PROJECT SUMMARY/ABSTRACT
Over 43M Americans (~13% of the population) will suffer from social anxiety disorder in their lifetime
(Kessler et al., 2012) – 20M of which will have fear of public speaking (Kessler et al., 1998). Cognitive-behavioral
therapy (a major component of which is exposure therapy) is a leading treatment for social anxiety disorder but
is only fully effective in ~45% of individuals (Loerinc, et al., 2015). Exposure therapy is the clinical proxy of
Pavlovian extinction in which the individual approaches their feared situation (e.g., social situation) without the
expected aversive outcome (e.g., negative social judgment). Several basic research findings show that stronger
reward processing is linked to better extinction of fear, suggesting that enhancing reward processing can improve
exposure therapy. First, reward processing is involved in extinction learning at the time of omission of an
expected aversive outcome, such that the omission is experienced as “relief-pleasantness” as measured by self-
report and by neural mechanisms of reward processing (e.g., Lange, et al., 2020). Second, direct stimulation of
the reward circuitry has been shown to enhance extinction of fear (Sierra, et al., 2023). Third, low self-reported
reward processing is associated with low relief-pleasantness (Leng, et al., 2022). Fourth, social anxiety disorder
is associated with poor reward processing (Cremers, et al., 2015). Lastly, anhedonia – a robust correlate of poor
reward processing and social anxiety – is associated with poor extinction of fear (Young, et al., 2021). Thus,
enhancing reward processing may be especially likely to improve exposure therapy outcomes in social anxiety
disorder (Aim 1) by increasing relief-pleasantness when an expected aversive event does not occur (Aim 2). In
this K23, we will conduct the first experimental therapeutics study investigating the effects of target engagement
(reward processing) on subsequent exposure therapy outcome (social anxiety; specifically, fear of public
speaking). To this end, socially anxious participants with a fear of public speaking and low reward processing
will undergo the behavioral portion of Positive Affect Treatment (PAT-B) or Relaxation Treatment; both
treatments are expected to decrease negative affect, but PAT-B is expected to improve reward processing more
than Relaxation Treatment (Craske et al., 2023). Subsequently, all participants will undergo Exposure Therapy
for fear of public speaking with the primary outcome being multi-modal assessment of public speaking anxiety.
For experimental therapeutics, the target is reward processing, which we will measure primarily as relief-
pleasantness in fMRI fear conditioning during extinction at the time of electric shock omission (measured neurally
and with computational modeling of self-report relief-pleasantness). The training plan will help the Candidate
gain expertise in experimental therapeutics, fMRI, and computational modeling in the service of his career goal:
to improve our understanding and treatment of anxiety disorders. This K23 may improve the efficacy of exposure
therapy, our understanding of its mechanisms, and help millions of people with social anxiety disorder.