Enhanced mental reinstatement of exposure treatment to improve the generalization of learning in claustrophobia

Abstract

Exposure therapy is the gold standard treatment for anxiety disorders, but reductions in fear following exposure often do not generalize well outside the context in which they took place. This study tested a strategy for increasing generalization that involved revisiting the memory of a prior exposure experience in order to enhance the retrieval of the learning that occurred. Forty-five participants (29 females, 16 males) with claustrophobia received exposure training consisting of repeated 5-minute trials lying inside a narrow cabinet laid on its back. One week later, they were randomly assigned to either enhanced mental reinstatement (EMR) or control procedures. Results of the exposure training showed significant decreases in subjective fear, heart rate and avoidance in the training context, as well as reduced claustrophobia symptoms. As expected, fear levels in the mock MRI scanner one week later increased relative to the exposure training context post-treatment. Compared to the control condition, the EMR intervention led to significantly reduced heart rate reactivity in the mock MRI scanner, but not to reduced self-reported fear or avoidance of the mock scanner, nor to differences in claustrophobia symptoms at one-month follow-up. Expectancy violations about coping self-efficacy, measured via participants’ surprise about their ability to effectively cope during exposure, predicted lower fear in the mock MRI regardless of condition. Fear-related expectancy violations, reflecting greater discrepancy in expected vs. actual fear levels during exposure, predicted greater fear in the mock MRI. Results highlight the potential for mental reinstatement of exposure to improve generalization of learning in claustrophobia, though effects may be limited. The impact of expectancy violations on exposure outcomes may depend on the type of expectancy that is violated.