exposure therapy for anxiety disorders: from fear reduction to fear enhancement
DESCRIPTION
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. Exposure Therapy. - PowerPoint PPT PresentationTRANSCRIPT
Exposure Therapy for Anxiety Disorders: From Fear
Reduction to Fear EnhancementMichelle G. Craske, Ph.D.
July, 2012Professor of Psychology
Professor of Psychiatry and Biobehavioral SciencesDirector, UCLA Anxiety Disorders Research Center
UCLA
Exposure TherapyExposure Therapy• Repeated, systematic exposure to feared
stimuli
– In vivo – situations, objects, places, people– Interoceptive – sensations– Imaginal – images and memories
Exposure TherapyExposure 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
Exposure-Based TherapiesExposure-Based Therapies• However:
– Treatment refusal• ??30% (Issakidis & Andrews, 2004)
– Attrition • 15-30% (Haby et 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)
• 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
QUESTIONSQUESTIONS
RECIPROCAL INHIBITIONRECIPROCAL 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)
EMOTIONAL PROCESSING THEORYEMOTIONAL PROCESSING THEORY (Foa & Kozak, 1986; Foa & McNally, 1996)
Fear Structure
Stimulus Response
Threat Meaning
Within sessionHabituation of fear
Between sessionHabituation of fear
Neutral Meaning
FEAR REDUCTION FEAR REDUCTION
• “Stay in the situation until fear subsides”
• Is fear reduction predictive of outcome?
FEAR REDUCTIONFEAR 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)
Within session habituation: Contaminant anxiety (Kircanski, Mystkowski, Mortazavi, Baker & Craske, 2012, J Beh Th & Exp Psych)
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)
Spider FearsPreBAT
Exposure Trials3 min, 1 min ITIFear < 10 (4.3)*
Overlearning200% more (10.7)*
ControlNo more*
PostBAT
3-week Follow-UpBAT
Farchione & Craske, 2002
FEAR EXPRESSION VS FEAR LEARNINGFEAR 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)
FEAR EXPRESSION VS FEAR LEARNINGFEAR 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)
FEAR EXPRESSION VS FEAR LEARNINGFEAR 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)
Mechanisms of Extinction LearningMechanisms 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)
PRE-EXPOSURE-------EXPOSURE--------------------------------------------POST-EXPOSURE
Excitatory Threat
Expectancy
Inhibitory Nonthreat
Expectancy
?
Time ContextNew
AdverseEvents
Retrieval Cues
No Fear Fear
Habituation not a central mechanism
Mismatch with expectancy for adverse events
Neural inhibitory regulation: vmPFC over amygdala
In tact
INHIBITORY LEARNINGINHIBITORY 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?
ANXIETY DISORDERS: DEFICITS IN INHIBITIONANXIETY 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)
Craske, Waters, Bergman et al., 2008Craske, Waters, Bergman et al., 2008Behavior Research & TherapyBehavior Research & Therapy
Control High Risk Anxious
Child No diagnosesN = 15
No diagnosesN = 13
Anxiety diagnosesN = 24
Mother/Father
Nodiagnoses
Anxiety diagnoses
Mixed group
Method
• Acquisition phase:– 16 trials:
• 8 CS+ (geometric shape paired with 107db tone)• 8 CS- (alternate shape presented alone)
0 s 7 s 8 s
ToneCS+
CS-
16 trials8 CS+ (UCS),
8 CS-8 trials
4 CS +, 4 CS-8 trials
4 CS +, 4 CS-
acquisition extinction 1 week spontaneousrecovery
Craske, Waters, Bergman et al., 2008Craske, Waters, Bergman et al., 2008Behavior Research & TherapyBehavior Research & Therapy
Conditioning: F(1, 110) = 7.88, p < .001, β = -.15Extinction: F(1, 55) = 6.19, p = .003, β = -.10Extinction retest: F(1, 50) = 9.54, p = .003, β = -.09
ANXIETY DISORDERS: DEFICITS IN INHIBITIONANXIETY 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)
Craske et al., 2009, 2012Craske et al., 2009, 2012
8 baseline trials 8 context trials 8 baseline trials 8 context trials
15 45
+
5 35
0 55 0 55 0 55 0 55 0 55 0 55 0 55 0 55
+
15 45 5 35
+
15 455 35 15 45 5 35
+ + +++ + + + + ++
+
+
Stimulation
Safe – Danger Phases
SAFE – NO CONTRACTION WILL BE GIVEN
DANGER – CONTRACTION MAY BE GIVEN
Count down
Craske, Waters et al. (2009). Biological Psychiatry
2.5
3
3.5
4
4.5
51
to 4
5 to
8
1 to
4
5 to
8
Dis
tal
Pro
xim
al
Dis
tal
Pro
xim
al
Dis
tal
Pro
xim
al
Dis
tal
Pro
xim
al
1 to
4
5 to
8
1 to
4
5 to
8
Baseline Context Safe Threat Safe Threat Baseline Context
Pre-contraction Post-contraction
Contextual Threat Explicit Threat Contextual Threat
EMG
mag
nitu
de [l
n]
Low
Medium
High
Before Contraction After Contraction
Prediction of Onset of Anxiety Disorders: Safe/Danger SR InterceptsCraske et al., 2012 J of Abnormal Psychology
Effects for ADs above and beyond covarying N, UDD, danger
p<.05
INHIBITORY LEARNING IN EXPOSURE THERAPYINHIBITORY 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
Not erasure of fear memory-reconsolidation
Craske et al., 2008; Craske et al., 2012
Culver, Vervliet, & Craske, in submissionCulver, 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
Culver, Vervliet, & Craske, in submissionCulver, Vervliet, & Craske, in submission
Group Habituation Conditioning Drug Extinction Extinction
Ingestion Phase 1 Phase 2
CSA (4) CSA + US (8) CSA (8) CSA (8)
Single Placebo CSB (4) CSB + US (8) Placebo CSB (8) CS- (8)
CS- (4) CS- (8) CS- (8)
CSA (4) CSA + US (8) CSA (8) CSAB (8)
Compound Placebo CSB (4) CSB + US (8) Placebo CSB (8) CS- (8)
CS- (4) CS- (8) CS- (8)
CSA (4) CSA + US (8) CSA (8) CSA (8)
Single Caffeine CSB (4) CSB + US (8) Caffeine CSB (8) CS- (8)
CS- (4) CS- (8) CS- (8)
CSA (4) CSA + US (8) CSA (8) CSAB (8)
Compound Caffeine CSB (4) CSB + US (8) Caffeine CSB (8) CS- (8)
CS- (4) CS- (8) CS- (8)
Culver, Vervliet, & Craske, in submissionCulver, Vervliet, & Craske, in submission
Skin Conductance Responses to CSA or CSAB
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Extinction Phase 1 Trial 8 (CSA) Extinction Phase 2 Trial 1 (CSA or CSAB)
Trial
Skin
Con
duct
ance
Res
pons
e
CC CP
SC SP
Figure 29
Culver, Vervliet, & Craske, in submissionCulver, Vervliet, & Craske, in submission
CSA at Spontaneous Recovery Test
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
CC CP SC SP
Group
Skin
Con
duct
ance
Res
pons
e
**
Figure 33
Group Habituation Conditioning Extinction
Control CS+ (4) CS+ + US (8) CS+ (24)
CS- (4) CS- (8) CS- (24)
Reinforced CS+ (4) CS+ + US (8) CS+ (24)*
CS- (4) CS- (8) CS- (24)
*2:8 Partial Reinforcement Schedule, 6 total CS+ + US pairings
Culver, Stephens & Craske, in submissionCulver, 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)
CS+ during Extinction
-0.1
0
0.1
0.2
0.3
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Trial
Skin
Con
duct
ance
Res
pons
eControl
Reinforced
Figure 7
Culver, Stephens, & Craske, in submissionCulver, Stephens, & Craske, in submission
CS+ during Extinction
-6
-4
-2
0
2
4
6
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Trial
Expe
ctan
cy R
atin
gControl
Reinforced
Figure 9
Culver, Stephens & Craske, in submissionCulver, Stephens & Craske, in submission
CS+ from End of Extinction to Spontaneous Recovery Test
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
End of Extinction Spontaneous Recovery Test
Trial
Skin
Con
duct
ance
Res
pons
eControl
Reinforced
Figure 15
Culver, Stephens & Craske, in submissionCulver, Stephens & Craske, in submission
Not erasure of fear memory-reconsolidation
Craske et al., 2008; Craske et al., 2012
VARIABILITYVARIABILITY
• 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
Rowe & Craske, 1998, Behaviour Research & Therapy
• 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
VARIABILITYVARIABILITY
Acrophobia: Final Height in BAT
Lang & Craske, 2000, Behaviour Research & TherapyAutonomic arousal and subjective distress did NOT habituate in Varied Group
Contaminant AnxietyPreBAT
PostBAT
2 Week Follow-UpBAT
Random Variable
3 sessions
BlockMassed
3 sessions
Kircanski, Mystkowski, Mortazavi, Baker & Craske, 2012J of Beh Ther & Exp Psych
Exposure Session RV Group BM Group
Session 1
Session 2
Session 3
Same number of exposure tasks (total and with each item), and total minutes of exposure
Look at close (7 min.)…Spread on body (7 min.)
Look at close (7 min.)…Spread on body (7 min.)
Look at close (7 min.)…Spread on body (7 min.)
Look at close (2 min.)…Spread on body (12 min.)
Look at close (12 min.)…Spread on body (2 min.)
Spread on body (6 min.)…Look at close (8 min.)
SUDS during exposure (third day)Kircanski, Mystkowski, Mortazavi, Baker & Craske, 2012
SUDS for novel BAT itemsKircanski, Mystkowski, Mortazavi, Baker & Craske, 2012
d=.20
HR for novel BAT itemsKircanski, Mystkowski, Mortazavi, Baker & Craske, 2012
d=.37
Contaminant Fear: Emotional Variability Throughout Exposure, R2 = .19
(Kircanski, Mystkowski, Mortazavi, Baker & Craske, 2012)
Above and beyond starting fear, peak fear, ending fear, fear habituation
Public Speaking Fear: Emotional Variability Throughout Exposure, R2=.12(Culver, Stoyanova, & Craske, 2012)
Above and beyond starting fear, peak fear, ending fear, fear habituation
VARIABILITY IN FEARVARIABILITY IN FEAR
• Variability in fear (ups and downs) throughout exposure may enhance long-term outcome because:
– Emotional state as retrieval cue or context (Bjork & Bjork, 1992, 2006; Bouton et al., 2006)
– Repeated opportunities to disconfirm expectancies for negative outcomes (i.e., deepened extinction; Rescorla, 2006)
– Engagement (vs avoidance) throughout exposure and flexible responding to cues (vs rules)
Not erasure of fear memory-reconsolidation
Craske et al., 2008; Craske et al., in press;
Extinction and Affect LabelingExtinction and Affect Labeling
Language in
response to
emotional
stimuli
Increased
Activation of the
RVLPFC
Decreased
Amygdala
Activity
Improved managem
ent of negative
affectActivation of the Medial Prefrontal
Cortex (mPFC)
Extinction: primarily medial PFC believed to inhibit amygdala at recall of extinction (Sotres-Bayon, Cain, & Le Doux, 2006)
Affect Labeling: Disruption Theory (Lieberman, 2007)
Healthy Controls (within group)(Tabibnia, Lieberman & Craske, 2008, Emotion)
+
3.5 sec 2.5 sec 5, 6, or 7 sec
BOMB
ExposureOnly
NegativeLabel(Irrelevant)
Day 1
NegativeLabel(Relevant)
NeutralLabel(Relevant)
FACE
BLOOD
3.5 sec 2.5 sec 5, 6, or 7 sec
3.5 sec 2.5 sec 5, 6, or 7 sec
3.5 sec 2.5 sec 5, 6, or 7 sec
Healthy Controls (within group)(Tabibnia, Lieberman & Craske, 2008, Emotion)
6 sec 5, 6, or 7 sec
ExposureOnly
NegativeLabel(Irrelevant)
Day 8
NegativeLabel(Relevant)
NeutralLabel(Relevant)
NovelPictures
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
Healthy Controls (within group)(Tabibnia, Lieberman & Craske, 2008, Emotion)
0.25
0.30
0.35
0.40
0.45
0.50
Exposure Only Negative LabelIrrelevant
Negative LabelRelevant
Neutral LabelRelevant
Novel
SCR
(µSi
emen
s)
Day1Day8
p < 0.05
p < 0.05 p < 0.0005 p < 0.01 p = n.s.
Spider Fearful (between group)(Tabibnia, Lieberman & Craske, 2008, Emotion)
+
3.5 sec 2.5 sec 5, 6, or 7 sec
WAR
ExposureOnlyGroup
NegativeLabelGroup
Day 1
NeutralLabelGroup
PET
3.5 sec 2.5 sec 5, 6, or 7 sec
3.5 sec 2.5 sec 5, 6, or 7 sec
--------------------------------------------------------
--------------------------------------------------------
Day 1
Day 1
Spider Fearful (between group)(Tabibnia, Lieberman & Craske, 2008, Emotion)
0.25
0.30
0.35
0.40
0.45
0.50
Exposure Only Negative Label Neutral Label
SCR
(µSi
emen
s)
Day1Day8 ExposedDay8 Novel
p < 0.0005 p < 0.05 p < 0.07
p < 0.01
irrelevant
Role of VLPFC-MPFC: Healthy controls(Tabibnia, Craske, & Lieberman, in submission)
+
BOMB
ExposureOnly
NegativeLabel(Irrelevant)
Day 1: fMRI
NegativeLabel(Relevant)
ControlNeutralPictures
+
BLOOD
3.5 sec 2.0 sec 0.5 sec
3.5 sec 2.0 sec 0.5 sec
3.5 sec 2.0 sec 0.5 sec
3.5 sec 2.0 sec 0.5 sec
Role of VLPFC-MPFC: healthy controls(Tabibnia, Craske, & Lieberman, in submission)
6 sec 5, 6, or 7 sec
ExposureOnly
NegativeLabel(Irrelevant)
Day 8: Psychophysiology
NegativeLabel(Relevant)
ControlNeutralPictures
NovelNegativePictures
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
6 sec 5, 6, or 7 sec
Affect LabelingAffect Labeling• Tabibnia, Lieberman & Craske (2008): affect labeling enhanced fear
attenuation at follow-up (skin conductance response and heart rate) relative to fixation cross
• Tabibnia, Craske & Lieberman (in submission): neural correlates during affect labeling predict skin conductance one week later:
NegRel v. Jitter (text)
-0.20
-0.15
-0.10
-0.05
0.00
0.05
0.10
0.15
0.20
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
RVLPFC activity
SCR
chan
ge (µS
iem
ens)
r = -0.66
NegRel v. Jitter (text)
-0.20
-0.15
-0.10
-0.05
0.00
0.05
0.10
0.15
0.20
-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0
MPFC activity
SCR
chan
ge (µS
iem
ens)
r = -0.69
Affect Labeling in Exposure SessionsKircanski, Lieberman & Craske (in press) Psych Science
Labeling Reappraisal
Distraction
Exposure-Alone
E.g., “Sitting in front of the ugly spider makes me very nervous.”
E.g., “Sitting in front of the little spider is not dangerous for me.”
E.g., “There is a table in front of the couch in my den.”
-1
-0.5
0
0.5
1SC
R Ch
ange
Immediate Post-Test to One-Week Post-Test
Affect LabelingReappraisalDistractionExposure-Alone
0
0.5
1
1.5
2
Num
ber o
f Add
ition
al S
teps
Co
mpl
eted
Immediate Post-Test to One-Week Post-Test
Affect Labeling
Reappraisal
Distraction
Exposure-AloneLabeling superior to reappraisal
Labeling akin to acceptance
Brief Acceptance and Commitment Therapy and Exposure for Panic Disorder: A pilot study.Alicia E. Meuret1, Michael P. Twohig2, David Rosenfield1, Steve C. Hayes3, & Michelle G. Craske 4
CBT vs ACT:Arch, J. J., Eifert, G. H., Davies, C., Plumb, J. C., Rose, R.
D., & Craske, M. G., in press, JCCP
Inclusion Criteria:• met DSM-IV-TR diagnostic criteria for one or more anxiety disorders with a
Clinician Severity Rating (CSR) ≥ 4 on the Anxiety Disorders Interview Schedule-IV
• Ages 18-60• Medication-free or stabilized on medication• Not undergoing other psychotherapy
Exclusion Criteria:• history of psychiatric hospitalization in the past 5 years• serious medical conditions/pregnancy• active suicidal ideation and/or severe depression• history of a psychotic disorder, bipolar disorder, mental retardation, or organic
brain damage• substance abuse or dependence within the last 6 months
Treatments
• 12 sessions tailored to the principal anxiety disorder
CBT ACTPsychoeducation & Rationale
= controlPsychoeducation & Rationale
= relinquish controlBreathing retraining Mindfulness & acceptance
Cognitive restructuring Mindfulness & acceptance
Interoceptive exposure Willingness, mindfulness & acceptance of internal cues
Naturalistic and in vivo exposure
Willingness to accept anxiety while moving in direction that is consistent with life values
Shows reliable CSR change1 and Does not meet clinical diagnostic criteria (CSR ≤ 3) Assessment
CBT ACT 2 p Post-treatment 51.0% (25/49) 44.7% (17/38) .34 .56
6-month 59.5% (22/37) 44.4% (12/27) 1.41 .24
12-month 50.0% (16/32) 54.5% (12/22) .11 .74
1 Reliable change required the following minimum improvement values from pre-treatment (see Supplementary Materials for computational details): principal disorder clinical severity rating (CSR) = 2.75
Arch, J. J., Eifert, G. H., Davies, C., Plumb, J. C., Rose, R. D., & Craske, M. G., in press, JCCP
Moderators:Moderators:Mood disorder comorbidityMood disorder comorbidity
p < .01
p = .01
NS
p = .05
Significant Mood comorbidity x Group interaction
Moderators: Anxiety sensitivityModerators: Anxiety sensitivity
NS
NS p < .05
p < .01
NS
Significant Group x ASI2 interaction
Moderators: Experiential AvoidanceModerators: Experiential Avoidance
Significant AAQ2 x Group interaction at 12-mo
NS
p < .01
NS NSp < .05
High experiential avoidance Low experiential avoidance
DESIGNBaselineScreenADIS
Lab TasksQuestionnaires
fMRI
12 Weeks
CBT ACT WL
PostADIS
Lab TasksQuestionnaires
fMRI
Follow-upADIS
Lab TasksQuestionnaires
Ses
sion
By
Ses
sion
Med
iato
r M
easu
res
Craske et al., in prep
PARTICIPANTS
INCLUSION CRITERIAPrincipal diagnosis of Social Anxiety Disorder
18-45 years of ageRight handed
English speaking
EXCLUSION CRITERIASubstance abuse/dependence last 6 months
Serious medical conditionsSevere depression or active suicidality
History of bipolar, psychosis, MR, brain damageHistory of psychiatric hospitalizations in last 5 years
OUTCOME MEASURES
ADIS-IV CSR Social AnxietyADIS-IV CSR Most Severe Comorbid DisorderAdditional Treatment
Symptoms - SIAS (Social Interaction Anxiety Scale) - SPS (Social Phobia Scale) - LSAS-SR (Liebowitz Social Anxiety Scale-Self-Report) - SSPI (Self Statements During Public Speaking)Acceptance - FFMQ (Five Faces Mindfulness Questionnaire) - MMAS (Mindful Attention Awareness) - AAQ-16 ( Acceptance and Action Questionnaire)Quality of Life InventoryACQ (Anxiety Control Questionnaire)
DIAGNOSTIC
QUESTIONNAIRES
Laboratory Assessment
• Spatial cueing
• IAPS
• Hyperventilation (first and second)
• Public speaking
fMRI tasks
• Affect labeling (faces)
• Video clips of facial expressions and matching verbal statements (pos, neg, neutral):– (1) imagine that these people are saying this to you – (2) notice (accept) emotional response – (3) decrease emotional response
• Observe self giving speech
• Prepare to give speech after fMRI (pre only)
• Cyberball task (post only)
ConclusionConclusion• The long term success of exposure
therapy depends on strength and retrievability of inhibitory associations and underlying neural regulation
• Fear reduction within exposure therapy has little to do with long term outcomes
ConclusionConclusion• Exposure outcomes enhanced by strategies
such as– increased number of phobic stimuli (increases fear
arousal)– occasional negative outcomes (sustained fear
arousal)– variability of stimuli and emotional response
(sustained fear arousal)– affect labeling of emotions and stimuli (akin to
acceptance based approaches)
ConclusionConclusion• Comparison between treatment packages
(CBT and ACT) useful but does not expand out understanding of exposure mechanisms
• Need for more mechanistic research