Extinction learning in childhood anxiety disorders, obsessive compulsive disorder and post-traumatic stress disorder: implications for treatment

ABSTRACT

Introduction: Threat conditioning and extinction play an important role in anxiety disorders, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Although these conditions commonly affect children, threat conditioning and extinction have been primarily studied in adults. However, differences in phenomenology and neural architecture prohibit the generalization of adult findings to youth.

Areas covered: A comprehensive literature search using PubMed and PsycInfo was conducted to identify studies that have used differential conditioning tasks to examine threat acquisition and extinction in youth. The information obtained from this review helps to clarify the influence of these processes on the etiology and treatment of youth with OCD, PTSD and other anxiety disorders. Thirty studies of threat conditioning and extinction were identified

Expert commentary: Youth with anxiety disorders, OCD, and PTSD have largely comparable threat acquisition relative to unaffected controls, with some distinctions noted for youth with PTSD or youth who have suffered maltreatment. However, impaired extinction was consistently observed across youth with these disorders and appears to be consistent with deficiencies in inhibitory learning. Incorporating strategies to improve inhibitory learning may improve extinction learning within extinction-based treatments like cognitive behavioral therapy (CBT). Strategies to improve inhibitory learning in CBT are discussed.

KEYWORDS:

• Conditioning
• extinction
• threat
• fear
• anxiety disorders
• obsessive compulsive disorder
• post-traumatic stress disorder
• adolescence
• inhibitory learning
• exposure therapy

Declaration of interest

JF McGuire receives grant support from the Tourette Association of American and the National Institutes of Mental Health (NIMH) through T32MH073517. The views expressed within this article represent those of the authors, were not influenced by this funding source, and are not intended to represent the position of NIMH. SP Orr receives grant support from the National Institutes of Health/National Institute of Mental Health (NIH/NIMH) in part through 1R21MH101567, Department of Defense, and Department of Veterans Affairs. JT McCracken receives support from the National Institute of Health in part through T32MH073517, Seaside Therapeutics, Roche, and Otsuka. He has served as a consultant to BioMarin and PharmaNet. EA Storch receives grant support from the National Institute of Mental Health in part through R01MH093381, CDC, Agency for Healthcare Research and Quality, IOCDF, All Children’s Hospital Research Foundation, and Ortho-McNeil Scientific Affairs. He receives textbook honorarium from Springer publishers, American Psychological Association, Lawrence Erlbaum, Elsevier, and Wiley-Blackwell. He is a consultant for RuiJin Hospital and Rogers Memorial Hospital, and is on the Speaker’s Bureau and Scientific Advisory Board for the IOCDF. He receives research support from the All Children’s Hospital Guild Endowed Chair. J Piacentini receives support for his work from National Institute of Mental Health (NIMH) in part through T32MH073517, Tourette Syndrome Association (TSA), Pfizer and the Pettit Family Foundation; book royalties from Oxford University Press and Guilford Publications, and speaking honoraria from the Tourette Association of America, International OCD Foundation (IOCDF), and Trichotillomania Learning Center. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Notes

1. Ledoux has recently made the compelling argument that the process of ‘fear conditioning’ can be explained solely in terms of associations created and stored in amygdala circuits and that, consequently, there is no need to infer that conscious feelings of ‘fear’ are necessary for this associative learning process [91]. Ledoux has suggested that ‘threat conditioning’ is a more precise term for describing what has traditionally been referred to as ‘fear conditioning’ and that the concept of ‘fear’ be used when referencing what individuals subjectively report as fear. We will follow this suggested convention throughout the manuscript [91].