Treatment of claustrophobias and snake/spider phobias: fear of arousal and fear of context

The Efficacy and Therapeutic Alliance of Augmented Reality Exposure Therapy in Treating Adults With Phobic Disorders: Systematic Review

BACKGROUND

Phobic disorders are characterized by excessive fear of a stimulus that can affect the quality of a patient's life. The lifetime prevalence in adults is 7.7% to 12.5%. The current literature provides evidence-based inferences about the effectiveness of in-vivo exposure therapy (IVET) in treating phobia. However, this method can put the therapist and the client in danger, with high drop out and refusal rates. A newer approach for exposure therapy using augmented reality technology is under assessment.

OBJECTIVE

This systematic review investigated the novel technology's efficacy, cost-efficacy, and therapeutic alliance in treating adults with phobia.

METHODS

An extensive search was conducted using 4 major databases (MEDLINE, PsycINFO, Embase, and Scopus) using a comprehensive list of synonyms for augmented reality exposure therapy (ARET) and phobic disorders. The search targeted any randomized control trial testing ARET in adults with phobic disorders up to August 8, 2022.

RESULTS

A total of 6 studies were included, with 208 participants providing results. Studies investigating the efficacy of ARET compared to no intervention showed significant results (P<.05) in the ARET group improvement. Head-to-head comparative studies comparing ARET to IVET showed no significant difference (P>.05) in the effectiveness and therapeutic alliance between both therapies. Further, the results demonstrated that the ARET group had a better long-term effect than IVET, with the ability to put the patients in more situations to face the feared object.

CONCLUSIONS

The current data suggest clinically significant efficacy and a promising therapeutic alliance of ARET. However, no data are available investigating the cost-effectiveness of ARET. Further research is warranted to ascertain ARET's cost-effectiveness and examine its efficacy in other populations and anxiety conditions.

Optimal attentional focus during exposure in specific phobia: a meta-analysis

Over the last 30 years, researchers have disagreed over the consequences of diverting attention from threat for exposure efficacy, which is an important theoretical and clinical debate. Therefore, the present meta-analysis assessed the efficacy of attentionally focused exposure against distracted and attentionally uninstructed exposure regarding distress, behavioral, and physiological outcomes. We included 15 randomized studies with specific phobia, totaling 444 participants and targeting outcomes at post-exposure and follow-up. Results indicated no difference between the efficacy of distracted exposure as opposed to focused or uninstructed exposure for distress and physiology. For behavior, at post-exposure, results were marginally significant in favor of distracted as opposed to focused exposure, while at follow-up results significantly favored distraction. However, concerning behavior, uninstructed exposure was superior to distraction. Moderation analyses revealed that, regarding distress reduction and approach behavior, distracted exposure significantly outperformed focused exposure when the distracter was interactive (g=1.010/g=1.128) and exposure was spread over the course of multiple sessions (g=1.527/g=1.606). No moderation analysis was significant for physiological measures. These findings suggest that distraction during exposure could be less counterproductive than previously considered and even beneficial under certain circumstances. Theoretical implications and future directions for research are discussed.

Neural activity associated with monitoring the oscillating threat value of a tarantula

Phylogenetic threats such as spiders evoke our deepest primitive fears. When close or looming, such threats engage evolutionarily conserved monitoring systems and defense reactions that promote self-preservation. With the use of a modified behavioral approach task within functional MRI, we show that, as a tarantula was placed closer to a subject's foot, increased experiences of fear coincided with augmented activity in a cascade of fear-related brain networks including the periaqueductal gray, amygdala, and bed nucleus of the stria terminalis. Activity in the amygdala was also associated with underprediction of the tarantula's threat value and, in addition to the bed nucleus of the stria terminalis, with monitoring the tarantula's threat value as indexed by its direction of movement. Conversely, the orbitofrontal cortex was engaged as the tarantula grew more distant, suggesting that this region emits safety signals or expels fear. Our findings fractionate the neurobiological mechanisms associated with basic fear and potentially illuminate the perturbed reactions that characterize clinical phobias.

Component fears of claustrophobia associated with mock magnetic resonance imaging

A conceptualization of claustrophobia [Rachman, S., & Taylor, S. (1993). Analyses of claustrophobia. Journal of Anxiety Disorders, 7, 281-291] was evaluated in the context of magnetic resonance imaging. One hundred eleven students responded to questionnaires that quantified fear of suffocation, fear of restriction, and sensitivity to anxiety symptoms. Sixty-four of them were then exposed to a mock magnetic resonance imaging assessment; maximum subjective fear during the mock assessment was self-reported, behavioral reactions to the mock assessment were characterized, and heart rates before and during the assessment were recorded. Scores for fear of suffocation, fear of restriction, and anxiety sensitivity were used to predict subjective, behavioral, and cardiac fear. Subjective fear during the mock assessment was predicted by fears of suffocation and public anxiousness. Behavioral fear (escape/avoidance) was predicted by fears of restriction and suffocation, and sensitivity to symptoms related to suffocation. Cardiac fear was predicted by fear of public anxiousness. The criterion variance predicted was impressive, clearly sufficient to legitimize both the research preparation and the conceptualization of claustrophobia that was evaluated.

Treatment of specific phobia in adults

This is a comprehensive review of treatment studies in specific phobia. Acute and long-term efficacy studies of in vivo exposure, virtual reality, cognitive therapy and other treatments from 1960 to 2005 were retrieved from computer search engines. Although specific phobia is a chronic illness and animal extinction studies suggest that relapse is a common phenomenon, little is known about long-term outcome. Treatment gains are generally maintained for one year, but longer follow-up studies are needed to better understand and prevent relapse. Acutely, the treatments are not equally effective among the phobia subtypes. Most phobias respond robustly to in vivo exposure, but it is associated with high dropout rates and low treatment acceptance. Response to systematic desensitization is more moderate. A few studies suggest that virtual reality may be effective in flying and height phobia, but this needs to be substantiated by more controlled trials. Cognitive therapy is most helpful in claustrophobia, and blood-injury phobia is uniquely responsive to applied tension. The limited data on medication have not been promising with the exception of adjunctive D-clycoserine. Despite the acute benefits of in vivo exposure, greater attention should be paid to improve treatment acceptance and retention, and additional controlled studies of more acceptable treatments are needed.

The assessment and treatment of specific phobias: a review

Specific phobia is one of the most common and easily treated mental disorders. In this review, empirically supported assessment and treatment procedures for specific phobia are discussed. Exposure-based treatments in particular are highlighted given their demonstrated effectiveness for this condition. The format and characteristics of exposure-based treatment and predictors of treatment response are outlined to provide recommendations for maximizing outcome. In addition, several other treatments for specific phobia are reviewed and critiqued, including cognitive therapy, virtual reality, eye movement desensitization and reprocessing, applied tension, and pharmacologic treatments. The review concludes with a discussion of future directions for research.

Imagined risk of suffocation as a trigger for hyperventilation

OBJECTIVE

Although hyperventilation has been hypothesized to play a role in many pathologies, its critical triggers remain poorly understood. The present experiment aimed to test whether stronger hyperventilation responses occur in response to suggested risk of suffocation compared with other fearful situations in high- and low-trait anxious women.

METHODS

Fractional end-tidal CO2-concentration (FetCO2), respiratory frequency, and inspiratory volume were measured nonintrusively in high- (n = 24) and low- (n = 24) trait anxious women during imagery of 3 fear, 1 tension, 1 depressive, and 3 relaxation scripts. The fear scripts were equal in ratings of unpleasantness and arousal but differed regarding the inclusion of suggested risk of suffocation and entrapment. After each imagery trial, participants rated the emotional dimensions of pleasantness, arousal, and dominance and the vividness of their imagery.

RESULTS

Decreases in FetCO2 occurred in all fear scripts. High-trait anxious women showed a stronger reduction in FetCO2 compared with low-trait anxious women during the fear script suggesting risk of suffocation but not during the other fear scripts. This effect was unrelated to any of the self-reported fear ratings. Self-reported fear of entrapment was associated with an overall lower FetCO2 but not with enhanced reactivity to imagined entrapment.

CONCLUSION

High-trait anxiety is associated with stronger respiratory responsivity to imagined risk of suffocation and may constitute a specific vulnerability factor for the development of panic disorder and claustrophobia.

Fear responses to mock magnetic resonance imaging among college students: toward a prototype experiment

Two hundred randomly selected student participants (139 females, 61 males) responded initially to questionnaires that quantified variables such as state and trait anxiety, anxiety sensitivity, claustrophobia, and panic/agoraphobia. Later they were informed that a mock magnetic resonance imaging (MRI) procedure was upcoming, and were prompted to provide self-efficacy ratings vis-à-vis completing the procedure. Finally, the participants' behavioral reactions to a mock MRI procedure were characterized; their heart beats were recorded and ratings of fearfulness were acquired. One purpose of the research was simply to tally numbers of participants who responded fearfully in various ways: 7 failed the procedure behaviorally, 7 others completed the procedure but did so fearfully, 17 others completed the procedure but manifested excessive heart-rate responsivity. A second purpose of the research was to "predict" subjects' fear-response categorization psychometrically and/or with self-efficacy ratings: psychometric data related to claustrophobia predicted subjects' fear-response categorization as did self-efficacy ratings. According to these results mock MRI assessment among college students provides a promising context for research on claustrophobia.

A review of psychological factors/processes affecting anxious responding during voluntary hyperventilation and inhalations of carbon dioxide-enriched air

Despite advances in our understanding of the nature of anxiety-related responding during periods of elevated bodily arousal, it is not necessarily evident by what psychological mechanisms anxiety is produced and maintained. To address this issue, researchers have increasingly employed biological challenge procedures to examine how psychological factors affect anxious responding during elevated bodily arousal. Of the challenging procedures, hyperventilation and inhalations of carbon dioxide-enriched air have been among the most frequently employed, and a relatively large body of literature using these procedures has now accumulated. Unfortunately, existing reviews do not comprehensively examine findings from hyperventilation and inhalations of carbon dioxide studies, and only rarely the methodological issues specific to these studies. To address these issues, we review the voluntary hyperventilation and carbon dioxide-enriched air literature in order to identify the primary methodological issues/limitations of this research and address the extent to which psychological variables influence anxious responding to such challenges. Overall, we conclude challenge research is a promising paradigm to examine the influence of psychological variables in anxious responding, and that such work will likely be enhanced with greater attention to psychological process issues.

Research on posttreatment return of claustrophobic fear, arousal, and avoidance using mock diagnostic imaging

Fear sometimes returns after attenuation via exposure. Return of fear is poorly understood due to conflicting results from diverse experiments. This article reports on two experiments in which claustrophobic fear during mock diagnostic imaging was attenuated and allowed to return so the experiments could be evaluated and return of fear studied. Attentional focus versus distraction during exposure was a between-subjects independent variable. Attempts were made to predict return of fear, return of heart-rate responsivity, and behavioral avoidance using levels of fear and heart-rate during initial mock diagnostic imaging as predictor variables. One third of participants displayed return of fear, heart-rate response, or avoidance 1 week after fear reduction. Heart-rate response during initial mock imaging predicted posttreatment return-of-fear classification; level of fear during initial imaging did not. Neither initial heart rate nor initial fear predicted return of heart-rate reactivity or avoidance. The experiments are offered as models for programmatic research.

Context-specificity of relapse: effects of therapist and environmental context on return of fear

Context-specificity of fear extinction was tested among 65 participants who were fearful of spiders by manipulating the contexts used for exposure treatment and two-week follow-up assessment. Context was defined by both meaningful (presence of a particular therapist) and incidental (room location and furnishings) environmental cues. Distinct phobic stimuli were used to examine interactions of context with stimulus. Physiological, behavioral and verbal indices of fear were measured. Results provided modest support for context-specific return of fear. With one stimulus, participants assessed in a non-treatment context at follow-up exhibited greater returns in heart rate levels. In addition, three of four participants who could not touch the stimulus at follow-up had been tested in a non-treatment context. Future investigations may benefit from greater distinctions between contexts or manipulation of contextual features more directly relevant to fear. Finally, post hoc analyses identified high trait anxiety, slow treatment response, recovery of phobic cognitions and long duration/high intensity phobic encounters post-treatment as significant predictors of increased return of fear.