BackgroundThe real‐world effectiveness of exposure‐based therapies for youth depends on the willingness and ability of young people to tolerate confronting their fears, which can be experienced as highly aversive and create problems with treatment engagement and acceptance. Recently, neuroscientific research on the nonconscious basis of fear has been translated into novel exposure interventions that bypass conscious processing of feared stimuli and that thus do not cause phobic youth to experience distress. We present a review of these unconscious exposure interventions.MethodsA PRISMA‐based search yielded 20 controlled experiments based on three paradigms that tested if fear‐related responses could be reduced without conscious awareness in highly phobic, transition‐age youth: 14 randomized controlled trials (RCTs), 5 fMRI studies (1 was also an RCT), 4 psychophysiological studies (3 were also RCTs), and 1 ERP study. We conducted meta‐analyses of outcomes where feasible.ResultsUnconscious exposure interventions significantly (1) reduced avoidance behavior (range of Cohen's d = 0.51–0.95) and self‐reported fear (d = 0.45–1.25) during in vivo exposure to the feared situation; (2) reduced neurobiological indicators of fear (d = 0.54–0.62) and concomitant physiological arousal (d = 0.55–0.64); (3) activated neural systems supporting fear regulation more strongly than visible exposure to the same stimuli (d = 1.2–1.5); (4) activated regions supporting fear regulation that mediated the reduction of avoidance behavior (d = 0.70); (5) evoked ERPs suggesting encoding of extinction memories (d = 2.13); and (6) had these effects without inducing autonomic arousal or subjective fear.ConclusionsUnconscious exposure interventions significantly reduce a variety of symptomatic behaviors with mostly moderate effect sizes in transition‐age youth with specific phobias. fMRI and physiological findings establish a neurophysiological basis for this efficacy, and suggest it occurs through extinction learning. Unconscious exposure was well tolerated, entirely unassociated with drop out, and is highly scalable for clinical practice. However, a number of limitations must be addressed to assess potential clinical impacts, including combining unconscious exposure with exposure therapy to boost treatment acceptance and efficacy.

中文翻译：

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推进过渡时期青少年焦虑症的治疗：无意识暴露治疗效果的回顾


背景基于暴露的疗法对青少年的现实有效性取决于年轻人忍受面对恐惧的意愿和能力，这种恐惧可能会让人感到高度厌恶，并在治疗参与和接受方面产生问题。最近，关于恐惧的无意识基础的神经科学研究已转化为新颖的暴露干预措施，绕过对恐惧刺激的有意识处理，因此不会导致恐惧症青少年经历痛苦。我们对这些无意识暴露干预措施进行了回顾。方法基于 PRISMA 的搜索产生了 20 个基于三种范式的对照实验，这些实验测试了是否可以在高度恐惧的过渡年龄青少年中无意识地减少恐惧相关反应：14 项随机对照试验（ RCT）、5 项 fMRI 研究（1 项也是 RCT）、4 项心理生理学研究（3 项也是 RCT）和 1 项 ERP 研究。我们在可行的情况下对结果进行了荟萃分析。结果无意识暴露干预显着 (1) 减少了体内暴露于恐惧情境期间的回避行为（科恩 d 范围 = 0.51–0.95）和自我报告的恐惧（d = 0.45–1.25） ; (2) 恐惧的神经生物学指标（d = 0.54–0.62）和伴随的生理唤醒（d = 0.55–0.64）减少； (3) 激活的神经系统比暴露在相同刺激下更能支持恐惧调节 (d = 1.2–1.5)； （4）支持恐惧调节的激活区域介导回避行为的减少（d = 0.70）； (5) 诱发的 ERP 表明消退记忆的编码 (d = 2.13)； (6)在不引起自主神经唤醒或主观恐惧的情况下产生这些效果。结论无意识暴露干预显着减少了患有特定恐惧症的过渡年龄青少年的各种症状行为，且效果大多中等。功能磁共振成像和生理学研究结果为这种功效奠定了神经生理学基础，并表明它是通过消退学习发生的。无意识暴露的耐受性良好，与退出完全无关，并且对于临床实践具有高度可扩展性。然而，必须解决许多限制，以评估潜在的临床影响，包括将无意识暴露与暴露疗法相结合，以提高治疗接受度和疗效。