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Maximizing Exposure Therapy: An Inhibitory Learning Approach
... Two foundational components of CBT for SAD are cognitive restructuring and exposure to feared social situations (Hope et al., 2006). Cognitive restructuring aims to reduce maladaptive automatic thoughts and cognitive distortions contributing to social anxiety using a variety of thought-challenging strategies (Clark & Beck, 2010), while exposures involve learning to tolerate remaining in feared situations through repeated practice (Craske et al., 2014). Previous research has identified multiple process-based mechanisms underlying reductions in social anxiety following treatment, many of which are associated with client engagement in cognitive restructuring and exposure exercises (Aldao et al., 2014;Craske et al., 2014). ...
... Cognitive restructuring aims to reduce maladaptive automatic thoughts and cognitive distortions contributing to social anxiety using a variety of thought-challenging strategies (Clark & Beck, 2010), while exposures involve learning to tolerate remaining in feared situations through repeated practice (Craske et al., 2014). Previous research has identified multiple process-based mechanisms underlying reductions in social anxiety following treatment, many of which are associated with client engagement in cognitive restructuring and exposure exercises (Aldao et al., 2014;Craske et al., 2014). Process-based mechanisms refer to "theory-based, dynamic, progressive, and multilevel changes" that are expected to facilitate improvements in targeted outcomes (e.g., social anxiety symptoms; Hofmann & Hayes, 2019, p. 38). ...
... For example, studies have shown decreases in maladaptive emotion regulation strategies (e.g., avoidance, suppression, rumination) and increases in adaptive emotion regulation strategies (e.g., cognitive reappraisal, mindfulness, acceptance) throughout cognitive restructuring and exposure phases of CBT for social anxiety (Aldao et al., 2014;Brozovich et al., 2015), which predicted subsequent decreases in social anxiety symptoms Kocovski et al., 2015). Studies have also implicated reductions in avoidance behaviors, improvements in distress tolerance, and fear habituation as mechanisms underlying changes in social anxiety symptoms following exposures (Craske et al., 2014;Foa & McNally, 1996). ...
Cognitive-behavioral therapy (CBT) is an evidence-based treatment for social anxiety disorder that has been found to elicit significant changes in process-based mechanisms (e.g., emotion regulation strategies), which subsequently lead to reductions in social anxiety and associated functional impairment; however, CBT may be less effective for socially anxious individuals experiencing high self-criticism and low self-compassion. Compassion-focused therapy (CFT) has been used to address these tendencies in socially anxious individuals, but research in this area is limited. The present case study examined changes in social anxiety symptoms, self-compassion, emotion regulation strategies, and functional impairment throughout the course of treatment with a young, Chinese American woman using a novel integration of CBT and CFT for social anxiety disorder. The client experienced significant reductions in social anxiety and functional impairment across treatment, which was accompanied by reductions in fear and avoidance ratings for feared social scenarios. Significant mechanistic changes were also observed, including decreases in maladaptive emotion regulation strategies (i.e., suppression, rumination) and increases in self-compassion and adaptive emotion regulation strategies (i.e., expressive engagement, cognitive reappraisal). Findings support the efficacy of integrating compassion-focused strategies with CBT for social anxiety for a young adult with prominent tendencies of self-criticism and low self-compassion.
... In exposure therapy, for instance, the feared situation or object is presented in the absence of an aversive outcome to achieve extinction of the fear response. While this procedure can lead to a decrease in fear responding, this reduction sometimes remains specific to the therapeutic context, and fails to generalize to the outside world 1,2 . Such deficits in updating of aversive beliefs have been linked to anxiety disorders. ...
... Consequently, state-dependent learning often leads to abrupt jumps in an agent's predictions, called state switches, which reflect when a state change was detected and implemented into the next prediction. In addition, such a learning mechanism can also explain a persistence of previous experiences despite new learning, similar to relapse phenomena observed in clinical practice during which clinically extinguished fear fails to generalize to everyday life 1 . ...
... The gradual learning perspective assumes that shock contingencies during the acquisition phase lead to gradual strengthening of a cue-outcome association, which is then gradually weakened, and hence forgotten, during the extinction phase 23,24 . However, experiments 25 and clinical observations 1 have challenged this view. Most importantly, seemingly extinguished memories can return unexpectedly, either after a sufficient period of time has elapsed (spontaneous recovery) 26 , an explicit change of context (renewal) 25 or a presentation of the US on its own (reinstatement) 27 . ...
Updating beliefs in changing environments can be driven by gradually adapting expectations or by relying on inferred hidden states (i.e. contexts), and changes therein. Previous work suggests that increased reliance on context could underly fear relapse phenomena that hinder clinical treatment of anxiety disorders. We test whether trait anxiety variations in a healthy population influence how much individuals rely on hidden-state inference. In a Pavlovian learning task, participants observed cues that predicted an upcoming electrical shock with repeatedly changing probability, and were asked to provide expectancy ratings on every trial. We show that trait anxiety is associated with steeper expectation switches after contingency reversals and reduced oddball learning. Furthermore, trait anxiety is related to better fit of a state inference, compared to a gradual learning, model when contingency changes are large. Our findings support previous work suggesting hidden-state inference as a mechanism behind anxiety-related to fear relapse phenomena.
... Although extensive methodological differences likely contribute to the varied findings, research also suggests that the mixed findings may be due to the nature of inhibitory learning. Rather than erase the original conditional stimulus-unconditional stimulus association, unreinforced conditional stimulus presentations may create a new, inhibitory association (conditional stimulus-no unconditional stimulus association; Craske et al., 2014;Todd et al., 2014). Therefore, after exposure therapy, a conditional stimulus will signal both the nonavailability of the unconditional stimulus (i.e. the new inhibitory conditional stimulus-no unconditional stimulus association) and the occurrence of the conditional stimulus (i.e. the original excitatory conditional stimulus-unconditional stimulus association). ...
... The Rescorla Wagner model (1972) posits that extinction learning occurs when there is a mismatch between what an individual thinks will occur and what actually occurs. Greater expectancy violations result in stronger inhibitory learning (Craske et al., 2014) and better treatment outcomes (Hilleke et al., 2021). Therefore, clients should participate in exposure activities designed to maximally violate their CS-US expectancies. ...
... Expected outcomes should include the anticipated unconditional stimulus and its cost. After the exposure activity is completed, clients should reflect on whether these outcomes occurred (Craske et al., 2014). Because exposure activities are designed to violate expectancies, predicted outcomes rarely occur, and when they do, they are almost never as bad as expected. ...
Biophobia refers to a fear of living things, which leads to alienation from nature. The literature examining the underlying mechanisms and treatment of biophobia is sparse.
This review aims to increase the readers' understanding of biophobia by examining the more extensive literature on specific phobias, namely animal phobia, as it most closely resembles biophobia.
Fear, anxiety and disgust play an important role in specific phobias. Their triggers and functions are reviewed in the context of animal phobia.
Theoretical models for specific phobias suggest that phobias develop because genetically linked behavioural patterns interact with normal development fears and environmental factors. Phobias are then maintained by cognitive and behavioural mechanisms.
Exposure therapy, the gold standard treatment for specific phobia, functions to override the maladaptive stimulus–stimulus and stimulus‐response associations responsible for animal and other specific phobias. Its delivery and efficacy are reviewed.
We recommend that readers interested in biophobia use the existing knowledge on animal phobia and specific phobia in general to treat biophobia and generate research hypotheses for future study.
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... Cognitive-behavioral therapy (CBT), either in an individual or group format, is the treatment of choice for SAD [15]. This therapeutic approach uses many techniques, but exposure is considered the main component responsible for treatment success [16,17]. This technique involves exposing, often gradually, the individual to anxiety-provoking stimuli in order to learn that the object of their anxiety or fear is not threatening [17,18]. ...
... This therapeutic approach uses many techniques, but exposure is considered the main component responsible for treatment success [16,17]. This technique involves exposing, often gradually, the individual to anxiety-provoking stimuli in order to learn that the object of their anxiety or fear is not threatening [17,18]. In vivo exposure allows direct contact with the feared stimulus in real time; however, it raises challenges regarding the therapist's control over the situation and the absence of privacy. ...
... Immersion in the experimental VE resulted in a statistically significant increase of more than six points for STICSA and more than three points on the Likert scale of the SUDS-A. There is no typical anxiety level that can be used to gauge whether stimuli are appropriate for optimal therapeutic exposure (see [17,18,22]), because anxiety level will vary within and between sessions depending on tasks agreed upon with patients. However, stimuli that could not elicit anxiety because they are virtual would not be useful for exposure. ...
The effectiveness of in virtuo exposure-based treatment of performance-only social anxiety disorder (SAD) has been demonstrated in several studies. However, few studies have validated virtual environments with participants suffering from generalized SAD. The goal of this study is to confirm the potential of a virtual environment in inducing anxiety in adults suffering from generalized SAD, compared to adults without SAD, when engaged in awkward social interactions. Differences between participants from two different countries were also explored. The sample consisted of 15 participants with SAD from Canada, 17 participants without SAD from Canada, 16 participants with SAD from Spain, and 21 participants without SAD from Spain. All participants were immersed in a control virtual environment and in an experimental virtual environment considered potentially anxiety-inducing for individuals with generalized SAD. As hypothesized, results showed that the experimental virtual environment induced a higher level of anxiety than the control environment among participants with SAD compared to those without SAD. The impact on anxiety of each socially threatening task performed during the experimental immersion was statistically significant. In terms of anxiety responses, no significant differences were found between participants from Canada and Spain. However, spatial presence and ecological validity were higher in Canadians than in Spaniards. Unwanted negative side effects induced by immersions in virtual reality were higher in the SAD group. This study highlights the importance for therapists to engage people with SAD in clinically relevant tasks while immersed in VR psychotherapeutic applications.
... Although pain education may be useful, it is often not sufficient to tackle avoidance behaviour [147,148], so principles rooted in exposure therapy may be necessary to address potential avoidance behaviour [94,131]. By letting patients experience that the expected catastrophe ('My back will snap during lifting with a bent back') does not occur, their expectation will be violated and they can learn that these activities are safe to perform [149,150]. This will increase confidence in their ability to perform these activities and it will extinguish avoidance behaviour [149], which in turn will decrease disability. ...
... By letting patients experience that the expected catastrophe ('My back will snap during lifting with a bent back') does not occur, their expectation will be violated and they can learn that these activities are safe to perform [149,150]. This will increase confidence in their ability to perform these activities and it will extinguish avoidance behaviour [149], which in turn will decrease disability. A recent randomised clinical trial showed that this approach is superior to general exercise therapy for reducing pain and disability in patients with chronic spinal pain [151]. ...
Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.
... For people suffering from severe symptoms, another potential mechanism is inhibitory learning (Craske et al., 2014). It is assumed that following repeated exposure, memory representations underlying emotions could be modified. ...
... As such, the old association between the stimulus and aversive consequences is inhibited by this newly-learned association. Among the techniques that could enhance inhibitory regulation, linguistic processing is an essential one (Craske et al., 2014). Studies showed that linguistic processing activated a cortical area responsible for processing emotional information and the executive function of inhibition, which dampened the reactivity of amygdala to the emotional aspects of an image (e.g., Lieberman et al., 2007). ...
IntroductionExpressive writing is a promising tool to promote physical and emotional health. This meta-analysis took the initiative to examine the effects of expressive writing on quality of life relevant outcomes among Asian populations.Method
To determine the long-term effects, the literature search identified 11 experimental studies with randomized controlled trials and follow-up assessments. The final analysis included 38 reported effect sizes and a total of 1188 participants.ResultsThe results suggested that for the current sample, there were no significant group differences between expressive writing and control conditions at the first follow-up assessment, g = 0.05 (p = 0.53), nor at the second follow-up assessment, g = 0.04 (p = 0.73). Change score analyses showed non-significant changes from baseline to first follow-up, g = 0.01 (p = 0.78) and from baseline to second follow-up, g = 0.04 (p = 0.55). In addition, moderator analyses did not detect substantial moderators pertaining to participant characteristics (physical health, immigration status) or intervention features (topic focus, prompt structure, time lapse of events).DiscussionTaken together, these findings indicate that to optimize treatment outcomes for Asian populations, expressive writing interventions need to consider salient concerns in cultural communities and the sociocultural impact on individual tendencies towards emotional processing. Implications for the design of writing interventions are discussed.
... Behavioral models of trauma also emphasize the role of classical conditioning during traumatic events. When extreme events are paired with internal experiences of overwhelming fear, this fear can become conditioned and generalize to places and situations that remind individuals of the traumatic events (Craske et al., 2014). This understanding has led to the proliferation of exposure therapies for PTSD, which aim to extinguish the association between trauma reminders and the danger that occurred during the traumatic event. ...
... This understanding has led to the proliferation of exposure therapies for PTSD, which aim to extinguish the association between trauma reminders and the danger that occurred during the traumatic event. According to the inhibitory learning approach, repeatedly presenting trauma reminders in safe situations eventually leads to the inhibition of the original fear association that was made during the traumatic event (Craske et al., 2014). ...
Background:
In contrast to the vast clinical, theoretical, and empirical literature on the impact of trauma, relatively few studies have reviewed the trauma measures that researchers and clinicians can choose to use in their work. This scoping review aimed to catalog all trauma measures (trauma exposure and its subjective responses) that have been published in the peer-reviewed literature, developed for use with adult populations.
Method:
Through a systematic search of the literature and the screening of 19,631 abstracts, a total of 363 unique trauma measures were identified.
Result:
Most of these measures were developed for assessment purposes rather than for clinical screening or diagnostic purposes. Most of these measures are patient-self-report measures that assess trauma exposure in the patients' lifetime, or subsequent symptoms, particularly cognitive impairments.
Discussion:
Complications in the trauma literature are highlighted, including the use of very similar abbreviations of measures, substantial discrepancies regarding the definition of trauma, and the general assumption that a potentially traumatic event inevitably leads to traumatic distress rather than a path of resilience.
... After a traumatic event, fear extinction is achieved by repeated exposure to reminders of the traumatic event without the feared outcome. This mechanism is suggested to be the basis of exposure therapy for PTSD and other anxiety disorders [3]. ...
Accumulating evidence suggests that rapid eye movement sleep (REM) supports the consolidation of extinction memory. REM is disrupted in PTSD, and REM abnormalities after traumatic events increase the risk of developing PTSD. Therefore, it was hypothesized that abnormal REM in trauma-exposed individuals may pave the way for PTSD, by interfering with the processing of extinction memory. In addition, PTSD patients display reduced vagal activity. Vagal activity contributes to the strengthening of memories, including fear extinction memory, and recent studies show that the role of vagus in memory processing extends to memory consolidation during sleep. Therefore, it is plausible that reduced vagal activity during sleep in trauma-exposed individuals may be an additional mechanism that impairs extinction memory consolidation. However, to date, the contribution of sleep vagal activity to the consolidation of extinction memory or any emotional memory has not been investigated. To test these hypotheses, we examined the association of extinction memory with REM characteristics and REM vagal activity (indexed as high frequency heart rate variability; HF-HRV) in a large sample of trauma-exposed individuals (n=113). Consistent with our hypotheses, REM sleep characteristics (increased REM density and shortened REM latency) were associated with poorer physiological and explicit extinction memory. Furthermore, higher HF-HRV during REM was associated with better explicit extinction memory. These findings support the notion that disrupted REM may contribute to PTSD by impairing the consolidation of extinction memory and indicate the potential utility of interventions that target REM sleep characteristics and REM vagal activity in fear-related disorders.
... The mechanism of change is considered to be habituation (Foa and Kozak, 1986) or inhibitory learning, whereby learning of new non-threat (i.e. inhibitory) associations interferes with the individual's ability to retrieve previously established fear-associated responses (Craske et al., 2014). Using either theoretical framework, the ultimate goal is stopping the patient from seeking reassurance and their carers providing it (Gillihan et al., 2012). ...
Excessive reassurance seeking (ERS) is believed to play an important role in maintaining mental health problems, in particular anxiety disorders such as obsessive-compulsive disorder and health anxiety. Despite this, therapists commonly give into patients’ requests for reassurance in clinical settings and are generally unsure how to handle the issue both in therapy itself and concerning advice to the patient’s loved ones. In order to increase our understanding of therapists’ perception of ERS and how interventions for ERS are managed, we examined therapists’ perception and understanding of ERS, including its function, which emotional problems therapists associate it with, and what treatment interventions they consider important for managing ERS. Qualified therapists ( n =197) were benchmarked against international expert consensus ( n =20) drawn from leading clinical researchers. There was evidence that clinical experience right up to the expert level may result in less reassurance giving within treatment settings. Still, there were enough inconsistencies between the experts and other clinicians to suggest that ERS remains poorly understood and is not consistently dealt with clinically. Results are discussed in terms of how current treatment interventions may be limited for treating ERS, highlighting the need to consider new approaches for dealing with this complicated interpersonal behaviour.
Key learning aims
(1) To describe the role of excessive reassurance seeking in checking behaviour, including its negative personal and interpersonal consequences.
(2) To learn that therapists commonly report finding it difficult to manage reassurance seeking.
(3) To learn that therapists’ beliefs about excessive reassurance seeking may play a key role in helping us understand how to tackle this complicated behaviour.
(4) To consider what therapeutic interventions may be appropriate and helpful for treating excessive reassurance seeking.
... /fpsyt. . on mental disorders using computational theories only at the conceptual level (30,31,83). Our study demonstrated empirically that if the networks possessed risks for reduced flexibility, such as low stochasticity in neural dynamics, they could be ameliorated by increasing ambiguity in the external environment. ...
Neuropsychiatric disorders are highly prevalent and are causing an enormous disease burden globally. For instance, according to an estimation by the World Health Organization, 4.4 and 3.6% of the global population lived with depressive and anxiety disorders in 2015, respectively (World Health Organization, 2017). The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2019, mental disorders accounted for 4.9% of global disability-adjusted life-years (DALYS), making it one of the top ten leading causes of disease burden globally (GBD 2019 Mental Disorders Collaborators, 2022). One of the most important causes of such a high prevalence, high disability of neuropsychiatric disorders is our lack of precise understanding of the psychopathological and neurobiological mechanisms underlying these disorders, which holds us back from developing effective prevention and treatment strategies.
This Research Topic is a collection of eleven cutting-edge studies that help advance our understanding of the psychopathological and neurobiological mechanisms of neuropsychiatric disorders with novel methods and techniques. Specifically, six studies take a computational psychiatry approach. One study takes a neuroimaging approach, one genetic approach, and one psychometrical approach. Finally, two studies take a meta-analytic approach.
Computational psychiatry represents a novel approach that tries to solve problems in psychiatry by applying mathematical methods (Montague et al., 2012; Chen et al., 2015; Friston, 2023). One theory-driven approach attempts to provide mechanistic insights by specifying and testing psychological and neurobiological processes that are believed to generate the illness or its symptoms. This approach is in line with current conceptualization of mental disorders based on neurobiological processes such as the Research Domain Criteria (RDoC) project (Insel et al., 2010; Barlati et al., 2020) and the Hierarchical Taxonomy of Psychopathology (HiTOP) (Kotov et al., 2022). Another data-driven approach attempts to make predictions of diagnosis or treatment with a theory-free perspective by employing various statistical models and machine learning algorithms. Six articles in this Research Topic employ either a theory- or data-driven approach.
Soda et al. provides mechanistic insights into developmental disorders with a computational model that combines hierarchical Bayesian models and neural network models. In this model, the agent learns the underlying probabilistic structure of the environment with a neural system that acquires a hierarchical Bayesian representation of the underlying structure. In their simulation, the authors manipulated the neural stochasticity in the environment during learning and found that when the neural stochasticity is low (meaning that neural noise is low and that the agent's behavior tends to be deterministic), the agent showed altered hierarchical representation and reduced flexibility, mimicking cognitive changes in developmental disorders. Gauld and Depannemaecker proposes a generic model aimed at capturing the dynamics of psychiatric symptoms. In this model, the symptoms of psychiatric diseases are simulated with internal factors, temporal specificities and symptomatology, with environmental noises. With this model, the authors simulated three different psychiatric disorders. Schizophrenia is characterized by pathology evolving following an outbreak; bipolar disorders is characterized by kindling and bursts in symptoms; persistent complex bereavement disorder is characterized by susceptibility to the external environment (i.e., bereavement).
Hagiwara et al. tries to clarify the common vs. unique cognitive computational mechanisms associated with depression and anxiety, two disorders that often co-occur (Chen, 2022). According to the Cumulative Prospect Theory (Tversky and Kahneman, 1992), people tend to overweight small probabilities and underweight large probabilities (i.e., an inverted S-shaped nonlinear probability weighting curve). Hagiwara et al. found that subjects with more depressive but not anxiety symptoms tend to show a weakened inverted S-shaped probability weighting curve, indicating increased risk aversion at small probabilities and reduced risk aversion at large probabilities. Such an alteration in probability weighting has also been reported in females under high levels of chronic stress (Lei et al., 2021). Interestingly, two studies (Shimizu et al.; Watarai et al., 2023) demonstrate that recalling positive autobiographical memories, such as memories of a happy family vacation, affects probability weighting in a way that is in the opposite direction compared to the influence by depressive symptoms (Hagiwara et al.) and chronic stress in females (Lei et al., 2021). These findings suggest the potential usefulness of such an intervention for the treatment of altered decision-making in psychiatric disorders.
Lei et al. advances our understanding of the comorbidity of depressive and anxiety disorders by investigating the patterns of the co-occurrence of their symptoms. Using latent class analysis, a data-driven approach, the authors identified four symptoms patterns or classes that are characterized by different levels of co-occurrence of depressive and anxiety symptoms. Furthermore, each pattern is associated with distinct psychological risk factors, indicating unique etiologies. Chacko et al. provides insights into the link of stress to PTSD and obesity using natural language processing of over 10,000 peer-reviewed publications. The authors identified 34 metabolic mediators, among which Neuropeptide-Y and cortisol were found to reduce PTSD severity but worsen obesity, while oxytocin reduces both PTSD severity and obesity.
Cognitive task-based neuroimaging such as functional near-infrared spectroscopy is another useful paradigm for the study of neuropsychiatric diseases. In a perspective article, Ren et al. gives a comprehensive introduction to a multi-cognitive task paradigm that includes emotional picture identification task, verbal fluency task, and so on. By alternating between resting state and different tasks, the authors argue, this paradigm helps to probe the function of different brain networks in neuropsychiatric diseases.
Rohlfing et al. employs a genetic approach and investigates the association between catechol-O-methyltransferase (COMT) Val158Met polymorphism and substance use. COMT is an enzyme that degrades catecholamines and the presence of the Met allele in the COMT Val158Met polymorphism is associated with lower COMT activity and thus higher concentrations of extra-synaptic dopamine. The authors found that the presence of the Met allele is associated more cigarettes smoked per day and lower motivation on the monetary incentive delay task. Li et al. takes a meta-analytic approach and evaluates the effect of cognitive bias modification (CBM) on depressive symptoms in adults. CBM is a therapy grounded in the Cognitive Theory of depression which proposes that cognitive bias underlies the development and maintenance of depressive symptoms by changing the availability of negative vs. positive information (Beck and Dozois, 2011). CBM, on the other hand, aims to change these cognitive biases. Based on ten randomized controlled trials, Li et al. reported a significant effect of CBM on depressive symptoms with g = −0.64. Moreover, the effect size is higher for CBM targeting interpretation (g = −1.45) compared to targeting attention (g = −0.63) or imagery (g = −0.48). Khan et al. also takes a meta-analytic approach and estimates the prevalence of neuropsychiatric symptoms in patients with systemic lupus erythematosus (SLE) in Pakistan. Based on thirteen studies, the authors estimate that the prevalence is the highest for cognitive dysfunction (32%), followed by headache (10%), seizures (6%), and psychosis (4%). The high prevalence emphasizes the importance of effective management of neuropsychiatric symptoms in addition to clinical treatment of SLE itself. Lastly, Rakshasa-Loots and Laughton employs a psychometric approach and presents the protocol designed to test the reliability and validity of the isiXhosa Translation of the Patient Health Questionnaire (PHQ-9), a widely employed measure of depression severity.
... As constructivists, we are suspicious of such a possibility. Even if behavioral methods are used (e.g., exposure), we would expect that clients would elaborate meaning for them (see research on exposure and the inhibitory learning approach and on how the cognitive elaboration of exposure expands its potential; Craske et al., 2014). From this elaboration, IMs would necessarily emerge. ...
... MDMA is posited to strengthen the therapeutic alliance, particularly the therapist-patient bond, by increasing feelings of safety and acceptance (57) and reducing clients' social threat sensitivity (56), thereby reducing the need for safety behaviors that normally disrupt or prolong the process of creating emotional intimacy for people with SAD. Through the lens of inhibitory learning theory, 8-h MDMA sessions where clients repeatedly behave authentically and are met with safety from the therapists, provide a prolonged context for expectancy violations to occur and new learning to solidify (58). This may be augmented as a consequence of reduced amygdala activity during MDMA administration. ...
Background:
Social anxiety disorder (SAD) is a serious and prevalent psychiatric condition that heavily impacts social functioning and quality of life. Though efficacious treatments exist for SAD, remission rates remain elevated and a significant portion of those affected do not access effective treatment, suggesting the need for additional evidence-based treatment options. This paper presents a protocol for an open-label pilot study of MDMA-assisted therapy (MDMA-AT) for social anxiety disorder. The study aims to assess preliminary treatment outcomes, feasibility and safety, and psychological and physiological processes of change in the treatment of SAD with MDMA-AT. A secondary aim includes the development of a treatment manual for MDMA-AT for SAD.
Method:
The outlined protocol is a randomized, open-label delayed treatment study. We will recruit 20 participants who meet criteria with moderate-to-severe social anxiety disorder (SAD) of the generalized subtype. Participants will be randomly assigned to an immediate treatment (n = 10) or delayed treatment condition (n = 10). Those in the immediate treatment condition will proceed immediately to active MDMA-AT consisting of three preparation sessions, two medicine sessions in which they receive oral doses of MDMA, and six integration sessions over approximately a 16-week period. The delayed treatment condition will receive the same intervention after a 16-week delay. Our primary outcome is SAD symptom reduction as measured by the Liebowitz Social Anxiety Scale administered by blinded raters at post-treatment and 6 month follow up. Secondary outcomes include changes in functional impairment, feasibility and safety measures, and novel therapeutic processes of change including shame and shame-related coping, belongingness, self-concealment, and self-compassion at post-treatment. Exploratory outcomes are also discussed.
Discussion:
The results of this pilot trial advance the field's understanding of the acceptability and potential effectiveness of MDMA-AT for social anxiety disorder and provide an overview of relevant therapeutic mechanisms unique to SAD. We hope findings from this protocol will inform the design of subsequent larger-scale randomized controlled trials (RCT) examining the efficacy of MDMA-AT for SAD.
Clinical trial registration:
https://clinicaltrials.gov/, NCT05138068.
... ERP method involves progressive, deliberate, and voluntary exposure to stimuli triggering obsessive thoughts and anxiety while knowingly averting compulsive, neutralisation or avoidance behaviour (response prevention) and it represents a very effective CBT technique for treating OCD (Hezel and Simpson 2019). Recent theory suggests that ERP facilitates new adaptive responses by inhibitory learning that promotes new association with feared stimuli competing with the former nonadaptive response that does not disappear completely (Craske et al. 2014). By withholding compulsive reactions, OCD patients are able to learn new associations to feared stimuli (Powers et al. 2007). ...
Introduction
Obsessive–compulsive disorder (OCD) is characterised by recurrent, repetitive, and unwanted thoughts or impulses triggering significant anxiety. Exposure and response prevention is currently the first-line therapy for OCD. The goal of this validation study was to confirm the potential of the VR house environment that incorporates OCD-specific items that cluster around major symptom dimensions: ‘contamination’, ‘symmetry’, ‘checking’ and ‘hoarding’ to induce anxiety and compulsive behaviour in patients with OCD.
Method
We assessed a sample of OCD patients ( n = 44) that was compared to a group of healthy controls ( n = 31). The severity of OCD symptoms was assessed in all subjects. During a single session, participants were asked to approach a set of 10 stimuli (covering four OCD dimensions) and rate their current intensity of distress/anxiety and compulsive tendencies (scales 0–5) provoked by observing each stimulus. Before and after the VR exposure, participants completed questionnaires assessing subjective levels of anxiety (before/after VR exposure), their sense of presence in VR and experienced simulator sickness.
Results
The results show that the OCD group reports elevated levels of distress and compulsive behaviour when confronted with VR exposure stimuli compared to the control group, but no increase in anxiety levels has been observed after the VR exposure. The subjective ratings of provoked distress and compulsive behaviour are not associated with severity of OCD symptoms, perceived sense of presence, association with cybersickness symptoms is weak.
Conclusion
Our data suggest that the VR house environment is a suitable tool for VR exposure therapy in OCD patients as it demonstrates OCD symptom provocation relevant for individual patients.
... Exposure therapy uses the basis of fear extinction to confront the individual with the feared stimulus without the feared outcome in the hope that over time, anxiety reduces when faced with the original feared stimulus (Foa & Kozak, 1986;Lovibond, 2004). The aim is to create a non-threat association with the feared stimulus to reduce anxiety and discomfort (Craske et al., 2014;Butler & Heimberg, 2020) and therefore subsequent avoidance of stimulus. Exposure therapy principles are used in this case study. ...
Avoidant Restrictive Food Intake Disorder (ARFID) is a serious eating disorder, characterised by problematic eating habits that cause significant nutritional deficiencies. Having only been recently acknowledged as a distinct category, there is little research regarding best practice guidelines, especially among the adult population. In addition, ARFID often coexists with autism, and very little is known about how the diagnoses affect each other, further complicating treatment options. This case study reflects on the treatment of a young autistic woman with ARFID within an inpatient eating disorder setting. Using principles of food exposure, food trials were introduced as a way to increase food variety as well as overall nutrition. Results are promising, with the patient reaching a much safer weight and being able to increase her repertoire of food. While results are not generalisable to a wider population, it is hoped that similar approach could be used with other individuals who have ARFID and autism when aiming to increase nutrition and variety.
... The longer sessions enabled us to try multiple variations of experiments and to build on and quickly test ideas that emerged during the session. From an inhibitory learning perspective, this promoted 'deepened extinction' by combining multiple stimulus cues and generalisability through variability in the way we delivered the experiments (Craske et al., 2014). However, by completing multiple interventions in each session, we are unable to make strong hypotheses about which interventions most contributed to change. ...
There is preliminary evidence that CBT may be helpful for improving symptoms of misophonia, but the key mechanisms of change are not yet known for this disorder of decreased tolerance to everyday sounds. This detailed case study aimed to describe the delivery of intensive, formulation-driven CBT for an individual with misophonia and report on session-by-session outcomes using a multi-dimensional measurement tool (SFive). The patient was offered 12 hours of treatment over five sessions, using transdiagnostic and misophonia-specific interventions. Reliable and clinically significant change was found from baseline to one-month follow-up. Visual inspection of outcome graphs indicated that change occurred on the ‘outbursts’ and ‘internalising appraisals’ SFive subscales following assessment, and on the ‘emotional threat’ subscale after the first treatment session. The other two subscales started and remained below a clinically significant level. The biggest symptom change appeared to have occurred after the second session, which included interventions engaging with trigger sounds. The results demonstrated the individualised nature of misophonia, supporting the use of individually tailored treatment for misophonia and highlighting the importance of using a multi-dimensional measurement tool.
Key learning aims
• (1) To understand misophonic distress from a CBT perspective.
• (2) To learn a formulation-driven approach to misophonia.
• (3) To apply transdiagnostic interventions to misophonia.
• (4) To learn about misophonia-specific interventions.
• (5) To consider the value of a multi-dimensional measure of misophonia.
... The ability to learn and update information in response to threat and safety is a cornerstone of adaptive behaviour (Carpenter et al., 2019;Pittig et al., 2018). Classical threat conditioning paradigms are thought to model processes related to pathological fear and anxiety, as well as crucial principles underlying exposure-based therapies for anxiety and stress disorders (Craske et al., 2014). Threat conditioning paradigms typically include an acquisition phase, in which a neutral conditioned stimulus (CS+: e.g., visual cue) is reinforced with an aversive stimulus (unconditioned stimulus, US: e.g., electric shock). ...
Previous research has demonstrated that individuals with high levels of Intolerance of Uncertainty (IU) have difficulty updating threat associations to safety associations. Notably, prior research has focused on measuring IU-related differences in threat and safety learning using arousal-based measures such as skin conductance response. Here we assessed whether IU-related differences in threat and safety learning could be captured using eye-tracking metrics linked with gaze behaviours such as dwelling and scanning. Participants (N = 144) completed self-report questionnaires assessing levels of IU and trait anxiety. Eye movements were then recorded during each conditioning phase: acquisition, extinction learning, and extinction retention. Fixation count and fixation duration served as indices of conditioned responding. Patterns of threat and safety learning typically reported for physiology and self-report were observed for the fixation count and fixation duration metrics during acquisition and to some extent in extinction learning, but not for extinction retention. There was little evidence for specific associations between IU and disrupted safety learning (e.g., greater differential responses to the threat vs. safe cues during extinction learning and retention). While there was tentative evidence that IU was associated with shorter fixation durations (e.g., scanning) to threat vs. safe cues during extinction retention, this effect did not remain after controlling for trait anxiety. IU and trait anxiety similarly predicted greater fixation count and shorter fixation durations overall during extinction learning, and greater fixation count overall during extinction retention. IU further predicted shorter fixation durations overall during extinction retention. However, the only IU-based effect that remained significant after controlling for trait anxiety was that of fixation duration overall during threat extinction learning. Our results inform models of anxiety, particularly in relation to how individual differences modulate gaze behaviour during threat conditioning.
... For those who have successfully completed therapy, smartphone application-based IE exercises could replace booster sessions which are shown to be beneficial (Gearing et al., 2013). Unfortunately, a substantial number of individuals experience a return of fear following exposure (Craske et al., 2014). Following successful exposure, relapses can occur where after an elapsed amount of time or change in context, the anxiety associated with the stimuli or situation returns following fear extinction (Shin & Newman, 2018;Vervliet et al., 2013). ...
Introduction:
Emerging technological interventions for psychological disorders are being developed continually. Offering imaginal exposure exercises as a self-help intervention presents the opportunity to acquire foundational skills to address social anxiety. The current study evaluates the feasibility and effectiveness of a novel smartphone application for social interaction anxiety.
Methods:
Participants (n = 82) were adults meeting criteria for social anxiety disorder. They were randomly assigned to imaginal exposure (IE; n = 39) or self-monitoring (n = 43) delivered multiple times daily via a smartphone application for a one-week trial. It was expected that participants using the IE exercises would demonstrate significantly greater declines in social anxiety in addition to increases in self-efficacy and that compliance would serve as a predictor of outcome. Mixed-effects models were utilized.
Results:
Participants using IE (vs. self-monitoring) evidenced significantly greater reductions in social anxiety from pre- to post-treatment and at 1-month follow-up. Similarly, IE (vs. self-monitoring) led to significantly greater increases in self-efficacy from pre- to post-treatment and 1-month follow-up. Further, more completed IE exercises predicted significantly greater changes in social anxiety and self-efficacy at subsequent timepoints compared with self-monitoring.
Conclusions:
Findings suggest that a brief IE self-help intervention was effective in targeting social interaction anxiety.
... Typical hedging strategies used by the airline companies is also a topic worth for analysis. Hedging could be subdivided into operational hedging and financial hedging in the Airline Industry [2]. Various Airline companies hedge differently in terms of their hedging ratio and hedging tools used to prevent decrease in business's financial performance, when facing risks such as foreign exchange risk and jet fuel price fluctuation. ...
As a classic industry with high competitiveness, the airline companies are constantly exposed to external risks like oil price fluctuations. The volatility of the oil market as well as the global evolving unpredictable situations are putting uncertain adverse pressure on their financial performance and operation. It is without doubt that jet fuel price is remained as always, a hot spot of the insiders’ communication. The nature of the industry, as well as the interactions between various market players and evolving international changes make the risk analysis and management an essential practice. This paper provides an analysis of the airline industry, with emphasis on related counterparties such as the oil market. Risk analysis on jet fuel fluctuations and the perspectives of hedging was discussed as a financial measure for reducing risk exposure and gaining more constant revenues. Examples of hedging adopted by the players in the industry were provided. The results of the study strengthen previous studies that report an impact of fuel hedging mitigates the risks, rather than reinforce the firm value.
... Virtual reality allows public speakers to practice in a situation very similar to what they will face in real life. People can practice where, when, and as often as they need to build their confidence and be ready to give a speech (Craske et al., 2014;Scheveneels et al., 2019). In addition, the training can be progressive and controlled in terms of the number of participants, their nonverbal behaviors, and so on, resulting in much more efficient and faster learning (Eckert & Mower, 2020). ...
Virtual reality has shown great potential in many fields, especially in business and psychology. By immersing someone in a new computer‐generated reality, it is possible to create realistic, safe, and controllable simulations for research and training, as well as new three‐dimensional‐enriched consumer experiences and services. Most of these environments, especially in the metaverse, rely on virtual representations of people called avatars. The design and non‐verbal behaviors of these avatars must be carefully crafted to provide a realistic and truly immersive experience. This paper aims to understand how avatar nonverbal behaviors (i.e., body posture, facial expression, and head movement) are perceived by users immersed in a virtual reality context, a very common situation encountered in many simulations and especially during training. Therefore, the first objective of this study is to validate, through an experiment with 125 participants, how the audience's levels of emotional valence and arousal are perceived in virtual reality. Based on these results, a library of audience non‐verbal behaviors corresponding to different arousal and valence levels is now available for future applications. The experiment also examines the benefits of using low‐end versus high‐end virtual reality headsets, and photo‐realistic versus cartoon avatars. The results have implications for the design of realistic, challenging, and interactive virtual audiences.
... Expectancy violation 61 is a concept embedded within exposure therapy, which has been a mainstay of treatment for anxiety disorders for decades. 62 When applied to musculoskeletal pain, expectancy violation represents the discrepancy between expected and experienced pain during a specific movement or task. It is theorised that a mismatch between expectation and experience is critical for new learning 62,63 and the updating of possible unhelpful understandings about pain. ...
Objective:
Rotator cuff-related shoulder pain is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for rotator cuff-related shoulder pain. However, the causal mechanisms underpinning the beneficial effects of exercise for rotator cuff-related shoulder pain are not well understood. Moreover, how individuals with lived experience of rotator cuff-related shoulder pain believe exercise helped or did not help is unknown. This study aimed to gain insights into how individuals with rotator cuff-related shoulder pain believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.
Methods:
This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semistructured interview. The data were coded by 2 members of the research team (JKP & NC) and verified by a third (BS). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.
Results:
Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psycho-emotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.
Conclusions:
Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with rotator cuff-related shoulder pain was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.
Impact:
Exercise is a recommended primary, first-line intervention to manage rotator cuff-related shoulder pain. The results of this study suggest that a positive experience and outcome with exercise for rotator cuff-related shoulder pain is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context an exercise program is prescribed and delivered should be considered by clinicians.
... Interoceptive exposures for PTSD often involve inducing the interoceptive sensations (e.g., elevated heart rate, shallow breathing) that were experienced during the traumatic event, but in a safe context (i.e., therapy setting), to target expectancy of predicted negative outcomes (e.g., experiencing further trauma or expectancies about not being able to tolerate the distress). Additionally, interoceptive exposures for PTSD may be combined with imaginal or in vivo exposures to optimize inhibitory learning (97). Inducing interoceptive sensations may elicit memories of the traumatic event that could be elaborated on through a combined imaginal exposure. ...
Posttraumatic stress disorder (PTSD) is a psychiatric condition characterized by sustained symptoms, including reexperiencing, hyperarousal, avoidance, and mood alterations, following exposure to a traumatic event. Although symptom presentations in PTSD are heterogeneous and incompletely understood, they likely involve interactions between neural circuits involved in memory and fear learning and multiple body systems involved in threat processing. PTSD differs from other psychiatric conditions in that it is a temporally specific disorder, triggered by a traumatic event that elicits heightened physiological arousal, and fear. Fear conditioning and fear extinction learning have been studied extensively in relation to PTSD, because of their central role in the development and maintenance of threat-related associations. Interoception, the process by which organisms sense, interpret, and integrate their internal body signals, may contribute to disrupted fear learning and to the varied symptom presentations of PTSD in humans. In this review, the authors discuss how interoceptive signals may serve as unconditioned responses to trauma that subsequently serve as conditioned stimuli, trigger avoidance and higher-order conditioning of other stimuli associated with these interoceptive signals, and constitute an important aspect of the fear learning context, thus influencing the specificity versus generalization of fear acquisition, consolidation, and extinction. The authors conclude by identifying avenues for future research to enhance understanding of PTSD and the role of interoceptive signals in fear learning and in the development, maintenance, and treatment of PTSD.
... Consistent with our manipulation of expectancy violation, however, the HE groups reported higher expectancy ratings than the LE groups. Because no US was presented during extinction, higher US-expectancy ratings also imply stronger expectancy violation, and according to the inhibitory learn ing model, stronger expectancy violation should have led to a stronger formation of the CS-noUS association (Craske et al., 2014;Craske et al., 2022;Scheveneels, Boddez, Vervliet, et al., 2019). As predicted by the inhibitory learning model, the HE groups indeed reported lower subjective threat compared to the LE groups at the end of the extinction phase on Day 1, providing causal evidence for the notion that the strength of expectancy violation is related to the decline of subjective threat during fear extinction. ...
Background
Exposure therapy is at the core of the treatment of pathological anxiety. While the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. Therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning.
Method
In total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. To experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. Consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively.
Results
We found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. On Day 2, inhibitory CS-noUS associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings.
Conclusion
These findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety.
Introduction: Although several trials have demonstrated the effectiveness of Virtual Reality Exposure Therapy (VRET) for reducing social anxiety, there is little understanding about the factors that lead to symptom reduction across different treatment designs. Such factors may include outcome expectancy, therapeutic alliance, presence (perception of being in the virtual environment) and social presence (perception of interacting with others). We report on findings from a pilot trial of VRET targeting social anxiety in people who stutter, and examine the association of these four factors with treatment outcome.
Methods: People who stutter reporting heightened social anxiety ( n = 22) took part in the trial after being recruited via online adverts. Remotely delivered VRET was administered to participants in three sessions across three weeks. Each session targeted both performative and interactive anxiety. A virtual therapist helped participants to engage with treatment strategies, whilst also guiding them through exercises.
Results: Findings showed that presence and social presence were both negatively related to changes in fear of negative evaluation between pre- and post-treatment. However, presence, outcome expectancy and therapeutic alliance were positively related to changes in social anxiety symptoms. Furthermore, outcome expectancy and therapeutic alliance were quadratically related to fear of negative evaluation change. Nevertheless, the effect of presence on social anxiety, and the effects of presence and therapeutic alliance on fear of negative evaluation must be interpreted with caution as these were not large enough to reach sufficient statistical power. Therapeutic alliance did not mediate the relationship between outcome expectancy and treatment outcome.
Discussion: These findings suggest that the current VRET protocol affected social anxiety and fear of negative evaluation differently. We discuss how presence may underlie these mixed associations. We also suggest that the unexpected positive effects on social anxiety symptoms may have resulted from insufficient treatment strategies which inadvertently encouraged maladaptive learning.
Exposure therapy is an evidence-based psychotherapeutic technique for anxiety and related disorders. However, the dropout rate ranges from 10%–30%, and poor outcomes such as dropout are predicted by lower resting heart rate variability (HRV), which, in turn, predicts neural correlates of anxiety. Incorporating biofeedback into traditional exposure therapy has the potential to improve patient outcomes and experience through two protocols: (a) framing respiration and HRV biofeedback as a preparatory intervention for exposure therapy and (b) integrating selected biofeedback modalities into traditional exposure therapy sessions.
Despite the high prevalence of anxiety disorders in children and adolescents and the existence of effective evidence-based treatments for them, access to psychological care remains a major public health concern. Summer camps may provide an effective treatment avenue for youth who might not otherwise have access to care. This study describes the design and implementation of Fear Facers, a semi-structured, five-day, daytime exposure therapy-based summer camp designed for youth with a primary diagnosis of obsessive-compulsive disorder (OCD), social anxiety, separation anxiety, or a specific phobia. Preliminary data regarding feasibility and patient outcomes is also reported. Among 52 children and adolescents aged 7 to 16 who attended one of six camp sessions between 2018 and 2021, significant reductions in anxiety (d = 0.54) and OCD symptoms (d = 0.57) were observed from pre-camp to immediately post-camp. A subset of campers who were followed for an additional three months post-camp (n = 22) showed maintenance of treatment gains. Retention rates for the intervention were high. Our investigation provides further support for the use of a camp-based design for cognitive-behavioral approaches, and may provide a unique setting to maximize elements of inhibitory learning in exposures. We also discuss a number of elements regarding feasibility that need consideration for those hoping to develop similar interventions.
COVID-19 has imposed physical, mental, and emotional isolation contributing to adverse mental health outcomes in children and adolescents. For school children struggling with trauma, the pandemic has both exacerbated existing symptoms and served as a source for trauma. Due to the increase in psychological distress, there has never been a higher need for evidence-based trauma treatment. Several trauma-based intervention programs in school psychological practice improve symptoms, strengthen psychological resilience, and improve school functioning. Nevertheless, some schools post-COVID-19 have adopted remote or hybrid service delivery that requires flexible interventions, and delivering a key trauma technique in these programs, exposure, and response prevention can be challenging. In this mini-review, we provide recommendations for school-based practitioners looking to conduct narrative and in vivo exposures to meet the demands of this in-person/virtual service delivery landscape. We emphasize the utility of exposure therapy for trauma, discuss modifications for implementing exposure-based techniques for trauma when working with clients remotely, and provide tips for collaborating with parents and teachers.
Extinction learning is tremendously adaptive as it allows an animal to adjust their behavior in a changing environment. Yet, extinction is not without limitations and fear often reemerges over time (i.e. spontaneous recovery). Relative to adults, adolescent rodents and humans are particularly prone to spontaneous recovery following extinction. In this study, we aimed to address whether combining methods of fear regulation (extinction and conditioned inhibition) can facilitate extinction retention. Early adolescent (29 days old, n = 81) and adult (70 days old, n = 80) mice underwent extinction with or without a safety cue present. Safety cue presentations were systematically varied to overlap with or alternate with fear cue presentations. We found that initial safety learning was faster in adolescent mice. In addition, intermixing safety cues into extinction reduced spontaneous recovery during a test two weeks later. The decrease in spontaneous recovery relative to a standard extinction protocol was greater in adolescents than adults. Together, our findings provide initial evidence that safety learning may be inherently stronger during adolescence. These results inform the parameters by which conditioned safety and extinction learning may be merged to augment the inhibition of fear. While methods to enhance fear regulation are valuable for any age, the potential to do so during adolescence is particularly striking.
The focus of this chapter is an overview of integrating virtual reality (VR) technology within the context of exposure therapy for anxiety disorders, a gold standard treatment, with a focus on how VR can help facilitate extinction learning processes integral to these interventions. The chapter will include an overview of advantages of incorporating VR within exposure therapy, and benefits specifically within an inhibitory learning approach for extinction training. A review of the empirical literature on the effectiveness of VR exposure therapy for specific phobia and PTSD will be provided, as well as practical overview of how to effectively incorporate VR within exposure therapy.KeywordsAnxiety, Extinction learning, PTSD, Specific phobia, Translational science, Virtual reality
Many children with Williams syndrome struggle with fears and phobias that significantly impact their daily lives. Yet, there is sparse literature about the impact of behavioral interventions to treat anxiety and phobias among children with Williams syndrome. Using observational coding of intervention videos, the current study examines patterns of the therapist's use of play and humor and relations to child behavioral responses for four children with Williams syndrome who were identified as treatment responders to humor- and play-infused exposure therapy for fears and anxieties. Sessions were coded for therapist behaviors (exposure with or without play/humor, stimulus type used during exposure, passive or invited attention to feared stimulus, and spontaneous parent participation in exposure) as well as positive, negative, and neutral child behaviors (verbalizations and behaviors). Temporal patterns between therapist and child behaviors were analyzed using lag sequential analyses. The results showed that tolerance of feared stimuli improved for two of the four children following this play- and humor-infused exposure therapy approach, and the remaining two participants demonstrated progress beyond tolerating the feared stimulus and showed increased positive behaviors with the feared stimulus across sessions. Findings also showed patterns of therapist attunement to the child's anxiety level demonstrated through efforts to flexibly adjust the degrees of exposure. Therapist-initiated invited attention behaviors, indicative of the therapist's use of narration and priming, were associated with child tolerance and positive behaviors during exposure to the feared stimulus. Limitations of this study include a very small sample size, short duration of intervention, and a single-subject research design, which limit the generalizability of findings. Implications and future directions of this research are discussed.
Alterations in extinction learning relate to the development and maintenance of anxiety disorders across the lifespan. While exposure therapy, based on principles of extinction, can be highly effective for treating anxiety, many patients do not show sufficient improvement following treatment. In particular, evidence suggests that exposure therapy does not work sufficiently for up to 40% of children who receive this evidence-based treatment.Importantly, fear learning and extinction, as well as the neural circuitry supporting these processes, undergo dynamic changes across development. An improved understanding of developmental changes in extinction learning and the associated neural circuitry may help to identify targets to improve treatment response in clinically anxious children and adolescents. In this chapter, we provide a brief overview of methods used to study fear learning and extinction in developmental populations. We then review what is currently known about the developmental changes that occur in extinction learning and related neural circuitry. We end this chapter with a discussion of the implications of these neurodevelopmental changes for the characterization and treatment of pediatric anxiety disorders.KeywordsExtinction learningAnxietyDevelopmentfMRI
Fear extinction is a topic of central importance in translational neuroscience. It integrates knowledge from various disciplines, including clinical psychology, experimental psychology, psychiatry, cellular and systems neuroscience, and pharmacology. The experimental phenomenon of extinction was first discovered by Ivan P. Pavlov more than 100 years ago and still forms the basis for investigating the psychological and physiological mechanisms that drive extinction of fear. Here, I present old and new ways to think about fear conditioning and extinction from a psychologist’s point of view. Extinction is a simple phenomenon with a complex machinery. Enhancing the behavioral analysis of extinction is necessary to advance research in neighboring disciplines as well and to increase our chances to develop extinction enhancers that might further improve efficacy of extinction-based therapies to treat dysfunctional fears. For that purpose, I address a number of fundamental questions in this chapter to clarify psychological viewpoints on the process of fear extinction. What is extinction? What is an association? What is fear? What can we learn from fear extinction? My goal is to reinforce critical thinking about basic assumptions underlying fear extinction and to open up new avenues for further research.KeywordsAssociative learningConditioningExtinctionFear Pavlov
Objectives:
Public speaking (PS) is frequently necessary in many professional, educational, and personal settings. Mastering this communication skill is particularly important in today's society. Training techniques for PS have been described in the literature. Given that PS anxiety affects performance, especially voice characteristics and speech fluency, the purpose of this scoping review is to examine, map, and narratively summarize the available evidence on PS interventions that target or affect voice or speech.
Methods:
An extensive literature search was conducted in three bibliographic databases: Medline ALL/Ovid, PsycINFO/Ovid, and Eric/Ovid. Of the 850 studies identified, 22 met the eligibility criteria, and one was added from the reference lists of the included studies.
Results:
A total of 23 studies were included. The interventions identified aim to improve speaking skills either by explicitly targeting the voice or speech (direct intervention, n = 15) or by targeting the cognitive, behavioral, psychological, or physical environment impacting the speaker's production (indirect intervention, n = 8).
Conclusions:
This scoping review provides the first published methodological summary of the characteristics of existing PS interventions that target or affect voice and speech. Heterogeneous characteristics were observed. Further studies are needed to determine which interventions are most effective.
Vindigni, G. (2023). An Interdisciplinary Study on Generative AI: Exploring Its Efficacy in Mental Health Interventions within the Gaming Ecosystem. British Journal of Healthcare and Medical Research, Vol - 10(4). 30-61. DOI:10.14738/bjhmr.104.15114.
The integration of generative artificial intelligence with game mechanics in e-health
innovations holds promise for addressing mental health challenges. However, the extent to which this inter-section can provide effective, applicable, and safe interventions remains unclear. In this regard, this paper evaluates the effectiveness, usability, and benefits of integrating generative AI and gaming in e- health innovations for mental well-being. (1) Background: Through a multidisciplinary approach and the utilisation of secondary sources drawn from various disciplines like healthcare, psychology, and computer science, the study seeks a comprehensive understanding of the study topic. Findings show that the integration of generative AI with game mechanics in mental health interventions offers effective and engaging interventions, fostering emotional connection, therapeutic outcomes, and usability. However, ethical considerations, content filtering, and data privacy issues should be addressed for safe implementation. (2) Methods: Through a multidisciplinary approach with regard to theory triangulation, investigator triangulation, and utilisation of secondary sources drawn from various disciplines like healthcare, psychology, computer science, and databases such as PubMed, Science Direct, and BMC Public Health, the study seeks a comprehensive understanding of the study topic. Numerous quantified sources published on or after 2020 were investigated for design triangulation in terms of determinants, indicators, and deductive rigour in the formation of search terms. (3) Results: The thematic analysis shows that the integration of generative AI with game mechanics in mental health interventions offers effective and engaging interventions, fostering emotional connection, therapeutic outcomes, and usability. However, ethical considerations, content filtering, and data privacy issues should be addressed for safe implementation. (4) Conclusions: Generative AI-driven game mechanics interventions have illustrated significant increases in emotional connection, engagement, and therapeutic outcomes in mental health interventions. Particularly, the increased emotional connection, engagement, and positive therapeutic outcomes associated with generative AI-powered game mechanics enhance the quality-of-service delivery to people with mental health as the enjoyment and motivation of playing games increase the effectiveness and acceptance of AI in the healthcare environment.
Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with a variable clinical presentation. In this chapter, we provide an overview of three empirically supported psychosocial treatments for OCD: cognitive therapy (CT), exposure and response prevention (ERP), and acceptance and commitment therapy (ACT). We first describe symptom presentation and clinical characteristics of OCD and discuss issues related to comorbidity and differential diagnoses. We also provide a list of useful assessment instruments. We then describe the major therapeutic strategies of the three interventions, discuss similarities and differences between them, and review evidence for their efficacy. We end with an illustrative case example and a discussion of how CT, ERP, and ACT can be used as a “toolkit” that allows therapists to provide comprehensive and flexible clinical care for individuals with OCD.KeywordsObsessive-compulsive disorder (OCD)Exposure and response prevention (ERP)Cognitive therapy (CT)Imaginal exposureIn vivo exposureAcceptance and commitment therapy (ACT)
In this chapter, we discuss principles of cognitive-behavioral therapy (CBT) for panic disorder. We begin by describing the presentation of panic disorder (PD) from a cognitive-behavioral perspective, then examining the evaluation and assessment of PD, and then examining the treatment components of CBT for PD. We detail treatment plans, goal formation, and agenda setting. Finally, we review empirical support for this treatment and future directions in the treatment of PD. The chapter concludes with a case vignette illustrating how CBT can be used to treat panic disorder.KeywordsPanic disorderExposurePanic attacksAssessmentPsychoeducationCognitive restructuring
Eating disorders are complex illnesses characterized by distorted cognitions and self-destructive behaviors. There are several distinct elements separating eating disorder diagnoses; however, eating disorders share a similar core psychopathology—an overvaluation of eating, shape, and/or weight on one’s self worth. This similar core psychopathology lends itself to a transdiagnostic treatment approach. Cognitive Behavioral Therapy-Ten (CBT-T) for eating disorders is an evidence-based treatment that builds on the fundamental theory and approaches of CBT with a focus on rapid symptom change. In this chapter, we describe CBT-T and illustrate its application using a case example.KeywordsCognitive behavioral therapyEating disordersAnorexia nervosaBulimia nervosaBinge-eating disorderOther specified feeding or eating disorderExposure and response prevention
Cognitive-behavioral therapy (CBT) is a type of time-limited, goal-oriented psychological therapy that focuses on how thoughts, behaviors, and emotions interact with one another. Through CBT, patients learn to increase their awareness of thoughts, emotions, and behaviors, and practice specific cognitive and behavioral skills to then change maladaptive thoughts and behavioral patterns. Goals that are observable, manageable, and achievable are identified and targeted during structured therapy sessions, which typically occur once a week for several weeks, then gradually taper down in frequency. This chapter provides a general overview of the structure of CBT from the orientation and assessment period to the end of treatment.KeywordsSession structureClinical assessmentCase conceptualizationTreatment planGoal setting
In their review, Sandhu et al. (2023) outline a framework for the study of uncertainty, particularly in the context of psychopathology. The authors correctly argue that clinically-derived intolerance of uncertainty can be better understood through a computational lens. One aspect of the proposed framework is the uncertainty about the number of latent states in the environment. This is indeed an important aspect, however, as pointed out by the authors the relationship between state inference and uncertainty extends beyond the uncertainty about the number of states. In this commentary I will briefly expand on this relationship. Specifically, I will suggest that uncertainty largely determines the process of state inference and that the desire to reduce uncertainty may lead to increased tendency to identify latent structures. I will also demonstrate with simulations the importance of taking state inference into account in computational models to dissociate its contributions from uncertainty related processes.
While fear generalizes widely, extinction is stimulus-specific. Using a hybrid conditioning/episodic memory paradigm, subjects encoded nonrepeating category exemplars during fear conditioning and extinction. Twenty-four hours later, a surprise memory test included old, similar, and novel category exemplars. Results showed strong dissociation between pattern completion (generalization) and pattern separation (discrimination) in episodic memory for items encoded during fear conditioning versus extinction, respectively. These data suggest that directly threat-conditioned stimuli are better recognized at the expense of mnemonic precision, whereas discrimination is enhanced for extinguished stimuli. Overly precise extinction memory may be a contributing factor to fear relapse.
Identifying active ingredients of psychological interventions is a major goal of psychotherapy researchers that is often justified by the promise that it will lead to improved patient outcomes. Much of this "active ingredients" research is conducted within randomized controlled trials (RCTs) with patient populations, putting it in Phase T2 of the clinical-translational spectrum. I argue that RCTs in patient populations are very "messy laboratories" in which to conduct active ingredient work and that T0 and T1 research provide more controlled contexts. However, I call attention to the long road from identifying active ingredients of CBTs, whether in T0, T1, or T2 research, to improving outcomes. Dissemination and implementation research (T3 and T4 approaches) may be conceptually closer to improving outcomes. Given how common and disabling mental health symptoms are, I argue that if researchers want to improve patient outcomes, these research programs must receive more attention including work on the uptake of psychological interventions as well as work on optimal ordering of existing interventions.
La réalité virtuelle (RV) se taille une place justifiée dans le traitement des troubles d'anxiété. Mais pour la résilience, les données probantes révèlent qu'elle peut parfois constituer un gadget attrayant promu sur la base d'intérêts autres que scientifiques. Cet article fait le point sur les données probantes justifiant l'utilisation de la RV dans le traitement des troubles d'anxiété et illustre les limites de cet outil dans la régulation des émotions sous cliniques. Pour illustrer le rôle que peut jouer la RV dans le développement d'un outil d'appuis à la résilience, l'article présente un protocole de traitement en processus de validation chez les Inuit du Québec qui combine la RV, le biofeedback et des adaptations culturelles. See end of text for English abstract Mots-clés: Réalité virtuelle, régulation émotionnelle, anxiété, exposition, thérapie cognitive-comportementale, biofeedback. Correspondance: Stéphane Bouchard, Département de psychoéducation et psychologie, Université du Québec en Outaouais, CP 1250, Succ Hull, Gatineau (Québec), J8Y 6H2. courriel: stephane.bouchard@uqo.ca. Téléphone: 819-595-3900, poste 2360. © 2023. Association Scientifique pour la Modification du Comportement. Tous droits réservés. www.science-comportement.org Depuis quelques décennies, la régulation émotionnelle a gagné en popularité en sciences de la santé, en sciences sociales, en psychologie et en éducation. Cet intérêt envers la régulation émotionnelle s'explique notamment par son rôle central dans la vie quotidienne. La régulation émotionnelle représente un processus de modulation important pour un ou plusieurs aspects d'une expérience ou d'une réponse émotionnelle (Chambers et al., 2009). Il est également proposé que ce processus ait un impact sur l'intensité, la durée et l'expression des émotions (Gross et Thompson, 2007). Les écrits sur le sujet soulignent que la régulation émotionnelle inclut des stratégies explicites et implicites pour augmenter, maintenir ou diminuer des aspects de la réponse émotionnelle. Menin et Farach (2007) soulignent l'importance d'une forme de stratégies de régulation émotionnelle explicite, à savoir la régulation émotionnelle adaptative. Cette stratégie se traduit par la sélection et la mise en oeuvre volontaire de stratégies de régulation émotionnelle adaptées aux différentes étapes de ce processus générateur d'émotions, afin qu'une expérience émotionnelle puisse être vécue sainement (Mennin et Farach, 2007). Ces stratégies de régulation émotionnelle permettent aux personnes d'influencer les émotions qu'elles éprouvent, le moment où elles les éprouvent, la façon dont elles les vivent et la façon dont elles les expriment. Toutefois, certaines personnes ont de la difficulté à utiliser des stratégies de régulation émotionnelle adaptatives face à la perception d'une situation menaçante provoquant une expérience émotionnelle. Thayer et Lane (2000) proposent que ce serait notamment le cas des individus ayant un trouble d'anxiété, ces derniers ayant de la difficulté à privilégier une réponse fonctionnelle, ou à inhiber une réponse dysfonctionnelle, face aux stimuli qui sous-tendent leur trouble d'anxiété (p.ex., la réponse face à un chien pour une personne ayant une phobie spécifique des chiens).
Anxiety disorders are a significant cause of disability globally, yet only one in ten sufferers receives adequate quality treatment. Exposure-based therapies are effective in reducing symptoms associated with a number of anxiety disorders. However, few therapists use exposure techniques to treat these conditions, even when they are adequately trained in them, often because of concerns about provoking distress, drop out, logistical barriers, and other concerns. Virtual reality exposure therapy (VRET) can address many of these concerns, and a large body of research decisively shows that VRET is as efficacious for treating these conditions as in vivo exposures. Yet, use of VRET remains low. In this article, we discuss several factors we believe are contributing to low VRET adoption among therapists and raise potential solutions to address them. We consider steps that VR experience developers and researchers might take, such as leading studies of VRET's real-world effectiveness and treatment optimization trials and continuing to improve the fit of platforms with clinicians' workflows. We also discuss steps to address therapist reservations using aligned implementation strategies, as well as barriers for clinics, and the roles that professional organizations and payers could have in improving care by encouraging adoption of VRET.
72 college students learned 3 motor tasks under a blocked (low interference) or random (high interference) sequence of presentation. Retention was measured after a 10-min or 10-day delay under blocked and random sequences of presentation. Subsequent transfer to a task of either the same complexity or greater complexity than the originally learned tasks was also investigated. Results showed that retention was greater following random acquisition than under changed contextual interference conditions. Likewise, transfer was greater for random acquisition groups than for blocked acquisition groups. This effect was most notable when transfer was measured for the transfer task of greatest complexity. Results are considered as support for W. F. Battig's (1978) conceptualization of contextual interference effects on retention and transfer. (13 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
While many researchers have largely focused on principles of systematic desensitization and habituation
in explaining fear extinction, these processes have mixed evidence at best. In particular, these models
do not account for spontaneous recovery or reinstatement of fear, nor do they explain the context
dependency of extinction or rapid reacquisition. This may in part account for the significant number of
patients who fail to respond to our available treatments which rely on these principles in designing
exposure sessions. However, recent research is converging to suggest that an inhibitory model of fear
reduction, in which the original feared association (CS-US) remains but is inhibited by a newly formed
association (CS-noUS) representing safety, holds promise in explaining the long-term attenuation of fear
and anxiety. This paper reviews research in a number of areas, including neuroimaging,
psychophysiology, and psychopharmacology that all provide support for the inhibition model of anxiety.
Limitations to this body of research are discussed, along with recommendations for future research and
suggestions for improving exposure therapy for fear and anxiety disorders. Clinical implications
discussed in this paper include incorporating random and variable practice in exposure sessions,
multiple contexts, and pharmacological aides, among others.
Over the last 30years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g=1.010/g=1.128) and exposure was spread over the course of multiple sessions (g=1.527/g=1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.
Adolescent rats exhibit impaired extinction retention compared to pre-adolescent and adult rats. A single nonreinforced exposure to the conditioned stimulus (CS; a retrieval trial) given shortly before extinction has been shown in some circumstances to reduce the recovery of fear after extinction in adult animals. This study investigated whether a retrieval-extinction procedure would reduce the recovery of extinguished fear in adolescent rats. Furthermore, the effect of the retrieval-extinction sequence on fear recovery was examined by presenting the retrieval trial following extinction to some animals. In Experiment 1 adolescent rats received one nonreinforced CS presentation (a retrieval trial) or equivalent context exposure (no retrieval) 10 min before fear extinction. A retrieval trial shortly before extinction reduced overall levels of fear in both test contexts (i.e., it improved extinction retention and reduced renewal). In Experiment 2 a weakening of renewal was observed with a retrieval-extinction manipulation, regardless of whether the retrieval trial occurred in the training or extinction context. A key result was that a retrieval trial 10 min, but not 6 h, after extinction led to reduced overall levels of fear similar to that observed if the retrieval trial was given before extinction (Experiments 3 and 4), inconsistent with the current interpretation of the reduction in relapse being due to a disruption of reconsolidation. Together, these findings show that the impaired extinction retention observed in adolescents can be ameliorated by a very simple behavioral manipulation, but also raise some questions about the mechanisms underlying the retrieval-extinction effect.
This paper is an attempt to consider classical conditioning models of human fears and phobias in a contemporary context, and to consider how conditioning models might be of some theoretical help in this area. The paper covers (i) a contemporary review of the basic phenomena of human conditioning, (ii) a comparison of conditioning processes in humans and animals, (iii) a description of a contemporary model of human conditioning designed to accommodate recent research findings, (iv) a re-examination of the traditional criticisms of conditioning accounts of phobias in the light of this contemporary model, (v) a discussion of some of the features of fears and phobias that this model can address, and (vi) a brief discussion of the scope of this model and some implications for the treatment of clinical fears and phobias.
We argue herein that typical training procedures are far from optimal. The goat of training in real-world settings is, or should be, to support two aspects of posttraining performance: (a) the level of performance in the long term and (b) the capability to transfer that training to related tasks and altered contexts. The implicit or explicit assumption of those persons responsible for training is that the procedures that enhance performance and speed improvement during training will necessarily achieve these two goals. However, a variety of experiments on motor and verbal learning indicate that this assumption is often incorrect. Manipulations that maximize performance during training can be detrimental in the long term; conversely, manipulations that degrade the speed of acquisition can support the long-term goals of training. The fact that there are parallel findings in the motor and verbal domains suggests that principles of considerable generality can be deduced to upgrade training procedures.
Exposure-based treatments for clinical anxiety generally are very effective, but relapse is not uncommon. Likewise, laboratory studies have shown that conditioned fears are easy to extinguish, but they recover easily. This analogy is striking, and numerous fear extinction studies have been published that highlight the processes responsible for the extinction and return of acquired fears. This review examines and integrates the most important results from animal and human work. Overall, the results suggest that fear extinction is relatively easy to "learn" but difficult to "remember." It follows that treatments will benefit from an enhanced focus on the long-term retrieval of fear extinction. We review the available studies on the prevention of return of fear and the prospects of weakening fear memories forever. We show that the behavioral principles outlined in learning theory provide a continuous inspiration for preclinical (neurobiological) and clinical research on the extinction and return of fear.
Review of the literature indicates that, according to theories of selective attention, learning about a stimulus depends on attending to that stimulus; this is represented in 2-stage models by saying that Ss switch in analyzers as well as learning stimulus-response associations. It is argued that this assumption, however, is equally well represented in a formal model by the incorporation of a stimulus-specific learning-rate parameter, a, into the equations describing changes in the associative strength of stimuli. Previous theories of selective attention have also assumed that (a) Ss learn to attend to and ignore relevant and irrelevant stimuli (i.e., that a may increase or decrease depending on the correlation of a stimulus with reinforcement); and (b) there is an inverse relationship between the probabilities of attending to different stimuli (i.e., that an increase in a to one stimulus is accompanied by a decrease in a to others). The first assumption has been used to explain the phenomena of acquired distinctiveness and dimensional transfer, the second to explain those of overshadowing and blocking. It is argued that although the first assumption is justified by the data, the second is not: Overshadowing and blocking are better explained by the choice of an appropriate rule for changing a, such that a decreases to stimuli that signal no change from the probability of reinforcement predicted by other stimuli. (65 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Memories become labile when recalled. In humans and rodents alike, reactivated fear memories can be attenuated by disrupting
reconsolidation with extinction training. Using functional brain imaging, we found that, after a conditioned fear memory was
formed, reactivation and reconsolidation left a memory trace in the basolateral amygdala that predicted subsequent fear expression
and was tightly coupled to activity in the fear circuit of the brain. In contrast, reactivation followed by disrupted reconsolidation
suppressed fear, abolished the memory trace, and attenuated fear-circuit connectivity. Thus, as previously demonstrated in
rodents, fear memory suppression resulting from behavioral disruption of reconsolidation is amygdala-dependent also in humans,
which supports an evolutionarily conserved memory-update mechanism.
Renewal has been implicated as one of the underlying mechanisms in return of fear following exposure therapy. ABC renewal is clinically more relevant than ABA renewal and yet it is a weaker form of renewal, suggesting that conducting extinction treatment in multiple contexts may be sufficient to attenuate ABC renewal. Using self-reported expectancy of shock and startle blink responses the current study examined the effects of conducting extinction treatment in multiple contexts on ABC fear renewal. Participants (N = 68) received conditional stimulus (CS) and unconditional stimulus (US) pairings in one context (A) followed by extinction treatment (CS presentations alone) in either one other context (B) or three other contexts (BCD). Non-reinforced test trials in a novel context (E) resulted in renewal of extinguished conditioned behaviour for those who received extinction in only one context. However, renewal was attenuated for those who received extinction treatment in three contexts. No renewal was found for the control group that received the test trial in the same context as during extinction. Suggestions are provided for clinicians seeking to prevent or attenuate return of fear following exposure therapy.
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
The contextual interference effect is a learning phenomenon where interference during practice is beneficial to skill learning. That is, higher levels of contextual interference lead to poorer practice performance than lower levels while yielding superior retention and transfer performance. This rather counterintuitive effect, first demonstrated by Battig (1966) for verbal materials and later shown to be relevant to motor skill learning by Shea and Morgan (1979), has led to a considerable amount of research. In this article, we review the motor skills literature related to this effect by focusing on two research directions. First, evidence related to the generalizability of the effect is considered to identify possible parameters of the contextual interference effect. It is apparent that this effect is not applicable for learning all types of tasks and for all types of learners. Thus, task and individual characteristics are given particular consideration. Second, the explanations offered to establish what learning processes account for this effect are considered. Here, the different views proposed to explain the contextual interference are discussed along with research addressing this issue. Also, the relationship between the contextual interference effect and the practice variability hypothesis of Schmidt's schema theory is explored. Finally, future research directions are suggested with the goal of providing guidelines for research to enhance our present knowledge of the contextual interference effect and its relationship to motor skill learning.
Fear conditioning is one of the prime paradigms of behavioural neuroscience and a source of tremendous insight in the fundamentals of learning and memory and the psychology and neurobiology of emotion. It is also widely regarded as a model for the pathogenesis of anxiety disorders in a diathesis-stress model of psychopathology. Starting from the apparent paradox between the adaptive nature of fear conditioning and the dysfunctional nature of pathological anxiety, we present a critique of the human fear conditioning paradigm as an experimental model for psychopathology. We discuss the potential benefits of expanding the human fear conditioning paradigm by (1) including action tendencies as an important index of fear and (2) paying more attention to "weak" (i.e., ambiguous) rather than "strong" fear learning situations (Lissek et al., 2006), such as contained in selective learning procedures. We present preliminary data that illustrate these ideas and discuss the importance of response systems divergence in understanding individual differences in vulnerability for the development of pathological anxiety.
Memory loss in retrograde amnesia has long been held to be larger for recent periods than for remote periods, a pattern usually referred to as the Ribot gradient. One explanation for this gradient is consolidation of long-term memories. Several computational models of such a process have shown how consolidation can explain characteristics of amnesia, but they have not elucidated how consolidation must be envisaged. Here findings are reviewed that shed light on how consolidation may be implemented in the brain. Moreover, consolidation is contrasted with alternative theories of the Ribot gradient. Consolidation theory, multiple trace theory, and semantization can all handle some findings well but not others. Conclusive evidence for or against consolidation thus remains to be found.
Investigations of fear conditioning in rodents and humans have illuminated the neural mechanisms underlying cued and contextual fear. A critical question is how personality dimensions such as trait anxiety act through these mechanisms to confer vulnerability to anxiety disorders, and whether humans' ability to overcome acquired fears depends on regulatory skills not characterized in animal models. In a neuroimaging study of fear conditioning in humans, we found evidence for two independent dimensions of neurocognitive function associated with trait vulnerability to anxiety. The first entailed increased amygdala responsivity to phasic fear cues. The second involved impoverished ventral prefrontal cortical (vPFC) recruitment to downregulate both cued and contextual fear prior to omission (extinction) of the aversive unconditioned stimulus. These two dimensions may contribute to symptomatology differences across anxiety disorders; the amygdala mechanism affecting the development of phobic fear and the frontal mechanism influencing the maintenance of both specific fears and generalized anxiety.
Four conditioned suppression experiments examined the influence of contextual stimuli on the rat's fear of an extinguished conditioned stimulus (CS). When rats received pairings of a CS with shock in one context and then extinction of the CS in another context, fear of the CS was renewed when the CS was returned to and tested in the original context (Experiments 1 and 3). No such renewal was obtained when the CS was tested in a second context after extinction had occurred in the conditioning context (Experiment 4). In Experiment 2, shocks presented following extinction reinstated fear of the CS, but only if they were presented in the context in which the CS was tested. In each experiment, the associative properties of the contexts were independently assessed. Contextual excitation was assessed primarily with context-preference tests in which the rats chose to sit in either the target context or an adjoining side compartment. Contextual inhibition was assessed with summation tests. Although reinstatement was correlated with demonstrable contextual excitation present during testing, the renewal effect was not. Moreover, there was no evidence that contextual inhibition developed during extinction. The results suggest that fear of an extinguished CS can be affected by the excitatory strength of the context but that independently demonstrable contextual excitation or inhibition is not necessary for contexts to control that fear.
When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism.
In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned stimulus or a 'rest' control group that received only exposure to the apparatus in the first two phases. However, reacquisition was impaired relative to acquisition in a 'learning-experienced' group that had previously received conditioning and extinction with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls. The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced trials signal other reinforced trials.
The ABA renewal procedure involves pairing a conditional stimulus (CS) and an unconditional stimulus (US) in one context (A), presenting extinction trials of the CS alone in a second context (B), and nonreinforced test trials of the CS in the acquisition context (A). The renewal of extinguished conditioned behaviour is observed during test. The current study tested the effects of multiple extinction contexts and context similarity in attenuating renewal. Participants (N=99) took part in a fear conditioning ABA renewal procedure. Using a measure of self-reported expectancy of the US, ABA renewal was observed when a single extinction context that was dissimilar to the test context was used. Renewal was attenuated, though still present, when extinction occurred in multiple dissimilar extinction contexts or in a single extinction context that was similar to the test context. Renewal was completely abolished when multiple extinction contexts that were similar to the test context were combined. Multiple extinction contexts and context similarity act additively in their effect on attenuating renewal. The results are discussed in relation to the design of exposure therapy programs that seek to reduce relapse that can occur via renewal.
In this article I review research and theory on the "interference paradigms" in Pavlovian learning. In these situations (e.g., extinction, counterconditioning, and latent inhibition), a conditioned stimulus (CS) is associated with different unconditioned stimuli (USs) or outcomes in different phases of the experiment; retroactive interference, proactive interference, or both are often observed. In all of the paradigms, contextual stimuli influence performance, and when information is available, so does the passage of time. Memories of both phases are retained, and performance may depend on which is retrieved. Despite the similarity of the paradigms, conditioning theories tend to explain them with separate mechanisms. They also do not provide an adequate account of the context's role, fail to predict the effects of time, and overemphasize the role of learning or storage deficits. By accepting 4 propositions about animal memory (i.e., contextual stimuli guide retrieval, time is a context, different memories are differentially dependent on context, and interference occurs at performance output), a memory retrieval framework can provide an integrated account of context, time, and performance in the various paradigms.
Importance Obsessive-compulsive disorder (OCD) may be characterized by impaired self-regulation and behavioral inhibition. Elevated fear and anxiety are common characteristics of this disorder. The neurobiology of fear regulation and consolidation of safety memories have not been examined in this patient population.
Objective To examine the psychophysiological and neurobiological correlates of conditioned fear extinction in patients with OCD.
Design Cross-sectional, case-control, functional magnetic resonance imaging study.
Setting Academic medical center.
Participants Twenty-one patients with OCD and 21 healthy participants.
Main Outcomes and Measures Skin conductance responses and blood oxygenation level–dependent responses.
Results The between-group difference noted in our psychophysiological measure (skin conductance responses) was during extinction recall: patients with OCD showed impaired extinction recall relative to control subjects. Regarding the functional magnetic resonance imaging data, patients with OCD showed significantly reduced activation in the ventromedial prefrontal cortex across training phases. Moreover, reduced activation in the patients with OCD was noted in the caudate and hippocampus during fear conditioning, as well as in the cerebellum, posterior cingulate cortex, and putamen during extinction recall. Contrary to our prediction, OCD symptom severity was positively correlated with the magnitude of extinction memory recall. Also contrary to our prediction, functional responses of the ventromedial prefrontal cortex were positively correlated with symptom severity, and functional responses of the dorsal anterior cingulate cortex were inversely correlated with symptom severity.
Conclusions and Relevance As expected, our study showed that fear extinction and its neural substrates are impaired in patients with OCD. However, this study also yielded some surprising and unexpected results regarding the correlates between extinction capacity and its neural substrates and the severity of symptoms expressed in this disorder. Thus, our data report neural correlates of deficient fear extinction in patients with OCD. The negative correlations between fear extinction deficits and Yale-Brown Obsessive-Compulsive Scale symptoms in OCD suggest that there may be other factors, in addition to fear extinction deficiency, that contribute to the psychopathology of OCD.
primarily concerned with the generation of conditioned responses
contingency theory of learning
timing theories of learning and performance
comparator hypothesis of performance (PsycINFO Database Record (c) 2012 APA, all rights reserved)
When conditioning and extinction are conducted in different contexts, a return to the conditioning context causes a renewal of conditioned responding. The results of 4 experiments with rats in an appetitive conditioning preparation suggest that renewal results from a failure to retrieve extinction outside the extinction context. Presentation of a cue from extinction during renewal testing attenuated the renewal effect; attenuation depended on the cue's correlation with extinction. On its own, the cue did not elicit responding, suggesting it was not a conditioned excitor; it also failed tests for conditioned inhibition. The authors propose that it worked by retrieving a memory of extinction. The findings parallel previous results with spontaneous recovery and are thus consistent with the view that renewal and spontaneous recovery result from a common mechanism. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The theoretical and empirical basis of commonly accepted propositions concerning the role of behaviour in the practice of behavioural psychotherapy for anxiety problems is considered. A number of problems are identified, and an alternative, more explicitly cognitive hypothesis is described. According to this cognitive account, there is both a close relationship and specific interactions between “threat cognitions” and “safety seeking behaviour”. For any individual, safety seeking behaviour arises out of, and is logically linked to, the perception of serious threat. Such behaviour may be anticipatory (avoidant) or consequent (escape). Because safety seeking behaviour is perceived to be preventative, and focused on especially negative consequences (e.g. death, illness, humiliation), spontaneous disconfirmation of threat is made particularly unlikely by such safety seeking behaviours. By preventing disconfirmation of threat-related cognitions, safety seeking behaviour may be a crucial factor in the maintenance of anxiety disorders. The implications of this view for the understanding and treatment of anxiety disorders are discussed.
In four experiments utilizing an appetitive conditioning preparation, reacquisition of conditioned responding was found to
occur both rapidly and slowly following extinction. In Experiment 1, acquisition of responding to a tone that had been conditioned
and extinguished occurred more rapidly than acquisition in either a group that received equivalent exposure to the food unconditioned
stimulus or a “rest” control group that received only exposure to the apparatus in the first two phases. However, reacquisition
was impaired relative to acquisition in a “learning-experienced” group that had previously received conditioning and extinction
with a different stimulus. Experiments 2 and 3 produced similar results, but also found that high responding during reacquisition
was confined to trials that followed reinforced, rather than nonreinforced, trials. Experiment 4, in which very few initial
conditioning trials were used, produced reacquisition that was slow compared with both learning-experienced and rest controls.
The results are consistent with a role for sequential learning: Reacquisition is rapid when animals have learned that reinforced
trials signal other reinforced trials.
Recent research indicates that return of fear occurs when spider-fearful individuals are confronted with the phobic stimulus in a context different than the one used during exposure therapy (Mineka, Mystkowski, Hladek, & Rodriguez, 1999; Rodriguez, Craske, Mineka, & Hladek, 1999). However, limitations regarding fear measurement, lack of real-world context manipulations and statistical power suggest that further investigation is warranted. With these concerns in mind, 46 spider-fearful individuals received a 1-session exposure-based therapy in one of two contexts, and were followed-up 1 week later for fear assessment in the treatment context, as well as in a new context, in a counterbalanced order. Self-report data confirmed the hypothesis that return of fear will appear when individuals are tested for fear in a context different than the treatment context. In addition, changes in perceptions of safety, danger, control, and predictability did not mediate and/or moderate a contextually based return of fear. Limitations of the current study and directions for future study are discussed.
Although exposure treatment has been shown to be highly effective in ameliorating phobias, the return of fear (ROF) is often evidenced (see Rachman, 1989). The present study compared the effects of massed (single session), uniform-spaced (5, 5, 5 intervening days), and expanding-spaced (1, 4, 10 intervening days) schedules on fear reduction and ROF in an analog sample with self-reported public-speaking anxiety. Treatment utilized a standardized speech exposure task. It was predicted that although massed treatment would produce the greatest fear reduction by posttreatment, it would yield the greatest ROF at 1-month follow-up. The uniform schedule was expected to produce intermediate fear reduction by posttreatment and at follow-up, whereas the expanding schedule was predicted to generate the lowest fear reduction by posttreatment, but the least ROF at follow-up. All groups unexpectedly demonstrated comparable fear reduction by posttreatment, but, as predicted, massed treatment produced the greatest ROF at follow-up — fear ratings in this group no longer differed from pretreatment levels. Expanding and uniform treatments showed an impressive lack of ROF at follow-up; possible explanations for the unexpectedly robust performance of the uniform group are discussed. Given the high rates of attrition for the uniform schedule (50%), results provide preliminary support for the utility of an expanding schedule. Limitations of the present study, and theoretical and practical issues regarding spacing of treatment, are discussed.
Two appetitive conditioning experiments with rats examined reacquisition after conditioned responding was eliminated by either extinction or by a partial reinforcement procedure in which reinforced trials were occasionally presented among many nonreinforced trials. In Experiment 1, reacquisition to a conditional stimulus (CS) that had been conditioned and extinguished was more rapid than acquisition in a group that had received no prior conditioning. However, the addition of occasional reinforced trials to extinction slowed this rapid reacquisition effect. Experiment 2 replicated the result and showed that a procedure in which the CS and the unconditional stimulus (US) were unpaired in extinction interfered even further with reacquisition. The results suggest that rapid reacquisition is ordinarily produced when reinforced trials provide a contextual cue that can renew responding by signaling other acquisition trials (Ricker & Bouton, 1996). The effects of partial reinforcement in extinction are surprising from several theoretical perspectives and have useful clinical implications.
Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.
A differential fear conditioning paradigm was used with 107 healthy undergraduate participants to evaluate the effect of conditioned stimulus (CS) temporal properties on fear acquisition and extinction. Two minute duration CSs were used for Day 1 fear acquisition. Participants were randomized to receive either 1, 2, or 4min CS durations during Day 2 extinction. Extinction re-test was examined on Day 3 using the original acquisition CS duration (2min). Findings indicated that participants who were aware of the CS+/unconditioned stimulus (US) contingency (n=52) develop a temporal expectation about when the unconditioned stimulus will be delivered. Although the shorter duration CS resulted in greater fear reduction during extinction, cessation of fear responding at re-test was the same for CS extinction durations ranging from half the CS acquisition duration to twice the CS acquisition duration. Thus, extinction performance did not predict extinction at re-test, which could have important implications for optimizing exposure therapy for anxiety disorders.
In traditional exposure therapy for phobias and anxiety disorders, reduction of fear responding is used as an index of learning. However, recent evidence in animal models suggests that sustained arousal and enhanced fear responding throughout exposure may actually predict better long-term outcomes (Rescorla, 2000).
The effects of sustained arousal during exposure were investigated in a clinical analog sample of 59 participants fearful of public speaking. Participants completed exposure with or without the presence of additional excitatory stimuli which were intended to enhance arousal and fear responding throughout exposure.
Group assignment (exposure versus exposure with additional excitatory stimuli) did not significantly predict outcome at 1-week follow-up testing, as measured physiologically, subjectively, and behaviorally. A set of regression analyses investigating whether any exposure process measures predicted outcome indicated that sustained arousal throughout exposure as well as variability in subjective fear responding throughout exposure (e.g., Kircanski et al., 2011) predicted lower levels of fear at follow-up testing (p < 0.05; p < 0.001) after controlling for demographic variables as well as pre-exposure fear levels.
The excitatory stimuli used failed to produce the intended effects. However, some participants did maintain elevated arousal throughout exposure and this predicted better outcomes at 1-week follow-up testing.
Sustained arousal throughout exposure as well as variability in subjective fear responding during exposure may be better predictors of long-term outcomes than habituation of fear across exposure.
Traditional models and methods of exposure therapy utilize a fear hierarchy, whereby patients complete sets of exposures in a graduated manner, with the goal of fear habituation within and between sessions. In the current experiment, we examined whether this typical exposure paradigm was necessary to achieve clinical improvement.
Fifty undergraduate participants scoring in the top quartile of a self-report measure of contamination fears were randomly assigned to one of two groups: blocked and constant exposure (BC Group) and random and variable exposure (RV Group). Both groups completed three weekly sessions of exposure treatment, with subjective and psychophysiological indices of fear recorded throughout. Subjective, behavioral, and psychophysiological dependent measures were evaluated by an independent assessor at pre-treatment (PRE), post-treatment (POST), and two-week follow-up (2WFU).
Both the BC Group and RV Group exhibited decreases in subjective fear from PRE to POST and 2WFU, with no significant differences between groups. Partialing group, greater variability in subjective fear during exposure predicted lower subjective fear at 2WFU.
Despite significant findings for subjective fear, behavioral and psychophysiological findings were limited. Follow-up studies should investigate questions regarding traditional exposure within a clinical group.
These results support the notion that traditional exposure is sufficient, but not necessary, to produce clinical improvement in contamination-related fears. There may be benefits to variability in fear level during exposure, and evaluation of emotion variability during exposure therapy for other anxiety disorders is warranted.