Exposure therapy augmentation: A review and extension of techniques informed by an inhibitory learning approach

Towards a Clinically Valid Mechanistic Assessment of Exposure and Response Prevention: Preliminary Utility of an Exposure Learning Tool for Children with OCD

Despite advances in understanding mechanisms underlying fear processes, there remains a significant gap between insights produced via laboratory assessment and concrete tools for harnessing these insights in clinical practice. In addressing this gap, researchers would ideally introduce tools that are feasible for patients in clinical practice, easily disseminated to practitioners, and clinically useful. We present pilot data on the Exposure Experience Questionnaire (EEQ), a brief measure designed to assess exposure learning mechanisms. Ten children (ages 8-15) with a primary diagnosis of obsessive-compulsive disorder (OCD) underwent exposure and response prevention in which they completed weekly exposures in clinic and at home. During each exposure, children completed an exposure practice form which included the EEQ. Results suggest the preliminary feasibility and internal consistency of this measure, with comparable utility in clinic and home settings. The EEQ was associated in the expected direction with slope of OCD symptoms, such that greater exposure learning in both clinic and homework exposures predicted improved outcome. Although limited by small sample size, these data support the continued research on the feasibility and utility of the EEQ and suggest that quantifying learning processes following exposure may be a useful addition to mechanistic research in OCD.

Intensivierte Exposition zur Förderung des Inhibitionslernens bei Angststörungen

Zusammenfassung. Die Wirksamkeit von Expositionsverfahren bei Angststörungen ist hervorragend belegt. Dennoch profitieren viele Patient_innen nicht oder nicht ausreichend, was die Notwendigkeit zur Verbesserung der Verfahren deutlich macht. Vielversprechende Optimierungsstrategien lassen sich aus Modellen des Inhibitionslernens ableiten, andererseits aus der Beobachtung, dass die in expositionsbasierten klinischen Trials erreichten hohen Effektstärken in der Mehrzahl durch deutlich kürzere und intensivere Therapien verglichen mit der Routineversorgung erreicht werden. Der Forschungsverbund PROTECT-AD (Providing Tools for Effective Care and Treatment of Anxiety Disorders) untersucht in einer multizentrischen randomisierten Studie die Effekte einer intensivierten Expositionstherapie (Intensivierte psychotherapeutische Intervention, IPI) mit zeitlich ausgedehnter Selbstmanagementphase im Vergleich zu einem inhaltlich identischen, aber zeitlich gestreckten treatment as ususal (TAU) bei über 600 Patient_innen mit verschiedenen Angststörungen. Hier berichten wir, wie Intensivierung als Optimierungsstrategie therapeutisch umgesetzt werden kann. Unsere Erfahrungen zeigen, dass intensivierte Exposition von den Patient_innen sehr gut angenommen wird und eine Reihe praktischer und gesundheitsökonomischer Vorteile bieten kann.

Virtually Unexpected: No Role for Expectancy Violation in Virtual Reality Exposure for Public Speaking Anxiety

In the current study, we examined the role of expectancy violation and retrospective reasoning about the absence of feared outcomes in virtual reality exposure therapy (VRET). Participants fearful of public speaking were asked to give speeches in virtual reality. We asked each participant individually to report their expectancies about feared outcomes in public speaking situations and which of these could be tested in VRET. Each of the expectancies was categorized as being related to: (1) participants’ own reactions, (2) (overt) reactions of the audience, or (3) (covert) negative evaluation. We examined whether the proportion of testable expectancies could predict treatment outcome and which type of expectancies were evaluated as being more testable in VRET. Additionally, we experimentally manipulated retrospective reasoning about whether or not expectancies related to the overt reactions of the audience could be violated by providing verbal information after VRET about whether or not the virtual audience was interactive. A reduction in public speaking anxiety was observed from pre- to post-VRET. Treatment effects were, however, not predicted by the individually reported proportions of testable expectancies. Participants evaluated expectancies about their own reactions as being more testable in VRET compared to expectancies about reactions of the audience or about being negatively evaluated. In addition, we did not find evidence that the experimental manipulation regarding whether or not the audience was interactive influenced treatment effects. In conclusion, the results of the current study suggest that the effects of VRET are not univocally explained by the mechanism of expectancy violation.

Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges

Post-traumatic stress disorder (PTSD) is arguably the most common psychiatric disorder to arise after exposure to a traumatic event. Since its formal introduction in the DSM-III in 1980, knowledge has grown significantly regarding its causes, maintaining mechanisms and treatments. Despite this increased understanding, however, the actual definition of the disorder remains controversial. The DSM-5 and ICD-11 define the disorder differently, reflecting disagreements in the field about whether the construct of PTSD should encompass a broad array of psychological manifestations that arise after trauma or should be focused more specifically on trauma memory phenomena. This controversy over clarifying the phenotype of PTSD has limited the capacity to identify biomarkers and specific mechanisms of traumatic stress. This review provides an up-to-date outline of the current definitions of PTSD, its known prevalence and risk factors, the main models to explain the disorder, and evidence-supported treatments. A major conclusion is that, although trauma-focused cognitive behavior therapy is the best-validated treatment for PTSD, it has stagnated over recent decades, and only two-thirds of PTSD patients respond adequately to this intervention. Moreover, most people with PTSD do not access evidence-based treatment, and this situation is much worse in low- and middle-income countries. Identifying processes that can overcome these major barriers to better management of people with PTSD remains an outstanding challenge.

Modeling Hierarchical Versus Random Exposure Schedules in Pavlovian Fear Extinction: No Evidence for Differential Fear Outcomes

In exposure therapy, the client can either be confronted with the fear-eliciting situations in a hierarchical way or in a random way. In the current study we developed a procedure to investigate the effects of hierarchical versus random exposure on long-term fear responding in the laboratory. Using a fear conditioning procedure, one stimulus (CS+) was paired with an electric shock (US), whereas another stimulus was not paired with the shock (CS-). The next day, participants underwent extinction training including presentations of the CS-, CS+ and a series of morphed stimuli between the CS- and CS+. In the hierarchical extinction condition (HE; N = 32), participants were first presented with the CS-, subsequently with the morph most similar to the CS-, then with the morph most similar to that one, and so forth, until reaching the CS+. In the random extinction condition (RE; N = 32), the same stimuli were presented but in a random order. Fear responding to the CS+, CS- and a new generalization stimulus (GS) was measured on the third day. Higher expectancy violation, t(62) = -2.67, p = .01, physiological arousal, t(62) = -2.08, p = .04, and variability in US-expectancy ratings, t(62) = -2.25, p = .03, were observed in the RE condition compared to the HE condition, suggesting the validity of this novel procedure. However, no differences between the RE and HE condition were found in fear responding as tested one day later, F(1, 62) < 1. In conclusion, we did not find evidence for differential long-term fear responding in modeling hierarchical versus random exposure in Pavlovian fear extinction.

Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders

Current medication for anxiety disorders is suboptimal in terms of efficiency and tolerability, highlighting the need for improved drug treatments. In this review an overview of drugs being studied in different phases of clinical trials for their potential in the treatment of fear-, anxiety- and trauma-related disorders is presented. One strategy followed in drug development is refining and improving compounds interacting with existing anxiolytic drug targets, such as serotonergic and prototypical GABAergic benzodiazepines. A more innovative approach involves the search for compounds with novel mechanisms of anxiolytic action using the growing knowledge base concerning the relevant neurocircuitries and neurobiological mechanisms underlying pathological fear and anxiety. The target systems evaluated in clinical trials include glutamate, endocannabinoid and neuropeptide systems, as well as ion channels and targets derived from phytochemicals. Examples of promising novel candidates currently in clinical development for generalised anxiety disorder, social anxiety disorder, panic disorder, obsessive compulsive disorder or post-traumatic stress disorder include ketamine, riluzole, xenon with one common pharmacological action of modulation of glutamatergic neurotransmission, as well as the neurosteroid aloradine. Finally, compounds such as D-cycloserine, MDMA, L-DOPA and cannabinoids have shown efficacy in enhancing fear-extinction learning in humans. They are thus investigated in clinical trials as an augmentative strategy for speeding up and enhancing the long-term effectiveness of exposure-based psychotherapy, which could render chronic anxiolytic drug treatment dispensable for many patients. These efforts are indicative of a rekindled interest and renewed optimism in the anxiety drug discovery field, after decades of relative stagnation.

Exposure Therapy With Personalized Real-Time Arousal Detection and Feedback to Alleviate Social Anxiety Symptoms in an Analogue Adult Sample: Pilot Proof-of-Concept Randomized Controlled Trial

BACKGROUND

Exposure therapy is highly effective for social anxiety disorder. However, there is room for improvement.

OBJECTIVE

This is a first attempt to examine the feasibility of an arousal feedback-based exposure therapy to alleviate social anxiety symptoms in an analogue adult sample.

METHODS

A randomized, pilot, proof-of-concept trial was conducted to evaluate the acceptability, safety, and preliminary efficacy of our treatment program. Sessions were administered once a week for 4 weeks (1 hour each) to an analogue sample of 50 young adults who reported at least minimal social anxiety symptoms. Participants in both intervention and waitlist control groups completed assessments for social anxiety symptoms at the baseline, week 5, and week 10.

RESULTS

Most participants found the intervention acceptable (82.0%, 95% CI 69.0%-91.0%). Seven (14.9%, 95% CI 7.0%-28.0%) participants reported at least one mild adverse event over the course of study. No moderate or serious adverse events were reported. Participants in the intervention group demonstrated greater improvements on all outcome measures of public speaking anxiety from baseline to week 5 as compared to the waitlist control group (Cohen d=0.61-1.39). Effect size of the difference in mean change on the overall Liebowitz Social Anxiety Scale was small (Cohen d=0.13).

CONCLUSIONS

Our results indicated that it is worthwhile to proceed to a larger trial for our treatment program. This new medium of administration for exposure therapy may be feasible for treating a subset of social anxiety symptoms. Additional studies are warranted to explore its therapeutic mechanisms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02493010; https://clinicaltrials.gov/ct2/show/NCT02493010.

Augmentation of Extinction and Inhibitory Learning in Anxiety and Trauma-Related Disorders

Although the fear response is an adaptive response to threatening situations, a number of psychiatric disorders feature prominent fear-related symptoms caused, in part, by failures of extinction and inhibitory learning. The translational nature of fear conditioning paradigms has enabled us to develop a nuanced understanding of extinction and inhibitory learning based on the molecular substrates to systems neural circuitry and psychological mechanisms. This knowledge has facilitated the development of novel interventions that may augment extinction and inhibitory learning. These interventions include nonpharmacological techniques, such as behavioral methods to implement during psychotherapy, as well as device-based stimulation techniques that enhance or reduce activity in different regions of the brain. There is also emerging support for a number of psychopharmacological interventions that may augment extinction and inhibitory learning specifically if administered in conjunction with exposure-based psychotherapy. This growing body of research may offer promising novel techniques to address debilitating transdiagnostic fear-related symptoms.

N-Methyl D-aspartate receptor subunit signaling in fear extinction

N-Methyl D-aspartate receptors (NMDAR) are central mediators of glutamate actions underlying learning and memory processes including those required for extinction of fear and fear-related behaviors. Consistent with this view, in animal models, antagonists of NMDAR typically impair fear extinction, whereas partial agonists have facilitating effects. Promoting NMDAR function has thus been recognized as a promising strategy towards reduction of fear symptoms in patients suffering from anxiety disorders and post-traumatic disorder (PTSD). Nevertheless, application of these drugs in clinical trials has proved of limited utility. Here we summarize recent advances in our knowledge of NMDAR pharmacology relevant for fear extinction, focusing on molecular, cellular, and circuit aspects of NMDAR function as they relate to fear extinction at the level of behavior and cognition. We also discuss how these advances from animal models might help to understand and overcome the limitations of existing approaches in human anxiety disorders and how novel, more specific, and personalized approaches might help advance future therapeutic strategies.

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Cognitive Behavioral Therapy for Childhood Anxiety Disorders: a Review of Recent Advances

PURPOSE OF REVIEW

We review recent research validating cognitive behavioral therapy (CBT) as a first-line intervention for childhood anxiety disorders. We also review recent research aimed at enhancing exposure-based CBT components and adapting CBT to work with specific populations.

RECENT FINDINGS

Exposure-based CBT is a well-established intervention. Different research groups have found positive evidence to augment CBT by evaluating inhibitory learning principles, the role of parents in child treatment, an individualized case formulation, computer and online forms of CBT, and virtual and augmented reality systems for exposure practice. Specific programs have been developed to meet specific needs of preschoolers, adolescents, and children with comorbid autism spectrum disorder and anxiety. Successful adaptations to CBT exist and the field should continue to improve the generalizability, feasibility, and expected benefit of CBT to improve its effectiveness.