Change of Threat Expectancy as Mechanism of Exposure-Based Psychotherapy for Anxiety Disorders: Evidence From 8,484 Exposure Exercises of 605 Patients

Research output: Contribution to journalResearch articleContributedpeer-review


  • Andre Pittig - , University of Würzburg, Friedrich-Alexander University Erlangen-Nürnberg (Author)
  • Ingmar Heinig - , Institute of Clinical Psychology and Psychotherapy (Author)
  • Stephan Goerigk - , Institute of Clinical Psychology and Psychotherapy, Technical University of Munich (Author)
  • Jan Richter - , University of Greifswald, University of Hildesheim (Author)
  • Maike Hollandt - , University of Greifswald (Author)
  • Ulrike Lueken - , University of Würzburg, Humboldt University of Berlin (Author)
  • Paul Pauli - , University of Würzburg (Author)
  • Jürgen Deckert - , University of Würzburg (Author)
  • Tilo Kircher - , University of Marburg (Author)
  • Benjamin Straube - , University of Marburg (Author)
  • Peter Neudeck - , Protect-AD Study Site Cologne (Author)
  • Katja Koelkebeck - , University of Münster (Author)
  • Udo Dannlowski - , University of Münster (Author)
  • Volker Arolt - , University of Münster (Author)
  • Thomas Fydrich - , Humboldt University of Berlin (Author)
  • Lydia Fehm - , Humboldt University of Berlin (Author)
  • Andreas Strohle - , Charité – Universitätsmedizin Berlin (Author)
  • Christina Totzeck - , Ruhr University Bochum (Author)
  • Jürgen Margraf - , Ruhr University Bochum (Author)
  • Silvia Schneider - , Ruhr University Bochum (Author)
  • Jürgen Hoyer - , Chair of Behavioral Psychotherapy (Author)
  • Winfried Rief - , University of Marburg (Author)
  • Michelle G. Craske - , University of California at Irvine (Author)
  • Alfons O. Hamm - , University of Greifswald (Author)
  • Hans-Ulrich Wittchen - , Chair of Clinical Psychology and Psychotherapy, TUD Dresden University of Technology, Technical University of Munich (Author)


Individual responses to behavioral treatment of anxiety disorders vary considerably, which requires a better understanding of underlying processes. In this study, we examined the violation and change of threat beliefs during exposure. From 8,484 standardized exposure records of 605 patients with different anxiety disorders, learning indicators were derived: expectancy violation as mismatch between threat expectancy before exposure and threat occurrence, expectancy change as difference between original and adjusted expectancy after exposure, and prediction-error learning rate as extent to which expectancy violation transferred into change. Throughout sessions, high threat expectancy but low occurrence and adjusted expectancy indicated successful violation and change of threat beliefs by exposure. Expectancy violation, change, and learning rate substantially varied between patients. Not expectancy violation itself, but higher learning rate and expectancy change predicted better treatment outcome. Successful exposure thus requires expectancy violation to induce actual expectancy change, supporting learning from prediction error as transdiagnostic mechanism underlying successful exposure therapy.


Original languageEnglish
Pages (from-to)199-217
Number of pages19
JournalClinical psychological science
Issue number2
Early online date4 Oct 2022
Publication statusPublished - Mar 2023

External IDs

Scopus 85139437438
Mendeley bdceb879-1b4f-398c-a591-b772576e8357
ORCID /0000-0002-7762-4327/work/141543452
ORCID /0000-0002-1697-6732/work/148632185


ASJC Scopus subject areas


  • exposure therapy\ndissemination\nanxiety disorders\nposttraumatic stress disorder\nobsessive-compulsive disorder, anxiety disorders, prediction error, expectancy violation, treatment outcome, mechanisms of change