Reward Processes and Rehearsal in Exposure Therapy

The purpose of this study is to 1) examine the importance of self-reported relief following exposure and 2) test whether positive-focused rehearsal following exposure can improve treatment outcomes for participants who endorse fear of public speaking.

Exposure therapy is an extinction-based behavioral technique, often employed in the context of cognitive behavioral therapy. It involves strategically exposing an individual to a feared stimulus in an effort to generate new non-fear associations with that stimulus. Relief refers to the positive, rewarding emotions associated with the absence of an expected aversive outcome following exposure to a feared stimulus.

In the current study, participants will engage in a series of short public speaking exposures that take place over two sessions. After every two exposures, participants will be asked to complete either a positive or neutral rehearsal exercise, consisting of recalling either positive or neutral aspects of the speech exposures. At multiple points throughout the study, participants will complete ratings of reward sensitivity, positive affect, relief, and expectancy of the aversive outcome.

The investigators will test the following: 1) the relationship of reward sensitivity and positive affect with relief following exposures, 2) the relationship between relief after exposure and learning rate (i.e., learning that the feared stimulus does not predict an aversive outcome), 3) potential differences in exposure outcomes between the positive and neutral rehearsal groups.

Study Overview

• Status: Completed
• Conditions: Anxiety Disorders; Public Speaking Fear
• Intervention / Treatment: Behavioral: Exposure; Behavioral: Rehearsal

Detailed Description

Treatment response rates for cognitive behavioral therapy (CBT) across anxiety disorders average approximately 50% post-treatment and at follow-up. Thus, recent research has amplified efforts toward improving treatment methodology in an attempt to optimize clinical outcomes. Many efforts have targeted exposure therapy, an evidence-based behavioral technique during which a participant is strategically and repeatedly exposed to a feared stimulus in order to generate new non-fear associations with that stimulus.

Mechanisms of exposure therapy have been conceptualized using inhibitory retrieval models of extinction learning. These models, derived from Pavlovian conditioning, posit that extinction is dependent upon formation of an inhibitory association where the feared conditional stimulus (CS) no longer predicts the aversive unconditional stimulus (US). The new inhibitory CS-noUS association then competes with the original CS-US association. Research has demonstrated that greater expectation of US occurrence (US expectancy) followed by the unexpected omission of the US (i.e., expectancy violation) is associated with greater learning of the inhibitory association. Exposure therapy is a clinical proxy of extinction; in order to compete with the original association between public speaking (CS) and rejection (US), participants engage in repeated exposures to the CS without the US (no rejection) and form a new inhibitory association wherein public speaking no longer predicts rejection. Strategies to enhance this inhibitory learning process include mental rehearsal, where information from a previous exposure trial is recounted to reinforce the newly learned inhibitory association.

There is also promising evidence which suggests that reward processes may facilitate extinction learning, though studies have yet to be conducted in a clinical sample. Experimental studies have demonstrated that greater relief, a positive emotion that occurs following US omission, is associated with greater expectancy violation. This suggests that positive emotions during exposure (e.g., relief) may directly influence the extinction learning process. Reduced positive affect has been associated with decreased updating of US expectancies, leading to slower learning during extinction. In contrast, elevated positive affect has been associated with enhanced encoding, rehearsal, and retrieval processes, which may lead to faster learning during extinction and prevent return of fear (i.e., relapse). Strategies designed to enhance reward sensitivity and positive affect may therefore be an important avenue of future research to improve exposure therapy outcomes. While not yet applied during exposure, strategies aimed to increase reward sensitivity via positive-focused rehearsal have led to decreased anxiety, depression, and negative affect and increased positive affect. Recent work has shown that rehearsal without a positive focus immediately following exposure leads to reductions in anxiety. Therefore, rehearsal following exposure that specifically focuses on positive emotions to increase reward sensitivity has the potential to lead to even greater symptom improvement.

The current study seeks to examine the role of relief during extinction learning and to test whether positive-focused rehearsal exercise may be implemented to improve treatment outcomes in exposure therapy in a population of individuals who demonstrate excessive fear of public speaking. There are three main goals of the study: 1) examine the relationship of reward sensitivity and positive affect with relief following exposures, 2) examine the relationship between relief after exposure and learning rate (i.e., learning that the feared stimulus does not predict an aversive outcome), and 3) test the efficacy of a positive rehearsal exercise following exposure compared to a neutral rehearsal exercise.

Participants will engage in a series of short public speaking exposures that take place over two sessions. After every two exposures, participants will be asked to complete either a positive or neutral rehearsal exercise, consisting of recalling either positive or neutral aspects of the speech exposures. At multiple points throughout the study, participants will complete ratings of reward sensitivity, positive affect, relief, and expectancy of the aversive outcome.

• Study Type: Interventional
• Enrollment (Actual): 88
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90095
      • University of California, Los Angeles

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• English-speaking
• Elevated score on public speaking anxiety/avoidance screening questions

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Positive Rehearsal; After every two exposure trials, participants will complete a rehearsal exercise prompting reflection of expectancy violation and rehearsal of the inhibitory association between the conditional stimulus (i.e., speech) and the unconditional stimulus (i.e., rejection). During rehearsal, participants are prompted to identify positive emotional experiences associated with exposure trial outcomes.	Behavioral: Exposure; All participants complete two study visits, each consisting of 8 exposure trials for durations of 1 minute each, resulting in a total of 16 exposures. For each exposure, participants are assigned a speech topic and given 1 minute to give an unprepared speech to two study confederates.; Behavioral: Rehearsal; After every two exposures, participants will complete a rehearsal task where the participant is asked to use a positive or neutral approach to remember and recount the exposures they have just completed.
Active Comparator: Neutral Rehearsal; After every two exposure trials, participants will complete a rehearsal exercise prompting reflection of expectancy violation and rehearsal of the inhibitory association between the conditional stimulus (i.e., speech) and the unconditional stimulus (i.e., rejection). During rehearsal, participants are prompted to maintain a neutral, non-emotional stance and focus on overall exposure trial outcomes.	Behavioral: Exposure; All participants complete two study visits, each consisting of 8 exposure trials for durations of 1 minute each, resulting in a total of 16 exposures. For each exposure, participants are assigned a speech topic and given 1 minute to give an unprepared speech to two study confederates.; Behavioral: Rehearsal; After every two exposures, participants will complete a rehearsal task where the participant is asked to use a positive or neutral approach to remember and recount the exposures they have just completed.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Public Speaking Anxiety	Responses to two self-reported questions assessing public speaking anxiety and avoidance (scored from 0-8, where higher scores reflect greater public speaking anxiety and avoidance) and responses to the Personal Report of Public Speaking Anxiety (PRPSA; scored from 34-170, where higher scores reflect greater public speaking anxiety symptom severity).	Baseline through study completion, an average of 3 weeks.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Learning Rate	Learning rate was calculated by using computational modeling of a prediction error formula (e.g., Rescorla & Wagner, 1972), similar to previous approaches (Barnes-Horowitz, et al., in press; Zbozinek, Perez, et al., 2022). Prior to each exposure, participants rated their expected likelihood that their feared outcome would occur on the upcoming exposure (scores ranged from 0-100). Using computational modeling, these ratings across all exposures were then input into a prediction error formula in order to derive an estimated learning rate (i.e., rate of change in expectancy ratings across exposures) for each participant. Larger, more positive learning rate values reflect greater and faster learning via faster updating of expectancy ratings across exposures.	Sessions 1 through 2, an average of 2 weeks.
Relief Rate	Relief rate was calculated by using computational modeling of a prediction error formula (e.g., Rescorla & Wagner, 1972), similar to previous approaches (Barnes-Horowitz, et al., in press; Zbozinek, Perez, et al., 2022). After each exposure, if the feared outcome did not occur, participants rated the degree of relief they felt that their feared outcome did not occur (scores ranged from 0-100). Using computational modeling, these ratings across all exposures were then input into a prediction error formula in order to derive an estimated relief rate (i.e., rate of change in relief ratings across exposures) for each participant. Larger, more positive relief rate values reflect greater and faster updating of relief ratings across exposures.	Sessions 1 through 2, an average of 2 weeks.
Change in Positive Affect	Change in self-reported positive affect measured using a visual analog scale (scored from 1-9 where higher scores reflect greater positive affect).	Baseline through session 2, an average of 2 weeks.
Change in Reward Sensitivity	Change in self-reported reward sensitivity using the Positive Valence System Scale (PVSS; scored from 21-189 where higher scores reflect greater reward sensitivity).	Baseline through session 2, an average of 2 weeks.
Change in Reward Sensitivity	Change in self-reported reward sensitivity was assessed using the Behavioral Activation Scale (BAS). Items were rated on a four-point Likert scale (1 = strongly disagree; 4 = strongly agree) and summed (range of scores = 13-52), where higher scores reflect greater reward sensitivity.	Baseline through session 2, an average of 2 weeks.

Collaborators and Investigators

• Sponsor: University of California, Los Angeles

Study record dates

Study Major Dates

• Study Start (Actual): April 18, 2023
• Primary Completion (Actual): December 12, 2023
• Study Completion (Actual): December 12, 2023

Study Registration Dates

• First Submitted: November 6, 2023
• First Submitted That Met QC Criteria: November 9, 2023
• First Posted (Actual): November 15, 2023

Study Record Updates

• Last Update Posted (Actual): June 13, 2025
• Last Update Submitted That Met QC Criteria: May 28, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: anxiety; extinction; positive affect; reward sensitivity
• Additional Relevant MeSH Terms: Mental Disorders; Anxiety Disorders
• Other Study ID Numbers: IRB#23-000236

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No