benefit in Height Phobia
Raeder, F., Woud, M. L., Schneider, S., Totzeck, C., Adolph, D., Margraf, J., & Zlomuzica, A. (2019) · Cognitive Therapy and Research · doi:10.1007/s10608-019-10018-x · Cited by 32
Blackwell, S. E., Woud, M. L., Margraf, J., & Schönbrodt, F. D. (2019) · Clinical Psychological Science · doi:10.1177/2167702619858071 · Cited by 34
Tackling fear: Beyond associative memory activation as the only determinant of fear responding
Boddez, Y., Moors, A., Mertens, G., & Houwer, J. D. (2020) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2020.02.009 · Cited by 32
“Nonetheless, propositional beliefs concerning the presence of danger are exactly the mental events in which the fear conditioning community is interested (e.g., Craske et al., 2014; Pittig, Treanor, LeBeau, & Craske, 2018; Pittig, van den Bergh, & Vervliet, 2016; Weisman & Rodebaugh, 2018).”
BackgroundZaback, M., Luu, M. J., Adkin, A. L., & Carpenter, M. G. (2021) · Scientific Reports · doi:10.1038/s41598-020-79417-5 · Cited by 32
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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