Very Brief Exposure: Exploratory Development of a Novel Exposure Modality for Social Anxiety Disorder in Transition-Age Youth

As one of the most common and impairing disorders among adolescents, Social Anxiety Disorder (SAD) is helping to drive the ongoing mental health crisis in American youth. After their return to school following pandemic lockdowns, SAD has become even more prevalent and impairing in youth, and it is accompanied by

higher rates of Depression. Although exposure-based Cognitive-Behavioral Therapy (CBT) is effective for anxiety disorders in youth, 40-50% do not respond to it, and problems with treatment acceptance and dropout interfere with its real-world effectiveness. We have developed an efficacious exposure treatment for people

with Specific Phobia that does not evoke distress and thus avoidance behaviors. Very Brief Exposure (VBE) is the presentation of a series of masked pictures representing a person’s fears (e.g., judgmental faces), repeated many times in an exposure session. Ten RCTs have established VBE as an efficacious treatment for

Specific Phobia, consistently showing that it promotes tolerance of in vivo exposure to the feared situation, with moderate to large effect sizes. VBE can be delivered in a clinic without the need for trained therapists, at very low cost, making it potentially a highly scalable adjunctive intervention. Our goal is to develop VBE from the

treatment of transition-age youth with Spider Phobia to adolescents with SAD. To create VBE for SAD, we will: (1) create an ecologically valid VBE intervention for SAD; and (2) identify the neural circuits that VBE activates, and relate these circuit activations to effects on fear responses. These aims will allow us to determine if VBE

engages the same neural circuits in SAD that we have established as a target mechanism in Specific Phobia. 35 youth with SAD and 35 healthy controls, ages 16-22, will each receive: (1) VBE to SAD-relevant stimuli; (2) clearly visible exposure (CVE) to the same SAD stimuli; and (3) exposure to control stimuli, all during fMRI

scanning. They will provide periodic fear ratings, and we will continuously record skin conductance during the exposures. CVE is an active control condition used to manipulate conscious awareness of exposure and thereby illustrate the potential advantages of masked exposure (VBE) in engaging extinction circuits and

reducing fear responses. Our thesis is that exposure is more effective, both in terms of circuit activity and fear responses, when delivered as the micro-exposures of VBE than as consciously experienced stimuli. These preliminary data will establish a therapeutic target of VBE in SAD, laying the groundwork for a future R61-R33

proposal to determine whether VBE, when used as an adjunctive therapy, engages the same target to boost the efficacy of CBT for SAD in a randomized controlled trial. If VBE can be adapted successfully to SAD, it could be easily incorporated into exposure-based CBT to make it more acceptable for youth by enabling them

to develop exposure tolerance earlier in the process of therapy.