The fear of spiders: perceptual features assessed in augmented reality

Background

Persons with specific phobias typically generalize the dangerousness of the phobic animal to all members of its species, possibly as a result of malfunctioning brain circuitry normally providing quick and dirty identification of evolutionary-relevant stimuli. An objective assessment of which perceptual features make an animal more or less scary to phobic and non-phobic people would help overcome the limitations of the few studies available so far, based on self-reports.

Objective

To achieve this aim, we built an augmented reality setting where volunteers with different levels of fear of spiders were asked to make holographic spiders that look either dangerous or harmless. To reach this goal, a computerized interface allowed participants to modify the spider's perceptual features (hairiness, body/leg size, and locomotion) in real time.

Results

On average, the dangerous spiders were made hairy, thick, and moving according to spider-like locomotion; coherently, the harmless spiders were made hairless, slim, and moving according to a butterfly-like locomotion. However, these averaged preferences could not fully describe the complex relationship between perceptual preferences with each other and with arachnophobia symptoms. An example of a key finding revealed by cluster analysis is the similarity in perceptual preferences among participants with little or no fear of spiders, whereas participants with more arachnophobia symptoms expressed more varying preferences.

Conclusion

Perceptual preferences toward the spider's features were behaviorally assessed through an observational study, objectively confirming a generalization effect characterizing spider-fearful participants. These results advance our knowledge of phobic preferences and could be used to improve the acceptability of exposure therapies.

Virtual reality exposure therapy for fear of spiders: an open trial and feasibility study of a new treatment for arachnophobia

PURPOSE

This analogue pilot study examined the feasibility (i.e. preliminary results, safety, acceptability) of a new single-session treatment for adults with a fear of spiders.

MATERIALS

It used state-of-the-art consumer available VR-hardware for therapist-assisted exposure (VRET-AP). The VRET-AP is largely adapted from Öst's one-session treatment for arachnophobia (Öst, 1987), with the aim of addressing shortcomings of previous VRET treatments, such as marked differences in procedures compared to available and evidence based in-vivo treatments.

METHOD

Participants (N = 12) were screened for fear of spiders using the Spider Phobia Questionnaire (SPQ), Fear Questionnaire (FQ) and the Behavioral Approach Test (BAT), prior to and directly after treatment in a repeated measures quasi-experimental design. In addition, acceptance and completion rates were measured and participants were interviewed about their experience of the treatment. Mean ratings as well as Reliable Change Index (RCI) for individual trajectories were analyzed.

RESULTS

The results from the preliminary data indicates potential for improvements with large effect sizes (d = 0.90-1,384) in all measurements of spider fear at post-treatment. Reliable Change Index (RCI) analysis showed that spider fear diminished in all twelve participants although the change was certain in only two. None deteriorated. All that responded accepted the treatment and all 11 participants completed all levels in the treatment. No concerns or adverse effects were reported in the interviews which largely confirm the quantitative results.

CONCLUSION

VRET-AP is a feasible alternative for delivering effective treatment for fear of spiders and the results motivate larger, randomized trials of VRET-AP involving participants diagnosed with arachnophobia.

Effects of rhythmic eye movements during a virtual reality exposure paradigm for spider-phobic patients

Rhythmic eye movements performed during eye movement desensitization and reprocessing (EMDR) therapy have been shown to evoke a physiological de-arousal pattern.

OBJECTIVES

Here, we examined whether the efficacy of a virtual reality exposure therapy (VRET) paradigm for phobic patients could be improved by adding rhythmic eye movements.

DESIGN

Spider-phobic patients (N = 53) were randomly assigned to either a group performing rhythmic eye movements or a control group undergoing exposure without such eye movements.

METHODS

During the VRET session, heart rate, electrodermal activity, eye movements, and subjective fear ratings were recorded. Participants underwent behavioural avoidance tests before and after treatment as well as a follow-up 10-14 days later. Questionnaire data were assessed before exposure and at follow-up.

RESULTS

There were clear treatment effects in both groups with almost no group differences (i.e., the subjective fear ratings and the skin conductance response).

CONCLUSIONS

Contrary to our expectation, the implementation of rhythmic eye movements during virtual exposure did not enhance the effectiveness of the treatment. However, the eye movement group did show a significantly lower heart rate during exposure compared with the control group which might indicate a less stressful treatment.

PRACTITIONER POINTS

One-session Virtual Reality Exposure Therapy reduced fear of spiders effectively. Performing rhythmic eye movements during exposure did not enhance therapy effects. Rhythmic eye movements during exposure resulted in lower heart rate than standard exposure.

Treatment of Spider Phobia Using Repeated Exposures and Adjunctive Repetitive Transcranial Magnetic Stimulation: A Proof-of-Concept Study

BACKGROUND

Specific phobias represent the largest category of anxiety disorders. Previous work demonstrated that stimulating the ventromedial prefrontal cortex (vmPFC) with repetitive Transcranial Magnetic Stimulation (rTMS) may improve response to exposure therapy for acrophobia.

OBJECTIVE

To examine feasibility of accelerating extinction learning in subjects with spider phobia using intermittent Theta Burst Stimulation (iTBS) rTMS of vmPFC.

METHODS

In total, 17 subjects with spider phobia determined by spider phobia questionnaires [Spider Phobia Questionnaire (SPQ) and Fear of Spiders questionnaire (FSQ)] underwent ratings of fear of spiders as well as behavioral and skin conductance data during a behavioral avoidance test (BAT). Subjects then received a sequential protocol of in vivo spider exposure followed by iTBS for three sessions administered to either active or control treatment sites (vmPFC [n = 8] or vertex [n = 9], respectively), followed 1 week later by repetition of questionnaires and BAT.

RESULTS

All subjects improved significantly regardless of group across both questionnaires (FSQ η² = 0.43, p = 0.004; SPQ η² = 0.39, p = 0.008) and skin conductance levels during BAT (Wald χ² = 30.9, p < 0.001). Subjects in the vmPFC group tolerated lower treatment intensity than in the control group, and there was a significant correlation between treatment intensity, BAT subjective distress improvement, and physiologic measures (all ρ > 0.5).

CONCLUSION

This proof-of-concept study provides preliminary evidence that a sequential exposure and iTBS over vmPFC is feasible and may have rTMS intensity-dependent effects on treatment outcomes, providing evidence for future areas of study in the use of rTMS for phobias.

Spider Phobia: Neural Networks Informing Diagnosis and (Virtual/Augmented Reality-Based) Cognitive Behavioral Psychotherapy-A Narrative Review

Recent fMRI studies on specific animal phobias, particularly spider phobia (arachnophobia), have identified a large variety of specific brain regions involved in normal and disturbed fear processing. Both functional and structural brain abnormalities have been identified among phobic patients. Current research suggests that both conscious and subconscious fear processing play a crucial role in phobic disorders. Cognitive behavioral therapy has been identified as an effective treatment for specific phobias and has been associated with neuroplastic effects which can be evaluated using current neuroimaging techniques. Recent research suggests that new approaches using virtual (VR) or augmented reality (AR) tend to be similarly effective as traditional "in vivo" therapy methods and could expand treatment options for different medical or individual scenarios. This narrative review elaborates on neural structures and particularities of arachnophobia. Current treatment options are discussed and future research questions are highlighted.

Gender differences in avoidance and repetitive negative thinking following symptom provocation in men and women with spider phobia

OBJECTIVES

Women's greater prevalence of anxiety disorders compared to men is widely assumed to be partly due to gender differences in cognitive and behavioural factors that perpetuate anxiety, such as repetitive negative thinking (RNT) and avoidance. However, past studies assessing this assumption have not controlled for gender differences in baseline symptom severity, the type of stressful life experiences against which RNT and avoidance are measured, or emotional reactivity to these experiences.

DESIGN

Using a two-group design, the present study controlled for these confounds by comparing avoidance and RNT in relation to a controlled symptom provocation task in spider phobic men and women with equivalent spider fear severity on the Fear of Spiders Questionnaire.

METHODS

Participants engaged in a behavioural approach test (BAT) involving a live spider, during which they were assessed for avoidance (physical proximity to the spider) and subjective distress. Two weeks later, participants reported on their levels of negative affect and RNT experienced during the preceding weeks in relation to the BAT.

RESULTS

Women exhibited greater avoidance and reported greater RNT than men, despite reporting comparable distress and negative affect. Gender remained a significant predictor of avoidance when accounting for distress and also remained a significant predictor of RNT when accounting for depressive symptoms and negative affect.

CONCLUSIONS

These results provide in vivo evidence that heightened avoidance and RNT may perpetuate anxiety symptoms in women independently of gender differences in symptom severity, daily experiences, or emotional reactivity.

PRACTITIONER POINTS

Following symptom provocation, men and women with spider phobia differ in cognitive and behavioural coping responses. Women exhibit greater avoidance and repetitive negative thinking than men, and these differences are not attributable to gender differences in symptom severity or emotional reactivity. These findings provide novel evidence for gender differences in maintaining factors that perpetuate anxiety disorders whilst accounting for confounding factors present in prior research.

Theranostic markers for personalized therapy of spider phobia: Methods of a bicentric external cross-validation machine learning approach

OBJECTIVES

Embedded in the Collaborative Research Center "Fear, Anxiety, Anxiety Disorders" (CRC-TRR58), this bicentric clinical study aims at identifying biobehavioral markers of treatment (non-)response by applying machine learning methodology with an external cross-validation protocol. We hypothesize that a priori prediction of treatment (non-)response is possible in a second, independent sample based on multimodal markers.

METHODS

One-session virtual reality exposure treatment (VRET) with patients with spider phobia was conducted on two sites. Clinical, neuroimaging, and genetic data were assessed at baseline, post-treatment and after 6 months. The primary and secondary outcomes defining treatment response are as follows: 30% reduction regarding the individual score in the Spider Phobia Questionnaire and 50% reduction regarding the individual distance in the behavioral avoidance test.

RESULTS

N = 204 patients have been included (n = 100 in Würzburg, n = 104 in Münster). Sample characteristics for both sites are comparable.

DISCUSSION

This study will offer cross-validated theranostic markers for predicting the individual success of exposure-based therapy. Findings will support clinical decision-making on personalized therapy, bridge the gap between basic and clinical research, and bring stratified therapy into reach. The study is registered at ClinicalTrials.gov (ID: NCT03208400).

Quantitative representations of an exaggerated anxiety response in the brain of female spider phobics-a parametric fMRI study

We employed a novel parametric spider picture set in the context of a parametric fMRI anxiety provocation study, designed to tease apart brain regions involved in threat monitoring from regions representing an exaggerated anxiety response in spider phobics. For the stimulus set, we systematically manipulated perceived proximity of threat by varying a depicted spider's context, size, and posture. All stimuli were validated in a behavioral rating study (phobics n = 20; controls n = 20; all female). An independent group participated in a subsequent fMRI anxiety provocation study (phobics n = 7; controls n = 7; all female), in which we compared a whole-brain categorical to a whole-brain parametric analysis. Results demonstrated that the parametric analysis provided a richer characterization of the functional role of the involved brain networks. In three brain regions-the mid insula, the dorsal anterior cingulate, and the ventrolateral prefrontal cortex-activation was linearly modulated by perceived proximity specifically in the spider phobia group, indicating a quantitative representation of an exaggerated anxiety response. In other regions (e.g., the amygdala), activation was linearly modulated in both groups, suggesting a functional role in threat monitoring. Prefrontal regions, such as dorsolateral prefrontal cortex, were activated during anxiety provocation but did not show a stimulus-dependent linear modulation in either group. The results confirm that brain regions involved in anxiety processing hold a quantitative representation of a pathological anxiety response and more generally suggest that parametric fMRI designs may be a very powerful tool for clinical research in the future, particularly when developing novel brain-based interventions (e.g., neurofeedback training). Hum Brain Mapp 38:3025-3038, 2017. © 2017 Wiley Periodicals, Inc.

Re-presentation of Olfactory Exposure Therapy Success Cues during Non-Rapid Eye Movement Sleep did not Increase Therapy Outcome but Increased Sleep Spindles

Exposure therapy induces extinction learning and is an effective treatment for specific phobias. Sleep after learning promotes extinction memory and benefits therapy success. As sleep-dependent memory-enhancing effects are based on memory reactivations during sleep, here we aimed at applying the beneficial effect of sleep on therapy success by cueing memories of subjective therapy success during non-rapid eye movement sleep after in vivo exposure-based group therapy for spider phobia. In addition, oscillatory correlates of re-presentation during sleep (i.e., sleep spindles and slow oscillations) were investigated. After exposure therapy, spider-phobic patients verbalized their subjectively experienced therapy success under presence of a contextual odor. Then, patients napped for 90 min recorded by polysomnography. Half of the sleep group received the odor during sleep while the other half was presented an odorless vehicle as control. A third group served as a wake control group without odor presentation. While exposure therapy significantly reduced spider-phobic symptoms in all subjects, these symptoms could not be further reduced by re-presenting the odor associated with therapy success, probably due to a ceiling effect of the highly effective exposure therapy. However, odor re-exposure during sleep increased left-lateralized frontal slow spindle (11.0-13.0 Hz) and right-lateralized parietal fast spindle (13.0-15.0 Hz) activity, suggesting the possibility of a successful re-presentation of therapy-related memories during sleep. Future studies need to further examine the possibility to enhance therapy success by targeted memory reactivation (TMR) during sleep.

fMRI neurofeedback facilitates anxiety regulation in females with spider phobia

Background: Spider phobics show an exaggerated fear response when encountering spiders. This fear response is aggravated by negative and irrational beliefs about the feared object. Cognitive reappraisal can target these beliefs, and therefore has a fear regulating effect. The presented study investigated if neurofeedback derived from functional magnetic resonance imaging (fMRI) would facilitate anxiety regulation by cognitive reappraisal, using spider phobia as a model of anxiety disorders. Feedback was provided based on activation in left dorsolateral prefrontal cortex and right insula, as indicators of engagement and regulation success, respectively.

Methods: Eighteen female spider phobics participated in a randomized, controlled, single-blinded study. All participants completed a training session in the MRI scanner. Participants assigned to the neurofeedback condition were instructed to shape their regulatory strategy based on the provided feedback. Participants assigned to the control condition were asked to adapt their strategy intuitively.

Results: Neurofeedback participants exhibited lower anxiety levels than the control group at the end of the training. In addition, only neurofeedback participants achieved down-regulation of insula activation levels by cognitive reappraisal. Group differences became more pronounced over time, supporting learning as a mechanism behind this effect. Importantly, within the neurofeedback group, achieved changes in insula activation levels during training predicted long-term anxiety reduction.

Conclusions: The conducted study provides first evidence that fMRI neurofeedback has a facilitating effect on anxiety regulation in spider phobia.

Brain activity associated with illusory correlations in animal phobia

Anxiety disorder patients were repeatedly found to overestimate the association between disorder-relevant stimuli and aversive outcomes despite random contingencies. Such an illusory correlation (IC) might play an important role in the return of fear after extinction learning; yet, little is known about how this cognitive bias emerges in the brain. In a functional magnetic resonance imaging study, 18 female patients with spider phobia and 18 healthy controls were exposed to pictures of spiders, mushrooms and puppies followed randomly by either a painful electrical shock or nothing. In advance, both patients and healthy controls expected more shocks after spider pictures. Importantly, only patients with spider phobia continued to overestimate this association after the experiment. The strength of this IC was predicted by increased outcome aversiveness ratings and primary sensory motor cortex activity in response to the shock after spider pictures. Moreover, increased activation of the left dorsolateral prefrontal cortex (dlPFC) to spider pictures predicted the IC. These results support the theory that phobia-relevant stimuli amplify unpleasantness and sensory motor representations of aversive stimuli, which in turn may promote their overestimation. Hyper-activity in dlPFC possibly reflects a pre-occupation of executive resources with phobia-relevant stimuli, thus complicating the accurate monitoring of objective contingencies and the unlearning of fear.

How emotions affect logical reasoning: evidence from experiments with mood-manipulated participants, spider phobics, and people with exam anxiety

Recent experimental studies show that emotions can have a significant effect on the way we think, decide, and solve problems. This paper presents a series of four experiments on how emotions affect logical reasoning. In two experiments different groups of participants first had to pass a manipulated intelligence test. Their emotional state was altered by giving them feedback, that they performed excellent, poor or on average. Then they completed a set of logical inference problems (with if p, then q statements) either in a Wason selection task paradigm or problems from the logical propositional calculus. Problem content also had either a positive, negative or neutral emotional value. Results showed a clear effect of emotions on reasoning performance. Participants in negative mood performed worse than participants in positive mood, but both groups were outperformed by the neutral mood reasoners. Problem content also had an effect on reasoning performance. In a second set of experiments, participants with exam or spider phobia solved logical problems with contents that were related to their anxiety disorder (spiders or exams). Spider phobic participants' performance was lowered by the spider-content, while exam anxious participants were not affected by the exam-related problem content. Overall, unlike some previous studies, no evidence was found that performance is improved when emotion and content are congruent. These results have consequences for cognitive reasoning research and also for cognitively oriented psychotherapy and the treatment of disorders like depression and anxiety.

Triggers of fear: perceptual cues versus conceptual information in spider phobia

OBJECTIVE

Fear reactions in spider-phobic patients can be activated by specific perceptual cues or by conceptual fear-related information. Matching perceptual fear cues and fear-related information were expected to result in maximal fear responses, perceptual fear cues alone in less fear, and information alone in the weakest responses.

METHOD

We used virtual reality to manipulate the available cues and information. Forty-eight phobic patients and 48 healthy participants were repeatedly exposed to either a perceptual cue, information, or a combination of both.

RESULTS

In conditions with a fear-relevant perceptual cue, phobic patients reported increased fear compared to the condition with information only. Across exposures trials, these reactions diminished. Skin conductance in phobic patients was significantly higher in the combined than in the cue or the information condition.

CONCLUSIONS

Perceptual cues are essential for phobic fear reactions in spider phobia. In combination with fear-relevant information, perceptual cues activate an intense and persistent fear reaction.

Spider phobia is associated with decreased left amygdala volume: a cross-sectional study

BACKGROUND

Evidence from animal and human studies imply the amygdala as the most critical structure involved in processing of fear-relevant stimuli. In phobias, the amygdala seems to play a crucial role in the pathogenesis and maintenance of the disorder. However, the neuropathology of specific phobias remains poorly understood. In the present study, we investigated whether patients with spider phobia show altered amygdala volumes as compared to healthy control subjects.

METHODS

Twenty female patients with spider phobia and twenty age-matched healthy female controls underwent magnetic resonance imaging to investigate amygdala volumes. The amygdalae were segmented using an automatic, model-based segmentation tool (FSL FIRST). Differences in amygdala volume were investigated by multivariate analysis of covariance with group as between-subject factor and left and right amygdala as dependent factors. The relation between amygdala volume and clinical features such as symptom severity, disgust sensitivity, trait anxiety and duration of illness was investigated by Spearman correlation analysis.

RESULTS

Spider phobic patients showed significantly smaller left amygdala volume than healthy controls. No significant difference in right amygdala volume was detected. Furthermore, the diminished amygdala size in patients was related to higher symptom severity, but not to higher disgust sensitivity or trait anxiety and was independent of age.

CONCLUSIONS

In summary, the results reveal a relation between higher symptom severity and smaller left amygdala volume in patients with spider phobia. This relation was independent of other potential confounders such as the disgust sensitivity or trait anxiety. The findings suggest that greater spider phobic fear is associated with smaller left amygdala. However, the smaller left amygdala volume may either stand for a higher vulnerability to develop a phobic disorder or emerge as a consequence of the disorder.

Sleep promotes consolidation and generalization of extinction learning in simulated exposure therapy for spider fear

Simulated exposure therapy for spider phobia served as a clinically naturalistic model to study effects of sleep on extinction. Spider-fearing, young adult women (N = 66), instrumented for skin conductance response (SCR), heart rate acceleration (HRA) and corrugator electromyography (EMG), viewed 14 identical 1-min videos of a behaving spider before a 12-hr delay containing a normal night's Sleep (N = 20) or continuous daytime Wake (N = 23), or a 2-hr delay of continuous wake in the Morning (N = 11) or Evening (N = 12). Following the delay, all groups viewed this same video 6 times followed by six 1-min videos of a novel spider. After each video, participants rated disgust, fearfulness and unpleasantness. In all 4 groups, all measures except corrugator EMG diminished across Session 1 (extinction learning) and, excepting SCR to a sudden noise, increased from the old to novel spider in Session 2. In Wake only, summed subjective ratings and SCR to the old spider significantly increased across the delay (extinction loss) and were greater for the novel vs. the old spider when it was equally novel at the beginning of Session 1 (sensitization). In Sleep only, SCR to a sudden noise decreased across the inter-session delay (extinction augmentation) and, along with HRA, was lower to the novel spider than initially to the old spider in Session 1 (extinction generalization). None of the above differentiated Morning and Evening groups suggesting that intervening sleep, rather than time-of-testing, produced differences between Sleep and Wake. Thus, sleep following exposure therapy may promote retention and generalization of extinction learning.

Changes in facial electromyographic activity in spider-phobic girls after psychotherapy

Recent studies of spider phobia have indicated that disgust is a crucial disorder-relevant emotion and that the facial electromyogram (EMG) of the levator labii region is a reliable disgust indicator. The present investigation focused on EMG effects of psychotherapy in thirty girls (aged between 8 and 14 years) suffering from spider phobia. They were presented with phobia-relevant, generally fear-inducing, disgust-inducing and affectively neutral pictures in a first EMG session. Subsequently, patients were randomly assigned to either a therapy group or a waiting-list group. Therapy-group participants received a single session of exposure therapy in vivo. One week later a second EMG session was conducted. Patients of the waiting-list group received exposure therapy after the second EMG session. After therapy, the girls were able to hold a living spider in their hands and rated spiders more positive, and less arousing, fear- and disgust-inducing. Moreover, they showed a reduction of average levator labii activity in response to pictures of spiders, reflecting the reduction of feelings of disgust. A positive side effect of the therapy was a significant drop in overall disgust proneness and a decreased average activity of the levator labii muscle in response to generally disgust-inducing pictures. Results emphasize the role of disgust feelings in spider-phobic children and suggest that overall disgust proneness should also be targeted in therapy.

Exposure therapy leads to enhanced late frontal positivity in 8- to 13-year-old spider phobic girls

Neurobiological studies have demonstrated that psychotherapy is able to alter brain function in adults, however little exists on this topic with respect to children. This waiting-list controlled investigation focused on therapy-related changes of the P300 and the late positive potential (LPP) in 8- to 13-year-old spider phobic girls. Thirty-two patients were presented with phobia-relevant, generally disgust-inducing, fear-inducing, and affectively neutral pictures while an electroencephalogram was recorded. Participants received one session of up to 4h of cognitive-behavioral exposure therapy. Treated children showed enhanced amplitudes of the LPP at frontal sites in response to spider pictures. This result is interpreted to reflect an improvement in controlled attentional engagement and is in line with already existing data for adult females. Moreover, the girls showed a therapy-specific reduction in overall disgust proneness, as well as in experienced arousal and disgust when viewing disgust pictures. Thus, exposure therapy seems to have broad effects in children.

Attention training for reducing spider fear in spider-fearful individuals

Cognitive theorists propose that attentional biases for threatening information play an important role in the development and maintenance of anxiety disorders. If attentional biases for threat figure in the maintenance of anxiety, then the experimental reduction of the bias for threat (attention training) should reduce anxiety. We randomly assigned 41 spider-fearful individuals to receive either attention training (n=20) or control procedures (n=21). We used a modified dot-probe discrimination paradigm with photographs of spiders and cows to train attention. Training reduced attentional bias for spiders, but only temporarily. Although both groups declined in spider fear and avoidance, reduction in attentional bias did not produce significantly greater symptom reduction in the training group than in the control group. However, reduction in attentional bias predicted reduction in self-reported fear for the training group. The reduction in attentional bias for threat may have been insufficiently robust to produce symptom reduction greater than that produced by exposure to a live spider and spider photographs alone. Alternatively, attention training may be an unsuitable intervention for spider fear.

Disgust sensitivity and emotion regulation potentiate the effect of disgust propensity on spider fear, blood-injection-injury fear, and contamination fear

Research consistently reveals a relation between disgust and specific anxiety concerns, but research has only begun to investigate possible mechanisms by which this relation occurs. The current study tested whether disgust sensitivity (DS; a specific difficulty regulating disgust) and general emotion dysregulation (GED; non-emotion-specific regulation difficulties) moderated the relation between disgust propensity (DP) and spider fear, blood-injection-injury (BII) fear, and contamination fear. A total of 594 undergraduate students completed verbal-report measures of DP, DS, GED, negative affectivity, and spider, BII, and contamination fears. Results suggest that GED potentiates the ability of DP to predict spider and contamination fears, but not BII fears. DS potentiates the ability of DP to predict BII fears, but not spider or contamination fears. These data suggest that GED and DS are possible mechanisms that strengthen the influence of DP on spider, BII, and contamination fears. The present study demonstrates the utility of incorporating emotion regulation into the theory of disgust in certain anxiety disorders.