This model suggests that fear can be acquired through three different pathways: The indirect pathway allows for conditioning to occur even when CS and US are separated in time, as long as the subject learns the relationship between events Rachman, However, a number of other retrospective and prospective studies raised questions about the validity of this model.
Furthermore, when giving the choice, most phobic individuals choose panic attacks as the most important reason for their phobia Hofmann et al. Some studies defined a conditioning event as the CS-US pairing in which the US is a potentially harmful or traumatizing event such as a car accident or dog bite. In contrast, others used a more liberal definition and considered a panic attack as a possible US in the presence of the CS e.
This obviously raises the important question why uncued panic attacks happen in the first place for a discussion, see Bouton et al.
A further elaboration of the contemporary learning theory perspective on the etiology of anxiety disorders was provided by Mineka and Zinbarg This model assumes that, aside from direct or vicarious traumatic conditioning experiences, a number of other factors influence CS-US conditioning.
These factors include the perceptions of controllability and predictability of stressful events, the properties of the CS such as fear personal statement of faith, temporal proximity to stressful events, etc.
The case of post-traumatic stress disorder PTSD might illustrate some of these factors. PTSD is the only anxiety disorder that includes a direct conditioning event in its diagnostic definition.
Consistent with the conditioning model, war veterans with PTSD who are exposed to trauma cues by watching a video clip of a combat scene typically show intense emotional responses that are elicited by the specific trauma cues, which are the conditioned stimuli that were previously paired with the traumatic event e.
However, exposure to trauma is not sufficient to develop PTSD. Although the majority of individuals in a large community sample These data suggest that trauma exposure is not sufficient to develop PTSD. In other words, once confronted with a snake, the fear module of a snake phobic is activated and cannot be aborted easily by any cognitive strategies.
Therefore, the fear circuitry in rats suggests that the amygdala and its projections are involved in both the acquisition and expression of conditioned fear e. In sum, the simple Pavlovian conditioning model Mowrer, ; Watson, shows a number of significant weaknesses as a model of fear acquisition in humans.
As a result, a number of alternative models were discussed, including the preparedness theory e. Bouton et al.
As pointed out by McNally bnone of these theories can fully account for all cases, and some of them became so complex that it has been difficult to test them in the laboratory, let alone in clinical practice.
Common features of contemporary theories of fear acquisition include the consideration of temperamental variables, such as anxiety sensitivity McNally, aand cognitive processes.
These cognitive processes are evident in observational and informational learning, as well as during direct conditioning events.
Specifically, it has been demonstrated that US expectancies and the perception of controllability and predictability about stressful events are essential aspects of fear conditioning in humans. For the remainder of this discussion, I will refer to US expectancies and the perception of controllability and predictability of future events as cognitive processes. The goal is to identify these processes in extinction learning and exposure therapy and to discuss the implications for clinical research.
It remains unclear whether these cognitive processes causally implicate fear mechanisms or whether they are simply epiphenomenal correlates to the actual mediator. Nevertheless, there is sufficient evidence to conclude that extinction learning and exposure therapy are not simply automatic, unconscious, and low-level processes.
Instead, higher-order cognitive processes that modulate harm expectancy and the perception of control are closely linked to extinction learning and exposure therapy. Therefore, although often attempted in treatment component analyses, I will conclude that it is impossible to conduct successful exposure therapy without also changing these cognitive processes.
Fear acquisition and extinction involve the learning of associations between passively observed events. It is typically assumed that animals only learn about causal relations by using basic associative mechanisms. Causal reasoning allows the animal to predict outcomes on the basis of observation. Furthermore, a number of experimental studies have shown that cognitive factors directly modulate the CS-US contingency. It has further been shown that experimentally induced autonomic fear responses can be eliminated by simply informing subjects that the US will no longer follow the CS Grings, These findings suggest that extinction is caused by changes in expectancies and contingency beliefs that are doctoral thesis on innovation in long-term memory Lovibond, An experiment by Phelps et al.
The subjects never actually received a shock during the experiment. In sum, the literature on cognitive processes in extinction learning suggests about dissertation extinction is accompanied by changes in the CS-US contingency. Moreover, verbal instructions can directly modify extinction processes by changing this contingency, which could also explain the mechanism of exposure therapy.
Similarly, a number of psychological theories point to cognitive processes as the primary mechanism of change during exposure therapy. Cognitive therapy implies that changes in cognitions are responsible for treatment gains. Effective cognitive therapy targets all aspects of an emotional disorder, including emotional experience, behavior, and cognitions. Accordingly, Beck distinguishes among the help with college app essay, the experiential, and the behavioral approaches, all of which are important aspects of cognitive therapy.
As part of the intellectual approach, clients learn to identify their misconceptions, test the validity of their thoughts, and substitute them with more appropriate concepts.
The experiential approach helps clients to expose themselves to experiences in order to change these misconceptions.
The central element of the behavioral approach is to encourage the development of specific forms of behavior, which leads to more general changes in the way patients view themselves and the world. In cognitive therapy, cognitions are assumed to play a crucial role in the maintenance and development of the anxiety response. For example, in individuals with panic disorder, the catastrophic misinterpretation of the rush of physical sensations experienced during a panic attack is assumed to exacerbate their distress and perpetuate their difficulties Clark, how to write a research article Some cognitions are seen as specific to certain anxiety disorders.
For example, in the case of social phobia, the focus is usually placed upon the consequence of public scrutiny and subsequent negative evaluation. In contrast, individuals with agoraphobia feel distressed about the inability to escape or get help in case they develop panic or panic-like symptoms in a variety of situations.
Although some of the cognitions typically associated with each diagnosis may be disorder-specific, there are a number of commonalities of cognitions across the anxiety disorders. For example, all maladaptive anxiety-related cognitions are assumed to be future-oriented perceptions of danger or threat e.
This sense of danger may involve either physical e. During treatment, the patient is provided with an opportunity to challenge these beliefs by conducting hypotheses by exposing herself to situations that are likely associated with the expected harmful consequences.
In other words, the patient is encouraged to re-evaluate harm expectancy which, as I reviewed earlier, appears to be the commonality between extinction learning and exposure therapy. It has further been shown that repeated experiences with uncontrollable aversive events can lead to pathological emotional states, such as anxiety and depression e.
Therefore, it has long been suggested that the degree to which people view events as within their control may be a fundamental mediator of psychopathology and treatment e. Modern emotion theories assume that the unexpected experience of personal essay for college admission help of emotions may lead to anxiety disorders in vulnerable individuals because they view their own emotions or bodily reactions as out of control Barlow, In the case of panic disorder, for example, vulnerable individuals may unexpectedly experience a brief and intense burst of fear and subsequently develop anxiety over the possibility of the reoccurrence of this response in an uncontrollable manner.
It is hypothesized that all anxiety disorders share a lack of perceived control over negative emotional and bodily reactions. Again, this is consistent with the notion that changes in the CS-US expectancy are common elements of fear reduction in extinction learning, exposure therapy and cognitive-behavioral therapy.
Exposure is an important, if not the most important, treatment component of effective interventions for the range of anxiety disorders, including social phobia e. A case in point is social phobia.
Therefore, some investigators argued that a treatment that specifically targets dysfunctional beliefs about social situations should be more effective than simple exposure procedures. In only two of the trials did the effects of cognitive-behavior therapy exceed those of exposure alone at post-treatment Butler et al.
These component analyses studies were based on the assumption that simple exposure procedures are sub-optimal because the mechanism of change is via extinction learning, which is not mediated by cognitive changes. However, based on the present review, there is no evidence to support this assumption. Instead, the empirical evidence suggests that exposure procedures without explicit cognitive intervention strategies have very water term paper effects than comprehensive cognitive-behavioral treatments, simply because exposure therapy is mediated through changes in cognitions, and specifically changes in CS-US harm expectancy.
The efficacy of exposure therapy as compared to other, more comprehensive, treatment approaches has been surprising to many researchers.
Moreover, it has been surprising that exposure therapy not only alleviates specific anxiety symptoms but is also associated with improvement in general functioning and results in significant cognitive changes. For example, after reviewing the outcome literature of CBT and exposure therapy without explicit cognitive intervention for social phobia, Feske and Chambless wrote:.
Moreover, there was no evidence of differential dropout between the two treatment modalities. These findings are disappointing in light of the enthusiasm for CBT. These findings are only surprising if we assume that exposure therapy and extinction only involves primitive, automatic, and low-level processes that need to be supplemented with cognitive therapy to effectively target dysfunctional cognitive processes.
If, on the other hand, we assume that exposure therapy is cognitively mediated, we would expect exposure therapy to have very similar effects as more comprehensive treatments, such as cognitive therapy. Moreover, it has been shown that treatment changes during cognitive-behavioral therapy and exposure therapy are both mediated via changes in cognitions Hofmann, These data illustrate mass media essays importance of cognitive processes in exposure therapy.
Although the precise mechanism of treatment change during exposure therapy remains unclear, it can be concluded that repeated exposure practices whether with or without explicit cognitive strategies change harm expectancy, among other things. The effect of exposure therapy on other cognitive variables, such as changes in negative self-perception in social phobia, is difficult to explain at this stage and will require additional research.
Recognizing the importance of cognitive processes in fear acquisition, extinction, and exposure therapy offers a new possibility for intervention research, namely to improve the effects of exposure therapy with pharmacological interventions that are believed to act as cognitive enhancers. Animal research has shown that fear and extinction learning are both blocked by antagonists at the glutamatergic N -methyl-d-aspartate NMDA receptor, which is critically involved in learning and memory.
In an initial effort to demonstrate the utility of DCS as a method to enhance exposure therapy in humans, Ressler et al. Exposure therapy combined with DCS resulted in significantly larger reductions of acrophobia symptoms at 1 week and 3 months following treatment with no difference in efficacy between the 2 doses and no reports of adverse effects from DCS administration.
Subjects receiving DCS also showed significantly greater decreases in post-treatment skin conductance fluctuations during the virtual exposure and significantly greater improvement compared to placebo on general measures of real-world acrophobia symptoms that were evident early in treatment and were maintained at 3 months. In another double-blind placebo-controlled study, 27 patients with a principal DSM-IV diagnosis of social anxiety disorder social phobia were assigned to either receive 5 exposure group sessions plus DCS 50 mg or 5 exposure group sessions plus pill placebo Hofmann et al.
The exposure practices of increasing difficulty consisted of giving speeches about topics, chosen by the therapists, in front of the other group members or confederates and a video camera.
The level of social anxiety was assessed at baseline, post-treatment, and 1 month after the last session 1-month follow-up. The results showed that patients who received DCS prior to the exposure sessions showed greater reduction in their social anxiety than patients who received placebo prior to the exposures.
The difference between the two groups increased linearly with time, with the greatest treatment effects of DCS being evident at follow-up.
Together, the clinical outcome studies by Hofmann et al. However, the evidence is still preliminary and a number of additional studies around the world are currently being conducted to replicate and extend these early findings and to dissect the specific mechanism.
It was readily adopted as a model for fear acquisition and anxiety reduction in humans. However, the view that extinction learning is a low-level process that does not involve any higher-order cognitive processes was an overly simplistic and misleading conceptualization. As a result, early models of fear acquisition e. In humans, these processes are not only evident in cases of observational and informational learning, but can also be seen in changes of US expectancies and perception of controllability and predictability.
Similarly, it appears that extinction learning and exposure therapy involve higher-order cognitive processes. Specifically, the present review of the literature suggests that a reduction in US expectancy mediates extinction learning and exposure therapy, as well as cognitive-behavioral therapy. In essence, the present review of empirical data and theoretical models suggests that fear extinction in animals and exposure therapy in humans share similar cognitive processes that are associated with changes in CS-US expectancy.
Narrative writing styles conclude that exposure therapy is a form of cognitive intervention that specifically changes harm expectancy. Comparing conditioning studies with psychotherapy studies is not without problems — humans are more complex than animals; exposure therapy is more complex than extinction training; and anxiety is more complex than fear.
Basic emotions are believed to occur in all human beings, across all cultures. They fulfill useful, evolutionarily adaptive functions in dealing with fundamental life-tasks by mobilizing quick and adaptive reactions in response to threatening situations e. In contrast to fear, anxiety is conceptualized as literature review on customer satisfaction in insurance sector cognitive association that connects basic emotions such as fear to events, meanings and responses Barlow, ; Izard, Although fear and anxiety are different, both are adaptive emotional responses to threat.
If these emotions become maladaptive e. A closer examination of the animal literature on conditioning and extinction makes it difficult to distinguish fear and anxiety simply based on the involvement of cognitive processes. The present review suggests that even primitive Pavlovian fear conditioning and extinction are modulated and mediated by cognitive processes.
Specifically, extinction in animals is closely associated with changes in CS-US expectancy, and exposure therapy in humans is closely associated with changes in perception of predictability of stressful events, among other cognitive variables. Knowing the neuroscience literature, it should come as no surprise that cognitive processes are critically important in even primitive forms of learning. The fear circuitry in rats suggests that the amygdala and its projections with areas of the frontal lobe are involved in both the acquisition and expression of conditioned fear e.
Moreover, rats can predict outcomes simply on the basis of observation Bleisdell et al. For example, very few individuals with height phobia have experienced a fall from high examples application letter. Similarly, it is unlikely that a panic attack is the feared consequence, because exposure to heights typically produces intense fear and is, therefore, a highly likely and expected event.
Instead, patients with height phobia may be more likely to report fear of losing control and jumping or fainting and falling, although they never experienced such an event. Observation and informational learning are more likely pathways to establish CS-US expectancy that change as a result of exposure intervention. National Center for Biotechnology InformationU.
Clin Psychol Rev. Author manuscript; available in PMC Feb 1. Stefan G. Author information Copyright and License information Disclaimer. E-mail address: Copyright notice. See other articles in PMC that cite the published article. Abstract Anxiety disorders are highly prevalent. The customer support is definitely something that this service needs to work on. The customer support representatives are reachable through live chat, but they are not always available.
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