Advancing the treatment of anxiety disorders in transition‐age youth: a review of the therapeutic effects of unconscious exposure.
Open accessAbstract
Background: The real‐world effectiveness of exposure‐based therapies for youth depends on the willingness and ability of young people to tolerate confronting their fears, which can be experienced as highly aversive and create problems with treatment engagement and acceptance. Recently, neuroscientific research on the nonconscious basis of fear has been translated into novel exposure interventions that bypass conscious processing of feared stimuli and that thus do not cause phobic youth to experience distress. We present a review of these unconscious exposure interventions. Methods: A PRISMA‐based search yielded 20 controlled experiments based on three paradigms that tested if fear‐related responses could be reduced without conscious awareness in highly phobic, transition‐age youth: 14 randomized controlled trials (RCTs), 5 fMRI studies (1 was also an RCT), 4 psychophysiological studies (3 were also RCTs), and 1 ERP study. We conducted meta‐analyses of outcomes where feasible. Results: Unconscious exposure interventions significantly (1) reduced avoidance behavior (range of Cohen's d = 0.51–0.95) and self‐reported fear (d = 0.45–1.25) during in vivo exposure to the feared situation; (2) reduced neurobiological indicators of fear (d = 0.54–0.62) and concomitant physiological arousal (d = 0.55–0.64); (3) activated neural systems supporting fear regulation more strongly than visible exposure to the same stimuli (d = 1.2–1.5); (4) activated regions supporting fear regulation that mediated the reduction of avoidance behavior (d = 0.70); (5) evoked ERPs suggesting encoding of extinction memories (d = 2.13); and (6) had these effects without inducing autonomic arousal or subjective fear. Conclusions: Unconscious exposure interventions significantly reduce a variety of symptomatic behaviors with mostly moderate effect sizes in transition‐age youth with specific phobias. fMRI and physiological findings establish a neurophysiological basis for this efficacy, and suggest it occurs through extinction learning. Unconscious exposure was well tolerated, entirely unassociated with drop out, and is highly scalable for clinical practice. However, a number of limitations must be addressed to assess potential clinical impacts, including combining unconscious exposure with exposure therapy to boost treatment acceptance and efficacy.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
1 of 6 cited sources checked · 0 supported · 0 flagged · accuracy not yet measured
- Method
The review used a systematic PRISMA-guided search to identify published studies testing whether unconscious exposure to phobic stimuli reduced fear-related responses in phobic youth participants.
“We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a 27-item checklist to ensure high-quality systematic reviews (Page et al. 2021). The PRISMA guidelines enabled us to identify every published study, as recently as February 1, 2024, that tested the hypothesis that unconscious exposure to phobic stimuli reduced fear-related responses in phobic youth participants.”
Quote in the paperNot yet classified1 of 1 sources checked- cites Page et al. 2021 source
The Abstract and “How to use PRISMA 2020” identify PRISMA as a 27-item guideline for reporting systematic reviews, supporting the citation’s identification of the checklist. But the “Scope of the guideline” says PRISMA is not intended to guide review conduct or assess methodological quality. It therefore does not establish that following PRISMA ensured a high-quality search or identified every study; the phobic-youth search is the citing authors’ own account, not a finding of this source. (LLM, conf=0.87)
Experimental — accuracy not yet measured
- Finding
The paper reports that the DecNef intervention eliminated baseline amygdala activity and skin conductance responses to feared animals in phobic participants.
“The 5 daily sessions of DecNef eliminated baseline levels of amygdala activity (Cohen’s d=0.62) and SCRs (Cohen’s d=0.55) to pictures of other feared animals from the reinforced category.”
Quote in the paperNot yet classified - Finding
The discussion concludes that 19 of the 20 included studies suggest unconscious exposure is efficacious for specific phobia in transition-age youth.
“Although the studies and investigative teams in this review are relatively few, 19 of the 20 included studies suggest that unconscious exposure is an efficacious intervention for Specific Phobia in transition-age youth.”
Quote in the paperNot yet classified - Finding
The paper reports that visible exposure induces autonomic arousal and fear, whereas masked VBE reduces avoidance without inducing arousal or fear.
“Whereas visible exposure to spider images induces considerable autonomic arousal, causes phobic participants to experience fear, and does not affect their avoidance of the tarantula, VBE has precisely the opposite effects: it reduces avoidance without inducing either arousal or fear in phobic participants.”
Quote in the paperNot yet classified - Finding
The discussion argues that unconscious exposure induces new learning of non-aversive 'Stimulus→No fear' associations that facilitate fear extinction.
“Thus, these multiple dissociations between the effects of conscious versus unconscious exposure on autonomic arousal, subjective fear, and fear of the tarantula suggest that unconscious exposure induces new learning of “Stimulus→No fear” associations to facilitate fear extinction.”
Quote in the paperNot yet classified
- Finding
The review proposes that unconscious exposure and exposure therapy naturally complement each other and may be combined to maximize therapeutic effects.
“Unconscious exposure and exposure therapy naturally complement each other; integrating them in treatment would follow directly from the dual process model of fear (LeDoux & Pine, 2016; Öhman & Mineka, 2001).”
Quote in the paperNot yet classified0 of 1 sources checked- cites LeDoux & Pine, 2016; Öhman & Mineka, 2001
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Finding
The review says that the ERP study suggested unconscious exposure reduces fear via extinction learning in highly phobic adolescents.
“Snodgrass, Shevrin, Abelson and Kushwaha (2023) conducted an event-related potential (ERP) study suggesting that unconscious exposure reduces fear via extinction learning in highly phobic adolescents.”
Quote in the paperNot yet classified0 of 1 sources checked- cites Snodgrass, Shevrin, Abelson and Kushwaha (2023)
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Finding
The paper states that unconscious exposure bypasses the induction of experienced fear responses requiring conscious, controlled regulation strategies and facilitates extinction learning at an unconscious, implicit level.
“The psychophysiological and fMRI studies featured in this review have repeatedly demonstrated that unconscious exposure bypasses the induction of experienced fear responses requiring conscious, controlled regulation strategies, and thereby facilitates extinction learning at an unconscious, implicit level of processing.”
Quote in the paperNot yet classified - Finding
The discussion says that unconscious exposure can help phobic youth make initial gains in reducing physiological arousal and avoidance behavior and thereby better tolerate exposure therapy.
“Unconscious exposure can target first-level fear responses through its actions on extinction pathways and inhibitory learning, allowing phobic youth to make initial gains in the reduction of physiological arousal and avoidance behavior. These gains should allow them to better tolerate exposure therapy, and thereby boost treatment efficacy.”
Quote in the paperNot yet classified - Finding
The review reports that meta-analyses of VBE studies showed unconscious exposure made in vivo exposure more tolerable and reduced fear as participants moved closer to the feared situation.
“Meta-analyses of VBE studies showed that unconscious exposure reliably made in vivo exposure to the feared situation more tolerable for participants, who moved closer towards the feared situation and reported reduced fear of it.”
Quote in the paperNot yet classified - Finding
The paper states that unconscious exposure was entirely unassociated with treatment avoidance or drop out and was painless and non-distressing.
“Unconscious exposure was entirely unassociated with treatment avoidance or drop out, being painless and non-distressing.”
Quote in the paperNot yet classified - Finding
The review reports that VBE reduced avoidance of the tarantula only in phobic participants who were unaware of exposure.
“VBE reduced avoidance of the tarantula only in phobic participants who were unaware of exposure (N=279, n=128 VBE unaware and n=151 placebo unaware; F(1,277)=36.8, p=.0001, d=.73).”
Quote in the paperNot yet classified - Finding
The paper reports that fMRI and physiological findings support a neurophysiological basis for the efficacy of unconscious exposure and suggest that it works through extinction learning.
“fMRI and physiological findings establish a neurophysiological basis for this efficacy, and suggest it occurs through extinction learning.”
Quote in the paperNot yet classified - Finding
The review concludes that unconscious exposure interventions significantly reduce a variety of symptomatic behaviors in transition-age youth with Specific Phobias.
“Unconscious exposure interventions significantly reduce a variety of symptomatic behaviors with mostly moderate effect sizes in transition-age youth with Specific Phobias.”
Quote in the paperNot yet classified - Finding
The review states that unconscious exposure was well tolerated, entirely unassociated with drop out, and highly scalable for clinical practice.
“Unconscious exposure was well tolerated, entirely unassociated with drop out, and is highly scalable for clinical practice.”
Quote in the paperNot yet classified - Background
The introduction argues that avoidance of exposure creates problems with treatment avoidance and acceptance in youth exposure-based therapies.
“This inherent aspect of exposure creates considerable problems with treatment avoidance and acceptance, which plagues the real-world application of exposure-based therapies for youth”
Quote in the paperNot yet classified0 of 1 sources checked- cites Eaton, Bienvenu, & Miloyan, 2018; Gunter & Whittal, 2010; Iza, Olfson, Vermes, Hoffer, et al. 2013; Uman, Birnie, Noel, Parker, Chambers, et al. 2013
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Background
The paper states that unconscious exposure interventions were translated from neuroscientific research on the non-conscious basis of fear and are designed to bypass direct confrontation with the feared stimulus.
“These interventions represent translations of neuroscientific research on the non-conscious basis of fear, endeavoring to reduce fear via non-consicous exposure to the feared stimulus that bypasses direct confrontation of the feared stimulus and thus does not induce emotional distress.”
Quote in the paperNot yet classified0 of 1 sources checked- cites Balderston & Helstetter, 2010; Carlsson, Petersson, Lundqvist, Karlsson, et al. 2004; Ledoux & Pine, 2016; Morris, Öhman, & Dolan, 1998, 1999; Öhman & Mineka, 2001; Öhman & Soares, 1994; Whalen, Kagan, Cook, Davis et al. 2004
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Background
The review notes that a main limitation of unconscious exposure is that it has not yet been administered to children and younger adolescents under 16 with specific phobia or fear-based disorders.
“Unconscious exposure interventions have yet to be administered to children and younger adolescents (<16 years-old) with Specific Phobia or fear-based disorders.”
Quote in the paperNot yet classified - Background
The review says that specific phobia tends not to be associated with the extensive comorbidities that commonly occur with PTSD and social anxiety disorder.
“Moreover, Specific Phobia tends to not be associated with the extensive comorbidities that commonly occur with PTSD and SAD.”
Quote in the paperNot yet classified - Background
The review found that exposure-based therapies for youth depend on willingness and ability to tolerate confronting fears, and that this is often experienced as aversive.
“The efficacy of all exposure-based therapies for youth depends on their willingness and ability to tolerate directly confronting their fears, which for many is experienced as intolerably aversive.”
Quote in the paperNot yet classified - Method
The results section says VBE presents extremely brief masked images of feared stimuli repeatedly to engage unconscious processing of phobic stimuli.
“VBE presents a continuous series of extremely brief images (.02-.03 sec) representing a person’s fears, each phobic image being followed by a masking stimulus to prevent its conscious recognition. This sequence of phobic image-mask stimuli is repeated many times in an exposure session, the rationale being to continuously engage unconscious processing of phobic stimuli.”
Quote in the paperNot yet classified0 of 1 sources checked- cites Siegel, Weinberger, and colleagues
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Method
The authors' review used a PRISMA-based search and identified 20 controlled experiments across three paradigms that tested fear reduction without conscious awareness in transition-age youth.
“A PRISMA-based search yielded 20 controlled experiments based on three paradigms that tested if fear-related responses could be reduced without conscious awareness in highly phobic, transition-age youth: 14 randomized controlled trials, 5 fMRI studies (1 was also an RCT), 4 psychophysiological studies (3 were also RCTs), and 1 ERP study.”
Quote in the paperNot yet classified - Method
The review states that in VBE studies, continuous visual masking is used to prevent subjective awareness of exposure and thereby prevent distress that would otherwise interfere with fear-reducing effects.
“Continuous visual masking is used in VBE to prevent subjective awareness of exposure to phobic stimuli and thereby prevent highly phobic youth from experiencing distress, which would otherwise interfere with the fear-reducing effects of exposure.”
Quote in the paperNot yet classified
Statistics that don’t add up
Each reported p-value recomputed from its test statistic and degrees of freedom.
Inconsistent p-value: r(8)= −.73, p = .03
MinorThe paper reports p = .03 here; recomputing from the test statistic and its degrees of freedom gives p = .017 (two-tailed). The check cannot tell whether the statistic or the p-value is the misprint.
Reported p = .03 · recomputed p = .017
“r(8)= −.73, p=.03”
Statistics recomputed
Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.
- Doesn’t add upr(8) = -0.73reported p = .03 · recomputed p = .017
“r(8)= −.73, p = .03”
- ConsistentF(1, 342) = 32.5reported p = .0001 · recomputed p < .001
“F(1,342)=32.5, p = .0001”
The paper prints p at a floor (such as p < .001)
- ConsistentF(1, 235) = 26.3reported p = .0001 · recomputed p < .001
“F(1,235)=26.3, p = .0001”
The paper prints p at a floor (such as p < .001)
- ConsistentF(1, 134) = 11.3reported p = .001 · recomputed p = .001
“F(1,134)=11.3, p = .001”
- ConsistentF(1, 134) = 21.8reported p = .0001 · recomputed p < .001
“F(1,134)=21.8, p = .0001”
The paper prints p at a floor (such as p < .001)
- ConsistentF(1, 136) = 3.93reported p = .05 · recomputed p = .049
“F(1,136)=3.93, p = .05”
- ConsistentF(1, 134) = 27.5reported p = .0001 · recomputed p < .001
“F(1,134)=27.5, p = .0001”
The paper prints p at a floor (such as p < .001)
- ConsistentF(1, 63) = 7.67reported p = .007 · recomputed p = .007
“F(1,63)= 7.67, p = .007”
- ConsistentF(1, 277) = 36.8reported p = .0001 · recomputed p < .001
“F(1,277)=36.8, p = .0001”
The paper prints p at a floor (such as p < .001)
- ConsistentF(1, 63) = 0.75reported p = .39 · recomputed p = .390
“F(1,63)=.75, p = .39”
- Consistentr(8) = 0.82reported p = .01 · recomputed p = .004
“r(8)= .82, p = .01”
The paper prints p at a floor (such as p < .001)
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
The claimed exclusive focus on Specific Phobia omits a social-anxiety study
MinorThe limitations section says studies focused only on Specific Phobias, whereas the results include participants diagnosed with Social Anxiety Disorder.
“Thus far, studies have focused only on Specific Phobias.”
“Participants in one study met DSM-IV criteria for a diagnosis of Social Anxiety Disorder.”
The abstract and body give different numbers of paradigms
MinorThe abstract says the experiments used three paradigms, while the methods and results say they used four.
“A PRISMA-based search yielded 20 controlled experiments based on three paradigms”
“The 20 included studies were generated by 4 experimental paradigms”
The same ABM study is assigned different publication years
MinorThe description identifies the Maoz study as published in 2013, then cites it as a 2023 study in the next paragraph.
“Maoz, Abend, Fox, Pine and Bar-Haim (2013) tested whether subliminal ABM training would reduce social anxiety and social stress”
“Maoz et al. (2023) then randomized 51 HSAs to either subliminal ABM or placebo training.”
The no-arousal conclusion conflicts with an observed SCR increase
MinorThe abstract says the interventions had their effects without inducing autonomic arousal, but the ERP results report increased skin conductance responses during subliminal exposure.
“(6) had these effects without inducing autonomic arousal or subjective fear.”
“In the first half of trials, subliminal exposure to spider stimuli increased SCRs”
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Self-citationNo effect of very brief exposure to masked food pictures on fear of food in anorexia nervosa
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Flagged first, then by citations
Research works printed but not linked: 2
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Cited by
Sorted by citations
Jong, H. J. B.-D., Dejonckheere, E., Smeets, T., Lodder, P., & Karreman, A. (2025) · Cognition & Emotion · doi:10.1080/02699931.2025.2508400 · Cited by 1 · see citing works
“Being reluctant to undergo exposure is a considerable problem for patients – and especially youth – with an anxiety disorder, which is manifested through dropping out of therapy or avoidance of seeking professional help altogether (Radez et al., 2021; Reardon et al., 2017; Siegel & Peterson, 2025).”
- Authors
- Siegel, P., & Peterson, B. S.
- Affiliations
- Purchase College (US)
- University of Southern California (US)
- Corresponding author
- Siegel, Paul
- Venue
- Journal of Child Psychology and Psychiatry
- Publisher
- Wiley
- Published
- 2024-08-11
- Volume
- 66
- Issue
- 1
- Pages
- 98-121
- ISSN
- 0021-9630 (ISSN-L)
- 1469-7610
- PMC
- PMC11652263
- OpenAlex
- W4401497246
- Cited by
- 1
- References
- 119
- Citations by year
- 2025: 1
- FWCI
- 0.33
- Type
- journal article
- Language
- en
- Open access
- green
- pmc.ncbi.nlm.nih.gov
- Locations
- Journal of Child Psychology and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (submittedVersion)
- Europe PMC (PubMed Central) (submittedVersion)
- Funders
- National Institute of Mental Health (7R21MH101564‐02)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Life Sciences › Neuroscience › Cognitive Neuroscience › Memory and Neural Mechanisms
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- anxiety disorders, transition-age youth, specific phobia, avoidance behavior, fear extinction, memory extinction, fear regulation, autonomic arousal
- MeSH terms
- Adolescent, Anxiety Disorders, Fear
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