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Enhancing Inhibitory Learning in Exposure-Based Treatments

How to minimize the chances of "old problems" returning after successful ERP.

A challenge to ERP treatment for OCD even when inhibitory learning is the focus is that OCD-related fear associations may still return following successful treatment. For example, clients who leave treatment thinking they are “cured” may experience spontaneous recovery of fear associations, in which old triggers begin triggering them again and the OCD-related compulsions return (Quirk, 2002). Many clients may also have a renewal of their fears when context changes, especially if the context of the ERP treatment was consistent, such as always in the therapist’s office (Culver, Stoyanova, & Craske, 2011). Third, clients may have a reinstatement of their fear after adverse or stressful life events (Ricker & Bouton, 1996). Lastly, clients may also have a reacquisition of their feared associations when the obsession is paired with a real feared outcome. All of these outcomes are very common once the safety and familiarity of the traditional therapy setting is left.

What research in the cognitive and affective domains can shed light on is what therapeutic strategies may enhance inhibitory regulation, which scientists now know to be a challenge for individuals with severe OCD and other anxiety-based disorders. Research in social neuroscience suggests one such helpful strategy for augmenting inhibitory learning during ERP treatment involves linguistic processing, specifically affect labeling. Lieberman and colleagues (2007) found through a number of fMRI studies that verbally stating one’s emotions as they occur activates the right ventrolateral prefrontal cortex and reduces amygdala activity, both of which reduce anxious-style responding such as the behaviors exhibited with OCD compulsions. By engaging the prefrontal cortex responsible for executive functions, the brain puts its energy into planning and processing which “dampens” limbic system activity and the natural “fight or flight” response experienced during a feared stimuli or obsession. Additionally, it was found that compared to distraction techniques, cognitive reappraisal, and exposure alone, affect labeling in conjunction with ERP reduced skin conductance (e.g. sweat) as well as amygdala activity and these gains were held months later (Kircanski et al., 2012)!

Other important augments recently known to enhance inhibitory learning include using retrieval cues, engaging in therapy in multiple contexts so as to generalize learning at a higher rate, incorporating variability of stimuli into ERP tasks, and creating opportunities for occasionally reinforced extinction into the ERP instead of consistent extinction. The ideas here stem from literature indicating that the inhibitory association for a stimulus is more likely to deepen if the stimulus is occasionally paired with the actual feared outcome. These types of modified exposures create opportunities for OCD patients to learn greater cognitive flexibility and allow for the possibility that sometimes the feared situation may actually come true, which in turn encourages individuals to be discerning in their threat estimations. Additionally, the importance of emphasizing variability of stimuli and contexts into ERP stems from evidence that suggests inhibitory associations become stronger when multiple conditioned stimuli which have previously been associated with the same feared outcomes are confronted. Practically, what this means for treatment is that instead of creating “fear hierarchies” and engaging in exposures one by one, first “conquering” one fear and moving on to a “higher order” fear, it is actually more beneficial for therapists of OCD patients to integrate multiple feared items into just one exposure session. This better approximates the way in which conditioned stimuli are encountered in the real world and increases the likelihood that inhibitory associations will be retrieved when these feared situations are encountered.

Creative Commons/Oliver Kepka
Source: Creative Commons/Oliver Kepka

Given the recent support and evidence behind inhibitory learning as a mechanism by which ERP successfully works compared with dampened support for habituation as the primary component in ERP (read last article for more on the difference between habituation & inhibitory learning theories), the important next steps in this field will be integrating what such newer research indicates into the daily practices of therapists who specialize in OCD and anxiety-based disorders. An important consideration going back to the idea of social constructivism is that society has created a shared understanding of mental health professionals as “expert,” and this trust needs to be earned and kept by professionals in which it is placed, which is no small task. One way to deserve the trust which the public invests in mental health professionals is for therapists to stay responsible to their patients and to the profession by engaging continually with the literature relevant to their specific fields, and recognizing that the literature changes often, which will draw upon psychologists’ own willingness to stay cognitively flexible and open to best practices of the time which will inevitably evolve with further research in these domains, rather than ritualistically using outdated but comfortable and familiar techniques.


Culver, N. C., Stoyanova, M., & Craske, M. G. (2011). Clinical relevance of retrieval cues for attenuating context renewal of fear. Journal of Anxiety Disorder, 25, Pp. 284 – 292.

Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Davis, M., Duncan, E., Bradley, B., et al. (2010). Impaired fear inhibition is a biomarker of PTSD but not depression. Depression & Anxiety, 27, Pp. 244 – 251.

Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words. Psychological Science, 18, Pp. 421 – 428.

Quirk, G. J. (2002). Memory for extinction of conditioned fear is long-lasting and persists following spontaneous recovery. Learning & Memory, 9, Pp. 402 – 407.

Ricker, S. T., & Bouton, M. E. (1996). Reacquisition following extinction in appetitive conditioning. Animal Learning & Behavior, 24, Pp. 423 – 436.

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