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Effects of internal and external distraction and focus during exposure to blood-injury-injection stimuli

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Abstract

The present study examined the effects of attentional focus on fear reduction during exposure. Participants were randomly assigned to experimental conditions: exposure plus internal focus, exposure plus external focus, exposure plus internal distraction, exposure plus external distraction or exposure alone. Fifty blood-injury-injection fearful participants received 3 weekly exposure sessions. Participants in the distraction group reported the greatest fear reduction, with most notable reductions occurring for the external distraction condition. The distraction group also achieved a greater number of steps on a behavioral avoidance task at post-treatment, with the external distraction condition displaying greater approach behavior at follow-up. At follow-up the distraction group also displayed a greater increase in perceived control than the focusing group. Thus, distraction reduces fear within and between sessions and increases approach behavior in the longer-term, with exposure plus external distraction further facilitating this effect.

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... Other researchers have suggested that distraction may enhance the effects of exposure (Johnstone & Page, 2004; Oliver & Page, 2003, 2008). On the basis of the self-efficacy model ...
... play a puzzle; Schmid-Leuz, Elsesser, Lohrmann, Jöhren, & Sartory, 2007). The results of these studies are inconsistent, some favouring partial distraction (Johnstone & Page, 2004; Oliver & Page, 2003, 2008; Penfold & Page, 1999) and others suggesting the opposite (Grayson, Foa, & Steketee, 1982; Haw & Dickerson, 1998; Kamphuis & Telch, 2000; Mohlman & Zinbarg, 2000; Raes et al., 2009) or not showing significant differences between conditions (Antony, McCabe, Leeuw, Sano, & Swinson, 2001; Rose & Dudley McGlynn, 1997; Telch et al., 2004). ...
Article
Research has provided controversial results regarding the role of distraction (vs. attentional focus) during exposure therapy. In the present study, we manipulated the nature of the concepts activated during exposure. Sixty-six spider phobics were exposed to pictures of spiders and asked, or not, to form mental images of concepts that were either related or unrelated to spiders. At pre-exposure, mid-exposure, post-exposure, and follow-up, subjective distress, heart rate variability, and skin conductance responses were measured and the Fear of Spiders Questionnaire and a Behavioural Avoidance Test were performed. Results showed that the activation of concepts unrelated to spiders led to return of distress at follow-up. Moreover, the activation of concepts related to spiders decreased emotional and avoidance responses between sessions. This pattern of results suggests that the nature of the activated concepts does not influence subjective distress during exposure, but plays an important role in the maintenance of distress reduction between sessions.
... Working memory load can be thought of as a form of distraction, which may interfere with extinction by detracting attention from the conditioned stimulus, and by impeding new learning regarding the absence of the US (Weisman & Rodebaugh, 2018). While it is often assumed that distraction impedes exposure therapy, research has been less conclusive, with distraction found to be beneficial (Johnstone & Page, 2004;Oliver & Page, 2008;Penfold & Page, 1999), harmful (Dethier, Bruneau, & Philippot, 2015;Kamphuis & Telch, 2000;Mohlman & Zinbarg, 2000), and inconsequential (Antony,McCabe,Leeuw,Fig. 3. Working memory and extinction: Grand-averaged waveforms at the centro-parietal pooling where the LPP was scored (left) and headmaps depicting the spatial distribution of voltage for each condition, level of working memory load and LPP time window, shown separately for A) Block 1, B) Block 2 and C) Block 3. Waveforms were filtered with a high-pass filter of 12 Hz for illustrative purposes only (not analyses). Sano, & Swinson, 2001;Telch et al., 2004) to exposure therapy success. ...
Article
Distraction is typically discouraged during exposure therapy for anxiety, because it is thought to interfere with extinction learning by diverting attention away from anxiety-provoking stimuli. Working memory load is one form of distraction that might interfere with extinction learning. Alternatively, working memory load might reduce threat responding and benefit extinction learning by engaging prefrontal brain regions that have a reciprocal relationship with brain circuits involved in threat detection and processing. Prior work examining the effect of working memory load on threat extinction has been limited and has found mixed results. Here, we used the late positive potential (LPP), an event-related potential that is larger for threatening compared to non-threatening stimuli to assess the effect of working memory load on threat extinction. After acquisition, 38 participants performed three blocks of an extinction task interspersed with low and high working memory load trials. Results showed that overall, the LPP was reduced under high compared to low working memory load, and that working memory load slowed extinction learning. Results provide empirical evidence in support of limiting distraction during exposure therapy in order to optimize extinction learning efficiency.
... Thereby, it seems to be of no importance whether the dual-attention tasks are visually presented in a moving or nonmoving fashion. In this vein, the results of our study add evidence to previously reported research indicating the benefits of dual attention in processing traumatic memories [14,36] and reducing flashbacks [15] . ...
Article
Background: Currently, there is controversy on the possible benefits of dual-attention tasks during eye movement desensitization and reprocessing (EMDR) for patients with posttraumatic stress disorder (PTSD). Methods: A total of 139 consecutive patients (including 85 females) suffering from PTSD were allocated randomly among 3 different treatment conditions: exposure with eyes moving while fixating on the therapist's moving hand (EM), exposure with eyes fixating on the therapist's nonmoving hand (EF), and exposure without explicit visual focus of attention as control condition (EC). Except for the variation in stimulation, treatment strictly followed the standard EMDR manual. Symptom changes from pre- to posttreatment were measured with the Clinician-Administered PTSD Scale (CAPS) by an investigator blinded to treatment allocation. Results: In total, 116 patients completed the treatment, with an average of 4.6 sessions applied. Intention-to-treat analysis revealed a significant improvement in PTSD symptoms with a high overall effect size (Cohen's d = 1.96, 95% CI: 1.67-2.24) and a high remission rate of PTSD diagnosis (79.8%). In comparison to the control condition, EM and EF were associated with significantly larger pre-post symptom decrease (ΔCAPS: EM = 35.8, EF = 40.5, EC = 31.0) and significantly larger effect sizes (EM: d = 2.06, 95% CI: 1.55-2.57, EF: d = 2.58, 95% CI: 2.01-3.11, EC: d = 1.44, 95% CI: 0.97-1.91). No significant differences in symptom decrease and effect size were found between EM and EF. Conclusions: Exposure in combination with an explicit external focus of attention leads to larger PTSD symptom reduction than exposure alone. Eye movements have no advantage compared to visually fixating on a nonmoving hand.
... In this case, such control strategies would allow the individual to master facing arousal-related sensations with less anxiety than would otherwise have been the case. The experience of being relatively free from anxiety in the presence of the phobic stimulus (in this case, the feared arousal-related sensations) has been shown to improve perceived selfefficacy , thereby contributing to fear reduction (Oliver & Page, 2008). The self-efficacy perspective points to another crucial target of anxiety treatment, according to experts such as Barlow (1988)—namely, a sense of control. ...
Article
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Interoceptive exposure (IE) involves having an individual repeatedly induce and experience feared arousal-related sensations (e.g., shortness or breath, heart palpitations, dizziness) as a means of reducing the fear of those sensations. IE exercises such as hyperventilation, chair spinning, and breathing through a straw have been demonstrated effective in the treatment of panic attacks and panic disorder, both as part of a broader cognitive-behavioral program and as a stand-alone intervention. This article introduces a special issue of the Journal of Cognitive Psychotherapy focusing on cutting-edge findings on novel applications of IE in the treatment of anxiety and related disorders and research that begins to investigate IE's mechanisms of action. We set the stage for the following series of six original articles by first providing a historical review of the use of IE in cognitive-behavioral treatments of panic. We then provide a brief overview of the various theoretical perspectives that can be applied to understanding the mechanisms of action of IE in reducing fear of fear: conditioning, cognitive restructuring, emotional processing, self-efficacy, and emotional acceptance. Finally, we provide a brief overview of the articles included in the special issue. This special issue should prove helpful to cognitive-behavioral therapists in improving and expanding their use of IE in clinical practice. The issue also should stimulate additional research on the mechanisms of action of IE to ultimately permit refinement of treatments for anxiety and related disorders and, it is hoped, enhance the efficacy of cognitive-behavioral psychotherapy.
... A recent meta-analysis found that overall there was no difference between distracted versus focused exposure in terms of treatment outcome (Podinã et al., 2013). However, the results were in favor of distracted exposure -greater approach of and reduced distress concerning previously feared stimuli following treatmentrelative to focused exposure when there were multiple exposure sessions (Oliver and Page, 2008) and when distraction involved client-therapist interaction concerning something irrelevant to the exposure (e.g., Johnstone and Page, 2004). Parrish et al. (2008) suggested that the beneficial effects of distraction may be due to increases in self-efficacy and the belief that threat and the accompanying anxiety could be controlled, however, multiple sessions may be required in order to see this benefit. ...
Article
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Models of exposure therapy, one of the key components of cognitive behavioral therapy for anxiety disorders, suggest that attention may play an important role in the extinction of fear and anxiety. Evidence from cognitive research suggests that individual differences may play a causal role in the onset and maintenance of anxiety disorders and so it is also likely to influence treatment. We review the evidence concerning attention and treatment outcomes in anxiety disorders. The evidence reviewed here suggests that that attention biases assessed at pre-treatment might actually predict improved response to treatment, and in particular that prolonged engagement with threat as measured in tasks such as the dot probe is associated with greater reductions in anxious symptoms following treatment. We examine this research within a fear learning framework, considering the possible role of individual differences in attention in the extinction of fear during exposure. Theoretical, experimental and clinical implications are discussed, particularly with reference to the potential for attention bias modification programs in augmenting treatment, and also with reference to how existing research in this area might inform best practice for clinicians.
... There is evidence, though, that the use of attentional deployment ER strategies does not necessarily promote avoidance but may actually promote approach behavior. This idea is supported by results showing that the use of such strategies in exposure therapy sessions promotes perceived control and self-efficacy (Johnstone & Page, 2004;Oliver & Page, 2003) and increases the rate of approach behavior in follow-up sessions (Oliver & Page, 2008). One possibility is that attentional retraining does not actually promote systematic attentional avoidance but rather allows subjects to disengage from negative stimuli in a healthy manner (Amir et al., 2009), a skill impaired in high-anxiety clinical populations (Amir, Elias, Klumpp, & Przeworski, 2003). ...
Article
Emotional well-being depends on the ability to successfully engage a variety of coping strategies to regulate affective responses. Most studies have investigated the effectiveness of emotion regulation (ER) strategies that are deployed relatively later in the timing of processing that leads to full emotional experiences (i.e. reappraisal and suppression). Strategies engaged in earlier stages of emotion processing, such as those involved in attentional deployment, have also been investigated, but relatively less is known about their mechanisms. Here, we investigate the effectiveness of self-guided focused attention (FA) in reducing the impact of unpleasant pictures on the experienced negative affect. Participants viewed a series of composite images with distinguishable foreground (FG, either negative or neutral) and background (BG, always neutral) areas and were asked to focus on the FG or BG content. Eye-tracking data were recorded while performing the FA task, along with participants’ ratings of their experienced emotional response following the presentation of each image. First, proving the effectiveness of self-guided FA in down-regulating negative affect, focusing away from the emotional content of pictures (BG focus) was associated with lower emotional ratings. Second, trial-based eye-tracking data corroborated these results, showing that spending less time gazing within the negative FG predicted reductions in emotional ratings. Third, this reduction was largest among subjects who habitually use suppression to regulate their emotions. Overall, the present findings expand the evidence regarding the FA’s effectiveness in controlling the impact of emotional stimuli and inform the development of training interventions emphasizing attentional control to improve emotional well-being.
... Since 1993, numerous additional studies have been conducted with (continued) mixed findings. Many studies have shown that distraction is helpful during exposure (e.g., Johnstone & Page, 2004;Oliver & Page, 2008), that distraction is harmful to the exposure process (e.g., Schmid-Leuz, Elsesser, Lohrmann, Jöhren, & Sartory, 2007;Kamphuis & Telch, 2000;Telch et al., 2004), and that there are no differences between using and not using distraction (e.g., Antony et al., 2001;Rose & McGlynn, 1997). Given these mixed findings, it is important to consider what other factors may be involved, potentially leading to discrepant findings. ...
Article
Full-text available
Distraction is often discouraged in exposure therapy for anxiety disorders, but little is known about how beliefs about distraction may impact treatment outcome (with or without distraction). One barrier to understanding the impact of these beliefs is the lack of an available measure to assess this construct. In addition to proposing a theoretical basis for beliefs about distraction, we created and validated a questionnaire assessing maladaptive beliefs about distraction, the Beliefs about Distraction Inventory. An exploratory factor analysis with an unselected student sample (N = 506, 86 % female) suggested a two-factor solution, conceptualized as “distraction is necessary”, and “distraction is effective”. A confirmatory factor analysis using a contamination-fearful sample (N = 132, 87 % female) demonstrated adequate model fit. In both samples, the measure exhibited strong reliability and validity. Preliminary findings revealed that beliefs that “distraction is necessary” were more strongly associated with anxious psychopathology than beliefs that “distraction is effective”. Results are discussed in terms of cognitive-behavioural theories and therapies for anxiety and related disorders.
... It is well established that attention cannot be divided among several perceptual objects without any cost in performance (Duncan, 1984), in the same vein, paying attention to a distracting task would convey a cost in the performance of worrying and rumination (Oliver & Page, 2008). Just as magicians and illusionists employ different techniques for making their effects follow the rules for the management of attention, new treatments are trying to restore patient homeostasis by correcting the allocation of attentional resources (Hakamata et al., 2010), and fascinating new perspectives are just beginning to unfold with research on memory reconsolidation (Nader & Hardt, 2009). ...
... For blood-injection and dental phobia, available evidence consistently points out positive effects of distraction (Oliver & Page, 2008;Schmidt-Leuz, Elsesser, Lohrmann, Johren, & Sartory, 2007). Distraction during exposure exercises was associated with higher decreases in anxiety and, in one study, with less behavioral avoidance after exposure. ...
... Similarly, Oliver and Page (2003) found that the addition of distracting conversation to exposure therapy for bloodinjection-injury fear resulted in greater fear reduction as well as increased levels of perceived control when compared to exposure alone. In a subsequent investigation, Oliver and Page (2008) replicated the beneficial effects of distracting conversation during exposure therapy with the additional finding that distracting conversation about stimulus-irrelevant features of the environment more effectively enhanced exposure therapy than distracting conversation about the participant's non-anxiety related internal sensations. Although these findings appear to directly contradict that of Kamphuis and Telch (2000) and the distraction hypothesis in general, a potentially important distinction between the two sets of findings is the nature of the distraction. ...
... An extensive body of work examining distraction during exposure has been inconsistent. The range of conclusions regarding the effects of distraction ranges from malignant (e.g., Dethier, Bruneau, & Philippot., 2015;Kamphuis & Telch, 2000;Mohlman & Zinbarg, 2000), to benign (e.g., Antony, McCabe, Leeuw, Sano, & Swinson, 2001;Telch et al., 2004), and even to facilitative (e.g., Johnstone & Page, 2004;Oliver & Page, 2008;Penfold & Page, 1999). However, the studies finding enhancement via distraction are characterized by substantial limitations, including a lack of manipulation checks or exposureonly group (e.g., Johnstone & Page, 2004), the use of nonclinical samples coupled with a failure to replicate the effects in diagnosed samples, and an inability to maintain effects when the distractor is no longer present (Penfold & Page, 1999). ...
Article
Although exposure therapy is often considered a gold standard behavioral intervention for pathological anxiety, questions remain surrounding the mechanisms underlying exposure interventions, and some individuals are characterized by suboptimal treatment outcomes. Recently, a formulation known as the inhibitory learning theory, which is grounded in basic science principles of extinction learning and memory, has been proposed to provide a more parsimonious mechanistic explanation for the effects of exposure than previous, habituation-based models [Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. 2008. Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5-27; Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T., & Vervliet, B. 2014. Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23]. Strategies informed by this theory are proposed to maximize extinction learning by fostering the development of new, non-threat associations between stimuli in memory and enhancing the accessibility and retrieval of these safety-based associations. This comprehensive review serves as a critical examination of the empirical literature regarding major tenets of inhibitory learning theory and the potential for such techniques to augment exposure therapy for anxiety disorders. Limitations of the extant research, as well as potential future directions, are explored.
... Self-efficacy also increased significantly for both groups, reflecting increased confidence to perform spider-related tasks regardless of the extent of safety behavior use. This is inconsistent with previous findings that people who use safety behaviors report greater increases in self-efficacy and, as a result, improved performance on behavioral tasks, relative to those who are not permitted such coping strategies (Johnstone & Page, 2004, Oliver & Page, 2008. This discrepancy may be explained by the nature of the experimental manipulation across studies. ...
Article
The use of safety behaviors has been considered one of the primary maintaining mechanisms of anxiety disorders; however, evidence suggests that they are not always detrimental to treatment success (Milosevic & Radomsky, 2008). This study examined the effects of safety behaviors on behavioral, cognitive, and subjective indicators of fear during exposure for fear of spiders. A two-stage design was used to examine fear reduction and approach distance during an in vivo exposure task for participants (N=43) assigned to either a safety behavior use (SBU) or no safety behavior use (NSB) condition. Overall, both groups reported significant and comparable reductions in self-reported anxiety and negative beliefs about spiders at posttest and 1-week follow-up. Participants in the SBU group approached the spider more quickly than did participants in the NSB condition; however, participants in the SBU condition showed a small but significant decrease in approach distance at follow-up. These results call for a reconceptualization of the impact of safety behaviors on in vivo exposure.
... Relatedly, inhibitory learning theory suggests that patients should limit the use of distraction as a coping technique during exposure therapy. Research suggests that distraction is less effective during exposure than is focusing on the exercise, including the feared stimulus and the feeling of fear (Grayson, Foa, & Steketee, 1982;Kamphuis & Telch, 2000;Telch et al., 2004), though results have been mixed (e.g., Oliver & Page, 2008). From an inhibitory learning perspective, distraction has several adverse effects. ...
Article
This article reviews the articles in this issue that describe the strategies derived from the inhibitory learning model as applied to exposure therapy for anxiety disorders. The major principles of inhibitory learning are to create and strengthen nonthreat associations in memory (largely by engaging prefrontal cortical regions), and to effectively retrieve those nonthreat associations in the long term. Several case vignettes are provided that demonstrate how the principles of inhibitory learning (which include maximizing expectancy violations, limiting distraction, fear antagonistic actions, deepened extinction, elimination of safety behaviors, occasional reinforced extinction, increasing variability of exposures and offsetting reinstatement and context renewal effects) can be applied in clinical practice.
... Por otro lado, en tres estudios con muestras análogas (estudiantes con miedo a la sangre/inyecciones, universitarios fóbicos a las arañas) se ha visto que en comparación con la exposición focalizada, el empleo de la distracción parcial (conversar sobre temas no relacionados con el estímulo temido mientras se mantiene la atención visual en este) dio lugar a una mayor reducción del miedo subjetivo intra y entre sesiones, una mayor autoeficacia y control percibido y una ejecución de un mayor número de pasos en un test conductual; los resultados se mantuvieron en general en el seguimiento al mes (Johnstone y Page, 2004; Oliver y Page, , 2008. Con universitarios con miedo a la SIH, Oliver y Page (2008) compararon a lo largo de tres sesiones de 10 minutos tres condiciones de EV (sin conversación o con conversación centrada en las reacciones somáticas o en los aspectos externos de los estímulos temidos) y dos condiciones de distracción parcial (conversación sobre sensaciones internas neutrales o sobre temas externos). ...
Article
Podeu consultar la versió posterior a: http://hdl.handle.net/2445/6282 Several aspects of specific phobias are treated: nature, age at onset and course, prevalence, associated problems, etiology and maintenance, assessment methods and instruments, and efficacy and clinical utility of psychological and pharmacological treatments. Moreover, suggestions to apply the more efficacious psychological treatments are offered. S'aborden diversos aspectes de les fòbies específiques: naturalesa, edat de començament i curs, freqüència, problemes associats, gènesis i manteniment, mètodes i instruments d'avaluació, i eficàcia i utilitat clínica del tractament psicològic i farmacològic. A més, es proporcionen guies per a aplicar els tractaments psicològics més eficaços. Se abordan diversos aspectos de las fobias específicas: naturaleza, edad de comienzo y curso, frecuencia, problemas asociados, génesis y mantenimiento, métodos e instrumentos de evaluación, y eficacia y utilidad clínica del tratamiento psicológico y farmacológico. Además, se ofrecen guías para aplicar los tratamientos psicológicos más eficaces.
... A review of the extant empirical literature, however, paints a more complex picture. Although some studies have found that attentional focus during exposure facilitated fear reduction (e.g., Grayson, Foa, & Steketee, 1982), others have found that distraction produced greater fear reduction (e.g., Oliver & Page, 2008). These results suggest that not all forms of attentional avoidance are anti-therapeutic, and suggest that a more precise understanding of the distinct mechanisms involved in attentional avoidance is needed (see Craske et al., 2008;Rachman, Radomsky, & Shafran, 2008 for reviews). ...
Article
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The authors conducted a randomized, double-blind placebo-controlled trial to examine the efficacy of an attention training procedure in reducing symptoms of social anxiety in 44 individuals diagnosed with generalized social phobia (GSP). Attention training comprised a probe detection task in which pictures of faces with either a threatening or neutral emotional expression cued different locations on the computer screen. In the attention modification program (AMP), participants responded to a probe that always followed neutral faces when paired with a threatening face, thereby directing attention away from threat. In the attention control condition (ACC), the probe appeared with equal frequency in the position of the threatening and neutral faces. Results revealed that the AMP facilitated attention disengagement from threat from pre- to postassessment and reduced clinician- and self-reported symptoms of social anxiety relative to the ACC. The percentage of participants no longer meeting Diagnostic and Statistical Manual (4th ed.) criteria for GSP at postassessment was 50% in the AMP and 14% in the ACC. Symptom reduction in the AMP group was maintained during 4-month follow-up assessment. These results suggest that computerized attention training procedures may be beneficial for treating social phobia.
... Concerning attentional focus guiding: while one study finds that distraction is beneficial (Oliver and Page, 2008), three others find that distraction hinders extinction and lowers the success of ET (Dethier et al., 2015;Kamphuis and Telch, 2000;Telch et al., 2004). A third pair of studies find no effect of attentional focus guiding on treatment success (Antony et al., 2001;Waters et al., 2014). ...
Article
Although Exposure Therapy (ET) is the first-line treatment of Specific Phobia (SP), there is no clear consensus on which factors influence its success, and thus on how to conduct it most efficiently. This review summarizes the current state of research regarding this topic. N = 111 studies were in accordance with our eligibility criteria: participants had at least symptoms of SP, the intervention was ET and the study investigated a factor influencing its success. Best evidence for positive effects was found for low trait anxiety, high motivation and high self-efficacy before the ET, high cortisol levels and heart rate variation, evoking disgust additionally to anxiety, avoiding relaxation, focusing on cognitive changes, context variation, sleep, and memory-enhancing drugs. These factors may be conceptualized as modulating different aspects of learning as suggested in current models of ET that focus on inhibitory learning mechanisms. Limitations lie in the great heterogeneity concerning operationalization of factors and success. Based on these findings, we make suggestions for improvements in ET conduction and which factors should be researched in the future.
... Habituation -the reduction of a responsiveness after repeated stimulus presentation (McSweeney and Swindell, 2002) -has perennially been proposed to be the key mechanism of therapeutic change in exposure therapy. However, this assumption has been challenged by some findings (Barlow, 2004;Blakey and Abramowitz, 2016;Craske et al., 2008;Deacon et al., 2010;Hood et al., 2010;Meulders et al., 2016;Milosevic and Radomsky, 2008;Oliver and Page, 2008;Parrish et al., 2008;Rentz et al., 2003;Sy et al., 2011). As an alternative model that may explain the evidence in rodent models better, the inhibitory learning model of extinction proposes that the learned association of conditioned stimulus and unconditioned stimulus stays intact and that instead, the subject learns to inhibit the association (Craske, 2015;Craske et al., 2014). ...
Article
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Exposure therapy is a well-studied and highly efficacious treatment for phobic disorders. Although the neurobiological model of fear is well underpinned by various studies, the mechanisms of exposure therapy are still under discussion. Partly, this is due to the fact that most neurophysiological methods like fMRI are not able to be used in the natural therapeutic settings. The current study used in situ measurements of cortical blood oxygenation (O2Hb) during exposure therapy by means of functional near-infrared spectroscopy. 37 subjects (N = 30 completers) underwent exposure therapy during 5 adapted sessions in which subjects were exposed to Tegenaria Domestica (domestic house spider – experimental condition) and Dendrobaena Veneta/ Eisenaia hortensis (red earthworm – control condition). Compared to the control condition, patients showed higher O2Hb levels in the anticipation and exposure phase of spider exposure in areas of the cognitive control network (CCN). Further, significant decreases in O2Hb were observed during the session accompanied by reductions in fear related symptoms. However, while symptoms decreased in a linear quadratic manner, with higher reductions in the beginning of the session, CCN activity decreased linearly. Further, higher anxiety at the beginning of session one was associated with increased O2Hb in the CCN. This association decreased within the following sessions. The current study sheds light on the neuronal mechanisms of exposure therapy. The results are discussed in light of a phase model of exposure therapy that posits a role of cognitive control in the beginning and routine learning at the end of the therapy session.
... These results complement evidence identified by our recent investigations (Denkova et al., 2015;Iordan et al., 2019) by showing that self-guided FA is effective not only in reducing negative emotional experiences associated with the recollection of unpleasant autobiographical memories, but also when employed while viewing unpleasant pictorial stimuli. The effectiveness of attentional deployment strategies in regulating emotions has been demonstrated previously (Wadlinger & Isaacowitz, 2011;Webb et al., 2012), most commonly in the form of cognitive distraction (e.g., diverting attention to something task-irrelevant; Oliver & Page, 2008). However, some studies also identified the efficacy of externally guided FA in modulating emotional responses to pictorial stimuli (Ferri et al., 2013;Urry, 2010), but these latter studies employed experimental manipulations that involved the addition of guiding visual cues that do not exist in real life, thus reducing the ecological validity of the findings. ...
Article
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Emotional well-being depends on the ability to adaptively cope with various emotional challenges. Most studies have investigated the neural mechanisms of emotion regulation strategies deployed relatively later in the timing of processing that leads to full emotional experiences. However, less is known about strategies that are engaged in earlier stages of emotion processing, such as those involving attentional deployment. We investigated the neural mechanisms associated with self-guided Focused Attention (FA) in mitigating subjective negative emotional experiences. Functional magnetic resonance imaging (fMRI) data were recorded while participants viewed a series of composite negative and neutral images with distinguishable foreground (FG) and background (BG) areas. Participants were instructed to focus either on the FG or BG components of the images, and then rated their emotional experiences. Behavioral results showed that FA was successful in decreasing emotional ratings for negative images viewed in BG Focus condition. At the neural level, the BG Focus was associated with increased activity in regions typically implicated in top-down executive control (dorsolateral prefrontal cortex and lateral parietal cortex) and decreased activity in regions linked to affective processing (amygdala and ventrolateral prefrontal cortex). Dissociable brain activity linked to FA also was identified in visual cortices, including between the parahippocampal and fusiform gyri, showing increased versus decreased activity, respectively, during the BG Focus. These findings complement the evidence from prior FA studies with recollected emotional memories as internal stimuli and further demonstrate the effectiveness of self-guided FA in mitigating negative emotional experiences associated with processing of external unpleasant stimuli.
Article
Blood-injection-injury (BII) phobia is an anxiety disorder that can cause serious health consequences by interfering with medical treatment. Although attentional bias for threat appears to be a core feature of many anxiety disorders and a potential target of treatment, very little is known about attentional bias in BII phobia. In the present study, eye movements were recorded in individuals high and low in injection fear (HIF, LIF) during 18-s exposures to stimulus arrays containing injection, attack, appetitive, and neutral images. Evidence for attentional vigilance was mixed, as HIF individuals oriented to injection images more often than LIF individuals, but did not orient to injection images more often than other emotional images. In contrast, evidence of attentional avoidance was highly robust. HIF individuals rapidly disengaged from injection images on initial viewing and viewed these images less overall compared to other image types, a pattern not observed in the LIF group. Furthermore, attentional avoidance of injection threat was found to uniquely predict behavioral avoidance on an injection behavioral avoidance task (BAT), and group differences on the BAT were mediated by group differences in attentional avoidance. The implications of these findings for further delineating the nature and function of attentional biases in BII phobia are discussed.
Article
Blood-Injection-Injury (BII) phobia is associated with distress and avoidance in response to blood, injury, or receiving injections. BII phobia can therefore create problems for those receiving medical procedures such as chemotherapy. The prevalence rate of BII in the general population has been estimated to be less than 5% but as many as 19% of outpatients receiving chemotherapy surveyed by Carey and Harris (Behaviour Change 22:5–90, 2005) reported BII concerns. This study examined the extent and characteristics of BII concerns among outpatients receiving chemotherapy for the first time (n = 124). Almost 17% of the sample had scores on the Mutilation Questionnaire comparable to samples with clinical BII phobia. Those assigned to a high BII concern group based on Mutilation Questionnaire scores reported higher somatic and fainting responses to BII stimuli and elevated disgust sensitivity, compared to groups selected for low BII concerns. Females had significantly higher Mutilation Questionnaire scores than males. Thus, the BII concerns of outpatients receiving chemotherapy appear qualitatively similar to the concerns reported by clinical BII phobia samples and analogue student samples. We suggest that the standard inclusion of a brief, reliable screening measure of BII concerns for outpatients scheduled for chemotherapy, coupled with brief, effective interventions to reduce BII-related distress, may be warranted.
Article
Two experiments tested the effect of exposure to masked phobic stimuli at a very brief stimulus onset asynchrony on reducing the subjective experience of fear caused by in vivo exposure to a feared object. In the main experiment, 35 spider-fearful and 35 non-fearful participants were identified with a questionnaire and a Behavioural Avoidance Test (BAT) with a live tarantula. One week later, they were individually administered one of two continuous series of masked images: spiders or flowers. They engaged in the BAT again immediately thereafter. They provided ratings of subjective fear at the end of each BAT (pre- and post-manipulation). Very brief exposure to images of spiders reduced the fearful group's and not the non-fearful group's experience of fear at the end of the BAT. This effect was replicated with another sample of 26 spider-fearful participants from the same population. Theoretical implications are discussed.
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Background: This systematic review evaluated the effectiveness of exposure-based psychological and physical interventions for the management of high levels of needle fear and/or phobia and fainting in children and adults. Design/methods: A systematic review identified relevant randomized and quasi-randomized controlled trials of children, adults, or both with high levels of needle fear, including phobia (if not available, then populations with other specific phobias were included). Critically important outcomes were self-reported fear specific to the feared situation and stimulus (psychological interventions) or fainting (applied muscle tension). Data were pooled using standardized mean difference (SMD) or relative risk with 95% confidence intervals. Results: The systematic review included 11 trials. In vivo exposure-based therapy for children 7 years and above showed benefit on specific fear (n=234; SMD: -1.71 [95% CI: -2.72, -0.7]). In vivo exposure-based therapy with adults reduced fear of needles posttreatment (n=20; SMD: -1.09 [-2.04, -0.14]) but not at 1-year follow-up (n=20; SMD: -0.28 [-1.16, 0.6]). Compared with single session, a benefit was observed for multiple sessions of exposure-based therapy posttreatment (n=93; SMD: -0.66 [-1.08, -0.24]) but not after 1 year (n=83; SMD: -0.37 [-0.87, 0.13]). Non in vivo e.g., imaginal exposure-based therapy in children reduced specific fear posttreatment (n=41; SMD: -0.88 [-1.7, -0.05]) and at 3 months (n=24; SMD: -0.89 [-1.73, -0.04]). Non in vivo exposure-based therapy for adults showed benefit on specific fear (n=68; SMD: -0.62 [-1.11, -0.14]) but not procedural fear (n=17; SMD: 0.18 [-0.87, 1.23]). Applied tension showed benefit on fainting posttreatment (n=20; SMD: -1.16 [-2.12, -0.19]) and after 1 year (n=20; SMD: -0.97 [-1.91, -0.03]) compared with exposure alone. Conclusions: Exposure-based psychological interventions and applied muscle tension show evidence of benefit in the reduction of fear in pediatric and adult populations.
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This study tested the hypothesis that an immediate effect of exposure to masked phobic stimuli on avoidance of the corresponding feared object would be maintained 1 year later. Fifty-three spider-phobic participants were identified with a questionnaire and a Behavioral Avoidance Test (BAT) with a live tarantula. One week later, they were administered 1 of 3 types of exposure: very brief (25-ms, masked) or clearly visible (125-ms, unmasked) images of spiders, or very brief images of flowers. They engaged in the BAT again immediately thereafter. One year later, they returned for a follow-up BAT. The immediate effect of exposure to very brief spiders on reducing avoidance of the tarantula was still evident 1 year later. Endurance of an effect by masked stimuli of this duration has not been reported before. Potential theoretical implications are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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Over the last 30years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g=1.010/g=1.128) and exposure was spread over the course of multiple sessions (g=1.527/g=1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.
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Magnetic petrology integrates rock magnetism and conventional petrology in order to define the processes that create, alter and destroy magnetic minerals in rocks. By relating magnetic mineralogy, bulk magnetic properties, petrology and geochemistry to observed magnetic anomalies an understanding of the geological factors that control magnetic signatures is obtained, which can be used to improve geological interpretation of magnetic surveys. The magnetic properties of igneous intrusions, and hence the magnetic anomalies associated with them, reflect bulk rock composition, redox state, hydrothermal alteration and metamorphism. These geological variables are in turn controlled by tectonic setting, composition and history of the source region, depth of emplacement and nature of wall rocks. The fundamental control on magnetic mineralogy and bulk magnetic properties is partitioning of iron between silicate and oxide phases, which is strongly influenced by oxidation ratio. This paper reviews and synthesises information on relationships between the chemistry, mineralogy and metallogenic associations of igneous intrusions and their magnetic properties. Although links between magnetic properties and broad rock names are tenuous, refined rock classification enables magnetic properties to be predicted with reasonable confidence. Oxidised, magnetite-series, and reduced, ilmenite-series granitoids have quite distinct metallogeny. Cu, Mo and Au are associated with oxidised granitoids and Sn with reduced granitoids. Fractional crystallisation, which has a distinctive magnetic expression, plays an important role in generating magmatic-hydrothermal ore deposits. Hydrothermal alteration profoundly affects magnetic properties, in a generally predictable fashion. Implications for interpretation of magnetic anomalies associated with igneous intrusions and recognition of magnetic signatures of potential intrusive-related ore deposits are adduced.
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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.
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To test predictions derived from the emotional processing theory of fear reduction, claustrophobics (N=58) were randomized to one of four exposure conditions: (a) exposure with guided threat reappraisal, (b) exposure with a cognitive load distracter task, (c) exposure with both guided threat reappraisal and cognitive load distracter task and (d) exposure without guided threat reappraisal or cognitive load distracter task. We hypothesized that self-guided in vivo exposure would lead to less fear reduction if performed simultaneously with a cognitive load distracter task that severely taxes information processing resources. In contrast, we hypothesized that focusing on core threats during exposure would enhance fear reduction. The main findings were largely consistent with predictions. The cognitive load task (regardless of focus of available attention) had a detrimental effect on fear reduction, while guided threat reappraisal (regardless of cognitive load) had a facilitative effect. The greatest level of fear reduction and the lowest level of return of fear were observed in the exposure condition involving guided threat reappraisal without cognitive load. Clinical implications and directions for future research are discussed.
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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.
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Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
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Anxiety disorders are characterised by distorted beliefs about the dangerousness of certain situations and/or internal stimuli. Why do such beliefs persist? Six processes (safety-seeking behaviours, attentional deployment, spontaneous imagery, emotional reasoning, memory processes and the nature of the threat representation) that could maintain anxiety-related negative beliefs are outlined and their empirical status is reviewed. Ways in which knowledge about maintenance processes has been used to develop focussed cognitive therapy programmes are described and evaluations of the effectiveness of such programmes are summarized. Finally, ways of identifying the effective ingredients in cognitive therapy programmes are discussed.
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This paper deals with questionnaires tapping fears of snakes, spiders, mutilation, and public speaking. Psychometric description of the scales across several samples indicated consistent distribution characteristics. In addition, consistently high reliability estimates were obtained; available results on test-retest reliability and validity were also encouraging. Correlations of these tests with one another and with general measures of anxiety indicated little shared variance. Inclusion of these scales in fear assessment procedures is suggested to promote standardization of evaluation and comparability of results across samples and laboratories.
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In social cognitive theory, perceived self-efficacy to exercise control over potential threats plays a central role in anxiety arousal. Threat is a relational property reflecting the match between perceived coping capabilities and potentially hurtful aspects of the environment. People who believe they can exercise control over potential threats do not engage in apprehensive thinking and are not perturbed by them. But those who believe they cannot manage threatening events that might occur experience high levels of anxiety arousal. Experimental analyses of the microrelation between perceived self-efficacy and anxiety arousal reveal that perceived coping inefficacy is accompanied by high levels of subjective distress, autonomic arousal and catecholamine secretion. Environmental events are not always completely under personal control and most human activities contain some potential risks. The exercise of control over anxiety arousal, therefore, requires not only development of behavioral coping efficacy but also efficacy in controlling dysfunctional apprehensive cognitions. It is not frightful cognitions per se but the perceived self-inefficacy to turn them off that is the major source of anxiety arousal. Analyses of the causal structure of self-protective behavior show that anxiety arousal and avoidant behavior are mainly co-effects of perceived coping inefficacy.
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[This book] is written for students of cognitive psychology, and also for clinicians and researchers in the areas of cognition, stress and emotional disorders. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The purpose of this study was to examine the effects of control over exposure duration, and perceived emotional control in general, on fear during exposure. Eighty spider phobics were exposed to a tarantula spider over six trials. Subjects were divided into two groups: high perceived emotional control and low perceived emotional control. Half of each group were given control over the duration of each exposure trial and inter-trial interval, while the other half were yoked with members of the first half for the purposes of duration matching. Dependent measures included degree of actual fear experienced, and degree of fear predicted to occur. Neither perceived emotional control in general nor control over the duration of exposure affected fear levels, fear reduction, or fear prediction accuracy. The failure to replicate earlier observations of the anxiolytic effects of perceived control is attributed to brevity of exposure and the demanding nature of the experimental situation.
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Recent studies have generated mixed findings regarding the effects of distraction on exposure-based treatments. Results have also been inconsistent regarding the effects of monitoring and blunting coping styles on outcome. The present study attempted to integrate these two areas of research. We hypothesized that the effect of distraction on treatment outcome might depend on coping style. Specifically, we predicted that for blunters (i.e., individuals who tend to avoid threat-related information), distraction would interfere with the effects of exposure. However, we predicted that distraction might benefit monitors (i.e., individuals who tend to seek out threat-related information). Sixty individuals with a specific phobia of spiders underwent a single, two-hour session of exposure treatment. During the first hour, half of the participants were distracted by listening to an audiotape and the other half underwent exposure without distraction. In the second hour, all participants underwent focused exposure. Based on measures of heart rate, subjective fear, and behavioral testing, participants improved after one hour of treatment, and improved further during the second hour. However, neither distraction, coping style, nor their interaction had a significant effect on outcome. The present study provides support for the benefits of behavioral treatment for specific phobias. However, our hypotheses regarding distraction and coping style were not confirmed.
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Theoretical conceptualizations of distraction as an inhibitor of fear reduction during exposure were tested among 60 subjects with marked animal fears. Subjects underwent high or low intensity in vivo exposure in the presence of highly affective slides (high distraction), neutral slides (low distraction), or no slides. Self-reported attention did not differ between the high and low distraction groups; thus, data from these groups were combined in the analyses. The combination of distraction and high exposure intensity was found to interfere both with self-reported fear reduction during exposure and with the pre- to post-exposure behavioral approach tasks; improvement in pre- to post-exposure behavioral approach was impeded also. Distraction had no impact under low intensity exposure conditions. Counter to prediction, return of fear was not evident across groups. Heart rate increased in all groups during exposure, suggesting a possible sensitization effect. Theoretical and clinical implications are discussed, and recommendations for future research are provided.
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Nineteen snake and spider phobic subjects underwent three exposure conditions and a baseline condition, each lasting six minutes. In the distracted condition, subjects listened for specific target words during audiotaped passages while continuing to observe the phobic stimulus. In the focused condition, subjects were prompted to focus on features of the phobic stimulus and their own emotional responses. Dependent measures included ongoing subjective report of fear and heart rate, retrospective fear ratings, and percent of time focused on the phobic stimulus and emotional responses. Subjective fear ratings increased over the six-minute focused exposure, in comparison to stability of fear levels during distracted and natural exposure. Heart rate did not differ between conditions. Possible treatment and theoretical implications are described, including the natural tendency for phobics to counter an initial attentional shift towards phobic stimuli with secondary cognitive avoidance strategies.
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The present study examined the effects of attentional focus on anxiety reduction during in vivo exposure. Thirty-nine mildly blood- and injection-fearful subjects were randomly assigned to one of three brief (i.e., 10 minute) exposure conditions. Cognitive attention to the blood-and-injection stimuli was manipulated by engaging participants in either stimulus-relevant conversation (exposure-plus-focusing condition), stimulus-irrelevant conversation (exposure-plus-distraction condition), or no conversation (exposure alone). Attention was successfully manipulated, and while exposure-plus-distraction resulted in a greater decrease in anxiety within-session than both the exposure-plus-focusing and exposure-alone conditions, the three groups showed no difference at postexposure in the behavioral approach task. Implications for the practice of exposure techniques and theories of emotional processing are discussed.
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Measures of perceived control over different, specific spheres of an individual's life may form more homogeneous constructs than measures of a broad, general locus of control. Along these lines, it is likely that anxiety and the anxiety disorders may be characterized by a lack of perceived control over particular events and occurrences such as certain internal emotional reactions or externally threatening events. The present study was aimed at developing a questionnaire to measure this construct. Initial item selection was based on data from 250 anxious subjects. Reliability and factor-structure were replicated with a nonclinical group. The scale showed good inter-item and test-retest reliability as well as good discriminant and convergent validity. The scale appears promising for clinical application and for use in studies on the nature and treatment of anxiety and related disorders.
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The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of per- sonal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of ob- stacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more de- pendable the experiential sources, the greater are the changes in perceived self- efficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and be- havioral changes. Possible directions for further research are discussed.
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The Mutilation Questionnaire, (MQ) was examined in terms of its psychometric characteristics, its relation to Fear Survey Schedule-II Blood/Injury items, its ability to predict B/I-related fainting, a response common to many B I fearful persons, and its factor structure. In two separate samples of college subjects, females reported greater B/I fear than males, the distributions were positively skewed and negatively kurototic but internal consistency was adequate in both. The MQ correlated 0.75 with five B/I items taken from the FSS-II. While these two scales were comparable in assessing self-reported B/I fear, the MQ was more predictive of fainting. Discriminant analyses of the 30 MQ items in relation to prediction of subjects' faint histories resulted in 77% correct classification of faint history. However, responses to a single question concerning subjects' self assessment of B/I fear was equally as capable of classifying fainting status as the full MQ scale. Responses to the single fear question correlated 0.55 with faint history while MQ scores correlated only 0.45. Factor analyses of the MQ revealed two factors described as 'revulsion of B/I stimuli', accounting for 19% of item variance and 'fear of bodily damage', accounting for 7%. Implications of these results are discussed in terms of the FSS-II, the MQ and alternative means of B/I fear assessment.
Article
Instructions to focus upon feared somatic sensations were compared to instructions to engage in distracting tasks, while practising in vivo exposure to feared agoraphobic situations. Thirty individuals assigned a primary diagnosis of Panic Disorder with moderate to severe Agoraphobia were assigned randomly to one of the two treatment conditions. Assessments were conducted pre, post and 6 months following treatment completion, using subjective, behavioral and clinician-rated measures of change. Composite outcome criteria indicated a trend for distracted exposure to yield a higher percentage of improvement than focused exposure, at post assessment. However, focused exposure group members improved to a greater extent over the follow-up interval than members of the distracted group. These trends were relatively weak, given the absence of significant group by time interactions in terms of individual variable analyses. The results were discussed with reference to the role of distraction in fear reduction.
Article
Exposure to feared situations has been found to result in decrement in subjective anxiety and heart rate (HR) for anxiety-disordered patients. In a preliminary study using a crossover design, obsessive-compulsives experienced less return of fear during in vivo exposure when attention was focused on their feared obsessional stimuli than when it was distracted from them. Thus, attention seemed to facilitate between-session but not within-session habituation. The present study was conducted to replicate and extend the previous investigation using a between-groups design. Seventeen obsessive-compulsives with washing rituals were exposed to their most feared contaminant for two consecutive 90-min sessions under either distracting (playing a video game) or attention-focusing (observing and discussing the contaminant) conditions. Consistent with our earlier findings, HR response reduced substantially during attention-focusing but remained elevated during distraction. However, on subjective anxiety greater reduction was observed in the distraction condition, particularly during the first exposure session. Results are discussed in light of findings by other investigators regarding procedural manipulations during exposure.
Article
To investigate the effects of distraction and attention-focusing during in-vivo exposure to feared stimuli, the responses of 16 obsessive-compulsives with washing rituals were studied. A cross-over design was employed in which 6 of the subjects underwent exposure with attention focusing on the first day followed by exposure with distraction on the second day. The remaining subjects received the reverse order. Habituation of both heart rate and subjective anxiety was observed under both conditions, the rate of habituation tending to remain constant throughout the 90-min exposure. Greater between-session habituation and greater synchrony between the psychophysiological and the subjective measures of anxiety was observed when attention-focusing preceded distraction. Since habituation and synchrony have previously been found to be positively related to treatment outcome, the present results suggest that treatment by exposure to feared stimuli may be more effective if attention-focusing is promoted.
Article
A working definition of the concept of emotional processing is presented, with the aim of integrating a set of clinical and experimental observations. If successful, the concept may help to unify such apparently unrelated events as obsessions, the return of fear, abnormal grief reactions, nightmares, treatment failures, and so on.Factors that may facilitate or impede emotional processing are presented, and some circumstances that may give rise to initial difficulties in processing are mentioned. A number of theoretical problems are posed, and some methodological innovations offered.
Article
Heart beats, skin conductance, and subjective fear levels were recorded among eight pairs of DSM-III-R spider-phobic subjects (Experiment 1) and among eight pairs of DSM-III-R cockroach-phobic subjects (Experiment 2) who were exposed simultaneously to an approaching specimen during eight 4-minute trials. Control over the approach of the specimen alternated between subjects over trials. On different trials, both subjects were instructed either to attend closely to the features of the specimen or to attend closely to their bodily fear reactions. Among spider-phobic subjects (Experiment 1), Self-Control over the specimen produced higher skin conductance during exposure than did Partner-Control over the specimen; instructions to attend closely to the features of the specimen produced higher skin-conductance than did instructions to attend closely to one's bodily fear reactions. Among cockroach-phobic subjects (Experiment 2), Self-Control over the specimen produced higher skin conductance and higher self-reported fear than did Partner-Control over the specimen during the early exposures. Instructions to attend closely to the specimen produced higher skin conductance and higher self-reported fear throughout the experiment and higher heart rates early during the experiment than did instructions to attend to one's bodily reactions. Empirical generalizations based on these data are intended as contributions toward a fund of experimental information that, in due course, will be used to conceptualize the means by which exposure to feared stimuli leads to fear reduction.
Article
Fear sometimes returns after successful fear attenuation via in vivo exposure to fear signals. Post-treatment return of fear is of considerable interest both practically and theoretically, but factors associated with return of fear are poorly understood due to conflicting results from procedurally diverse experiments. This paper reports two very similar experiments in which fear of animal specimens was weakened then allowed to return so that factors associated with return of fear could be studied. In each experiment attentional focus versus distraction during exposure served as a between-subjects independent variable. In each case, attempts also were made to predict return of fear via several nonmanipulated variables: initial fear, initial avoidance during voluntary exposure, initial heart rate during voluntary exposure, and speed of fear reduction during repeated exposure trials. With the sample sizes used there was only suggestive evidence that return of fear was associated with distraction during exposure, and with relatively rapid fear decline during exposure. More importantly, the experiments are offered as standard, replicable models for research that will permit procedurally homogeneous investigations of variables with which return of fear is associated.
Article
Anxiety disorders are characterised by distorted beliefs about the dangerousness of certain situations and/or internal stimuli. Why do such beliefs persist? Six processes (safety-seeking behaviours, attentional deployment, spontaneous imagery, emotional reasoning, memory processes and the nature of the threat representation) that could maintain anxiety-related negative beliefs are outlined and their empirical status is reviewed. Ways in which knowledge about maintenance processes has been used to develop focussed cognitive therapy programmes are described and evaluations of the effectiveness of such programmes are summarized. Finally, ways of identifying the effective ingredients in cognitive therapy programmes are discussed.
Article
This study extends Penfold and Page's (1999) finding that exposure plus distraction enhanced within-session fear reduction to a phobic stimulus by examining whether the within-session advantage could be replicated and translated into longer-term gains. To test the effects of distraction, participants were assigned randomly to one of three experimental conditions; exposure plus focusing, exposure plus distraction, or exposure alone. Blood-injection fearful participants (N = 48) were assigned randomly to receive 3 weekly sessions of 10-min exposure under one of the experimental conditions. Consistent with the previous finding, exposure plus distraction showed the greatest within-session fear reduction. Participants in the exposure plus distraction condition also reported the greatest reduction in fear between sessions, at post-treatment, and at 1-month follow-up. Furthermore, participants in the exposure plus distraction condition reported continued increases in perceived control over their anxiety during the month following the exposure sessions. The data suggest that conversation is a distraction that can increase perceived control over anxiety and assists anxiety reduction.
Article
To replicate and extend the finding that distraction facilitates between session anxiety reduction (), 27 spider phobics underwent three 10-min sessions of in vivo exposure followed by one 10-min exposure session at a 4-week follow-up, while having either stimulus-relevant focused conversation or stimulus-irrelevant distracting conversation with the experimenter. Physiological arousal and subjective anxiety were measured during exposure, and self-efficacy, perceived control and performance on a behavioural task were measured at pre-treatment, post session-3, and follow-up. Monitoring and blunting coping styles were also measured at pre-treatment to assess their impact on treatment outcome. Despite equal physiological activation between the groups, those who underwent distracted exposure showed greater reductions in subjective fear within and between sessions, and showed greater increases in self-efficacy ratings, internal perceived control and performance on a behavioural task. Coping style did not interact with the effect of distraction or focusing during exposure, however blunters had less subjective anxiety reduction overall, particularly when they underwent focused exposure. Results are discussed in terms of the emotional processing model and self-efficacy theory.
Anxiety disorders: Psychological approaches to theory and treatment
  • M G Craske
Craske, M. G. (1999). Anxiety disorders: Psychological approaches to theory and treatment. Los Angeles: Westview Press.
Anxiety and its disorders: The nature and treatment of anxiety and panic
  • D H Barlow
Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford Press.