The potential impact of mindfulness on exposure and extinction learning in anxiety disorders

Effects of brief mindfulness training on smoking cue-reactivity in tobacco use disorder: Study protocol for a randomized controlled trial

BACKGROUND

The prevalence of Tobacco Use Disorder (TUD) represents a significant and pressing global public health concern, with far-reaching and deleterious consequences for individuals, communities, and healthcare systems. The craving caused by smoking cue is an important trigger for relapse, fundamentally hindering the cessation of cigarette smoking. Mindfulness interventions focusing on cue-reactivity was effective for the treatment of related dependence. Brief mindfulness training (BMT) meets the short-term needs for intervention but the effects still need to be examined. The objective of the present study is to investigate the impact of BMT intervention on smoking cue-reactivity among Chinese college students with TUD, to uncover the dynamic models of brain function involved in this process.

METHOD

A randomized control trial (RCT) based on electroencephalography (EEG) was designed. We aim to recruit 90 participants and randomly assign to the BMT and control group (CON) with 1:1 ratio. A brief mindfulness training will be administered to experimental group. After the intervention, data collection will be conducted in the follow-up stage with 5 timepoints of assessments. EEG data will be recorded during the smoking cue-reactivity task and 'STOP' brief mindfulness task. The primary outcomes include subjective reports of smoking craving, changes in EEG indicators, and mindfulness measures. The secondary outcomes will be daily smoking behaviours, affect and impulsivity, as well as indicators reflecting correlation between mindfulness and smoking cue-reactivity. To evaluate the impact of mindfulness training, a series of linear mixed-effects models will be employed. Specifically, within-group effects will be examined by analysing the longitudinal data. Additionally, the effect size for all statistical measurements will be reported, offering a comprehensive view of the observed effects.

DISCUSSION

The current study aims to assess the impact of brief mindfulness-based intervention on smoking cue-reactivity in TUD. It also expected to enhance our understanding of the underlying processes involved in brain function and explore potential EEG biomarkers at multiple time points.

TRIAL REGISTRATION

Trial registration number: ChiCTR2300069363, registered on 14 March 2023. Protocol Version 1.0., 10 April 2023.

Mindfulness training and exercise differentially impact fear extinction neurocircuitry

BACKGROUND

The ability to extinguish a maladaptive conditioned fear response is crucial for healthy emotional processing and resiliency to aversive experiences. Therefore, enhancing fear extinction learning has immense potential emotional and health benefits. Mindfulness training enhances both fear conditioning and recall of extinguished fear; however, its effects on fear extinction learning are unknown. Here we investigated the impact of mindfulness training on brain mechanisms associated with fear-extinction learning, compared to an exercise-based program.

METHODS

We investigated BOLD activations in response to a previously learned fear-inducing cue during an extinction paradigm, before and after an 8-week mindfulness-based stress reduction program (MBSR, n = 49) or exercise-based stress management education program (n = 27).

RESULTS

The groups exhibited similar reductions in stress, but the MBSR group was uniquely associated with enhanced activation of salience network nodes and increased hippocampal engagement.

CONCLUSIONS

Our results suggest that mindfulness training increases attention to anticipatory aversive stimuli, which in turn facilitates decreased aversive subjective responses and enhanced reappraisal of the memory.

Be more mindful: Targeting addictive responses by integrating mindfulness with cognitive bias modification or cue exposure interventions

This review provides an overview of the most prominent neurocognitive effects of cognitive bias modification (CBM), cue-exposure therapy and mindfulness interventions for targeting addictive responses. It highlights the key insights that have stemmed from cognitive neuroscience and brain imaging research and combines these with insights from behavioural science in building a conceptual model integrating mindfulness with response-focused CBM or cue-exposure interventions. This furthers our understanding of whether and how mindfulness strategies may i) facilitate or add to the induced response-focused effects decreasing cue-induced craving, and ii) further weaken the link between craving and addictive responses. Specifically, awareness/monitoring may facilitate, and decentering may add to, response-focused effects. Combined awareness acceptance strategies may also diminish the craving-addiction link. The conceptual model presented in this review provides a specific theoretical framework to deepen our understanding of how mindfulness strategies and CBM or cue-exposure interventions can be combined to greatest effect. This is important in both suggesting a roadmap for future research, and for the further development of clinical interventions.

Distress tolerance as a mechanism of mindfulness for depression and anxiety: Cross-sectional and diary evidence

Background

Both trait and state mindfulness are associated with less depression and anxiety, but the mechanisms remain unknown. Distress tolerance, an important transdiagnostic factor of emotional disorders, may mediate the relationship between mindfulness and depression/anxiety.

Method

Study 1 examined the mediation model at the between-person level in a large cross-sectional sample (n = 905). In Study 2, a daily diary study (n = 110) was conducted to examine within-person changes. Participants were invited to complete daily diaries measuring daily mindfulness, distress tolerance, depression and anxiety for 14 consecutive days.

Results

In Study 1, results of simple mediation analyses indicated that distress tolerance mediated the relationship between mindfulness and depression/anxiety at the between-person level. In Study 2, results of multilevel mediation analyses indicated that, in both the concurrent model and time-lagged model, daily distress tolerance mediated the effects of daily mindfulness on daily depression/anxiety at both the within- and between-person level.

Conclusions

Distress tolerance is a mechanism underlying the relationship between mindfulness and depression/anxiety. Individuals with high or fluctuating depression and anxiety may benefit from short-term or long-term mindfulness training to increase distress tolerance.

Psychedelics and neonihilism: connectedness in a meaningless world

The resurgence of psychedelic research explicitly targets treating mental health conditions largely through psychedelics-assisted psychotherapy. Current theories about mechanisms of change in psychedelics-assisted psychotherapy focus on mystical experiences as the main driver of symptom improvement. During these mystical experiences, participants report an enhanced sense of salience, connectedness, and meaning. Simultaneously, a growing psychedelic culture is also cultivating the use of psychedelics as medicine for relieving symptoms of anxiety and depression and promoting cognitive functions. We argue that an integral part of the excitement around the resurgence in psychedelics is in response to a meaning and alienation crisis that correlates with rising rates of anxiety and depression. Framing the absence of meaning as neonihilism, a contemporary correlate to the 19th-century phenomenon with unique features present in a neoliberal cultural context, we explore whether psychedelics combined with group therapy can provide answers to modern experiences of meaninglessness. Based on this exploration, we suggest concrete next steps both in the theory and practice of psychedelic psychotherapy toward what we are calling neonihilistic psychedelic group psychotherapy.

Electrophysiological correlates of mindfulness in patients with major depressive disorder

Objectives

Mindfulness-based interventions (MBI) can reduce both stress and depressive symptoms. However, the impact of mindfulness on stress level in depressed subjects remains unclear. This study aims to assess electrophysiological correlates of mindfulness in patients with major depressive disorder (MDD) at baseline, under stress exposure, and in relaxation following stress exposure.

Methods

Perceived mindfulness was assessed with the Freiburger Mindfulness Inventory (FMI) in 89 inpatients (mean age 51) with MDD [mean Beck Depression Inventory (BDI) 30]. Electrophysiological parameters [resting heart rate (RHR), heart rate variability (HRV), respiration rate, skin conductance, and skin temperature] were recorded at 5-min baseline, 1-min stress exposure, and 5-min self-induced relaxation.

Results

Freiburger Mindfulness Inventory was strongly inversely correlated with symptom severity measured by BDI (r = –0.53, p < 0.001). No correlations between FM score and electrophysiological parameters in any of the three conditions (baseline, stress exposure, relaxed state) could be found. The factor openness was associated with higher VLF (very low frequency of HRV) in the baseline condition. However, this correlation was no more significant after regression analysis when corrected for respiratory rate, age, and sex.

Conclusion

Autonomous nervous reactivity in depression was not associated with perceived mindfulness as measured by FMI score and presented electrophysiological parameters, despite the strong inverse correlation between state mindfulness and symptom severity.

Reductions in experiential avoidance explain changes in anxiety, depression and well-being after a mindfulness and self-compassion (MSC) training

OBJECTIVE

The mindfulness and self-compassion (MSC) protocol has shown efficacy in reducing mental illness symptoms and increasing well-being. However, little is known on how the positive outcomes are produced. This study explores how reductions in experiential avoidance following MSC training may explain changes in the participants' levels of anxiety, depression, and well-being.

METHODS

The 8-week protocol-based MSC training was delivered to 50 participants, and pre- to post- intervention changes in anxiety, depression, and well-being were measured. A series of mediation models were conducted, with changes in self-compassion as predictor, changes in experiential avoidance as mediator, and changes in mental health and well-being as outcome variables. Point estimates and bootstrap-corrected 95% confidence intervals were calculated to analyse indirect effects through experiential avoidance, by means of structural equation modeling (SEM).

RESULTS

Following MSC training, participants increased their levels of self-compassion, reduced experiential avoidance, and enhanced mental health (i.e., anxiety and depression symptoms) and well-being scores. Increases in self-compassion were associated with decreases in experiential avoidance, which in turn were connected with changes in anxiety, depression, and well-being from pre- to post-training. The indirect path through changes in experiential avoidance represented moderate to large proportions of the total effects of self-compassion change-scores on anxiety, depression, and well-being change-scores.

CONCLUSIONS

Reducing experiential avoidance and increasing psychological flexibility may be a key effect of MSC training linked to improvements of the participants' mental health and well-being scores. Self-compassion practices could exert effects on anxiety, depression and well-being mainly through promoting reductions in experiential avoidance.

Parenting Intervention for Psychological Flexibility and Emotion Regulation: Clinical Protocol and an Evidence-Based Case Study

Psychological flexibility has been found as a protective factor for several psychological problems, including the field of parenting. The present study aims to illustrate a clinical protocol, session by session, for the promotion of parental psychological flexibility and emotion regulation in a case study. The clinical protocol is based on third-wave behavior therapy in a brief intervention of four sessions. The intervention is presented in a clinical case of a mother with a child diagnosed with Oppositional Defiant Disorder. Both mother and child experienced problems with emotional regulation and psychological flexibility. The results show clinically significant improvements in psychological flexibility, emotional regulation, and stress parenting in the mother both after the intervention and at follow-up. In the child, emotional perspective-taking skills, acceptance, and valued actions improved. The case illustrates in detail the application of different strategies of acceptance, mindfulness, emotion regulation, and emotional defusion applicable to parenting. Clinical implications are discussed.

Psychological Dimensions Relevant to Motivation and Pleasure in Schizophrenia

Motivation and pleasure deficits are common in schizophrenia, strongly linked with poorer functioning, and may reflect underlying alterations in brain functions governing reward processing and goal pursuit. While there is extensive research examining cognitive and reward mechanisms related to these deficits in schizophrenia, less attention has been paid to psychological characteristics that contribute to resilience against, or risk for, motivation and pleasure impairment. For example, psychological tendencies involving positive future expectancies (e.g., optimism) and effective affect management (e.g., reappraisal, mindfulness) are associated with aspects of reward anticipation and evaluation that optimally guide goal-directed behavior. Conversely, maladaptive thinking patterns (e.g., defeatist performance beliefs, asocial beliefs) and tendencies that amplify negative cognitions (e.g., rumination), may divert cognitive resources away from goal pursuit or reduce willingness to exert effort. Additionally, aspects of sociality, including the propensity to experience social connection as positive reinforcement may be particularly relevant for pursuing social goals. In the current review, we discuss the roles of several psychological characteristics with respect to motivation and pleasure in schizophrenia. We argue that individual variation in these psychological dimensions is relevant to the study of motivation and reward processing in schizophrenia, including interactions between these psychological dimensions and more well-characterized cognitive and reward processing contributors to motivation. We close by emphasizing the value of considering a broad set of modulating factors when studying motivation and pleasure functions in schizophrenia.

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

Immediate & delayed effects of suppression and mindfulness as emotion regulation strategies

BACKGROUND & OBJECTIVES

Emotion regulation is an integral component of multiple physical and psychological functions, and problems with emotion regulation are thought to be involved with the development of psychological disorders. Most laboratory research on emotion regulation has been limited to investigating short-term impact during a single session.

DESIGN & METHODS

In the current study, we investigated the potential delayed consequences of the short-term use of two emotion regulation strategies: mindfulness and suppression. To do so, a two-session design was implemented, with 56 undergraduate participants viewing images under various regulation instructions at Time 1, returning one week later for a recognition memory test for these images at Time 2. Images were rated for valence and arousal at both time points.

RESULTS

We hypothesized that images encoded mindfully would elicit lower levels of anxiety upon re-exposure, while suppression would increase levels of anxiety. Results did not support original hypotheses: although participants reported being calmer and happier at re-exposure, this effect did not vary by strategy. High-anxiety participants reported higher arousal levels regardless of Instruction condition or Time Point.

CONCLUSIONS

These findings suggest that short-term use of emotion regulation does not impact feelings of calmness long-term, when exposed to anxiety-provoking stimuli.

Mindfulness-based interventions for eating disorders: The potential to mobilize multiple associative-learning change mechanisms

Mindfulness is a two-component skill that includes mindful awareness (attentional monitoring of present moment experience) and mindful acceptance (adopting an attitude of acceptance toward this experience). Although mindfulness-based interventions (MBIs) are efficacious for many conditions, there is a lack of research on MBIs for eating disorders (EDs). We propose that MBIs may be promising for EDs given their potential to mobilize not one, but multiple associative-learning change mechanisms in EDs-defined as adaptive processes of change involving one of two forms of associative-learning: Pavlovian and operant learning. We hypothesize how MBIs-via increasing either mindful awareness or mindful acceptance-may mobilize up to eight associative-learning change mechanisms, two involving Pavlovian learning, and six involving operant learning. We also elaborate on similarities and differences between MBIs and CBT approaches for EDs, as well as opportunities for synergy. Finally, we present recommendations for future research related to the development and evaluation of novel MBI interventions for EDs and the testing of mechanisms and patient-treatment matching hypotheses.

Is cognitive inflexibility a missing link? The role of cognitive inflexibility, alexithymia and intolerance of uncertainty in externalising and internalising behaviours in young people with autism spectrum disorder

BACKGROUND

Internalising (anxiety and low mood) and externalising (aggressive or outburst behaviours, and irritability) difficulties are very common in autism spectrum disorder (ASD) across the life span, relatively stable over time and often associated with poorer quality of life. Understanding the cognitive mechanisms underlying internalising and externalising difficulties in ASD is essential for developing targeted supports and interventions. In the present study, we investigated established and less-researched cognitive factors hypothesised to contribute to internalising and/or externalising difficulties in ASD, namely cognitive inflexibility (CI), intolerance of uncertainty (IU) and alexithymia. Based on previous models and clinical experience, we hypothesised that IU would lead to internalising symptoms, with alexithymia contributing to this pathway, and that CI would have a direct effect on externalising behaviours and may indirectly contribute to internalising symptoms via increasing IU.

METHODS

Our sample consisted of 95 5- to 18-year-olds presenting to a specialist neurodevelopmental clinic and receiving a diagnosis of ASD. Parents/caregivers completed questionnaires assessing ASD symptomatology, internalising and externalising difficulties, CI, IU and alexithymia. Structural equation modelling was used to examine the hypothesised pathways and relationships between the main variables of interest.

RESULTS

Cognitive Inflexibility played a significant direct role in the pathway from ASD symptoms to externalising symptoms in ASD, and indirect role via IU in the pathway to internalising problems. Relationships between alexithymia and both internalising and externalising symptoms were weaker, with alexithymia predicting internalising difficulties via IU only.

CONCLUSIONS

The finding of a direct pathway from CI to externalising behaviours is novel, as is the indirect role of CI in internalising symptomatology. Of the three cognitive mechanisms examined, only CI significantly predicted externalising symptoms. Possible implications for interventions and supports targeting these cognitive processes in ASD are discussed.

Minding the Gap: Leveraging Mindfulness to Inform Cue Exposure Treatment for Substance Use Disorders

Despite extinction-based processes demonstrating efficacy in the animal extinction and human anxiety literatures, extinction for substance use disorders (SUD) has shown poor efficacy (i. e., cue exposure treatment [CET]). Reasons for this lack of success include common threats to extinction, such as renewal and reinstatement. In recent decades, research on mindfulness for SUD has flourished, and a key aspect of these mindfulness-based interventions includes teaching individuals to stay present with whatever experience they have, even if unpleasant, without trying to change/escape/avoid it. Similarly, CET teaches individuals to not escape/avoid conditioned responses (e.g., craving) by engaging in drug use behavior. This paper discusses how mindfulness-based research and practices could positively influence CET through future research (e.g., Could mindfulness practice attenuate renewal? Might mindfulness training + CET enhance the ability to extinguish the most salient or motivational cues?), with the long-term goal of improving SUD treatment.

Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression

OBJECTIVE

Respiratory abnormalities are a hallmark of anxiety symptomatology and may serve as clinically useful modifiers for alleviating anxiety symptoms. However, gold-standard anxiety treatments (e.g., cognitive-behavioral interventions) often do not directly address respiratory components despite their theoretical utility and clinical accessibility. This review examined the clinical effectiveness of respiratory interventions, interventions that directly target respiration abnormalities and processes, in treating trait anxiety symptoms.

METHODS

The final analysis included 40 randomized controlled trials including at least one measure of trait anxiety, a respiratory-focused intervention group, and a non-respiratory control-group (active or inactive treatment). Overall effects of respiratory focused interventions were examined, as well as the effect of hypothesized moderators.

RESULTS

Respiratory component interventions yielded significantly greater improvements (moderate to large effect) in anxiety symptoms than controls, with the stronger effects observed in comparison to inactive, rather than active, control conditions. Significant heterogeneity in findings suggests that variability in intervention design, population, and control comparison may obfuscate interpretation of findings.

CONCLUSIONS

Evidence supports the clinical utility of respiratory interventions as either an independent anxiety treatment, or as an adjunct to other interventions. Clinical and research implications of findings along with recommendations for ongoing investigations in this domain are discussed.

A systematic review and meta-analysis of mindfulness- and acceptance-based interventions for affect intolerance/sensitivity

Affect intolerance/sensitivity, defined as one's sensitivity to, or inability to tolerate, affective states, is a transdiagnostic process implicated in the development and maintenance of numerous forms of psychopathology. Mindfulness and acceptance interventions are posited to improve affect intolerance/sensitivity; however, there has been no quantitative synthesis of this research to date. Seven electronic databases were searched up until November 2018. Hedges' g values, 95% confidence intervals, p-values, and Q-values were calculated for a series of random-effects models. Twenty-five studies (pooled N = 1778) met eligibility criteria and were included in the qualitative synthesis (n = 22 included in the meta-analysis). There was a small, significant effect of mindfulness and acceptance interventions on improving affect intolerance/sensitivity from pre-to post-intervention (Hedges' g = -0.37, 95% CI = -0.52 to -0.23, p < .001), with effects maintained up to 6-months (Hedges' g = -0.35, 95% CI = -0.61 to -0.09, p < .01). There was a significantly larger effect for studies with inactive compared to active controls. No significant effect size differences were found for intervention length (<8 vs. ≥ 8 sessions), intervention type (mindfulness vs. acceptance) or sample type (clinical vs. non-clinical). Mindfulness and acceptance interventions modestly improve affect intolerance/sensitivity.

Participant perspectives on the acceptability and effectiveness of mindfulness-based cognitive behaviour therapy approaches for obsessive compulsive disorder

Cognitive behavioural therapy (CBT) which includes Exposure and Response (ERP) is a highly effective, gold standard treatment for Obsessive-Compulsive Disorder (OCD). Nonetheless, not all patients with OCD significantly benefit from CBT. This has generated interest in the potential benefits of Mindfulness-Based Interventions (MBIs), either integrated with CBT, to enhance engagement with ERP tasks, or delivered as a stand-alone, first-line or therapy to augment CBT. This paper reports on two qualitative studies that involved a thematic analysis of interview data with participants in a 10-week Mindfulness-Based ERP (MB-ERP) course (study 1) and a 9-week Mindfulness-Based Cognitive Therapy course adapted for OCD (MBCT-OCD) (study 2). Whilst MB-ERP integrated a mindfulness component into a standard ERP protocol, MBCT-OCD adapted the psychoeducational components of the standard MBCT for depression protocol to suit OCD, but without explicit ERP tasks. Three common main themes emerged across MB-ERP and MBCT-OCD: 'satisfaction with course features', 'acceptability of key therapeutic tasks 'and 'using mindfulness to respond differently to OCD'. Sub-themes identified under the first two main themes were mostly unique to MB-ERP or MBCT-OCD, with the exception of '(struggles with) developing a mindfulness practice routine' whilst most of the sub-themes under the last main theme were shared across MB-ERP and MBCT-OCD participants. Findings suggested that participants generally perceived both MBIs as acceptable and potentially beneficial treatments for OCD, in line with theorised mechanisms of change.

Hippocampal circuits underlie improvements in self-reported anxiety following mindfulness training

INTRODUCTION

Mindfulness meditation has successfully been applied to cultivate skills in self-regulation of emotion, as it employs the unbiased present moment awareness of experience. This heightened attention to and awareness of sensory experience has been postulated to create an optimal therapeutic exposure condition and thereby improve extinction learning. We recently demonstrated increased connectivity in hippocampal circuits during the contextual retrieval of extinction memory following mindfulness training.

METHODS

Here, we examine the role of structural changes in hippocampal subfields following mindfulness training in a randomized controlled longitudinal study using a two-day fear-conditioning and extinction protocol.

RESULTS

We demonstrate an association between mindfulness training-related increases in subiculum and decreased hippocampal connectivity to lateral occipital regions during contextual retrieval of extinguished fear. Further, we demonstrate an association between decreased connectivity and decreases in self-reported anxiety following mindfulness training.

CONCLUSIONS

The results highlight the role of the subiculum in gating interactions with contextual stimuli during memory retrieval and, also, the mechanisms through which mindfulness training may foster resilience.

An electrophysiological investigation on the emotion regulatory mechanisms of brief open monitoring meditation in novice non-meditators

Despite a growing literature supporting the salutary effects of mindfulness meditation on emotion regulation, the underlying mechanisms linking neural and subjective changes occurring during the actual practice of meditation with emotion regulatory effects observed after meditation remains virtually unexplored. The current study sought to address this gap in knowledge by testing the hypothesis that adoption of internally-directed focused attention, indexed by increased alpha and theta spectral power, during brief open monitoring (OM) mindfulness meditation predicts reduced emotional reactivity, as measured by the late positive potential (LPP). Results revealed that the OM meditation did not produce demonstrable differences in alpha and theta power but did increase self-reported sleepiness relative to controls. Follow-up analyses showed that sleepiness uniquely moderated the effect of meditation on the LPP, such that less sleepiness during meditation, but not the control audio, corresponded to smaller LPPs to negative images. Change in theta, but not alpha power, between meditation and rest was positively correlated with the LPP even after controlling for sleepiness. Although the primary hypothesis was unsupported, the findings demonstrate that phenomenological and neural changes occurring during OM meditation may modulate its subsequent “off-the-cushion” effects on emotional reactivity.

Mindful Emotion Awareness Facilitates Engagement with Exposure Therapy: An Idiographic Exploration Using Single Case Experimental Design

Exposure therapy works through inhibitory learning, whereby patients are exposed to stimuli that elicit anxiety in order to establish safety associations. Mindful emotion awareness, or nonjudgmental and present-focused attention toward emotions, may facilitate engagement in exposures, which may in turn enhance therapeutic outcome. This study utilizes a single-case experimental design (n = 6) to investigate the effect of mindful emotion awareness training on the use of avoidant strategies during exposures, distress during exposures, overall mindfulness, experiential avoidance, and symptom reduction in a sample of participants with social anxiety disorder. Data were analyzed using a combination of visual inspection and quantitative effect size metrics commonly applied in single-case experimental designs. To further investigate the relationship between distress and avoidant strategy use, contemporaneous and cross-lagged correlations were run. Results highlight individual differences in responses to mindful emotion awareness training and exposure exercises. Given these individual differences, repeated assessment and monitoring over the course of treatment may help clinicians most effectively identify treatment skills that will be most helpful for individual patients.

Advancing the Study of Positive Psychology: The Use of a Multifaceted Structure of Mindfulness for Development

Positive psychology, as a distinctive paradigm, focuses on the remedy of pathologies and, by contrast, the promotion of positive experiences and conditions in life (e.g., encouraging a state of flourishing). Positive psychology, in its simplistic form, may provide evidence and insightful understanding into the proactivity of human agency (Seligman, 1999; Seligman and Csíkszentmihályi, 2000). Drawing from this emphasis, we have developed the theory of optimization, which attempts to explain the achievement of optimal functioning in life (e.g., optimal cognitive functioning: academic performance). By the same token, in the course of our research development into the theory of optimization, we have also delved into a comparable theoretical orientation, namely: the multifaceted nature of mindfulness, consisting of three interrelated components - the psychological component of mindfulness, the philosophical component of mindfulness, and the spiritual component of mindfulness. This conceptualization of mindfulness is rather unique for its incorporation of both Western and Eastern knowledge, philosophical viewpoints, and epistemologies into one holistic framework. The main premise of this conceptual analysis article is to advance the study of positive psychology by specifically introducing our recently developed model of mindfulness, in this case, the multifaceted structure of mindfulness with its three distinct components. Importantly, we make attempts to highlight the significance of this multifaceted model by situating it within the theory of optimization for academic learning. Using philosophical psychology and personal-based teaching and research reasoning, we provide a valid rationale as to how aspects of our proposed model of mindfulness (e.g., reaching a state of enlightenment) could act to facilitate and optimize a person's state of functioning (e.g., cognitive functioning). Moreover, we posit that our rationale regarding mindfulness as a potential "optimizing agent" for the purpose of optimal functioning could, indeed, emphasize and reflect the salient nature of positive psychology. In other words, we contend that an explanatory account of mindfulness from the perspectives of Confucianism and Buddhism could, in this analysis, coincide with and support the meaningful understanding and appreciation for the study of positive psychology in educational and non-educational contexts. We conclude the article by exploring the complex issue of methodology - that is, for example, how would a researcher measure, assess, and/or empirically validate the multifaceted nature of mindfulness?

Is There an Ace Up Our Sleeve? A Review of Interventions and Strategies for Addressing Behavioral and Neurobiological Effects of Adverse Childhood Experiences in Youth

Exposure to early life adversity (ELA) is a major public health crisis posing as a significant risk of immediate and sustained mental and physical health consequences. While a remarkable body of knowledge has been amassed showing psychological, cognitive, social, developmental, and neurobiological consequences of ELA exposure, little has been done to improve the long-term mental and physical health outcomes for youth exposed to ELA. Furthermore, neurobiological processes underlying poor outcomes in this population have been largely left out of prevention and intervention target efforts. In this review, we first describe ELA-related alterations across psychological and neurobiological systems in children and adolescents. Next, we describe existing evidence-based interventions targeting ELA-related outcomes. We then turn to experimental studies examining individual differences in mechanistic functioning consequent to ELA exposure, and strategies that target these mechanisms and modulate disrupted functioning. Finally, we highlight areas of future research that may be promising in engaging behavioral and neurobiological targets through novel preventive interventions or augmentation of existing interventions, thereby reducing negative mental and physical health outcomes later in life.

Self-compassion, meaning in life, and experiential avoidance explain the relationship between meditation and positive mental health outcomes

OBJECTIVE

Despite consistent evidence for the beneficial effects of meditation on mental health, little is known about the mechanisms that make mindfulness meditation effective.

METHOD

The levels of mental health, self-compassion, presence of meaning in life, and experiential avoidance of meditators (n = 414) and nonmeditators (n = 414) were measured and compared. Bootstrap-based structural equation modeling (SEM) modeling analyses were used to test multiple-step multiple-mediator models.

RESULTS

Meditation was positively associated with mental health, although the regularity of practice was an influential element to be considered. Significant indirect effects of meditation on mental health through self-compassion, meaning in life, and experiential avoidance were found. SEM models were able to account for 58% of the variance in mental health scores.

CONCLUSIONS

Self-compassion, presence of meaning in life, and reduced experiential avoidance may be active components of healthy meditation practices. Identifying the mechanisms involved in effective meditation practices has relevant implications for well-being and mental health-promoting interventions.

The effect of mindfulness training on extinction retention

Anxiety and trauma related disorders are highly prevalent, causing suffering and high costs for society. Current treatment strategies, although effective, only show moderate effect-sizes when compared to adequate control groups demonstrating a need to develop new forms of treatment or optimize existing ones. In order to achieve this, an increased understanding of what mechanisms are involved is needed. An emerging literature indicates that mindfulness training (MFT) can be used to treat fear and anxiety related disorders, but the treatment mechanisms are unclear. One hypothesis, largely based on findings from neuroimaging studies, states that MFT may improve extinction retention, but this has not been demonstrated empirically. To investigate this question healthy subjects either completed a 4-week MFT- intervention delivered through a smart-phone app (n = 14) or were assigned to a waitlist (n = 15). Subsequently, subjects participated in a two-day experimental protocol using pavlovian aversive conditioning, evaluating acquisition and extinction of threat-related responses on day 1, and extinction retention on day 2. Results showed that the MFT group displayed reduced spontaneous recovery of threat related arousal responses, as compared to the waitlist control group, on day 2. MFT did not however, have an effect on either the acquisition or extinction of conditioned responses day 1. This clarifies the positive effect of MFT on emotional functioning and could have implications for the treatment of anxiety and trauma related disorders.

The Association of Trait Mindfulness and Self-compassion with Obsessive-Compulsive Disorder Symptoms: Results from a Large Survey with Treatment-Seeking Adults

Little is known about the role of mindfulness and self-compassion in obsessive-compulsive disorder. This cross-sectional study examined associations of mindfulness and self-compassion with obsessive-compulsive disorder symptoms and with the obsessive beliefs and low distress tolerance thought to maintain them. Samples of treatment-seeking adults (N = 1871) and non-treatment-seeking adults (N = 540) completed mindfulness, self-compassion, obsessive-compulsive disorder, anxiety, depression, obsessive beliefs and distress tolerance questionnaires. Participants with clinically significant obsessive-compulsive disorder symptoms reported lower trait mindfulness and self-compassion compared to participants with clinically significant anxiety/depression and to non-clinical controls. Among the clinical sample, there were medium-large associations between mindfulness and self-compassion and obsessive-compulsive disorder symptoms, obsessive beliefs and distress tolerance. Mindfulness and self-compassion were unique predictors of obsessive-compulsive disorder symptoms, controlling for depression severity. Once effects of obsessive beliefs and distress tolerance were controlled, a small effect remained for mindfulness (facets) on obsessing symptoms and for self-compassion on washing and checking symptoms. Directions for future research and clinical implications are considered in conclusion.

Strengthened Hippocampal Circuits Underlie Enhanced Retrieval of Extinguished Fear Memories Following Mindfulness Training

BACKGROUND

The role of hippocampus in context-dependent recall of extinction is well recognized. However, little is known about how intervention-induced changes in hippocampal networks relate to improvements in extinction learning. In this study, we hypothesized that mindfulness training creates an optimal exposure condition by heightening attention and awareness of present moment sensory experience, leading to enhanced extinction learning, improved emotion regulation, and reduced anxiety symptoms.

METHODS

We tested this hypothesis in a randomized controlled longitudinal study design using a 2-day fear conditioning and extinction protocol. The mindfulness training group included 42 participants (28 women) and the control group included 25 participants (15 women).

RESULTS

We show that mindfulness training is associated with differential engagement of the right supramarginal gyrus as well as hippocampal-cortical reorganization. We also report enhanced hippocampal connectivity to the primary sensory cortex during retrieval of extinguished stimuli following mindfulness training.

CONCLUSIONS

These findings suggest hippocampal-dependent changes in contextual retrieval as one plausible neural mechanism through which mindfulness-based interventions enhance fear extinction and foster stress resilience.

Mindfulness and Interoceptive Exposure Therapy for Anxiety Sensitivity in Atrial Fibrillation: A Pilot Study

Atrial fibrillation is the most common cardiac arrhythmia and symptoms overlap with physiological sensations of anxiety. Patients with atrial fibrillation can demonstrate anxiety sensitivity even in the absence of actual atrial fibrillation symptoms. Interoceptive exposure is effective in treating anxiety sensitivity, and recently, mindfulness has been proposed as an enhancement strategy to facilitating inhibitory learning in exposure therapy. This pragmatic study piloted a brief mindfulness and interoceptive exposure treatment for anxiety sensitivity in atrial fibrillation. Eight participants with atrial fibrillation and elevated anxiety sensitivity from a hospital cardiology department participated in the treatment. Anxiety sensitivity significantly decreased during the course of the intervention. These initial findings show proof of concept for this brief intervention in a cardiac-specific behavioral medicine setting.

Approach as a key for success: Reduced avoidance behaviour mediates the effect of exposure therapy for fibromyalgia

Fibromyalgia (FM) is a prevalent chronic pain disorder associated with large suffering and substantial societal costs. Pain-related avoidance behaviour and hypervigilance to bodily symptoms are common in FM and contribute in maintaining and exacerbating the disorder. Exposure therapy targeting avoidance behaviours and hypervigilance has shown promise in the treatment of FM. The present study investigated mediators of treatment outcome in exposure therapy for FM. We used data from a randomised trial, where 140 participants were allocated to 10-week internet-delivered exposure therapy or to a waiting-list control condition. The main outcome variable (FM symptoms) and the hypothesized mediators (FM-related avoidance behaviour, mindful non-reactivity and FM-related worry) were measured weekly throughout treatment. Mediation analyses were conducted using linear mixed effects models with bootstrap replication and time-lagged analysis. Results indicated that all three process variables were significant mediators of FM severity. However, in the time-lagged analyses, only FM-related avoidance behaviour displayed a unidirectional relationship over time with FM symptoms, suggesting a causal effect. Thus, results illustrate that changes in avoidance behaviour mediate the outcome of exposure on FM symptoms, which implies that avoidance behaviour is an important treatment target in exposure therapy.

Decentering in Mindfulness and Cognitive Restructuring for Social Anxiety: An Experimental Study of a Potential Common Mechanism

The present study examined whether cognitive restructuring (CR) or mindfulness led to increases in decentering and whether changes in decentering were related to changes in anxiety and willingness to approach anxiety-provoking situations. Forty-six individuals with social anxiety completed speaking tasks before and after receiving CR, mindfulness, or control instructions. Overall, anxiety decreased and willingness increased from the first to second speech, with no differences across conditions. Decentering (measured by the Toronto Mindfulness Scale [TMS]) increased, with those in the mindfulness condition reporting more decentering. There was a nonsignificant, medium-sized effect on decentering, as measured by the Experiences Questionnaire (EQ)-Decentering factor, with those in CR reporting more decentering. Increases in decentering were associated with changes in self-reported anxiety and willingness. Findings indicate that mindfulness and CR led to changes in decentering, and that changes in decentering were related to changes in some, but not all, measures of anxiety.

The Effect of a Brief Mindfulness Training on Distress Tolerance and Stress Reactivity

Poor distress tolerance (DT) is considered an underlying facet of anxiety, depression, and a number of other psychological disorders. Mindfulness may help to increase DT by fostering an attitude of acceptance or nonjudgment toward distressing experiences. Accordingly, the present study examined the effects of a brief mindfulness training on tolerance of different types of distress, and tested whether trait mindfulness moderates the effect of such training. Undergraduates (n = 107) naïve to mindfulness completed a measure of trait mindfulness and underwent a series of stress tasks (cold pressor, hyperventilation challenge, neutralization task) before and after completing a 15-minute mindfulness training or a no-instruction control in which participants listened to relaxing music. Participants in the mindfulness condition demonstrated greater task persistence on the hyperventilation task compared to the control group, as well as a decreased urge to neutralize the effects of writing an upsetting sentence. No effect on distress ratings during the tasks were found. Overall trait mindfulness did not significantly moderate task persistence, but those with lower scores on the act with awareness facet of mindfulness demonstrated greater relative benefit of mindfulness training on the hyperventilation challenge. Mediation analyses revealed significant indirect effects of mindfulness training on cold pressor task persistence and urges to neutralize through the use of the nonjudge and nonreact facets of mindfulness. These results suggest that a brief mindfulness training can increase DT without affecting the subjective experience of distress.

All together now: utilizing common functional change principles to unify cognitive behavioral and mindfulness-based therapies

Cognitive behavior therapy (CBT) and mindfulness-based interventions (MBI) have made important contributions to resolving the global burden of mental illness. However, response rates are comparatively more modest for the distress disorders. Newer CBTs enriched with MBI components have emerged with promising findings for distress disorders but with a high degree of heterogeneity and, subsequently, an unclear path for determining the unique and synergistic contributions from CBTs and MBIs. We propose that one way to elucidate and improve upon this union is to identify common overarching principles (i.e. attention change; metacognitive change) that guide both approaches and to refine therapeutic processes to optimally reflect these common targets and their interplay (e.g. sequencing and dosing).

Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder

To further improve treatments, we need to better understand potential common treatment mechanisms, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990). Therefore, this study examined whether 12 sessions of Cognitive Behavioral Group Therapy (CBGT) for 63 clients (57.6% female, 50.8% White) diagnosed with social anxiety disorder led to increases in decentering and whether increased decentering was associated with improved outcome. Furthermore, this study examined whether decentering was associated with outcome over and above a competing mechanism-cognitive reappraisal. Overall, results indicated that CBGT in this study led to similar outcomes compared to previous studies and decentering increased over CBGT (d's from 0.81 to 2.23). Change in decentering predicted improvement on most, but not all, measures of outcome and those who no longer met criteria for social anxiety disorder at posttreatment had significantly greater change in decentering across therapy and significantly higher decentering scores at post-treatment compared to those who retained a social anxiety disorder diagnosis at posttreatment. Finally, changes in decentering predicted outcome over and above changes in reappraisal on all outcome measures. These results largely support the role of decentering in CBGT for social anxiety; however, the implications of the inconsistencies in results based on which outcome measure was used are discussed.

Memory creation and modification: Enhancing the treatment of psychological disorders

Modification of the ongoing influence of maladaptive cognitive, emotional, and behavioral patterns is a fundamental feature of many psychological treatments. Accordingly, a clear understanding of the nature of memory adaptation and accommodation to therapeutic learning becomes an important issue for (1) understanding the impact of clinical interventions, and (2) considering innovations in treatment strategies. In this article, we consider advances in the conceptualization of memory processes and memory modification research relative to clinical treatment. We review basic research on the formation of memories, the way in which new learning is integrated within memory structures, and strategies to influence the nature and degree to which new learning is integrated. We then discuss cognitive/behavioral and pharmacological strategies for influencing memory formation in relation to disorder prevention or treatment. Our goal is to foster awareness of current strategies for enhancing therapeutic learning and to encourage research on potential new avenues for memory enhancement in service of the treatment of mental health disorders. (PsycINFO Database Record

How willing are you? Willingness as a predictor of change during treatment of adults with obsessive-compulsive disorder

OBJECTIVE

Exposure and response prevention (ERP) is an effective treatment for individuals with obsessive-compulsive disorder (OCD), yet a substantial number of individuals with OCD do not fully respond to this intervention. Based on emerging experimental and clinical research on acceptance, this study sought to explore whether willingness to experience unpleasant thoughts, emotions, and bodily sensations during ERP was associated with improved treatment response.

METHODS

Two hundred eighty-eight adults with OCD receiving residential ERP provided self-rated willingness and other exposure-related variables during each daily coached ERP session. Obsessive-compulsive and depressive symptom severity was assessed every week. Multilevel modeling was used to study the impact of willingness on treatment outcome during the first 6 weeks of residential care.

RESULTS

Data indicated that individuals with higher willingness during ERP reported faster symptom reduction during residential treatment, even when controlling for length of stay, psychopharmacological intervention, depression, adherence, and rituals performed during ERP. These results appear to have both statistical and clinical significance.

CONCLUSIONS

Willingness to fully experience unpleasant and unwanted thoughts, emotions, and bodily sensations during exposures appears to be a marker of successful exposure therapy in adults with OCD. Future research should examine how willingness may enhance extinction learning during ERP.

Ultra-Brief Mindfulness Training Reduces Alcohol Consumption in At-Risk Drinkers: A Randomized Double-Blind Active-Controlled Experiment

Background

Like other complex psychosocial interventions, mindfulness-based treatments comprise various modality-specific components as well as nonspecific therapeutic ingredients that collectively contribute to efficacy. Consequently, the isolated effects of mindfulness strategies per se remain unclear.

Methods

Using a randomized double-blind design, we compared the isolated effects of 11-minutes of "supervised" mindfulness instruction against a closely matched active control (relaxation) on subjective, physiological, and behavioral indices of maladaptive alcohol responding in drinkers at risk of harm from alcohol use (n = 68). Simple follow-up instructions on strategy use were provided, but practice was unsupervised and not formally monitored.

Results

Both groups showed acute reductions in craving after training, although a trend group x time interaction (P = .056) suggested that this reduction was greater in the relaxation group (d = 0.722 P < .001) compared with the mindfulness group (d = 0.317, P = .004). Furthermore, upregulation of parasympathetic activity was found after relaxation (d = 0.562; P < .001) but not mindfulness instructions (d = 0.08; P > .1; group x time interaction: P = .009). By contrast, only the mindfulness group showed a reduction in past-week alcohol consumption at 7-day follow-up (-9.31 units, d = 0.593, P < .001), whereas no significant reduction was seen in the relaxation group (-3.00 units, d = 0.268, P > .1; group x time interaction: P = .026).

Conclusion

Very brief mindfulness practice can significantly reduce alcohol consumption among at-risk drinkers, even with minimal encouragement to use this strategy outside of the experimental context. The effects on consumption may therefore represent a lower bound of efficacy of "ultra-brief" mindfulness instructions in hazardous drinkers, at least at short follow-up intervals.

The mediating effect of mindful non-reactivity in exposure-based cognitive behavior therapy for severe health anxiety

Exposure-based cognitive behavior therapy (CBT) has been shown to be effective in the treatment of severe health anxiety, but little is known about mediators of treatment effect. The aim of the present study was to investigate mindful non-reactivity as a putative mediator of health anxiety outcome using data from a large scale randomized controlled trial. We assessed mindful non-reactivity using the Five Facets Mindfulness Questionnaire-Non-Reactivity scale (FFMQ-NR) and health anxiety with the Short Health Anxiety Inventory (SHAI). Participants with severe health anxiety (N=158) were randomized to internet-delivered exposure-based CBT or behavioral stress management (BSM) and throughout the treatment, both the mediator and outcome were measured weekly. As previously reported, exposure-based CBT was more effective than BSM in reducing health anxiety. In the present study, latent process growth modeling showed that treatment condition had a significant effect on the FFMQ-NR growth trajectory (α-path), estimate=0.18, 95% CI [0.04, 0.32], p=.015, indicating a larger increase in mindful non-reactivity among participants receiving exposure-based CBT compared to the BSM group. The FFMQ-NR growth trajectory was significantly correlated with the SHAI trajectory (β-path estimate=-1.82, 95% CI [-2.15, -1.48], p<.001. Test of the indirect effect, i.e. the estimated mediation effect (αβ) revealed a significant cross product of -0.32, which was statistically significant different from zero based on the asymmetric confidence interval method, 95% CI [-0.59, -0.06]. We conclude that increasing mindful non-reactivity may be of importance for achieving successful treatment outcomes in exposure-based CBT for severe health anxiety.

Mindfulness, Acceptance and Defusion Strategies in Smokers: a Systematic Review of Laboratory Studies

The psychological flexibility model (PFM) provides a framework for understanding and treating behavioural dysregulation in addictions. Rather than modulating the intensity of subjective experience, interventions based on, or consistent with, the PFM (PFM interventions) seek to alter the individual's relationship to internal states, such as craving, negative affect and drug-related thoughts, using mindfulness, acceptance and related strategies. Experimental (non-clinical) studies in smokers have examined the effects of specific isolated strategies informed by or consistent with the PFM (PFM strategies). Here, we systematically review these studies and determine the extent to which they conform to methodological standards indicative of high levels of internal validity. Eligible studies were identified through electronic database searches and assessed for the presence of specific methodological features. Provisional aggregate effect sizes were determined depending on availability of data. Of 1499 screened publications, 12 met the criteria. All examined aspects of private subjective experience relevant to abstinence (craving n = 12; negative affect n = 10), demonstrating effects favouring PFM strategies relative to inactive control conditions. However, only six assessed outcome domains consistent with the PFM and provided no consistent evidence favouring PFM strategies. Overall, most studies had methodological limitations. As such, high-quality experimental studies continue to be needed to improve our understanding of necessary and/or sufficient constituents of PFM-guided smoking cessation interventions. Recommendations for future research are discussed.

A Qualitative Study of Mindfulness Among Veterans With Posttraumatic Stress Disorder: Practices Differentially Affect Symptoms, Aspects of Well-Being, and Potential Mechanisms of Action

This qualitative study explored and compared the subjective experiences of 102 veterans with posttraumatic stress disorder (PTSD) who were randomly assigned to 1 of 4 arms: ( a) body scan, ( b) mindful breathing, ( c) slow breathing, or ( d) sitting quietly. Qualitative data were obtained via semistructured interviews following the intervention and analyzed using conventional content analysis. The percentage of participants within each intervention who endorsed a specific theme was calculated. Two-proportion z tests were then calculated to determine if the differences among themes endorsed in specific groups were statistically significant. Six core themes emerged from analysis of participant responses across the 4 groups: ( a) enhanced present moment awareness, ( b) increased nonreactivity, ( c) increased nonjudgmental acceptance, ( d) decreased physiological arousal and stress reactivity, ( e) increased active coping skills, and ( f) greater relaxation. More participants in the mindfulness intervention groups reported improvement in PTSD symptoms when compared to participants in non-mindfulness groups. Different types of intervention targeted different symptoms and aspects of well-being. Furthermore, type of intervention may have also differentially targeted potential mechanisms of action. This article highlights the importance of employing both quantitative and qualitative research methods when investigating the dynamic process of mindfulness and may inform how practices can be tailored to the needs of the veteran with PTSD.

Internet-Based Extinction Therapy for Worry: A Randomized Controlled Trial

Worry is a common phenotype in both psychiatric patients and the normal population. Worry can be seen as a covert behavior with primary function to avoid aversive emotional experiences. Our research group has developed a treatment protocol based on an operant model of worry, where we use exposure-based strategies to extinguish the catastrophic worry thoughts. The aim of this study was to test this treatment delivered via the Internet in a large-scale randomized controlled trial. We randomized 140 high-worriers (defined as > 56 on the Penn State Worry Questionnaire [PSWQ]) to either Internet-based extinction therapy (IbET) or to a waiting-list condition (WL). Results showed that IbET was superior to WL with an overall large between-group effect size of d = 1.39 (95% confidence interval [1.04,1.73]) on the PSWQ. In the IbET group, 58% were classified as responders. The corresponding figure for WL participants was 7%. IbET was also superior to the WL on secondary outcome measures of anxiety, depression, meta-cognitions, cognitive avoidance, and quality of life. Overall treatment results were maintained for the IbET group at 4- and 12-month follow-up. The results from this trial are encouraging as they indicate that worry can be targeted with an accessible and novel intervention for worry. Replication trials with active control group are needed.