Extinction and beyond: an expanded framework for exposure and response prevention for obsessive-compulsive disorder

Abstract

Exposure therapy is a first-line, empirically validated treatment for anxiety, obsessive-compulsive, and trauma-related disorders. Extinction learning is the predominant theoretical framework for exposure therapy, whereby repeated disconfirmation of a feared outcome yields fear reduction over time. Although this framework has strong empirical support and substantial translational utility, extinction learning is unlikely to be the sole process underlying the therapeutic effects of exposure therapy. In our clinic, we commonly treat obsessive-compulsive disorder (OCD) patients successfully with exposure therapy even when some or all of their feared outcomes are not amenable to disconfirmation and, by extension, to extinction learning. Herein, we present a generic clinical vignette illustrating a commonly encountered feared outcome in OCD that cannot be disconfirmed through exposure (damnation resulting from blasphemous thoughts). We describe two specific non-extinction-based strategies we commonly employ in such cases, and we associate these strategies with known change mechanisms that might account for their effectiveness: (1) non-associative habituation to aversive stimuli, and (2) fear-memory elicitation and subsequent reconsolidation. We discuss the limitations inherent in the reverse-translational approach taken and its opportunities for expanding the framework of exposure therapy.

Keywords: anxiety disorders; behavioral therapy; exposure therapy; extinction; obsessive-compulsive disorder.

Figure 1

(A) In a traditional laboratory extinction paradigm, the initial appraisal that a neutral stimulus (blue square) will be followed by an aversive outcome (shock) is usually acquired through conditioning. Repeated exposure to the blue square without shock is expected to result in new experiential learning in the form of extinction, evidenced by declining fear responses. (B) In a common presentation of OCD, repeatedly touching the bathroom doorknob would lead to extinction if the patient expects an aversive outcome and unambiguously does not experience it. (C) In another common presentation of OCD, fears of causing harm are readily disconfirmed through repeated exposures to the perceived “dangerous” situation. Of note, the patient may still harbor additional fears about the meaning of his thoughts, which would not be directly disconfirmed through the exposure described. (D) The feared outcome of going to Hell after death cannot be disconfirmed through exposure; a patient would be unlikely to experience extinction of this core fear. The patient’s fears about the meaning of her thoughts are also unlikely to be disconfirmed through simply omitting the compulsive ritual. Red X’s indicate successful extinction learning. Black squares represent absence of extinction learning.

Figure 2

The traditional framework centers on extinction learning as a means to fear reduction. Our expanded framework includes extinction learning as one of many mechanisms by which exposure therapy can bring about fear reduction.