Why you should Double your Anxiety in Therapy

This article is authored by Alan Garcia and Arielle Radin and is a part of the 2018 pre-graduate spotlight week

Despite being unpleasant, fear and anxiety are critical to our survival since they allow us to predict and escape from aversive events that might harm us. However, there comes a point when that fear and anxiety can be paralyzing for individuals when they experience them in non-threatening situations. Overall, there are various kinds of anxieties: normal everyday anxiety, which keeps us alert and out of danger, and maladaptive anxieties, which in clinical psychology are referred to as anxiety disorders. Anxiety disorders are more severe and incapacitating than normal everyday anxiety. For instance, clinical anxiety can develop when someone believes they are in a dangerous situation even when that situation is benign, and these feelings can be elicited by merely recalling an aversive situation previously experienced.

Specific phobias are another type of anxiety disorder in which particular stimuli like spiders, heights, or snakes evoke intense anxiety. Since these stimuli do not pose an actual threat they are referred to as irrational fears and regularly interfere with peoples’ lives. For example, someone with a fear of spiders (arachnophobia) might completely avoid any places containing spiders. This makes life difficult since spiders are very common in various environments.

Currently, one of the most popular ways to treat specific phobias is with exposure therapy. In exposure therapy a therapist gradually exposes the patient to their feared stimulus and equips them with relaxation skills. The idea is that the patient will learn that they are not in danger while in the presence of the phobic stimulus. However, this type of therapy is not perfect. Previous research has shown that the passage of time can cause the phobia to return (spontaneous recovery) and encountering the feared stimuli in a different context (renewal) can also bring back the phobia (Craske et al., 2014). The reason this occurs can be explained by Pavlovian conditioning and extinction learning, which serves as the foundation for exposure therapy. Pavlovian conditioning is a type of associative learning where a neutral stimulus (e.g. bell) is paired with an unconditional stimulus (food) and becomes a conditional stimulus that elicits a conditioned response (salivation).  On the other hand, the purpose of extinction learning is to present a conditioned stimulus (bell) by itself without the unconditioned stimulus (food). Over trials the subject will learn a new Pavlovian relationship: that the sound of the bell does not predict food. Consequently, their conditioned salivation response to the bell will decrease. One reason that exposure therapy works well for phobias is that it provides fearful individuals with a safe environment to face their fears and to learn that no actual harm will come from that stimulus. Additionally, research has shown that during extinction, subjects are not forgetting, instead they are learning (Rescorla & Wagner, 1972). The learning in extinction involves understanding that an aversive event will not happen. For instance, through extinction, a person with a phobia of spiders might learn that encountering a spider does not lead to being bitten or attacked. Furthermore, as someone learns to relax while encountering their phobia they take in cues from the environment, which act as safety cues that help them relax. This is why renewal occurs: a patient’s fear will return if they encounter a spider in their bathroom because the safety signals from the therapy room are no longer present.

Since simple exposure therapy is not perfect, recent research on what is referred to as “compound extinction” has been shown to be more efficacious in helping people overcome their phobias. Culver and colleges demonstrated that compound extinction seems to be better suited for exposure therapy than simple extinction based on results from their study where participants presented with compound trials demonstrated less fear responding compared with participants who received signal extinction trials only (2015). Overall, compound extinction can be thought of as a double dose of exposure therapy. In compound extinction the idea would be to present a spider fearful individual with 2 spiders instead of 1 to help them reduce their fear. Although this seems counterintuitive, there is a logical explanation for why this is much more effective. First, it is important to point out the importance of “mismatch” in learning: mismatch occurs when a person experiences something different from what they expected. In other words, the more mismatch there is between what you think is going to happen and what actually happens, the greater the learning takes place. Cognitive neuroscience research in the field of learning and memory has demonstrated that a mismatch in expectancies results in directing greater attention to the unexpected stimulus, and thus better learning (Metcalfe et al., 2015). Therefore, the more often a therapist gets fearful individuals to think that they will get bit (and then not actually get bit) the more that learning will occur and the less fear the patient will experience.   

Overall, many important implications can be learned from research on exposure therapy. These range from basic learning theory to how clinicians can assist patients experiencing anxiety disorders live better lives. However, it is apparent that treating phobias is a complex procedure. Nevertheless, individuals affected by phobias should not be discouraged because advances are being made in the treatment of these and many more anxiety disorders. 

Alan is a 4th year undergraduate student and research assistant at UCLA studying psychology and cognitive science. His research focuses on treatments for anxiety and depression. Alan plans to attend graduate school for clinical psychology and continue his research on treatments for anxiety disorders and depression. In his free time, he enjoys working out, going for long runs, and traveling with his family.

References

Culver, N. C., Vervliet, B., & Craske, M. G. (2015). Compound extinction: using the rescorla-wagner model to maximize exposure therapy effect for anxiety disorders. Clinical psychological science, 3(3). 335 - 348.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behavior research and therapy, 58, 10-23.

Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words: contributions of language to exposure therapy. Psychological Science, 23 (10). 1086- 1091.

Metcalfe, J., Casal-Roscum, L., Radin, A. & Friedman, D. (2015). On teaching old dogs new tricks. Psychological Science, 26(12). 1833-1842.

Mystkowski, J. L., Craske, M. G., Echiverri, A. M., & Labus, J. S. (2006). Mental reinstatement of context and return of fear in spider-fearful participants. Behavior Therapy, 37. 49-60.

Rescorla, R.A. (2006). Deepened extinction form compound stimulus presentation. Journal of Experimental Psychology: Animal Behavior Processes, 2. 135-144.

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 9eds.) Classical conditioning II: current research and theory, 66-99.