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Maximizing Inhibitory Learning

(From Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014)

Strategy What it Means Examples/Tips


• Obtain pre-exposure expectancies and
Maximizing the mismatch
engage in post-exposure processing.
Expectancy Violation between expectancy and
• Draw attention to fear cue and non-
outcome
occurrence of feared outcome

Emphasizing ability to • Discourage anxiety reduction strategies


Distress Tolerance
withstand distress • Encourage “sitting with” anxiety

Combining multiple fear • Eating a feared food while wearing belt


Deepened Extinction cues in the extinction around the stomach and listening to a
process story about vomiting

• Reassurance-seeking during the


Looking out for and exposure
Removal of Safety Signals discouraging use of safety • May remove safety cues at the outset of
signals and behaviors exposures or may phase out over the
course of treatment

• Jump around on hierarchy


Varying exposure
• Conduct exposures in different settings,
Variability conditions to facilitate
different times, and with different
retention of learning
clinicians

• Review learning from previous


Increasing the accessibility exposures
Retrieval Cues
of new associations • Use tangible cues to represent each
time an expectancy is violated

Encouraging linguistic • Ask patient to state emotions without


Affect Labeling processing via labeling of judgements or attempts to change the
emotions during exposures emotional state

Occasionally producing a
Occasional Reinforced pairing between the • Having the patient eat a dry, crumbly
Extinction patient’s fear cue and food which leads to some coughing
feared outcome
Exposure Procedure
1.1. Choose a step on the fear hierarchy. Start with items in the low- to moderate- SUDS range before
jumping to items higher on the hierarchy. Identify safety behaviors to look out for.

1.2. Pick a time to practice. Ensure you have enough time to complete an exposure. Remember to
conduct an exposure until habituation occurs and/or expectancies have been violated.

3. Pre-exposure processing. Obtain predictions about the exposure. What are they afraid might
happen? What’s the worst thing that could happen? How and when will they know if the feared
outcome has happened?

1.4. Take a SUDS rating. Take a pre-exposure anxiety/distress rating.

5. Do the exposure! Lean into the fear and amplify uncertainty. Be mindful of safety behaviors,
including reassurance-seeking. Stick with the exposure until habituation has occurred or expectancies
have been violated. Do not end an exposure at the height of distress.

1.6. Take more SUDS ratings. Keep taking SUDS ratings throughout the practice to track whether the
patient is habituating.

1.7. Post-exposure processing. Discuss what was learned during the practice. Focus on the non-
occurrence of the feared outcome. Emphasize other expectancies violated (e.g., patient was able to
tolerate the exposure much longer than anticipated, anxiety did not last as long as predicted).

1.8. Praise and Reward. Provide praise for bravery and implement rewards.
References and Resources
Selected Books and Manuals
• Thomas, J.J. & Eddy, K.T. (2018). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food
Intake Disorder: Children, Adolescents, and Adults. New York, NY: Cambridge University Press.
• March, J.S. & Mulle, K. (1998). OCD in Children & Adolescents: A Cognitive-Behavioral Treatment
Manual. New York, NY: The Guilford Press.
• Foa, E.B., Yadin, E., & Lichner, T.K. (2012). Exposure and Response (Ritual) Prevention for
Obsessive-Compulsive Disorder (Therapist Guide), 2nd Edition. New York, NY: Oxford University
Press.
• Piacentini, J., Langley, A., & Roblek, T. (2007). Cognitive-Behavioral Treatment of Childhood OCD:
It’s only a False Alarm (Therapist Guide). New York, NY: Oxford University Press.
• McKay, M. & Steketee, G.S. (1998). Overcoming Obsessive-Compulsive Disorder: Therapist
Protocol (Best Practices Series). Oakland, CA: New Harbinger Publications, Inc.
Published Case Studies
• Thomas, J.J., Brigham, K.S., Sally, S.T., Hazen, E.P, & Eddy, K.T. (2017). Case 18-2017 – An 11-
year-old girl with difficulty eating after a choking incident. New England Journal of Medicine, 24,
2377-2386.
• Ball, B., & Otto, M. (1994). Cognitive-behavioral treatment of choking phobia: 3 case studies.
Psychotherapy & Psychosomatics, 62(3-4), 207-211.
• Chorpita, B., Vitali, A., & Barlow, D. (1997). Behavioral treatment of choking phobia in an
adolescent: an experimental analysis. J Behav Ther Exp Psychiatry, 28(4), 307-315. doi:
10.1016/S0005-7916(97)00027-X.
• Maack, D., Deacon, B., & Zhao, M. (2013). Exposure therapy for emetophobia: a case study with
three-year follow-up. J Anxiety Disord, 27(5), 527-534. doi:10.1016/j.janxdis.2013.07.001.
• Veale, D. (2009). Cognitive behaviour therapy for a specific phobia of vomiting. The Cogn Behav
Therapist, 2, 272-288.
• Dumont E, Jansen A, Kroes D, de Haan E, Mulkens S. A new cognitive behavior therapy for
adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical
case series. Int J Eat Disord. 2019;52(4):447-58.
• Fischer AJ, Luiselli JK, Dove MB. Effects of clinic and in-home treatment on consumption and
feeding-associated anxiety in an adolescent with avoidant/restrictive food intake disorder.
Clinical Practice in Pediatric Psychology. 2015;3(2):154-66.
• Zucker NL, LaVia MC, Craske MG, Foukal M, Harris AA, Datta N, et al. Feeling and body
investigators (FBI): ARFID division-An acceptance-based interoceptive exposure treatment for
children with ARFID. Int J Eat Disord. 2019;52(4):466-72.
Inhibitory Learning Article
• Craske, M. G., Kircanski, K, Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008).
Optimizing inhibitory learning during exposure therapy. Behav Res & Ther, 46(1), 5-27. doi:
10.1016/j.brat.2007.10.003

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