Learning Safety

If you’ve ever dealt with significant fears of anything, you probably are very familiar with the old adage that, to overcome fear, you must face it. If you avoid the things you are afraid of, you will very likely stay afraid of them. If, however, you face them and nothing terrible happens, you will start to learn that the things you are afraid of are not as dangerous as they may have seemed. This approach to overcoming fear is formalized in one of the most powerful treatments we have in psychology: exposure therapy. Exposure therapy basically involves spending time in situations you’re afraid of, on purpose, over and over again. Over time, you might learn that the situations are not as threatening or dangerous as they seemed. You might also learn to feel less afraid and anxious in these situations, and even better, you might learn to tolerate feelings of fear and anxiety. In short, overcoming fear involves learning a lot of stuff. People who study exposure therapy often say that it helps people learn that situations are safe.

I recently returned from an interesting conference, where researchers were presenting on some of the latest advances in exposure therapy. One major trend over the last decade or so has been to use medications to improve the effects of exposure for patients with a variety of fears, such as social anxiety, fear of heights, and so on. In the past, the approach to medications was to prescribe agents that reduce anxiety, but the thinking these days is that this isn’t all that helpful. If you take an anxiety-reducing medication while you are doing exposure therapy, the research says you might be more likely to have a relapse once you finish exposure therapy and stop taking the medication. So, researchers decided to try a different approach. Instead of prescribing medication that reduces anxiety, they started prescribing medication that enhances memory. One such medication is called D-Cycloserine (DCS. I won’t bore you with the details of how it actually works, but it affects activity in areas of the brain involved in learning and memory and is perhaps the most commonly studied medication to enhance exposure therapy over the last decade or so. This work is based on the fairly simple idea that, if you learn that certain situations are safe, this will only help you if you actually remember what you learned! Perhaps these medications are a way to help people become more likely to remember that they have learned that certain places, objects, and situations are actually safe. The nice thing about DCS is that it has minimal side effects, is short-acting, and can be taken shortly before or after a therapy session.

OK, so it sounds like a great idea, but does it actually work? Although initial studies showed very promising findings, the findings since this idea was introduced 13 years ago have been pretty mixed. To figure out what’s going on here, some recent research has looked at weather the medication only works when people have had successful sessions. That is, the question here is whether the medication used to enhance your memory of safety only works if you actually learned that the situation was safe. That makes a lot of sense. If you had a crappy exposure session and didn’t learn anything, remembering what you learned is probably not going to help in the long run. Some of the hot-off-the-presses research has started to show that, if the exposure therapy session goes well, DCS might improve the effects of exposure therapy more than placebo, but if the session doesn’t go well, DCS might not help. Some of this work has been done with social anxiety disorder and fear of heights and has yet to extend to other fears. Although fairly preliminary, this work suggests that, when you’re going through the difficult work of learning that things you’re afraid of are safe, you want to remember your successes and perhaps forget your failures! If you’re interested in reading more about this interesting work, check out this link (https://www.ncbi.nlm.nih.gov/pubmed/23870811) and consider looking up the work of Dr. Jasper A. Smits, a leading researcher in this area. ~ Alexander L. Chapman, Ph.D., R.Psych.