OBJECTIVE:The Inhibitory Retrieval model of exposure therapy emphasizes expectancy change as a core mechanism of treatment. Evidence suggests important roles for both positive and negative affect during exposure therapy. The current study assesses the extent to which positive and negative affect moderate expectancy change during exposure therapy. METHOD:N = 77 adults with either social anxiety disorder or panic disorder completed a nine-session exposure therapy protocol: n = 41 were randomized to exposure therapy based on principles of extinction learning (Inhibitory Retrieval condition), during which they rated expectancy of an aversive outcome before and after each exposure; and n = 36 participants were randomized to exposure focused on fear reduction (Habituation condition), during which they rated subjective experiences of fear before and after each exposure. The Positive and Negative Affect Schedule (past month) was collected at baseline, mid-treatment and post-treatment. RESULTS:In the Inhibitory Retrieval condition, positive and negative affect each moderated the relationship between pre- and post-expectancy. Specifically, individuals with low positive affect relative to their own mean (p = .029) or high negative affect relative to other individuals (p < .001) reduced expectancies less when pre-expectancy was high. In the Habituation condition, neither positive nor negative affect moderated the relationship between pre- and post-exposure fear. CONCLUSIONS:Affect moderates expectancy change during exposure therapy modeled using Inhibitory Retrieval, such that higher negative affect and lower positive affect are associated with less expectancy change. Considering the historical emphasis on reducing negative affect, models of exposure therapy may additionally incorporate strategies to increase positive affect to maximize expectancy change.

Our objective was to assess predictors of exposure therapy outcome for social anxiety disorder and panic disorder. Specifically, we investigate whether expectancy updating or fear change during exposures are predictive of long-term anxiety reduction. We conducted a randomized controlled trial of 84 participants evaluating two forms of 9-session exposure therapy. One form of exposure therapy was based on the inhibitory retrieval model (i.e., expectancy updating), and the other was based on habituation principles (i.e., fear reduction). Our treatment outcome measures of anxiety symptomatology included the Liebowitz Social Anxiety Scale and the Panic Disorder Severity Scale; these were analyzed at pre-treatment, post-treatment, and 3-month follow-up. Our putative predictive measures were collected during exposures and included expectancy for the feared outcome and fear/anxiety. From these measures, we calculated expectancy change (post-exposure minus pre-exposure, averaged across exposures), learning rate derived from theory-based computational modeling of expectancy data, and fear change (post-exposure minus pre-exposure, averaged across exposures). We conducted structural equation modeling to assess whether these putative predictive measures predicted treatment outcome. Results showed that expectancy change significantly predicted post-treatment and 3-month follow-up anxiety; similarly, expectancy-based learning rate marginally predicted post-treatment anxiety and significantly predicted 3-month follow-up anxiety. Conversely, fear change did not predict anxiety symptoms. Lastly, expectancy change and expectancy-based learning rate predicted long-term anxiety even when controlling for fear change. In conclusion, reducing expectancy for feared outcomes during exposure predicts anxiety symptom reduction. Exposure therapy could benefit from exposures designed to update expectancies about feared outcomes rather than reduce within-exposure fear.

Despite the efficacy of exposure therapy for pediatric obsessive-compulsive disorder, a significant portion of patients fail to achieve remission, clinically significant change, or low levels of symptomatology. Thus, there is a need to more directly target treatment mechanisms in order to improve outcome. Although extinction learning and habituation are often touted as principal mechanisms of exposure therapy, numerous clinical, theoretical, and empirical errors act as barriers to effective research and implementation. The aim of the current paper is to discuss the extant basic science on extinction learning and habituation in order to elucidate common deviations that impede research and clinical practice, with the hope of stimulating more targeted psychotherapy research. Empirical studies and theoretical papers demonstrate numerous errors when attempting to target extinction learning including failing to identify unconditional stimuli, attempting extinction when there is no unconditional stimulus, and exposing patients to stimuli that are not conditional stimuli. Clinical scientists and practitioners routinely misuse the term habituation and employ methodology that has precluded our ability to understand habituation as a mechanism of exposure therapy. There are numerous theoretical errors plaguing the literature on Pavlovian extinction learning and habituation within exposure therapy.

Cognitive-behavioral therapy (CBT) for anxiety disorders requires that people learn to inhibit their fear during exposure to stimuli that no longer pose a threat. We investigate whether individual differences in this inhibitory learning ability, measured prior to treatment, can predict responsiveness to CBT for social anxiety disorder. Participants (N = 128) were randomized to CBT or a wait-list control and completed tests of fear generalization and extinction prior to and following the intervention period. Contrary to expectations, individual differences in extinction, measured at pretreatment, were not associated with treatment responses but there was evidence that these abilities changed over time due to treatment. Individual differences in fear generalization at pretreatment were associated with treatment responses. Weaker generalization between dangerous and perceptually similar but novel safe stimuli was associated with enhanced responding to CBT. These findings contribute to the development of a mechanistic approach to patient stratification where participants who are least likely to respond to CBT can be identified prior to treatment.

Pharmacological agents theorized to modulate fear extinction could enhance treatments for anxiety and trauma-related disorders, but fear conditioning and treatment studies testing these agents often yield null or conflicting results. We review principles of extinction learning relevant to the design of studies that test pharmacological enhancements of extinction. We then critically review the methodologies of existing studies for three pharmacological agents [d-cycloserine (DCS), glucocorticoids (GCs), and L-DOPA] with respect to key learning principles. While each agent has promising support in rodent models, many human studies are not designed to adequately detect an agent’s effects on extinction learning. We provide specific recommendations, informed by these learning principles, for future study designs that may clarify whether, how, and under what conditions agents impact extinction.

Background and objectives: The Inhibitory Retrieval Approach to exposure therapy for fears and anxiety emphasizes prediction error as one of several strategies for improving outcomes. Prediction error depends on disconfirmation of expectancies for the feared outcome, and thus exposure strategies that derive from inhibitory retrieval approaches emphasize expectancy violation during exposure. However, research studies examining expectancy violation in exposure therapy have treated expectancy as a stable characteristic, assuming that expectancy following an exposure exercise remains constant over time. This brief report outlines two different uses of a methodology for using ecological momentary assessment (EMA) to assess between-session expectancy following exposure during treatment for anxiety, and reports on pilot trial results. Methods: Adults with social anxiety disorder (N = 12) and spider phobia (N = 31) taking part in larger trials investigating exposure therapy completed EMA questionnaires assessing expectancy for their feared outcome for 2-4 days following each of two exposure sessions. Results: Expectancy ratings decreased from pre-to post-exposure and remained stable for 2-4 days following exposure. Limitations: This pilot study used a very limited sample size and should be replicated in a larger sample. Conclusions: Expectancy for feared outcome may be assessed using EMA following exposure sessions. Pilot results suggest that expectancy decreases immediately following exposures and remains stable afterwards.

OBJECTIVE:To investigate the role of extinction learning and habituation by comparing inhibitory retrieval to habituation-focused exposure for social anxiety and panic disorder. METHOD:In this assessor-blinded, parallel-group, two-arm randomized controlled clinical superiority trial, 89 treatment-seeking adults with social anxiety (n = 77) or panic disorder (n = 12) received nine weekly therapy sessions of inhibitory retrieval or habituation-focused exposure therapy. Outcomes were client-reported symptoms, interviewer-rated client distress and impairment, and a behavioral approach task. RESULTS:Modified intent-to-treat analyses were conducted using multilevel modeling. There were no group differences on principal outcomes of interviewer-rated distress and impairment, nor significant pairwise differences on symptom scores at posttreatment or follow-up (ps > .11). However, secondary and exploratory analyses revealed that relative to the habituation condition, participants in the inhibitory retrieval condition demonstrated significantly steeper decreases in self-reported anxiety from baseline to posttreatment, b = 0.05, 95% CI [0.01, 0.08], χ2(1) = 6.67, p = .010; session-by-session self-reported anxiety, b = 0.01, 95% CI [0.004, 0.02], χ2(1) = 12.33, p = .001; and distress during a behavioral approach task, f = .134, χ2(1) = 4.75, p = .029. Additionally, a higher percentage of participants in the inhibitory condition achieved clinically significant change on self-reported anxiety at posttreatment (43% vs. 13%), although there were no group differences on interviewer-rated indices of clinically significant change (ps > .42). CONCLUSION:Both methods of exposure therapy were effective. Exposure therapy targeting extinction learning modestly improved outcomes on secondary and exploratory measures although, aside from reliable and clinically significant change, group differences at posttreatment and follow-up were not significant. Habituation-focused exposure therapy was not superior on any measure. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Background: Social anxiety disorder (SAD) places a profound burden on public health and individual wellbeing. Systemic inflammation may be important to the onset and maintenance of SAD, and anti-inflammatory treatments have shown promise in relieving symptoms of SAD. In the present study, we conducted secondary analyses on data from a randomized clinical trial to determine whether C-reactive protein (CRP) concentrations and social anxiety symptoms decreased over the course of virtual reality exposure therapy, and whether changes in social anxiety symptoms as a function of treatment varied as a function of CRP. Method: Adult participants ( N = 78) with a diagnosis of SAD (59 % female) were randomized to receive exposure therapy alone, or exposure therapy supplemented with scopolamine. Social anxiety symptoms, salivary CRP, and subjective units of distress were measured across three exposure therapy sessions, at a post-treatment extinction retest, and at a 1-month follow-up. Results: CRP decreased over the course of treatment, b = -0.03 ( SE = 0.01), p =.02 95 %CI [-0.06, - 0.004], as did all social anxiety symptom domains and subjective distress. Higher CRP was associated with greater decreases from pre-treatment to 1-month follow-up in fear, b = -0.45 ( SE = 0.15), p =.004 95 %CI [-0.74, - 0.15], and avoidance, b = -0.62 ( SE = 0.19), p =.002 95 %CI [-1.01, -0.23], and in -session subjective distress from pre-treatment to post-treatment, b = -0.42 ( SE = 0.21), p =.05 95 %CI [-0.83, -0.001]. However, declines in CRP were not correlated with declines in fear, r = -0.07, p =.61, or avoidance, r = -0.10, p =.49, withinpersons. Conclusions: Virtual reality exposure therapy may be associated with an improvement in systemic inflammation in patients with severe SAD. Pre-treatment CRP may also be of value in predicting which patients stand to benefit the most from this treatment.

Objective: Positive and negative affect play critical roles in depression and anxiety treatment, but the dynamic processes of how affect changes over treatment in relation to changes in symptoms is unclear. The study goal was to examine relationships among changes in positive and negative affect with changes in depression and anxiety symptoms. Method: This secondary analysis used a combined sample (N = 196) of two trials (Craske et al., 2019, 2023) comparing positive affect treatment (PAT) to negative affect treatment. Longitudinal cross-lag panel models explored whether changes in positive and negative affect (Positive and Negative Affect Schedule; Watson et al., 1988) predicted subsequent changes in depression and anxiety symptoms (Depression Anxiety Stress Scales; Lovibond & Lovibond, 1995), whether symptoms predicted subsequent changes in affect, and whether treatment condition moderated these relationships. Results: Increases in positive affect predicted subsequent decreases in depression and anxiety symptoms, regardless of treatment condition. Symptoms did not reciprocally predict changes in positive affect. For individuals in PAT, decreases in negative affect predicted subsequent decreases in symptoms. Moreover, decreases in symptoms predicted subsequent decreases in negative affect, regardless of treatment condition. Conclusions: Results did not support a reciprocal relationship between positive affect and symptoms of depression and anxiety since positive affect predicted depression and anxiety symptoms but not vice versa. Results supported a reciprocal relationship between negative affect and symptoms of depression and anxiety since negative affect predicted depression and anxiety symptoms in PAT, and depression and anxiety symptoms predicted negative affect in both treatment conditions.

BACKGROUND AND OBJECTIVES:Fear activation and reduction have traditionally been considered important mechanisms of exposure therapy. Evidence to date is mixed and impeded by inadequate methodology. This study examined the extent to which fear activation and reduction within and across exposures predicted treatment outcomes for social anxiety disorder within a paradigm suitable for their measurement.METHODS:Sixty-eight adults with social anxiety disorder and fear of public speaking completed seven exposure sessions, each consisting of seven speeches conducted in virtual reality. Exposures were identical in duration, task requirements, and virtual public speaking situation. Fear was measured with skin conductance and subjective distress ratings. At baseline and post-treatment, participants completed a public speaking behavioral approach test with a panel of confederate judges; subjective fear was measured. A standardized questionnaire of anxiety symptoms was administered at baseline, post-treatment, and one-month follow-up.RESULTS:No indices of within- or between-session fear reduction, measured by subjective distress and skin conductance response, predicted treatment outcome. One measure of fear activation was associated with outcomes such that less activation predicted greater symptom reduction; remaining indices did not predict outcomes.LIMITATIONS:Data were collected in the context of a randomized controlled trial of scopolamine; drug group was included in analytic models to account for drug influence. VR exposures elicited mild levels of distress that may underestimate levels of distress in clinical settings.CONCLUSIONS:Findings failed to support fear activation or reduction within or across exposure sessions as significant predictors of treatment outcome for social anxiety. Treatment implications are discussed.

Cognitive behavioral therapy (CBT) focuses on decreasing negative affect rather than increasing positive affect and is ineffective for some individuals. A trial comparing novel Positive Affect Treatment (PAT) to Negative Affect Treatment (NAT; a form of CBT) showed that PAT more effectively increased positive affect and decreased negative affect, depression, and anxiety (Craske et al., 2019). The present exploratory study examined threat sensitivity as a treatment moderator. Threat sensitivity was operationalized as pre-treatment skin conductance response and unconditional stimulus (US) expectancy rating during extinction recall. Participants ( N = 43) then received 15 sessions of PAT or NAT. Growth curve models were tested to explore interactions between extinction recall and treatment condition over time. For skin conductance, weaker extinction recall predicted faster improvement in depression and anxiety in NAT than PAT, whereas stronger extinction recall predicted faster improvement in symptoms in PAT than NAT. Reduced US expectancy ratings predicted a faster decrease in symptoms, regardless of treatment condition. Individuals showing greater threat sensitivity, indexed by weaker extinction recall, may benefit more from a treatment that targets threat sensitivity than a treatment that targets reward sensitivity. Individuals showing the converse may benefit more quickly from a treatment that targets reward sensitivity than threat sensitivity.

Abstract This chapter discusses the importance of monitoring one’s daily activity and mood. It introduces the concept of positive activities, which will help clients appreciate the direct link between their behaviors, thoughts, and feelings. Engaging in positive activities is expected to produce a positive mood cycle and an upward spiral. Because reactivation of positive behaviors is thought to be effective in treating depression, the focus of Positive Affect Treatment (PAT) is on activities that are likely to generate positive emotions. Additionally, memory specificity training will help prevent clients from dismissing positive activities as irrelevant or unimportant. By monitoring their activities, clients will be able to identify which daily activities improve their mood.

Abstract This chapter covers the skills of shifting attention toward positive stimuli and improving prospective positive mental imagery. The skills address deficits in anticipation of reward by having clients learn to attribute their actions to positivity. Target attention is vital since the evidence shows that depressed mood and anhedonia are associated with limited sustained attention to positive stimuli. Focus on past experiences is achieved by re-evaluating situations. The skill of finding the silver linings is introduced, but therapists should know this sometimes triggers trauma, panic, and anxiety. The chapter emphasizes that diminishing self-attribution for positive outcomes limits the learning of reward.

AbstractThis chapter explores the general format and guiding principles of the Positive Affect Treatment (PAT) program. As it was developed with theory, science, and clinical experience in mind, PAT follows the rationale, components, and structure of traditional evidence-based therapies. However, flexibility is vital as individuals with anhedonia are lacking the prerequisites for cognitive–behavioral therapy to be successful. Treatments are expected to be tailored to each client’s particular deficits to ensure that maximum benefits ensue. The chapter covers the treatment module designed to deliver psychoeducation on the nature of anhedonia, therapy expectations and structure, and the concepts of the mood cycle.

Abstract This chapter covers the psychoeducation that should be provided to clients participating in the Positive Affect Treatment (PAT) program. This educational material includes an explanation of mood cycles and how to identify them and how one’s emotions, thoughts, behavior, and physical sensations are interrelated. Clients are expected to learn thinking and behavioral skills that can indirectly change how they feel. Clients will learn how to label their positive emotions, which increases attention to and experience of positivity. The difference between downward spirals and upward spirals is explained in this chapter as well. A primary goal of PAT is to help clients reach upward spirals.

Abstract This chapter provides the introductory information necessary for therapists interested in using the Positive Affect Treatment (PAT) program. It starts by describing anhedonia, which is a symptom cluster linked to the loss of interest or joy in usual activities. Anhedonia is a transdiagnostic symptom frequently found among people suffering from depression, anxiety, psychosis, and substance abuse. Advances in behavioral science and neuroscience suggest that specific mechanisms may contribute to anhedonia. The chapter covers the principles and procedures of PAT, a program that addresses the deficits of the reward system. Therapists familiar with basic principles of cognitive–behavioral interventions and mindfulness are recommended to conduct the treatment.

Positive Affect Treatment for Depression and Anxiety: Therapist Guide contains step-by-step detailed procedures for assessing and treating specific problems and diagnoses. According to the growing consensus, evidence-based practice offers the most responsible course of action for mental health professionals. The guide is intended for clinicians familiar with cognitive–behavioral therapy (CBT) and clinical presentations of depression, anxiety, and anhedonia. Positive Affect Treatment (PAT) was developed to specifically target areas of reward sensitivity that are believed to contribute to anhedonia. The treatment is expected to be an indispensable resource for all practitioners who wish to effectively and efficiently help individuals regain and improve their quality of life.

Abstract This chapter explores the importance and function of Building Positivity as part of the Positive Affect Treatment (PAT) program. It explains the process and provides case studies of practicing loving-kindness, appreciative joy, gratitude, and generosity. Evidence shows that engaging in gratitude and generosity leads to feeling more connected, having better relationships, and doing more prosocial behavior. Loving-kindness and appreciative joy are skills that use imagery and positive thinking to enhance relationships and change feelings. The chapter also discusses research showing that these practices increase positive emotions and well-being and decrease negative emotions. PAT’s Building Positivity exercises are strategies to improve mood, appreciate positive feelings, and form connections.