Effekte therapeutenbegleiteter versus patientengeleiteter Exposition bei Panikstörung mit Agoraphobie

Zusammenfassung. Theoretischer Hintergrund: Die Rolle der Therapeutenbegleitung während Expositionsübungen bei Panikstörung mit Agoraphobie (P/A) ist bislang ungeklärt. Eine kürzlich durchgeführte klinische Studie (MAC-Studie) lieferte Hinweise auf ein günstigeres Behandlungsergebnis bei Therapeutenbegleitung. Fragestellung: Wie lassen sich Effekte therapeutenbegleiteter Exposition (T+) im Vergleich zu Exposition ohne Therapeutenbegleitung (T–) erklären? Methode: Daten von 301 Patienten, die eine expositionsbasierte KVT mit bzw. ohne Therapeutenbegleitung erhalten hatten, wurden analysiert. Untersucht wurden der Einfluss der initialen Störungsschwere, des Sicherheitsverhaltens sowie differenzielle Effekte der Bedingungen auf die Angst vor der Angst. Zusätzlich wurde überprüft, inwieweit die Übungshäufigkeit in den Behandlungsbedingungen variiert und einen Mediator des Behandlungserfolgs darstellt. Ergebnisse: Störungsschwere und Sicherheitsverhalten zeigten keine differenziellen Effekte zwischen den Bedingungen; die T+ Bedingung führte jedoch zu stärkeren Reduktionen der Angst vor der Angst im Angstsensitivitätsindex. Patienten der T+ Bedingung führten häufiger selbständig Expositionsübungen durch, während Patienten in T– im Durchschnitt länger übten. Die Übungshäufigkeit stellte dabei einen Mediator des Behandlungserfolgs dar. Schlussfolgerungen: Günstigere Effekte einer therapeutenbegleiteten Exposition gehen auf stärkere Reduktionen der Angst vor der Angst sowie auf eine höhere Übungshäufigkeit im Selbstmanagement zurück.

Happy mouth and sad eyes: scanning emotional facial expressions

There is evidence that specific regions of the face such as the eyes are particularly relevant for the decoding of emotional expressions, but it has not been examined whether scan paths of observers vary for facial expressions with different emotional content. In this study, eye-tracking was used to monitor scanning behavior of healthy participants while looking at different facial expressions. Locations of fixations and their durations were recorded, and a dominance ratio (i.e., eyes and mouth relative to the rest of the face) was calculated. Across all emotional expressions, initial fixations were most frequently directed to either the eyes or the mouth. Especially in sad facial expressions, participants more frequently issued the initial fixation to the eyes compared with all other expressions. In happy facial expressions, participants fixated the mouth region for a longer time across all trials. For fearful and neutral facial expressions, the dominance ratio indicated that both the eyes and mouth are equally important. However, in sad and angry facial expressions, the eyes received more attention than the mouth. These results confirm the relevance of the eyes and mouth in emotional decoding, but they also demonstrate that not all facial expressions with different emotional content are decoded equally. Our data suggest that people look at regions that are most characteristic for each emotion.

Larger than life: overestimation of object size is moderated by personal relevance in obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

Along with other cognitive biases overestimation of threat (OET) has been implicated in the pathogenesis of obsessive-compulsive disorder (OCD). The present study investigated whether OET would not only manifest in cognitive distortions but, also in overestimations of the object size of disorder-related visual objects.

METHODS

A total of 65 participants with OCD and 55 healthy controls who were recruited via OCD online forums underwent an incidental learning paradigm consisting of two blocks. In Block 1, participants were asked to rate the valence and the personal relevance for individual OCD concerns of 40 pictures which varied in size. Differences in size, however, were not explicitly communicated to the participants. Stimuli were selected from four categories: 1. neutral, 2. fear-related but OCD-unrelated, 3. washing (OCD-related), and 4. checking (OCD-related). In Block 2, participants were asked to recollect the original size of each stimulus (depicted as a small thumbnail) on a seven point scale.

RESULTS

Whereas few group differences emerged for pre-defined OCD items, OCD-relevant items (individual judgments) were judged as significantly larger by patients with OCD relative to controls. The opposite pattern emerged for neutral items.

LIMITATIONS

The sample was recruited via online forums and had probable but not externally validated diagnoses of OCD. No psychiatric control group was recruited.

CONCLUSIONS

The present study indicates that OET may extend to neuropsychological tasks. Further research is needed to pinpoint whether OET occurs at the level of encoding suggesting a perceptual bias and/or occurs at the level of retrieval suggesting a memory bias.

Emotional scenes and facial expressions elicit different psychophysiological responses

We examined if emotional faces elicit physiological responses similar to pictures of emotional scenes. Forty one students viewed emotional scenes (negative, neutral, and positive) and emotional faces (angry, neutral, and happy). Heart rate, orbicularis oculi and electrodermal activity were measured continuously, and the startle reflex was elicited. Although the patterns of valence and arousal ratings were comparable, physiological response patterns differed. For scenes we replicated the valence-specific modulation of the startle response, heart rate deceleration, and the arousal-related modulation of the electrodermal response. In contrast, for faces we found valence-specific modulation only for the electrodermal response, but the startle and heart rate deceleration were modulated by arousal. Although arousal differences may account for some differences in physiological responding this shows that not all emotional material that is decoded similarly leads to the same psychophysiological output.

Motor-Incompatibility of Facial Reactions

Emotional cues facilitate motor responses that are associated with approach or avoidance. Previous research has shown that evaluative processing of positive and negative facial expression stimuli is also linked to motor schemata of facial muscles. To further investigate the influence of different types of emotional stimuli on facial reactions, we conducted a study with pictures of emotional facial expressions (KDEF) and scenes (IAPS). Healthy participants were asked to respond to the positive or negative facial expressions (KDEF) and scenes (IAPS) with specific facial muscles in a valence-congruent (stimulus valence matches muscle related valence) or a valence-incongruent condition (stimulus valence is contrary to muscle related valence). Additionally, they were asked to rate pictures in terms of valence and arousal. Muscular response latencies were recorded by an electromyogram. Overall, response latencies were shorter in response to facial expressions than to complex pictures of scenes. For both stimulus categories, response latencies with valence-compatible muscles were shorter compared to reactions with incompatible muscles. Moreover, correlations between picture ratings and facial muscle reactions for happy facial expressions as well as positive scenes reflect a direct relationship between perceived intensity of the subjective emotional experience and physiological responding. Results replicate and extend previous research, indicating that incompatibility effects are reliable across different stimulus types and are not limited to facial mimicry.

Early attentional deficits in an attention-to-prepulse paradigm in ADHD adults

Adults with attention-deficit/hyperactivity disorder (ADHD) were examined for early and late attentional processes as a function of controlled attention. The test paradigm was the attentional modulation of prepulse inhibition (PPI; early controlled attentional processing) and prepulse facilitation (PPF; late controlled attentional processing). In 49 patients and 49 controls, the authors measured acoustic startle responses to 96-dB startle pulses preceded 120, 240 (for PPI), 2,000, and 4,500 (for PPF) ms by a 68-dB prepulse noise. Geometric figures signaled that prepulses were to be ignored or attended to (automatic vs. controlled attention). ADHD patients exhibited deficits in prepulse modulation, but these reflected an interaction of controlled attention and time of information processing. Normal PPI and PPF occurred under all conditions except for controlled attentional modulation of PPI. Attention deficits in ADHD patients may reflect not general derangements in information processing or ability to attend but, rather, selective disturbances of controlled attention during early information processing.

Brain Activations to Emotional Pictures are Differentially Associated with Valence and Arousal Ratings

Several studies have investigated the neural responses triggered by emotional pictures, but the specificity of the involved structures such as the amygdala or the ventral striatum is still under debate. Furthermore, only few studies examined the association of stimuli's valence and arousal and the underlying brain responses. Therefore, we investigated brain responses with functional magnetic resonance imaging of 17 healthy participants to pleasant and unpleasant affective pictures and afterwards assessed ratings of valence and arousal. As expected, unpleasant pictures strongly activated the right and left amygdala, the right hippocampus, and the medial occipital lobe, whereas pleasant pictures elicited significant activations in left occipital regions, and in parts of the medial temporal lobe. The direct comparison of unpleasant and pleasant pictures, which were comparable in arousal clearly indicated stronger amygdala activation in response to the unpleasant pictures. Most important, correlational analyses revealed on the one hand that the arousal of unpleasant pictures was significantly associated with activations in the right amygdala and the left caudate body. On the other hand, valence of pleasant pictures was significantly correlated with activations in the right caudate head, extending to the nucleus accumbens (NAcc) and the left dorsolateral prefrontal cortex. These findings support the notion that the amygdala is primarily involved in processing of unpleasant stimuli, particularly to more arousing unpleasant stimuli. Reward-related structures like the caudate and NAcc primarily respond to pleasant stimuli, the stronger the more positive the valence of these stimuli is.

Visual face perception of adults with unilateral cleft lip and palate in comparison to controls--an eye-tracking study

OBJECTIVE

To assess how faces with a cleft lip and palate are perceived and to study how faces with and without a unilateral cleft lip and palate are viewed by individuals with a unilateral cleft lip and/or palate in comparison to nonaffected controls.

DESIGN

Prospective clinical study.

SETTING

Department of Orthodontics and Department of Psychology, University of Wuerzburg.

PARTICIPANTS

Thirty-three participants (20 men and 13 women; mean age, 25.4 ± 6.6 years) with a unilateral cleft lip and/or palate and a control group of 30 participants (15 men and 15 women; mean age, 26.8 ± 3.4 years) were enrolled in this study.

MAIN OUTCOME MEASURES

Eye movements were analyzed via an eye-tracking camera while all participants looked at pictures of faces with and without a unilateral cleft lip and palate.

RESULTS

The nose and the mouth area of pictures of faces with a unilateral cleft lip and palate were looked at significantly longer by both groups. Additionally, the participants with a unilateral cleft lip and/or palate looked at faces with and without a unilateral cleft lip and palate differently, taking more time to view the nose and less time to view the eyes compared with the participants without a cleft lip and palate.

CONCLUSION

When perceiving a face with a unilateral cleft lip and palate, the observer's gaze is distracted to the nose and mouth area. Moreover, participants with a unilateral cleft lip and/or palate themselves focused greater attention on those features that are anomalous on their own faces in comparison to participants without a cleft lip and palate. Specifically, this different scanpath is reflected in the cumulative duration of the eye movements as well as in the initial facial scan pattern.

Impact of facial asymmetry in visual perception: a 3-dimensional data analysis

INTRODUCTION

The aim of this controlled study was to analyze the degree and localization of 3-dimensional (3D) facial asymmetry in adult patients with cleft lip and palate (CLP) compared with a control group and its impact on the visual perception of faces.

METHODS

The degree of 3D asymmetry was analyzed with a novel method without landmarks in 18 adults with complete unilateral CLP and 18 adults without congenital anomalies. Furthermore, the CLP and control faces were rated for appearance, symmetry, and facial expression by 30 participants.

RESULTS

The results showed that adults with CLP had significantly greater asymmetry in their facial soft tissues compared with the control group. Moreover, the lower face, and particularly the midface, had greater asymmetry in the CLP patients. The perceptual ratings showed that adults with CLP were judged much more negatively than those in the control group.

CONCLUSIONS

With sophisticated 3D analysis, the real morphology of a face can be calculated and asymmetric regions precisely identified. The greatest asymmetry in CLP patients is in the midface. These results underline the importance of symmetry in the perception of faces. In general, the greater the facial asymmetry near the midline of the face, the more negative the evaluation of the face in direct face-to-face interactions.

Persons with cleft lip and palate are looked at differently

There is evidence that persons with cleft lip and palate (CLP) suffer psychosocial consequences as a result of their facial appearance. However, no data exist on how they are perceived by others. Our hypothesis was that CLP faces were looked at differently compared with faces lacking an anomaly. Eye movements of 30 healthy participants were recorded (via an eye-tracking camera) while they viewed photographs of faces with/without a CLP. Subsequently, the faces were rated for appearance, symmetry, and facial expression. When the CLP faces were viewed, there were significantly more initial fixations in the mouth and longer fixations in the mouth and nose regions, compared with reactions when control faces were viewed. Moreover, CLP faces were rated more negatively overall. When faces with CLP were viewed, attention was directed to the mouth and nose region. Together with the negative ratings, this may explain at least some of the social deprivations in persons with CLP, probably due to residual asymmetry.

How others perceive orthognathic patients: an eye-tracking study

AIM

To test the hypothesis that the faces of patients with a severe Class III are contemplated differently from and assessed more negatively than skeletal Class I patients in direct face-to-face interaction.

METHOD

The eye movements of 24 randomly recruited evaluators were analyzed with a noninvasive, infrared high-speed camera while looking at 18 standardized frontal photographs of adult orthognathic Class III patients and 18 photographs of adults with skeletal Class I relationships as controls. Additionally, all images were assessed for appearance, symmetry, and facial expression.

RESULTS

The Class III patients were rated significantly more negatively in terms of appearance, symmetry, and facial expression than the Class I individuals. The eye movement data revealed that orthognathic patients were appraised differently from the Class I individuals, with fewer fixations in the face center, especially around the mouth.

CONCLUSION

Skeletal Class III patients were characterized as less attractive than Class I individuals. Faces of Class III patients were visually perceived with different eye movements. These differences in visual perception are described for the first time in the present study. Although they were small, they are an indication of an objectively different perception of faces that are rated subjectively as less attractive and more asymmetric and exhibiting a more negative expression.

Mechanism of action in CBT (MAC): methods of a multi-center randomized controlled trial in 369 patients with panic disorder and agoraphobia

Cognitive behavioral therapy (CBT) is efficacious for panic disorder with agoraphobia (PD/A). Nevertheless, the active ingredients of treatment and the mechanisms through which CBT achieves its effects remain largely unknown. The mechanisms of action in CBT (MAC) study was established to investigate these questions in 369 patients diagnosed with PD/A. The MAC study utilized a multi-center, randomized controlled design, with two active treatment conditions in which the administration of exposure was varied, and a wait-list control group. The special feature of MAC is the way in which imbedded experimental, psychophysiological, and neurobiological paradigms were included to elucidate therapeutic and psychopathological processes. This paper describes the aims and goals of the MAC study and the methods utilized to achieve them. All aspects of the research design (e.g., assessments, treatment, experimental procedures) were implemented so as to facilitate the detection of active therapeutic components, and the mediators and moderators of therapeutic change. To this end, clinical, behavioral, physiological, experimental, and genetic data were collected and will be integrated.

Abnormal affective responsiveness in attention-deficit/hyperactivity disorder: subtype differences

BACKGROUND

Emotional-motivational dysfunctions likely contribute to attention-deficit/hyperactivity disorder (ADHD), especially to hyperactive and impulsive symptoms. This study examined the affective modulation of the startle reflex in a large sample of ADHD patients. The aim was to compare subtypes of ADHD.

METHODS

One hundred ninety-seven unmedicated adult ADHD patients (127 combined type [ADHD-C]; 50 inattentive type [ADHD-I]; 20 hyperactive-impulsive type [ADHD-HI]) and 128 healthy control subjects were examined. The affect-modulated startle response as well as valence and arousal ratings were assessed for pleasant, neutral, and unpleasant picture stimuli.

RESULTS

Control subjects exhibited startle response attenuation and potentiation by pleasant and unpleasant pictures, respectively. In ADHD-HI, startle response was not attenuated by pleasant and not potentiated by unpleasant stimuli. In ADHD-C, startle response was not attenuated by pleasant pictures, and ADHD-I responded similar to control subjects but startle response was attenuated to a lesser degree by pleasant stimuli. The ADHD-HI group rated all pictures as more positive, and male ADHD-HI rated unpleasant stimuli as less arousing.

CONCLUSIONS

This is the first study to assess the affect-modulated startle response in ADHD. It confirms emotional dysfunctions in these patients; all subtypes showed more or less diminished emotional reactions to pleasant stimuli. The hyperactive-impulsive type was also marked by blunted reactions to unpleasant stimuli. Results suggest that response patterns to emotional cues or reward may help to differentiate ADHD subtypes. Blunted emotional reactivity is especially pronounced in ADHD patients with symptoms of hyperactivity and impulsivity (ADHD-C, ADHD-HI).

Is eye to eye contact really threatening and avoided in social anxiety?--An eye-tracking and psychophysiology study

The effects of direct and averted gaze on autonomic arousal and gaze behavior in social anxiety were investigated using a new paradigm including animated movie stimuli and eye-tracking methodology. While high, medium, and low socially anxious (HSA vs. MSA vs. LSA) women watched animated movie clips, in which faces responded to the gaze of the participants with either direct or averted gaze, their eye movements, heart rate (HR) and skin conductance responses (SCR) were continuously recorded. Groups did not differ in their gaze behavior concerning direct vs. averted gaze, but high socially anxious women tended to fixate the eye region of the presented face longer than MSA and LSA, respectively. Furthermore, they responded to direct gaze with more pronounced cardiac acceleration. This physiological finding indicates that direct gaze may be a fear-relevant feature for socially anxious individuals in social interaction. However, this seems not to result in gaze avoidance. Future studies should examine the role of gaze direction and its interaction with facial expressions in social anxiety and its consequences for avoidance behavior and fear responses. Additionally, further research is needed to clarify the role of gaze perception in social anxiety.

And yet they correlate: psychophysiological activation predicts self-report outcomes of exposure therapy in claustrophobia

The study examines whether self-reported fear and physiological activation are concordant when claustrophobic patients are exposed to small spaces, whether the measures change in synchrony for individual patients and whether initial activation of measures can predict the outcome of an exposure treatment. Ten patients with claustrophobia participated in six in-vivo exposure sessions with continuous monitoring of self-reported fear and their EKG. Partial pressure of carbon dioxide (pCO(2)), a measure of hyperventilation, was available in a subsample of patients. While evidence for concordance of self-reported fear and heart rate was limited, the measures changed synchronously within subjects. Most importantly, higher heart rate at the beginning of the first exposure session predicted better treatment outcome. Because self-reported fear turned out not to be a reliable predictor of the outcome, this is interpreted as evidence for the incremental validity of physiological measures of fear.

Fear of negative evaluation and the hypervigilance-avoidance hypothesis: an eye-tracking study

The hypervigilance-avoidance hypothesis assumes that anxious individuals initially attend to and subsequently avoid threatening stimuli. In this study pairs of emotional (angry or happy) and neutral facial expressions were presented to students of high or low fear of negative evaluation (FNE) while their eye movements were recorded. High FNE participants initially looked more often at emotional compared to neutral faces, indicating an attentional bias for emotional facial expressions. This effect was further modulated by the sex of the face, as high FNE clearly showed a preference for happy female faces. Analysis of the time course of attention revealed that high FNE looked at the emotional faces longer during the first second of stimulus exposure, whereas they avoided these faces in the consecutive time interval from 1 to 1.5 s. These results partially support the hypervigilance-avoidance hypothesis and additionally indicate the relevance of happy faces for high FNE. Further research should clarify the meaning of happy facial expressions as well as the influence of the sex of the observed face in social anxiety.

Categorization and evaluation of emotional faces in psychopathic women

Psychopathic individuals have been shown to respond less strongly than normal controls to emotional stimuli. Data about their ability to judge emotional facial expressions are inconsistent and limited to males. To measure categorical and dimensional evaluations of emotional facial expressions in psychopathic and non-psychopathic women, 13 female psychopathic forensic inpatients, 15 female non-psychopathic forensic inmates and 16 female healthy participants were tested in an emotion-categorizing task. Emotional facial expressions were presented briefly (33 ms) or until buttonpress. Participants were to classify emotional expressions, and to rate their valence and arousal. Group differences in categorization were observed at both presentation times. Psychopathic patients performed worst with briefly presented sad expressions. Moreover, their dimensional evaluation resulted in less positive ratings for happy expressions and less arousal for angry expressions compared with the responses of non-psychopathic and normal subjects. Results shed light on the mechanism possibly underlying the emotional deficits in psychopathic women.

Exposure to heights in a theme park: fear, dizziness, and body sway

Fear of heights results in the experience of dizziness and measurable body sway. We investigated the relationship between fear, dizziness, and body sway during height exposure 16 m above ground. Thirty five healthy participants stood on a force-plate to measure sway before, during, and after exposure and an ECG was recorded. Self-report measures were anticipated fear and dizziness before exposure, as well as actual fear and dizziness during the three situations. For all participants, fear, dizziness, and body sway were increased during exposure. Anticipated fear most reliably predicted body sway during exposure. In addition, persons scoring high on trait fear of heights anticipated and experienced more fear during exposure, but this relationship was not found for any objective measure. There was no evidence that vestibular function moderates the relationship between sub-clinical fear and body sway. The results underline the importance of cognitive factors, like anticipatory anxiety and overestimation of bodily symptoms, in fear of heights.

Enhancement of activity of the primary visual cortex during processing of emotional stimuli as measured with event-related functional near-infrared spectroscopy and event-related potentials

In this study we investigated whether event-related near-infrared spectroscopy (NIRS) is suitable to measure changes in brain activation of the occipital cortex modulated by the emotional content of the visual stimuli. As we found in a previous pilot study that only positive but not negative stimuli differ from neutral stimuli (with respect to oxygenated haemoglobin), we now measured the event-related EEG potentials and NIRS simultaneously during the same session. Thereby, we could evaluate whether the subjects (n = 16) processed the positive as well as the negative emotional stimuli in a similar way. During the task, the subjects passively viewed positive, negative, and neutral emotional pictures (40 presentations were shown in each category, and pictures were taken from the International Affective Picture System, IAPS). The stimuli were presented for 3 s in a randomized order (with a mean of 3 s interstimulus interval). During the task, we measured the event-related EEG potentials over the electrode positions O1, Oz, O2, and Pz and the changes of oxygenated and deoxygenated haemoglobin by multichannel NIRS over the occipital cortex. The EEG results clearly show an increased early posterior negativity over the occipital cortex for both positive as well as negative stimuli compared to neutral. The results for the NIRS measurement were less clear. Although positive as well as negative stimuli lead to significantly higher decrease in deoxygenated haemoglobin than neutral stimuli, this was not found for the oxygenated haemoglobin.