Optimizing threat expectancy change during exposure therapy for anxiety disorders: Study protocol for a mechanism-focused two-arm parallel group randomized controlled superiority trial with sequential Bayes factor design
Abstract
Background: Anxiety disorders are highly prevalent and associated with significant personal and societal burden. Exposure-based cognitive behavioral therapy (CBT) is a first-line treatment, yet response varies widely, with remission rates of 50–70% and relapse in 5–14% of patients. Targeting mechanisms of change underlying successful exposure-based CBT may improve treatment efficacy. This study aims to optimize exposure-based CBT by enhancing learning rates through tailored post- exposure processing focused on threat expectancy change. Methods: This is a two-arm parallel-group randomized controlled superiority trial comparing optimized exposure with post-exposure processing versus exposure without post-processing in adults with panic disorder, agoraphobia, social anxiety disorder, or specific phobia. The primary outcome is the exposure-related learning rate, calculated from patients’ threat expectancy ratings before and after exposure. A predefined sequential Bayes factor design is used to evaluate evidence continuously, with a maximum sample size of 70 per group. Secondary outcomes include threat expectancy change, cognitive immunization processes, and longitudinal trajectories of expectancy change assessed via ecological momentary assessment (EMA). Data are collected within manualized exposure-based CBT, including standardized exposure worksheets, psychometric assessments, and EMA. Discussion: This study represents a novel, mechanism-focused approach to optimizing exposure- based CBT. By prioritizing the enhancement of learning rates over symptom reduction in the first step, the trial increases feasibility, efficiency, and scientific rigor. If successful, this approach could inform personalized, adaptive treatment protocols that target core mechanisms of change. The findings may advance process-based psychotherapy and improve long-term outcomes for anxiety disorders.
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BibTeX
@misc{pittig2026optimizing,
title = {{Optimizing threat expectancy change during exposure therapy for anxiety disorders: Study protocol for a mechanism-focused two-arm parallel group randomized controlled superiority trial with sequential Bayes factor design}},
author = {Andre Pittig and Lena Waltemate and Simon Blackwell and Roxana Pittig},
howpublished = {PsyArXiv},
year = {2026},
month = oct,
doi = {10.31234/osf.io/sw6pg_v1},
url = {https://osf.io/preprints/psyarxiv/sw6pg_v1/},
note = {CC BY 4.0},
}
RIS
TY - UNPB
TI - Optimizing threat expectancy change during exposure therapy for anxiety disorders: Study protocol for a mechanism-focused two-arm parallel group randomized controlled superiority trial with sequential Bayes factor design
AU - Andre Pittig
AU - Lena Waltemate
AU - Simon Blackwell
AU - Roxana Pittig
PY - 2026
DA - 2026/10/22
PB - PsyArXiv
DO - 10.31234/osf.io/sw6pg_v1
UR - https://osf.io/preprints/psyarxiv/sw6pg_v1/
AB - Background: Anxiety disorders are highly prevalent and associated with significant personal and societal burden. Exposure-based cognitive behavioral therapy (CBT) is a first-line treatment, yet response varies widely, with remission rates of 50–70% and relapse in 5–14% of patients. Targeting mechanisms of change underlying successful exposure-based CBT may improve treatment efficacy. This study aims to optimize exposure-based CBT by enhancing learning rates through tailored post- exposure processing focused on threat expectancy change. Methods: This is a two-arm parallel-group randomized controlled superiority trial comparing optimized exposure with post-exposure processing versus exposure without post-processing in adults with panic disorder, agoraphobia, social anxiety disorder, or specific phobia. The primary outcome is the exposure-related learning rate, calculated from patients’ threat expectancy ratings before and after exposure. A predefined sequential Bayes factor design is used to evaluate evidence continuously, with a maximum sample size of 70 per group. Secondary outcomes include threat expectancy change, cognitive immunization processes, and longitudinal trajectories of expectancy change assessed via ecological momentary assessment (EMA). Data are collected within manualized exposure-based CBT, including standardized exposure worksheets, psychometric assessments, and EMA. Discussion: This study represents a novel, mechanism-focused approach to optimizing exposure- based CBT. By prioritizing the enhancement of learning rates over symptom reduction in the first step, the trial increases feasibility, efficiency, and scientific rigor. If successful, this approach could inform personalized, adaptive treatment protocols that target core mechanisms of change. The findings may advance process-based psychotherapy and improve long-term outcomes for anxiety disorders.
ER -