The Effect of Cognitive Restructuring Before Exposure for Claustrophobia on Expectancy and Outcome


Kirstyn L. Krause




CR Before:Engaging in Cognitive Intervention Before Exposure
CR After:Engaging in Cognitive Intervention After Exposure


Behavioral: CR After Exposure
Behavioral: CR Before Exposure

Study type


Funder types



REB 2018-161

Details and patient eligibility


Whether used alone or in combination with other approaches, strategies such as cognitive restructuring (CR) and exposure are well-established treatments for anxiety. CR involves identifying and challenging thoughts, beliefs, or assumptions that maintain anxiety, and exposure involves confronting feared situations, typically in a gradual manner. Many theories have been proposed to explain why exposure is effective. One theory posits that corrective learning occurs only when expectations about the outcome of a situation are violated. Therefore, exposure is thought to be effective when the discrepancy between the expected and actual outcome is maximized. One group of researches has suggested that engaging in CR prior to exposure will prematurely reduce the discrepancy between expectancy and outcome, resulting in less inhibitory learning. As such, they recommend that CR only be conducted after exposure in order to consolidate learning about expectancy violation. This recommendation has not been experimentally studied and is in contrast to what is typically practiced clinically. CR is often introduced in therapy prior to exposure. The present study will determine whether conducting CR before exposure results in (1) greater initial reductions in expectation following CR before exposure, (2) less expectancy violation, and (3) poorer treatment gains at posttreatment and 1-month followup. Eighty-two participants with claustrophobia will be randomly assigned to receive either CR before exposure or CR after exposure. The intervention will be conducted in a single session.

Full description

Inhibitory learning is the extinction of a behavioral response through repeated presentations of a conditioned stimulus (CS) in the absence of an unconditioned stimulus (US, CS-noUS). The CS first elicits a behavioral response through excitatory learning - repeated pairing with the US that naturally elicits the same behavioral response (CS-US). One way that inhibitory learning can be maximized in exposure is by violating one's expectancy about CS-US relationship, such that the individual is surprised by the outcome (e.g., CS-noUS). The purpose of the present study is to evaluate the recommendation to avoid cognitive interventions before exposure. Specifically, the aim is to discover whether cognitive interventions before exposure prematurely reduce expected feared outcome ratings, leading to smaller expectancy violation and poorer inhibitory learning (i.e., exposure session or intervention gains) compared to conducting exposures with a consolidation period following exposure.


97 patients




17 to 65 years old


No Healthy Volunteers

Inclusion criteria

Self-reported proficiency in English language.

High claustrophobic fear as demonstrated by:

  • Self-report of moderate anxiety (score of at least 2 out of 4) if participant had to lie down in small dark chamber without windows for several minutes.
  • Endorsement of claustrophobia according to the DSM-5 criteria for Specific Phobia, with or without Criterion F.
  • Exiting of wooden claustrophobic chamber before 2 minutes have passed, or self-reported fear rating at or exceeding 50/100 fear while in the chamber.

Exclusion criteria

  • Current or past cognitive behavioral therapy (i.e., cognitive therapy, exposure) for claustrophobia or anxiety and related disorders in the past year
  • Change in dose of psychotropic medication in the past 3 months.
  • Use of benzodiazepine more frequently than once per week in the past 3 months.
  • Diagnosis of current (past month) panic disorder or agoraphobia.
  • Claustrophobia due to or worsened by current (past month) posttraumatic stress disorder (PTSD).
  • Participants with current (past month) diagnosis of severe depression, bipolar disorder, alcohol/substance use, or psychosis.
  • Presence of imminent suicidality or homicidality.
  • Self-reported medical condition that may make it dangerous for participant to experience heightened emotions or arousal (e.g., heart condition/disease, respiratory problem, asthma triggered by intense emotion/arousal).
  • Participation in professional treatment for claustrophobia between the end of the first lab meeting and the 1-month follow-up (Note: This does not include self-help exposure practice).
  • Weight or height exceeding maximum capacity of claustrophobic chamber (e.g., weight over 250 lbs, height over 6 feet 5 inches).

Trial design

Primary purpose




Interventional model

Parallel Assignment


None (Open label)

97 participants in 2 patient groups

CR Before Exposure
Experimental group
Participants in this arm will receive 15 minutes of CR (preparation) before engaging in exposure and will complete the 15-minute questionnaire filler task after exposure.
Behavioral: CR Before Exposure
CR After Exposure
Experimental group
Participants in this arm will complete the 15-minute questionnaire filler task before exposure and receive 15 minutes of CR (consolidation) after engaging in exposure.
Behavioral: CR After Exposure

Trial contacts and locations



Data sourced from

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