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Optimizing Exposure Therapy for Anxiety Disorders: An Inhibitory Learning and Inhibitory Regulation Approach
Abstract
Exposure-based cognitive-behavioral therapy is the treatment of choice for anxiety disorders. Unfortunately, many individuals fail to benefit from treatment or demonstrate a return of fear. Inhibitory learning and inhibitory regulation models provide a parsimonious and unifying framework from which to situate exposure therapy and provide useful strategies to augment exposure therapy, especially as individuals with anxiety disorders show inhibitory deficits. This paper provides an overview of our application of inhibitory learning from the science of extinction, and inhibitory regulation from the neuroscience of emotion regulation, to exposure therapy for anxiety disorders.
... Pavlovian fear conditioning is an important model of the etiology and treatment of anxiety-related disorders and there is robust empirical evidence on the efficacy of its clinical applications (Andreatta, Genheimer, Wieser, & Pauli, 2020;Bouton, Mineka, & Barlow, 2001;Craske, 2015;Fullana et al. 2020;Hermann et al. 2020;Laborda, Polack, Miguez, & Miller, 2014;Michael, Blechert, Vriends, Margraf, & Wilhelm, 2007;Pittig, van den Berg, & Vervliet, 2016;Pittig, Treanor, LeBeau, & Craske, 2018). Typical fear conditioning preparations focus on passive emotional reactions that are produced by an association between an initially neutral stimulus, known as conditioned stimulus (CS), and an aversive stimulus (unconditioned stimulus, US; Bouton & Bolles, 1980;Lovibond, Davis, & O'Flaherty, 2000;Rescorla & Heth, 1975). ...
... Under various circumstances, fear responses can re-occur after extinction (Bouton, García-Gutierrez, Zilski, & Moody, 2006) or after exposure therapy. The latter has shown to not be effective for everyone (Craske, 2015), an important reason for further research in human acquisition and extinction of fear. ...
... It is widely recognized that inhibitory learning is key to understand extinction, as the original association between conditioned and unconditioned stimuli (CS-US) is not erased during this phase; rather, it remains otherwise intact, while a new inhibitory association is learned (CS-no US) (Bouton et al., 2007;Craske, 2015). Inhibitory learning, in this case, learning about safety cues, has been shown to be impaired in individuals with anxiety-related disorders or vulnerability to these disorders. ...
Please
Virtual Reality (VR) is a promising tool for the study of cued fear conditioning in humans because it allows the use of complex and realistic experimental situations. The present study aims to validate a task for the acquisition and extinction of cued fear learning through VR with ecologically relevant Unconditional Stimuli (USs). In a first experiment (n = 69), we evaluated the effectiveness of six USs specially created to be presented in a virtual environment and to provoke physiological and affective reactions of fear. The two stimuli that evoked significantly higher than baseline electromyographic responses during three trials were then selected to be used as the USs in a second experiment. Experiment 2 (n = 51) aimed to determine if the previously selected US could generate a conditioned response (CR) when associated with another visual stimulus (Conditioned Stimulus; CS) in a differential conditioning paradigm, and subsequently go through extinction. We measured physiological, subjective and behavioral responses of fear, and evaluated their relationship to trait anxiety. This study showed that visual CSs in a VR environment can potentiate a startle reflex during acquisition, but we observed no discrimination between stimuli that signaled the US (fear cues CS+) and stimuli that signaled the absence of the US (safety cue CS-). Nevertheless, differential learning was observed in subjective measures (US expectancy and retrospective anxiety ratings) during acquisition, where participants responded differently to fear and safety cues. Subjective CRs, but not physiological, were reduced during extinction. No changes were observed in response suppression presented with CS, and no relationship was found between trait anxiety and fear responses. We conclude that VR is an appropriate model to elicit valid unconditioned fear responses (URs). The results of the present experiments are particularly important given that subjective CRs (observed in Experiment 2) account for an important part of the clinical experience of anxiety-related disorders, which may help to translate the use of VR to exposure therapy. Future research could improve the task to effectively generate differential physiological and behavioral responses with greater sensitivity to individual differences.
... Many of these criticisms stemmed from the inability of early conditioning approaches to account for diverse factors involved in the development of people's anxieties, such as the individual differences illustrated in the cases cited above. More recently, however, a resurgence of interest in learning approaches has occurred, as these approaches have incorporated some of the complexity inherent in contemporary basic learning theory and research (e.g., Barlow 2002;Craske 1999;Mineka & Zinbarg 1996. ...
... Many of those who develop panic attacks and PD also develop some degree of agoraphobic avoidance-that is, avoidance of situations in which they fear or expect they may have a panic attack (e.g., Barlow 2002, Craske 1999. Agoraphobic anxiety and avoidance have long been thought to develop as a result of exteroceptive conditioning of anxiety to situations in which panic attacks have occurred in the past. ...
... Two major risk factors for agoraphobia are gender and employment: Women are more likely than men to develop agoraphobia, and people who work outside of the home are less likely than those who do not work outside of the home to develop agoraphobia (Barlow 2002, Craske 1999. The learning theory approach can explain both of these factors. ...
The authors describe how contemporary learning theory and research provide the basis for models of the etiology and maintenance of anxiety and related disorders. They argue that contemporary learning theory accounts for much of the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the limitations of earlier behavioral approaches, which were overly simplistic and have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term likelihood that experiences with stressful events will lead to the development of anxiety disorders. They also discuss how contextual variables during and after stressful learning experiences influence the maintenance of anxiety disorder symptoms. Thus, contemporary learning models provide a rich and nuanced understanding of the etiology and course of anxiety and related disorders.
Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
... Craske & Mystkowski, 2006). Depressive symptoms may blunt emotional arousal and therefore hinder extinction learning within the context of ERP (Craske, 2015;Zbozinek & Craske, 2017). In addition, Foa and colleagues (1983) speculated that depression may interfere with the habituation process by increasing emotional reactivity during exposure, thereby lengthening the amount of time needed for habituation and, potentially, effective treatment gains. ...
... Unlike habituation-based models, the inhibitory learning model asserts that exposure allows for the development of safety-based associations that inhibit the previously learned fear-based associations (Jacoby & Abramowitz, 2016). It should be noted that despite the promising evidence of the inhibitory learning model for ERP in animal samples and a general shift in the field toward acceptance of this model (Craske, 2015), the evidence base in human subjects is still preliminary (Abramowitz, Blakey, Reuman, & Buchholz, 2018). Importantly, parallel to the impact of depression on extinction learning, deficits in affect labeling and emotional arousal appear to hinder inhibitory learning (Craske, 2015). ...
... It should be noted that despite the promising evidence of the inhibitory learning model for ERP in animal samples and a general shift in the field toward acceptance of this model (Craske, 2015), the evidence base in human subjects is still preliminary (Abramowitz, Blakey, Reuman, & Buchholz, 2018). Importantly, parallel to the impact of depression on extinction learning, deficits in affect labeling and emotional arousal appear to hinder inhibitory learning (Craske, 2015). In addition, there is evidence that depression-related emotional reactivity can lead to experiential avoidance (by way of focus on distress elimination as opposed to distress tolerance), which can impede inhibitory learning (Abramowitz, 2013). ...
Studies investigating the impact of depressive symptoms on obsessive-compulsive disorder (OCD) treatment have yielded mixed findings. The purpose of the study is to extend previous research, which primarily used outpatient samples, to determine whether depression affects OCD treatment outcome among patients receiving intensive residential treatment. OCD patients receiving residential treatment based primarily on exposure and response prevention (ERP) provided data regarding symptoms of depression and OCD at admission and discharge. Patients reported large and significant reductions in OCD symptoms over the course of treatment. Change in OCD symptoms was not significantly affected by depressive symptoms, including patients with severe depressive symptoms. Change in depressive symptoms over the course of treatment was, however, robustly related to change in OCD symptoms, especially among patients who began treatment with severe symptoms of depression. These findings suggest that cognitive-behavior therapy delivered in a residential treatment setting drastically reduces OCD symptoms regardless of depressive symptoms.
... Studies (e.g., Baker et al. 2010, in a sample of acrophobic sample) showed that one trial of 'disconfirmation' exposure each day (staying in the situation for periods of time that exceeded the point at which they believed the aversive event was expected to occur) was as effective as multiple trials of 'non-disconfirmation' exposure each day. The exposure tasks in this approach target the increase of new learning, omitting the emphasis on fear reduction or instructions such as stay in the situation until fear declines (Craske 2015). It has been noted that traditional cognitive restructuring techniques (e.g., threat overestimation or decatastrophizing) can impede the expectancy violation process during extinction. ...
... For instance, such cognitive restructuring prior exposure can reduce the threat expectancy and jeopardize the extinction learning. According to Craske (2015), cognitive restructuring exercises are reserved post-exposure, as a tool to enhance the assimilation of learning. ...
Social anxiety disorder (SAD), i.e., fear or anxiety in social situations, is a frequent and debilitating condition that can affect various life domains. The chapter provides a brief overview of SAD and its subtype, public speaking anxiety. The second section of the discussion focuses on exposure therapy and specifically a modern mode of delivery that involves virtual reality technology. Additionally, the underlying mechanisms of exposure therapy that lead to effective treatment outcomes are being discussed. It is suggested that a better understanding of how exposure works and the underlying mechanisms involved in effective change is essential to enhancing clinical outcomes.
... Studies indicate that in vivo exposure is the core therapeutic mechanism (57,(59)(60)(61). In general, exposure therapy is based on the assumption that phobic anxiety and fear are reduced by repeated exposure to feared or avoided stimuli, resulting in habituation and fear extinction by repeated violation of threat expectancy (62,63). In this respect, two main theoretical approaches exist: according to the "emotional processing theory, " within-and between-session habituation during CBT framed exposure are deemed key in predicting fear reduction and longterm correction of cognitive mechanisms. ...
... Meanwhile, more recent approaches focus on inhibitory learning, a concept revolving around the idea that the fear stimulus memory get co-opted with a second, less threatening and context specificity memory which enables inhibition of the older stimulus memory. Inhibitory learning is currently deemed the more suitable explanation model for anxiety disorders, especially since these patients display impaired inhibitory regulation and learning and thus extinction (63). Exposure is usually performed step-bystep according to the perceived individual difficulty hierarchy, which relates to a particular exposure situation (0 = no threat expectancy, easy to handle; 100 = maximum threat expectancy, extremely difficult to handle). ...
Background
Anxiety disorders are the most frequent mental disorders. Among the different subtypes, specific phobias are the commonest. Due to the ongoing SARS-CoV-19 pandemic, blood-injury-injection phobia (BII) has gained wider attention in the context of large-scale vaccination campaigns and public health. In this BII phobia mini-review and case report, we describe the successful treatment of a severe BII phobia case with combined fainting and psychogenic non-epileptic seizures (PNES) and demonstrate the role of specialized outpatient care.
Case Report
The patient was a 28-year-old woman. She suffered from intense fear and recurrent fainting with regard to needles, injections, injuries, and at the sight of blood since early childhood. Medical history revealed infrequent events suggestive of PNES following panic attacks after sustained exposure to phobic stimuli. Family history was positive for circulation problems and BII fears. Psychopathological evaluation confirmed BII phobia symptoms and diagnosis was made according to the DSM-5. The Multidimensional Blood/Injury Phobia Inventory short version (MBPI-K) revealed severe manifestation of the disease. Neurological examination was ordinary. Repeated electroencephalography detected no epileptic pattern. Cranial magnetic resonance imaging showed normal morphology. Treatment was carried out by a seasoned, multidisciplinary team. Cognitive behavior therapy and exposure were performed. Modification of standard treatment protocol was necessary due to hurdles posed by recurrent fainting and a severe panic-triggered dissociative PNES during in vivo exposure. Modification was implemented by limiting in vivo exposure intensity to moderate anxiety levels. In addition to applied muscle tension and ventilation techniques, increased psychoeducation, cognitive restructuring, and distress tolerance skills (e.g., ice pack, verbal self-instructions) were used to strengthen the patient's situational control during in vivo exposure. A total of 15 sessions were performed. Therapy success was proven by 83% reduction in MBPI-K rating, SARS-CoV-19 vaccination, and a blood draw without psychological assistance, fainting, or seizure.
Conclusion
Taken together, this case demonstrates the potential of and need for specialized outpatient care and individualized treatment for severe BII phobia patients in order to provide them the perspective to have necessary medical procedures done and get vaccinated.
... Anticipated negative outcome probability and severity of the behavioral experiment were measured with visual analog scales (VAS; 0 = not at all likely/not at all; 100 = very likely/horrible; see Craske, 2015). Three VASs were added to measure current anxiety and helplessness while thinking of the behavioral experiment and willingness to conduct the behavioral experiment (0 = none/not at all willing; 100 = extreme/extremely willing). ...
... First, we assessed how many participants actually completed the behavioral experiment in each group (yes/no). Second, the level of distress during the behavioral experiment was measured retrospectively on a VAS (0 = none; 100 = extreme; see Craske, 2015). Third, safety behavior was measured on two VASs to assess whether participants completed the behavioral experiment as planned and whether they used safety behavior (0 = not at all; 100 = extremely well/a lot). ...
Distressing mental images are common in anxiety disorders and can make it difficult for patients to confront feared situations. This study examined whether imagery rescripting focused on a feared social situation prepares participants to engage in a feared situation. Sixty healthy individuals were asked to formulate a behavioral experiment to test negative beliefs about a social situation they feared. They were assigned to one of two groups: imagery rescripting focused on the feared outcome of the behavioral experiment or no imagery rescripting (i.e., a break). All participants were then asked to complete ratings scales and to conduct the behavioral experiment. Before the behavioral experiment, the imagery rescripting condition, compared to the control condition, showed reduced anticipated probability and severity of the feared outcome, lower anxiety and helplessness levels, and increased willingness to conduct the behavioral experiment. Imagery-based interventions focused on feared outcomes seem promising to prepare anxious individuals to engage in treatment.
... Occasional reinforced extinction describes a treatment strategy where, during exposure, the US is delivered once in a while to the patient (Craske et al., 2014). Examples for this strategy are inducing a panic attack during exposure for panic disorder or a social rejection during exposure for social phobia (Craske, 2015). The strategy is, however, not applicable for every US (e.g., the fear of falling off a bridge). ...
... Further building upon the context-dependency of CS-noUS associations, a strategy proposed by the inhibitory learning model is to pharmacologically block the contextual encoding in the hippocampus during extinction training using scopolamine, a muscarinic cholinergic antagonist (Craske, 2015;Craske et al., 2018). Administration of scopolamine before fear extinction led to an attenuation of fear renewal in rats (Zelikowsky et al., 2013). ...
Virtual reality exposure therapy (VRET) is an effective cognitive-behavioral treatment for anxiety disorders that comprises systematic confrontations to virtual representations of feared stimuli and situations. However, not all patients respond to VRET, and some patients relapse after successful treatment. One explanation for this limitation of VRET is that its underlying mechanisms are not yet fully understood, leaving room for further improvement. On these grounds, the present thesis aimed to investigate two major research questions: first, it explored how virtual stimuli induce fear responses in height-fearful participants, and second, it tested if VRET outcome could be improved by incorporating techniques derived from two different theories of exposure therapy. To this end, five studies in virtual reality (VR) were conducted. Study 1 (N = 99) established a virtual environment for height exposure using a Computer Automatic Virtual Environment (CAVE) and investigated the effects of tactile wind simulation in VR. Height-fearful and non-fearful participants climbed a virtual outlook, and half of the participants received wind simulation. Results revealed that height-fearful participants showed stronger fear responses, on both a subjective and behavioral level, and that wind simulation increased subjective fear. However, adding tactile wind simulation in VR did not affect presence, the user's sense of 'being there' in the virtual environment. Replicating previous studies, fear and presence in VR were correlated, and the correlation was higher in height-fearful compared to non-fearful participants. Study 2 (N = 43) sought to corroborate the findings of the first study, using a different VR system for exposure (a head-mounted display) and measuring physiological fear responses. In addition, the effects of a visual cognitive distractor on fear in VR were investigated. Participants' fear responses were evident on both a subjective and physiological level---although much more pronounced on skin conductance than on heart rate---but the virtual distractor did not affect the strength of fear responses. In Study 3 (N = 50), the effects of trait height-fearfulness and height level on fear responses were investigated in more detail. Self-rated level of acrophobia and five different height levels in VR (1 m--20 m) were used as linear predictors of subjective and physiological indices of fear. Results showed that subjective fear and skin conductance responses were a function of both trait height-fearfulness and height level, whereas no clear effects were visible for heart rate. Study 4 (N = 64 + N = 49) aimed to advance the understanding of the relationship between presence and fear in VR. Previous research indicates a positive correlation between both measures, but possible causal mechanisms have not yet been identified. The study was the first to experimentally manipulate both presence (via the visual and auditive realism of the virtual environment) and fear (by presenting both height and control situations). Results indicated a causal effect of fear on presence, i.e., experiencing fear in a virtual environment led to a stronger sense of `being there' in the virtual environment. However, conversely, presence increased by higher scene realism did not affect fear responses. Nonetheless, presence seemed to have some effects on fear responding via another pathway, as participants whose presence levels were highest in the first safe context were also those who had the strongest fear responses in a later height situation. This finding indicated the importance of immersive user characteristics in the emergence of presence and fear in VR. The findings of the first four studies were integrated into a model of fear in VR, extending previous models and highlighting factors that lead to the emergence of both fear and presence in VR. Results of the studies showed that fear responses towards virtual heights were affected by trait height-fearfulness, phobic elements in the virtual environment, and, at least to some degree, on presence. Presence, on the other hand, was affected by experiencing fear in VR, immersion---the characteristics of the VR system---and immersive user characteristics. Of note, the manipulations of immersion used in the present thesis, visual and auditory realism of the virtual environment and tactile wind simulation, were not particularly effective in manipulating presence. Finally, Study 5 (N = 34) compared two different implementations of VRET for acrophobia to investigate mechanisms underlying its efficacy. The first implementation followed the Emotional Processing Theory, assuming that fear reduction during exposure is crucial for positive treatment outcome. In this condition, patients were asked to focus on their fear responses and on the decline of fear (habituation) during exposures. The second implementation was based on the inhibitory learning model, assuming that expectancy violation is the primary mechanism underlying exposure therapy efficacy. In this condition, patients were asked to focus on the non-occurrence of feared outcomes (e.g., 'I could fall off') during exposure. Based on predictions of the inhibitory learning model, the hypothesis for the study was that expectancy-violation-based exposure would outperform habituation-based exposure. After two treatment sessions in VR, both treatment conditions effectively reduced the patients' fear of heights, but the two conditions did not differ in their efficacy. The study replicated previous studies by showing that VRET is an effective treatment for acrophobia; however, contrary to the assumption, explicitly targeting the violation of threat expectancies did not improve outcome. This finding adds to other studies failing to provide clear evidence for expectancy violation as the primary mechanism underlying exposure therapy. Possible explanations for this finding and clinical implications are discussed, along with suggestions for further research.
... In his experiments, Pavlov described associative learning of unconditioned (US) and conditioned stimuli (CS) in animals. Even today his ideas are used as an experimental paradigm to characterise abnormal behaviour, e.g. in the inhibition learning theory (Craske, 2015;Craske et al., 2008). However, it is now understood that the simple formation of a 'reflex' connection between US and CS explaining conditioned response (CS = UC = > CR) is much more complicated, and the data suggest that perception of causality may underpin how the conditioning process develops (De Houwer, 2020;Mackintosh, 2003;Rescorla, 1988). ...
Background
Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.
Aims
In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between ‘common elements’ and ‘mechanisms of change’ in psychological treatment.
Method
The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between ‘common factors’ and ‘mechanisms of change’, and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.
Conclusion
Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become ‘stuck’ in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.
... Si bien la terapia de exposición ha demostrado ser altamente efectiva, aproximadamente un 50% de los individuos fallan en lograr cambios clínicamente significativos con terapia cognitivo conductual para los trastornos de ansiedad basadas en la exposición (Butler et al., 2006;Chambless & Ollendick, 2001;Norton & Price, 2007). Del mismo modo, existe un porcentaje de individuos que varía entre el 19% y 62%, que presentan un retorno del miedo ante eventos que fueron tratados en terapia (Craske, 2015). Lo anterior representa una limitación en el abordaje terapéutico, dado que no garantiza el mantenimiento de los beneficios de los tratamientos basados en la exposición en contextos clínicos. ...
... Pero es en el contexto de la investigación clínica donde la participación de procesos asociativos en la extinción de la memoria espacial tiene su mayor valor heurístico. La memoria espacial se ha considerado un componente de la memoria declarativa (Morellini, 2013;Morris, 2013), y disfunciones en esta última se han asociado a trastornos de ansiedad (Bremner, Vermetten, Afzal, & Vythilingam, 2004;Ehlers & Clark, 2000), los cuales son tratados a partir de terapias basadas en la extinción (i.e., terapia de exposición; Craske, 2015). Dada la evidencia que demuestra que la remoción de una meta en tareas espaciales puede desencadenar comportamientos relacionados con un estado de ansiedad en roedores (Schulz, Houston, Buddenberg, & Topic, 2007) y en humanos (Pickering, Díaz, & Gray, 1995), es posible entonces utilizar la extinción de la memoria espacial como un modelo para la investigación clínica de la ansiedad. ...
Se investigó la participación de procesos asociativos en la extinción de la memoria espacial en humanos. Tres grupos de participantes fueron entrenados para aprender la localización de una plataforma oculta, cuya ubicación fue señalada por un conjunto de claves distales. Durante un ensayo de prueba sin plataforma, los grupos mostraron una preferencia por el cuadrante reforzado, la cual fue disminuyendo gradualmente y sin diferencias entre ellos. La pérdida de dicha preferencia se ajustó adecuadamente a una función exponencial. Esto es consistente con un efecto de extinción, el cual ocurrió tal y como lo predicen algunos modelos de aprendizaje asociativo. Se discuten las implicaciones teóricas y aplicadas de dicho resultado.
... 65 Evidence for the efficacy in adolescents with chronic pain is still scarce, 30 with only few heterogenic studies implementing these treatment strategies. Given that for extinction learning and habituation to occur during interoceptive exposure in sensu the imagined feared stimulus must evoke fear-processing structures, 10,35,40 the present imagery paradigm may form a basis for feared imagined stimuli to be implemented in exposure in sensu. 30 ...
According to the bio-informational theory of emotion by Lang, mental imagery of fearful stimuli activates physiological and behavioural response systems, even in the absence of sensory input. We investigated whether instructed mental imagery of pain-associated (not painful) interoceptive sensations entails a threat value and elicits increased startle response, skin conductance level (SCL), and heart rate (HR) indicative of defensive mobilization in adolescents with chronic pain. Additionally, self-reported measures (fear, fear of pain, desire to avoid) were assessed. Adolescents (11-18 years) with chronic headache (CH, n = 46) or chronic abdominal pain (CAP, n = 29) and a control group (n = 28) were asked to imagine individualized pain-associated, neutral and standardized fear scripts. During pain-associated compared with neutral imagery, both pain groups showed higher mean HR, with CH also showing higher HR reactivity, while HR acceleration was not observed within control group. In contrast, during pain-associated compared with neutral imagery, startle response magnitude and SCL remained unchanged in all groups. Additionally, overall levels in self-reports were higher during pain-associated compared with neutral imagery, but significantly more pronounced in the pain groups compared with the control group. Results suggest that the mere imagination of pain-associated sensations elicits specific autonomic fear responses accompanied by increased self-reported fear in adolescents with chronic pain. The specific modulation of heart rate shed new light on our understanding of multimodal fear responses in adolescents with chronic pain and may help to refine paradigms to decrease fear of interoceptive sensations in chronic pain.
... With and/or without the support of a therapist, the patients expose themselves to anxiety-provoking situations and gain new insights into their alarming physical symptoms and their need for safety strategies and avoidance [8]. Whereas Foa and Kozak [9] emphasize the mechanism of habituation in their "emotional processing theory, " Craske [10] highlights the importance of the approach of inhibitory learning and inhibitory regulation to maximize the effectiveness of exposure therapy. ...
Background
Due to several treatment barriers, many individuals with panic disorder do not receive evidence-based treatment. One promising option to narrow this treatment gap is Internet-based psychotherapy, which has been shown particularly effective in guided formats. Still, there remains room for improvement to make these digital therapies more accessible, cost-efficient, and aligned with best practices for in-person interventions (e.g., exposure). The smartphone app “Invirto – Treatment for Anxiety” offers digitally guided, evidence-based treatment of panic disorders including virtual reality (VR) for exposure therapy. The aim present study is to investigate the efficacy, safety, and acceptance of Invirto in comparison to a care-as-usual (CAU) control group.
Methods
We plan to conduct a randomized controlled trial with two conditions (intervention vs. CAU), three assessment times via online surveys (t0: baseline; t1: 3 months after baseline; t2: follow-up assessment 6 months after baseline), and a total of 128 participants with a clinical diagnosis of panic disorder (symptoms must be experienced ≥ 1 year). Recruitment will take place via email, phone, and the study website. The primary outcome will be the change in anxiety symptoms as measured by Beck’s Anxiety Inventory from t0 to t1. Secondary outcomes will be the change in anxiety symptoms (measured by the Panic and Agoraphobia Scale, PAS; Questionnaire on panic-related Anxieties, Cognitions and Avoidance, ACA), depressive symptoms (measured by the Beck-Depression-Inventory, BDI-II), treatment satisfaction (measured by the Client Satisfaction Questionnaire, CSQ-8; Treatment Adherence Perception Questionnaire, TAPQ-adapt; Positive and Negative Effects of Psychotherapy Scale, PANEPS-I), psychological flexibility (measured by the Acceptance and Action Questionnaire-II, AAQ-II), and dissociation during VR exposure (measured by an adapted version of the Peritraumatic Dissociative Experiences Questionnaire, PDEQ-adapt). Participants in the intervention group will receive access to the intervention (Invirto) right after t0, while the CAU group will receive access to Invirto after t1. We expect a larger change in both the primary and secondary outcomes from t0 to t1 in the intervention group in comparison to the CAU group.
Discussion
This study is one of the first to evaluate an Internet-based intervention for people with panic disorder that includes self-application of VR exposure therapy. The findings are expected to extend the body of knowledge about effective Internet-based treatment options for people with panic disorder. The empirical and clinical implications and the limitations of the study are discussed.
Trial registration
DRKS00027585 (www.drks.de/drks_web/), date of registration: 13 January 2022.
... Interventions such as cognitive behavioral therapy (CBT), considered a gold-standard intervention for anxiety in the general population (Abramowitz et al., 2019), are infrequently tested in pregnant samples. Exposure therapy, a potent behavioral treatment approach used in CBT, reduces anxiety by weakening learned associations between feared stimuli and negative outcomes, and strengthening inhibitory learning (i.e., a feared stimulus does not signal threat) (Craske, 2015). Exposure therapy has only two Randomized Controlled Trials (RCTs; Burger et al., 2020;Loughnan et al., 2019) that have tested its efficacy for pregnant women, while over 90 RCTs have tested exposure therapy in nonpregnant adults (Bandelow et al., 2015). ...
Objective: Exposure therapy is the frontline treatment for anxiety among adults but is underutilized during pregnancy. We qualitatively assess the prospective acceptability of exposure therapy among pregnant Latinas with elevated anxiety, a group that experiences mental health disparities. Method: Pregnant Latinas (N = 25) with elevated anxiety were interviewed regarding their acceptability of exposure therapy following the receipt of an informational clinical video vignette. Interviews were analyzed using deductive content analysis guided by the Theoretical Framework of Acceptability to understand pregnant Latinas’ views about exposure therapy. Results: Nineteen themes were identified across seven theoretically driven subdomains of acceptability. Women expressed acceptability enhancing factors for exposure therapy including feeling hopeful about its effects, a belief that treatment could benefit their broader family, and a preference for treatment during pregnancy as opposed to the postpartum period. Women also expressed challenges to exposure therapy acceptability such as managing family reactions to prenatal psychotherapy, conflict with cultural conceptions of the maternal role, and perceived difficulty using exposure for avoidance related to prenatal health. Conclusion: Identified themes provide insights about exposure acceptability among pregnant women and can be used to bettter engage Latinas in anxiety interventions, ultimately improving clinical outcomes.
... In this regard, our affective relationship memories are predominantly unconsciously (implicitly) constructed, stored, and recalled in the limbic structures (LeDoux, 1996(LeDoux, , 2012(LeDoux, , 2019Panksepp and Biven, 2012;Lane et al., 2020;Solms, 2021). Therefore, affect-guided interventions are essential for the success of emotion exposure in anxiety disorders (Foa et al., 1998), specifically inhibitory learning mechanisms (Craske, 2015), respectively emotional transformations to change emotion schemas associated with attachment ruptures (Elliott et al. 2004;Greenberg et al., 2015;Lane et al., 2020) and also for persistent personality changes (Davanloo, 1995;McCullough, 1997;Abbass, 2015Abbass, , 2017, such as by engaging implicit semantic memory systems (Messina et al., 2016;Solms, 2021, Weinberger et al., 2020. Structural and functional neural changes in cortical, but especially subcortical, regions are hypothesized precisely for long-term characterological effects (Grawe, 2004;Tarzwell, 2017;Roth, 2019;Solms, 2021). 2 Following Grawe's neuroscientific hypothesis, successful psychotherapy should specifically address the underlying disturbed activity of limbic centers (see also Solms, 2021;Panksepp, 1998Panksepp, , 2012Barrett, 2017, Roth, 2019, as these are increasingly recognized as causative for the emergence of many symptomatic psychological conditions. ...
Summary:
Feelings as a compass and central focus for therapeutic interventions for lasting change is becoming an essential guideline across therapy schools. However, the different approaches understand affect- based mechanisms of change quite different. This results in different principles of interventions, which influence the therapy outcome in different ways. In the context of the conception of an integrative treatment heuristic ("Affect-focused Transtheoretical Experiential Model of Change", "ATEM"), psychotherapeutically relevant emotion theories are elaborated between biologistic and constructivist perspectives. We differentiate concepts that relate to feelings (affects, instincts, drives, emotions, emotion schemes) for a common understanding in the field of psychotherapy.
First, on a primary level, it is illustrated how affect systems can be located in the spectrum of basic psychological needs as unconditioned, archaic survival programs. On a secondary level, emotions are described as socially conditioned predictive models (emotion schemes) that emerge via subjectively meaningful experiences, enter the implicit memory system, and are automatically activated via specific stimuli. Lastly, the tertiary level concerns the way we learned to express our feelings. Affects are primary guides for survival - but at the secondary and tertiary levels, it is easy to get trapped in the case of biographically difficult experiences. Once a maladaptive schemes enter the complex memory store, it has an unconscious effect and influence on the way we live our lives leading to symptoms that we treat in psychotherapy.
Finally, we elaborate that feelings are the subjective experience of the self in the moment and the link between needs, their affect systems, emotion schemas, and their representations of mental maps that are predominantly implicit. With these distinctions, we also seek to clarify terminology. The term "emotion" in particular is often used in different ways, sometimes as "feeling" (subjective emotion), or "affect" (“instinct”, "primary or basic emotion"), or even as a protective ("secondary or instrumental emotion") or defensive mechanism (shame-based self-devaluation). There is a need for a precise and differentiated understanding of basically need oriented principles of change in psychotherapy, because (integrative) therapeutic work along the neurobiological pathways requires different approaches and interventions. For a lasting therapeutic change, overcoming avoidance of trauma based aversive fear circuits towards adaptive feelings and corrective emotional experiences with an emotionally fully present therapist are of central importance.
... Contrary to the assumption that the highest possible induction of distress and subsequent decline are necessary in exposure therapy, it has been argued that (besides expectancy violation) a sustained level of distress is a prominent predictor of long-term outcome [64,65] and thus needs to be induced in exposure treatment. In the present VERP, we achieved a sustained level of disgust over the course of the sessions, particularily in patients 6, 7, and 8 (Fig. 3), highlighting the feasibility of VERP in C-OCD. ...
... Given the role of the vmPFC in emotionally driven evaluative functions (e.g., reward processing and internal mood states) (12), excessive activity within these loops has been hypothesized to drive OCD symptoms (7) and could make it difficult for patients to break the vicious cycle of anxiety-provoking thoughts and repetitive behavior that are targeted in treatment. Indeed, less vmPFC-limbic connectivity has been found to predict better ERP outcomes (13), in line with traditional learning theories that ERP may reduce fear by extinction (14,15) or inhibitory learning (16), processes that rely on the frontolimbic circuitry of the vmPFC (7). On the other hand, greater activity in the striatum and in the thalamus have been identified as indicators that specifically predict a better treatment response in those with OCD than in those with anxiety disorders (17). ...
Objective:
Cortical-subcortical hyperconnectivity related to affective-behavioral integration and cortical network hypoconnectivity related to cognitive control have been demonstrated in obsessive-compulsive disorder (OCD); the study objective was to examine whether these connectivity patterns predict treatment response.
Methods:
Adolescents (ages 12-17) and adults (ages 24-45) were randomly assigned to 12 sessions of exposure and response prevention (ERP) or stress management therapy (SMT), an active control. Before treatment, resting-state connectivity of ventromedial prefrontal cortical (vmPFC), cingulo-opercular, frontoparietal, and subcortical regions was assessed with functional MRI. OCD severity was assessed with the Yale-Brown Obsessive Compulsive Scale before, during, and after treatment. Usable fMRI and longitudinal symptom data were obtained from 116 patients (68 female; 54 adolescents; 60 medicated).
Results:
ERP produced greater decreases in symptom scores than SMT. ERP was selectively associated with less vmPFC-subcortical (caudate and thalamus) connectivity in both age groups and primarily in unmedicated participants. Greater symptom improvement with both ERP and SMT was associated with greater cognitive-control (cingulo-opercular and frontoparietal) and subcortical (putamen) connectivity across age groups. Developmental specificity was observed across ERP and SMT treatments, such that greater improvements with ERP than SMT were associated with greater frontoparietal-subcortical (nucleus accumbens) connectivity in adolescents but greater connectivity between frontoparietal regions in adults. Comparison of response-predictive connections revealed no significant differences compared with a matched healthy control group.
Conclusions:
The results suggest that less vmPFC-subcortical connectivity related to affect-influenced behavior may be important for ERP engagement, whereas greater cognitive-control and motor circuit connectivity may generally facilitate response to psychotherapy. Finally, neural predictors of treatment response may differ by age.
... Exposure-based strategies for treating anxiety disorders target extinction processes (e.g., inhibitory learning) that underlie persistent conditioned responses to nonthreatening stimuli (Craske, 2015). Identifying lab-based predictors of treatment responses is an important goal of clinical neuroscience research on threat learning. ...
Background
Major theories propose that perturbed threat learning is central to pathological anxiety, but empirical support is inconsistent. Failures to detect associations with anxiety may reflect limitations in quantifying conditioned responses to anticipated threat, and hinder translation of theory into empirical work. In prior work, we could not detect threat-specific anxiety effects on states of conditioned threat using psychophysiology in a large sample of patients and healthy comparisons. Here, we examine the utility of an alternative fear potentiated startle (FPS) scoring in revealing associations between anxiety and threat conditioning and extinction in this dataset. Secondary analyses further explored associations among conditioned threat responses, subcortical morphometry, and treatment outcomes.
Methods
Youths and adults with anxiety disorders and healthy comparisons (n = 306; 178 female participants; 8–50 years) previously completed a well-validated differential threat learning paradigm. FPS and skin conductance response (SCR) quantified psychophysiological responses during threat conditioning and extinction. In this report, we examined normalizing raw FPS scores to intertrial interval as baseline to address challenges in more common approaches to FPS scoring which could mask group effects. Secondary analyses examined associations between FPS and subcortical morphometry and with response to exposure-based cognitive behavioral therapy in a subsample of patients.
Results
Patients and comparisons showed comparable differential threat conditioning using FPS and SCR. While SCR suggested comparable extinction between groups, FPS revealed stronger retention of threat contingency during extinction in individuals with anxiety disorders. Extinction indexed with FPS was not associated with age, morphometry, or anxiety treatment outcome.
Conclusion
ITI-normalized FPS may have utility in detecting difficulties in extinguishing conditioned threat responses in anxiety. These findings provide support for extinction theories of anxiety and encourage continued research on aberrant extinction in pathological anxiety.
... In other words, anxiety-provoking situations often include approach-avoidance conflicts, i.e., mixed-outcome situations in which avoidance of an aversive outcome is conflicted with the loss of competing rewards and vice versa . In line with this notion, exposure therapy, the gold-standard psychological treatment for anxiety disorders, includes an approach-avoidance conflict in which the patient must confront the anxiety-provoking situation to improve well-being and function (Craske, 2015). Despite the vital role of avoidance in anxiety disorders and its detrimental effects on well-being and function, knowledge about the psychological mechanisms underlying why individuals differ in their tendency to avoid rather than approach when facing an approach-avoidance conflict is incomplete . ...
Excessive avoidance causes functional impairment and maintains anxiety disorders. In the laboratory, approach-avoidance conflict tasks (AACT) can be used to study approach-avoidance behavior in mixed outcome situations (i.e., the same behavior entails both aversive and rewarding consequences). We tested the feasibility of a novel, internet-delivered AACT (iAACT) by conceptually replicating results from laboratory AACTs, including the temporal stability of results and the relation between trait anxiety and approach-avoidance behavior. Individuals from the general population (n = 186) completed a measure of trait anxiety and the iAACT, which entailed choosing either to approach aversive stimuli (image-sound) and receive a reward (points), or to avoid them and not receive a reward (i.e., costly avoidance). The temporal stability of approach-avoidance behavior was assessed by inviting participants to repeat the iAACT six weeks later (n = 91). Consistent with previous findings in laboratory AACTs, results showed that approach behavior to aversive stimuli increased with higher reward levels. These findings were replicated in the follow-up session. Also consistent with previous studies, higher trait anxiety was associated with elevated costly avoidance. In conclusion, the consistency of our results with laboratory studies indicates that the iAACT is feasible and may provide a cost-effective and scalable method to study anxiety-related approach-avoidance behavior remotely.
... This is highly evident for exposure treatments, which were traditionally understood as interventions based on the mechanism of habituation (Grayson, Foa, & Steketee, 1982) and inhibition learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). During the last decade, however, more emphasis was put on the potential of exposure treatments to trigger expectation changes (Craske, 2015;Craske et al., 2014;Craske, Hermans, & Vervliet, 2018;McKay, 2020). Current results indicate that exposure therapy is more effective if based on expectation-violation models compared to mere habituation models (Pittig et al., 2021;Pittig, van den Berg, & Vervliet, 2016;Schemer, Körfer, & Glombiewski, 2020). ...
Expectations are a central maintaining mechanism in mental disorders and most psychological treatments aim to directly or indirectly modify clinically relevant expectations. Therefore, it is crucial to examine why patients with mental disorders maintain dysfunctional expectations, even in light of disconfirming evidence, and how expectation-violating situations should be created in treatment settings to optimize treatment outcome and reduce the risk of treatment failures. The different psychological subdisciplines offer various approaches for understanding the underlying mechanisms of expectation development, persistence, and change. Here, we convey recommendations on how to improve psychological treatments by considering these different perspectives. Based on our expectation violation model, we argue that the outcome of expectation violation depends on several characteristics: features of the expectation-violating situation; the dynamics between the magnitude of expectation violation and cognitive immunization processes; dealing with uncertainties during and after expectation change; controlled and automatic attention processes; and the costs of expectation changes. Personality factors further add to predict outcomes and may offer a basis for personalized treatment planning. We conclude with a list of recommendations derived from basic psychology that could contribute to improved treatment outcome and to reduced risks of treatment failures.
... The changes found in the neural response to these fMRI tasks after therapy might, therefore, reflect changes in these mental processes; the specific causes of these changes remain ambiguous. The identified brain regions can be regarded as in line with inhibitory learning as one of the most recently discussed crucial mechanisms in the treatment of anxiety (e.g., Craske, 2015). However, several other processes are potentially responsible for the neural changes observed. ...
Successful psychotherapy for anxiety disorders is thought to be linked to functional neural changes in prefrontal control areas and fear-related limbic regions. Thus, discovering such therapy-associated neural changes might point to relevant mechanisms of action. Using AES-SDM, we conducted a coordinate-based meta-analysis of 22 whole-brain datasets (n = 419 anxiety patients) from 18 studies identified by our systematic literature search following PRISMA criteria (preregistration available at OSF: https://osf.io/dgc4p). In these studies, fMRI data was collected in response to negative stimuli during cognitive-emotional tasks before and after psychotherapy. Post-psychotherapy, activation decreased in the right insula, the anterior cingulate cortex, and the dorsolateral prefrontal cortex; no region had increased activation. A subgroup analysis for CBT revealed additional decrease in the supplementary motor area. Reduced activation in limbic and frontal regions might indicate therapy-associated normalization regarding the perception of internal and external threat, subsequent allocation of cognitive resources, and changes in effortful cognitive control. Due to the integration of diverse treatments and experimental tasks, these changes presumably reflect global effects of successful psychotherapy.
... Further, IU may interfere with treatment response (Frank & Mckay, 2019;Knowles & Olatunji, 2019;Wake et al., 2020) in a variety of ways. For example, IU may interfere with: (1) motivation to avoid or diminish psychotherapeutic experiences that focus on change (Katz et al., 2017;Leite & Kuiper, 2008), (2) inhibitory (or safety) learning (Blakey & Abramowitz, 2016;Craske, 2015;Tanovic et al., 2018;Wake et al., 2021), and (3) positive treatment expectations (Price & Anderson, 2012). Because IU is associated with social anxiety, interpretation bias of positive events, and SAD treatment response, examining its relation to changes in the tendency to interpret positive social events negatively may help optimize SAD treatment outcomes. ...
Background
Individuals with social anxiety disorder (SAD) report interpreting social events negatively regardless of valence. Fear of causing discomfort to others and intolerance of uncertainty (IU) are associated with negative interpretations of positive social situations. However, no studies have examined whether these negative interpretations change over CBT for SAD, nor predictors of such changes. This study examined if: negative interpretations of positive social events improve during CBT for SAD; these negative interpretations correlate with social anxiety symptom severity, fear of causing discomfort to others, and IU at the start of treatment; and fear of causing discomfort to others, IU and its subfactors at the start of treatment predict changes in these negative interpretations over treatment.
Methods
Eighty-five treatment-seeking DSM diagnosed individuals with primary SAD completed measures of the tendency to interpret positive events negatively pre-post CBT, and IU and fears of causing discomfort to others at pre-treatment.
Results
Results demonstrated significant pre-post decreases after CBT for SAD in negative interpretations of positive social events. All measures were significantly correlated with each other. None of the pre-treatment variables significantly predicted decreases in negative interpretations of positive social events over treatment.
Conclusions
CBT may be effective in reducing these negative interpretations.
... Moreover, VR exposure is highly limited in comparison to in vivo exposure because "contamination" by touching things is not possible in VR. Contrary to the assumption that the highest possible induction of distress and subsequent decline are necessary in exposure therapy, it has been argued that (besides expectancy violation) a sustained level of distress is a prominent predictor of long-term outcome [64,65] and thus needs to be induced in exposure treatment. In the present VERP, we achieved a sustained level of disgust over the course of the sessions, particularily in patients 6, 7, and 8 (Fig. 3), highlighting the feasibility of VERP in C-OCD. ...
Exposure therapy in virtual reality is successful in treating anxiety disorders. Studies on exposure and response prevention in virtual reality (VERP) in obsessive-compulsive disorder (OCD) are rare, and it is unclear whether distress associated with other emotions than anxiety (e.g., disgust) can be evoked. The present study aimed to investigate whether distress can be induced during VERP in patients with contamination-related OCD (C-OCD) and a primary feeling of disgust. We treated eight female patients with C-OCD with the primary emotion of disgust over six weeks with VERP and assessed their OC symptoms before and after the intervention period with the Y-BOCS. We measured subjective units of distress (SUD), heart rate and skin conductivity (arousal), sense of presence, and simulator sickness during four consecutive exposure sessions. VERP was able to induce distress and arousal. The qualitative feedback was heterogeneous and sense of presence moderate. Patients’ OC symptoms reduced over the treatment period with medium to large effect sizes, but only two patients were considered responders; two patients discontinued treatment due to lack of treatment success. Although VERP was able to induce distress and arousal associated with disgust and evoked a moderate sense of presence, the low rate of symptom reduction diminishes the positive results. Possible reasons for the heterogeneous results and implications are discussed. Trial registration: German Registry for Clinical Studies (DRKS00016929), 10.04.2019.
... The inhibitory dimension of intolerance of uncertainty has relatively greater similarity and association with constructs that inhibit or diminish curiosity, exploration, and self-regulation, such as maladaptive behavioral avoidance (e.g., being paralyzed by uncertainty; Birrell et al., 2011;Shapiro et al., 2020) and indecisiveness (Lauderdale et al., 2019). Being paralyzed by uncertainty may interfere with effective inhibitory (or safety) learning of nonthreatening associations (Craske, 2015). I-IU may be associated with these negative interpretation tendencies through avoidance (Shapiro et al., 2020), indecisiveness (Rassin & Muris, 2005), and inhibitory (or safety) learning mechanisms (Talkovsky & Norton, 2016). ...
Objective:
Although previous studies have demonstrated the association between social anxiety symptom severity and the tendency to appraise positive social events negatively among individuals with social anxiety disorder, no study has examined mediators of this relationship. The current study sought to examine whether intolerance of uncertainty and its subfactors mediate the relationship between social interaction anxiety and the tendency to interpret positive social events negatively.
Method:
One hundred and sixty-five individuals with social anxiety disorder completed measures of social interaction anxiety symptom severity, intolerance of uncertainty, and negative interpretations of positive social events.
Results:
Total intolerance of uncertainty and the inhibitory-intolerance of uncertainty subscale scores significantly mediated the relationship between social interaction anxiety and negative interpretations of positive events. Exploratory post-hoc analyses regarding the possible contributing role of depression demonstrated mixed results. The same mediation pattern was found in the full sample as well as those without a secondary comorbid mood disorder diagnosis. In contrast, serial mediation showed a mediating role of depressive symptom severity.
Conclusion:
Inhibitory-intolerance of uncertainty plays a role in the relationship between social interaction anxiety and negative interpretations of positive social events.
... This is not surprising as evolutionarily significant threats to survival would tend to be specific animals, situations or events that are novel and unexpected, prompting both aversive experiences of fear and protective behavioral action tendencies to promote survival and adaptation (e.g. Craske, 2015;Panayiotou et al., 2021). ...
The present study presents a standardized database of 348 affective in the Greek language, including pleasant and unpleasant nouns and adjectives, and neutral adjectives in Greek language. The norms are based on the ratings made by 229 native Greek speaking young adults on affective (emotionality, valence, arousal, dominance) and psycho-linguistic dimensions (ambiguity, abstraction, imageability, familiarity) of the words. The words were selected and translated from four different sources, including the Affective Norms for English words (Bradley, M. M., & Lang, P. J. (1999). Affective norms for English words (ANEW): Instruction manual and affective ratings. Technical report C-1, the center for research in psychophysiology), the Affective Norms for Polish words (Imbir, Behavior Research Methods 47:860–870, 2015), the Norms of valence and arousal for English words (Warriner et al., Behavior Research Methods 45:1191–1207, 2013) and from the Greek lexicon of New Greek Language (Mpampiniotis, Leksiko tis Neas Ellinikis Glossas (Dictionary of the Contemporary Greek Language), Kentro Leksikologias, Athens, 2002). The participants assessed an average of 70 words through an online survey procedure. Results present the affective and psycholinguistic features of the words. Also, results provide associations between affective and psycholinguistic aspects of the word stimuli. Hence, the study produces insights on the effects of psycho-linguistic parameters of word stimuli on the affective ones and their interactions, by combining evaluations of valence and arousal and/or including ratings for affective and psycholinguistic dimensions of the words. As such, the current study offers a valuable resource that enables researchers working with Greek speaking populations to control or manipulate the affective or psycho-linguistic dimensions of words in different experimental paradigms, adjust them to specific experimental questions or issues of interest, and extract more accurate findings and conclusions. The newly developed database is freely available for researchers and can be found here: http://dx.doi.org/10.23668/psycharchives.5079
... Another intriguing area for further research is to examine the treatment effect of delivering ERP treatment within the two mechanism-of-change frameworks elucidated in the introduction. The literature seems to support an inhibitory learning approach of fear tolerance and extinction; delivering ERP within this framework could increase its efficacy (Craske et al., 2008;Craske, 2015). Delivering ERP within an EPT framework which encourages fear habituation could also be of interest, although some have suggested this method could create more opportunities for relapse (Abramowitz and Arch, 2014;Jacoby and Abramowitz, 2016). ...
Exposure and Response Prevention (ERP) is considered the most effective psychotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). The literature supports its adoption yet results vary and vagueness regarding therapy protocol exists. We present an updated review and meta-analysis to provide clarity in the comparison of strict ERP protocol to control or active therapy groups. Moderator analyses were conducted to investigate treatment effect of cognitive elements, hours of therapy and duration of OCD.
A systematic literature search, concluded in January 2021, identified twenty-four studies, published between 1997 and 2018, including a total of 1134 patients. The main analysis assessed the difference between pre-treatment and post-treatment scores compared amongst ERP and the other groups.
We found a statistically significant different reduction in pre-treatment to post-treatment Yale-Brown Obsessive Compulsive Scale scores between ERP therapy versus other groups. We also found a statistically significant moderation effect of cognitive elements. The other two moderators, hours of therapy and OCD duration, were non-significant.
Our review suggests that ERP was superior to the other groups, including both neutral and active treatments, in reducing OCD symptomatology and should therefore be recommended as an optimal therapy. Future research should focus on tailoring ERP to the individual and investigating further refinements.
... Handelt es sich jedoch um ein sich wiederholendes Problem, um niedrige Resilienz oder hohe Vulnerabilität, so wird man stärker auf die prädisponierenden Faktoren eingehen und dem Aufbau transdiagnostischer Kompetenzen und Fertigkeiten mehr Gewicht geben, wie dies z. B. in den verschiedenen Fertigkeitstrainings oder den Ansätzen einer strukturorientierten psychodynamischen Therapie beschrieben wurde (Rudolf 2006 Auch die Exposition in der Verhaltenstherapie wird zwischenzeitlich sehr stark als Intervention verstanden, um Patientenerwartungen zu modifizieren (Craske 2015;Craske et al. 2014). Allerdings ist es etwas zu naiv gedacht, dass man Patienten nur erwartungskorrigierende Erfahrungen vermitteln muss und dies dann zu einer Korrektur der Erwartungen führen würde. ...
... When conducting future studies in a larger sample, we recommend to further explore the relationship between latent fear conditioning and treatment response. By gaining more insight in this topic, we might eventually be able to predict who will respond to CBT, and for whom we need to design innovative augmentation strategies that include cognitive, pharmacological or neuromodulative techniques (Craske, 2015;Heinig et al., 2017;Karpova et al., 2011;Kindt, Soeter, & Vervliet, 2009;Thase, Weiller, Zhang, Weiss, & McIntyre, 2018). ...
Recent meta-analyses indicated differences in fear acquisition and extinction between patients with anxiety-related disorders and comparison subjects. However, these effects are small and may hold for only a subsample of patients. To investigate individual trajectories in fear acquisition and extinction across patients with anxiety-related disorders (N = 104; before treatment) and comparison subjects (N = 93), data from a previous study (Duits et al., 2017) were re-analyzed using data-driven latent class growth analyses. In this explorative study, subjective fear ratings, shock expectancy ratings and startle responses were used as outcome measures. Fear and expectancy ratings, but not startle data, yielded distinct fear conditioning trajectories across participants. Patients were, compared to controls, overrepresented in two distinct dysfunctional fear conditioning trajectories: impaired safety learning and poor fear extinction to danger cues. The profiling of individual patterns allowed to determine that whereas a subset of patients showed trajectories of dysfunctional fear conditioning, a significant proportion of patients (≥50 %) did not. The strength of trajectory analyses as opposed to group analyses is that it allows the identification of individuals with dysfunctional fear conditioning. Results suggested that dysfunctional fear learning may also be associated with poor treatment outcome, but further research in larger samples is needed to address this question.
Muscle dysmorphia (MD) is a specifier of body dysmorphic disorder (BDD) characterized by intrusive thoughts surrounding muscularity and associated compulsive behaviors. Core features of MD include preoccupation with muscle size, compulsive weight training, avoidance of body exposure, and substantial psychiatric comorbidity. Regarding assessment for MD, multidimensional self-report MD measures should be prioritized since specific MD symptoms show significant relationships with associated comorbidity. Furthermore, when assessing for MD, clinicians should ensure that eating disorders are ruled out, given high symptom overlap between these conditions. Despite the severity of MD, treatment options are scarce. Cognitive behavioral therapy for BDD may be selected as an initial treatment approach, as this modality is efficacious in treating BDD, contains an MD module, and has been used in MD cases. However, the use of this modality to specifically improve MD symptoms requires empirical investigation. Additional therapeutic techniques that may be effective in reducing MD symptoms include techniques from empirically supported modalities for related disorders, such as enhanced cognitive behavioral therapy for eating disorders or dialectical behavior therapy. In conclusion, MD is a specifier of BDD that requires future research on treatment efficacy, assessment, and clinical course of symptoms.
Excessive avoidance and slow extinction of fear are hallmarks of anxiety disorders. We have previously found that overnight fasting diminishes excessive avoidance and speeds up fear extinction by decreasing subjective relief during threat omissions. Since relief tracks the reward prediction error signal that governs safety learning, we hypothesized that these effects of fasting might be linked to a decreased activation in brain regions related to reward prediction error processing. Hence, we replicated our previous study in a 3T-MRI scanner. Overnight fasting increased effective avoidance and sped up fear extinction learning. During extinction, the fasting group showed lower activations in the ventromedial prefrontal cortex and nucleus accumbens in response to threat omissions signaled by a safe cue. Nucleus accumbens activations were modulated by relief in the control group. This study provides support for overnight fasting as an adjunct to treatments for anxiety, but the effects should be investigated in anxious patients.
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.
Behavioural activation is a central component of cognitive-behavioural therapy for major depression. Findings from basic research on inhibitory learning and its clinical applications suggest that the effectiveness of behavioural activation could be further enhanced if a special focus is placed on the experience of expectation violations. Accordingly, this article presents a treatment approach that adds the aspect of expectation violation to behavioural activation in the treatment of depression. Central to this is the experience that depressed patients perceive the conduction of planned activities usually as less exhausting than expected and more enjoyable than expected. Furthermore, in the subsequent discussion of the meaning of such an expectation-violating experience, it is aimed to prevent patients from devaluing that experience, such that patients learn that they often expect activities to be disproportionately aversive, but that this expectation is usually not confirmed. As a result, they have more confidence in themselves and can approach future activities more optimistically. A small feasibility study with depressed patients (N = 7) treated in a day-care psychiatric hospital showed that the treatment approach presented here can be implemented well and is well accepted by the patients. This can be the basis for a larger clinical study to evaluate its effectiveness.
Background and objectives:
Negative expectations (NEs) are fundamental to various mental disorders. Finding ways to modulate NEs would help to improve clinical treatment. The present study investigated how previously formed expectations of social rejection are revised in the context of novel positive social experiences, and whether their revision can be modulated by differentially shifting participants' attentional focus.
Methods:
Our sample of 124 healthy participants was randomly assigned to four experimental conditions and received manipulated social feedback in multiple alleged webcam conferences. All groups went through three experimental phases that began with predominantly negative social feedback, then either transitioned to predominantly positive social feedback or continued to predominantly negative social feedback, and ultimately transitioning to a phase with no explicit social feedback. The experimental conditions differed in what they were instructed to focus on when receiving positive social feedback.
Results:
Receiving novel positive social feedback led to substantial changes in social expectations, but this effect was not modulated by the instructions the participants were given. Descriptive trends revealed that both instructions improved NE modification, although this effect was not robust to extinction in one condition.
Limitations:
To prevent our cover story from being compromised, we could not perform an immediate manipulation check of the instructions given. Nevertheless, some of the sample seemed suspicious about the cover story.
Conclusion:
Our results suggest that established expectations of social rejection can be revised when unexpectedly experiencing social acceptance. Nevertheless, more research is needed on potential instructions that could be used to optimize the modification of NEs.
Adolescent depression is a serious and debilitating disorder associated with lifelong negative outcomes, including heightened risk for recurrence into adulthood, psychiatric comorbidities, and suicide. Among evidence-based treatments for adolescents, psychotherapies for depression have the smallest effect sizes of all psychiatric conditions studied. Advancing care for depression in adolescents is complex due to the heterogeneity in etiology and co-occurring difficulties among youth presenting with depression symptoms. This and a companion paper (Lewandowski et al., 2022) draw on a recent multisite collaboration that focused on implementing depression treatment for adolescents within clinical and research contexts. Specifically, this paper will review our work adapting behavioral activation (BA) as a principle-based framework to improve effectiveness and efficiency of depression treatment used within clinical and research settings in academic medical centers. Piloted adaptations include the use of BA principles to address idiographic drivers of depression and in-session BA “exposures” to illustrate BA principles. Case vignettes illustrate these adaptations of BA to address adolescent depression in the context of co-occurring difficulties.
With a lack of experimental designs in psychotherapy/counselling process research, evidence is limited regarding which therapeutic style is helpful for which patient and the role of expectations. Therefore, the aim of this experimental study was to manipulate the therapeutic style and clients' expectations towards psychological counselling and investigate their effects on counselling outcome. Eighty healthy participants (74% female, Mage = 31.2 years, SDage = 12.21) received a single counselling session focussing on interpersonal conflicts. We defined two therapeutic styles (relationship‐focussed vs. problem‐focussed) based on the interpersonal circumplex, and participants were led to believe they would receive one of the two styles. In the actual counselling session, they received either the expected or the contrary, resulting in a 2 x 2 design. Primary outcome rated by participants was subjective impairment caused by the conflict 2 weeks after the session; secondary outcomes were satisfaction with the session and perceived working alliance. The successful implementation of the proposed therapeutic styles was confirmed by adherence ratings (U = 25.50, p < 0.001) and ratings of counsellors’ behaviour in the circumplex model (p < 0.001) for the friendly and hostile dimensions. Impairment was significantly reduced 2 weeks after the counselling session, but this effect was dependent on neither the therapeutic style, clients' expectations, nor their interaction. The study provides the first evidence that a single counselling session appears to be effective in alleviating impairment caused by an interpersonal conflict, independent of the counselling style and client expectations. The novel experimental design provides a basis for further process research in psychological counselling and psychotherapy.
Cognitive-behavioral therapy (CBT) with exposure is an effective treatment for childhood anxiety disorders; however, by nature it may involve much discomfort, often rendering engagement during exposure a challenge. An examination of factors related to engagement during exposure in CBT for anxiety is needed; yet, a search of the extant literature found few appropriate assessment tools. Thus, the current study focuses on developing and testing a measure of self-efficacy specific to exposure tasks, a construct likely to contribute to engagement during exposures. Twenty-four parent-child dyads were recruited, and parent, child, and clinician assessments were completed. Analyses revealed significant increases in self-efficacy in tandem with reductions in anxiety symptoms and increases in social and family functioning. Internal consistency was acceptable to excellent across time. Observed effect sizes were promising, warranting greater investigation of the self-efficacy measure. Further investigation into factors contributing to child engagement during exposure in CBT for anxiety is needed.
Patients with cardiovascular disease (CVD) routinely experience panic-like symptoms of shortness of breath, chest pain, and palpitations but also face high medical risk when ignoring chest pain symptoms and delaying seeking medical attention. When devising exposure therapy for anxiety in a patient with known heart disease, cognitive restructuring associated with exposure therapy requires adaption to incorporate this element of risk. Moreover, certain interoceptive symptom induction experiments may be harmful and lead to cardiopathogenesis. This chapter will therefore outline approaches to exposure therapy for anxiety when CVD is a known and medically verified comorbidity. Specifically, this chapter overviews literature pertinent to understanding common symptoms of CVDs and those overlapping with anxiety disorders. Different exposure-based therapy models are described along with required adaptions to safely and successfully undertake exposure therapy in patients with CVD.KeywordsAnxiety disorderPanic disorderCardiovascular diseaseCoronary heart diseaseSymptom induction
Fear extinction is easy to achieve but difficult to maintain, as evidenced by the relapse of fear after extinction. Counterconditioning and novelty-facilitated extinction have been shown to interfere with fear expression without erasing it. Because of the similarity between the two extinction paradigms, we extended the standard extinction, which merely omitted the expected threat outcomes after exposure to original threat cues. The modified paradigm provided a stimulus (neutral picture or positive picture) to replace the omitted threat outcomes during extinction. Sixty-four healthy volunteers were randomized into three groups for a three-day procedure: fear acquisition (day 1), fear extinction (day 2), and fear recall and generalization test (day 3). Our results showed the modified extinction paradigm failed to prevent fear expression in spontaneous recovery and reinstatement tests. However, novelty-facilitated extinction showed powerful effects in preventing fear generalization. Besides, there was a negative correlation between spontaneous recovery index and emotion regulation scores. We speculated that emotion and prediction error may be important factors influencing fear extinction and affect fear recall and generalization. Overall, this study suggests that novelty-facilitated extinction had a superior effect in preventing fear generalization, providing new perspectives for enhancing the effect of exposure therapy.
Cognitive Behavioural Therapy (CBT) is the first line treatment for anxiety disorders in youth however many adolescents do not benefit. Behavioural exposure is believed to be the critical ingredient of CBT and research with adults has shown that labelling affect, but not positive coping statements, enhances exposure outcomes. However, many CBT protocols for young people involve using positive coping statements alongside exposure. We compared the effects of exposure with positive coping statements, affect labelling, and neutral statements on fear responses in adolescents (age 13–14 years) with public speaking anxiety as they delivered a series of speeches in front of a pre-recorded classroom audience. Self-rated anxiety, heart rate, and observer ratings of expressed anxiety were assessed pre-test, immediate post-test and at 1-week follow-up. Neither affect labelling nor positive coping statements enhanced exposure on any measure from pre-test to 1-week follow-up. While there was an initial advantage of exposure with positive coping statements for post-speech self-reported anxiety, this effect was not maintained, and there was a significant increase in anxiety from immediate post-test to 1-week follow-up in this condition, compared to the other conditions. The short-term benefits from generating positive coping statements may explain why this is often employed in the treatment of anxiety problems in young people, but also indicate that it may not confer any advantage in the longer term. These intriguing findings highlight the urgent need for further attention to improve understanding of how to optimise exposure in young people and maximise treatment outcomes.
Background
A key clinical issue is how to maximise the belief change central to cognitive therapy. Physiological arousal is a key internal cue confirming threat beliefs in anxiety disorders. Deeper extinction of anxiety may occur if catastrophizing responses to physiological arousal are inhibited prior to joint exposure with external phobic stimuli. The aim of the study was to test whether increasing physiological arousal using exercise increases the benefits of behavioural tests.
Methods
Sixty individuals with a fear of heights had one session of VR cognitive treatment. They were randomised to have the treatment either with periods of intense physical exercise (cycling at 80% of maximum heart rate) prior to exposures or without. Linear mixed effects models were used to check the manipulation and test the primary hypothesis of a group difference in degree of conviction in the phobic threat belief.
Results
Heart rate was significantly higher in the exercise group throughout compared with the control group. Both groups showed significant reductions in threat beliefs after the VR treatment (d = 1.0, p < 0.001) but there was no significant group difference (d = 0.1, p = 0.56).
Discussion
An increase in physiological arousal achieved via exercise did not enhance cognitive change in beliefs about feared stimuli.
Bei der Panikstörung treten als charakteristisches Merkmal unerwartete Panikattacken auf. Typisch sind das plötzliche und z. T. als spontan erlebtes Einsetzen unangenehmer Symptome. Die häufigsten wahrgenommenen Symptome während eines Panikanfalls sind Herzrasen, Schwindel/Benommenheit und Atemnot. Im Laufe der Zeit wird immer mehr Angst vor den Attacken entwickelt, sodass es zu Vermeidungsverhalten kommen kann. Panikattacken können auch im Rahmen weiterer Störungen auftreten. Hauptmerkmal der Agoraphobie ist die Angst an Orten oder in Situationen zu sein, von denen eine Flucht schwierig oder peinlich sein könnte. Teilweise können damit Panikanfälle einhergehen. Die Panikstörung und die Agoraphobie gehören zu den häufigsten Angststörungen, zeigen eine hohe Komorbidität mit anderen Angststörungen, depressiven Störungen, somatoformen Störungen und Abhängigkeitsstörungen. Hauptbestandteile der Psychotherapie sind die Psychoedukation, kognitive Interventionen und Expositionen in vivo.
In diesem Kapitel wird beschrieben, welche Rolle grundlegende Lernformen bei der Entstehung, Aufrechterhaltung und Therapie von psychischen Störungen spielen. Die Grundprinzipien und wichtigsten Begriffe der klassischen Konditionierung, der operanten Konditionierung und des Modelllernens werden erläutert. Anhand zahlreicher Beispiele und Anwendungen wird gezeigt, dass funktionales ebenso wie dysfunktionales menschliches Verhalten durch bekannte und gut erforschte Lernmechanismen erklärt werden kann. Jede (angehende) Psychotherapeutin sollte diese Mechanismen kennen, um sie in der therapeutischen Praxis zum Vorteil der Patienten einsetzen zu können.
This study describes the development and pilot evaluation of a smartphone- delivered Ecological Momentary Intervention (EMI) for people with social anxiety symptoms. Using a software engineering framework (agile modeling, model-driven development, bottom-up development), mental health experts and software developers collaborated to develop a 4-module EMI app designed to reduce social anxiety in real-time. Fifty-five participants with social anxiety were randomly allocated to the EMI or a wait-list control arm. App downloads, usage and user satisfaction data were collected and mental health outcomes assessed at baseline and post-intervention. Software development practices allowed mental health experts to distil core elements of a psychological intervention into discrete software components but there were challenges in engaging mental health experts in the process. Relative to control there was no significant reduction in social anxiety among the EMI participants in the pilot trial. However, post-test data were available for only 4 intervention and 10 control participants and only 2 (4.0%) of the EMI participants downloaded the app. The two participants who both accessed the app and completed the post-test reported being satisfied with the intervention. Future research should address managing resources and providing additional training to support ongoing engagement with key stakeholders.
Current education and training in psychological interventions is mostly based on different ‘schools’ (traditions such as cognitive–behavioural or psychodynamic therapy), and strong identification with these specific traditions continuously hinders a scientifically based development of psychotherapy. This review is selective rather than systematic and comprehensive. In addition to the consideration of other influential publications, we relied on a literature search in Web of Science using the following terms (update: 24 December 2020): (psychotherapy AND meta-analy* AND competence*). After summarising current problems, a pathway for solving these problems is presented. First, we have to recategorise psychological interventions according to the mechanisms and subgoals that are addressed. The interventions can be classified according to the foci: (1) skills acquisition (eg, communication, emotion regulation, mentalisation); (2) working with relationship patterns and using the therapeutic relationship to modify them; and (3) clarification of motives and goals. Afterwards, the training of psychotherapists can switch from focusing on one theoretical framework to learning the different competences for modification according to these new categories. The selection of topics to be addressed should follow best evidence-based mechanisms and processes of mental disorders and interventions. Psychology offers knowledge about these mechanisms that can be understood as a basic science for psychological treatments in general. This requires better connection with basic science, new research efforts that focus on treatment subgoals, theory-overarching optimisation of the selection and personalisation of treatments, and new types of training for psychotherapists that are designed to optimise therapists’ competences accordingly, instead of limiting training programmes to one single theoretical framework.
The authors draw together and develop previous timing models for a broad range of conditioning phenomena to reveal their common conceptual foundations: First, conditioning depends on the learning of the temporal intervals between events and the reciprocals of these intervals, the rates of event occurrence. Second, remembered intervals and rates translate into observed behavior through decision processes whose structure is adapted to noise in the decision variables. The noise and the uncertainties consequent on it have both subjective and objective origins. A third feature of these models is their timescale invariance, which the authors argue is a very important property evident in the available experimental data. This conceptual framework is similar to the psychophysical conceptual framework in which contemporary models of sensory processing are rooted. The authors contrast it with the associative conceptual framework.
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)
Exposure therapy for anxiety disorders is translated from fear conditioning and extinction. While exposure therapy is effective in treating anxiety, fear sometimes returns after exposure. One pathway for return of fear is reinstatement: unsignaled unconditional stimuli following completion of extinction. The present study investigated the extent to which valence of the conditional stimulus (CS+) after extinction predicts return of CS+ fear after reinstatement. Participants (N = 84) engaged in a differential fear conditioning paradigm and were randomised to reinstatement or non-reinstatement. We hypothesised that more negative post-extinction CS+ valence would predict higher CS+ fear after reinstatement relative to non-reinstatement and relative to extinction retest. Results supported the hypotheses and suggest that strategies designed to decrease negative valence of the CS+ may reduce the return of fear via reinstatement following exposure therapy.
Social phobia (SP) has been associated with amygdala hyperreactivity to fear-relevant stimuli. However, little is known about the neural basis of SP individuals' capacity to down-regulate their responses to such stimuli and how such regulation varies as a function of comorbid depression and anxiety. We completed an fMRI study wherein SP participants without comorbidity (n=30), with comorbid depression (n=18), and with comorbid anxiety (n=19), and healthy controls (n=15) were scanned while completing an affect labeling emotion regulation task. Individuals with SP as a whole exhibited a reversal of the pattern observed in healthy controls in that they showed up-regulation of amygdala activity during affect labeling. However, subsequent analyses revealed a more complex picture based on comorbidity type. While none of the SP subgroups showed the normative pattern of amygdala down-regulation, it was those with comorbid depression specifically who showed significant up-regulation. Effects could not be attributed to differences in task performance, amygdala reactivity, or right ventral lateral prefrontal cortex (RVLPFC) engagement, but may stem from dysfunctional communication between amygdala and RVLPFC. Furthermore, the particularly altered emotion regulation seen in those with comorbid depression could not be fully explained by symptom severity or state anxiety. Results reveal altered emotion regulation in SP, especially when comorbid with depression.
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.
Significance
Research on Pavlovian fear conditioning has been very successful in revealing what has come to be called the brain’s fear system. The field has now matured to the point where a sharper conceptualization of what is being studied could be very useful as we go forward. Terms like “fear conditioning” and “fear system” blur the distinction between processes that give rise to conscious feelings of fear and nonconscious processes that control defense responses elicited by threats. These processes interact but are not the same. Using terms that respect the distinction will help focus future animal research on brain circuits that detect and respond to threats, and should also help clarify the implications of this work for understanding how normal and pathological feelings of fear come about in the human brain.
State anxiety was investigated as a moderator of learning to discriminate between safe and danger cues and transfer of fear inhibition within a conditioning paradigm. Participants were induced into a state of high anxiety (n = 21) or low anxiety (n = 24). Inhibitory learning was measured by the reduction in threat expectancy to the presentation of a safety cue (cue that predicts the absence of threat) concurrently with a danger cue (cue that predicts the presence of threat) compared to the presentation of the danger cue alone. As expected, state anxiety induction interfered with inhibitory learning. The current finding is the first to demonstrate that state anxiety has direct causal influence on fear inhibition.
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.
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.
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.
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)
Evaluative conditioning (EC) is one of the terms that is used to refer to associatively induced changes in liking. Many controversies have arisen in the literature on EC. Do associatively induced changes in liking actually exist? Does EC depend on awareness of the fact that stimuli are associated? Is EC resistant to extinction? Does attention help or hinder EC? As an introduction to this special issue, we will discuss the extent to which the papers that are published in this issue help to resolve some of the controversies that surround EC. We also speculate about possible boundary conditions of EC and attempt to reconcile conflicting results on the functional properties of EC.
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 current study evaluated the degree to which startle reflexes (SRs) in safe conditions versus danger conditions were predictive of the onset of anxiety disorders. Specificity of these effects to anxiety disorders was evaluated in comparison to unipolar depressive disorders and with consideration of level of neuroticism. A startle paradigm was administered at baseline to 132 nondisordered adolescents as part of a longitudinal study examining risk factors for emotional disorders. Participants underwent a repetition of eight safe-danger sequences and were told that delivery of an aversive stimulus leading to a muscle contraction of the arm would occur only in the late part of danger conditions. One aversive stimulus occurred midway in the safe-danger sequences. Participants were assessed for the onset of anxiety and unipolar depressive disorders annually over the next 3 to 4 years. Larger SR magnitude during safe conditions following delivery of the aversive stimulus predicted the subsequent first onset of anxiety disorders. Moreover, prediction of the onset of anxiety disorders remained significant above and beyond the effects of comorbid unipolar depression, neuroticism, and subjective ratings of intensity of the aversive stimulus. In sum, elevated responding to safe conditions following an aversive stimulus appears to be a specific, prospective risk factor for the first onset of anxiety disorders.
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.
Recent findings obtained in patients with phobias or trauma-related anxiety disorders raise doubts concerning the interrelation between acute fear relief during an exposure-based therapeutic session and beneficial treatment progress. In a mouse model explicit for exposure therapy, we challenge the view that within-session fear reduction is the turning point for relearning of a stimulus-threat association. Even though within-session extinction of auditory-cued fear memory was identical for prolonged and spaced tone presentations, only the latter caused between-session extinction. Furthermore, spaced tone presentations led to between-session extinction even in the complete absence of within-session extinction, as observed for remote fear memories and in case of abolished cannabinoid receptor type 1 signaling. Induction of between-session extinction was accompanied by an increase in the number of c-Fos-positive neurons within the basolateral amygdala, the cingulate cortex, and the dentate gyrus, independent of the level of within-session extinction. Together, our findings demonstrate that within-session extinction is neither sufficient nor essential for between-session extinction, thus calling for a reconsideration of current concepts underlying exposure-based therapies.
“I can’t get the memories out of my mind! The images come flooding back in vivid detail, triggered by the most inconsequential things, like a door slamming or the smell of stir-fried pork. Last night, I went to bed, was having a good sleep for a change. Then in the early morning a storm-front passed through and there was a bolt of crackling thunder. I awoke instantly, frozen in fear. I am right back in Viet Nam, in the middle of the monsoon season at my guard post. I am sure I’ll get hit in the next volley and convinced I will die. My hands are freezing, yet sweat pours from my entire body. I feel each hair on the back of my neck standing on end. I can’t catch my breath and my heart is pounding. I smell a damp sulfur smell. Suddenly I see what’s left of my buddy Troy, his head on a bamboo platter, sent back to our camp by the Viet Cong. Propaganda messages are stuffed between his clenched teeth. The next bolt of lightning and clap of thunder makes me jump so much that I fall to the floor..... ” (Paraphrased from a war veteran’s conversations with Dr. R. L. Gelman, Dept. of Psychiatry, Yale University School of Medicine).
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.
Although exposure therapy is an effective treatment for anxiety disorders, fear sometimes returns following successful therapy. The Rescorla-Wagner model predicts that presenting two fear-provoking stimuli simultaneously (compound extinction) will maximize learning during exposure and reduce the likelihood of relapse. Participants were presented with either single extinction trials only or single extinction trials followed by compound extinction trials. In addition, participants within each extinction group were randomized to caffeine or placebo ingestion prior to extinction to investigate the mechanism by which compound extinction may maximize learning (enhanced associative change or enhanced responding). Participants presented with compound trials demonstrated significantly less fear responding at spontaneous recovery compared with participants who received single extinction trials only. Ingestion of caffeine also provided some protection from spontaneous recovery (as measured by valence ratings). At the reinstatement test, only compound extinction trials predicted less fear responding; caffeine ingestion prior to extinction did not attenuate reinstatement effects.
The metabolic challenge of trauma disrupts hippocampal functioning, which is necessary for processing the complex co-occurring elements comprising the traumatic context. Poor contextual memory of trauma may subsequently contribute to intrusive memories and overgeneralization of fear. Glucose consumption following trauma may be a means to protect hippocampal functioning and contextual fear learning. This study experimentally examined the effect of glucose on hippocampal-dependent contextual learning versus cued fear learning in humans.
Forty-two male participants underwent cued conditioning with an unconditional stimulus (US) (shock) paired with a discrete conditional stimulus (geometric shape) and context conditioning (requiring hippocampal processing) with a US unpredictably paired with a background context (picture of room). Participants were then blindly randomized to consume either a 25 g glucose or sweet-tasting placebo drink and returned for a test phase 24 hours later. Measures included acoustic startle response, US expectancy, blood glucose levels, and arousal ratings.
The glucose group showed superior retention of hippocampal-dependent contextual learning at test relative to the placebo group, as demonstrated by acoustic startle response and US expectancy ratings. Glucose and placebo groups did not differ on any measure of cued fear learning at test.
This study provides experimental evidence that in mildly stressed humans postconditioning glucose consumption improves retention of hippocampal-dependent contextual learning but not cued learning. Ultimately, glucose consumption following trauma may be a means of improving learning about the traumatic context, thereby preventing subsequent development of symptoms of posttraumatic stress.
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)
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.
Re-exposure to the unconditioned stimulus (US) following fear extinction in the laboratory produces reinstatement of fear. Similarly in clinical situations, anxiety patients may experience adverse events that reinstate fear following successful exposure therapy. The current study employed two USs, shock and loud noise, to examine whether a US that is qualitatively different but of the same valence as the original acquisition US can produce reinstatement in human fear conditioning. Both standard and cross-US reinstatement manipulations led to elevated fear as indexed by skin conductance. However, cross-US reinstatement was accompanied by elevated expectancy of the US that had been presented during the reinstatement manipulation, not the US that had been used to establish fear in acquisition. This result implies that reinstatement may involve the development of new fears. Context conditioning and cognitive processes were implicated as possible mechanisms. The current findings suggest that clinical relapse attributed to reinstatement may not always reflect the reactivation of old fears but may instead represent new fears worthy of clinical examination.
Three indicators of emotional processing — peak response, habituation within sessions, and habituation across sessions — were examined in relation to therapy outcome with 14 obsessive-compulsives who were treated by 15 sessions of exposure in imagination and in vivo. Treatment outcome was evaluated by therapist, independent assessor, and self-ratings of target symptoms. Processes during therapy were assessed via self-report of anxiety as well as cardiac and electrodermal responses recorded during treatment sessions 6 and 14. Overall, the treatment was successful. As hypothesized, fear activation during exposure and habituation within sessions were evident in both self-report and physiological measures; habituation across sessions was observed in group means only for self-report. Also as hypothesized, both fear activation during exposure and greater habituation across sessions predicted better posttreatment ratings of obsessional fear. Habituation within sessions did not predict individual differences in outcome. These results support the theoretical formulation developed by Foa and Kozak (1986) to explain the effects of exposure therapy.
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.
A differential fear conditioning paradigm was used with 107 healthy