A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.

Targeting beliefs and behaviours in misophonia: a case series from a UK specialist psychology service

BACKGROUND

Misophonia, a disorder of decreased sound tolerance, can cause significant distress and impairment. Cognitive behavioural therapy (CBT) may be helpful for improving symptoms of misophonia, but the key mechanisms of the disorder are not yet known.

AIMS

This case series aimed to evaluate individual, formulation-driven CBT for patients with misophonia in a UK psychology service.

METHOD

A service evaluation of one-to-one therapy for patients with misophonia (n=19) was conducted in a specialist psychology service. Patients completed an average of 13 hours of therapy with a focus on the meaning applied to their reactions to sounds and associated behaviours. Primary outcome measures were the Misophonia Questionnaire (MQ) and the Amsterdam Misophonia Scale (A-MISO-S). Repeated measures t-tests were used to compare scores from pre-treatment to follow-up, and reliable and clinically significant change on the MQ was calculated.

RESULTS

Scores significantly improved on both misophonia measures, with an average of 38% change on the MQ and 40% change on the A-MISO-S. From pre-treatment to follow-up, 78% of patients showed reliable improvement on the MQ and 61% made clinically significant change.

CONCLUSIONS

Limitations included a lack of control group, small sample size, and the use of an outcome measure that had not been thoroughly validated for a treatment-seeking sample. These results suggest that one-to-one, formulation-driven CBT for misophonia is worth exploring further using experimental design. Potential mechanisms to explore further include feared consequences of escalating reactions, the role of safety-seeking behaviours and the impact of early memories associated with reactions to sounds.

Mechanisms of Action in Exposure Therapy

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.

Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy

BACKGROUND

Exposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome.

METHOD

In a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions.

RESULTS

In a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings.

CONCLUSIONS

The results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.

Assessing the inhibitory properties of a latent inhibitor in flavor-aversion learning

In Experiment 1, rats received 16 nonreinforced trials of exposure to a flavor (A) that was subsequently used as the conditioned stimulus in flavor-aversion conditioning. In the critical condition, Flavor A was presented in compound with a different novel flavor on each of the eight daily trials. This treatment produced latent inhibition, in that this preexposure retarded conditioning just as did 16 trials with A alone. Rats in the control conditions, given no preexposure or exposure just to the sequence of novel flavors, learned readily. Experiment 2 examined the effects of these forms of preexposure on performance on a summation test, in which Flavor A was presented in compound with a separately conditioned flavor (X). The preexposure procedure in which A was presented along with novel flavors rendered A effective in inhibiting the response conditioned to X on that test. The conclusion, that this form of training can establish the target stimulus as a conditioned inhibitor, is predicted by the account of latent inhibition put forward by Hall and Rodríguez (2010) which proposes that the latent inhibition effect is a consequence both of a reduction in the associability of the stimulus and of a process of inhibitory associative learning that opposes the initial expectation that a novel event will be followed by some consequence.

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder

BACKGROUND

Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD.

METHOD

Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data.

RESULTS

VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43).

DISCUSSION

Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

[Psychotherapy of anxiety disorders: state of the art]

BACKGROUND

Alongside depression, anxiety disorders are the most frequent reason for consulting a psychotherapist.

OBJECTIVE

This article describes the recent progress in understanding basic learning processes in anxiety treatment, the resulting therapeutic procedures, the current state of knowledge on the efficacy of the various psychotherapeutic procedures and on the moderators of the success of treatment.

MATERIAL AND METHODS

The English and German language literature was reviewed and compiled, with an emphasis on the last 10 years.

RESULTS

Cognitive-behavioral therapy (CBT) achieves the best and broadest level of evidence across all anxiety disorders. Initial studies have also provided emerging evidence for the efficacy of manualized short-term psychodynamic treatment. The most discussed mechanism of action is that of inhibitory learning. Augmentation strategies and personalized treatment approaches are gaining in relevance.

CONCLUSION

Current models of inhibitory learning are rooted in basic research and foster a deeper understanding of the underlying neurobiological mechanisms. In order to optimize success of exposure treatment in vulnerable subgroups of patients, many procedural, device-based and pharmacological augmentation strategies are currently under investigation, whereby the latter are mostly still in the stage of (pre)clinical testing.

An analysis of fear inhibition and fear extinction in a sample of veterans with obstructive sleep apnea (OSA): Implications for co-morbidity with post-traumatic stress disorder (PTSD)

Obstructive sleep apnea (OSA) is a respiratory condition characterized by interrupted sleep due to repeated, temporary collapse of the soft tissue of the upper airway that can lead to a cascade of physiological and psychological adverse health outcomes. The most common therapeutic interventions for OSA patients include the application of continuous positive airway pressure (CPAP) which acts to keep the airway open and, as such, provides less interrupted and more restorative sleep. Improved sleep has been linked to more efficacious treatments for psychiatric conditions most notably those that include cognitive-behavioral elements, new learning, and memory consolidation. In the current study, we investigated the acquisition, inhibition, and extinction of conditioned fear in OSA patients, before and after CPAP therapy, using an established fear-potentiated startle paradigm. Patients with OSA displayed an intact ability to acquire, inhibit, and extinguish fear prior to CPAP treatment and this ability was significantly enhanced following CPAP usage. In addition, those patients with more severe OSA, as measured by apnea-hypopnea index (AHI), were more likely to show improved fear inhibition and extinction. Lastly, we observed impairments in discrimination between reinforced and nonreinforced conditioned stimuli, in the inhibition of fear, and in fear extinction in a subset of patients with OSA and co-morbid posttraumatic stress disorder (PTSD). These data suggest that evolving treatment algorithms for PTSD should address disrupted sleep problems prior to initiation of inhibition/extinction-based exposure therapies.

Deficits in opioid receptor-mediated prediction error contribute to impaired fear extinction during adolescence

Adolescent-onset anxiety disorders are more common and costly than those that emerge later in life. Unfortunately, nearly half of adolescents undergoing cognitive behavioural therapies, including exposure therapies, show significant symptom relapse. Such poor treatment outcomes are consistent with preclinical work examining fear extinction, in which adolescents show persistent fear to extinguished cues. Both extinction and exposure are dependent on the generation of prediction error (i.e., the difference between the expected and actual outcome of a cue presentation), a process which involves the opioid system. We investigated the contribution of prediction error signalling to extinction during adolescence using the opioid receptor antagonist naloxone. We demonstrated that unlike in juvenile and adult rats, fear expression during extinction training and test in adolescent rats was unaffected by naloxone, suggesting that adolescent rats are impaired in using prediction error signalling to extinguish fear under typical conditions. However, in two circumstances where adolescents exhibit good extinction retention, opioid receptor blockade impaired extinction retention, suggesting that the recruitment of prediction error signalling mechanisms promotes extinction in this age group, just as it does in adults. Importantly, additional extinction training may be required to enable prediction error mechanisms to be recruited during adolescence.

Exposure therapy vs lifestyle intervention to reduce food cue reactivity and binge eating in obesity: A pilot study

BACKGROUND AND OBJECTIVES

Learning models of overeating predict that exposure therapy is effective in reducing food cue reactivity and overeating. This pilot study tested an eight-session exposure therapy aimed at inhibitory learning vs. an active control condition aimed at lifestyle improvement for obesity (treatment-as-usual). Main outcomes are snacking behavior, eating psychopathology, food cue reactivity, and weight loss. Change in overeating expectancies was assessed as mediator for outcomes, and the associations between habituation of eating desires and outcomes were investigated in the exposure condition. Sleep quality was investigated as moderator for outcomes.

METHODS

45 overweight women were randomly assigned to the exposure intervention or control condition. The main outcomes, overeating expectancies and sleep quality were re-assessed at post-treatment and three-month follow-up. Habituation of eating desires was measured during exposure sessions.

RESULTS

Compared to the control intervention, exposure led to a significantly stronger reduction in snacking behavior of exposed foods, though this effect did not generalize to non-exposed foods, and stronger binge eating frequency. The exposure condition lost significantly more weight at post-treatment and follow-up than the lifestyle condition. Changes of expectancies mediated the effect of condition on kcal consumption of exposed foods, while habituation during exposure was not related to better treatment outcome. Sleep quality did not moderate the effect of condition on treatment outcome.

LIMITATIONS

Small sample size and limited follow-up period.

CONCLUSIONS

This short exposure therapy reduced snacking behavior, binge eating and weight more than a lifestyle intervention and is therefore a recommendable intervention for obesity and overeating disorders.

Development of 'learn to dare!': An online assessment and intervention platform for anxious children

BACKGROUND

Many children and adolescents suffer from problematic levels of anxiety, but the multitude of these children do not receive an intervention. It is of importance to increase the accessibility and availability of child anxiety interventions, as to identify and treat anxious children early and successfully. Online platforms that include information, assessments and intervention can contribute to this goal. Interventions for child anxiety are frequently based on Cognitive Behavioral Therapy, because of its strong theoretical and empirical basis. However, the working mechanisms of Cognitive Behavioral Therapy in children are poorly studied. To our knowledge, mediation studies on child anxiety are non-existent regarding online Cognitive Behavioral Therapy.

METHODS

We will aim at children aged 8-13 years with problematic anxiety. We recruit these children via the community setting, and refer them to our online platform 'Learn to Dare!' (in Dutch: 'Leer te Durven!'), https://leertedurven.ou.nl, where information about child anxiety and our research is freely accessible. After an active informed consent procedure, the participants can access the screening procedure, which will select the children with problematic anxiety levels. Thereafter, these children will be randomized to an online intervention based on Cognitive Behavioral Therapy (n = 120) or to a waitlist control (WL, n = 120). The intervention consists of 8 sessions with minimal therapist support and contains psycho-education, exposure (based on inhibitory learning), cognitive restructuring and relapse prevention. Child anxiety symptoms and diagnoses, cognitions, avoidance behavior and level of abstract reasoning are measured. Assessments are the same for both groups and are performed before and after the proposed working mechanisms are offered during the intervention. A follow-up assessment takes place 3 months after the final session, after which children in the waitlist control group are offered to take part in the intervention.

DISCUSSION

This protocol paper describes the development of the online platform 'Learn to Dare!', which includes information about child anxiety, the screening procedure, anxiety assessments, and the online intervention. We describe the development of the online intervention. Offering easy accessible interventions and providing insight into the working mechanisms of Cognitive Behavioral Therapy contributes to optimizing Cognitive Behavioral Therapy for anxious youth.

Virtual reality exposure therapy for adolescents with fear of public speaking: a non-randomized feasibility and pilot study

BACKGROUND

Public Speaking Anxiety (PSA) is a common anxiety with onset in adolescence and early adulthood. With the advent of consumer virtual reality (VR) technology, VR-delivered exposure therapy is now a scalable and practical treatment option and has previously been shown to be efficacious with adults. In this non-randomized feasibility and pilot trial, we explore the effect of one-session (90 min) VR-delivered exposure therapy for adolescents (aged 13-16) with PSA.

METHODS

A total of 27 adolescents were recruited from Norwegian high schools and completed self-report measures of PSA twice prior to treatment, 1 week after treatment, and at 1 and 3 month follow-up. Heart rate was recorded during the treatment session. A low-cost head-mounted VR display with a custom-built VR stimuli material depicting a cultural and age appropriate classroom and audience were used when a series of speech (exposure exercises) were performed.

RESULTS

Linear mixed effects model revealed a significant decrease in PSA symptoms (Cohen's d = 1.53) pre-post treatment, and improvements were maintained at follow-ups. Physiological data revealed a small increase in heart rate during exposure tasks. Based on feedback from the adolescents, the feasibility of the intervention was increased during the trial.

CONCLUSIONS

The results show that low-cost, consumer VR hardware can be used to deliver efficacious treatment for PSA in adolescents, in a feasible one-session format.

Enhancing Inhibitory Learning: The Utility of Variability in Exposure

Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.

Basic Strategies of Cognitive Behavioral Therapy

Cognitive behavioral therapy's main strategies are active, problem-focused, and collaborative. Cognitive restructuring is a strategy in which clinicians help patients to identify, evaluate, and modify inaccurate or otherwise unhelpful thinking associated with emotional distress. Behavioral activation provides a framework for patients, particularly those who are depressed, to increase engagement in activities that provide a sense of accomplishment or pleasure. The goal of exposure is for anxious patients to experience an extinction of fear by having planned contact with feared stimuli and situations. Problem solving allows patients to systematically approach and address their life problems by using cognitive and behavioral techniques.

An empirical review of potential mediators and mechanisms of prolonged exposure therapy

Prolonged exposure (PE) is an empirically-supported treatment for posttraumatic stress disorder (PTSD), but the precise mechanism(s) by which PE promotes symptom change are not well established. Understanding how PE works is critical to improving clinical outcomes, advancing dissemination efforts, and enhancing transdiagnostic models of psychopathology. However, mechanisms research conducted in clinical treatment settings is complex, and findings may be difficult to interpret without appropriate context. This is the first review of potential mechanisms of PE to provide such context, by rigorously evaluating empirical findings in line with essential criteria for effective research on mechanisms (or mediators). We begin by describing six putative mechanisms identified by emotional processing theory and contemporary models of fear extinction, before thoroughly reviewing empirical findings from clinical research on PE and similar PTSD treatments. We provide a detailed description of each study and mechanism test, as well as ratings of strength of evidence and quality of evaluation based on a novel rating scheme. We highlight variables with strong evidence (belief change and between-session habituation), intermediate evidence (inhibitory learning and emotional engagement), and minimal support (narrative organization and within-session habituation). After discussing limitations of the extant literature and this review, we summarize specific challenges for research on PE mechanisms and highlight directions for future study based on clinical and research implications.

Occasion setting, inhibition, and the contextual control of extinction in Pavlovian and instrumental (operant) learning

An occasion setter is a stimulus that modulates the ability of another stimulus to control behavior. A rich history of experimental investigation has identified several important properties that define occasion setters and the conditions that give rise to occasion setting. In this paper, we first consider the basic hallmarks of occasion setting in Pavlovian conditioning. We then review research that has examined the mechanisms underlying the crucial role of context in Pavlovian and instrumental extinction. In Pavlovian extinction, evidence suggests that the extinction context can function as a negative occasion setter whose role is to disambiguate the current meaning of the conditioned stimulus; the conditioning context can also function as a positive occasion setter. In operant extinction, in contrast, the extinction context may directly inhibit the response, and the conditioning context can directly excite it. We outline and discuss the key results supporting these distinctions.

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

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

Enhancing inhibitory learning to reduce overeating: Design and rationale of a cue exposure therapy trial in overweight and obese women

The prevalence of overweight and obesity has increased substantially over the last decades. Weight loss attempts in overweight individuals are common, though they seldom result in successful long-term weight loss. One very promising treatment is food cue exposure therapy, during which overweight individuals are repeatedly exposed to food-associated cues (e.g., the sight, smell and taste of high-calorie foods, overeating environments) without eating in order to extinguish cue-elicited appetitive responses to food cues. However, only few studies have tested the effectiveness of cue exposure, especially with regards to weight loss. For exposure treatment of anxiety disorders, it has been proposed that inhibitory learning is critical for exposure to be effective. In this RCT, we translated techniques proposed by Craske et al. (2014) to the appetitive domain and developed a novel cue exposure therapy for overeating aimed at maximizing inhibitory learning. The current RCT tested the effectiveness of this 8-session cue exposure intervention relative to a control intervention in 45 overweight adult (aged 18-60) females at post-treatment and 3-month follow-up, of which 39 participants completed the study. Weight loss, eating psychopathology, food cue reactivity, and snacking behaviour were studied as main treatment outcomes, and mediators and moderators of treatment effects were studied. The presented study design represents an innovative effort to provide valuable clinical recommendations for the treatment of overeating and obesity.

Maximizing exposure therapy: an inhibitory learning approach

Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a 'fear habituation' approach and 'belief disconfirmation' approach within standard cognitive-behavior therapy. Exposure optimization strategies include (1) expectancy violation, (2) deepened extinction, (3) occasional reinforced extinction, (4) removal of safety signals, (5) variability, (6) retrieval cues, (7) multiple contexts, and (8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.