High Current Anxiety Symptoms, But Not a Past Anxiety Disorder Diagnosis, are Associated with Impaired Fear Extinction

VR for Studying the Neuroscience of Emotional Responses

Emotions are frequently considered as the driving force of behavior, and psychopathology is often characterized by aberrant emotional responding. Emotional states are reflected on a cognitive-verbal, physiological-humoral, and motor-behavioral level but to date, human research lacks an experimental protocol for a comprehensive and ecologically valid characterization of such emotional states. Virtual reality (VR) might help to overcome this situation by allowing researchers to study mental processes and behavior in highly controlled but reality-like laboratory settings. In this chapter, we first elucidate the role of presence and immersion as requirements for eliciting emotional states in a virtual environment and discuss different VR methods for emotion induction. We then consider the organization of emotional states on a valence continuum (i.e., from negative to positive) and on this basis discuss the use of VR to study threat processing and avoidance as well as reward processing and approach behavior. Although the potential of VR has not been fully realized in laboratory and clinical settings yet, this technological tool can open up new avenues to better understand the neurobiological mechanisms of emotional responding in healthy and pathological conditions.

A Preliminary Test of Novelty-Facilitated Extinction in Individuals With Pathological Anxiety

Studies with rodents and healthy humans suggest that replacing the expected threat with a novel outcome improves extinction and reduces the return of conditioned fear more effectively than threat omission alone. Because of the potential clinical implications of this finding for exposure-based anxiety treatments, this study tested whether the same was true in individuals with pathological anxiety (i.e., met DSM-5 diagnostic criteria for an anxiety disorder and/or obsessive-compulsive disorder (OCD). In this preliminary test of novelty-facilitated extinction, 51 unmedicated individuals with pathological anxiety were randomized to standard extinction (n = 27) or novelty-facilitated extinction (n = 24). Participants returned 24 h later to test extinction recall and fear reinstatement. Skin conductance responses (SCR) were the dependent measure of conditioned fear. Participants in both groups learned the fear association but variably extinguished it. Novelty did not facilitate extinction in this preliminary trial. Findings underscore the importance of translating paradigms from healthy humans to clinical samples, to ensure that new treatment ideas based on advances in basic neuroscience are relevant to patients.

Contextual modulation of conditioned responses in humans: A review on virtual reality studies

Conditioned response (CRs) triggered by stimuli predicting aversive consequences have been confirmed across various species including humans, and were found to be exaggerated in anxious individuals and anxiety disorder patients. Importantly, contextual information may strongly modulate such conditioned responses (CR), however, there are several methodological boundaries in the translation of animal findings to humans, and from healthy individuals to patients. Virtual Reality (VR) is a useful technological tool for overcoming such boundaries. In this review, we summarize and evaluate human VR conditioning studies exploring the role of the context as conditioned stimulus or occasion setter for CRs. We observe that VR allows successful acquisition of conditioned anxiety and conditioned fear in response to virtual contexts and virtual cues, respectively. VR studies also revealed that spatial or temporal contextual information determine whether conditioned anxiety and conditioned fear become extinguished and/or return. Novel contexts resembling the threatening context foster conditioned fear but not conditioned anxiety, suggesting distinct context-related generalization processes. We conclude VR contexts are able to strongly modulate CRs and therefore allow a comprehensive investigation of the modulatory role of the context over CR in humans leading to conclusions relevant for non-VR and clinical studies.

Fear and anxiety about COVID-19 among local and overseas Chinese university students

This study aimed to establish a new COVID-19 Fear (Higher Education) scale to investigate the relationship between fear and generalised anxiety symptoms among Chinese students in mainland China, Hong Kong, and other countries. 219 Chinese university students studying in universities in mainland China (n = 76, 34.7%), Hong Kong (n = 66, 30.1%), and overseas (i.e., outside of China as international students, n = 77, 35.2%) participated in an online study from March 31, 2020 to April 4. Participants completed a newly developed COVID-19 Fear (Higher Education) scale to measure three domains of fear including fear of infection, fear of instability and fear of insecurity related to the COVID-19 pandemic. They also completed the Generalized Anxiety Disorder 7-item scale (GAD-7) on the severity of anxiety symptoms. About 9.6% of the participants could be classified as exhibiting high anxiety level according to the GAD-7. More students studying overseas (about 15%) were classified into the high GAD group when compared to students studying in both mainland China (6.6%) and Hong Kong (6.1%). MANOVA results showed that students studying in Hong Kong and overseas had more concerns related to preventive measures related to COVID-19 than their mainland counterparts did. We concluded that international students studying away from their home country would have higher risk to develop anxiety problems during a collective trauma such as the COVID-19 pandemic. Education institutions should provide support services including online support groups, social media groups for mutual support to alleviate the fear and anxiety of international students.

A translational perspective on neural circuits of fear extinction: Current promises and challenges

Fear extinction is the well-known process of fear reduction through repeated re-exposure to a feared stimulus without the aversive outcome. The last two decades have witnessed a surge of interest in extinction learning. First, extinction learning is observed across species, and especially research on rodents has made great strides in characterising the physical substrate underlying extinction learning. Second, extinction learning is considered of great clinical significance since it constitutes a crucial component of exposure treatment. While effective in reducing fear responding in the short term, extinction learning can lose its grip, resulting in a return of fear (i.e., laboratory model for relapse of anxiety symptoms in patients). Optimization of extinction learning is, therefore, the subject of intense investigation. It is thought that the success of extinction learning is, at least partly, determined by the mismatch between what is expected and what actually happens (prediction error). However, while much of our knowledge about the neural circuitry of extinction learning and factors that contribute to successful extinction learning comes from animal models, translating these findings to humans has been challenging for a number of reasons. Here, we present an overview of what is known about the animal circuitry underlying extinction of fear, and the role of prediction error. In addition, we conducted a systematic literature search to evaluate the degree to which state-of-the-art neuroimaging methods have contributed to translating these findings to humans. Results show substantial overlap between networks in animals and humans at a macroscale, but current imaging techniques preclude comparisons at a smaller scale, especially in sub-cortical areas that are functionally heterogeneous. Moreover, human neuroimaging shows the involvement of numerous areas that are not typically studied in animals. Results obtained in research aimed to map the extinction circuit are largely dependent on the methods employed, not only across species, but also across human neuroimaging studies. Directions for future research are discussed.

Core Mechanisms of Cognitive Behavioral Therapy for Anxiety and Depression: A Review

This article reviews the extant literature on mediators of change in cognitive behavioral therapy (CBT) for anxiety and depression. The authors briefly discuss the efficacy of CBT for anxiety and depression and methods of mediation analysis and detection. Then the authors discuss fear extinction in anxiety treatment and cognitive change in depression treatment.

Optimizing exposure-based CBT for anxiety disorders via enhanced extinction: Design and methods of a multicentre randomized clinical trial

Exposure-based psychological interventions currently represent the empirically best established first line form of cognitive-behavioural therapy for all types of anxiety disorders. Although shown to be highly effective in both randomized clinical and other studies, there are important deficits: (1) the core mechanisms of action are still under debate, (2) it is not known whether such treatments work equally well in all forms of anxiety disorders, including comorbid diagnoses like depression, (3) it is not known whether an intensified treatment with more frequent sessions in a shorter period of time provides better outcome than distributed sessions over longer time intervals. This paper reports the methods and design of a large-scale multicentre randomized clinical trial (RCT) involving up to 700 patients designed to answer these questions. Based on substantial advances in basic research we regard extinction as the putative core candidate model to explain the mechanism of action of exposure-based treatments. The RCT is flanked by four add-on projects that apply experimental neurophysiological and psychophysiological, (epi)genetic and ecological momentary assessment methods to examine extinction and its potential moderators. Beyond the focus on extinction we also involve stakeholders and routine psychotherapists in preparation for more effective dissemination into clinical practice.