Same same but different: Threat expectancy change and fear reduction as readouts of exposure rationales are only weakly associated and contribute differentially to treatment outcome in anxiety disorders
Responses to exposure therapy vary across individuals, emphasizing the need for a deeper understanding of its underlying mechanisms. This study examined two key processes during exposure that serve as readouts of different clinical rationales: (1) within-session fear reduction (measured as the decline from peak to end fear within an exposure exercise) and (2) threat expectancy processes (assessed via expectancy violation, expectancy change, and learning rate). Data from 516 patients with anxiety disorders who completed at least 10 exposure exercises in a clinical trial were analyzed. Results showed that expectancy measures and fear reduction were only weakly correlated within exposure exercises. While no significant differences were found in their time courses, both readouts independently predicted treatment success. Specifically, a higher learning rate and greater relative fear reduction were associated with better outcomes. These findings highlight the clinical relevance of monitoring fear reduction and expectancy-related readouts as indicators of two distinct exposure rationales - the fear reduction rationale and the threat expectancy rationale. Although it remains unclear whether they reflect separate mechanisms of change or different aspects of a shared mechanism, addressing both rationales may help optimize and personalize exposure therapy.
Authors
- Katharina Domschke (ORCID: https://orcid.org/0000-0002-2550-9132)
- Andre Pittig (ORCID: https://orcid.org/0000-0003-3787-9576)
- Paul Pauli (ORCID: https://orcid.org/0000-0003-0692-6720)
- Ingmar Heinig (ORCID: https://orcid.org/0000-0002-7762-4327)
- Ulrike Lueken (ORCID: https://orcid.org/0000-0003-1564-4012)
- Silvia Schneider (ORCID: https://orcid.org/0000-0003-0698-8411)
- Katja Koelkebeck (ORCID: https://orcid.org/0000-0002-0469-3997)
- Maike Hollandt (ORCID: https://orcid.org/0000-0001-5052-7271)
- Jan Richter (ORCID: https://orcid.org/0000-0002-7127-6990)
- Alfons O. Hamm (ORCID: https://orcid.org/0000-0002-3352-6231)
- Thomas Fydrich (ORCID: https://orcid.org/0000-0003-0122-2302)
- Jürgen Margraf (ORCID: https://orcid.org/0000-0001-5207-7016)
- Jürgen Deckert (ORCID: https://orcid.org/0000-0003-1008-4650)
- Benjamin Straube (ORCID: https://orcid.org/0000-0002-9837-0944)
- Stephan A. Goerigk (ORCID: https://orcid.org/0000-0002-3021-0346)
- Christina Totzeck (ORCID: https://orcid.org/0000-0001-6750-9256)
- Winfried Rief (ORCID: https://orcid.org/0000-0002-7019-2250)
- Andreas Ströhle (ORCID: https://orcid.org/0000-0003-0935-3702)
- Udo Dannlowski (ORCID: https://orcid.org/0000-0002-0623-3759)
- Tilo T. J. Kircher (ORCID: https://orcid.org/0000-0002-2514-2625)
- Peter Neudeck
- Hans‐Ulrich Wïttchen (ORCID: https://orcid.org/0000-0002-6311-7711)
- Jürgen Hoyer (ORCID: https://orcid.org/0000-0002-1697-6732)
- Volker Arolt
Institutions
- University of Hildesheim (DE)
- Philipps University of Marburg (DE)
- University of Cologne (DE)
- University of Münster (DE)
- University of Würzburg (DE)
- Universitätsmedizin Greifswald (DE)
- University Medical Center Freiburg (DE)
- Universität Greifswald (DE)
- Humboldt-Universität zu Berlin (DE)
- Universitätsklinikum Würzburg (DE)
- University of Göttingen (DE)
- Technische Universität Dresden (DE)
- Charité - Universitätsmedizin Berlin (DE)
- Ludwig-Maximilians-Universität München (DE)
- Bethel University (US)
- Ruhr University Bochum (DE)
Publication Details
- Journal
- Behaviour Research and Therapy
- Published
- 2025-09-24
- DOI
- https://doi.org/10.1016/j.brat.2025.104856
- Citations
- 1
- Primary Topic
- Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Type
- article
- Field-Weighted Citation Impact
- 2.12