Negative beliefs of spider phobics: A psychometric evaluation of the spider phobia beliefs questionnaire

Spider vs. guns: expectancy and attention biases to phylogenetic threat do not extend to ontogenetic threat

Introduction

Attention bias plays an important role in specific fears and phobias. Previous studies revealed that a-priori expectancies affect attention toward neutral stimuli but not threatening stimuli. The aim of the current study was to test whether this selective influence of expectancies on attention is specific to phylogenetic threat (i.e., spiders) or whether it can be generalized to ontogenetic threat (i.e., guns). Correspondingly, we directly compared expectancy effects on attentional allocation to phylogenetically vs. ontogenetically threatening stimuli.

Method

Expectancies were manipulated by presenting a cue indicating the likelihood of the appearance of a deviant picture in a visual search array. The array included eight distractors and one neutral (phone/bird) or threatening (gun/spider) deviant picture. In a comprehensive design, we examined the effects of stimulus type (phylogenetic/ontogenetic) and visual background (white and sterile/complex and ecological). Individual differences such as intolerance of uncertainty and spider fear were also measured.

Results

Results showed that attention bias toward spiders does not extend to threatening ontogenetic stimuli (i.e., guns). Our previous findings on attention bias toward spiders were replicated and a small to medium positive correlation was found between reaction time to bird targets and pre-existing fear of spider levels. Cues were used to detect threatening as well as neutral targets on both background types, except for spider targets on a complex background, replicating previous results. A small to medium positive correlation was also found between fear of spiders and intolerance of uncertainty.

Discussion

Together, these results suggest that expectancy and attentional processes may differ between ontogenetic and phylogenetic threat. Importantly, the effects of expectancy on attentional allocation depend on an interaction between the type of threat (ontogenetic/phylogenetic), visual factors, and individual differences.

Improving the efficacy of exposure therapy using projection-based augmented reality for the treatment of cockroach phobia: a randomised clinical trial protocol

INTRODUCTION

In vivo exposure is the treatment of choice for specific phobia (SP), but this technique presents limitations related to access and acceptability. Augmented reality (AR) offers advantages like maximising strategies such as 'variability' (varying stimuli, durations, levels of intensity or the order of the items), control by the therapist, or 'exposure to multiple contexts', which can produce positive effects in terms of fear renewal and generalisation of the results. The aim of this study is to test the efficacy of varying the phobic stimuli during treatment with AR: using multiple stimuli (MS) versus a single stimulus (SS) in participants with SP.

METHODS AND ANALYSIS

Participants (N=80) with a diagnosis of an SP of cockroaches will be randomised into two conditions: (1) projection-based AR exposure therapy with MS (P-ARET MS); (2) P-ARET with an SS (P-ARET SS). The measures are related to the efficacy results (fear, avoidance and negative thoughts, performance on the behavioural avoidance test (BAT) and preferences). The primary outcome measure is the BAT, and the secondary outcome measures are the BAT through AR, Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales Patient's Improvement Scale, and Beck Depression Inventory Second Edition. Five evaluation moments will be included: preintervention, postintervention, and 1-month, 6-month, and 12-month follow-ups. The treatment will follow the guidelines of the 'one-session treatment'. Student's t-tests to compare the two groups on the post-test will be applied. In addition, two-way analysis of variances with repeated measures in one of the two factors (pretest, post-test and follow-ups) will be carried out to compare intragroup differences.

ETHICS AND DISSEMINATION

The Universitat Jaume I Ethics Committee (Castellón, Spain) granted approval for the study (CD/64/2019). Dissemination will include publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04563403.

Effectiveness of a projection-based augmented reality exposure system in treating cockroach phobia: study protocol of a randomised controlled trial

BACKGROUND

Despite being the treatment of choice for phobic disorders, in vivo exposure treatment (IVET) presents some important limitations related mainly to low acceptance and high drop-out rates. Augmented reality (AR) technologies can help to overcome these limitations. Evidence supports the use of AR in exposure treatment for small animal phobia. A new projection-based AR exposure treatment system (P-ARET) that offers the possibility of projecting the animals in a natural and non-intrusive environment has been developed. There are no randomised controlled trials (RCTs) available that have tested the efficacy of this system in cockroach phobia. This paper aims to present the protocol of an RCT that evaluates the efficacy of the P-ARET, versus an IVET group and a waiting list control group (WL), in carrying out exposure treatment for cockroach phobia.

METHODS/DESIGN

Participants will be randomly allocated to one of three conditions: (1) P-ARET, (2) IVET and (3) WL. Both treatment conditions will follow the 'one-session treatment' guidelines. As a diagnostic measure, the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual for Mental Health Disorders-Version 5 will be used. The Behavioral Avoidance Test will be used as the primary outcome measure. Secondary outcome measures will include an attentional biases task (measured using eye-tracking technology), the Fear of Cockroaches Questionnaire, Cockroach Phobia Beliefs Questionnaire, Fear and Avoidance Scales, Beck Depression Inventory second edition, Disgust Propensity and Sensitivity Scale-Revised-12, State-Trait Anxiety Inventory, Clinician Severity Scale, and Expectation and Satisfaction with the Treatment Scale. The evaluation protocol will include pretreatment and post-treatment evaluations and 1, 6 and 12 months of follow-ups. Intention-to-treat and per-protocol analyses will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Universitat Jaume I (Castellón, Spain; 13 December 2019). The results of the presented RCT will be disseminated in presentations at international scientific meetings and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04563390.

Alternative Paradigms in Animal Health Decisions: A Framework for Treating Animals Not Only as Commodities

Simple Summary

Since zoonotic diseases can be transmitted from animals to humans, more comprehensive measures are needed when preventing and controlling these diseases. Because the value of animals is mainly based on monetary terms, animals are typically treated as commodities, impacting public health decisions. Therefore, a framework is proposed to value the health of animals beyond money for public health decision-making with a “One Health” approach. The aim is to have more comprehensive animal values based on the opinion of societies. However, tackling the dilemmas related to animal diseases, public health, and welfare still represents a challenge and a work in progress.

Abstract

Zoonoses are diseases transmitted from (vertebrate) animals to humans in the environment. The control and prevention of these diseases require an appropriate way to measure health value for prudent and well-balanced decisions in public health, production costs, and market values. Currently, the impact of diseases and animal disease control measures are typically assessed in monetary values, thus lacking consideration of other values such as emotional, societal, ecological, among others. Therefore, a framework is proposed that aims to explore, understand, and open up a conversation about the non-monetary value of animals through environmental and normative ethics. This method might help us complement the existing metrics in health, which are currently DALY and zDALY, adding more comprehensive values for animal and human health to the “One Health” approach. As an example of this framework application, participants can choose what they are willing to give in exchange for curing an animal in hypothetical scenarios selecting a human health condition to suffer, the amount of money, and lifetime as a tradeoff. Considering animals beyond their monetary value in public health decisions might contribute to a more rigorous assessment of the burden of zoonotic diseases, among other health decisions. This study is structured as follows: after a brief introduction of zoonoses, animal health, and health metrics, briefly, different environmental health perspectives are presented. Based on this, a framework for animal health decisions is proposed. This framework introduces the “anthropozoocentric interface” based on anthropocentrism and zoocentrism perspectives.

Facing Your Fear in Immersive Virtual Reality: Avoidance Behavior in Specific Phobia

Specific phobias are the most common anxiety disorder and are characterized by avoidance behavior. Avoidance behavior impacts daily function and is proposed to impair extinction learning. However, despite its prevalence, its objective assessment remains a challenge. To this end, we developed a fully automated experimental procedure using immersive virtual reality. The procedure contained a behavioral search, forced-choice, and an approach task with varying degrees of freedom and task relevance of the stimuli. In this study, we examined the sensitivity and feasibility of these tasks to assess avoidance behavior in patients with specific phobia. We adapted the tasks by replacing the originally conditioned stimuli with a spider and a neutral animal and investigated 31 female participants composed of 15 spider-phobic and 16 non-phobic participants. As the non-phobics were quite heterogeneous in terms of their Fear of Spiders Questionnaire (FSQ) scores, we subdivided them into six “fearfuls” that had elevated FSQ scores, and 10 “non-fearfuls” that had no fear of spiders. The phobics successfully managed to complete the procedure and showed consistent avoidance behavior across all behavioral tasks. Compared to the non-fearfuls, which did not show any avoidance behavior at all, the phobics looked at the spider much more often and clearly directed their body toward it in the search task. In the approach task, they hesitated most when they were close to the spider, and their difficulty to touch the spider was reflected in a strong increase in right hand acceleration changes. The fearfuls showed avoidance behavior depending on the tasks: strongest in the search task and weakest in the approach task. Additionally, we identified subjective valence ratings of the spider as the main influence on both objective avoidance behavior and subjective well-being after exposure, mediating the effect of the FSQ. In summary, the behavioral tasks are well suited to assess avoidance behavior in phobic participants and provide detailed insights into the process of avoidance.

Measuring fear evoked by the scariest animal: Czech versions of the Spider Questionnaire and Spider Phobia Beliefs Questionnaire

BACKGROUND

Although tiny in size and mostly harmless, spiders evoke exceptional fear in a significant part of the population and arachnophobia is one of the most common anxiety disorders with prevalence 2.7-6.1%. Two standard measures have been widely used to reliably assess the emotional and cognitive component of spider fear, the Spider Questionnaire (SPQ) and Spider Phobia Beliefs Questionnaire (SBQ). We aimed to develop and validate their Czech translations, describe distribution of spider fear in the Czech population, and analyse its association with disgust propensity and other sociodemographic characteristics.

METHODS

In Phase 1, we developed Czech translations of both questionnaires using a back-translation procedure and then tested their psychometric properties against their English versions in a counterbalanced experimental design using the Mann-Whitney U test and two-sided t-test. In Phase 2, we analysed scores on the Czech SPQ and SBQ on a larger sample. We evaluated the effects of age, gender, level of education, biology background, and association with the assessments of snake fear (i.e. the Snake Questionnaire, SNAQ) and disgust propensity (i.e. the Disgust Scale-Revised, DS-R) using a Spearman correlation, redundancy analysis, and general linear models.

RESULTS

We have demonstrated that the Czech SPQ and SBQ are equivalent to their originals and show excellent test-retest reliability (SPQ: 0.93; SBQ: 0.87-0.90). In total, 398 (10.3%) out of 3863 subjects reached the cut-off point for potential spider phobia. In addition, SPQ and SBQ scores were highly correlated (0.73-0.79), significantly more than with the SNAQ (0.21-0.32) or the DS-R (0.36-0.40). Two multivariate statistical methods revealed a significant association between the gender, age, level of education, biology background, or disgust propensity and the SPQ scores.

CONCLUSION

The Czech SPQ and SBQ may produce reliable and valid assessments of spider fear, but they must be further psychometrically tested considering the limitation of this study before wider use. We corroborate previous findings that fear of spiders is significantly associated with sociodemographic variables, such as gender, age, or education, as well as with the individual level of disgust propensity.

Expectations of objective threats and aversive feelings in specific fears

Mistaken beliefs about danger posed by feared stimuli are considered a key factor causing and maintaining fears. Such beliefs are intriguing because many fearful people express them, but acknowledge they are untrue in reality. While previous research indicates fearful individuals may not wholly endorse their beliefs about objective threats (e.g., the spider will bite), expectations of negative subjective consequences (e.g., I will feel terrible) are also likely to be important. We investigated the extent to which participants' expectations of objective and subjective threats were sensitive to manipulations that encouraged them to consider whether their expectations were likely to happen in reality. Across five online experiments (N = 560, or 727 with more liberal inclusion criteria), such manipulations produced lower expectancy ratings for objective but not subjective threats (versus participants who gave ratings without the manipulation). Most participants reported that anticipation of negative feelings was more concerning than actual danger. Hence, numerous fear-relevant expectations about objective threat-considered central in understanding why people are irrationally afraid-respond to small cognitive manipulations. Additionally, expectations of negative subjective experiences during fear-provoking encounters appear to be more consistently endorsed, and feature prominently in fearful individuals' concerns about what will happen in a fear-relevant situation.

Effectiveness of a smartphone-based, augmented reality exposure app to reduce fear of spiders in real-life: A randomized controlled trial

Although in vivo exposure therapy is highly effective in the treatment of specific phobias, only a minority of patients seeks therapy. Exposure to virtual objects has been shown to be better tolerated, equally efficacious, but the technology has not been made widely accessible yet. We developed an augmented reality (AR) application (app) to reduce fear of spiders and performed a randomized controlled trial comparing the effects of our app (six 30-min sessions at home over a two-week period) with no intervention. Primary outcome was subjective fear, measured by a Subjective Units of Distress Scale (SUDS) in a Behavioural Approach Test (BAT) in a real-life spider situation at six weeks follow-up. Between Oct 7, 2019, and Dec 6, 2019, 66 individuals were enrolled and randomized. The intervention led to significantly lower subjective fear in the BAT compared to the control group (intervention group, baseline: 7.12 [SD 2.03] follow-up: 5.03 [SD 2.19] vs. control group, baseline: 7.06 [SD 2.34], follow-up 6.24 [SD 2.21]; adjusted group difference -1.24, 95 % CI -2.17 to -0.31; Cohen's d = 0.57, p = 0.010). The repeated use of the AR app reduces subjective fear in a real-life spider situation, providing a low-threshold and low-cost treatment for fear of spiders.

Augmenting exposure therapy with pre-extinction fear memory reactivation and deepened extinction: A randomized controlled trial

BACKGROUND

Pre-extinction fear memory reactivation (PE-FMR) and deepened extinction (DE) enhance long-term extinction of shock-conditioned fear, and may also enhance long-term extinction of naturally acquired fear. Preliminary data suggest that PE-FMR may additionally boost the speed of fear reduction during exposure therapy.

DESIGN

Randomized controlled trial, factorial design.

METHODS

Participants with elevated fears of either spiders or snakes were randomized to (1) exposure therapy alone (n = 41), (2) exposure therapy + PE-FMR (n = 42), (3) exposure therapy + DE (n = 41), or (4) exposure therapy + PE-FMR + DE (n = 42). Participants were assessed at baseline, post-treatment, and one-week follow-up on subjective and behavioral indices of phobia. Because treatment length was tailored to speed of fear reduction, survival analyses were used to examine the speed of fear reduction during treatment.

RESULTS

DE did not improve clinical outcomes at post-treatment or follow-up, whereas PE-FMR produced more rapid fear reduction and was able to achive equivalent outcomes even when the duration of exposure therapy (tailored to speed of fear reduction) was shortened by an average of 21%.

CONCLUSIONS

Data suggest that PE-FMR is a promising strategy for reducing the overall duration of exposure-based therapies.

CLINICAL TRIAL REGISTRATION

(clinicaltrials.gov)NCT02160470.

Neuronal correlates of spider phobia in a combined fNIRS-EEG study

Specific phobia is associated with aberrant brain activation in confrontation paradigms with phobic stimuli. In previous EEG research enhanced event-related potentials (ERPs) in the late-positive potential (LPP) window have been observed. Further, studies with functional near-infrared spectroscopy (fNIRS) and fMRI suggest that spider phobia is associated with enhanced activation within cortical and subcortical areas. In the current study we investigated the neuronal correlates of spider phobia in a combined fNIRS-EEG study. To this end, 37 spider phobic patients (PP) and 32 healthy controls (HC) underwent a symptom provocation paradigm during which subjects watched video clips of spiders and domestic animals (confrontation phase) after being primed on the content of the video (anticipation phase). Simultaneously, fNIRS, EEG, electromyography (EMG), electrocardiography and behavioral measures were assessed. Results showed increased LPP amplitudes, increased hemodynamic responses in the cognitive control network, and increased EMG activity and heart rate during spider conditions in PP in comparison to HC. Furthermore, in behavioral ratings PP showed higher emotional distress and avoidance. Behavioral ratings, fNIRS and EEG data showed positive correlations on a between-subject as well as on a within-subject level. Our results merge the existing data on neurophysiological correlates of phobic stimulus processing in hemodynamic and electrophysiological research and extend those of static visual material (pictures) to dynamic visual material (videos).

Faster detection of snake and spider phobia: revisited

Snake and spider phobia are one of the most prevalent anxiety disorders, yet quick and reliable measures are rather scarce. Recently, attempts have been made to shorten two widespread measures of snake and spider fear, the Snake Questionnaire (SNAQ) and Spider Questionnaire (SPQ). The new 12-item scales demonstrate very good psychometric qualities in terms of internal consistency and discriminatory power. Using the same approach on a bigger sample from another cultural background, we aimed to verify psychometric properties of the short scales. In total, 2 644 Czechs completed the SNAQ, 1 816 of which also completed the SPQ. The item response theory revealed that nine and seven items on the shorter SNAQ and SPQ, respectively, were identical with the Hungarian study. The 12-item scales show excellent reliability (α = 0.84 and 0.91) and highly correlate with scores on the full versions (r = 0.81 and 0.89) as well as with fear and disgust ratings of snake and spider images. Thus, despite slight discrepancies in the selected items, we confirm that the shorter SNAQ and SPQ keep considerable diagnostic strengths and can be used in the clinical practice as reliable, easy-to- administer, and fast screening tools for snake and spider phobia.

Cortical oxygenation during exposure therapy - in situ fNIRS measurements in arachnophobia

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This is the first study that assessed cortical hemodynamic reactions during exposure therapy in situ.

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During exposure patients showed increased activity in the cognitive control network (CCN) compared to a control condition.

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CCN activity deceased during the session.

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Further, CCN activity was associated with fear ratings at the beginning of the session and this relationship decreased from session to session.

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.

No pills, more skills: The adverse effect of hormonal contraceptive use on exposure therapy benefit

Hormonal contraceptive use can aggravate existing symptoms of anxiety and depression and influence the response to pharmacologic treatment. The impact of hormonal contraceptive use on non-pharmacological treatment efficacy in anxiety disorders is less well explored. Oral contraceptives, which suppress endogenous sex hormone secretion, can alter fear extinction learning. Fear extinction is considered the laboratory proxy of exposure therapy in anxiety disorders. This study set out to examine whether oral contraceptive use is related to exposure-based treatment response in specific phobia. We recruited spider-phobic women (n = 28) using oral contraceptives (OC) and free-cycling women (n =26, No-OC). All participants were subjected to an identical in-vivo exposure. Exposure-based symptom improvement was assessed with several behavioral and subjective indices at pre-treatment, post-treatment and six-weeks follow-up. No-OC women showed higher pre-exposure fear levels on the FSQ and SPQ. OC women showed slightly less pronounced exposure benefit compared to their free-cycling counterparts (No-OC woman) as reflected by lower levels of fear reduction from pre-treatment to follow-up on the subjective level. After correction for multiple testing, OC and No-OC women showed differences in self-report measures (SPQ, FAS and SBQ) from pre- to follow-up treatment but not from pre-to post-treatment. These findings implicate that oral contraceptive use can account for differential exposure-based fear symptom improvement. Our study highlights the importance of monitoring and managing hormonal contraceptives use in the context of non-pharmacological exposure-based interventions.

The Scarier the Better: Maximizing Exposure Therapy Outcomes for Spider Fear

Background: While exposure therapy effectively reduces anxiety associated with specific phobias, not all individuals respond to treatment and some will experience a return of fear after treatment ceases. Aims: This study aimed to test the potential benefit of increasing the intensity of exposure therapy by adding an extra step that challenged uncontrollability (Step 15: allowing a spider to walk freely over one's body) to the standard fear hierarchy. Method: Fifty-one participants who had a severe fear of spiders completed two 60-min exposure sessions 1 week apart in a context that was either the same or different from the baseline and follow-up assessment context. Participants were categorized into groups based on the last hierarchy step they completed during treatment (Step 14 or fewer, or Step 15). Results: Those who completed Step 15 had greater reductions in fear and beliefs about the probability of harm from baseline to post-treatment than those who completed fewer steps. Although completing Step 15 did not prevent fear from returning after a context change, it allowed people to maintain their ability to tolerate their fear, which earlier steps did not. Despite some fear returning after a context change, individuals who completed Step 15 tended to report greater reductions in fear from baseline to the follow-up assessment than participants who completed 14 or fewer steps. Conclusions: Overall, these results suggest that more intensive exposure that directly challenges harm beliefs may lead to greater changes in fear and fear beliefs than less intensive exposure.

Effects of heart rate variability biofeedback during exposure to fear-provoking stimuli within spider-fearful individuals: study protocol for a randomized controlled trial

Background

Specific phobias are among the most common anxiety disorders. Exposure therapy is the treatment of choice for specific phobias. However, not all patients respond equally well to it. Hence, current research focuses on therapeutic add-ons to increase and consolidate the effects of exposure therapy. One potential therapeutic add-on is biofeedback to increase heart rate variability (HRV). A recent meta-analysis shows beneficial effects of HRV biofeedback interventions on stress and anxiety symptoms. Therefore, the purpose of the current trial is to evaluate the effects of HRV biofeedback, which is practiced before and utilized during exposure, in spider-fearful individuals. Further, this trial is the first to differentiate between the effects of a HRV biofeedback intervention and those of a low-load working memory (WM) task.

Methods

Eighty spider-fearful individuals participate in the study. All participants receive a training session in which they practice two tasks (HRV biofeedback and a motor pseudo-biofeedback task or two motor pseudo-biofeedback tasks). Afterwards, they train both tasks at home for 6 days. One week later, during the exposure session, they watch 16 1-min spider video clips. Participants are divided into four groups: group 1 practices the HRV biofeedback and one motor pseudo-task before exposure and utilizes HRV biofeedback during exposure. Group 2 receives the same training, but continues the pseudo-biofeedback task during exposure. Group 3 practices two pseudo-biofeedback tasks and continues one of them during exposure. Group 4 trains in two pseudo-biofeedback tasks and has no additional task during exposure. The primary outcome is fear of spiders (measured by the Fear of Spiders Questionnaire and the Behavioral Approach Test). Secondary outcomes are physiological measures based on electrodermal activity, electrocardiogram and respiration.

Discussion

This RCT is the first one to investigate the effects of using a pre-trained HRV biofeedback during exposure in spider-fearful individuals. The study critically contrasts the effects of the biofeedback intervention with those of pseudo-tasks, which also require WM capacity, but which do not have a physiological base. If HRV biofeedback is effective in reducing fear of spiders, it would represent an easy-to-use tool to improve exposure-therapy outcomes.

Trial registration

Deutsches Register Klinischer Studien, DRKS00012278. Registered on 23 May 2017, amendment on 5 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2554-2) contains supplementary material, which is available to authorized users.

Generalization of Extinguished Fear to Untreated Fear Stimuli after Exposure

Exposure therapy is highly effective in treating excessive fear related to specific objects and/or situations. However, patients with anxiety disorders often display a generalization of fear responses toward conceptually and perceptually related stimuli and situations. It is unclear whether the beneficial effects of exposure on fear reduction toward treated fear stimuli can extend to untreated fear stimuli. Here, we investigated whether basic principles of extinction generalization apply to exposure. Spider-phobic participants were randomly assigned to either two sessions of exposure treatment (n=23) with spiders or no-treatment (n=24). Prior to and after treatment, behavioral approach tests (BATs) were conducted to examine avoidance, fear and disgust responses toward the treated phobic stimulus (spider as the extinction stimulus). Likewise, BATs with the untreated fear stimulus (cockroach) were conducted to dissect the generalization of treatment effects. Treatment was highly effective in increasing approach behavior toward both treated and untreated fear stimuli. Generalization of treatment effects were evident on the behavioral (approach distance during the BAT), subjective (fear levels during the BAT) and psychophysiological level (heart rate during the BAT). However, a stronger decline in disgust was only evident for the treated fear stimulus. Notably, the herein attained generalization effects were not context-dependent. Hence, exposure therapy for spider phobia was effective in reducing fear of untreated stimuli which share common fear-evoking characteristics with spiders but were never presented during the respective exposure treatment. These findings provide clinical evidence for extinction generalization across different fear-evoking stimuli mediated via exposure.

Attention in action and perception: Unitary or separate mechanisms of selectivity?

What is the relation between the two visual stream hypothesis and selective visual attention? In this chapter, we first consider this question at a theoretical level before presenting an example of work from our lab that examines the question: Under what conditions does the emotional content of a visual object influence visually guided action? Previous research has demonstrated that fear can influence perception, both consciously and unconsciously, but it is unclear when fear influences visually guided action. The study tested participants with varying degrees of spiderphobia on two visually guided pointing tasks, while manipulating the emotional valence of the target (positive and negative) and the cognitive load of the participant (single vs dual task). Participants rapidly moved their finger from a home position to a suddenly appearing target image on a touch screen. The images were emotionally negative (e.g., spiders and scorpions) or positive (e.g., flowers and food). In order to test the effect of emotional valence on the online control of the reach, the target either remained static or jumped to a new location. In both the single and dual tasks, a stream of digits were presented on the screen near the finger's starting location, but only in the dual task were participants asked to identify a letter somewhere in the stream. In the single task, increased fear of spiders reduced the speed and accuracy of the movement. In the dual task, increased fear impaired letter identification, but pointing actions were now equally efficient for low- and high-fear participants. These results imply that the finger's autopilot is influenced by emotional content only when attention can be fully devoted to the identification of the emotion-evoking images. As such, the results support the view that the mechanisms of selection are not the same in the two visual streams.

The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective

In the context of clinical anxiety, safety behaviors are actions performed to prevent, escape, or minimize feared catastrophes and/or associated distress. Research consistently implicates safety behaviors in the development and maintenance of anxiety disorders; accordingly, safety behaviors are traditionally eliminated during exposure treatments for pathological anxiety. The notion that safety behaviors are ubiquitously deleterious in the context of exposure has recently been challenged, yet findings regarding safety behaviors' effects on exposure outcomes are limited, mixed, and controversial. Furthermore, developments in explanatory models for exposure's effectiveness (e.g., inhibitory learning theory) highlight other possible consequences of safety behaviors performed during exposure. Unfortunately, these theoretical advances are neglected in experimental research. The present review critically examines the literature addressing the role of safety behaviors in exposure therapy from an inhibitory learning perspective. Limitations, future directions, and clinical recommendations are also discussed.

In Vivo versus Augmented Reality Exposure in the Treatment of Small Animal Phobia: A Randomized Controlled Trial

Although in vivo exposure is the treatment of choice for specific phobias, some acceptability problems have been associated with it. Virtual Reality exposure has been shown to be as effective as in vivo exposure, and it is widely accepted for the treatment of specific phobias, but only preliminary data are available in the literature about the efficacy of Augmented Reality. The purpose of the present study was to examine the efficacy and acceptance of two treatment conditions for specific phobias in which the exposure component was applied in different ways: In vivo exposure (N = 31) versus an Augmented Reality system (N = 32) in a randomized controlled trial. "One-session treatment" guidelines were followed. Participants in the Augmented Reality condition significantly improved on all the outcome measures at post-treatment and follow-ups. When the two treatment conditions were compared, some differences were found at post-treatment, favoring the participants who received in vivo exposure. However, these differences disappeared at the 3- and 6-month follow-ups. Regarding participants' expectations and satisfaction with the treatment, very positive ratings were reported in both conditions. In addition, participants from in vivo exposure condition considered the treatment more useful for their problem whereas participants from Augmented Reality exposure considered the treatment less aversive. Results obtained in this study indicate that Augmented Reality exposure is an effective treatment for specific phobias and well accepted by the participants.

Augmented Reality: A Brand New Challenge for the Assessment and Treatment of Psychological Disorders

Augmented Reality is a new technological system that allows introducing virtual contents in the real world in order to run in the same representation and, in real time, enhancing the user's sensory perception of reality. From another point of view, Augmented Reality can be defined as a set of techniques and tools that add information to the physical reality. To date, Augmented Reality has been used in many fields, such as medicine, entertainment, maintenance, architecture, education, and cognitive and motor rehabilitation but very few studies and applications of AR exist in clinical psychology. In the treatment of psychological disorders, Augmented Reality has given preliminary evidence to be a useful tool due to its adaptability to the patient needs and therapeutic purposes and interactivity. Another relevant factor is the quality of the user's experience in the Augmented Reality system determined from emotional engagement and sense of presence. This experience could increase the AR ecological validity in the treatment of psychological disorders. This paper reviews the recent studies on the use of Augmented Reality in the evaluation and treatment of psychological disorders, focusing on current uses of this technology and on the specific features that delineate Augmented Reality a new technique useful for psychology.

fMRI neurofeedback facilitates anxiety regulation in females with spider phobia

Background: Spider phobics show an exaggerated fear response when encountering spiders. This fear response is aggravated by negative and irrational beliefs about the feared object. Cognitive reappraisal can target these beliefs, and therefore has a fear regulating effect. The presented study investigated if neurofeedback derived from functional magnetic resonance imaging (fMRI) would facilitate anxiety regulation by cognitive reappraisal, using spider phobia as a model of anxiety disorders. Feedback was provided based on activation in left dorsolateral prefrontal cortex and right insula, as indicators of engagement and regulation success, respectively.

Methods: Eighteen female spider phobics participated in a randomized, controlled, single-blinded study. All participants completed a training session in the MRI scanner. Participants assigned to the neurofeedback condition were instructed to shape their regulatory strategy based on the provided feedback. Participants assigned to the control condition were asked to adapt their strategy intuitively.

Results: Neurofeedback participants exhibited lower anxiety levels than the control group at the end of the training. In addition, only neurofeedback participants achieved down-regulation of insula activation levels by cognitive reappraisal. Group differences became more pronounced over time, supporting learning as a mechanism behind this effect. Importantly, within the neurofeedback group, achieved changes in insula activation levels during training predicted long-term anxiety reduction.

Conclusions: The conducted study provides first evidence that fMRI neurofeedback has a facilitating effect on anxiety regulation in spider phobia.

Effects of cognitive-behavioral therapy on brain responses to subliminal and supraliminal threat and their functional significance in specific phobia

BACKGROUND

Neurocircuitry models of anxiety disorders suggest dysregulated mechanisms encompassing both automatic and elaborate threat processing. However, the extent to which these processes might be differentially modified by psychotherapy and the neural basis of such changes are unknown. We examined the effects of cognitive-behavioral therapy (CBT) in patients with anxiety disorder on brain responses to subliminal and supraliminal threat.

METHODS

3-Tesla functional magnetic resonance imaging was used to assess neural responses to disorder-related stimuli, presented during two backward-masking conditions employed to manipulate stimulus awareness. In 28 spider-phobic patients randomly assigned to a therapy group or a waiting-list control group scanning was performed before and after completing CBT or a waiting period. Scanning was performed one time in 16 healthy control subjects. Self-report and behavioral measures were used to relate CBT-mediated brain activation changes with symptom improvement.

RESULTS

Untreated patients demonstrated abnormal hyperactivation in the amygdala, fusiform gyrus, insula, anterior cingulate cortex, and dorsomedial prefrontal cortex. Successful CBT was reflected in an overall downregulation in these fear circuitry structures, especially in the right amygdala and anterior cingulate cortex, with reductions in amygdala responsiveness associated with self-reported symptom improvement. However, subliminal threat induced a pattern of right-lateralized hyperactivation in the amygdala and fusiform gyrus that was subject to intersession habituation across groups without showing significant sensitivity to CBT.

CONCLUSIONS

These results challenge prevailing models that emphasize a role for amygdala automaticity in the maintenance of anxiety. Our results suggest CBT-related changes in neural activation associated with fear responses to consciously perceived threat.

Sleep enhances exposure therapy

BACKGROUND

Sleep benefits memory consolidation. Here, we tested the beneficial effect of sleep on memory consolidation following exposure psychotherapy of phobic anxiety.

METHOD

A total of 40 individuals afflicted with spider phobia according to DSM-IV underwent a one-session virtual reality exposure treatment and either slept for 90 min or stayed awake afterwards.

RESULTS

Sleep following exposure therapy compared with wakefulness led to better reductions in self-reported fear (p = 0.045, d = 0.47) and catastrophic spider-related cognitions (p = 0.026, d = 0.53) during approaching a live spider, both tested after 1 week. Both reductions were associated with greater percentages of stage 2 sleep.

CONCLUSIONS

Our results indicate that sleep following successful psychotherapy, such as exposure therapy, improves therapeutic effectiveness, possibly by strengthening new non-fearful memory traces established during therapy. These findings offer an important non-invasive alternative to recent attempts to facilitate therapeutic memory extinction and consolidation processes with pharmacological or behavioral interventions.

Moving from virtual reality exposure-based therapy to augmented reality exposure-based therapy: a review

This paper reviews the move from virtual reality exposure-based therapy to augmented reality exposure-based therapy (ARET). Unlike virtual reality (VR), which entails a complete virtual environment (VE), augmented reality (AR) limits itself to producing certain virtual elements to then merge them into the view of the physical world. Although, the general public may only have become aware of AR in the last few years, AR type applications have been around since beginning of the twentieth century. Since, then, technological developments have enabled an ever increasing level of seamless integration of virtual and physical elements into one view. Like VR, AR allows the exposure to stimuli which, due to various reasons, may not be suitable for real-life scenarios. As such, AR has proven itself to be a medium through which individuals suffering from specific phobia can be exposed "safely" to the object(s) of their fear, without the costs associated with programing complete VEs. Thus, ARET can offer an efficacious alternative to some less advantageous exposure-based therapies. Above and beyond presenting what has been accomplished in ARET, this paper covers some less well-known aspects of the history of AR, raises some ARET related issues, and proposes potential avenues to be followed. These include the type of measures to be used to qualify the user's experience in an augmented reality environment, the exclusion of certain AR-type functionalities from the definition of AR, as well as the potential use of ARET to treat non-small animal phobias, such as social phobia.

Brain, body, and cognition: neural, physiological and self-report correlates of phobic and normative fear

The phobic fear response appears to resemble an intense form of normal threat responding that can be induced in a nonthreatening situation. However, normative and phobic fear are rarely contrasted directly, thus the degree to which these two types of fear elicit similar neural and bodily responses is not well understood. To examine biological correlates of normal and phobic fear, 21 snake phobic and 21 nonphobic controls saw videos of slithering snakes, attacking snakes and fish in an event-related fMRI design. Simultaneous eletrodermal, pupillary, and self-reported affective responses were collected. Nonphobic fear activated a network of threat-responsive brain regions and involved pupillary dilation, electrodermal response and self-reported affect selective to the attacking snakes. Phobic fear recruited a large array of brain regions including those active in normal fear plus additional structures and also engendered increased pupil dilation, electrodermal and self-reported responses that were greater to any snake versus fish. Importantly, phobics showed greater between- and within-subject concordance among neural, electrodermal, pupillary, and subjective report measures. These results suggest phobic responses recruit overlapping but more strongly activated and more extensive networks of brain activity as compared to normative fear, and are characterized by greater concordance among neural activation, peripheral physiology and self-report. It is yet unclear whether concordance is unique to psychopathology, or rather simply an indicator of the intense fear seen in the phobic response, but these results underscore the importance of synchrony between brain, body, and cognition during the phobic reaction.

The effect of a retrieval cue on the return of spider fear

BACKGROUND AND OBJECTIVES

Exposure therapy is often used as treatment for anxiety disorders. However, a change in context after exposure can result in fear renewal. This renewal can be attenuated by using retrieval cues stemming from the exposure context. The present study investigated the effect of such a cue in spider-fearful persons.

METHODS

Thirty-three participants underwent an in vivo exposure session while wearing a bracelet (retrieval cue). After exposure, half of the participants continued to wear the bracelet at home until follow-up (cue groups); the other half handed over the bracelet after exposure (no cue groups). Half of the participants in each group received the follow-up in the exposure context (AAcue and AAnocue); for the other half follow-up was conducted in a novel environment (ABcue and ABnocue).

RESULTS

A switch in context at follow-up resulted in more self-reported anxiety and arousal compared to no switch. However, the retrieval cue did not attenuate this renewed responding.

LIMITATIONS

The number of participant per condition was limited, which might have obscured possible retrieval cue effects due to a lack of power. Additionally, information about the retrieval cue was provided after exposure, which might have weakened the association between the cue and exposure therapy. Furthermore, no autonomic measures were incorporated, restricting the effect to self-report measures. For future studies we would recommend to explicitly link the retrieval cue before onset of the exposure session and to incorporate autonomic measures.

CONCLUSIONS

Our findings indicate that a switch in context resulted in more self-reported anxiety and arousal, but that a cue stemming from the exposure context did not attenuate this renewal.

Well that changes everything! The genesis of memory bias for threat with implications for delayed onset in anxiety disorders

BACKGROUND AND OBJECTIVES

A number of aetiological pathways have been proposed in the development of anxiety disorders, including those associated with stressful triggering situations. Life events can provide new meaning to past situations, potentially leading to the delayed onset of a disorder. Whether or not a disorder will emerge is theoretically related to one's appraisal and memory of prior events, and memory biases are proposed to exist for threat-related information in association with anxiety. Given that new events may change the meaning of past experiences, threatening information may change one's memory for once-neutral events.

METHODS

The current study aimed to examine the effect of threatening information on memory for previously encoded (neutral) stimuli. Undergraduate participants (n = 81) interacted with 30 neutral objects (displayed in two boxes) and completed a recall memory test for these objects. They were then randomly assigned to receive either new threatening or new neutral information about half (one box) of the already-learned objects; a second recall test was then administered.

RESULTS

Individuals given threatening information showed a greater proportion of memory for items that were manipulated to total items recalled than did individuals given new non-threatening information.

LIMITATIONS

A nonclinical sample reported relatively low ratings of disgust and anxiety. Additionally, the time between the two memory tests was brief, likely differing from the actual occurrence of delayed onset disorders.

CONCLUSIONS

Results showed the genesis of a memory bias for threat in the presumed absence of an attentional bias, and are discussed in terms of the delayed onset of anxiety disorders.

Exposure therapy triggers lasting reorganization of neural fear processing

A single session of exposure therapy can eliminate recalcitrant and disabling fear of phobogenic objects or situations. We studied neural mechanisms of this remarkable outcome by monitoring changes in brain activity as a result of successful 2-h treatment. Before treatment, phobogenic images excited activity in a network of regions, including amygdala, insula, and cingulate cortex, relative to neutral images. Successful therapy dampened responsiveness in this fear-sensitive network while concomitantly heightening prefrontal involvement. Six months later, dampened fear-network activity persisted but without prefrontal engagement. Additionally, individual differences in the magnitude of visual cortex activations recorded shortly after therapy predicted therapeutic outcomes 6 mo later, which involved persistently diminished visual responsiveness to phobogenic images. Successful therapy thus entailed stable reorganization of neural responses to initially feared stimuli. These effects were linked to fear-extinction mechanisms identified in animal models, thus opening new opportunities for the treatment and prevention of debilitating anxiety disorders.

Danger Expectancies, Self-efficacy and Subjective Anxiety as Mediators of Avoidance Behaviour in Spider Phobia

Forty-five participants diagnosed with specific phobia (spiders) gave ratings of subjective anxiety, self-efficacy and the probability of being bitten or injured by a spider while completing a behavioural avoidance test involving exposure to a live spider. Testing was performed before and after treatment and at a 3-month follow-up. Results indicated that subjective anxiety was a more useful predictor of avoidance behaviour than self-efficacy. Danger expectancies in relation to being bitten and/or injured by a spider were not found to be a significant cognitive symptom in the majority of spider phobia sufferers during the behavioural avoidance test with a live spider. Methodological factors that may account for the low reporting of danger-related cognitions in the present study are discussed.

Pathways to change in one-session exposure with and without cognitive intervention: an exploratory study in spider phobia

It is well established that exposure therapy is an effective treatment for anxiety disorders. It is less clear, however, which mechanisms are crucial in explaining its success. In previous studies, cognitive change has been identified as a mediating variable. Several theorists have argued that the addition of cognitive interventions will, therefore, result in enhanced treatment effects. We tested this hypothesis by examining cognitive mediation of treatment in a purely behavioral versus a cognitive-behavioral exposure format. Thirty-one spider phobics were randomly assigned to either behavioral exposure or to exposure as a test for maladaptive cognitions (i.e., behavioral experiments). Both treatment formats showed large treatment effects and strong cognitive mediation of these effects. This indicates that, even when cognitions are not explicitly targeted, exposure effects are cognitively mediated. This challenges the idea that cognitions have to be explicitly challenged to elicit cognitive change in exposure treatment.

Comprehension of self-report evidence-based measures of anxiety

BACKGROUND

Given their applicability in diverse settings and for a wide range of purposes, the generalizability of self-report symptom measures is particularly important. An understudied factor in the development and validation of self-report measures is the degree to which they are difficult to comprehend. This study evaluated the difficulty of self-report measures of anxiety with respect to several domains, including formatting, length, and linguistic problems.

METHODS

Ninety-two evidence based measures of anxiety were evaluated for comprehension level.

RESULTS

The majority of anxiety measures included challenging elements of formatting, linguistic ability, and readability. Measures of obsessive-compulsive disorder were associated with the highest level of comprehension (i.e., greatest difficulty).

CONCLUSIONS

The validity of self-report measures relies on the ability of respondents to understand the instructions and measure items. Factors related to the comprehension of self-report measures should be included among the basic psychometric properties in measure development and validation. Future research on the development of self-report measures that can be more broadly applicable across levels of education and literacy are of particular importance to research, clinical, and public health agendas.

The relative contributions of fear and disgust reductions to improvements in spider phobia following exposure-based treatment

The present study examines the relative contributions of changes in state fear and disgust emotions to improvements in spider phobia observed with exposure-based treatment. Sixty-one treatment-seeking spider fearful individuals underwent a one-session exposure in vivo treatment. Growth curve analyses indicated that treatment was associated with significant improvements in state fear and disgust reactions to a live spider and self-reported trait spider phobia symptoms. Mediation analyses demonstrated that changes over time in state fear and disgust each explained unique variance in improvements in phobic symptoms over time. Examination of the effect size of the mediated pathways suggests that changes in fear and changes in disgust are important to reductions in the severity of spider phobia symptoms during exposure-based treatment. The implications of these findings for conceptualizing the role of fear and disgust emotions in the maintenance and treatment of spider phobia are discussed.