Exposure-based Therapy Research Articles

Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

MAOA gene hypomethylation in panic disorder-reversibility of an epigenetic risk pattern by psychotherapy.

Epigenetic signatures such as methylation of the monoamine oxidase A (MAOA) gene have been found to be altered in panic disorder (PD). Hypothesizing temporal plasticity of epigenetic processes as a mechanism of successful fear extinction, the present psychotherapy-epigenetic study for we believe the first time investigated MAOA methylation changes during the course of exposure-based cognitive behavioral therapy (CBT) in PD. MAOA methylation was compared between N=28 female Caucasian PD patients (discovery sample) and N=28 age- and sex-matched healthy controls via direct sequencing of sodium bisulfite-treated DNA extracted from blood cells. MAOA methylation was furthermore analyzed at baseline (T0) and after a 6-week CBT (T1) in the discovery sample parallelized by a waiting time in healthy controls, as well as in an independent sample of female PD patients (N=20). Patients exhibited lower MAOA methylation than healthy controls (P<0.001), and baseline PD severity correlated negatively with MAOA methylation (P=0.01). In the discovery sample, MAOA methylation increased up to the level of healthy controls along with CBT response (number of panic attacks; T0–T1: +3.37±2.17%), while non-responders further decreased in methylation (−2.00±1.28% P=0.001). In the replication sample, increases in MAOA methylation correlated with agoraphobic symptom reduction after CBT (P=0.02–0.03). The present results support previous evidence for MAOA hypomethylation as a PD risk marker and suggest reversibility of MAOA hypomethylation as a potential epigenetic correlate of response to CBT. The emerging notion of epigenetic signatures as a mechanism of action of psychotherapeutic interventions may promote epigenetic patterns as biomarkers of lasting extinction effects.

Cost effectiveness of internet-based cognitive behaviour therapy and behavioural stress management for severe health anxiety

ObjectivesInternet-delivered exposure-based cognitive behaviour therapy (ICBT) has been shown to be effective in the treatment of severe health anxiety. The health economic effects of the treatment have, however, been insufficiently...

1130 Preliminary Effects of Exposure-Based Cognitive Behavior Therapy for Children With Pain Predominant Functional Gastrointestinal Disorders

1130 Preliminary Effects of Exposure-Based Cognitive Behavior Therapy for Children With Pain Predominant Functional Gastrointestinal Disorders

Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.

Enhancing panic and smoking reduction treatment with d-cycloserine: Study protocol for a randomized controlled trial

There has been relatively little attention focused on treatment strategies for smokers with panic attacks despite their increased risk of relapse. Panic and Smoking Reduction Treatment (PSRT) integrates standard smoking cessation treatment with an exposure-based intervention targeting the mechanisms underlying panic-smoking relations. Building upon emerging evidence supporting the efficacy of d-cycloserine (DCS) for augmenting exposure-based therapy, we are conducting an initial test of the efficacy of DCS for enhancing PSRT outcomes. Utilizing a randomized, double-blind trial comparing PSRT+DCS to PSRT+placebo, we will obtain initial effect sizes for short-term and long-term smoking cessation outcomes and perform an initial test of putative mechanisms.

PET Mapping of Neurofunctional Changes in a Posttraumatic Stress Disorder Model.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that occurs after exposure to a traumatic event. This study aimed to investigate the neurobiologic changes before and after exposure-based therapy by PET in a rat model of PTSD. Serial (18)F-FDG PET imaging studies were performed under the control (tone presentation), fear-conditioning, and extinction retrieval phases. Neuroactivity marker c-Fos protein was used for immunostaining. Increased glucose metabolism was observed in the bilateral amygdala after fear-conditioning (P < 0.001) and in the right posterior insular cortex under extinction retrieval (P < 0.001) compared with the control phase. Increased c-Fos expression in the posterior insular cortex under extinction retrieval was positively correlated to the glucose metabolism (P < 0.01). Our results indicated that the amygdala plays a key role in fear memory formation and, most importantly, the insular cortex is related to the retrieval of extinction memory. (18)F-FDG PET may provide a promising in vivo approach for evaluating exposure-based therapy of PTSD.

Can Transcranial Direct Current Stimulation Augment Extinction of Conditioned Fear?

Exposure-based therapy parallels extinction learning of conditioned fear. Prior research points to the ventromedial prefrontal cortex as a potential site for the consolidation of extinction learning and subsequent retention of extinction memory. The present study aimed to evaluate whether the application of non-invasive transcranial direct current stimulation (tDCS) during extinction learning enhances late extinction and early recall in human participants. Forty-four healthy volunteers completed a 2-day Pavlovian fear conditioning, extinction, and recall paradigm while skin conductance activity was continuously measured. Twenty-six participants received 2 mA anodal tDCS over EEG coordinate AF3 during extinction of a first conditioned stimulus. The remaining 18 participants received similar tDCS during extinction of a second conditioned stimulus. Sham stimulation was applied for the balance of extinction trials in both groups. Normalized skin conductance changes were analyzed using linear mixed models to evaluate effects of tDCS over late extinction and early recall trials. We observed a significant interaction between timing of tDCS during extinction blocks and changes in skin conductance reactivity over late extinction trials. These data indicate that tDCS was associated with accelerated late extinction learning of a second conditioned stimulus after tDCS was combined with extinction learning of a previous conditioned stimulus. No significant effects of tDCS timing were observed on early extinction recall. Results could be explained by an anxiolytic aftereffect of tDCS and extend previous studies on tDCS-induced modulation of fear and threat related learning processes. These findings support further exploration of the clinical use of tDCS.

Association of Resting Metabolism in the Fear Neural Network With Extinction Recall Activations and Clinical Measures in Trauma-Exposed Individuals.

Exposure-based therapy, an effective treatment for posttraumatic stress disorder (PTSD), relies on extinction learning principles. In PTSD patients, dysfunctional patterns in the neural circuitry underlying fear extinction have been observed using resting-state or functional activation measures. It remains undetermined whether resting activity predicts activations during extinction recall or PTSD symptom severity. Moreover, it remains unclear whether trauma exposure per se affects resting activity in this circuitry. The authors employed a multimodal approach to examine the relationships among resting metabolism, clinical symptoms, and activations during extinction recall. Three cohorts were recruited: PTSD patients (N=24), trauma-exposed individuals with no PTSD (TENP) (N=20), and trauma-unexposed healthy comparison subjects (N=21). Participants underwent a resting positron emission tomography scan 4 days before a functional MRI fear conditioning and extinction paradigm. Amygdala resting metabolism negatively correlated with clinical functioning (as measured by the Global Assessment of Functioning Scale) in the TENP group, and hippocampal resting metabolism negatively correlated with clinical functioning in the PTSD group. In the PTSD group, dorsal anterior cingulate cortex (dACC) resting metabolism positively correlated with PTSD symptom severity, and it predicted increased dACC activations but decreased hippocampal and ventromedial prefrontal cortex activations during extinction recall. The TENP group had lower amygdala resting metabolism compared with the PTSD and healthy comparison groups, and it exhibited lower hippocampus resting metabolism relative to the healthy comparison group. Resting metabolism in the fear circuitry correlated with functioning, PTSD symptoms, and extinction recall activations, further supporting the relevance of this network to the pathophysiology of PTSD. The study findings also highlight the fact that chronic dysfunction in the amygdala and hippocampus is demonstrable in PTSD and other trauma-exposed individuals, even without exposure to an evocative stimulus.

FEAR CONDITIONING AND EXTINCTION IN YOUTH WITH OBSESSIVE-COMPULSIVE DISORDER.

Fear acquisition and extinction are central constructs in the cognitive-behavioral model of obsessive-compulsive disorder (OCD), which underlies exposure-based cognitive-behavioral therapy (CBT). Youth with OCD may have impairments in fear acquisition and extinction that carry treatment implications. We examined these processes using a differential conditioning procedure. Forty-one youth (19 OCD, 22 community comparisons) completed a battery of clinical interviews, rating scales, and a differential conditioning task that included habituation, acquisition, and extinction phases. Skin conductance response (SCR) served as the primary dependent measure. During habituation, no difference between groups was observed. During acquisition, differential fear conditioning was observed across participants as evidenced by larger SCRs to the CS+ compared to CS-; there were no between-group differences. Across participants, the number and frequency of OCD symptoms and anxiety severity was associated with greater reactivity to stimuli during acquisition. During extinction, a three-way interaction and follow-up tests revealed that youth with OCD showed a different pattern of SCR extinction compared to the community comparison group. Youth with OCD exhibit a different pattern of fear extinction relative to community comparisons. This may be attributed to impaired inhibitory learning and contingency awareness in extinction. Findings suggest the potential benefit of utilizing inhibitory-learning principles in CBT for youth with OCD, and/or augmentative retraining interventions prior to CBT to reduce threat bias and improve contingency detection.

Editorial: Advances in Virtual Agents and Affective Computing for the Understanding and Remediation of Social Cognitive Disorders.

Editorial: Advances in Virtual Agents and Affective Computing for the Understanding and Remediation of Social Cognitive Disorders.

Treatment options for the specific phobias

Specific phobias are among the most common psychological problems both in men and women. For treatment of specific phobias, exposure-based therapy is the first choice followed by cognitive therapy, relaxation techniques and short-term pharmacotherapy. Long-term pharmacotherapy for specific phobias, is associated with adverse drug reactions and drug abuse, thus not a reasonable choice for long-term symptom control. Glucocorticoids and d-cycloserine (DCS) cause fear reduction when used in combination with exposure based therapy. Being a non-anxiolytic DCS accelerates fear reduction during exposure by facilitating memory consolidation during post-treatment phase. Adjuvant cortisol to exposure therapy also caused great reduction in fear in spider phobia.

Does the Theoretical Perspective of Exposure Framing Matter? Acceptance, Fear Reduction/Cognitive Reappraisal, and Values-Framing of Exposure for Social Anxiety.

Exposure-based therapy represents a first line treatment for anxiety disorders, but it is often underused. One target for improving client engagement is manipulating the theoretical perspective from which exposure is framed. Ninety-six adults with elevated social anxiety were enrolled in a two-session exposure therapy intervention. Participants were randomized to one of four conditions: (a) fear reduction/cognitive reappraisal, (b) acceptance, (c) personal values, or (d) experimental control The first three included brief psychoeducation and condition-specific experiential exercises and rationale; all four included in-session speech exposure and between-session exposure for homework. Results revealed that compared to the experimental control, the three active conditions reported significantly higher treatment credibility, initial in-vivo exposure engagement, and improvement in social anxiety symptoms. The three active conditions showed few differences among themselves. This study demonstrates that a brief exposure intervention using a credible rationale led to initial engagement in exposure therapy and improvement in social anxiety symptoms.

The Efficacy of Psychological Therapies for Specific Phobias in Adults and Some Unanswered Questions

Background: Specific phobias are common across the lifespan. Although exposure-based therapies have the most evidence of efficacy, reviews have cautioned that evaluations of some interventions are limited in number and have pointed to the need for more research. Furthermore, several permitted the inclusion of non-randomized clinical trials or samples exhibiting elevated fear but not necessarily a full diagnosis. We sought to update the literature on the empirical support of psychological treatments for specific phobias in adults through the selection of studies that met stringent criteria along with application of the system developed by Chambless and Hollon [1998: J Consult Clin Psychol 66: 7-18], which had not in isolation been done so previously. Methods: Electronic searches of the PubMed and PsycINFO databases were conducted in February 2014 to identify suitable randomized clinical trials. Thirty-eight met our inclusion criteria. Results: In vivo exposure was the most researched psychological therapy and found to be efficacious and specific. The evidence for virtual reality exposure was less strong though it had a similar level of empirical support. Several other therapies, including applied tension for blood phobia, were found to be possibly efficacious pending replication by other groups. Conclusions: Exposure-based therapy is the optimal treatment for specific phobias, but several gaps remain in the literature. Most studies investigated interventions for spider phobia. More clinical trials conducted by independent research teams are needed on therapies for other subtypes. There is a dearth of literature on the treatment of phobic disorders in older adults and medically unwell patients. This needs to be a priority on research agendas since we have an aging population. Moreover, failure to address blood-injection-injury phobia in a timely manner in patients who are under the care of medical services may affect adherence to recommendations and lead to a deterioration in health. Keywords: Empirically supported treatments, qualitative review, randomized clinical trials.

Embodied simulation in exposure-based therapies for posttraumatic stress disorder—a possible integration of cognitive behavioral theories, neuroscience, and psychoanalysis

Exposure to the trauma memory is the common denominator of most evidence-based interventions for posttraumatic stress disorder (PTSD). Although exposure-based therapies aim to change associative learning networks and negative cognitions related to the trauma memory, emotional interactions between patient and therapist have not been thoroughly considered in past evaluations of exposure-based therapy. This work focuses on recent discoveries of the mirror-neuron system and the theory of embodied simulation (ES). These conceptualizations may add a new perspective to our understanding of change processes in exposure-based treatments for PTSD patients. It is proposed that during exposure to trauma memories, emotional responses of the patient are transferred to the therapist through ES and then mirrored back to the patient in a modulated way. This process helps to alleviate the patient's sense of loneliness and enhances his or her ability to exert control over painful, trauma-related emotional responses. ES processes may enhance the integration of clinical insights originating in psychoanalytic theories—such as holding, containment, projective identification, and emotional attunement—with cognitive behavioral theories of learning processes in the alleviation of painful emotional responses aroused by trauma memories. These processes are demonstrated through a clinical vignette from an exposure-based therapy with a trauma survivor. Possible clinical implications for the importance of face-to-face relationships during exposure-based therapy are discussed.

The Reduction of Fear of Movement-related Pain

Previous research indicates that reducing fear of movement-related pain is hampered by engaging in safety-seeking behavior. We tested the hypothesis that fear reduction is only disrupted by behavior that serves a pain-avoidance goal (safety-seeking), but not when it is serving an achievement goal. Using the voluntary joystick movement paradigm, fear of a painful joystick arm movement was successfully acquired by repeatedly pairing this joystick movement with a painful electrocutaneous stimulus (unconditioned stimulus [pain-US]) and this fear was subsequently extinguished using a Pavlovian extinction procedure. During extinction, a Safety group and Reward group both pressed a safety button, whereas a third Control group did not. Pain-US expectancy and fear of movement-related pain ratings show a gradual fear reduction in the Control Group, but a return of fear when the button is pressed to avoid the pain-US (Safety group). When the same button is used to attain a reward (Reward group), subsequent return of fear is attenuated. In addition, we investigated the reliability of the return of fear in the Safety group and Reward group, using a customized Reliable Change Index. This index confirms that the return of fear was only reliable in the Safety group, and that this return of fear is associated with more perceived control over the nonoccurrence of the pain-US when pressing the button. These results highlight the importance of motivational context in understanding the role of safety-seeking behavior in exposure-based therapies.

Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability.

IntroductionThe essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance.ObjectiveIn addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT.MethodWe performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols.ResultsResults showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD.ConclusionThe main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatment.

Interventions for Individuals With High Levels of Needle Fear: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials.

This systematic review evaluated the effectiveness of exposure-based psychological and physical interventions for the management of high levels of needle fear and/or phobia and fainting in children and adults. A systematic review identified relevant randomized and quasi-randomized controlled trials of children, adults, or both with high levels of needle fear, including phobia (if not available, then populations with other specific phobias were included). Critically important outcomes were self-reported fear specific to the feared situation and stimulus (psychological interventions) or fainting (applied muscle tension). Data were pooled using standardized mean difference (SMD) or relative risk with 95% confidence intervals. The systematic review included 11 trials. In vivo exposure-based therapy for children 7 years and above showed benefit on specific fear (n=234; SMD: -1.71 [95% CI: -2.72, -0.7]). In vivo exposure-based therapy with adults reduced fear of needles posttreatment (n=20; SMD: -1.09 [-2.04, -0.14]) but not at 1-year follow-up (n=20; SMD: -0.28 [-1.16, 0.6]). Compared with single session, a benefit was observed for multiple sessions of exposure-based therapy posttreatment (n=93; SMD: -0.66 [-1.08, -0.24]) but not after 1 year (n=83; SMD: -0.37 [-0.87, 0.13]). Non in vivo e.g., imaginal exposure-based therapy in children reduced specific fear posttreatment (n=41; SMD: -0.88 [-1.7, -0.05]) and at 3 months (n=24; SMD: -0.89 [-1.73, -0.04]). Non in vivo exposure-based therapy for adults showed benefit on specific fear (n=68; SMD: -0.62 [-1.11, -0.14]) but not procedural fear (n=17; SMD: 0.18 [-0.87, 1.23]). Applied tension showed benefit on fainting posttreatment (n=20; SMD: -1.16 [-2.12, -0.19]) and after 1 year (n=20; SMD: -0.97 [-1.91, -0.03]) compared with exposure alone. Exposure-based psychological interventions and applied muscle tension show evidence of benefit in the reduction of fear in pediatric and adult populations.

Remediation of Childhood Math Anxiety and Associated Neural Circuits through Cognitive Tutoring.

Math anxiety is a negative emotional reaction that is characterized by feelings of stress and anxiety in situations involving mathematical problem solving. High math-anxious individuals tend to avoid situations involving mathematics and are less likely to pursue science, technology, engineering, and math-related careers than those with low math anxiety. Math anxiety during childhood, in particular, has adverse long-term consequences for academic and professional success. Identifying cognitive interventions and brain mechanisms by which math anxiety can be ameliorated in children is therefore critical. Here we investigate whether an intensive 8 week one-to-one cognitive tutoring program designed to improve mathematical skills reduces childhood math anxiety, and we identify the neurobiological mechanisms by which math anxiety can be reduced in affected children. Forty-six children in grade 3, a critical early-onset period for math anxiety, participated in the cognitive tutoring program. High math-anxious children showed a significant reduction in math anxiety after tutoring. Remarkably, tutoring remediated aberrant functional responses and connectivity in emotion-related circuits anchored in the basolateral amygdala. Crucially, children with greater tutoring-induced decreases in amygdala reactivity had larger reductions in math anxiety. Our study demonstrates that sustained exposure to mathematical stimuli can reduce math anxiety and highlights the key role of the amygdala in this process. Our findings are consistent with models of exposure-based therapy for anxiety disorders and have the potential to inform the early treatment of a disability that, if left untreated in childhood, can lead to significant lifelong educational and socioeconomic consequences in affected individuals. Significance statement: Math anxiety during early childhood has adverse long-term consequences for academic and professional success. It is therefore important to identify ways to alleviate math anxiety in young children. Surprisingly, there have been no studies of cognitive interventions and the underlying neurobiological mechanisms by which math anxiety can be ameliorated in young children. Here, we demonstrate that intensive 8 week one-to-one cognitive tutoring not only reduces math anxiety but also remarkably remediates aberrant functional responses and connectivity in emotion-related circuits anchored in the amygdala. Our findings are likely to propel new ways of thinking about early treatment of a disability that has significant implications for improving each individual's academic and professional chances of success in today's technological society that increasingly demands strong quantitative skills.

Enhanced endocannabinoid signaling boosts signal propagation through the hippocampal trisynaptic circuit and facilitates safety learning

Anxiety disorders like post-traumatic stress disorder or obsessive-compulsive disorder are frequently diagnosed and often occur in combination with other mental illnesses. Exposure-based therapies along with medication are widely used as treatment for most of these brain based diseases. The frequently used benzodiazepines are usually considered second-line due their impact on amnestic functions. In contrast, substances targeting the endocannabinoid system were found to be effective anxiolytics without disadvantages on memory function. However, the changes in millisecond-scale brain circuit dynamics that might underlie their therapeutic actions remain elusive. Here, enabled by a recently developed voltage-sensitive dye imaging assay in mouse brain slices, we compared the impact of diazepam and the cannabinoid neurotransmission enhancer AM404 on neuronal activity propagations through the entire trisynaptic circuitry of the hippocampus (“HTC”: perforant path dentate gyrus-area CA3-CA1 output subfield). Bath applied diazepam (1 µM) depressed activity propagations (“HTC-Waves”), which coincided with impaired safety learning. In contrast, bath applied AM404 (10 µM) boosted HTC-Waves in CA regions, and facilitated safety learning. These effects were absent in D1CB1-KO mice. Collectively, we demonstrate opposing effects of two anxiolytic drugs on the hippocampal network that might underlie their inverse impact on amnestic functions during exposition-based therapies.