Threat expectancy bias and treatment outcome in patients with panic disorder and agoraphobia

Effectiveness of exposure-based treatment for childhood anxiety disorders: An open clinical trial to test its relation with indices of emotional processing and inhibitory learning

BACKGROUND AND OBJECTIVES

The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises.

METHODS

Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change.

RESULTS

From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations.

LIMITATIONS

As patients also received other treatment elements, the results cannot be interpreted unequivocally.

CONCLUSIONS

The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.

The Persian COVID stress scales (Persian-CSS) and COVID-19-related stress reactions in patients with obsessive-compulsive and anxiety disorders

The COVID Stress Scales (CSS) were designed to assess stress related to the COVID-19 pandemic. Emerging evidence indicates that people with anxiety disorders (ADs) and obsessive-compulsive disorder (OCD) may be more negatively impacted by COVID-19 than those with mood disorders or healthy individuals. Accordingly, this study sought to validate the Persian CSS (Persian-CSS) and to compare COVID-19-related stress reactions among patients with specific ADs and OCD. Patients with OCD (n = 300) and ADs (n = 310) completed the Persian-CSS and other scales developed to assess anxiety-related traits and COVID-19-related distress. The Persian-CSS replicated a five-factor structure similar to the original CSS in OCD and ADs. The total CSS and its scales had good reliability and validity. Patients with generalized anxiety disorder, panic disorder, and OCD had higher COVID-19 stress reactions than patients with social anxiety disorder and specific phobia. Patients with panic disorder had higher danger and contamination fears and xenophobia than patients with OCD. The study suggests that the Persian-CSS is a valid scale to be used in patients with OCD and ADs, each of whom differs in their specific patterns of COVID-19-related stress reactions.

What's the Risk? Fearful Individuals Generally Overestimate Negative Outcomes and They Dread Outcomes of Specific Events

Although it is an adaptive mechanism that danger usually elicits fear, it seems that fearful individuals overestimate the danger associated with their feared objects or situations. Previous research has not systematically distinguished between the estimated risk of an encounter with fear-relevant stimuli and the expected unpleasant outcomes of such encounters. Furthermore, it is not clear if biased risk perception is specific to an individual's fear or generalized to all negative events. In an online-survey (N = 630) we assessed the estimated risk to encounter fear-relevant stimuli and the expectations of negative outcomes of such encounters. Items contained three domains (spiders, snakes, and everyday fear triggers). In regression analyses we examined the specific associations between fear and risk estimations. In addition, we compared subgroups with specific fears and low fearful individuals. While an individual's fear score was not related to the estimated risk of an encounter with fear-specific stimuli, it was related to an overestimation of negative outcomes in all domains. The perceived risk of aversive outcomes was most pronounced for an individual's specific fear. Furthermore, an individual's specific fear was most predictive of the estimated risk of a negative fear-relevant outcome. Highly fearful individuals overestimate the risk of negative outcomes of fear-relevant encounters. Specifically, they dread outcomes of encounters with their feared object. Differentiating fear-relevant components of risk perception provides insights into the cognitions which may motivate maladaptive avoidance behavior.

Low Perceived Self-Efficacy Impedes Discriminative Fear Learning

Perceived self-efficacy refers to a subject’s expectation about the outcomes his/her behavior will have in a challenging situation. Low self-efficacy has been implicated in the origins and maintenance of phobic behavior. Correlational studies suggest an association between perceived self-efficacy and learning. The experimental manipulation of perceived self-efficacy offers an interesting approach to examine the impact of self-efficacy beliefs on cognitive and emotional functions. Recently, a positive effect of an experimentally induced increased self-efficacy on associative learning has been demonstrated. Changes in associative learning constitute a central hallmark of pathological fear and anxiety. Such alterations in the acquisition and extinction of conditioned fear may be related to cognitive and neurobiological factors that predict a certain vulnerability to anxiety disorders. The present study builds on previous own work by investigating the effect of an experimentally induced low perceived self-efficacy on fear acquisition, extinction and extinction retrieval in a differential fear conditioning task. Our results suggest that a negative verbal feedback, which leads to a decreased self-efficacy, is associated with changes in the acquisition of conditioned fear. During fear acquisition, the negative verbal feedback group showed decreased discrimination of fear responses between the aversive and safe conditioned stimuli (CS) relative to a group receiving a neutral feedback. The effects of the negative verbal feedback on the acquisition of fear discrimination learning were indexed by an impaired ability to discriminate the probability of receiving a shock during acquisition upon presentation of the aversive (CS+) relative to the safe stimuli (CS−). However, the effects of low self-efficacy on discrimination learning were limited to fear acquisition. No differences between the groups were observed during extinction and extinction retrieval. Furthermore, analysis of other outcome measures, i.e., skin conductance responses and CS valence ratings, revealed no group differences during the different phases of fear conditioning. In conclusion, lower perceived self-efficacy alters cognitive/expectancy components of discrimination during fear learning but not evaluative components and physiological responding. The pattern of findings suggests a selective, detrimental role of low(er) self-efficacy on the subject’s ability to learn the association between ambiguous cues and threat/safety.

Acceptance-based interoceptive exposure for young children with functional abdominal pain

Functional abdominal pain (FAP) is a common childhood somatic complaint that contributes to impairment in daily functioning (e.g., school absences) and increases risk for chronic pain and psychiatric illness. Cognitive behavioral treatments for FAP target primarily older children (9 + years) and employ strategies to reduce a focus on pain. The experience of pain may be an opportunity to teach viscerally hypersensitive children to interpret the function of a variety of bodily signals (including those of hunger, emotions) thereby reducing fear of bodily sensations and facilitating emotion awareness and self-regulation. We designed and tested an interoceptive exposure treatment for younger children (5-9 years) with FAP. Assessments included diagnostic interviews, 14 days of daily pain monitoring, and questionnaires. Treatment involved 10 weekly appointments. Using cartoon characters to represent bodily sensations (e.g., Gassy Gus), children were trained to be "FBI agents" - Feeling and Body Investigators - who investigated sensations through exercises that provoked somatic experience. 24 parent-child dyads are reported. Pain (experience, distress, and interference) and negative affect demonstrated clinically meaningful and statistically significant change with effect sizes ranging from 0.48 to 71 for pain and from 0.38 to 0.61 for pain distress, total pain: X2 (1, n = 24) = 13.14, p < 0.0003. An intervention that helps children adopt a curious stance and focus on somatic symptoms reduces pain and may help lessen somatic fear generally.

CLINICAL TRIAL REGISTRATION

NCT02075437.

Fear-relevant illusory correlations in different fears and anxiety disorders: A review of the literature

Fearful individuals often overestimate the relationship between fear-relevant stimuli and aversive consequences. Such fear-relevant illusory correlations (ICs) might be involved in the maintenance of anxiety disorders. In this literature review, we found clear evidence that ICs are present and enhanced in fear of animals. We also revealed some evidence for ICs related to fear of flying, social anxiety, contamination fear, panic disorder, and post-traumatic stress disorder, but with considerably less clarity. Fear-relevant ICs seem to be best explained by both a priori expectancies and biased encoding of the experienced associations. Studies to date suggest that one important biased encoding process is the enhanced aversiveness/salience of fear-relevant outcomes. Future studies may improve insight by developing more reliable IC measures and testing the effect of encoding processes on treatment outcomes.