Ultra-brief behavioral skills trainings for blood injection injury phobia

Biofeedback Training to Increase P co2 in Asthma With Elevated Anxiety: A One-Stop Treatment of Both Conditions?

OBJECTIVE

Anxiety is highly prevalent in individuals with asthma. Asthma symptoms and medication can exacerbate anxiety, and vice versa. Unfortunately, treatments of comorbid anxiety and asthma are largely lacking. A problematic feature common to both conditions is hyperventilation. It adversely affects lung function and symptoms in asthma and anxiety. We examined whether a treatment to reduce hyperventilation, shown to improve asthma symptoms, also improves anxiety in asthma patients with high anxiety.

METHOD

One hundred twenty English- or Spanish-speaking adult patients with asthma were randomly assigned to either Capnometry-Assisted Respiratory Training (CART) to raise P co2 or feedback to slow respiratory rate (SLOW). Although anxiety was not an inclusion criterion, 21.7% met clinically relevant anxiety levels on the Hospital Anxiety and Depression Scale (HADS). Anxiety (HADS-A) and depression (HADS-D) scales, anxiety sensitivity (Anxiety Sensitivity Index [ASI]), and negative affect (Negative Affect Scale of the Positive Affect Negative Affect Schedule) were assessed at baseline, posttreatment, 1-month follow-up, and 6-month follow-up.

RESULTS

In this secondary analysis, asthma patients with high baseline anxiety showed greater reductions in ASI and PANAS-N in CART than in SLOW ( p values ≤ .005, Cohen d values ≥ 0.58). Furthermore, at 6-month follow-up, these patients also had lower ASI, PANAS-N, and HADS-D in CART than in SLOW ( p values ≤ .012, Cohen d values ≥ 0.54). Patients with low baseline anxiety did not have differential outcomes in CART than in SLOW.

CONCLUSIONS

For asthma patients with high anxiety, our brief training designed to raise P co2 resulted in significant and sustained reductions in anxiety sensitivity and negative affect compared with slow-breathing training. The findings lend support for P co2 as a potential physiological target for anxiety reduction in asthma.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00975273 .

Counter pressure maneuvers for syncope prevention: A semi-systematic review and meta-analysis

Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment cardiovascular control. However, these recommendations are largely based on theoretical benefit, with limited data evaluating the efficacy of CPM to prevent syncope in the real-world setting. We conducted a semi-systematic literature review and meta-analysis to assess CPM efficacy, identify literature gaps, and highlight future research needs. Articles were identified through a literature search (PubMed, April 2022) of peer-reviewed publications evaluating the use of counter pressure or other lower body maneuvers to prevent syncope. Two team members independently screened records for inclusion and extracted data. From 476 unique records identified by the search, 45 met inclusion criteria. Articles considered various syncopal conditions (vasovagal = 12, orthostatic hypotension = 8, postural orthostatic tachycardia syndrome = 1, familial dysautonomia = 2, spinal cord injury = 1, blood donation = 10, healthy controls = 11). Maneuvers assessed included hand gripping, leg fidgeting, stepping, tiptoeing, marching, calf raises, postural sway, tensing (upper, lower, whole body), leg crossing, squatting, “crash” position, and bending foreword. CPM were assessed in laboratory-based studies (N = 28), the community setting (N = 4), both laboratory and community settings (N = 3), and during blood donation (N = 10). CPM improved standing systolic blood pressure (+ 14.8 ± 0.6 mmHg, p < 0.001) and heart rate (+ 1.4 ± 0.5 bpm, p = 0.006), however, responses of total peripheral resistance, stroke volume, or cerebral blood flow were not widely documented. Most patients experienced symptom improvement following CPM use (laboratory: 60 ± 4%, community: 72 ± 9%). The most prominent barrier to employing CPM in daily living was the inability to recognize an impending faint. Patterns of postural sway may also recruit the skeletal muscle pump to enhance cardiovascular control, and its potential as a discrete, proactive CPM needs further evaluation. Physical CPM were successful in improving syncopal symptoms and producing cardiovascular responses that may bolster against syncope; however, practical limitations may restrict applicability for use in daily living.

Predicting vasovagal reactions to a virtual blood donation using facial image analysis

Background

People with needle fear experience not only anxiety and stress but also vasovagal reactions (VVR), including nausea, dizziness, sweating, pallor changes, or even fainting. However, the mechanism behind needle fear and the VVR response are not yet well understood. The aim of our study was to explore whether fluctuations in facial temperature in several facial regions are related to the level of experienced vasovagal reactions, in a simulated blood donation.

Study design and methods

We recruited 45 students at Tilburg University and filmed them throughout a virtual blood donation procedure using an Infrared Thermal Imaging (ITI) camera. Participants reported their fear of needles and level of experienced vasovagal reactions. ITI data pre‐processing was completed on each video frame by detecting facial landmarks and image alignment before extracting the mean temperature from the six regions of interest.

Results

Temperatures of the chin and left and right cheek areas increased during the virtual blood donation. Mixed‐effects linear regression showed a significant association between self‐reported vasovagal reactions and temperature fluctuations in the area below the nose.

Discussion

Our results suggest that the area below the nose may be an interesting target for measuring vasovagal reactions using video imaging techniques. This is the first in a line of studies, which assess whether it is possible to automatically detect levels of fear and vasovagal reactions using facial imaging, from which the development of e‐health solutions and interventions can benefit.

A comprehensive group-based cognitive behavioural treatment for blood-injection-injury phobia

OBJECTIVES

A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention.

METHODS

Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting).

RESULTS

There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others.

CONCLUSION

Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting.

PRACTITIONER POINTS

Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.

Transcutaneous Auricular Vagus Nerve Stimulation Combined With Slow Breathing: Speculations on Potential Applications and Technical Considerations

OBJECTIVES

Transcutaneous auricular vagus nerve stimulation (taVNS) is a relatively novel noninvasive neurostimulation method that is believed to mimic the effects of invasive cervical VNS. It has recently been suggested that the effectiveness of taVNS can be enhanced by combining it with controlled slow breathing. Slow breathing modulates the activity of the vagus nerve and is used in behavioral medicine to decrease psychophysiological arousal. Based on studies that examine the effects of taVNS and slow breathing separately, this article speculates on some of the conditions in which this combination treatment may prove effective. Furthermore, based on findings from studies on the optimization of taVNS and slow breathing, this article provides guidance on how to combine taVNS with slow breathing.

MATERIALS AND METHODS

A nonsystematic review.

RESULTS

Both taVNS and slow breathing are considered promising add-on therapeutic approaches for anxiety and depressive disorders, chronic pain, cardiovascular diseases, and insomnia. Therefore, taVNS combined with slow breathing may produce additive or even synergistic beneficial effects in these conditions. Studies on respiratory-gated taVNS during spontaneous breathing suggest that taVNS should be delivered during expiration. Therefore, this article proposes to use taVNS as a breathing pacer to indicate when and for how long to exhale during slow breathing exercises.

CONCLUSIONS

Combining taVNS with slow breathing seems to be a promising hybrid neurostimulation and behavioral intervention.

An Anti-hyperventilation Instruction Decreases the Drop in End-tidal CO2 and Symptoms of Hyperventilation During Breathing at 0.1 Hz

Breathing at a frequency of around 0.1 Hz is widely used in basic research and in applied psychophysiology because it strongly increases fluctuations in the cardiovascular system and affects psychological functioning. Volitional control of breathing often leads to hyperventilation among untrained individuals, which may produce aversive symptoms and alter the psychological and physiological effects of the paced breathing. The present study investigated the effectiveness of a brief anti-hyperventilation instruction during paced breathing at a frequency of 0.1 Hz. Forty-six participants were randomly assigned to one of two groups: a group given an anti-hyperventilation instruction and a control group without such an instruction. The instruction asked participants to avoid excessively deep breathing and to breathe shallowly and naturally. Participants performed the breathing task for 10 min. Hyperventilation was measured by partial pressure of end-tidal CO₂ (PetCO₂); furthermore, symptoms of hyperventilation, feeling of air hunger, task difficulty, and affective state were measured by self-report. The results showed that paced breathing without instruction decreased PetCO₂ by 5.21 mmHg and that the use of the anti-hyperventilation instruction reduced the drop in PetCO₂ to 2.7 mmHg. Symptoms of hyperventilation were lower in the group with the anti-hyperventilation instruction. Neither the feeling of air hunger nor task difficulty were affected by the instruction. There were no significant effects of the instruction on affective state. The present study indicates that a brief anti-hyperventilation instruction may be used to decrease drop in PetCO₂ and symptoms of hyperventilation during breathing at 0.1 Hz and that the instruction is well tolerated.

Recent developments in the intervention of specific phobia among adults: a rapid review

Specific phobia is highly prevalent worldwide. Although the body of intervention studies is expanding, there is a lack of reviews that summarise recent progress and discuss the challenges and direction of research in this area. Hence, this rapid review seeks to systematically evaluate the available evidence in the last five years in the treatment of specific phobias in adults. Studies published between January 2014 to December 2019 were identified through searches on the electronic databases of Medline and PsychINFO. In total, 33 studies were included. Evidence indicates that psychotherapy, and in particular cognitive behaviour therapy, when implemented independently or as an adjunctive, is a superior intervention with large effect sizes. Technology-assisted therapies seem to have a beneficial effect on alleviating fears and are described to be more tolerable than in vivo exposure therapy. Pharmacological agents are investigated solely as adjuncts to exposure therapy, but the effects are inconsistent; propranolol and glucocorticoid may be promising. A handful of cognitive-based therapies designed to alter fear arousal and activation pathways of phobias have presented preliminary, positive outcomes. Challenges remain with the inherent heterogeneity of specific phobia as a disorder and the accompanying variability in outcome measures and intervention approaches to warrant a clear conclusion on efficacy.

Large-Group One-Session Treatment: A Feasibility Study of Exposure Combined With Applied Tension or Diaphragmatic Breathing in Highly Blood-Injury-Injection Fearful Individuals

Objective: Large-group one-session treatments (LG-OSTs) might represent a promising treatment tool as increasing evidence suggests their effectiveness in individuals with different situational fears. In the present study, we explored feasibility and effectiveness of an exposure-based LG-OST protocol applying applied tension and diaphragmatic breathing as coping strategies in a sample of 40 individuals, highly fearful of blood-injury-injection (BII).

Method: We assessed participants’ BII-fear using questionnaires and a behavioral approach test (BAT) before and after treatment, consisting of a blood-drawing procedure. Stability of treatment effects was assessed via online-survey at 7-month follow-up.

Results: The LG-OST procedure evidenced feasible and effective. Pre-post treatment comparisons showed medium to large treatment effects (d = 0.40–0.93) regarding the questionnaire measures. After being treated, 70% of the individuals successfully underwent a blood drawing. Moreover, participants continued to improve in the post follow-up interval leading to large treatment effects (d = 1.19–1.62).

Conclusion: In treating BII-fear, LG-OSTs might not only serve within a framework of a stepped care approach but also could represent a useful single-treatment option. Additionally, due to their high efficiency and standardization of treatment delivery, LG-OST protocols might foster research at the interface of basic and clinical research.

Effects of respiratory and applied muscle tensing interventions on responses to a simulated blood draw among individuals with high needle fear

Fear of blood and needles increases risk for presyncopal symptoms. Applied muscle tension can prevent or attenuate presyncopal symptoms; however, it is not universally effective. This study examined the effects of applied muscle tension, a respiratory intervention, and a no treatment control condition, on presyncopal symptoms and cerebral oxygenation, during a simulated blood draw with individuals highly fearful of needles. Participants (n = 95) completed questionnaires, physiological monitoring, and two trials of a simulated blood draw with recovery. Presyncopal symptoms decreased across trials; however, no group differences emerged. Applied muscle tension was associated with greater cerebral oxygenation during trial two, and greater end-tidal carbon dioxide during both trials. The respiratory intervention did not differ from the no treatment control. Applied muscle tension is an intervention that can increase cerebral oxygenation and end-tidal carbon dioxide. While the respiratory intervention is promising within therapeutic settings, it was not efficacious after a brief audio training.