Clinical Skills - Exposure and Optimising Exposure

Question 1

Criticism of habituation-based exposure (Craske et al., 2014)

Answer 1

Although built upon principles of associative learning through fear conditioning and extinction, studies with adults failed to find significant relationship between within-exposure habituation and level of fear on behavioural avoidance tests at follow-up, and long-term relapses under habituation model

Question 2

Inhibitory Learning Model (Craske et al., 2014)

Answer 2

Suggest that associations learned during threat-condition (when fear acquired) are not weakened or forgotten but compete with new non-threatening associations in exposure

Focuses on need to develop new non-threatening associations that overshadow excitatory threatening association, with success reflected through effective consolidation, retrievability, and generalisability of new inhibitory learning assessed during follow-up, rather than degree of fear reduction between/within exposure sessions

Question 3

Craske et al (2014) Optimising Exposure in Adults

Answer 3

Expectancy Violation (of frequency or intensity of aversive outcomes) - yielded as much long-term benefit at follow-up with just one trial per two days compared to repeated trials of exposure each for acrophobia (Baker et al., 2010); values graded exposure but in terms of violating conditions (e.g., duration of exposure) and not necessarily tied to fear level (hierarchy in habituation-based models)

Removal of Safety Signals/Behaviours - these alleviate stress in short term but when not needed, fear returns, with effect believed to derive from interference with development of inhibitory associations; mixed evidence in adults; (+) detrimental to exposure therapy, whereas instructions to refrain from using safety behaviours improved outcomes; (-) use of hygienic wipes following exposures for those with contamination fears didn’t reduce effectiveness of exposure

Varying Stimuli to Increase Generalisation

Affect Labelling - encouraging patients to describe emotional experience during exposure

Question 4

Plaisted et al (2021)

Answer 4

Meta-analysis of 21 studies that had core exposure-based treatment component: (1) replicated superior effect of exposure on treatment response; (2) only 3 studies reported association between time spent on exposure / number of exposures and treatment outcomes

Preliminary evidence for specific optimisation strategies, such as dropping safety behaviours in exposure, and parents/therapists discouraging avoidance (supports Craske et al., 2014), but not one significant finding replicated by another study for same timepoint using same methodology, limited number of studies, and heterogeneity across studies, as well as only 7/29 including follow-up beyond 3mo so no conclusions of long-term effects

Question 5

Affect Labelling (Plaisted et al., 2022)

Answer 5

Adolescents randomised to (1) exposure with affect labelling and negative prediction; (2) exposure with positive coping statement; (3) exposure with neutral sentence (control)

Used pre-recorded audience scenes of other students, told speech then going to be rated by teachers

No significant differences between groups from pre-test to 1w follow-up on measures of self-rated anxiety symptoms, heart rate, or observer-ratings of expressed anxiety

For post-speech subjective distress ratings, initial advantage of exposure with positive coping statement > however, at 1w follow-up, reverse pattern seen, with lowest SUDS (Subjective Units of Distress Scale) scores for affect labelling

However, done in only 13-14-year-olds, and this point of adolescence likely marked my cognitive immaturity which has been suggested to lower treatment outcomes (Kendall & Peterman, 2015), so perhaps this is why no clear significant differences