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Bustamante J, Soto M, Miguez G, Quezada-Scholz VE, Angulo R, Laborda MA. Extinction in multiple contexts reduces the return of extinguished responses: A multilevel meta-analysis. Learn Behav 2023:10.3758/s13420-023-00609-w. [PMID: 38010486 DOI: 10.3758/s13420-023-00609-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/29/2023]
Abstract
Extinguished responses have been shown to reappear under several circumstances, and this reappearance is considered to model behaviors such as relapse after exposure therapy. Conducting extinction in multiple contexts has been explored as a technique to decrease the recovery of extinguished responses. The present meta-analysis aimed to examine whether extinction in multiple contexts can consistently reduce the recovery of extinguished responses. After searching in several databases, experiments were included in the analysis if they presented extinction in multiple contexts, an experimental design, and an adequate statistical report. Cohen's d was obtained for each critical comparison and weighted to obtain the sample's average weighted effect size. Analyses were then performed using a multilevel meta-analytic approach. Twenty-five studies were included, with a total sample of 37 experiments or critical comparisons. The analyses showed a large effect size for the sample, moderated by the length of conditioned stimulus exposure, type of experimental subject, and type of recovery. The robust effect of extinction in multiple contexts on relapse should encourage clinicians to consider extinction in multiple contexts as a useful technique in therapy and research.
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Affiliation(s)
- Javier Bustamante
- Institute of Social Sciences, Universidad de O'Higgins, Av. Libertador Bernardo O'Higgins 611, Rancagua, Chile
| | - Marcela Soto
- School of Psychology, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Santiago, Chile
| | - Gonzalo Miguez
- Department of Psychology, Universidad de Chile, Av. Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Vanetza E Quezada-Scholz
- Department of Psychology, Universidad de Chile, Av. Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Rocío Angulo
- Institute of Social Sciences, Universidad de O'Higgins, Av. Libertador Bernardo O'Higgins 611, Rancagua, Chile
| | - Mario A Laborda
- Department of Psychology, Universidad de Chile, Av. Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile.
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Woronko SE, Jessup SC, Armstrong T, Anwyl-Irvine AL, Dalmaijer ES, Olatunji BO. A novel probe of attentional bias for threat in specific phobia: Application of the "MouseView.js" approach. J Anxiety Disord 2023; 96:102700. [PMID: 36965222 DOI: 10.1016/j.janxdis.2023.102700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 02/27/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023]
Abstract
Although attentional bias for threat has been implicated in anxiety disorders, traditional attentional bias measures have been criticized for lack of reliability and validity, and eye tracking technologies can be cost-prohibitive. MouseView.js was recently developed to mimic eye tracking online by using the computer cursor as a proxy for gaze, and although it is equally reliable, MouseView.js' utility for capturing attentional bias for threat in anxiety-related disorders remains unclear. To fill this knowledge gap, snake phobic and non-phobic participants (N = 62) completed a behavioral avoidance task (BAT) and the MouseView.js task which consisted of 10-second exposures to blurred, side-by-side images of either pleasant-neutral or threat-neutral pairings and were instructed to freely move the mouse to reveal the images. Results demonstrated that snake phobic participants had significantly shorter average mouse dwell time on threat images than non-phobic individuals and showed a significant reduction in average dwell time on threat images following the first presentation of the threat-neutral pairing. Additionally, dwell time on threat images significantly mediated the group differences in steps completed on the BAT. Results highlight the utility of MouseView.js in capturing avoidant patterns of attentional bias for threat that may also partially drive avoidance in snake phobia. Implications for capturing attentional bias for threat in anxiety disorders more broadly are discussed.
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Affiliation(s)
- Sarah E Woronko
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Sarah C Jessup
- Department of Psychology, Vanderbilt University, Nashville, TN, USA.
| | | | | | - Edwin S Dalmaijer
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK; School of Psychological Science, University of Bristol, Bristol, UK
| | - Bunmi O Olatunji
- Department of Psychology, Vanderbilt University, Nashville, TN, USA.
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Acquisition and extinction across multiple virtual reality contexts. LEARNING AND MOTIVATION 2023. [DOI: 10.1016/j.lmot.2022.101857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Knowles KA, Tolin DF. Mechanisms of Action in Exposure Therapy. Curr Psychiatry Rep 2022; 24:861-869. [PMID: 36399234 DOI: 10.1007/s11920-022-01391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE OF REVIEW Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness. RECENT FINDINGS Recent studies have examined mechanisms of exposure-based interventions across multiple levels of analysis, from cognitive and behavioral changes that occur during treatment to the neurobiological mechanisms underlying fear extinction. Belief change and reductions in safety behaviors and avoidance mediate symptom improvements during exposure therapy, suggesting plausible cognitive and behavioral mechanisms. On the neural level, increased activation of prefrontal regions during extinction learning is a likely mechanism of exposure. Improved understanding of the biological mechanisms of exposure have led to exciting developments in clinical research, including pharmacological augmentation, though clinical translation of basic research has produced mixed results. Though still in development, such translational research is a promising future direction for exposure-based interventions.
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Affiliation(s)
- Kelly A Knowles
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT, 06106, USA
| | - David F Tolin
- Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT, 06106, USA. .,Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA.
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Effects of confronting the feared outcome during exposure therapy on the return of fear: An analogue study. J Behav Ther Exp Psychiatry 2022; 76:101747. [PMID: 35738693 DOI: 10.1016/j.jbtep.2022.101747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 02/02/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Although exposure therapy is an efficacious treatment for anxiety disorders, fear often returns after treatment. From an inhibitory learning perspective, long-term improvement depends not only on learning that feared stimuli are safe, but also that it is safe to experience the emotional response triggered by these stimuli. Accordingly, the current study examined the effects of occasional threat reinforcement during repeated exposure to multiple cues on the return of fear in snake phobia by incorporating reminders of the feared outcome. METHODS Snake fearful community adults (N = 74) were randomized to either repeated exposure to multiple cues or exposure to multiple cues that also explicitly depicted the feared outcome (snake biting someone). A measure of self-reported threat expectancy and a threat-relevant behavioral approach task (BAT) were administered pre-exposure, post-exposure, and at a one-week follow-up. RESULTS Compared to the multiple-cue exposure group, the multiple-cue + fear-outcome group showed significantly less subjective expectancy for a snake to bite and increased behavioral approach of snake images at one-week follow-up. The fear-outcome group also reported significantly greater variability in distress during exposure than the multiple-cue exposure group and this difference mediated the intervention effect on behavioral approach at follow-up. LIMITATIONS Findings are limited by the use of videos as an analogue to exposure and a computer-delivered BAT. CONCLUSIONS These findings suggest presentation of the feared outcome may result in more variability in distress during exposure therapy and this may partially explain the maintenance of behavioral gains.
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Teunisse AK, Pembroke L, O’Gradey‐Lee M, Sy M, Rapee RM, Wuthrich VM, Creswell C, Hudson JL. A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people. JCPP ADVANCES 2022; 2:e12080. [PMID: 37431458 PMCID: PMC10242975 DOI: 10.1002/jcv2.12080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/01/2022] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny. AIMS This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years. METHOD Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure. RESULTS From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication. CONCLUSIONS A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.
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Affiliation(s)
- Alessandra K. Teunisse
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Lorna Pembroke
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Maddison O’Gradey‐Lee
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
- Black Dog InstituteUniversity of New South WalesRandwickNew South WalesAustralia
| | - Megan Sy
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Ronald M. Rapee
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Viviana M. Wuthrich
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
| | - Cathy Creswell
- Department of Experimental Psychology and Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jennifer L. Hudson
- Centre for Emotional HealthSchool of Psychological SciencesMacquarie University, Macquarie ParkNew South WalesAustralia
- Black Dog InstituteUniversity of New South WalesRandwickNew South WalesAustralia
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Bautista CL, Teng EJ. Merging Our Understanding of Anxiety and Exposure: Using Inhibitory Learning to Target Anxiety Sensitivity in Exposure Therapy. Behav Modif 2021; 46:819-833. [PMID: 33825494 DOI: 10.1177/01454455211005073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Exposure-based therapies are the gold standard treatment for anxiety disorders, and recent advancements in basic and clinical research point to the need to update the implementation of exposure. Recent research has highlighted the importance of transdiagnostic factors such as anxiety sensitivity (AS), or fear of anxiety-related sensations. Elevated AS is common among all anxiety disorders and contains three dimensions, or expectancies, that can be used to guide treatment. Recently, treatments directly targeting AS have shown potential in reducing symptoms of anxiety. In addition, inhibitory learning theory (ILT) provides an alternative explanation of exposure processes based on basic learning research. ILT extends the current framework by accounting for renewal of fear, which is important given the substantial number of individuals who experience a return of symptoms following treatment. The current paper will provide an overview of ILT and discuss several ILT techniques that can be used to target AS. These two converging bodies of research hold strong potential for optimizing treatment for anxiety.
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Affiliation(s)
- Chandra L Bautista
- Michael E. DeBakey VA Medical Center, Houston, TX, USA.,The Center for Innovative Treatment of Anxiety and Stress, Houston, TX, USA
| | - Ellen J Teng
- Michael E. DeBakey VA Medical Center, Houston, TX, USA.,The Center for Innovative Treatment of Anxiety and Stress, Houston, TX, USA.,VA South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
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Carpenter JK, Pinaire M, Hofmann SG. From Extinction Learning to Anxiety Treatment: Mind the Gap. Brain Sci 2019; 9:brainsci9070164. [PMID: 31336700 PMCID: PMC6680899 DOI: 10.3390/brainsci9070164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 12/27/2022] Open
Abstract
Laboratory models of extinction learning in animals and humans have the potential to illuminate methods for improving clinical treatment of fear-based clinical disorders. However, such translational research often neglects important differences between threat responses in animals and fear learning in humans, particularly as it relates to the treatment of clinical disorders. Specifically, the conscious experience of fear and anxiety, along with the capacity to deliberately engage top-down cognitive processes to modulate that experience, involves distinct brain circuitry and is measured and manipulated using different methods than typically used in laboratory research. This paper will identify how translational research that investigates methods of enhancing extinction learning can more effectively model such elements of human fear learning, and how doing so will enhance the relevance of this research to the treatment of fear-based psychological disorders.
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Affiliation(s)
- Joseph K Carpenter
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd floor, Boston, MA 02215, USA
| | - Megan Pinaire
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd floor, Boston, MA 02215, USA
| | - Stefan G Hofmann
- Department of Psychological and Brain Sciences, Boston University, 900 Commonwealth Ave, 2nd floor, Boston, MA 02215, USA.
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Tsao SD, McKay D. The effects of exposure on the generalization of habituation on multiple indices of disgust. Bull Menninger Clin 2019; 83:3-24. [PMID: 30888855 DOI: 10.1521/bumc.2019.83.1.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Examination of habituation to disgust-related stimuli has received limited experimental investigation. In this study, 38 undergraduates were divided into two groups. The vomit-blood (VB) group was first exposed to a realistic approximation of vomit and allowed to habituate to this stimulus, while the blood-vomit (BV) group was first allowed to habituate to a realistic approximation of blood. Following the habituation phase, each group underwent a short exposure to the unexposed stimuli (blood in the VB group, vomit in the BV group). Physiological and self-report assessments were collected during exposure. Self-report habituation was observed for both groups. In addition, only muscle tension at the levator labii and heart rate in the VB group demonstrated significant changes that could be interpreted as habituation. Consistent with previous literature, muscle tension at the levator labii appeared to be a unique indicator of disgust responding. Implications and suggestions for future research are discussed.
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Affiliation(s)
- Steven D Tsao
- Center for Anxiety and Behavior Therapy, Bryn Mawr, Pennsylvania
| | - Dean McKay
- Department of Psychology, Fordham University, Bronx, New York
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Krisch KA, Bandarian-Balooch S, Neumann DL. Effects of extended extinction and multiple extinction contexts on ABA renewal. LEARNING AND MOTIVATION 2018. [DOI: 10.1016/j.lmot.2017.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.
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