The Effect of Cognitive Restructuring Before Exposure for Claustrophobia on Expectancy and Outcome
Condition: CR Before:Engaging in Cognitive Intervention Before Exposure; CR After:Engaging in Cognitive Intervention After Exposure
MeSH terms: Phobic Disorders
Study type: Interventional

Summary: 
      Whether used alone or in combination with other approaches, strategies such as cognitive
      restructuring (CR) and exposure are well-established treatments for anxiety. CR involves
      identifying and challenging thoughts, beliefs, or assumptions that maintain anxiety, and
      exposure involves confronting feared situations, typically in a gradual manner. Many theories
      have been proposed to explain why exposure is effective. One theory posits that corrective
      learning occurs only when expectations about the outcome of a situation are violated.
      Therefore, exposure is thought to be effective when the discrepancy between the expected and
      actual outcome is maximized. One group of researches has suggested that engaging in CR prior
      to exposure will prematurely reduce the discrepancy between expectancy and outcome, resulting
      in less inhibitory learning. As such, they recommend that CR only be conducted after exposure
      in order to consolidate learning about expectancy violation. This recommendation has not been
      experimentally studied and is in contrast to what is typically practiced clinically. CR is
      often introduced in therapy prior to exposure. The present study will determine whether
      conducting CR before exposure results in (1) greater initial reductions in expectation
      following CR before exposure, (2) less expectancy violation, and (3) poorer treatment gains
      at posttreatment and 1-month followup. Eighty-two participants with claustrophobia will be
      randomly assigned to receive either CR before exposure or CR after exposure. The intervention
      will be conducted in a single session.
    

Detailed description: 
      Inhibitory learning is the extinction of a behavioral response through repeated presentations
      of a conditioned stimulus (CS) in the absence of an unconditioned stimulus (US, CS-noUS). The
      CS first elicits a behavioral response through excitatory learning - repeated pairing with
      the US that naturally elicits the same behavioral response (CS-US). One way that inhibitory
      learning can be maximized in exposure is by violating one's expectancy about CS-US
      relationship, such that the individual is surprised by the outcome (e.g., CS-noUS). The
      purpose of the present study is to evaluate the recommendation to avoid cognitive
      interventions before exposure. Specifically, the aim is to discover whether cognitive
      interventions before exposure prematurely reduce expected feared outcome ratings, leading to
      smaller expectancy violation and poorer inhibitory learning (i.e., exposure session or
      intervention gains) compared to conducting exposures with a consolidation period following
      exposure.
    

Intervention name(s): CR Before Exposure; CR After Exposure
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants complete 15 minutes of CR (Preparation) using the "evidence technique" outlined in the cognitive-behavioral manual Mind Over Mood (Greenberger & Padesky, 2016). This technique involves evaluating the validity of expected feared outcomes. Next, participants complete six 5-minute exposure trials using a claustrophobic chamber and other materials (e.g., scarf, mask, handcuffs). Finally, participants complete the 15-minute self-report filler task (including questions from the MMPI-2, Butcher et al., 1989) which acts as a no-treatment comparison to CR being conducted after exposure in the other arm of the study.; Participants complete the 15-minute self-report filler task (including questions from the MMPI-2, Butcher et al., 1989) which acts as a no-treatment comparison to CR being conducted before exposure in the other arm of the study. Next, participants complete six 5-minute exposure trials using a claustrophobic chamber and other materials (e.g., scarf, mask, handcuffs). Then, participants complete 15 minutes of CR (Consolidation, Craske et al.'s, 2014) by calculating the difference between predicted and actual expected feared outcomes, and identifying identify (1) whether they believe their feared outcomes occurred (Yes/No), (2) describe how they know this to be true, and (3) reflect on what they learned about their feared outcome or expectancy through exposure.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Participants will complete baseline pretreatment outcome measures at the first visit to the lab. All participants will watch the same psychoeducation video explaining the nature of anxiety and rationale for exposure therapy. Participants will then be randomly assigned to either the CR Before condition or the CR After condition. CR Before will complete 15 minutes of CR (Preparation) before engaging in six 5-minute exposure trials in a claustrophobic chamber, and complete the 15-minute filler task after exposure. CR After will complete the 15-minute filler task before exposure, engage in six 5-minute exposure trials in a claustrophobic chamber, and engage in 15 minutes of CR (Consolidation) after exposure. Participants will complete posttreatment outcome measures immediately following the intervention. Participants will return one month later to complete followup outcome measures.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Anxiety; Specific Phobia; Claustrophobia; Exposure; Cognitive therapy; Cognitive restructuring; Consolidation; Inhibitory learning; Expectancy violation; Expectancy; Exposure therapy; Anxiety disorder