Toward a standard experiment for studying post-treatment return of fear

Heart Rate Variability Predicts Therapy Outcome in Anxiety Disorders: The Role of Inhibitory Learning

Exposure therapy has been shown to be useful for the treatment of anxiety disorders. However, there are individual differences in the extent to which this intervention is effective in reducing symptoms, and a substantial number of patients may experience a return of fear (ROF). The factors associated with successful therapy outcomes are an important topic of investigation as these factors might influence the nature of the interventions as well as enhance our understanding of the process associated with the disorder and its treatment. Here, we investigated the effect of resting heart rate variability (HRV) on ROF following exposure therapy in social phobics. In particular, using path modeling, we assessed the hypothesis that resting HRV prospectively predicts inhibitory learning, which, in turn, prospectively predicts ROF at follow-up. Forty adult participants (60% female) diagnosed with Social Anxiety Disorder were assigned to a single massed exposure therapy session. Self-reported behavioral and physiological responses were recorded pre-treatment, immediately following treatment, and at one-month follow-up. The Personalized Implicit Association Task (PIAT) was used as an implicit measure of inhibitory learning, and HF-HRV was taken as a measure of vagal activity. Results revealed that those with high pre-treatment HRV reported less negative implicit attitude towards public speaking after exposure (b = -0.044, p =.047) and showed reduced residual symptoms one month after treatment. (b = 2.247, p =.013). Taken together these results support exposure therapy models that emphasize the importance of inhibitory learning in extinction and are consistent with research linking HRV to inhibition.

Too little, too much, or just right? Does the amount of distraction make a difference during contamination-related exposure?

BACKGROUND AND OBJECTIVES

The extant literature has shown mixed results regarding the impact of distraction use on exposure outcome; however, a wide variety of distraction tasks have been utilized across studies. In order to better understand these discrepant findings, we aimed to evaluate the impact of differing levels of distraction on exposure outcome. Additionally, treatment acceptability and changes in self-efficacy were assessed to evaluate how these may differ as a function of distraction use.

METHODS

In Experiment 1 (N = 176 participants tested), distraction tasks were experimentally validated through assessing changes in reaction time when completing concurrent tasks. Based on Experiment 1, distraction tasks were selected for use in Experiment 2, in which contamination-fearful participants were randomly assigned to one of four conditions: no, low, moderate, or high distraction during an exposure session. Participants (N = 124) completed a behavioural approach test and self-efficacy measure pre- and post-exposure and at one-week follow-up. Treatment acceptability was assessed immediately following the exposure session.

RESULTS

There were no significant differences between conditions for changes in behavioural approach pre-to post-exposure or at one-week follow-up. However, increases in self-efficacy pre-to post-exposure were greatest for moderate distraction, and treatment acceptability was highest with moderate and high distraction.

LIMITATIONS

Participants were not assessed for clinical severity, were not treatment-seeking, and only one specific type of fear was investigated.

CONCLUSIONS

Distraction (at any level) did not appear to negatively impact exposure outcome (all conditions improved pre-to post-exposure and at follow-up), but utilizing moderate to high amounts of distraction increased treatment acceptability.

Attentional focus during exposure in spider phobia: The effect of valence and schematicity of a partial distractor

This study examines the impact of partial distractor valence and schematicity (i.e., their relation to fear representation) on exposure efficacy. One hundred forty-one spider phobics were exposed to spider pictures and asked, in a between-subjects experimental design, to form mental images of words that were fear related (to spiders) and negative (schematic negative), fear unrelated and negative (non-schematic negative) or fear unrelated and positive (non-schematic positive). Multilevel measures of anxiety were performed at pre-exposure, post-exposure and 6 days' follow-up. Results show that both of the negative condition groups displayed similar results on all outcome variables and systematically differed from the positive condition group. While the latter group displayed a stronger decline in distress during exposure itself, the other groups showed greater exposure benefits: a stronger decline in emotional and avoidance responses and skin conductance responses from pre- to post-exposure and more approach behaviours when confronted with a real spider. The critical feature of distraction thus seems not to be the fact of being distracted from the phobic stimulus, but rather the fact of performing emotional avoidance by distracting oneself from negative affect. The results highlight that the acceptance of aversive emotional states is a critical active process in successful exposure.

Exposure treatment in multiple contexts attenuates return of fear via renewal in high spider fearful individuals

BACKGROUND AND OBJECTIVES

Research has demonstrated that after exposure treatment, re-exposure to a previously feared stimulus outside of the treatment context can result in renewal of fear. The current study investigated whether conducting exposure treatment in multiple real-life contexts can attenuate renewal of fear.

METHODS

Forty-six moderate to high spider fearful individuals were randomly allocated to groups that received exposure treatment in either one context or three contexts. Follow-up testing was conducted one week and four weeks after exposure in the treatment context or a novel context.

RESULTS

Renewal of fear was found for the single extinction context group when exposed to the feared object in a novel context with self-report of fear, heart rate, and behavioural avoidance. However, renewal of fear was attenuated for the multiple extinction context group.

LIMITATIONS

The sample included moderate to high spider fearful participants rather than clients with spider phobia, potentially limiting the generalisability of the findings to clinical populations.

CONCLUSIONS

Using multiple extinction contexts in combination with other methods of attenuating renewal (e.g., context similarity) may provide a means to reduce the risk of renewal of fear.

Optimal attentional focus during exposure in specific phobia: a meta-analysis

Over the last 30 years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g=1.010/g=1.128) and exposure was spread over the course of multiple sessions (g=1.527/g=1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.

Extinction treatment in multiple contexts attenuates ABC renewal in humans

Renewal has been implicated as one of the underlying mechanisms in return of fear following exposure therapy. ABC renewal is clinically more relevant than ABA renewal and yet it is a weaker form of renewal, suggesting that conducting extinction treatment in multiple contexts may be sufficient to attenuate ABC renewal. Using self-reported expectancy of shock and startle blink responses the current study examined the effects of conducting extinction treatment in multiple contexts on ABC fear renewal. Participants (N = 68) received conditional stimulus (CS) and unconditional stimulus (US) pairings in one context (A) followed by extinction treatment (CS presentations alone) in either one other context (B) or three other contexts (BCD). Non-reinforced test trials in a novel context (E) resulted in renewal of extinguished conditioned behaviour for those who received extinction in only one context. However, renewal was attenuated for those who received extinction treatment in three contexts. No renewal was found for the control group that received the test trial in the same context as during extinction. Suggestions are provided for clinicians seeking to prevent or attenuate return of fear following exposure therapy.

Reinstatement of fear in humans: autonomic and experiential responses in a differential conditioning paradigm

The present study investigated reinstatement of fear in humans using an aversive differential conditioning paradigm. Two neutral human face pictures were presented during habituation, acquisition, extinction, and postreinstatement phases. One picture served as a conditioned stimulus (CS) reinforced by an unconditioned stimulus (US) in the form of electrical stimulation (CS+) and the second picture as a control stimulus that was never reinforced (CS-). The prediction that in a reinstatement manipulation a previously extinguished fear response in humans can be reinstated in a reinstatement group by the mere presentation of three unpredicted electrical stimulations (USs) was tested. Participants in the control group were not exposed to unpredicted USs and no reinstatement effect was expected. Outcome measures included subjective US expectancy ratings and skin conductance responses. Results showed non-selective return of the fear response due to fear recovery associated with both CSs (CS+/CS-) in the reinstatement group. Unexpected fear recovery was observed for both CSs (CS+/CS-) in control participants. Results are discussed with respect to context conditioning, fear generalisation, and anxiety-related cognitive mechanisms underlying fear recovery after extinction.

Relapse of successfully treated anxiety and fear: theoretical issues and recommendations for clinical practice

Despite the existence of effective interventions for anxiety disorders, relapse--or the return of fear--presents a significant problem for patients and clinicians in the longer term. The present paper draws on the experimental and clinical behavioural literature, reviewing the mechanisms by which the return of fear can occur. The aim of the paper was to generate a list of treatment recommendations for clinicians aimed at reducing relapse in successfully treated anxiety disorders. Clinical and experimental literature on the mechanisms of renewal, reinstatement, spontaneous recovery and reacquisition are reviewed. These are linked with the clinical and experimental literature on the return of fear in successfully treated anxiety. A list of recommendations to assist in reducing the probability of relapse in successfully treated anxiety is presented. This list includes methods for use in behavioural (exposure) treatment of anxiety disorders that aim to enhance clinical outcomes. Despite the significant problem of relapse in successfully treated anxiety, there are methods available to reduce the probability of relapse through return of fear. Clinicians engaging in treatment of anxiety disorders should be mindful of these methods to ensure optimal patient outcome.

Effects of internal and external distraction and focus during exposure to blood-injury-injection stimuli

The present study examined the effects of attentional focus on fear reduction during exposure. Participants were randomly assigned to experimental conditions: exposure plus internal focus, exposure plus external focus, exposure plus internal distraction, exposure plus external distraction or exposure alone. Fifty blood-injury-injection fearful participants received 3 weekly exposure sessions. Participants in the distraction group reported the greatest fear reduction, with most notable reductions occurring for the external distraction condition. The distraction group also achieved a greater number of steps on a behavioral avoidance task at post-treatment, with the external distraction condition displaying greater approach behavior at follow-up. At follow-up the distraction group also displayed a greater increase in perceived control than the focusing group. Thus, distraction reduces fear within and between sessions and increases approach behavior in the longer-term, with exposure plus external distraction further facilitating this effect.

Research on posttreatment return of claustrophobic fear, arousal, and avoidance using mock diagnostic imaging

Fear sometimes returns after attenuation via exposure. Return of fear is poorly understood due to conflicting results from diverse experiments. This article reports on two experiments in which claustrophobic fear during mock diagnostic imaging was attenuated and allowed to return so the experiments could be evaluated and return of fear studied. Attentional focus versus distraction during exposure was a between-subjects independent variable. Attempts were made to predict return of fear, return of heart-rate responsivity, and behavioral avoidance using levels of fear and heart-rate during initial mock diagnostic imaging as predictor variables. One third of participants displayed return of fear, heart-rate response, or avoidance 1 week after fear reduction. Heart-rate response during initial mock imaging predicted posttreatment return-of-fear classification; level of fear during initial imaging did not. Neither initial heart rate nor initial fear predicted return of heart-rate reactivity or avoidance. The experiments are offered as models for programmatic research.