Covert Fear Research Articles

Modes of Large-Scale Brain Network Organization during Threat Processing and Posttraumatic Stress Disorder Symptom Reduction during TF-CBT among Adolescent Girls

Posttraumatic stress disorder (PTSD) is often chronic and disabling across the lifespan. The gold standard treatment for adolescent PTSD is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), though treatment response is variable and mediating neural mechanisms are not well understood. Here, we test whether PTSD symptom reduction during TF-CBT is associated with individual differences in large-scale brain network organization during emotion processing. Twenty adolescent girls, aged 11–16, with PTSD related to assaultive violence completed a 12-session protocol of TF-CBT. Participants completed an emotion processing task, in which neutral and fearful facial expressions were presented either overtly or covertly during 3T fMRI, before and after treatment. Analyses focused on characterizing network properties of modularity, assortativity, and global efficiency within an 824 region-of-interest brain parcellation separately during each of the task blocks using weighted functional connectivity matrices. We similarly analyzed an existing dataset of healthy adolescent girls undergoing an identical emotion processing task to characterize normative network organization. Pre-treatment individual differences in modularity, assortativity, and global efficiency during covert fear vs neutral blocks predicted PTSD symptom reduction. Patients who responded better to treatment had greater network modularity and assortativity but lesser efficiency, a pattern that closely resembled the control participants. At a group level, greater symptom reduction was associated with greater pre-to-post-treatment increases in network assortativity and modularity, but this was more pronounced among participants with less symptom improvement. The results support the hypothesis that modularized and resilient brain organization during emotion processing operate as mechanisms enabling symptom reduction during TF-CBT.

Brain activation in response to overt and covert fear and happy faces in women with borderline personality disorder.

Borderline personality disorder (BPD) is a serious condition involving emotion dysregulation. Past research has identified BPD-associated differences within fronto-limbic circuitry during conditions of processing negative emotion. Functional magnetic resonance imaging (fMRI) paradigms that incorporate overt and covert (masked) presentations of emotional stimuli can provide complementary information about neural systems underlying emotion processing (e.g., both slow [overt] and fast [covert; automatic] processing pathways). This study examined brain activation during processing of overt and covert presentations of emotional faces in 12 women with BPD and 12 age-matched healthy controls. To assess a range of emotional valence and arousal, we examined responses to fear, happy and neutral expressions. All participants underwent an fMRI scanning session in which participants passively viewed emotional faces. Scanning sessions consisted of 5 runs including: (1) Overt Fear (OF) versus Neutral (N), (2) Covert Fear (CF) versus Covert Neutral (CN), (3) Overt Happy (OH) versus N, (4) Covert Happy (CH) versus CN, and (5) N versus fixation. We compared whole-brain activation between groups for each run. In response to overt fear, BPD patients showed greater activation both in left amygdala and in several frontal cortical regions. There were no significant differences in brain activation in response to overt happy faces. In response to covert fear and covert happy stimuli, the BPD group also showed greater activation than controls in several regions including frontal and temporal cortical regions, as well as cerebellum and thalamus. These findings add to prior reports suggesting increased amygdala activation in BPD, but we found this only in the overt fear versus fixation condition. In this sample, BPD patients showed hyper-activation, rather than hypo-activation, of cortical regulatory regions during overt fear. Enhanced cortical recruitment in response to covert fear and happy faces in BPD could reflect a more extended response system in which stimuli that typically only activate automatic pathways are additionally tapping into cortical regulatory systems. The observation of this pattern both in response to fear and in response to happy presentations suggests that the effect of arousal may be as or more impactful than the effect of emotional valence.

Physical Activity and Sport Participation in Youth with Congenital Heart Disease: Perceptions of Children and Parents

This study explored perceptions toward physical activity and sport in the lives of youth with congenital heart disease. Thirteen cardiac participants were interviewed in the presence of their parents, and a process of inductive analysis was conducted. Sport was not considered a valued pursuit despite the belief that it is essential for the attainment of good health. Low-self efficacy and fatigue were influenced by covert fears and exclusion and further decreased the value ascribed to sport and physical activity. Nontraditional activities, support from others, and perceptions of mastery played a crucial role in enabling participation and facilitated the journey toward recovery. Findings are discussed within the context of self-efficacy theory and may inform the design of safe and enjoyable physical activity opportunities for this population.

Neural Biases to Covert and Overt Signals of Fear: Dissociation by Trait Anxiety and Depression

Although biases toward signals of fear may be an evolutionary adaptation necessary for survival, heightened biases may be maladaptive and associated with anxiety or depression. In this study, event-related potentials (ERPs) were used to examine the time course of neural responses to facial fear stimuli (versus neutral) presented overtly (for 500 msec with conscious attention) and covertly (for 10 msec with immediate masking to preclude conscious awareness) in 257 nonclinical subjects. We also examined the impact of trait anxiety and depression, assessed using psychometric ratings, on the time course of ERPs. In the total subject group, controlled biases to overtly processed fear were reflected in an enhancement of ERPs associated with structural encoding (120-220 msec) and sustained evaluation persisting from 250 msec and beyond, following a temporo-occipital to frontal topography. By contrast, covert fear processing elicited automatic biases, reflected in an enhancement of ERPs prior to structural encoding (80-180 msec) and again in the period associated with automatic orienting and emotion encoding (230-330 msec), which followed the reverse frontal to temporo-occipital topography. Higher levels of trait anxiety (in the clinical range) were distinguished by a heightened bias to covert fear (speeding of early ERPs), compared to higher depression which was associated with an opposing bias to overt fear (slowing of later ERPs). Anxiety also heightened early responses to covert fear, and depression to overt fear, with subsequent deficits in emotion encoding in each case. These findings are consistent with neural biases to signals of fear which operate automatically and during controlled processing, feasibly supported by parallel networks. Heightened automatic biases in anxiety may contribute to a cycle of hypervigilance and anxious thoughts, whereas depression may represent a "burnt out" emotional state in which evaluation of fear stimuli is prolonged only when conscious attention is allocated.

Covert fears and anxiety in asthma and congenital heart disease.

To compare anxiety, fears and behavioural problems in children with asthma and children with congenital heart disease, and with the normative population. To also review the influence of maternal anxiety, time since diagnosis and severity of disease. Children administered Fear Survey Scale (FSSC-R) and Child Manifest Anxiety Scale (R-CMAS). Mothers given Child Behaviour Checklist (CBCL) and State Trait Anxiety Scale (STAI-S and STAI-T). Normative means and SDs compared with means and SDs for both medical groups. The mother's scores on the STAI-S and STAI-T scales were correlated with the child's scores on the FSSC-R and the R-CMAS. Outpatient Asthma and Cardiology multidisciplinary Clinics at a tertiary care paediatric facility, Alberta Children's Hospital. Forty children with asthma (aged 6--17 years) were compared with 39 children with congenital heart disease. Intake questionnaires and interviews determined these children to be without obvious psycho-social problems. Children with asthma and children with congenital heart disease had more medical fears, and more physiological anxiety than normative samples. Increased maternal anxiety was correlated in both groups with increased child anxiety, medical fears and behavioural problems in the child. Similarly, increased severity of asthma or cardiac problems was associated with more physiological anxiety and more fears. Less time since diagnosis of the disease adversely affected social interactions in both groups of children. Physiological anxiety, medical fears and maternal anxiety are important issues requiring attention in asthma and cardiac disease, even in the absence of obvious psychosocial problems. There may be specific problems with a recent diagnosis of a chronic illness.

Age Differences in Levels of Overt and Covert Death Anxiety

The current study explored the relationship between conscious (overt) and unconscious (covert) death anxiety and chronological age, wherein composite scores as well as factor scores were used in the comparison of younger and older adults. Results indicated that there were reliable age differences in both overt and covert levels of death fear. Contrary to previous literature, older adults evidenced higher levels of overt fear, while younger adults' covert fears were greater. These data further substantiate the distinction between overt and covert levels of death anxiety in adulthood, where cumulative differential loss experiences over the course of a lifetime most likely lessen the need to deny fears of one's own death, while sensitizing older persons to the loss of intimate relationships with others.

Covert fears, anxiety and depression in congenital heart disease.

This study compared anxiety, fears, depression and behavioural problems as occurring in children with congenital heart disease, comparing them with samples of normal children. It further considered the influence of maternal anxiety, as well as analyzing a subgroup of children with cyanotic forms of congenital heart disease to determine if they were at higher risk than acyanotic children for the problems identified. We recruited 40 consecutive children with congenital heart disease without obvious psychosocial problems from the Cardiology clinic at the Alberta Children's Hospital. Of the 40 children, 39 families consented to have the children participate, of which 24 were cyanotic and 15 acyanotic. Children completed the revised versions of the Fear Survey Scale-Revised and the Child Manifest Anxiety Scale as well as the Child Depression Inventory. Mothers completed the Child Behaviour Checklist, and the State Trait Anxiety Scale. Children with congenital heart diseases demonstrated more medical fears, and more physiological anxiety, than the normative samples. More specifically, children with cyanotic forms of congenital heart disease demonstrated more fears of the unknown, physiological anxiety, depression, and delinquent behaviors than the acyanotic children with congenital heart disease. Mothers of the children with cyanotic forms of congenital heart disease scored higher on both the state and trait scales, with higher maternal anxiety correlating with higher anxiety, medical fears and behavioral problems in the child. In a clinical setting, children with congenital heart diseases who do not present with psychological adjustment problems are still at risk for covert physiological anxiety, medical fears, depression and behavioral problems. The children with cyanotic malformations represent a subgroup at higher risk for these problems, which may be further exacerbated by increased maternal anxiety.

Levels of Death Anxiety in Terminally Ill Persons: A Cross Validation and Extension

In order to explore the viability of the distinction between overt and covert levels of death fear, 141 individuals (32 HIV positive who had full-blown AIDS, 39 HIV positive without full-blown AIDS, 70 age-matched controls) were administered measures of conscious and unconscious death anxiety as well as a variety of self-report scales assessing life satisfaction, well-being, regrets about one's life, and hopelessness. While results suggested minimal differences to exist between the above groups for measures of conscious death fear, there were substantive, though in some respects, unanticipated differences across groups in aspects of covert fear tapping concerns about the interruption of goals and achievements, isolation from others, and pain, disease, and suffering. Results also suggested that there were both adjustment-related advantages and disadvantages associated with the appearance of symptoms signaling the appearance of full-blown AIDS. Neither gender nor the duration of time one had been living with the diagnosis of either HIV disease or AIDS influenced death fear.

Effects of Death Education on Conscious and Unconscious Death Anxiety

One-hundred sixty-two adults varying in the extent to which they participated in either didactic or experiential forms of death education versus those who had no such exposure to death and dying-related issues completed both self-report measures of overt death fear as well as twenty-five sentence completion stems assessing unconscious covert death fears. Data analysis suggested that in contrast to previous research, didactic death education was effective in altering death anxiety. However, such effects were restricted to measures of covert death fear. These findings suggest that the previously reported moderate impact of death education on death attitudes may be a consequence of too much attention to self-reported concerns, and that the effects of death education may be much greater if more emphasis is placed on unconscious covert fears about one's mortality, wherein a didactic approach may yield more success.

Locus of Control-Levels of Death Anxiety Relationships

In an effort to more fully understand locus of control-death fear relationships, fifty-nine individuals were administered the Levenson Locus of Control scale, the Collett-Lester and Templer scales measuring overt death fear, and a sentence completion task assessing dimensions of covert fear. Correlational analysis suggested interactions among aspects of locus of control and aspects of death fear varying along the death/dying, self/other, and overt/covert continua. These data are felt to enable one to more completely understand the role that perceived controllability of life events play in determining individual reactions to one's own or another's death.

Impact of Hospice Volunteer Training on Death Anxiety and Locus of Control

This investigation examined the effects of a hospice volunteer training program on locus of control and death anxiety. Experimental participants consisted of hospice volunteers who underwent an eight-week volunteer training course ( N = 29) and controls who were selected from the hospice mailing list ( N = 30). Results indicated both groups decreased in generalized conscious death fear, but increased in their conscious fear of others' deaths, although experimental participants did so to a somewhat greater extent. An overall decrease in several unconscious death-related fears (e.g., loss of control, overall covert death anxiety) was also observed. Training participants repressed death fears more often, relative to controls. While training seemed to sensitize participants to the uncontrollability of death, covert fears of loss of goals and achievements were lower for volunteers with training than for controls. Regardless of training, unconscious fears appeared to become conscious, as did Templer death anxiety scores (indicating a lessening of denial), with the exception of overt fear of the death of others, suggesting that hospice volunteers may continue to fear the loss of others irrespective of training.