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Kooistra MJ, Hoeboer CM, Oprel DAC, Schoorl M, van der Does W, van Minnen A, de Kleine RA. Distress variability during exposure therapy and its relationship with PTSD symptom decline. J Behav Ther Exp Psychiatry 2024; 85:101983. [PMID: 39133979 DOI: 10.1016/j.jbtep.2024.101983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 07/12/2024] [Accepted: 08/02/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND AND OBJECTIVES Inhibitory Learning Theory (ILT) framework implies that in-session distress variability may promote extinction learning and thereby enhance exposure therapy efficacy. Thus far, research has mainly focused on in-session distress reduction. The aim of the current study was to assess whether in-session distress variability predicts next session PTSD symptom decline in PTSD patients receiving prolonged exposure (PE). METHODS Eighty-six patients with PTSD received 14 to 16 sessions of PE. Using dynamic panel models, we assessed the temporal relation (i.e., within-persons) between in-session distress variability and PTSD symptom decline. Moreover, we assessed the averaged relation (i.e., between-persons) between in-session distress variability and PTSD symptom decline. RESULTS Temporal analyses showed that in-session distress variability did not precede PTSD symptom improvement. Averaged analyses showed that distress variability was related to PTSD symptom improvement. LIMITATION The operationalization of distress variability appeared to deviate from its theoretical conceptualization. CONCLUSIONS In absence of distress reduction, distress variability can vary. However, our findings suggest that in-session distress variability does not drive symptom reduction during PE. In contrast, averaged over participants, distress variability was related to symptom improvement, suggesting that those with a more variable distress pattern across sessions show better treatment response. More empirical work is needed to shed light on the effect of distress variability during exposure sessions on treatment outcome and to offer grounds for clinical recommendations.
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Affiliation(s)
- Marike J Kooistra
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Chris M Hoeboer
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
| | - Danielle A C Oprel
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Maartje Schoorl
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Willem van der Does
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Agnes van Minnen
- PSYTREC, Prof. dr. Bronkhorststraat 2, 3723 MB, Bilthoven, the Netherlands; Radboud University, Behavioural Science Institute, Nijmegen, the Netherlands.
| | - Rianne A de Kleine
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
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Rosenberg BM, Moreira JFG, Leal ASM, Saragosa-Harris NM, Gaines E, Meredith WJ, Waizman Y, Ninova E, Silvers JA. Functional connectivity between the nucleus accumbens and amygdala underlies avoidance learning during adolescence: Implications for developmental psychopathology. Dev Psychopathol 2024:1-13. [PMID: 39324228 DOI: 10.1017/s095457942400141x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
BACKGROUND Reward and threat processes work together to support adaptive learning during development. Adolescence is associated with increasing approach behavior (e.g., novelty-seeking, risk-taking) but often also coincides with emerging internalizing symptoms, which are characterized by heightened avoidance behavior. Peaking engagement of the nucleus accumbens (NAcc) during adolescence, often studied in reward paradigms, may also relate to threat mechanisms of adolescent psychopathology. METHODS 47 typically developing adolescents (9.9-22.9 years) completed an aversive learning task during functional magnetic resonance imaging, wherein visual cues were paired with an aversive sound or no sound. Task blocks involved an escapable aversively reinforced stimulus (CS+r), the same stimulus without reinforcement (CS+nr), or a stimulus that was never reinforced (CS-). Parent-reported internalizing symptoms were measured using Revised Child Anxiety and Depression Scales. RESULTS Functional connectivity between the NAcc and amygdala differentiated the stimuli, such that connectivity increased for the CS+r (p = .023) but not for the CS+nr and CS-. Adolescents with greater internalizing symptoms demonstrated greater positive functional connectivity for the CS- (p = .041). CONCLUSIONS Adolescents show heightened NAcc-amygdala functional connectivity during escape from threat. Higher anxiety and depression symptoms are associated with elevated NAcc-amygdala connectivity during safety, which may reflect poor safety versus threat discrimination.
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Affiliation(s)
- Benjamin M Rosenberg
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - João F Guassi Moreira
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Adriana S Méndez Leal
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | | | - Elizabeth Gaines
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Wesley J Meredith
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Yael Waizman
- Department of Psychology, University of Southern California, Los Angeles, CA, USA
| | - Emilia Ninova
- College of Social Work, Florida State University, Tallahassee, FL, USA
| | - Jennifer A Silvers
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Melles H, Jansen A. Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa. J Eat Disord 2024; 12:141. [PMID: 39272190 PMCID: PMC11395645 DOI: 10.1186/s40337-024-01094-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Anxiety is a core characteristic of anorexia nervosa and a potential target of exposure therapy, which requires a profound understanding of the patients' fears in order to be successful. The knowledge about fears in anorexia nervosa that should be targeted during exposure therapy can be enriched by laboratory research to the precise emotional and behavioral responses of anorexia nervosa patients when they are exposed to disorder relevant fear stimuli. METHODS In the laboratory, patients with anorexia nervosa (n = 15) and healthy controls (n = 51) were exposed to 1. their own body weight and a 10% higher body weight on the scale, 2. a standardized lab breakfast, and 3. five virtual bodies with different BMIs ranging from extreme underweight to lower healthy weight. The participants emotional (anxiety, disgust, satisfaction, acceptance) and behavioral responses (calorie consumption) were assessed. Patients with anorexia nervosa but not the healthy controls then received an intensive exposure treatment (~ 30 individual exposure sessions) targeting their individual fears, next to standard care. After the exposure treatment, it was investigated whether the patients' responses to the laboratory tasks changed. RESULTS Across all tasks, the patients reported more anxiety than healthy controls. The patients also consumed less calories during the breakfast and accepted the different body weights on the scale less than healthy controls. During the virtual body exposure, the patients' emotional responses did not differ per avatar but they reacted more negatively towards avatars with healthier weights than did healthy controls. After the exposure treatment, the patients reported less fears and they consumed more calories while their BMIs had increased. They were also more accepting of healthier weights. CONCLUSIONS Exposure to food-, body- and weight-related stimuli in the laboratory induces emotional reactions in patients with anorexia nervosa that are informative for the identification of exposure therapy treatment targets. In addition, exposure therapy targeting individual fears in patients with anorexia nervosa led to symptom reduction and is a promising intervention for the treatment of anorectic fears, though more research is needed to optimize its efficacy.
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Affiliation(s)
- Hanna Melles
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Anita Jansen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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Barry TJ, Hallford DJ. Transdiagnostic and transtherapeutic strategies for optimising autobiographical memory. Behav Res Ther 2024; 180:104575. [PMID: 38852230 DOI: 10.1016/j.brat.2024.104575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Abstract
Our memories for past personally experienced autobiographical events play an important role in therapy, irrespective of presenting issue, diagnoses or therapeutic modality. Here, we summarise evidence for how autobiographical memory abilities can influence our mental health and the relevance of this for the treatment of mental health problems. We then guide the reader through principles and strategies for optimising autobiographical memory within treatment. We ground these recommendations within research for stand-alone interventions for improving autobiographical memory and from studies of how to support the formation and retrieval of therapeutic memories. Options are given for clinicians to guide clients in improving retrieval of autobiographical memories within treatment, for improving autobiographical memory for the therapeutic experience itself, and for creating improvements in autobiographical memory that endure post-treatment. We also provide worksheets for clinicians to use within treatment.
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Affiliation(s)
- T J Barry
- Department of Psychology, University of Bath, Bath, UK.
| | - D J Hallford
- School of Psychology, Deakin University, Melbourne, Australia
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King S, Stapert SZ, Winkens I, van der Naalt J, van Heugten CM, Rijkeboer MM. Efficacy of an Intensive Exposure Intervention for Individuals With Persistent Concussion Symptoms Following Concussion: A Concurrent Multiple Baseline Single-Case Experimental Design (SCED) Study. J Head Trauma Rehabil 2024; 39:E419-E429. [PMID: 38478748 DOI: 10.1097/htr.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
OBJECTIVE After a concussion, 1 in 3 patients report persistent symptoms and experience long-term consequences interfering with daily functioning, known as persistent concussion symptoms (PCS). Evidence suggests PCS is (partly) maintained by anxious thoughts about brain functioning, recovery, and experienced symptoms, leading to avoidance behaviors, which may prevent patients from meeting life demands. We aimed to investigate the efficacy of a newly developed intensive exposure intervention for individuals with PCS after concussion aimed to tackle avoidance behavior. SETTING Participants took part in the intervention at the Maastricht University faculty. PARTICIPANTS Four participants who experienced PCS after concussion partook in the exploratory study. Participants' age ranged between 20 and 32 (mean = 26.5, SD = 5.9) years, with an average length of time after the concussion of 9.8 months. DESIGN A concurrent multiple-baseline single-case design was conducted. The baseline period (A phase) length was randomly determined across participants (3, 4, 5, or 6 weeks). The exposure intervention (B phase) was conducted by psychologists over a 4-week period and consisted of 3 stages: exploration (2 sessions), active exposure (12 sessions conducted over 1 week), and 2 booster sessions. MAIN MEASURES Participants answered daily questions on a visual analog scale related to symptom experience, satisfaction with daily functioning, and degree of avoidance of feared activities. Additional outcomes included symptom severity, catastrophizing, fear of mental activity, anxiety, depression, and societal participation. RESULTS Tau-U yielded significant effects ( P < .05) for all participants on all measures when comparing baseline and intervention phases. The pooled standardized mean difference was high for all measures (symptom experience = 0.93, satisfaction of daily functioning = 1.86, and activity avoidance = -2.05). CONCLUSIONS The results show efficacy of the newly developed intensive exposure treatment for PCS after concussion, which is based on the fear avoidance model. Replication in a larger heterogeneous sample is warranted and needed.
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Affiliation(s)
- Skye King
- Author Affiliations: Departments of Neuropsychology and Psychopharmacology (Ms King and Drs Stapert, Winkens, and van Heugten) and Clinical Psychological Science (Dr Rijkeboer), Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands; Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands (Ms King and Drs Winkens and van Heugten); Department of Clinical and Medical Psychology, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands (Dr Stapert); and Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Dr van der Naalt)
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Kirchner L, Rief W, Müller L, Buchwald H, Fuhrmann K, Berg M. Depressive symptoms and the processing of unexpected social feedback: Differences in surprise levels, feedback acceptance, and "immunizing" cognition. PLoS One 2024; 19:e0307035. [PMID: 39186743 PMCID: PMC11346924 DOI: 10.1371/journal.pone.0307035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 06/26/2024] [Indexed: 08/28/2024] Open
Abstract
Negative social expectations are a key symptom of depression. It has been suggested that individuals with depressive symptoms tend to maintain these expectations by devaluing new experiences that do not fit prior expectations. However, our understanding of the role of such "immunizing" cognition in response to unexpected social feedback in depression, as well as the cognitive mechanisms involved, remains limited. This study investigated the association between depressive symptoms and the cognitive processing of unexpected positive or negative social feedback using a novel, video-based approach featuring naturalistic social stimuli in a subclinical online sample (N = 155). We also examined how surprise levels, feedback acceptance and immunizing cognition relate to other cognitive processes, such as attributional style and rumination, using cross-sectional network analyses. Robust multiple linear regression analyses revealed that depressive symptoms were associated with higher surprise levels (R2adj. = .27), lower feedback acceptance (R2adj. = .19), and higher levels of immunizing cognition (R2adj. = .09) in response to unexpected positive social feedback, but only partially to unexpected negative social feedback. The network analysis suggested that self-efficacy expectations for coping with negative feelings and acceptance of positive social feedback had the strongest expected influence on the different cognitive processes. Our study highlights the challenges that individuals with depressive symptoms face in utilizing positive social feedback to modify negative expectations. For clinicians, our findings suggest the importance of promoting acceptance of positive social feedback, while simultaneously inhibiting immunizing cognition and avoiding the use of overly positive feedback.
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Affiliation(s)
- Lukas Kirchner
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Lilly Müller
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Hannah Buchwald
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Kari Fuhrmann
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
| | - Max Berg
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Marburg, Marburg, Germany
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Jessup SC, Armstrong T, Hord CM, Dalmaijer ES, Olatunji BO. A multilevel examination of an inhibitory retrieval approach to exposure: Differentiating the unique and combined effects of multiple-context and multiple-stimulus cues. J Behav Ther Exp Psychiatry 2024; 86:101986. [PMID: 39178486 DOI: 10.1016/j.jbtep.2024.101986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/30/2024] [Accepted: 08/11/2024] [Indexed: 08/25/2024]
Abstract
BACKGROUND AND OBJECTIVES A proposed strategy for attenuating the return of fear is conducting exposure therapy in multiple contexts (e.g., different locations), which is believed to enhance the generalizability of safety learning. Although conducting exposure in multiple contexts can be differentiated from conducting exposure with multiple stimuli, the two strategies are often conflated. Furthermore, researchers have not yet determined whether one of these strategies, or a combination thereof, is most effective in attenuating fear renewal. METHODS Accordingly, the present treatment-analogue study examined the unique and combined effects of multiple-context and multiple-stimulus imagery-based exposure manipulations on threat expectancy, behavioral approach/anxiety, and attentional bias for threat over Zoom. Community adults (N = 134) who met diagnostic criteria for snake phobia were randomized to exposure to a single snake in multiple environmental contexts (MC), exposure to multiple snakes in a single environmental context (MS), or exposure to multiple snakes in multiple environmental contexts (MS/MC). RESULTS Results revealed significant reductions in threat expectancy and behavioral anxiety, but not attentional bias for threat in all three groups. However, behavioral approach declined over the course of exposure in the MS/MC condition but remained stable in the MC and MS conditions. There were no significant group differences in behavioral approach/anxiety or attentional bias at a one-week follow-up. However, participants in the MC condition reported lower threat expectancy at a one-week follow-up than the other groups and this group difference was partially mediated by lower mean distress during exposure. CONCLUSIONS Implications of these findings for the inhibitory retrieval theory are discussed.
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Genheimer H, Pauli P, Andreatta M. Elemental and configural representation of a conditioned context. Behav Brain Res 2024; 471:115119. [PMID: 38906481 DOI: 10.1016/j.bbr.2024.115119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024]
Abstract
A context can be conceptualized as a stable arrangement of elements or as the sum of single elements. Both configural and elemental representations play a role in associative processes. This study aimed to explore the respective contributions of these two representations of a context in the acquisition of conditioned anxiety in humans. Virtual reality (VR) can be an ecologically valid tool to investigate context-related mechanisms, yet the influence of the sense of presence within the virtual environment remains unclear. Forty-eight healthy individuals participated in a VR-based context conditioning wherein electric shocks (unconditioned stimulus, US) were unpredictably delivered in one virtual office (CTX+), but not in the other (CTX-). During the test phase, nine elements from each context were presented singularly. We found a cluster of participants, who exhibited heightened anticipation of the US for anxiety-related elements as compared to the other group. In contrast to their clear elemental representation, these individuals showed diminished discriminative responses between the two context's configurations. Discriminative responses to the contexts were boosted in those individuals, who had a weaker elemental representation. Importantly, the individual sense of presence significantly influenced the conditioned responses. These findings align with the dual-representation view of context and provide insights into the role of presence in eliciting (conditioned) anxiety responses.
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Affiliation(s)
- Hannah Genheimer
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, University of Würzburg, Germany
| | - Paul Pauli
- Department of Biological Psychology, Clinical Psychology, and Psychotherapy, University of Würzburg, Germany; Center of Mental Health, Medical Faculty, University of Würzburg, Germany
| | - Marta Andreatta
- General Psychiatry and Psychotherapy, University Hospital Tübingen, Germany.
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Rosenberg BM, Barnes-Horowitz NM, Zbozinek TD, Craske MG. Reward processes in extinction learning and applications to exposure therapy. J Anxiety Disord 2024; 106:102911. [PMID: 39128178 PMCID: PMC11384290 DOI: 10.1016/j.janxdis.2024.102911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 07/08/2024] [Accepted: 07/26/2024] [Indexed: 08/13/2024]
Abstract
Anxiety disorders are common and highly distressing mental health conditions. Exposure therapy is a gold-standard treatment for anxiety disorders. Mechanisms of Pavlovian fear learning, and particularly fear extinction, are central to exposure therapy. A growing body of evidence suggests an important role of reward processes during Pavlovian fear extinction. Nonetheless, predominant models of exposure therapy do not currently incorporate reward processes. Herein, we present a theoretical model of reward processes in relation to Pavlovian mechanisms of exposure therapy, including a focus on dopaminergic prediction error signaling, coinciding positive emotional experiences (i.e., relief), and unexpected positive outcomes. We then highlight avenues for further research and discuss potential strategies to leverage reward processes to maximize exposure therapy response, such as pre-exposure interventions to increase reward sensitivity or post-exposure rehearsal (e.g., savoring, imaginal recounting strategies) to enhance retrieval and retention of learned associations.
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Affiliation(s)
- Benjamin M Rosenberg
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
| | - Nora M Barnes-Horowitz
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
| | - Tomislav D Zbozinek
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Michelle G Craske
- Department of Psychology, University of California, Los Angeles (UCLA), Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Bohus M, Vonderlin R. [Dialectical behavioral therapy for complex posttraumatic stress disorder (DBT-PTSD): an evidence-based disorder-specific treatment program]. DER NERVENARZT 2024; 95:630-638. [PMID: 38874612 DOI: 10.1007/s00115-024-01680-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024]
Abstract
Dialectical behavioral therapy for complex posttraumatic stress disorders (DBT-PTSD) is a modular treatment program that was developed at the Central Institute for Mental Health at the University of Heidelberg, Germany in 2005-2021. DBT-PTSD is designed to meet the needs of patients with complex PTSD related to sexual or physical trauma in childhood and adolescence. It is specifically designed for patients suffering from severe emotional dysregulation, persistent self-injury, chronic suicidal ideation, severe dissociative symptoms and a markedly negative self-concept with a high level of guilt, shame, self-loathing and interpersonal problems. To address these different core symptoms, DBT-PTSD combines evidence-based therapeutic strategies: principles, rules, and skills of DBT, trauma-specific cognitive and exposure-based techniques, imaginative interventions and procedures for behavioral change. The treatment program is designed to be carried out in an outpatient (45 weeks) or residential (12 weeks) setting. The results from two randomized controlled trials showed large effect sizes across very different symptom domains and a significant superiority of DBT-PTSD over Cognitive Processing Therapy (CPT). Based on these results, DBT-PTSD is currently a promising evidence-based treatment program for all features of a complex PTSD after sexual abuse in childhood and adolescence.
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Affiliation(s)
- Martin Bohus
- Klinik für Psychosomatik und Psychotherapeutische Medizin, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland.
- McLean Hospital, Harvard Medical School, Boston, MA, USA.
- Forschungs- und Behandlungszentrum für Psychische Gesundheit, Abteilung für Klinische Psychologie und Psychotherapie, Ruhr Universität Bochum, Bochum, Deutschland.
| | - Ruben Vonderlin
- Klinik für Psychosomatik und Psychotherapeutische Medizin, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, J5, 68159, Mannheim, Deutschland
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11
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de Jong R, Lommen MJJ, de Jong PJ, van Hout WJPJ, Duin-van der Marel ACE, Nauta MH. Effectiveness of exposure-based treatment for childhood anxiety disorders: An open clinical trial to test its relation with indices of emotional processing and inhibitory learning. J Behav Ther Exp Psychiatry 2024; 83:101942. [PMID: 38309121 DOI: 10.1016/j.jbtep.2024.101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND AND OBJECTIVES The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises. METHODS Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change. RESULTS From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations. LIMITATIONS As patients also received other treatment elements, the results cannot be interpreted unequivocally. CONCLUSIONS The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Peter J de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | | | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
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Rief W, Asmundson GJG, Bryant RA, Clark DM, Ehlers A, Holmes EA, McNally RJ, Neufeld CB, Wilhelm S, Jaroszewski AC, Berg M, Haberkamp A, Hofmann SG. The future of psychological treatments: The Marburg Declaration. Clin Psychol Rev 2024; 110:102417. [PMID: 38688158 DOI: 10.1016/j.cpr.2024.102417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.
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Affiliation(s)
- Winfried Rief
- Philipps-University of Marburg, Department of Psychology, Clinical Psychology and Psychotherapy Group, Marburg, Germany.
| | | | - Richard A Bryant
- University of New South Wales, School of Psychology, Sydney, New South Wales, Australia
| | - David M Clark
- University of Oxford, Department of Experimental Psychology, Oxford, UK
| | - Anke Ehlers
- University of Oxford, Department of Experimental Psychology, Oxford, UK
| | - Emily A Holmes
- Uppsala University, Department of Women's and Children's Health, Uppsala, Sweden; Karolinska Institutet, Department of Clinical Neuroscience, Solna, Sweden
| | | | - Carmem B Neufeld
- University of São Paulo, Department of Psychology, Ribeirão Preto, SP, Brazil
| | - Sabine Wilhelm
- Massachusetts General Hospital and Harvard School of Medicine, Boston, USA
| | - Adam C Jaroszewski
- Massachusetts General Hospital and Harvard School of Medicine, Boston, USA
| | - Max Berg
- Philipps-University of Marburg, Department of Psychology, Clinical Psychology and Psychotherapy Group, Marburg, Germany
| | - Anke Haberkamp
- Philipps-University of Marburg, Department of Psychology, Clinical Psychology and Psychotherapy Group, Marburg, Germany
| | - Stefan G Hofmann
- Philipps-University of Marburg, Department of Psychology, Translational Clinical Psychology Group, Marburg, Germany
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13
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Klein AM, Hagen A, Mobach L, Zimmermann R, Baartmans JMD, Rahemenia J, de Gier E, Schneider S, Ollendick TH. The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology. Clin Child Fam Psychol Rev 2024; 27:602-625. [PMID: 38616213 PMCID: PMC11222243 DOI: 10.1007/s10567-024-00476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/16/2024]
Abstract
Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.
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Affiliation(s)
- Anke M Klein
- Developmental and Educational Psychology, Leiden University, Leiden, The Netherlands.
| | - Annelieke Hagen
- Developmental and Educational Psychology, Leiden University, Leiden, The Netherlands
| | - Lynn Mobach
- Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands
- Pro Persona Institute for Integrated Mental Health Care, Wolfheze, The Netherlands
| | - Robin Zimmermann
- Mental Health Research and Treatment Center (FBZ), Ruhr University, Bochum, Germany
| | | | - Jasmin Rahemenia
- Developmental and Educational Psychology, Leiden University, Leiden, The Netherlands
| | | | - Silvia Schneider
- Mental Health Research and Treatment Center (FBZ), Ruhr University, Bochum, Germany
| | - Thomas H Ollendick
- Department of Psychology, Child Study Center, Virginia Tech, Blacksburg, USA
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14
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Himle JA, LeBeau RT, Jester JM, Kilbourne AM, Weaver A, Brydon DM, Tucker KM, Hamameh N, Castriotta N, Craske MG. Work-Related Cognitive Behavioral Therapy for racially and economically diverse unemployed persons with social anxiety: A randomized clinical trial. J Anxiety Disord 2024; 104:102875. [PMID: 38763062 DOI: 10.1016/j.janxdis.2024.102875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024]
Abstract
Individuals with Social Anxiety Disorder (SAD) are at risk for employment problems. This multi-site trial examined the efficacy of Work-Related Cognitive Behavioral Therapy provided alongside vocational services as usual (WCBT+VSAU), a group-based treatment designed to improve mental health and employment outcomes for individuals with SAD. Vocational service-seeking participants with SAD (N = 250) were randomized to either WCBT+VSAU or VSAU-alone. Hypotheses were that participants randomized to WCBT+VSAU would report less social anxiety, less depression, and more hours worked than participants randomized to VSAU-alone. WCBT+VSAU participants had significantly greater improvements on the Liebowitz Social Anxiety Scale (LSAS; d=-.25, CI=-0.49 to -0.02, p = .03) at post-assessment compared to VSAU-alone. The conditions did not differ on any variable at later time points or on secondary outcomes. Unexpectedly, participants randomized to VSAU-alone experienced LSAS improvements, similar to WCBT+VASU at later timepoints. Baseline psychological flexibility (beta=-.098 [-0.19-0.008]) and depression (beta=-0.18 [-0.34-0.009]) moderated change in social anxiety. Participants with lower psychological flexibility and higher depression responded more strongly to WCBT+VSAU than VSAU-alone over the duration of the study, suggesting that WCBT+VSAU may particularly benefit those with greater psychopathology. Results indicate that vocational centers are promising settings for treating SAD and employment-focused refinements are likely needed to improve work outcomes.
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Affiliation(s)
- Joseph A Himle
- School of Social Work, University of Michigan, USA; Department of Psychiatry, Medical School, University of Michigan, USA.
| | - Richard T LeBeau
- Department of Psychology, University of California Los Angeles, USA
| | - Jennifer M Jester
- Department of Psychiatry, Medical School, University of Michigan, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, Medical School, University of Michigan, USA; Quality Enhancement Research Initiative, US Department of Veterans Affairs, Washington, DC, USA
| | - Addie Weaver
- School of Social Work, University of Michigan, USA
| | | | | | | | - Natalie Castriotta
- University of California, San Diego, USA; VA San Diego Healthcare System, USA
| | - Michelle G Craske
- Department of Psychology, University of California Los Angeles, USA; Department of Psychiatry & Biobehavioral Sciences, USA
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15
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Berg H, Webler RD, Klein S, Kushner MG. Extinction and beyond: an expanded framework for exposure and response prevention for obsessive-compulsive disorder. Front Psychol 2024; 15:1331155. [PMID: 38882510 PMCID: PMC11176611 DOI: 10.3389/fpsyg.2024.1331155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/15/2024] [Indexed: 06/18/2024] Open
Abstract
Exposure therapy is a first-line, empirically validated treatment for anxiety, obsessive-compulsive, and trauma-related disorders. Extinction learning is the predominant theoretical framework for exposure therapy, whereby repeated disconfirmation of a feared outcome yields fear reduction over time. Although this framework has strong empirical support and substantial translational utility, extinction learning is unlikely to be the sole process underlying the therapeutic effects of exposure therapy. In our clinic, we commonly treat obsessive-compulsive disorder (OCD) patients successfully with exposure therapy even when some or all of their feared outcomes are not amenable to disconfirmation and, by extension, to extinction learning. Herein, we present a generic clinical vignette illustrating a commonly encountered feared outcome in OCD that cannot be disconfirmed through exposure (damnation resulting from blasphemous thoughts). We describe two specific non-extinction-based strategies we commonly employ in such cases, and we associate these strategies with known change mechanisms that might account for their effectiveness: (1) non-associative habituation to aversive stimuli, and (2) fear-memory elicitation and subsequent reconsolidation. We discuss the limitations inherent in the reverse-translational approach taken and its opportunities for expanding the framework of exposure therapy.
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Affiliation(s)
- Hannah Berg
- Department of Psychology, University of Minnesota Twin Cities, Minneapolis, MN, United States
- Laureate Institute for Brain Research, Tulsa, OK, United States
| | - Ryan D Webler
- Department of Psychology, University of Minnesota Twin Cities, Minneapolis, MN, United States
| | - Samuel Klein
- Department of Psychology, University of Minnesota Twin Cities, Minneapolis, MN, United States
| | - Matt G Kushner
- Department of Psychiatry, University of Minnesota Twin Cities, Minneapolis, MN, United States
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16
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Xu J, Falkenstein MJ, Kuckertz JM. Feeling more confident to encounter negative emotions: The mediating role of distress tolerance on the relationship between self-efficacy and outcomes of exposure and response prevention for OCD. J Affect Disord 2024; 353:19-26. [PMID: 38423365 PMCID: PMC11059676 DOI: 10.1016/j.jad.2024.02.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND While exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond. In an effort to better understand the mechanisms behind ERP, the inhibitory learning model emphasizes the roles of increasing perceived self-efficacy and distress tolerance. While self-efficacy and distress tolerance have separately been shown to predict OCD symptoms and treatment outcomes, no studies have assessed their joint effects in ERP. The current study examined distress tolerance as a mediator of the relationship between self-efficacy and ERP outcomes. METHODS Patients in an intensive ERP-based treatment program (N = 116) completed weekly self-report measures. RESULTS Over the course of treatment, as OCD symptoms reduced, self-efficacy and distress tolerance both significantly increased. Importantly, increases in self-efficacy and distress tolerance mediated each other in explaining symptom reduction, suggesting a possible bi-directional effect. LIMITATIONS The temporal relationship between changes in self-efficacy and distress tolerance is worthy of further investigation. In addition, the current sample had limited racial diversity and might not be representative of patients receiving lower levels of care. Findings merit replication to be ascertained of their reliability. CONCLUSIONS Findings suggest that during ERP, patients gain confidence in their abilities both to cope with general challenges and to withstand distress, potentially helping them engage with exposures and overcome initial fears. These findings provide support for the inhibitory learning model and highlight the mechanistic roles of self-efficacy and distress tolerance in ERP. Clinical implications to target both in treatment are discussed.
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Affiliation(s)
- Junjia Xu
- Obsessive Compulsive Disorder Institute, McLean Hospital, United States of America
| | - Martha J Falkenstein
- Obsessive Compulsive Disorder Institute, McLean Hospital, United States of America; Harvard Medical School, United States of America
| | - Jennie M Kuckertz
- Obsessive Compulsive Disorder Institute, McLean Hospital, United States of America; Harvard Medical School, United States of America.
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17
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Lörsch F, Kollei I, Steins-Loeber S. The effects of a retrieval cue on renewal of conditioned responses in human appetitive conditioning. Behav Res Ther 2024; 176:104501. [PMID: 38520963 DOI: 10.1016/j.brat.2024.104501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/25/2024]
Abstract
Contextual renewal of reward anticipation may be one potential mechanism underlying relapse in eating and substance use disorders. We therefore tested retrieval cues, a method derived from an inhibitory retrieval-based model of extinction learning to attenuate contextual renewal using an appetitive conditioning paradigm. A pilot study was carried out in Experiment 1 to validate a differential chocolate conditioning paradigm, in which a specific tray was set up as a conditioned stimulus (CS) for eating chocolate (unconditioned stimulus, US). Using an ABA renewal design in Experiment 2, half of the participants were presented with a retrieval cue in the acquisition phase (group AC) and the other half in the extinction phase (group EC). Presentation of the retrieval cue in the EC was associated with reduced renewal of US-expectancy, while there was a clear renewal effect for US-expectancy in the AC. One limitation was the difference in cue presentations between both groups due to the number of trials in acquisition and extinction. Experiment 3 therefore aimed at replicating the results of Experiment 2, but with fewer cue presentations for the EC to match the AC. No significant group differences were observed indicating no effect of the retrieval cue. Theoretical and clinical implications in light of the differing results are discussed.
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Affiliation(s)
- Frank Lörsch
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, 96047, Bamberg, Germany.
| | - Ines Kollei
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, 96047, Bamberg, Germany
| | - Sabine Steins-Loeber
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Markusplatz 3, 96047, Bamberg, Germany
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18
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Reilly EE, Wierenga CE, Grange DL. Testing the role of associative learning in evidence-based treatments for anorexia nervosa. Int J Eat Disord 2024; 57:1088-1095. [PMID: 38323377 PMCID: PMC11093706 DOI: 10.1002/eat.24161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/08/2024]
Abstract
Treatments for anorexia nervosa (AN) remain ineffective for many patients. Processes that can account for differential treatment outcomes remain mostly unknown. We propose that the field test the role of associative learning in current psychological treatments. We hold that this line of research could yield actionable information for understanding non-response and improving long-term outcomes. To make this argument, we define associative learning and outline its proposed role in understanding psychiatric disorders and their treatment. We then briefly review data exploring associative learning in AN. We argue that associative learning processes are implicitly implicated in existing treatments; by this rationale, baseline differences in learning may interfere with treatment response. Finally, we outline future research to test our hypotheses. Altogether, future research aimed at better understanding how associative learning may contribute to AN symptom persistence has the potential to inform novel directions in intervention research. PUBLIC SIGNIFICANCE: There is a pressing need to improve outcomes in treatments for anorexia nervosa (AN). We propose that individual differences in associative learning-the ability to form and update associations between cues, contexts, behaviors, and outcomes-may account for differential response to existing treatments. Undertaking this research could provide an understanding of how current treatments work and inform new approaches for those who may be at risk of poor outcomes.
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Affiliation(s)
- Erin E. Reilly
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
| | | | - Daniel Le Grange
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California, USA
- Department of Psychiatry & Behavioral Neuroscience (Emeritus), The University of Chicago, Chicago, Illinois, USA
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19
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Boschet-Lange JM, Scherbaum S, Pittig A. Temporal dynamics of costly avoidance in naturalistic fears: Evidence for sequential-sampling of fear and reward information. J Anxiety Disord 2024; 103:102844. [PMID: 38428276 DOI: 10.1016/j.janxdis.2024.102844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/24/2023] [Accepted: 02/19/2024] [Indexed: 03/03/2024]
Abstract
Excessive avoidance is characteristic for anxiety disorders, even when approach would lead to positive outcomes. The process of how such approach-avoidance conflicts are resolved is not sufficiently understood. We examined the temporal dynamics of approach-avoidance in intense fear of spiders. Highly fearful and non-fearful participants chose repeatedly between a fixed no spider/low reward and a spider/high reward option with varying fear (probability of spider presentation) and reward information (reward magnitude). By sequentially presenting fear and reward information, we distinguished whether decisions are dynamically driven by both information (sequential-sampling) or whether the impact of fear information is inhibited (cognitive control). Mouse movements were recorded to assess temporal decision dynamics (i.e., how strongly which information impacts decision preference at which timepoint). Highly fearful participants showed stronger avoidance despite lower gains (i.e., costly avoidance). Time-continuous multiple regression of their mouse movements yielded a stronger impact of fear compared to reward information. Importantly, presenting either information first (fear or reward) enhanced its impact during the early decision process. These findings support sequential sampling of fear and reward information, but not inhibitory control. Hence, pathological avoidance may be characterized by biased evidence accumulation rather than altered cognitive control.
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Affiliation(s)
- Juliane M Boschet-Lange
- University of Würzburg, Department of Psychology (Biological Psychology, Clinical Psychology, and Psychotherapy), Marcusstraße 9-11, 97070 Würzburg, Germany
| | - Stefan Scherbaum
- Technische Universität Dresden, Department of Psychology, Dresden, Germany
| | - Andre Pittig
- University of Göttingen, Institute of Psychology, Translational Psychotherapy, Göttingen, Germany.
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20
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Kampa M, Stark R, Klucken T. The impact of extinction timing on pre-extinction arousal and subsequent return of fear. Learn Mem 2024; 31:a053902. [PMID: 38627067 PMCID: PMC11098463 DOI: 10.1101/lm.053902.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/07/2024] [Indexed: 04/19/2024]
Abstract
Exposure-based therapy is effective in treating anxiety, but a return of fear in the form of relapse is common. Exposure is based on the extinction of Pavlovian fear conditioning. Both animal and human studies point to increased arousal during immediate compared to delayed extinction (>+24 h), which presumably impairs extinction learning and increases the subsequent return of fear. Impaired extinction learning under arousal might interfere with psychotherapeutic interventions. The aim of the present study was to investigate whether arousal before extinction differs between extinction groups and whether arousal before extinction predicts the return of fear in a later (retention) test. As a highlight, both the time between fear acquisition and extinction (immediate vs. delayed) and the time between extinction and test (early vs. late test) were systematically varied. We performed follow-up analyses on data from 103 young, healthy participants to test the above hypotheses. Subjective arousal ratings and physiological arousal measures of sympathetic and hypothalamic pituitary adrenal axis activation (tonic skin conductance and salivary cortisol) were collected. Increased pre-extinction arousal in the immediate extinction group was only confirmed for subjective arousal. In linear regression analyses, none of the arousal measures predicted a significant return of fear in the different experimental groups. Only when we aggregated across the two test groups, tonic skin conductance at the onset of extinction predicted the return of fear in skin conductance responses. The overall results provide little evidence that pre-extinction arousal affects subsequent extinction learning and memory. In terms of clinical relevance, there is no clear evidence that exposure could be improved by reducing subjective or physiological arousal.
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Affiliation(s)
- Miriam Kampa
- Department of Clinical Psychology and Psychotherapy, University of Siegen, 57072 Siegen, Germany
- Bender Institute of Neuroimaging, Justus Liebig University, 35394 Giessen, Germany
| | - Rudolf Stark
- Bender Institute of Neuroimaging, Justus Liebig University, 35394 Giessen, Germany
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig University, 35394 Giessen, Germany
- Center for Mind, Brain, and Behavior (CMBB), University of Marburg, 35032 Marburg, Germany and Justus Liebig University, 35394 Giessen, Germany
| | - Tim Klucken
- Department of Clinical Psychology and Psychotherapy, University of Siegen, 57072 Siegen, Germany
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21
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van Veen SC, Zbozinek TD, van Dis EAM, Engelhard IM, Craske MG. Positive mood induction does not reduce return of fear: A virtual reality exposure study for public speaking anxiety. Behav Res Ther 2024; 174:104490. [PMID: 38354451 DOI: 10.1016/j.brat.2024.104490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
Previous laboratory work has shown that induction of positive mood prior to fear extinction decreases the negative valence of the conditional stimulus (CS) and reduces reinstatement of fear. Before translating these insights to clinical practice, it is important to test this strategy in anxious individuals. Students with a high fear of public speaking (N = 62) were randomized to either a positive mood induction, a negative mood induction, or no induction control group. All participants performed two weekly sessions of virtual reality exposure and a 1-week follow-up test including a spontaneous recovery test and reinstatement test after a social rejection (unconditional stimulus). We used self-reported fear measures and skin conductance responses. We expected that the positive group, compared to the other groups, would evaluate the CS (i.e., speaking in front of an audience) as less negative following exposure and would show less spontaneous recovery and reinstatement of fear following a social rejection. Although mood was successfully manipulated, there were no group differences in CS valence following exposure. In all conditions, VR exposure successfully reduced public speaking fear, and these effects were stable at follow-up. In contrast with expectations, the positive group showed more spontaneous recovery of CS negative valence than the negative group. To conclude, we found no evidence that positive mood induction prior to exposure optimizes exposure effects for anxious individuals.
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Affiliation(s)
| | - Tomislav D Zbozinek
- Division of Humanities and Social Sciences, California Institute of Technology, Pasadena, CA, United States
| | - Eva A M van Dis
- Department of Clinical Psychology, Utrecht University, the Netherlands
| | - Iris M Engelhard
- Department of Clinical Psychology, Utrecht University, the Netherlands.
| | - Michelle G Craske
- Department of Psychology, University of California, Los Angeles, CA, United States
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22
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Roesmann K, Asbrand J. Developmental pathways in youth anxiety disorders: potential mechanisms for (mal)adapting to crises and improving treatment - a commentary on Klein et al. (2023). J Child Psychol Psychiatry 2024; 65:229-232. [PMID: 37815123 DOI: 10.1111/jcpp.13905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/11/2023]
Abstract
The ability to cope with threats is crucial in today's troubling times, especially for young people who are still developing coping mechanisms. Psychopathology and the development of anxiety disorders can be viewed as a failure to adapt to changing demands. We draw on a study by Klein et al. (Journal of Child Psychology and Psychiatry, 2023), which showed that anxious youths exhibited stronger conditioned fear responses and, during delayed extinction learning, greater electrocortical differences between threat and safety stimuli. Interestingly, these signatures of learning processes were also associated with treatment outcomes. We argue for developmentally sensitive research: Individual learning and associated cognitive-affective changes are strongly age-dependent and represent the key mechanism for both anxiety development and treatment. They also interact with social and environmental factors. Based on the call for age- and context-sensitive research, future research should focus on establishing reliable risk profiles that consider a variety of factors to enable evidence-based, individualized treatment decisions.
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Affiliation(s)
- Kati Roesmann
- Institute of Psychology, Unit of Clinical Psychology and Psychotherapy in Childhood and Adolescence, University of Osnabrueck, Osnabruck, Germany
- Department of Psychology, Unit of Clinical Psychology and Psychotherapy, University of Siegen, Siegen, Germany
| | - Julia Asbrand
- Institute of Psychology, Department of Clinical Psychology in Childhood and Adolescence, University of Jena, Jena, Germany
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23
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Heinig I, Weiß M, Hamm AO, Hein G, Hollandt M, Hoyer J, Kanske P, Richter J, Wittchen HU, Pittig A. Exposure traced in daily life: improvements in ecologically assessed social and physical activity following exposure-based psychotherapy for anxiety disorders. J Anxiety Disord 2024; 101:102792. [PMID: 37989038 DOI: 10.1016/j.janxdis.2023.102792] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/02/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Although exposure-based cognitive-behavioral therapy for anxiety disorders has frequently been proven effective, only few studies examined whether it improves everyday behavioral outcomes such as social and physical activity. METHODS 126 participants (85 patients with panic disorder, agoraphobia, social anxiety disorder, or specific phobias, and 41 controls without mental disorders) completed smartphone-based ambulatory ratings (activities, social interactions, mood, physical symptoms) and motion sensor-based indices of physical activity (steps, time spent moving, metabolic activity) at baseline, during, and after exposure-based treatment. RESULTS Prior to treatment, patients showed reduced mood and physical activity relative to healthy controls. Over the course of therapy, mood ratings, interactions with strangers and indices of physical activity improved, while reported physical symptoms decreased. Overall results did not differ between patients with primary panic disorder/agoraphobia and social anxiety disorder. Higher depression scores at baseline were associated with larger changes in reported symptoms and mood ratings, but smaller changes in physical activity CONCLUSIONS: Exposure-based treatment initiates increased physical activity, more frequent interaction with strangers, and improvements in everyday mood. The current approach provides objective and fine-graded process and outcome measures that may help to further improve treatments and possibly reduce relapse.
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Affiliation(s)
- Ingmar Heinig
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany.
| | - Martin Weiß
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Alfons O Hamm
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Grit Hein
- Department of Psychiatry, Psychosomatics, and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany
| | - Maike Hollandt
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Philipp Kanske
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Jan Richter
- Department of Biological and Clinical Psychology/Psychotherapy, University of Greifswald, Greifswald, Germany; Department of Experimental Psychopathology University of Hildesheim, Hildesheim, Germany
| | - Hans-Ulrich Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Andre Pittig
- Translational Psychotherapy, Institute of Psychology, University of Goettingen, Germany
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24
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Kodzaga I, Dere E, Zlomuzica A. Generalization of beneficial exposure effects to untreated stimuli from another fear category. Transl Psychiatry 2023; 13:401. [PMID: 38114494 PMCID: PMC10730830 DOI: 10.1038/s41398-023-02698-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 11/26/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Previous research has shown that fear associated with one stimulus often spreads to other stimuli with similar perceptual features as well as across different stimulus categories. Exposure is considered as the most effective intervention to attenuate exaggerated fear. The extent to which exposure treatment effects can generalize to fears not targeted during treatment remains elusive. Previous studies on possible generalization of beneficial effects of exposure used stimuli sharing the same stimulus category and/or stimuli having high perceptual similarity. The current study examined whether exposure treatment generalization can be achieved for untreated stimuli which do not share any perceptual resemblance and belong to a different fear category. An analogue sample of fifty participants with fear of spiders (animal-related fears) and heights (natural environment-related fears) was tested. Participants have been randomly assigned to either an exposure treatment (n = 24) or a control condition (n = 26). Exposure treatment was designed to only target participants' fear of spiders, leaving their fear of heights untreated. Results demonstrated that the effects of exposure treatment generalized to fear of heights, as indicated by a reduction in behavioral avoidance, as well as self-reported acrophobia symptoms. The present study confutes the assumption that generalization of exposure effects to untreated fears is based on perceptual similarity. Clearly, further research is required to determine the decisive factors, in order to expand the generalization effect permanently to any given type of fear.
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Affiliation(s)
- Iris Kodzaga
- Department of Behavioral and Clinical Neuroscience, Ruhr-University Bochum (RUB), D-44787, Bochum, Germany
| | - Ekrem Dere
- Department of Behavioral and Clinical Neuroscience, Ruhr-University Bochum (RUB), D-44787, Bochum, Germany
- Sorbonne Université. UFR des Sciences de la Vie, F-75005, Paris, France
| | - Armin Zlomuzica
- Department of Behavioral and Clinical Neuroscience, Ruhr-University Bochum (RUB), D-44787, Bochum, Germany.
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Zeghari R, Gindt M, Guivarch J, Auby P, Robert P, Rolling J, Schröder C, Valo P, Askenazy F, Fernandez A. July 14th 2016 Nice Terrorist Attack Court Trial: A Protocol on Sleep Quality and Somatic Symptoms as Markers of Risk for Traumatic Reactivation in Adolescents Exposed to This Attack. Healthcare (Basel) 2023; 11:2953. [PMID: 37998445 PMCID: PMC10671086 DOI: 10.3390/healthcare11222953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
The court trial of the 14th of July 2016 terrorist attack in Nice (France) opened in September 2022 and ended in December 2022. Engaging in court proceedings, whether as a victim or a witness, can lead to a significant risk of traumatic reactivation (i.e., the re-emergence of post-traumatic stress symptoms). The present protocol aimed to improve knowledge of the pathophysiology of traumatic reactivation due to the media coverage of the trial by assessing sleep disturbances and somatic symptoms that could reappear if there is a traumatic reactivation. Method and Analysis: This is a monocentric longitudinal study, with recruitment solely planned at the Nice Pediatric Psychotrauma Center (NPPC). We intended to include 100 adolescents aged 12 to 17 years who were directly or indirectly exposed to the attack and included in the "14-7" program). Assessments began one month before the trial, in August 2022, and were scheduled once a month until the end of the trial. A smartwatch recorded sleep activity. Somatic and PTSD symptoms and sleep were assessed through validated questionnaires. The main analyses comprised the variance and regression analyses of predictors of clinical evolution over time. Ethics and Dissemination: The National Ethics Committee "NORD OUEST III" approved the "14-7" program protocol (number 2017-A02212-51). The specific amendment for this research was approved in April 2022 by the same national ethical committee. Inclusions started in August 2022.
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Affiliation(s)
- Radia Zeghari
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Morgane Gindt
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Jokthan Guivarch
- Department of Child Psychiatry, APHM, 13009 Marseille, France;
- CANOP Institut de Neurosciences de la Timone, UMR 7289, CNRS, Aix Marseille University, 13005 Marseille, France
- Faculty of Medicine, Aix-Marseille University, 13005 Marseille, France
| | - Philippe Auby
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Philippe Robert
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Julie Rolling
- Regional Center for Psychotraumatism Great East, Strasbourg University Hospital, 67000 Strasbourg, France
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, 67000 Strasbourg, France
- CNRS UPR3212-Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, 67000 Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, 67091 Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, 67091 Strasbourg, France
| | - Carmen Schröder
- Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, 67000 Strasbourg, France
- CNRS UPR3212-Research Team “Light, Circadian Rhythms, Sleep Homeostasis and Neuropsychiatry”, Institute of Cellular and Integrative Neurosciences, 67000 Strasbourg, France
- Excellence Centre for Autism and Neurodevelopmental Disorders STRAS&ND, 67091 Strasbourg, France
- Sleep Disorders Centre & International Research Centre for ChronoSomnology (Circsom), University Hospitals Strasbourg, 67091 Strasbourg, France
- Expert Centre for High-Functioning Autism, Fondation FondaMental, 67000 Strasbourg, France
| | - Petri Valo
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Florence Askenazy
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
| | - Arnaud Fernandez
- Nice Pediatric Psychotrauma Center (NPPC), Child and Adolescent Psychiatry Department, Hôpitaux Pédiatriques Universitaires Lenval, 06200 Nice, France
- CoBTeK (Cognition-Behaviour-Technology) Lab, Université Cote d’Azur, 06000 Nice, France
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Bonanno GR, Met Hoxha E, Robinson PK, Ferrara NC, Trask S. Fear Reduced Through Unconditional Stimulus Deflation Is Behaviorally Distinct From Extinction and Differentially Engages the Amygdala. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2023; 3:756-765. [PMID: 37881558 PMCID: PMC10593882 DOI: 10.1016/j.bpsgos.2023.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/19/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023] Open
Abstract
Background Context fear memory can be reliably reduced by subsequent pairings of that context with a weaker shock. This procedure shares similarities with extinction learning: both involve extended time in the conditioning chamber following training and reduce context-elicited fear. Unlike extinction, this weak-shock exposure has been hypothesized to engage reconsolidation-like processes that weaken the original memory. Methods We directly compared the weak-shock procedure with extinction using male and female Long Evans rats. Results Both repeated weak-shock exposure and extinction resulted in decreased context freezing relative to animals that received context fear conditioning but no subsequent context exposure. Conditioning with the weak shock was not enough to form a persistent context-shock association on its own, suggesting that the weak-shock procedure does not create a new memory. Weak-shock exposure in a new context can still reduce freezing elicited by the training context, suggesting that it reduces responding through a different process than extinction, which does not transcend context. Finally, reduced fear behavior produced through both extinction and weak-shock exposure was mirrored by reduced zif268 expression in the basolateral amygdala. However, only the weak-shock procedure resulted in changes in lysine-48 polyubiquitin tagging in the synapse of the basolateral amygdala, suggesting that this procedure produced long-lasting changes in synaptic function within the basolateral amygdala. Conclusions These results suggest that the weak-shock procedure does not rely on the creation of a new inhibitory memory, as in extinction, and instead may alter the original representation of the shock to reduce fear responding.
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Affiliation(s)
| | - Erisa Met Hoxha
- Purdue University Department of Psychological Sciences, West Lafayette, Indiana
| | - Payton K. Robinson
- Purdue University Department of Psychological Sciences, West Lafayette, Indiana
| | - Nicole C. Ferrara
- Purdue University Department of Psychological Sciences, West Lafayette, Indiana
- Rosalind Franklin University of Medicine and Science Discipline of Physiology and Biophysics, North Chicago, Illinois
- Center for Neurobiology of Stress Resilience and Psychiatric Disorders, North Chicago, Illinois
| | - Sydney Trask
- Purdue University Department of Psychological Sciences, West Lafayette, Indiana
- Purdue Institute for Integrative Neuroscience, West Lafayette, Indiana
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Matheve T, Hodges P, Danneels L. The Role of Back Muscle Dysfunctions in Chronic Low Back Pain: State-of-the-Art and Clinical Implications. J Clin Med 2023; 12:5510. [PMID: 37685576 PMCID: PMC10487902 DOI: 10.3390/jcm12175510] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.
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Affiliation(s)
- Thomas Matheve
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Ghent University, 9000 Gent, Belgium;
- REVAL—Rehabilitation Research Center, Faculty of Rehabilitation Sciences, UHasselt, 3500 Diepenbeek, Belgium
| | - Paul Hodges
- NHMRC—Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Australia;
| | - Lieven Danneels
- Spine, Head and Pain Research Unit Ghent, Department of Rehabilitation Sciences, Ghent University, 9000 Gent, Belgium;
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28
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Cohen ZD, Barnes-Horowitz NM, Forbes CN, Craske MG. Measuring the active elements of cognitive-behavioral therapies. Behav Res Ther 2023; 167:104364. [PMID: 37429044 DOI: 10.1016/j.brat.2023.104364] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 06/09/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.
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Affiliation(s)
- Zachary D Cohen
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States.
| | | | - Courtney N Forbes
- Department of Psychology, University of California, Los Angeles, United States
| | - Michelle G Craske
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, United States; Department of Psychology, University of California, Los Angeles, United States
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29
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Waters AM, Ryan KM, Luck CC, Craske MG, Lipp OV. Approximating exposure therapy in the lab: Replacing the CS+ with a similar versus a different stimulus and including additional stimuli resembling the CS+ during extinction. Behav Res Ther 2023; 167:104357. [PMID: 37364363 DOI: 10.1016/j.brat.2023.104357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023]
Abstract
Recent studies have shown that extinction training including the conditional stimulus (CS+) and stimuli that are similar to the CS + enhances extinction retention and generalisation to novel stimuli. However, in a clinical setting, the CS+ is rarely available for use during exposure therapy. The aim of the present study was to determine if replacing the CS+ with a similar versus different stimulus, and including other similar stimuli during extinction, could reduce fear at test on par with extinction using the original CS+ with and without other similar stimuli. In an experiment conducted in a single session, participants completed a habituation phase followed by an acquisition phase using two dog images presented with (CS+) and without (CS-) an acoustic unconditional stimulus (US). Participants were randomly allocated to four extinction conditions: similar CS + dog with novel dog images (Similar replacement extinction condition); different CS + dog with novel dog images (Different replacement extinction condition); original CS + dog with novel dog images (Multiple extinction control condition); and original CS + without novel dog images (Standard extinction control condition). All participants completed a test phase with the original CSs followed by a generalisation test with another two novel dog images. All groups acquired, and then extinguished differential skin conductance responses (SCRs) with no differences observed between groups. Whereas the Similar replacement extinction group and the Multiple and Standard extinction control groups did not exhibit significant differential SCRs when re-exposed to the original CS + relative to the CS- at test, differential responding to the CSs was significant at test in the Different replacement extinction group. There were no significant differences between groups in SCRs to the two novel dog images during the generalisation phase and in between-phase subjective ratings. Findings suggest that replacement stimuli used during extinction should be as similar as possible to the CS + to reduce physiological arousal to the original CS+.
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Affiliation(s)
| | | | | | - Michelle G Craske
- Department of Psychology & Department of Psychiatry & Biobehavioral Sciences, UCLA, United States
| | - Ottmar V Lipp
- School of Psychology and Counselling, Queensland University of Technology, Australia
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Blossom JB, Jungbluth N, Dillon-Naftolin E, French W. Treatment for Anxiety Disorders in the Pediatric Primary Care Setting. Child Adolesc Psychiatr Clin N Am 2023; 32:601-611. [PMID: 37201970 DOI: 10.1016/j.chc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Anxiety disorders are among the most diagnosed mental health problems in children and adolescents. Without intervention, anxiety disorders in youth are chronic, debilitating, and amplify risk of negative sequelae. Youth with anxiety present to primary care frequently and often families choose to first discuss mental health concerns with their pediatricians. Both behavioral and pharmacologic interventions can be effectively implemented in primary care, and research demonstrates the effectiveness of both approaches.
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Affiliation(s)
- Jennifer B Blossom
- Department of Psychology, University of Maine, 376 Williams Hall, Orono, ME 04473, USA.
| | - Nathaniel Jungbluth
- Seattle Children's, Partnership Access Line, P.O. Box 51023, Seattle, WA 98115-1023, USA
| | - Erin Dillon-Naftolin
- Seattle Children's, Partnership Access Line, P.O. Box 51023, Seattle, WA 98115-1023, USA; Seattle Children's, Child and Adolescent Psychiatry and Behavioral Medicine, M/S OA.5.154, PO Box 5371, Seattle, WA 98145-5005, USA; University of Washington, Child and Adolescent Psychiatry, Seattle, WA, USA
| | - William French
- Seattle Children's, Partnership Access Line, P.O. Box 51023, Seattle, WA 98115-1023, USA; Seattle Children's, Child and Adolescent Psychiatry and Behavioral Medicine, M/S OA.5.154, PO Box 5371, Seattle, WA 98145-5005, USA; University of Washington, Child and Adolescent Psychiatry, Seattle, WA, USA
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31
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Gromer D, Hildebrandt LK, Stegmann Y. The Role of Expectancy Violation in Extinction Learning: A Two-Day Online Fear Conditioning Study. CLINICAL PSYCHOLOGY IN EUROPE 2023; 5:e9627. [PMID: 37732150 PMCID: PMC10508258 DOI: 10.32872/cpe.9627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 04/03/2023] [Indexed: 09/22/2023] Open
Abstract
Background Exposure therapy is at the core of the treatment of pathological anxiety. While the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. Therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning. Method In total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. To experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. Consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively. Results We found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. On Day 2, inhibitory CS-noUS associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings. Conclusion These findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety.
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Affiliation(s)
- Daniel Gromer
- Department of Psychology, University of Würzburg, Würzburg, Germany
| | | | - Yannik Stegmann
- Department of Psychology, University of Würzburg, Würzburg, Germany
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32
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Bilek EL, Meyer AE, Tomlinson R, Chen C. Pilot Study of Self-Distancing Augmentation to Exposure Therapy for Youth Anxiety. Child Psychiatry Hum Dev 2023:10.1007/s10578-023-01540-x. [PMID: 37231323 DOI: 10.1007/s10578-023-01540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 05/27/2023]
Abstract
This pilot examines a self-distancing augmentation to exposure. Nine youth with anxiety (ages 11-17; 67% female) completed treatment. The study employed a brief (eight session) crossover ABA/BAB design. Exposure difficulty, engagement with exposure, and treatment acceptability were examined as primary outcome variables. Visual inspection of plots indicated that youth completed more difficult exposures during augmented exposure sessions [EXSD] than classic exposure sessions [EX] by therapist- and youth-report and that therapists reported higher youth engagement during EXSD than EX sessions. There were no significant differences between EXSD and EX on exposure difficulty or engagement by therapist- or youth-report. Treatment acceptability was high, although some youth reported that self-distancing was "awkward". Self-distancing may be associated with increased exposure engagement and willingness to complete more difficult exposures, which has been linked to treatment outcomes. Future research is needed to further demonstrate this link, and link self-distancing to outcomes directly.
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Affiliation(s)
- Emily L Bilek
- Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Rd., SPC 5765, Ann Arbor, MI, 48109, USA.
| | - Allison E Meyer
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rachel Tomlinson
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Carol Chen
- Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Rd., SPC 5765, Ann Arbor, MI, 48109, USA
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33
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Melles H, Duijvis S, Jansen A. Inhibitory Learning during Exposure Treatment in Anorexia Nervosa: A Practical Guide. Behav Sci (Basel) 2023; 13:bs13050370. [PMID: 37232607 DOI: 10.3390/bs13050370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Exposure therapy is known to be an effective intervention in the treatment of anxiety-related disorders. In eating disorders, such as anorexia nervosa, anxiety and avoidance are identified as maintenance factors. Therefore, they may constitute an important treatment target, suitable for the use of exposure therapy. Remarkably, exposure techniques to target fears and avoidance behaviors are not commonly used in the treatment of anorexia nervosa. We present a practical guide for the implementation of exposure therapy in the treatment of anorexia nervosa. We outline how exposure therapy is supposed to work according to the inhibitory learning model and how the exposure intervention can be designed for individuals with anorexia nervosa. Practical examples are provided through the case presentation of a patient with anorexia nervosa who completed 31 exposure sessions that focused on her fears of food, eating, weight, weight gain, their feared social consequences and the associated safety behaviors.
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Affiliation(s)
- Hanna Melles
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Stefanie Duijvis
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Anita Jansen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
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Kooistra MJ, Hoeboer CM, Oprel DAC, Schoorl M, van der Does W, Ter Heide JJ, van Minnen A, de Kleine RA. Changes in trauma-related cognitions predict subsequent symptom improvement during prolonged exposure in patients with childhood abuse-related PTSD. Behav Res Ther 2023; 163:104284. [PMID: 36870242 DOI: 10.1016/j.brat.2023.104284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/10/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
Change in negative posttraumatic cognitions is a proposed mechanism through which Prolonged Exposure (PE) leads to symptom reduction of posttraumatic stress disorder (PTSD). A strong case for posttraumatic cognitions as a change mechanism in PTSD treatment can be made by establishing temporal precedence of change in cognitions. The current study examines the temporal relationship between change in posttraumatic cognitions and PTSD symptoms during PE, using the Posttraumatic Cognitions Inventory. Patients with DSM-5 defined PTSD following childhood abuse (N = 83) received a maximum of 14-16 sessions of PE. Clinician-rated PTSD symptom severity and posttraumatic cognitions were assessed at baseline, week 4, 8, and 16 (post-treatment). Using time-lagged mixed effect regression models, we found that posttraumatic cognitions predicted subsequent PTSD symptom improvement. Notably, when using the items of an abbreviated version of the PTCI (PTCI-9), we found a mutual relationship between posttraumatic cognitions and PTSD symptom improvement. Crucially, the effect of change in cognitions on PTSD symptom change was greater than the reverse effect. The current findings corroborate change in posttraumatic cognitions as a change process during PE, but cognitions and symptoms cannot be completely separated. The PTCI-9 is a short instrument that appears suitable to track cognitive change over time.
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Affiliation(s)
- Marike J Kooistra
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Chris M Hoeboer
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands.
| | - Danielle A C Oprel
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Maartje Schoorl
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Willem van der Does
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | | | - Agnes van Minnen
- PSYTREC, Bronkhorststraat 2, 3723 MB, Bilthoven, the Netherlands; Radboud University, Behavioural Science Institute, Nijmegen, the Netherlands.
| | - Rianne A de Kleine
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
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35
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Moses K, Gonsalvez CJ, Meade T. Barriers to the use of exposure therapy by psychologists treating anxiety, obsessive-compuslive disorder, and posttraumatic stress disorder in an Australian sample. J Clin Psychol 2023; 79:1156-1165. [PMID: 36449416 DOI: 10.1002/jclp.23470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
BACGROUND Exposure therapy is a core component of the evidence-based treatment of anxiety, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). Despite this, many clinicians fail to use exposure therapy in clinical practice, with research highlighting a number of potential barriers. Those findings raise serious concerns regarding the effective dissemination and delivery of evidence-based treatments that in turn have a major impact on client care and cost-effectiveness of psychological interventions. AIMS The present study aims to examine barriers to the use of exposure therapy in the clinical practice of Australian psychologists treating anxiety, OCD and PTSD. METHOD One hundred registered psychologists, aged between 23 and 71 years and 84% female, participated in this study via online survey. RESULTS Results suggest that the most common barriers to the use of exposure therapy include lack of confidence, negative beliefs about exposure therapy, insufficient underpinning theoretical knowledge, client-specific barriers, and logistical limitations. CONCLUSIONS Future research may further examine those barriers and the components of additional training and supervision that can increase the uptake of exposure therapy, particularly in clinical areas where it is a gold standard of practice.
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Affiliation(s)
- Karen Moses
- School of Psychology, Western Sydney University, Penrith, Australia
| | - Craig J Gonsalvez
- School of Psychology, Western Sydney University, Penrith, Australia.,Translational Health Research Institute, Western Sydney University, Penrith, Australia
| | - Tanya Meade
- School of Psychology, Western Sydney University, Penrith, Australia.,Translational Health Research Institute, Western Sydney University, Penrith, Australia
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36
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Endhoven B, De Cort K, Matthijssen SJMA, de Jongh A, van Minnen A, Duits P, Schruers KRJ, van Dis EAM, Krypotos AM, Gerritsen L, Engelhard IM. Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE). BMC Psychiatry 2023; 23:157. [PMID: 36918861 PMCID: PMC10011792 DOI: 10.1186/s12888-022-04320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/18/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness. METHODS A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment. DISCUSSION The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach. TRIAL REGISTRATION ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.
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Affiliation(s)
- Bart Endhoven
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands.
- Altrecht Academic Anxiety Center, Nieuwe, Houtenseweg 12, 3524 SH, Utrecht, The Netherlands.
| | - Klara De Cort
- Academic Anxiety Center, Mondriaan/PsyQ, Oranjeplein 10, 6624 KD, Maastricht, The Netherlands
- Department of Psychiatry and Neuropsychology, Maastricht University, PO Box 616, 6200MD, Maastricht, The Netherlands
| | - Suzy J M A Matthijssen
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
- Altrecht Academic Anxiety Center, Nieuwe, Houtenseweg 12, 3524 SH, Utrecht, The Netherlands
| | - Ad de Jongh
- PSYTREC, Professor Bronkhorstlaan 2, 3723 MB, Bilthoven, The Netherlands
- Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam), Gustav Mahlerlaan 3004, 1081 LA, Amsterdam, The Netherlands
| | - Agnes van Minnen
- PSYTREC, Professor Bronkhorstlaan 2, 3723 MB, Bilthoven, The Netherlands
- Behavioural Science Institute, Radboud University, PO Box 9104, 6500HE, Nijmegen, The Netherlands
| | - Puck Duits
- Altrecht Academic Anxiety Center, Nieuwe, Houtenseweg 12, 3524 SH, Utrecht, The Netherlands
| | - Koen R J Schruers
- Academic Anxiety Center, Mondriaan/PsyQ, Oranjeplein 10, 6624 KD, Maastricht, The Netherlands
- Department of Psychiatry and Neuropsychology, Maastricht University, PO Box 616, 6200MD, Maastricht, The Netherlands
- Research Group Health Psychology, PO Box 3726, 3000, Leuven, KU, Belgium
| | - Eva A M van Dis
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
| | - Angelos M Krypotos
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
- Research Group Health Psychology, PO Box 3726, 3000, Leuven, KU, Belgium
| | - Lotte Gerritsen
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
| | - Iris M Engelhard
- Department of Clinical Psychology, Utrecht University, PO Box 80140, 3508 TC, Utrecht, The Netherlands
- Altrecht Academic Anxiety Center, Nieuwe, Houtenseweg 12, 3524 SH, Utrecht, The Netherlands
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Vervliet B. Fear Extinction as a Psychologist Views It. Curr Top Behav Neurosci 2023; 64:3-18. [PMID: 37498494 DOI: 10.1007/7854_2023_433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Fear extinction is a topic of central importance in translational neuroscience. It integrates knowledge from various disciplines, including clinical psychology, experimental psychology, psychiatry, cellular and systems neuroscience, and pharmacology. The experimental phenomenon of extinction was first discovered by Ivan P. Pavlov more than 100 years ago and still forms the basis for investigating the psychological and physiological mechanisms that drive extinction of fear. Here, I present old and new ways to think about fear conditioning and extinction from a psychologist's point of view. Extinction is a simple phenomenon with a complex machinery. Enhancing the behavioral analysis of extinction is necessary to advance research in neighboring disciplines as well and to increase our chances to develop extinction enhancers that might further improve efficacy of extinction-based therapies to treat dysfunctional fears. For that purpose, I address a number of fundamental questions in this chapter to clarify psychological viewpoints on the process of fear extinction. What is extinction? What is an association? What is fear? What can we learn from fear extinction? My goal is to reinforce critical thinking about basic assumptions underlying fear extinction and to open up new avenues for further research.
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Affiliation(s)
- Bram Vervliet
- Brain and Cognition, KU Leuven, Leuven, Belgium.
- Leuven Brain Institute, Leuven, Belgium.
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Kindt M, Elsey JWB. A paradigm shift in the treatment of emotional memory disorders: Lessons from basic science. Brain Res Bull 2023; 192:168-174. [PMID: 36442693 DOI: 10.1016/j.brainresbull.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/10/2022] [Accepted: 11/24/2022] [Indexed: 11/26/2022]
Abstract
Experiments demonstrating post-reactivation amnesia for learned fear in animals have generated a novel and influential hypothesis on the plasticity of memory, usually referred to as memory reconsolidation. The clinical potential of pharmacologically disrupting the process of memory reconsolidation has sparked a wave of interest into whether this phenomenon can also be demonstrated in humans, and ultimately harnessed for therapeutic purposes. In this essay we outline how the work of Karim Nader and colleagues has moved the field forward from a focus on extinction learning to the prospect of disrupting memory reconsolidation. We then review some promising findings on the necessary conditions, as well as potential boundary conditions, of pharmacologically disrupting the process of memory reconsolidation obtained in our laboratory. Even though laboratory experiments in animals and humans suggest that we may be at the brink of a breakthrough in fundamentally changing emotional memories, the necessary and sufficient conditions for targeting and disrupting memory reconsolidation in clinical practice are largely unknown. There is likely no universally effective reactivation procedure for triggering the reconsolidation of clinically significant emotional memories, and the impact of subtle boundary conditions observed in basic experiments compounds this issue. Notwithstanding these challenges, the discovery of changing emotional memory through disrupting the process of memory reconsolidation has unquestionably invigorated the field.
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Knowles KA, Jessup SC, Olatunji BO. Facing Uncertainty: A Comparison of Hierarchical and Variable Exposure Interventions for Contamination Fear. J Obsessive Compuls Relat Disord 2023; 36:100777. [PMID: 36582425 PMCID: PMC9794192 DOI: 10.1016/j.jocrd.2022.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
Consistent with the inhibitory retrieval approach, one proposed modification to improve the effectiveness of exposure-based interventions is to maximize variability by not proceeding linearly up an exposure hierarchy. Accordingly, the present study compares hierarchical and variable exposure interventions for contamination-fearful individuals and examines the role of uncertainty to predict intervention outcomes. Participants (N=73) were randomly assigned to complete a single-session exposure intervention using a standard hierarchy or a variable exposure intervention in which hierarchy items were randomly presented. Participants completed a behavioral approach task (BAT) at baseline and two follow-up visits over a two-week period. Both interventions resulted in a significant decrease in anxiety and disgust as well as more BAT steps completed but did not differ from one another. However, individuals in the variable exposure condition reported less variability in uncertainty during exposure compared to those in the standard condition, d=.78. Furthermore, lower levels of variability in uncertainty predicted greater reductions in anxiety and disgust post-intervention. Consistent with previous studies, variable exposure did not convey additional benefit over standard, hierarchical exposure. The experience of uncertainty during exposure is an important yet understudied process that warrants additional investigation.
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Craske MG, Sandman CF, Stein MB. How can neurobiology of fear extinction inform treatment? Neurosci Biobehav Rev 2022; 143:104923. [DOI: 10.1016/j.neubiorev.2022.104923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/08/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
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Knowles KA, Tolin DF. Mechanisms of Action in Exposure Therapy. Curr Psychiatry Rep 2022; 24:861-869. [PMID: 36399234 DOI: 10.1007/s11920-022-01391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE OF REVIEW Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness. RECENT FINDINGS Recent studies have examined mechanisms of exposure-based interventions across multiple levels of analysis, from cognitive and behavioral changes that occur during treatment to the neurobiological mechanisms underlying fear extinction. Belief change and reductions in safety behaviors and avoidance mediate symptom improvements during exposure therapy, suggesting plausible cognitive and behavioral mechanisms. On the neural level, increased activation of prefrontal regions during extinction learning is a likely mechanism of exposure. Improved understanding of the biological mechanisms of exposure have led to exciting developments in clinical research, including pharmacological augmentation, though clinical translation of basic research has produced mixed results. Though still in development, such translational research is a promising future direction for exposure-based interventions.
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Affiliation(s)
- Kelly A Knowles
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT, 06106, USA
| | - David F Tolin
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT, 06106, USA. .,Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA.
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Winkler CD, Koval P, Phillips LJ, Felmingham KL. Does prediction error during exposure relate to clinical outcomes in cognitive behavior therapy for social anxiety disorder? A study protocol. Front Psychiatry 2022; 13:1000686. [PMID: 37082515 PMCID: PMC10111196 DOI: 10.3389/fpsyt.2022.1000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Facing your fears, or exposure therapy, is an effective psychological intervention for anxiety disorders that is often thought to work through fear extinction learning. Fear extinction learning is a type of associative learning where fear reduces through repeated encounters with a feared situation or stimulus in the absence of aversive outcomes. Laboratory research suggests fear extinction learning is driven by threat prediction errors, defined as when fearful predictions do not eventuate. Threat prediction error and its relationship to exposure therapy outcomes haven't been studied enough in actual therapy settings. It remains unclear whether prediction error and extinction learning are central mechanisms of exposure therapy. We are conducting a longitudinal and observational study of how threat prediction error during exposure in social anxiety disorder (SAD) treatment relates to session-by-session symptom change and treatment outcome in addition to exposure surprise and learning outcome. We aim to recruit 65 adults with a primary diagnosis of SAD through an outpatient psychology clinic. Participants will receive 12 sessions of individual manualized cognitive behavioral therapy (CBT), adapted from an efficacious group protocol, that includes graded exposure. Exposure processes, including self-report measures of anxiety, threat prediction, threat outcomes, surprise, and learning outcome, will be measured with smartphone-based event-contingent ecological momentary assessments (EMAs) of all behavioral experiments completed during treatment. Clinical outcomes include self-reported social anxiety symptoms and social threat appraisals, at each session, post and 3-months after treatment. Prediction error will be operationalized as the mismatch between the threat prediction and threat outcome. The joint effect of threat prediction and threat outcome on session-by-session symptom change, treatment outcome, exposure surprise, and learning outcome will be explored using multilevel modeling. The present study will help determine whether threat prediction error during exposures in SAD treatment is related to theoretically implied clinical outcomes. This would contribute to the larger research aim of clarifying exposure therapy mechanisms.
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Affiliation(s)
- Christopher D. Winkler
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
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Carona C, Ramos K, Salvador C. Psychotherapy by Reciprocal Inhibition: Wolpe's unique legacy to the evolution of cognitive–behavioural therapy. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
SUMMARY
The book Psychotherapy by Reciprocal Inhibition (1968) is widely acclaimed as the masterwork of Joseph Wolpe, a great pioneer in the development of behavioural therapy, and is considered one of the most influential books in the history of clinical psychology. In this article, a brief biography of Wolpe is followed by a critical review of the book that illustrates his major contributions to the evolution of cognitive–behavioural therapy (CBT) as the most empirically supported model of psychotherapy.
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Effective – and tolerable: Acceptance and Side Effects of Intensified Exposure for Anxiety Disorders. Behav Ther 2022; 54:427-443. [PMID: 37088502 DOI: 10.1016/j.beth.2022.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 09/19/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022]
Abstract
Despite striking empirical support, exposure-based treatments for anxiety disorders are underutilized. This is partially due to clinicians' concerns that patients may reject exposure or experience severe side effects, particularly in intensive forms of exposure. We examined acceptance and side effects of two randomly assigned variants of prediction error-based exposure treatment differing in temporal density (1 vs. 3 sessions/week) in 681 patients with panic disorder, agoraphobia, social anxiety disorder, and multiple specific phobias. Treatment acceptance included treatment satisfaction and credibility, engagement (i.e., homework completion), and tolerability (i.e., side effects, dropout, and perceived treatment burden). Side effects were measured with the Inventory for the Balanced Assessment of Negative Effects of Psychotherapy (INEP). We found treatment satisfaction, credibility, and engagement to be equally high in both variants of exposure-based treatment, despite higher treatment burden (β = 0.25) and stronger side effects (β = 0.15) in intensified treatment. 94.1% of patients reported positive effects in the INEP. 42.2% reported side effects, with treatment stigma (16.6%), low mood (14.8%) and the experience to depend on the therapist (10.9%) being the most frequently reported. The mean intensity of side effects was low. We conclude that prediction error-based exposure treatment is well accepted by patients with different anxiety disorders and that patients also tolerate temporally intensified treatment, despite higher perceived treatment burden and stronger side effects. Clinicians should be aware of the most frequent side effects to take appropriate countermeasures. In sum, temporal intensification appears to be an acceptable strategy to achieve faster symptom reduction, given patients' well-informed consent.
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Merz CJ, Wolf OT. How stress hormones shape memories of fear and anxiety in humans. Neurosci Biobehav Rev 2022; 142:104901. [DOI: 10.1016/j.neubiorev.2022.104901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/29/2022]
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The Impact of COVID-19 Related Social Distancing on Mental Health Outcomes: A Transdiagnostic Account. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116596. [PMID: 35682179 PMCID: PMC9180779 DOI: 10.3390/ijerph19116596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 12/23/2022]
Abstract
The COVID-19 pandemic, and the social distancing practices that followed, have been associated with increased prevalence of emotional disorders. However, not all individuals affected by COVID-19-related social distancing experienced elevations in emotional disorder symptoms. Understanding this phenomenon is of crucial public health significance given the burden of emotional disorders on individuals and systems. In this narrative review, we consider the differential impact of COVID-19-related social distancing on mental health outcomes from a transdiagnostic perspective. We argue that individuals high in negative affect and aversive reactivity to emotion, that is, neuroticism, and who respond to such emotional experiences with emotion-motivated avoidant coping, are most likely to experience emotional disorders in the context of COVID-19 social distancing. We acknowledge the pro-social and adaptive function of some types of avoidance during the pandemic, which may have initially buffered against negative mental health outcomes. Implications of this conceptualization for treatment of emotional disorders in the present sociocultural context are discussed.
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