Change of threat expectancy as mechanism of exposure-based psychotherapy for anxiety disorders: Evidence from 8484 exposure exercises of 605 patients

Abstract

Individual responses to behavioral treatment of anxiety disorders vary considerably, calling for better understanding of underlying processes. This study examined the violation and change of threat beliefs during exposure. From 8484 standardized exposure records of 605 patients with different anxiety disorders, learning indicators were derived: Expectancy violation as mismatch between threat expectancy before exposure and threat occurrence, expectancy change as difference between original and adjusted expectancy after exposure, and prediction-error learning rate as extent to which expectancy violation transferred into change. Throughout sessions, high threat expectancy but low occurrence and adjusted expectancy indicated violation and change of threat beliefs by exposure. Expectancy violation, change, and learning rate substantially varied between patients. Not expectancy violation itself, but higher learning rate and expectancy change predicted better treatment outcome. Successful exposure thus requires expectancy violation to induce actual expectancy change, supporting learning from prediction error as transdiagnostic mechanism underlying successful exposure therapy.

From Information to Worry: How Selective Interrogation of Information Shapes Expectancies in the Prenatal Period

“…When considering applied implications, our findings indicate that targeting expectancies might be an effective approach for interventions aiming to reduce prenatal worry. The role of negative expectancies in anxiety disorders has been established by prior research (Pittig et al, 2023). For example, individuals with social anxiety disorder tend to hold disproportionately negative expectancies concerning situations in which they might face social judgment, such as when giving a speech (Taylor et al, 2010).…”

Evidence for non-linear extinction learning and no influence of intolerance of uncertainty: investigating US expectancies in a VR fear conditioning paradigm

“…Exposure therapies can also be improved in the long term by looking at factors potentially moderating their effectiveness. Pittig et al (2023) have already found that the exposure related learning rates in exposure therapies is the best predictor of treatment success, but also shows high interindividual variability. We investigated IU as a potential moderating factor involved in the high variability of exposure-related learning (i.e.…”

“…Recently, a large clinical trial focused on changes of threat expectancies during exposure as a predictor of treatment success (Pittig et al, 2023). Pittig et al recorded patients' threat expectancies before and after several exposure sessions.…”

“…Clarifying the influence of IU on measures such as US expectancies is important though, since these measures are the ones that can be used in real-life exposure therapy (e.g. Pittig et al, 2023). Methodological reasons might explain these disparate findings.…”

Studying the Influence of Single Social Interactions on Approach and Avoidance Behavior – A Multimodal Investigation in Immersive Virtual Reality

“…Indeed, avoidance might be an effective short-term strategy to regulate the fear response and is therefore potentially reinforced as a useful coping mechanism. However, this tactic most likely maintains or increases anxiety in the long run, as there is no exposure to situations with a positive outcome to correct negative expectations (Pittig et al, 2023). To investigate the behavioral, attentional and physiological mechanisms involved in the development and maintenance of anxiety disorders, conditioning procedures serve as a valuable research paradigm (Haaker et al, 2019;Lonsdorf et al, 2017).…”