Advertisement

Helping Exposure Succeed: Learning Theory Perspectives on Treatment Resistance and Relapse

  • Mark B. Powers
  • Bram Vervliet
  • Jasper A.J. Smits
  • Michael W. Otto
Chapter
Part of the Series in Anxiety and Related Disorders book series (SARD)

Abstract

Exposure-based interventions are core to the psychosocial treatment of anxiety disorders. Protocols utilizing these elements are associated with some of the highest effect sizes in the anxiety treatment literature (e.g., Hofmann & Smits, 2008). These interventions rely on the use of experience to aid the learning of safety in relation to the core fears underlying anxiety disorders; yet, the efficacy of these interventions may be limited by a number of contextual and procedural challenges. This chapter provides a review of studies of these procedures and parameters and provides a conceptual overview of a heuristic for guiding exposure interventions. Relative to this heuristic we attend to the stimulus properties, duration, spacing, gradation, and, particularly, context of exposure interventions.

Keywords

Anxiety Disorder Social Anxiety Disorder Panic Disorder Extinction Trial Fear Memory 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. Baeyens, F., Eelen, P., Van den Bergh, O., & Crombez, G. (1989). Acquired affective-evaluative value: Conservative but not unchangeable. Behaviour Research and Therapy, 27(3), 279–287.PubMedCrossRefGoogle Scholar
  2. Barlow, D. H. (2002). Anxiety and its disorders (2nd ed.). New York: The Guilford Press.Google Scholar
  3. Barlow, D., & Craske, M. (2007). Mastery of your anxiety and panic (4th ed.). New York: Oxford University Press.Google Scholar
  4. Barlow, D. H., Leitenberg, H., Agras, W. S., & Wincze, J. P. (1969). The transfer gap in systematic desensitization: An analogue study. Behaviour Research and Therapy, 7(2), 191–196.PubMedCrossRefGoogle Scholar
  5. Basoglu, M., Marks, I. M., Kilic, C., Brewin, C. R., & Swinson, R. P. (1994). Alprazolam and exposure for panic disorder with agoraphobia. Attribution of improvement to medication predicts subsequent relapse. British Journal of Psychiatry, 164(5), 652–659.PubMedCrossRefGoogle Scholar
  6. Baum, M., Andrus, T., & Jacobs, W. J. (1990). Extinction of a conditioned emotional response: Massed and distributed exposures. Behaviour Research and Therapy, 28(1), 63–68.PubMedCrossRefGoogle Scholar
  7. Borkovec, T., & Grayson, J. B. (1980). Consequence of increasing the functional impact of internal emotional stimuli (Vol. 6). New York: Plenum Press.Google Scholar
  8. Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy, 26(2), 137–149.PubMedCrossRefGoogle Scholar
  9. Bouton, M. E. (1993). Context, time, and memory retrieval in the interference paradigms of Pavlovian learning. Psychological Bulletin, 114(1), 80–99.PubMedCrossRefGoogle Scholar
  10. Bouton, M. E. (2000). A learning theory perspective on lapse, relapse, and the maintenance of behavior change. Health Psychology, 19(1, Supplement 1), 57–63.PubMedCrossRefGoogle Scholar
  11. Bouton, M. E. (2002). Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction. Biological Psychiatry, 52(10), 976–986.PubMedCrossRefGoogle Scholar
  12. Bouton, M. E., & Brooks, D. C. (1993). Time and context effects on performance in a Pavlovian discrimination reversal. Journal of Experimental Psychology: Animal Behavior Processes, 19(2), 165–179.CrossRefGoogle Scholar
  13. Bouton, M. E., Garcia-Gutierrez, A., Zilski, J., & Moody, E. W. (2006). Extinction in multiple contexts does not necessarily make extinction less vulnerable to relapse. Behaviour Research and Therapy, 44(7), 983–994.PubMedCrossRefGoogle Scholar
  14. Bouton, M. E., Kenney, F. A., & Rosengard, C. (1990). State-dependent fear extinction with two benzodiazepine tranquilizers. Behavioral Neuroscience, 104(1), 44–55.PubMedCrossRefGoogle Scholar
  15. Bouton, M. E., & King, D. A. (1983). Contextual control of the extinction of conditioned fear: Tests for the associative value of the context. Journal of Experimental Psychology: Animal Behavior Processes, 9(3), 248–265.PubMedCrossRefGoogle Scholar
  16. Bouton, M. E., & Ricker, S. T. (1994). Renewal of extinguished responding in a second context. Animal Learning and Behavior, 22(3), 317–324.CrossRefGoogle Scholar
  17. Bouton, M. E., Rosengard, C., Achenbach, G. G., Peck, C. A., & Brooks, D. C. (1993). Effects of contextual conditioning and unconditional stimulus presentation on performance in appetitive conditioning. The Quarterly Journal of Experimental Psychology Section B, 46(1), 63–95.Google Scholar
  18. Bouton, M. E., Woods, A. M., & Pineno, O. (2004). Occasional reinforced trials during extinction can slow the rate of rapid reacquisition. Learning and Motivation, 35, 371–390.CrossRefGoogle Scholar
  19. Brooks, D. C., & Bouton, M. E. (1993). A retrieval cue for extinction attenuates spontaneous recovery. Journal of Experimental Psychology: Animal Behavior Processes, 19(1), 77–89.PubMedCrossRefGoogle Scholar
  20. Brooks, D. C., & Bowker, J. L. (2001). Further evidence that conditioned inhibition is not the mechanism of an extinction cue’s effect: A reinforced cue prevents spontaneous recovery. Learning & Behavior, 29(4), 381–388.CrossRefGoogle Scholar
  21. Brooks, D. C., Karamanlian, B. R., & Foster, V. L. (2001). Extinction and spontaneous recovery of ataxic tolerance to ethanol in rats. Psychopharmacology (Berlin), 153(4), 491–496.CrossRefGoogle Scholar
  22. Burns, D. D. (1980). Feeling good: The new mood therapy. New York: William Morrow & Co.Google Scholar
  23. Cain, C. K., Blouin, A. M., & Barad, M. (2003). Temporally massed CS presentations generate more fear extinction than spaced presentations. Journal of Experimental Psychology: Animal Behavior Processes, 29(4), 323–333.PubMedCrossRefGoogle Scholar
  24. Chaplin, E. W., & Levine, B. A. (1981). The effects of total exposure duration and interrupted versus continuous exposure in flooding therapy. Behavior Therapy, 12(3), 360–368.CrossRefGoogle Scholar
  25. Chelonis, J. J., Calton, J. L., Hart, J. A., & Schachtman, T. R. (1999). Attenuation of the renewal effect by extinction in multiple contexts. Learning and Motivation, 30(1), 1–14.CrossRefGoogle Scholar
  26. Craske, M., Hermans, D., & Vansteenwegen, D. (2006). Fear and learning. Washington DC: American Psychological Association.Google Scholar
  27. Cruz-Neira, C., Sandin, D. J., & DeFanti, T. A. (1993). Surround-screen projection-based virtual reality: The design and implementation of the CAVE. Proceedings of the 20th annual conference on computer graphics and interactive techniques. New York: ACMGoogle Scholar
  28. Davis, M. (1970). Effects of interstimulus interval length and variability on startle-response habituation in the rat. Journal of Comparative Physiological Psychology, 72(2), 177–192.CrossRefGoogle Scholar
  29. Dyckman, J. M., & Cowan, P. A. (1978). Imaging vividness and the outcome of in vivo and imagined scene desensitization. Journal of Consulting and Clinical Psychology, 46(5), 1155–1156.PubMedCrossRefGoogle Scholar
  30. Effting, M., & Kindt, M. (2007). Contextual control of human fear associations in a renewal paradigm. Behaviour Research and Therapy, 45(9), 2002–2018.PubMedCrossRefGoogle Scholar
  31. Eifert, G. H., & Forsyth, J. P. (2005) Acceptance & commitment therapy for anxiety disorders. Oakland, CA: Harbinger Publications Inc.Google Scholar
  32. Emmelkamp, P. M. (1982). Phobic and obsessive-compulsive disorders. New York: Plenum Press.Google Scholar
  33. Emmelkamp, P. M., & Ultee, K. A. (1974). A comparison of “successive approximation” and “self observation” in the treatment of agoraphobia. Behavior Therapy, 5, 2002–2018.Google Scholar
  34. Emmelkamp, P. M., & Wessels, H. (1975). Flooding in imagination vs flooding in vivo: A comparison with agoraphobics. Behaviour Research and Therapy, 13(1), 7–15.PubMedCrossRefGoogle Scholar
  35. Feigenbaum, W. (1988). Long-term efficacy of ungraded versus graded massed exposure in agoraphobics. In I. Hand, & H. U. Wittchen (Eds.), Panic and phobias: Treatments and variables affecting course and outcome (pp.149–158). Berlin: Springer-Verlag.Google Scholar
  36. Flack, W. F. (2006). Peripheral feedback effects of facial expressions, bodily postures, and vocal expressions on emotional feelings. Cognition & Emotion, 20(2), 177–195.CrossRefGoogle Scholar
  37. Foa, E. B., & Chambless, D. L. (1978). Habituation of subjective anxiety during flooding in imagery. Behaviour Research and Therapy, 16(6), 391–399.PubMedCrossRefGoogle Scholar
  38. Foa, E. B., Jameson, J. S., Turner, R. M., & Payne, L. L. (1980). Massed vs. spaced exposure sessions in the treatment of agoraphobia. Behaviour Research and Therapy, 18(4), 333–338.PubMedCrossRefGoogle Scholar
  39. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35.PubMedCrossRefGoogle Scholar
  40. Foa, E. B., & Wilson, R. (2001). Stop obsessing! New York: Bantam Books.Google Scholar
  41. Gelder, M. G., Bancroft, J. H., Gath, D. H., Johnston, D. W., Mathews, A. M., & Shaw, P. M. (1973). Specific and non-specific factors in behaviour therapy. British Journal of Psychiatry, 123(575), 445–462.PubMedCrossRefGoogle Scholar
  42. Girodo, M., & Henry, D. R. (1976). Cognitive, psychological and behavioral components of anxiety in flooding. Canadian Journal of Behavioral Sciences, 8, 224–231.CrossRefGoogle Scholar
  43. Grayson, J. B., Foa, E. B., & Steketee, G. S. (1986). Exposure in vivo of obsessive-compulsives under distracting and attention-focusing conditions: Replication and extension. Behaviour Research and Therapy, 24(4), 475–479.PubMedCrossRefGoogle Scholar
  44. Gunther, L. M., Denniston, J. C., & Miller, R. R. (1998). Conducting exposure treatment in multiple contexts can prevent relapse. Behaviour Research and Therapy, 36(1), 75–91.PubMedCrossRefGoogle Scholar
  45. Hafner, J., & Marks, I. (1976). Exposure in vivo of agoraphobics: Contributions of diazepam, group exposure, and anxiety evocation. Psychological Medicine, 6(1), 71–88.PubMedCrossRefGoogle Scholar
  46. Harris, J. A., Jones, M. L., Bailey, G. K., & Westbrook, R. F. (2000). Contextual control over conditioned responding in an extinction paradigm. Journal of Experimental Psychology: Animal Behavior Processes, 26(2), 174–185.PubMedCrossRefGoogle Scholar
  47. Hayes, S. A., Hope D. A., & Heimberg, R. G. (2008). The pattern of subjective anxiety during in-session exposures over the course of cognitive-behavioral therapy for clients with social anxiety disorder. Behavior Therapy, 39, 286–299.PubMedCrossRefGoogle Scholar
  48. Hofmann, S. G., & Otto, M. W. (2008). Cognitive behavior therapy for social anxiety disorder: Evidence-based and disorder-specific treatment techniques. New York: Routledge.Google Scholar
  49. Hofmann, S. G., & Smits, J. A. J. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632.PubMedCrossRefGoogle Scholar
  50. Johnstone, K. A., & Page, A. C. (2004). Attention to phobic stimuli during exposure: The effect of distraction on anxiety reduction, self-efficacy and perceived control. Behaviour Research and Therapy, 42(3), 249–275.PubMedCrossRefGoogle Scholar
  51. Kamphuis, J. H., & Telch, M. J. (2000). Effects of distraction and guided threat reappraisal on fear reduction during exposure-based treatments for specific fears. Behaviour Research and Therapy, 38(12), 1163–1181.PubMedCrossRefGoogle Scholar
  52. Kirsch, I., Wolpin, M., & Knutson, J. L. (1975). A comparison of in vivo methods for rapid reduction of “stage fright” in the college classroom: A field experiment. Behavior Therapy, 6, 1163–1181.CrossRefGoogle Scholar
  53. Lang, A. J., & Craske, M. G. (2000). Manipulations of exposure-based therapy to reduce return of fear: A replication. Behaviour Research and Therapy, 38(1), 1–12.PubMedCrossRefGoogle Scholar
  54. Larsen, R. J., Kasimatis, M., & Frey, K. (1992). Facilitating the furrowed brow: An unobtrusive test of the facial feedback hypothesis applied to unpleasant affect. Cognition and Emotion, 6, 1–12.Google Scholar
  55. Litvak, S. B. (1969). A comparison of two brief group behavior therapy techniques on the reduction of avoidance behavior. The Psychological Record, 19, 1–12.Google Scholar
  56. Lovibond, P. F., Davis, N. R., & O‘Flaherty, A. S. (2000). Protection from extinction in human fear conditioning. Behaviour Research and Therapy, 38(10), 1–12.CrossRefGoogle Scholar
  57. Lovibond, P. F., Preston, G. C., & Mackintosh, N. J. (1984). Contextual control of conditioning and latent inhibition. Journal of Experimental Psychology: Animal Behavior Processes, 10, 1–12.CrossRefGoogle Scholar
  58. Mackintosh, N. J. (1974). The Psychology of Animal Learning. New York: Academic Press.Google Scholar
  59. Mackintosh, N. J. (1975). A theory of attention: Variations in the associability of stimuli with reinforcement. Psychological Review, 82, 276–298.CrossRefGoogle Scholar
  60. Marescau, Vansteenwegen, Vervliet, Eelen Marescau, V. Vansteenwegen, D. Vervliet, B. & Eelen, P. The attenuation of renewal by an extinction retrieval cue in human contingency learning Unpublished manuscript.Google Scholar
  61. Marks, I., Boulougouris, J., & Marset, P. (1971). Flooding versus desensitization in the treatment of phobic patients: A crossover study. British Journal of Psychiatry, 119(551), 353–375.PubMedCrossRefGoogle Scholar
  62. McCutcheon, B. A., & Adams, H. E. (1975). The physiological basis of implosive therapy. Behaviour Research and Therapy, 13(2–3), 93–100.PubMedCrossRefGoogle Scholar
  63. Milad, M. R., Orr, S. P., Pittman, R. K., & Rauch, S. L. (2005). Context modulation of memory for fear extinction in humans. Psychophysiology, 42(4), 456–464.PubMedCrossRefGoogle Scholar
  64. Miller, B. V., & Levis, D. J. (1971). The effects of varying short visual exposure times to a phobic test stimulus on subsequent avoidance behavior. Behaviour Research and Therapy, 9(1), 17–21.PubMedCrossRefGoogle Scholar
  65. Mineka, S., Mystkowski, J. L., Hladek, D., & Rodriguez, B. I. (1999). The effects of changing contexts on return of fear following exposure therapy for spider fear. Journal of Consulting and Clinical Psychology, 67(4), 599–604.PubMedCrossRefGoogle Scholar
  66. Mystkowski, J. L., Craske, M. G., & Echiverri, A. M. (2002). Treatment context and return of fear in spider phobia. Behavior Therapy, 33(3), 399–416.CrossRefGoogle Scholar
  67. Mystkowski, J. L., Mineka, S., Vernon, L. L., & Zinbarg, R. E. (2003). Changes in caffeine states enhance return of fear in spider phobia. Journal of Consulting and Clinical Psychology, 71(2), 243–250.PubMedCrossRefGoogle Scholar
  68. Otto, M. W., Smits, J. A., & Reese, H. E. (2005). Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults: Review and analyses. Clinical Psychology: Science and Practice, 12, 243–250.CrossRefGoogle Scholar
  69. Peck, C. A., & Bouton, M. E. (1990). Context and performance in aversive-to-appetitive and appetitive-to-aversive transfer. Learning and Motivation, 21, 243–250.CrossRefGoogle Scholar
  70. Powers, M. B., & Emmelkamp, P. M. (2008). Virtual reality exposure for anxiety disorders: A meta-analysis. Journal of Anxiety Disorders, 22, 243–250.CrossRefGoogle Scholar
  71. Powers, M. B., Smits, J. A., & Telch, M. J. (2004). Disentangling the effects of safety-behavior utilization and safety-behavior availability during exposure-based treatment: A placebo-controlled trial. Journal of Consulting and Clinical Psychology, 72(3), 448–454.PubMedCrossRefGoogle Scholar
  72. Powers, M. B., Smits, J. A. J., Whitley, D., Bystritsky, A., & Telch, M. J. (2008). The effect of attributional processes concerning medication taking on return of fear. Journal of Consulting and Clinical Psychology, 76(3), 478–490.PubMedCrossRefGoogle Scholar
  73. Rabavilas, A. D., Boulougouris, J. C., & Stefanis, C. (1976). Duration of flooding sessions in the treatment of obsessive-compulsive patients. Behaviour Research and Therapy, 14(5),349–355.PubMedCrossRefGoogle Scholar
  74. Rentz, T. O., Powers, M. B., Smits, J. A., Cougle, J. R., & Telch, M. J. (2003). Active-imaginal exposure: Examination of a new behavioral treatment for cynophobia (dog phobia). Behaviour Research and Therapy, 41(11), 1337–1353.PubMedCrossRefGoogle Scholar
  75. Rescorla, R. A. (2001). Experimental extinction. In R. R. Mowrer, & S. B. Klein (Eds.), A Handbook of contemporary learning theories (pp. 1337–1353). Mahwah, NJ: Erlaum.Google Scholar
  76. Rescorla, R. A., & Wagner, A. R. (1972). A theory of Pavlovian conditioning: Variations in the effectiveness of reinforcement and nonreinforcement. In A. H. Black, & W. F. Prokasy (Eds.), Classical conditioning II (pp.1337–1353). New York: Appleton Century Crofts.Google Scholar
  77. Rodriguez, B. I., Craske, M. G., Mineka, S., & Hladek, D. (1999). Context-specificity of relapse: Effects of therapist and environmental context on return of fear. Behavioural Research and Therapy, 37(9), 845–862.CrossRefGoogle Scholar
  78. Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616.PubMedCrossRefGoogle Scholar
  79. Rowe, M. K., & Craske, M. G. (1998a). Effects of an expanding-spaced vs massed exposure schedule on fear reduction and return of fear. Behaviour Research and Therapy, 36(7–8), 701–717.PubMedCrossRefGoogle Scholar
  80. Rowe, M. K., & Craske, M. G. (1998b). Effects of varied-stimulus exposure training on fear reduction and return of fear. Behaviour Research and Therapy, 36(7–8), 719–734.PubMedCrossRefGoogle Scholar
  81. Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., et al. (2000). Dismantling cognitive-behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417–424.PubMedCrossRefGoogle Scholar
  82. Sherman, A. R. (1972). Real-life exposure as a primary therapeutic factor in the desensitization treatment of fear. Journal of Abnormal Psychology, 79(1), 19–28.PubMedCrossRefGoogle Scholar
  83. Stern, R., & Marks, I. (1973). Brief and prolonged flooding: A comparison in agoraphobic patients. Archives of General Psychiatry, 28(2), 270–276.PubMedCrossRefGoogle Scholar
  84. Strack, F., Martin, L. L., & Stepper, S. (1988). Inhibiting and facilitating conditions of the human smile: A nonobtrusive test of the facial feedback hypothesis. Journal of Personality and Social Psychology, 54(5), 768–777.PubMedCrossRefGoogle Scholar
  85. Telch, M. J., Valentiner, D. P., Ilai, D., Young, P. R., Powers, M. B., & Smits, J. A. (2004). Fear activation and distraction during the emotional processing of claustrophobic fear. Journal of Behavior Therapy and Experimental Psychiatry, 35(3), 219–232.PubMedCrossRefGoogle Scholar
  86. Tsao, J. C. I., & Craske, M. G. (2000). Timing of treatment and return of fear: Effects of massed, uniform-, and expanding-spaced exposure schedules. Behavior Therapy, 31(3), 479–497.CrossRefGoogle Scholar
  87. Vansteenwegen, D., Hermans, D., Vervliet, B., Francken, G., Beckers, T., Baeyens, F., et al. (2005). Return of fear in a human differential conditioning paradigm caused by a return to the original acquisition context. Behaviour Research and Therapy, 43(3), 323–336.PubMedCrossRefGoogle Scholar
  88. Vansteenwegen, D., Vervliet, B., Iberico, C., Baeyens, F., Van den Bergh, O., & Hermans, D. (2007). The repeated confrontation with videotapes of spiders in multiple contexts attenuates renewal of fear in spider-anxious students. Behaviour Research and Therapy, 45, 1169–1179.PubMedCrossRefGoogle Scholar
  89. Watson, J. P., Mullett, G. E., & Pillay, H. (1973). The effects of prolonged exposure to phobic situations upon agoraphobic patients treated in groups. Behaviour Research and Therapy, 11(4), 531–545.PubMedCrossRefGoogle Scholar
  90. Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: The role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26, 159–161.CrossRefGoogle Scholar
  91. Wolitzky, K. B., & Telch, M. J. (2009). Augmenting in vivo exposure with fear antagonistic action strategies: Results from a randomized clinical trial. Behavior Therapy, 40, 57–71.Google Scholar
  92. Zajonc, R. B., Murphy, S. T., & Inglehart, M. (1989). Feeling and facial efference: Implications of the vascular theory of emotion. Psychological Review, 96, 395–416.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Mark B. Powers
    • 1
  • Bram Vervliet
    • 1
  • Jasper A.J. Smits
    • 2
  • Michael W. Otto
    • 3
  1. 1.University of AmsterdamAmsterdamThe Netherlands
  2. 2.Department of PsychologySouthern Methodist UniversityDallasUSA
  3. 3.Department of PsychologyBoston UniversityBostonUSA

Personalised recommendations