{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T06:15:59Z","timestamp":1788243359491,"version":"build-2803163510"},"reference-count":39,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,30]],"date-time":"2026-08-30T00:00:00Z","timestamp":1788048000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: Glucocorticoids have been shown to improve fear extinction learning in preclinical and human studies. We hypothesized an impact of the circadian rhythm of cortisol on exposure therapy in patients with anxiety spectrum disorders. Methods: Sixteen patients suffering from obsessive\u2013compulsive disorder and eight with agoraphobia participated in a pilot randomized prospective cohort study. During two therapist-guided sessions of exposure therapy with response prevention, both starting either at 08:00 (morning group) or at 16:00 (late afternoon group), subjective units of distress (SUD) and salivary cortisol levels were assessed repeatedly. Results: While expected significant diurnal differences in salivary cortisol emerged between daytime groups, after controlling for chronotype, no significant differences were detected in our exposure process indicators of within-session and between-session habituation and distress-related expectancy violation towards maximal SUD and SUD at end. Nearly one-hundred subjects in each group would be needed to gain statistically significant daytime differences for these indicators as per case number estimation. Conclusions: Our preliminary results from this transdiagnostic sample do not provide support for scheduling exposure sessions in the morning. Further research should consider cortisol administration before exposure sessions to test whether different doses of exogenous glucocorticoids can augment exposure therapy outcomes.<\/jats:p>","DOI":"10.3390\/jcm15176735","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T05:45:13Z","timestamp":1788241513000},"page":"6735","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Is Morning Exposure Therapy More Successful? Pilot Data on Exposure Process Indicators and Diurnal Cortisol in Obsessive\u2013Compulsive Disorder or Agoraphobia"],"prefix":"10.3390","volume":"15","author":[{"given":"Michael","family":"Kellner","sequence":"first","affiliation":[{"name":"Department of Psychiatry and Psychotherapy, TUM University Hospital Klinikum Rechts Der Isar, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Maja","family":"Santai Mareljic","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Psychotherapy, TUM University Hospital Klinikum Rechts Der Isar, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Alexander","family":"Yassouridis","sequence":"additional","affiliation":[{"name":"Max Planck Institute of Psychiatry, 80336 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,30]]},"reference":[{"key":"ref_1","unstructured":"Abramowitz, J.S., Deacon, B.J., and Whiteside, S.P.H. (2019). Exposure Therapy for Anxiety: Principles and Practice, The Guilford Press. [2nd ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"S85","DOI":"10.4103\/psychiatry.IndianJPsychiatry_516_18","article-title":"Exposure and response prevention for obsessive-compulsive disorder: A review and new directions","volume":"61","author":"Hezel","year":"2019","journal-title":"Indian J. Psychiatry"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Elsner, B., Jacobi, T., Kischkel, E., Schulze, D., and Reuter, B. (2021). Mechanisms of exposure and response prevention in obsessive-compulsive disorder: Effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy. BMC Psychiatry, 22.","DOI":"10.1186\/s12888-022-03701-z"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/j.tics.2025.06.011","article-title":"Pharmacological enhancement of fear extinction","volume":"30","author":"Davis","year":"2026","journal-title":"Trends Cogn. Sci."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1055\/s-0035-1569371","article-title":"Does pregnenolone enhance exposure therapy in obsessive-compulsive disorder?\u2014A pilot, interim report of a randomized, placebo-controlled, double-blind study","volume":"49","author":"Kellner","year":"2016","journal-title":"Pharmacopsychiatry"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1016\/j.janxdis.2009.10.011","article-title":"Enhancing exposure therapy for anxiety disorders with glucocorticoids: From basic mechanisms of emotional learning to clinical applications","volume":"24","author":"Bentz","year":"2010","journal-title":"J. Anxiety Disord."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/j.bbr.2015.03.006","article-title":"Adrenal-dependent diurnal modulation of conditioned fear extinction learning","volume":"286","author":"Woodruff","year":"2015","journal-title":"Behav. Brain Res."},{"key":"ref_8","first-page":"1776","article-title":"Extinction of conditioned fear is better learned and recalled in the morning than in the evening","volume":"44","author":"Spencer","year":"2013","journal-title":"J. Psychiatr. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.brat.2014.06.009","article-title":"Endogenous cortisol levels influence exposure therapy in spider phobia","volume":"60","author":"Michael","year":"2014","journal-title":"Behav. Res. Ther."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"113288","DOI":"10.1016\/j.psychres.2020.113288","article-title":"Cortisol, DHEA and DHEA-S during exposure therapy in patients with obsessive-compulsive disorder\u2014Secretion patterns and prediction of treatment response","volume":"291","author":"Kellner","year":"2020","journal-title":"Psychiatry Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1150","DOI":"10.4103\/indianjpsychiatry.indianjpsychiatry_566_24","article-title":"Within-session habituation and salivary cortisol during exposure treatment in obsessive-compulsive disorder\u2014A link and an influence of DHEA?","volume":"66","author":"Kellner","year":"2024","journal-title":"Indian J. Psychiatry"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.psychres.2012.04.029","article-title":"Non-response of cortisol during stressful exposure therapy in patients with obsessive-compulsive disorder--preliminary results","volume":"199","author":"Kellner","year":"2012","journal-title":"Psychiatry Res."},{"key":"ref_13","unstructured":"First, M.B., Williams, J.B.W., Karg, R.S., and Spitzer, R.L. (2019). SCID-5-CV\u2014Strukturiertes Klinisches Interview f\u00fcr DSM-5-St\u00f6rungen\u2014Klinische Version. German Adaptation of the Structured Clinical Interview for DSM-5 Disorders\u2014Clinical Version, Hogrefe."},{"key":"ref_14","first-page":"119","article-title":"The validation of the Dimensional Obsessive-Compulsive Scale (DOCS) on a German-speaking sample","volume":"31","author":"Jahn","year":"2020","journal-title":"Verhaltenstherapie"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1159\/000072184","article-title":"Reliability of the German version of the Yale-Brown Obsessive Compulsive Scale","volume":"13","author":"Jacobsen","year":"2003","journal-title":"Verhaltenstherapie"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1016\/S0165-1781(97)00118-2","article-title":"The use of the Panic and Agoraphobia Scale in a clinical trial","volume":"77","author":"Bandelow","year":"1998","journal-title":"Psychiatry Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1046\/j.1439-054X.2001.01149.x","article-title":"The validity of a German version of Morningness-Eveningness-Questionnaire developed by Horne and \u00d6stberg","volume":"5","author":"Griefahn","year":"2001","journal-title":"Somnology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1007\/s00115-006-2098-7","article-title":"Reliability and validity of the revised Beck Depression Intentory (BDI-II). Results from German samples","volume":"78","author":"Kuehner","year":"2007","journal-title":"Nervenarzt"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/j.jpsychires.2010.07.002","article-title":"Stress hormones during flooding therapy and their relationship to therapy outcome in patients with panic disorder and agoraphobia","volume":"45","author":"Siegmund","year":"2011","journal-title":"J. Psychiatr. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.psyneuen.2014.10.008","article-title":"High cortisol awakening response and cortisol levels moderate exposure-based psychotherapy success","volume":"51","author":"Meuret","year":"2015","journal-title":"Psychoneuroendocrinology"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1016\/j.psyneuen.2016.09.008","article-title":"Timing matters: Endogenous cortisol mediates benefits from early-day psychotherapy","volume":"74","author":"Meuret","year":"2016","journal-title":"Psychoneuroendocrinology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1337","DOI":"10.1016\/j.jpsychires.2011.04.010","article-title":"Intensive two-day cognitive-behavioral intervention decreases cortisol secretion in soldiers suffering from specific phobia to wear protective mask","volume":"45","author":"Brand","year":"2011","journal-title":"J. Psychiatr. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1026\/1616-3443.34.2.121","article-title":"Mind over matter: Psychobiological effects of exposure therapy in arachnophobia","volume":"34","author":"Gaab","year":"2005","journal-title":"Z. Klin. Psychol. Psychother."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1016\/j.janxdis.2012.04.001","article-title":"Persistence of anxiety disorders and concomitant changes in cortisol","volume":"26","author":"Dierckx","year":"2012","journal-title":"J. Anxiety Disord."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1016\/j.janxdis.2017.02.007","article-title":"Cortisol as a predictor of psychological therapy response in anxiety disorders\u2014Systematic review and meta-analysis","volume":"47","author":"Fischer","year":"2017","journal-title":"J. Anxiety Disord."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"104657","DOI":"10.1016\/j.psyneuen.2020.104657","article-title":"Endogenous in-session cortisol during exposure therapy predicts symptom improvement: Preliminary results from a scopolamine-augmentation trial","volume":"116","author":"Kuhlman","year":"2020","journal-title":"Psychoneuroendocrinology"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"704","DOI":"10.1007\/s10608-023-10463-9","article-title":"Endogenous cortisol levels, sleep or vigilance: Which factors contribute to better exposure therapy outcomes in the morning?","volume":"48","author":"Sopp","year":"2024","journal-title":"Cogn. Ther. Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.1176\/ajp.152.9.1365","article-title":"Possible role of atrial natriuretic hormone in pituitary-adrenocortical unresponsiveness in lactate-induced panic","volume":"152","author":"Kellner","year":"1995","journal-title":"Am. J. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1016\/j.psyneuen.2009.08.003","article-title":"A striking pattern of cortisol non-responsiveness to psychosocial stress in patients with panic disorder with concurrent normal cortisol awakening responses","volume":"35","author":"Petrowski","year":"2010","journal-title":"Psychoneuroendocrinology"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1159\/000283560","article-title":"Attenuated neuroendocrine response to hypoglycemic stress in patients with panic disorder","volume":"92","author":"Jezova","year":"2010","journal-title":"Neuroendocrinology"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1177\/0269881108098821","article-title":"Desynchrony of fear in phobic exposure","volume":"24","author":"Schruers","year":"2010","journal-title":"J. Psychopharmacol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"5585","DOI":"10.1073\/pnas.0509184103","article-title":"Glucocorticoids reduce fear in humans","volume":"103","author":"Soravia","year":"2006","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"6621","DOI":"10.1073\/pnas.1018214108","article-title":"Glucocorticoids enhance extinction-based psychotherapy","volume":"108","author":"Bentz","year":"2011","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1139","DOI":"10.1016\/j.brat.2010.07.009","article-title":"Does habituation matter? Emotional processing theory and expsoure therapy","volume":"48","author":"Baker","year":"2010","journal-title":"Behav. Res. Ther."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1037\/ccp0000315","article-title":"Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD","volume":"86","author":"Benito","year":"2018","journal-title":"J. Consult. Clin. Psychol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1016\/j.cpr.2017.07.003","article-title":"An empirical review of potential mediators and mechanisms of prolonged exposure therapy","volume":"56","author":"Cooper","year":"2017","journal-title":"Clin. Psychol. Rev."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1002\/cpp.2039","article-title":"Emotional processing theory put to test: A meta-analysis on the association between process and outcome measure in exposure therapy","volume":"24","author":"Rupp","year":"2017","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1016\/0960-0760(91)90055-A","article-title":"Corticosterone regulation of brain and lymphoid corticosteroid receptors","volume":"39","author":"Lowy","year":"1991","journal-title":"J. Steroid Biochem. Mol. Biol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1007\/BF03339594","article-title":"Dexamethasone suppression test: Corticosteroid receptors regulation in mononuclear leukocytes of young and aged subjects","volume":"8","author":"Zovato","year":"1996","journal-title":"Aging Clin. Exp. 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