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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]
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“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
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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
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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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Norton, P. J., & Price, E. C. (2007) · Journal of Nervous & Mental Disease · doi:10.1097/01.nmd.0000253843.70149.9a · Cited by 612
SOP: A Model of Automatic Memory Processing in Animal Behavior
Wagner, A. R. (2014) · doi:10.4324/9781315798820-6 · Cited by 508
Contemporary Learning Theories: Pavlovian Conditioning and the Status of Traditional Learning Theory
Kehoe, E. J., Klein, S. B., & Mowrer, R. R. (1991) · The American Journal of Psychology · doi:10.2307/1423162 · Cited by 483
Cognitive Therapy of Anxiety Disorders: Science and Practice
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Models and mechanisms of anxiety: evidence from startle studies
Grillon, C. (2008) · Psychopharmacology · doi:10.1007/s00213-007-1019-1 · Cited by 456 · cited 1×
“Fear conditioning is considered a valid model for many of the anxiety disorders, including panic disorder, social anxiety disorder, specific phobia, obsessive compulsive disorder, and posttraumatic stress disorder (Grillon, 2008).”
Impaired fear inhibition is a biomarker of PTSD but not depression
Jovanovic, T., Norrholm, S. D., Blanding, N. Q., Davis, M., Duncan, E., Bradley, B., & Ressler, K. J. (2010) · Depression and Anxiety · doi:10.1002/da.20663 · Cited by 444 · cited 1×
“…regulation during extinction, that characterize individuals with anxiety disorders or elevated trait anxiety (e.g., Indovina, Robbins, Nunez-Elizalde, Dunn, & Bishop, 2011; Jovanovic et al., 2010; Milad et al., 2009, 2013; RougemontBucking et al., 2011; see Craske et al., 2012 for a summary).”
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Disruption of Reconsolidation Erases a Fear Memory Trace in the Human Amygdala
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“This effect has since been demonstrated in healthy human samples (Agren et al., 2012; Schiller et al., 2010).”
Quirk, G. J. (2002) · Learning & Memory · doi:10.1101/lm.49602 · Cited by 360 · cited 1×
“First, conditional fear shows spontaneous recovery (Quirk, 2002), meaning that the strength of the CR increases in proportion to the amount of time since the end of extinction.”
Extinction in human fear conditioning
Hermans, D., Craske, M. G., Mineka, S., & Lovibond, P. F. (2006) · Biological Psychiatry · doi:10.1016/j.biopsych.2005.10.006 · Cited by 328 · cited 1×
“Third, reinstatement of conditional fear occurs if unsignaled (or unpaired) US presentations occur in between extinction and retest (Rescorla & Heth, 1975; Hermans et al., 2005; Van Damme et al., 2006).”
Self-citationFear-Conditioning Mechanisms Associated with Trait Vulnerability to Anxiety in Humans
Indovina, I., Robbins, T. W., Núñez-Elizalde, A. O., Dunn, B. D., & Bishop, S. J. (2011) · Neuron · doi:10.1016/j.neuron.2010.12.034 · Cited by 310
Milad, M. R., Furtak, S. C., Greenberg, J. L., Keshaviah, A., Im, J. J., Falkenstein, M. J., Jenike, M., Rauch, S. L., & Wilhelm, S. (2013) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2013.914 · Cited by 308 · cited 1×
“…regulation during extinction, that characterize individuals with anxiety disorders or elevated trait anxiety (e.g., Indovina, Robbins, Nunez-Elizalde, Dunn, & Bishop, 2011; Jovanovic et al., 2010; Milad et al., 2009, 2013; RougemontBucking et al., 2011; see Craske et al., 2012 for a summary).”
Altered Processing of Contextual Information during Fear Extinction in PTSD: An fMRI Study
Rougemont-Bücking, A., Linnman, C., Zeffiro, T. A., Zeidan, M. A., Lebron-Milad, K., Rodriguez-Romaguera, J., Rauch, S. L., Pitman, R. K., & Milad, M. R. (2011) · CNS Neuroscience & Therapeutics · doi:10.1111/j.1755-5949.2010.00152.x · Cited by 292
A retrieval cue for extinction attenuates spontaneous recovery.
Brooks, D. C., & Bouton, M. E. (1993) · Journal of Experimental Psychology Animal Behavior Processes · doi:10.1037/0097-7403.19.1.77 · Cited by 272
What's wrong with fear conditioning?
Beckers, T., Krypotos, A.-M., Boddez, Y., Effting, M., & Kindt, M. (2013) · Biological Psychology · doi:10.1016/j.biopsycho.2011.12.015 · Cited by 272
A physiological model of phobic anxiety and desensitization
LADER, M. H., & Mathews, A. (1968) · Behaviour Research and Therapy · doi:10.1016/0005-7967(68)90021-1 · Cited by 257
Statistical theory of distributional phenomena in learning
Estes, W. K. (1955) · Psychological Review · doi:10.1037/h0046888 · Cited by 246 · cited 2×
“Variability is believed to enhance the storage capacity of newly learned information (Bjork & Bjork, 1992, 2006), pair the information to-be-learned with more retrieval cues (Estes, 1955), or generate a rule that captures the invariance among tasks (Schmidt & Bjork, 1992), which renders the information more retrievabl…”
Reinstatement of fear responses in human aversive conditioning
Hermans, D., Dirikx, T., Vansteenwegenin, D., Baeyens, F., den Bergh, O. V., & Eelen, P. (2004) · Behaviour Research and Therapy · doi:10.1016/j.brat.2004.03.013 · Cited by 240
Davey, G. C. L. (1992) · Advances in Behaviour Research and Therapy · doi:10.1016/0146-6402(92)90010-l · Cited by 240 · cited 1×
“expectancies regarding the frequency or intensity of aversive outcomes (Davey, 1992; Gallistel & Gibbon, 2000; Rescorla & Wagner, 1972).”
Role of inhibition in exposure therapy
Craske, M. G., Liao, B., Brown, L., & Vervliet, B. (2012) · Journal of Experimental Psychopathology · doi:10.5127/jep.026511 · Cited by 237 · cited 3×
“…regulation during extinction, that characterize individuals with anxiety disorders or elevated trait anxiety (e.g., Indovina, Robbins, Nunez-Elizalde, Dunn, & Bishop, 2011; Jovanovic et al., 2010; Milad et al., 2009, 2013; RougemontBucking et al., 2011; see Craske et al., 2012 for a summary).”
Self-citationBrooks, D. C., & Bouton, M. E. (1994) · Journal of Experimental Psychology Animal Behavior Processes · doi:10.1037//0097-7403.20.4.366 · Cited by 235 · cited 1×
“One option for enhancing retrieval of extinction learning and offsetting context renewal is to include retrieval cues (of the CS-no US association) during extinction training to be used in other contexts once extinction is over (Brooks & Bouton,1994; Dibbets &Maes, 2011; Vansteenwegen et al., 2006).”
Exposure Therapy and Extinction: Clinical Studies.
Craske, M. G., & Mystkowski, J. L. (2007) · American Psychological Association eBooks · doi:10.1037/11474-011 · Cited by 232 · cited 2×
“Clinically, this effect parallels the return of fear that commonly occurs with the lapse of time since completion of exposure therapy (e.g., Craske & Mystkowski, 2006; Craske & Rachman, 1986).”
Self-citationSloan, T., & Telch, M. J. (2002) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(01)00007-9 · Cited by 223 · cited 1×
“In phobic samples, the availability and use of safety signals and behaviors has been shown to be detrimental to exposure therapy (Sloan & Telch, 2002), whereas instructions to refrain from using safety behaviors improved outcomes (Salkovskis, 1991).”
Adrenergic transmission facilitates extinction of conditional fear in mice
Cain, C. K., Blouin, A. M., & Barad, M. (2004) · Learning & Memory · doi:10.1101/lm.71504 · Cited by 215 · cited 1×
“Notably, sustained arousal throughout extinction is associated with less fear at retest in animals (Rescorla, 2006) and in humans (Culver, Stephans & Craske, under review), arousal consolidates extinction memories (Cain et al., 2004) and in several of our studies, failure to habituate throughout exposure therapy was n…”
Conducting exposure treatment in multiple contexts can prevent relapse
Gunther, L. M., Denniston, J. C., & Miller, R. R. (1998) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(97)10019-5 · Cited by 210
Arch, J. J., & Craske, M. G. (2009) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2009.05.001 · Cited by 208 · cited 1×
“Deficits in inhibition and anxiety disorders A substantial number of individuals fail to achieve clinically significant symptom relief from exposure-based therapies (Arch & Craske, 2009) or experience a return of fear following exposure therapy (see Craske & Mystkowski, 2006).”
Self-citationEffects of varied-stimulus exposure training on fear reduction and return of fear
Rowe, M. K., & Craske, M. G. (1998) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(97)10017-1 · Cited by 202 · cited 2×
“We found that variability in terms of timing between exposure sessions (i.e., progressively longer intervals between exposure sessions) led to superior outcomes at follow-up than nonvariable-massed exposure in spider fearful samples (Rowe & Craske, 1998; Tsao & Craske, 2000).”
Self-citationProtection from extinction in human fear conditioning
Lovibond, P. F., Davis, N. R., & O'Flaherty, A. S. (2000) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(99)00121-7 · Cited by 189
Deepened extinction from compound stimulus presentation.
Rescorla, R. A. (2006) · Journal of Experimental Psychology Animal Behavior Processes · doi:10.1037/0097-7403.32.2.135 · Cited by 183 · cited 5×
“A second strategy is “deepened extinction” (Rescorla, 2000, 2006), in which either multiple fear CSs are first extinguished separately before being combined during extinction, or a previously extinguished cue is paired with a novel CS.”
InfluentialThe effects of changing contexts on return of fear following exposure therapy for spider fear.
Mineka, S., Mystkowski, J. L., Hladek, D., & Rodriguez, B. I. (1999) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.67.4.599 · Cited by 177
Deacon, B., Kemp, J. J., Dixon, L. J., Sy, J. T., Farrell, N. R., & Zhang, A. R. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.06.006 · Cited by 176 · cited 1×
“Deacon et al. (2013) found that interoceptive exposure that continued until the patient’s expectancy of an aversive outcome reached less than 5% was superior to standard interoceptive exposure.”
Neural networks and perceptual learning
Tsodyks, M. V., & Gilbert, C. D. (2004) · Nature · doi:10.1038/nature03013 · Cited by 166 · cited 1×
“Indeed, research suggests that repeated exposure leads to improved perceptual learning/stimulus discrimination (Tsodyks & Gilbert, 2004).”
Dissociation of within- and between-Session Extinction of Conditioned Fear
Plendl, W., & Wotjak, C. T. (2010) · Journal of Neuroscience · doi:10.1523/jneurosci.6038-09.2010 · Cited by 162 · cited 2×
“…against habituation approaches, neither fear reduction nor ending fear levels predict long term outcome from extinction or exposure (Baker et al., 2010; Culver et al., 2012; Kircanski et al., 2012; Plendl & Wotjak, 2010; Prenoveau et al., 2013; Rescorla, 2006 e discussed in prior sections).”
Does habituation matter? Emotional processing theory and exposure therapy for acrophobia
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010) · Behaviour Research and Therapy · doi:10.1016/j.brat.2010.07.009 · Cited by 161 · cited 4×
“…evidence against habituation approaches, neither fear reduction nor ending fear levels predict long term outcome from extinction or exposure (Baker et al., 2010; Culver et al., 2012; Kircanski et al., 2012; Plendl & Wotjak, 2010; Prenoveau et al., 2013; Rescorla, 2006 e discussed in prior…”
InfluentialSelf-citationEffects of recent exposure to a conditioned stimulus on extinction of Pavlovian fear conditioningPreprint
Chan, W. Y. M., Leung, H. T., Westbrook, R. F., & McNally, G. P. (2010) · Learning & Memory · doi:10.1101/lm.1912510 · Cited by 156
Mental Reinstatement of Context and Return of Fear in Spider-Fearful Participants
Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006) · Behavior Therapy · doi:10.1016/j.beth.2005.04.001 · Cited by 154 · cited 1×
“, 2011), although instructions to mentally reinstate what was learned during exposure (an instructional retrieval cue) had more robust effects in reducing context renewal in another study (Mystkowski et al., 2006).”
Self-citationTreatment context and return of fear in spider phobia
Mystkowski, J. L., Craske, M. G., & Echiverri, A. M. (2002) · Behavior Therapy · doi:10.1016/s0005-7894(02)80035-1 · Cited by 153 · cited 1×
“These effects have been observed in clinical analog samples undergoing exposure therapy and follow-up testing in the same versus different contexts (Mystkowski et al., 2002; Mystkowski et al., 2003; Mysktowski et al., 2006; Culver, Stoyanova & Craske, 2011).”
Self-citationContext-specificity of relapse: effects of therapist and environmental context on return of fear.
Rodriguez, B. I., Craske, M., Mineka, S., & Hladek, D. (1999) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(98)00106-5 · Cited by 152
Self-citationManipulations of exposure-based therapy to reduce return of fear: a replication
Lang, A. J., & Craske, M. G. (2000) · Behaviour Research and Therapy · doi:10.1016/s0005-7967(99)00031-5 · Cited by 149 · cited 4×
“Also, variability in terms of the stimuli used during exposure led to positive outcomes in terms of spontaneous recovery in spider fearful and height fearful samples (Lang & Craske, 2000; Rowe & Craske, 1998), although a third study of contaminant anxiety showed trends only (Kircanski et al., 2012).”
InfluentialSelf-citationConsolidation of Long-Term Memory: Evidence and Alternatives.
Meeter, M., & Murre, J. M. J. (2004) · Psychological Bulletin · doi:10.1037/0033-2909.130.6.843 · Cited by 148 · cited 1×
“Indeed, mental rehearsal, or in this case mental rehearsal of the inhibitory CS-no US association, is an important component of memory consolidation (Joos, 2011; Meeter & Murre, 2004).”
Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., Van den Bergh, O., & Hermans, D. (2007) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.08.023 · Cited by 148 · cited 2×
“…have been shown to offset context renewal in rodent samples (e.g., Gunther, Denniston, & Miller, 1998), in human laboratory studies (e.g., Bandarian Balooch & Neumann, 2011, Bandarian Balooch, Neumann, & Boschen, 2012) and in a clinical analog study of exposure therapy (Vansteenwegen et al., 2007).”
Self-citationIs aversive learning a marker of risk for anxiety disorders in children?
Craske, M. G., Waters, A. M., Lindsey Bergman, R., Naliboff, B., Lipp, O. V., Negoro, H., & Ornitz, E. M. (2008) · Behaviour Research and Therapy · doi:10.1016/j.brat.2008.04.011 · Cited by 146
Self-citationSalkovskis, P. M., Hackmann, A., Adrian Wells, A., Gelder, M., & Clark, D. M. (2007) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.02.008 · Cited by 143
Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2011.10.010 · Cited by 140 · cited 12×
“, repeated increases following decreases in minute to minute fear levels) is a positive predictor of outcomes in contaminant anxiety and public speaking anxiety (Kircanski et al., 2012; Culver et al., 2012).”
InfluentialSelf-citationExtinction in multiple contexts does not necessarily make extinction less vulnerable to relapse
Bouton, M. E., Garcı́a-Gutiérrez, A., Zilski-Pineño, J. M., & Moody, E. W. (2005) · Behaviour Research and Therapy · doi:10.1016/j.brat.2005.07.007 · Cited by 138
Tabibnia, G., Lieberman, M. D., & Craske, M. G. (2008) · Emotion · doi:10.1037/1528-3542.8.3.307 · Cited by 135
Self-citationTsao, J. C. I., & Craske, M. G. (2000) · Behavior Therapy · doi:10.1016/s0005-7894(00)80026-x · Cited by 131 · cited 1×
“We found that variability in terms of timing between exposure sessions (i.e., progressively longer intervals between exposure sessions) led to superior outcomes at follow-up than nonvariable-massed exposure in spider fearful samples (Rowe & Craske, 1998; Tsao & Craske, 2000).”
Self-citationReacquisition following extinction in appetitive conditioning
Ricker, S. T., & Bouton, M. E. (1996) · Animal Learning & Behavior · doi:10.3758/bf03199014 · Cited by 126 · cited 1×
“Fourth, rapid reacquisition of the CR is seen if the CS-US pairings are repeated following extinction (Ricker & Bouton, 1996).”
The role of extinction and reinstatement in attentional bias to threat: A conditioning approach
Damme, S. V., Crombez, G., Hermans, D., Koster, E. H. W., & Eccleston, C. (2005) · Behaviour Research and Therapy · doi:10.1016/j.brat.2005.11.008 · Cited by 111
Memory and society psychological perspectives
Nilsson, L. (2006) · Cited by 109
Occasional reinforced trials during extinction can slow the rate of rapid reacquisition
Bouton, M. E., Woods, A. M., & Pineño, O. (2004) · Learning and Motivation · doi:10.1016/j.lmot.2004.05.001 · Cited by 109 · cited 4×
“As with animal studies (Bouton et al., 2004), we found that occasional reinforced extinction sustained fear arousal during extinction but attenuated the subsequent reacquisition of fear in a human conditioning study (Culver et al.”
InfluentialChanges in caffeine states enhance return of fear in spider phobia.
Mystkowski, J. L., Mineka, S., Vernon, L. L., & Zinbarg, R. E. (2003) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.71.2.243 · Cited by 108
Emotional variability and sustained arousal during exposure
Culver, N. C., Stoyanova, M., & Craske, M. G. (2012) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2011.10.009 · Cited by 106 · cited 4×
“…against habituation approaches, neither fear reduction nor ending fear levels predict long term outcome from extinction or exposure (Baker et al., 2010; Culver et al., 2012; Kircanski et al., 2012; Plendl & Wotjak, 2010; Prenoveau et al., 2013; Rescorla, 2006 e discussed in prior sections).”
InfluentialSelf-citationExtinction can be enhanced by a concurrent excitor.
Rescorla, R. A. (2000) · Journal of Experimental Psychology Animal Behavior Processes · doi:10.1037//0097-7403.26.3.251 · Cited by 101 · cited 1×
“A second strategy is “deepened extinction” (Rescorla, 2000, 2006), in which either multiple fear CSs are first extinguished separately before being combined during extinction, or a previously extinguished cue is paired with a novel CS.”
Reducing contamination by exposure plus safety behaviour
Rachman, S., Shafran, R., Radomsky, A. S., & Zysk, E. (2011) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2011.02.010 · Cited by 96
Neumann, D. L., Lipp, O. V., & Cory, S. E. (2006) · Behaviour Research and Therapy · doi:10.1016/j.brat.2006.02.001 · Cited by 90 · cited 1×
“On the other hand, one conditioning study in rodents (Bouton, García-Gutiérrez, Zilkski, & Moody, 2006) and another conditioning study in humans (Neumann et al., 2007) failed to demonstrate detectable benefits of multiple contexts throughout extinction on context renewal, suggesting that the effects are unstable.”
The acquisition, extinction, and spontaneous recovery of a conditioned operant response.
Graham, C. H., & Gagné, R. M. (1940) · Journal of Experimental Psychology · doi:10.1037/h0060674 · Cited by 87
Vansteenwegen, D., Vervliet, B., Hermans, D., Beckers, T., Baeyens, F., & Eelen, P. (2006) · Behaviour Research and Therapy · doi:10.1016/j.brat.2005.10.014 · Cited by 83 · cited 1×
“One option for enhancing retrieval of extinction learning and offsetting context renewal is to include retrieval cues (of the CS-no US association) during extinction training to be used in other contexts once extinction is over (Brooks & Bouton,1994; Dibbets &Maes, 2011; Vansteenwegen et al., 2006).”
Self-citationDeacon, B. J., Sy, J. T., Lickel, J. J., & Nelson, E. A. (2010) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2009.10.004 · Cited by 82
Woods, A. M., & Bouton, M. E. (2006) · Learning and Motivation · doi:10.1016/j.lmot.2006.07.003 · Cited by 81
Extinction treatment in multiple contexts attenuates ABC renewal in humans
Bandarian‐Balooch, S., Neumann, D. L., & Boschen, M. J. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2012.06.003 · Cited by 80
Optimizing Treatment and Instruction: Implications of a New Theory of Disuse
Bjork, R. A., & Bjork, E. L. (2013) · Psychology Press eBooks · doi:10.4324/9780203086254-13 · Cited by 79
Memory retrieval before or after extinction reduces recovery of fear in adolescent ratsPreprint
Baker, K., McNally, G. P., & Richardson, R. (2013) · Learning & Memory · doi:10.1101/lm.031989.113 · Cited by 78
All we need is a cue to remember: The effect of an extinction cue on renewal
Dibbets, P., Havermans, R. C., & Arntz, A. R. (2008) · Behaviour Research and Therapy · doi:10.1016/j.brat.2008.05.007 · Cited by 72 · cited 1×
“One risk of retrieval cues, however, is that they may acquire an inhibitory value and became a safety signal (Dibbets et al. 2008).”
Clinical relevance of retrieval cues for attenuating context renewal of fear
Culver, N. C., Stoyanova, M., & Craske, M. G. (2010) · Journal of Anxiety Disorders · doi:10.1016/j.janxdis.2010.10.002 · Cited by 70 · cited 1×
“In clinical analog anxious samples, the effects of a retrieval cue (distinctive pen and clip board) upon context renewal were very weak in one study (Culver et al., 2011), although instructions to mentally reinstate what was learned during exposure (an instructional retrieval cue) had more robust…”
Self-citationBandarian‐Balooch, S., & Neumann, D. L. (2010) · Learning and Motivation · doi:10.1016/j.lmot.2010.08.008 · Cited by 65 · cited 2×
“…have been shown to offset context renewal in rodent samples (e.g., Gunther, Denniston, & Miller, 1998), in human laboratory studies (e.g., Bandarian Balooch & Neumann, 2011, Bandarian Balooch, Neumann, & Boschen, 2012) and in a clinical analog study of exposure therapy (Vansteenwegen et al., 2007).”
Meuret, A. E., Wolitzky-Taylor, K. B., Twohig, M. P., & Craske, M. G. (2012) · Behavior Therapy · doi:10.1016/j.beth.2011.08.002 · Cited by 64
Self-citationFailure to replicate the deleterious effects of safety behaviors in exposure therapy
Sy, J. T., Dixon, L. J., Lickel, J. J., Nelson, E. A., & Deacon, B. J. (2011) · Behaviour Research and Therapy · doi:10.1016/j.brat.2011.02.005 · Cited by 61 · cited 1×
“Similarly, Deacon and colleagues have failed to replicate the deleterious effect of continuing to engage in safety behaviors (including the availability of the safety behavior but without actual engagement of it) during exposure in claustrophobic fear (Deacon et al., 2010; Sy et al., 2011).”
Current Controversies in the Anxiety Disorders
Geller, J. L., & Goisman, R. M. (1997) · Psychiatric Services · doi:10.1176/ps.48.8.1085 · Cited by 50
Human fear conditioning and extinction: Timing is everything…or is it?
Prenoveau, J. M., Craske, M. G., Liao, B., & Ornitz, E. M. (2012) · Biological Psychology · doi:10.1016/j.biopsycho.2012.02.005 · Cited by 48
Self-citationReturn of fear: Perceived skill and heart‐rate responsivity
Craske, M. G., & Rachman, S. (1987) · British Journal of Clinical Psychology · doi:10.1111/j.2044-8260.1987.tb01346.x · Cited by 45
Self-citationThe effect of an extinction cue on ABA-renewal: Does valence matter?
Dibbets, P., & Maes, J. H. R. (2011) · Learning and Motivation · doi:10.1016/j.lmot.2010.12.003 · Cited by 34
Optimal attentional focus during exposure in specific phobia: A meta-analysis
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Contingency and Relative Associative Strength
Klein, S. B., & Mowrer, R. R. (2014) · Psychology Press eBooks · doi:10.4324/9781315801896-10 · Cited by 25
Repetitive thought in human (fear) conditioning: Strengthening the acquisition and extinction memory
Joos, E. (2012) · Lirias · Cited by 6
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Using Neuroscience to Help Understand Fear and Anxiety: A Two-System Framework
LeDoux, J. E., & Pine, D. S. (2016) · American Journal of Psychiatry · doi:10.1176/appi.ajp.2016.16030353 · Cited by 1,035
“anxiety evoked during exposure (132), postexposure consolidation (120), or the use of particular outcome measures to”
BackgroundChildhood Adversity and Neural Development: A Systematic Review
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Self-citation
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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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