Exposure Therapy for Anxiety Disorders: From Fear Reduction to Fear Enhancement

1. Exposure Therapy for Anxiety Disorders: From Fear Reduction to Fear Enhancement Michelle G. Craske, Ph.D. July, 2012 Professor of Psychology Professor of Psychiatry and Biobehavioral Sciences Director, UCLA Anxiety Disorders Research Center UCLA

2. Exposure Therapy • Repeated, systematic exposure to feared stimuli • In vivo – situations, objects, places, people • Interoceptive – sensations • Imaginal – images and memories

3. Exposure Therapy • Exposure-based therapies, with or without adjunctive coping skills, highly effective for anxiety disorders (e.g., Norton & Price, 2007; Hofmann & Smits, 2008) • Panic disorder/Agoraphobia • Obsessive compulsive disorder • Social anxiety disorder • Specific phobias • Generalized anxiety disorder • Posttraumatic stress disorder

4. Exposure-Based Therapies • However: • Treatment refusal • ??30% (Issakidis& Andrews, 2004) • Attrition • 15-30% (Habyet al., 2006) • Limited-response rates • Non-response rates average 40% to 50% (Loerinc et al., in submission) • Fear returns • 19-62% experience return of fear (Craske & Mystkowski, 2006)

5. QUESTIONS • What are the mechanisms of exposure therapy for fears and anxiety disorders? • How can exposure-based learning be optimized? • To enhance response rate and reduce relapse rate

6. RECIPROCAL INHIBITION Systematic desensitization (Wolpe, 1959) relaxation as a counter-conditioner of anxiety minimal level of fear responding during SD critical to learning process and outcome But; SD equally effective without relaxation (e.g., McGlynn et al., 1978) Exposure therapy equally effective without coping skills (Norton & Price, 2007; Longmore & Worrell, 2006) Flooding therapy, involving high arousal, as effective as graduated exposure (e.g., Foa et al., 2005; Miller, 2002)

7. EMOTIONAL PROCESSING THEORY(Foa & Kozak, 1986; Foa & McNally, 1996)Fear Structure Within session Habituation of fear Stimulus Response Threat Meaning Neutral Meaning Between session Habituation of fear

8. FEAR REDUCTION • “Stay in the situation until fear subsides” • Is fear reduction predictive of outcome?

14. FEAR REDUCTION • Subjective and physiological responding typically declines across exposure trials • But, poor predictor of outcome • Regression models (Kozak et al., 1988; Pitman et al., 1996a,b; Baker et al., 2010; Kircanski et al., 2012; Culver et al., 2012) • Experimental paradigms: overlearning (Farchione & Craske, 2002)

15. Within session habituation: Contaminant anxiety (Kircanski, Mystkowski, Mortazavi, Baker & Craske, 2012, J Beh Th & Exp Psych)

16. FEAR REDUCTION • Subjective and physiological responding typically declines across exposure trials • But, poor predictor of outcome • Regression models (Kozak et al., 1988; Pitman et al., 1996a,b; Baker et al., 2010; Kircanski et al., 2012; Culver et al., 2012) • Experimental paradigms: overlearning (Farchione & Craske, 2002)

17. Spider Fears Pre BAT Exposure Trials 3 min, 1 min ITI Fear < 10 (4.3)* Overlearning 200% more (10.7)* Control No more* Post BAT 3-week Follow-Up BAT

18. Farchione & Craske, 2002

19. FEAR EXPRESSION VS FEAR LEARNING • Expression of fear during or at the end of exposure is not a good marker of learning, as assessed at a later point in time (Craske et al., 2008; Craske et al., 2012)

20. FEAR EXPRESSION VS FEAR LEARNING • Memory research (non-emotional): • Performance during instruction not a reliable index of learning • Learning occurs without change in performance and vice versa (Bjork & Bjork, 2006)

21. FEAR EXPRESSION VS FEAR LEARNING • Extinction learning (emotional): • Fear reduction during or at end of extinction training does not predict responding upon re-test (Bouton et al., 2006; Rescorla, 2006; Plendl, Wolfgang et al., 2010)

22. Mechanisms of Extinction Learning • Habituation not a central mechanism underlying extinction (Davis, 2000) • Formation of inhibitory associations: • the original CS-US association learned during fear conditioning is not erased during extinction, but rather is left intact alongside secondary inhibitory learning about the CS-US association (e.g., Bouton & King, 1983; Bouton, 1993)

23. PRE-EXPOSURE-------EXPOSURE--------------------------------------------POST-EXPOSUREPRE-EXPOSURE-------EXPOSURE--------------------------------------------POST-EXPOSURE Time Context Retrieval Cues New Adverse Events In tact Excitatory Threat Expectancy ? Habituation not a central mechanism Inhibitory Nonthreat Expectancy No Fear Fear Mismatch with expectancy for adverse events Neural inhibitory regulation: vmPFC over amygdala

24. INHIBITORY LEARNING • How can inhibitory learning be maximized during exposure therapy? • How can inhibitory learning be maximally retrieved at a later point in time, after completion of exposure therapy?

25. ANXIETY DISORDERS: DEFICITS IN INHIBITION • Anxiety disorders characterized by • elevated excitatory learning (CS+) (Lissek et al., 2005; Craske et al., 2008) • Amygdala (Milad, 2007, 2009) • deficits in inhibitory learning (CS- and extinction) (Lissek et al., 2005; Craske et al., 2008; Liao & Craske, in press) • vmPFC (Milad, 2007, 2009) • deficits in safety learning (Craske et al., 2009; Craske et al., in press)

26. Craske, Waters, Bergman et al., 2008Behavior Research & Therapy

27. Method • Acquisition phase: • 16 trials: • 8 CS+ (geometric shape paired with 107db tone) • 8 CS- (alternate shape presented alone) Tone CS+ CS- 0 s 7 s 8 s

28. 16 trials 8 CS+ (UCS), 8 CS- 8 trials 4 CS +, 4 CS- 8 trials 4 CS +, 4 CS- acquisition extinction 1 week spontaneous recovery

29. Craske, Waters, Bergman et al., 2008Behavior Research & Therapy Conditioning: F(1, 110) = 7.88, p < .001, β = -.15 Extinction: F(1, 55) = 6.19, p = .003, β = -.10 Extinction retest: F(1, 50) = 9.54, p = .003, β = -.09

30. ANXIETY DISORDERS: DEFICITS IN INHIBITION • Anxiety disorders characterized by • elevated excitatory learning (CS+) (Lissek et al., 2005; Craske et al., 2008) • Amygdala (Milad, 2007, 2009) • deficits in inhibitory learning (CS- and extinction) (Lissek et al., 2005; Craske et al., 2008; Liao & Craske, in press) • vmPFC (Milad, 2007, 2009) • deficits in safety learning (Craske et al., 2009; Craske et al., in press)

31. Craske et al., 2009, 2012 8 context trials 8 baseline trials 8 context trials 8 baseline trials Safe – Danger Phases Stimulation 5 35 5 35 15 45 15 45 5 35 5 35 15 45 15 45 + + + + + + + + + + + + + + + + 0 55 0 55 0 55 0 55 0 55 0 55 0 55 0 55

32. SAFE – NO CONTRACTION WILL BE GIVEN

33. DANGER – CONTRACTION MAY BE GIVEN Count down

34. Craske, Waters et al. (2009). Biological Psychiatry

35. Prediction of Onset of Anxiety Disorders: Safe/Danger SR Intercepts Craske et al., 2012 J of Abnormal Psychology Before Contraction After Contraction p<.05 Effects for ADs above and beyond covarying N, UDD, danger

36. INHIBITORY LEARNING IN EXPOSURE THERAPY • How can inhibitory learning be maximized during exposure therapy • How can inhibitory learning be maximally retrieved at a later point in time, after completion of exposure therapy • Especially for individuals with anxiety disorders who have deficits in inhibitory learning

37. Craske et al., 2008; Craske et al., 2012 Not erasure of fear memory-reconsolidation

38. Culver, Vervliet, & Craske, in submission • Mismatch between expectancy of adverse event and its absence of occurrence (Rescorla & Wagner, 1974) • Deepened extinction – mismatch between expectancy and outcome for more than one stimulus (Rescorla, 2006) • Exposure to public speaking; exposure to sweating and public speaking

39. Culver, Vervliet, & Craske, in submission

40. Skin Conductance Responses to CSA or CSAB 0.9 CC CP SC SP 0.8 0.7 0.6 0.5 Skin Conductance Response 0.4 0.3 0.2 0.1 0 Extinction Phase 1 Trial 8 (CSA) Extinction Phase 2 Trial 1 (CSA or CSAB) Trial Figure 29 Culver, Vervliet, & Craske, in submission

41. CSA at Spontaneous Recovery Test 1 * 0.9 * 0.8 0.7 0.6 Skin Conductance Response 0.5 0.4 0.3 0.2 0.1 0 CC CP SC SP Group Figure 33 Culver, Vervliet, & Craske, in submission

42. Culver, Stephens & Craske, in submission Partial reinforced trials during extinction are surprising  increase salience of CS  facilitates learning of CS-noUS on subsequent trials (e.g., exposure to public speaking with occasional ridicule)

43. Culver, Stephens, & Craske, in submission

44. Culver, Stephens & Craske, in submission

45. Culver, Stephens & Craske, in submission

46. Craske et al., 2008; Craske et al., 2012 Not erasure of fear memory-reconsolidation

47. VARIABILITY • Random and variable practice enhances retrievability of newly learned information (Magill & Hall, 1990) • Increases storage strength (Bjork & Bjork, 2992) • Stimulus fluctuation theory - more retrieval cues (Bjork & Bjork, 1992) • Generalization - generates a rule that captures the invariance among tasks (Schmidt & Bjork, 1992) • In contrast, traditional exposure based treatments employed blocked and constant practice

48. Rowe & Craske, 1998, Behaviour Research & Therapy

49. VARIABILITY • Lang & Craske, 2000 • Acrophobia • Blocked = repeat exposure to same height four times, in the same manner, before proceeding to the next height • Random = move randomly from one height to the next, and approach in multiple ways

50. Acrophobia: Final Height in BAT Autonomic arousal and subjective distress did NOT habituate in Varied Group Lang & Craske, 2000, Behaviour Research & Therapy