Effect of distraction and coping style on in vivo exposure for specific phobia of spiders

The relative efficacy and efficiency of single- and multi-session exposure therapies for specific phobia: A meta-analysis

Exposure therapy is the preferred treatment for specific phobia (SP), with evidence supporting its efficacy whether delivered over multiple sessions or as a single session, such as One-Session Treatment. In this meta-analysis, we compared the efficiency and effectiveness of single- and multi-session exposure for SP. PsycINFO, Embase, MEDLINE, and Cochrane were systematically searched for peer-reviewed articles reporting the effects of multi-session (k = 30) and/or single-session (k = 55) in vivo exposure on SP symptoms in clinical populations (n = 1758 participants). A random-effects model was used to synthesise and compare the pre-post treatment effects (Hedges' g) on approach behaviour and self-reported SP symptoms. Mean total treatment time was significantly longer for multi-session exposure than for single-session. There were no significant differences in the pooled effect sizes of single-session and multi-session exposure at post-treatment and follow-up assessments; effect sizes were large for all outcomes. Phobia subtype significantly moderated the effect size for both treatment approaches, although the direction of association differed according to the outcome measures. Results suggest no evidence for differences in the effectiveness of single- and multi-session exposure, but single-session is more time efficient. These outcomes suggest that policies to facilitate access to single-session exposure would be beneficial.

Modulation of threat extinction by working memory load: An event-related potential study

Distraction is typically discouraged during exposure therapy for anxiety, because it is thought to interfere with extinction learning by diverting attention away from anxiety-provoking stimuli. Working memory load is one form of distraction that might interfere with extinction learning. Alternatively, working memory load might reduce threat responding and benefit extinction learning by engaging prefrontal brain regions that have a reciprocal relationship with brain circuits involved in threat detection and processing. Prior work examining the effect of working memory load on threat extinction has been limited and has found mixed results. Here, we used the late positive potential (LPP), an event-related potential that is larger for threatening compared to non-threatening stimuli to assess the effect of working memory load on threat extinction. After acquisition, 38 participants performed three blocks of an extinction task interspersed with low and high working memory load trials. Results showed that overall, the LPP was reduced under high compared to low working memory load, and that working memory load slowed extinction learning. Results provide empirical evidence in support of limiting distraction during exposure therapy in order to optimize extinction learning efficiency.

The Effect of Augmented Reality and Virtual Reality on Inducing Anxiety for Exposure Therapy: A Comparison Using Heart Rate Variability

Claustrophobia is an anxiety disorder characterized by the fear of enclosed spaces. Although medication treatment can effectively control symptoms, the effects quickly disappear once medication is discontinued. Many studies have shown that combining psychotherapy and medication is more efficacious than solely using medication. However, the weaknesses of the traditional psychotherapy are that it is time-consuming and expensive. Alternatively, vivo exposure therapy is proposed in which anxiety is gradually triggered with stimuli. Targeting claustrophobia is diagnosed using the traditional method, and this study established virtual reality (VR) and augmented reality (AR) environments consistent with claustrophobic characteristics, comparing the two using an experimental process to examine whether VR and AR environments are equally capable of triggering anxiety in participants. This study further analysed the efficacies of VR and AR by measuring changes in participant's heart rates variability (HRV) and examining data from survey questionnaires. HRV results indicated that the proposed VR system and AR system were both able to trigger anxiety. Furthermore, the AR environment produced a stronger experience for the participants and caused physiological reactions more evident than those caused by the VR environment. Regarding the anxiety questionnaire, the participants suggested that their anxiety was significantly higher in the VR environment than in the AR environment.

Too little, too much, or just right? Does the amount of distraction make a difference during contamination-related exposure?

BACKGROUND AND OBJECTIVES

The extant literature has shown mixed results regarding the impact of distraction use on exposure outcome; however, a wide variety of distraction tasks have been utilized across studies. In order to better understand these discrepant findings, we aimed to evaluate the impact of differing levels of distraction on exposure outcome. Additionally, treatment acceptability and changes in self-efficacy were assessed to evaluate how these may differ as a function of distraction use.

METHODS

In Experiment 1 (N = 176 participants tested), distraction tasks were experimentally validated through assessing changes in reaction time when completing concurrent tasks. Based on Experiment 1, distraction tasks were selected for use in Experiment 2, in which contamination-fearful participants were randomly assigned to one of four conditions: no, low, moderate, or high distraction during an exposure session. Participants (N = 124) completed a behavioural approach test and self-efficacy measure pre- and post-exposure and at one-week follow-up. Treatment acceptability was assessed immediately following the exposure session.

RESULTS

There were no significant differences between conditions for changes in behavioural approach pre-to post-exposure or at one-week follow-up. However, increases in self-efficacy pre-to post-exposure were greatest for moderate distraction, and treatment acceptability was highest with moderate and high distraction.

LIMITATIONS

Participants were not assessed for clinical severity, were not treatment-seeking, and only one specific type of fear was investigated.

CONCLUSIONS

Distraction (at any level) did not appear to negatively impact exposure outcome (all conditions improved pre-to post-exposure and at follow-up), but utilizing moderate to high amounts of distraction increased treatment acceptability.

Attentional focus during exposure in spider phobia: The effect of valence and schematicity of a partial distractor

This study examines the impact of partial distractor valence and schematicity (i.e., their relation to fear representation) on exposure efficacy. One hundred forty-one spider phobics were exposed to spider pictures and asked, in a between-subjects experimental design, to form mental images of words that were fear related (to spiders) and negative (schematic negative), fear unrelated and negative (non-schematic negative) or fear unrelated and positive (non-schematic positive). Multilevel measures of anxiety were performed at pre-exposure, post-exposure and 6 days' follow-up. Results show that both of the negative condition groups displayed similar results on all outcome variables and systematically differed from the positive condition group. While the latter group displayed a stronger decline in distress during exposure itself, the other groups showed greater exposure benefits: a stronger decline in emotional and avoidance responses and skin conductance responses from pre- to post-exposure and more approach behaviours when confronted with a real spider. The critical feature of distraction thus seems not to be the fact of being distracted from the phobic stimulus, but rather the fact of performing emotional avoidance by distracting oneself from negative affect. The results highlight that the acceptance of aversive emotional states is a critical active process in successful exposure.

Cognitive Coping Style and the Effectiveness of Distraction or Sensation-Focused Instructions in Chronic Pain Patients

AIM

This study set out to investigate whether cognitive coping strategies that match participants' preferred coping style effectively reduce pain intensity and situational anxiety in a population of people with chronic pain.

METHOD

Chronic pain patients (N = 43) completed questionnaires on coping style, pain intensity, self-efficacy, and situational/trait anxiety. Participants were classified as Monitors (n = 16) or Blunters (n = 19) based on their Miller Behavioural Style Scale score. Participants were then provided with an audiotaped intervention in which they were instructed to focus on pain sensations or to engage in a distraction task and then to rate the pain intensity and their anxiety during and after the attentional focus and distraction conditions. The two interventions were each completed by all participants, having been presented in counterbalanced order.

RESULTS

Findings revealed that Monitors' level of anxiety decreased following a congruent (i.e., sensation-focused) intervention. No effects were obtained in terms of perceived pain. For blunters, however, their perceived levels of anxiety and pain did not attenuate following a congruent, distraction-focused intervention.

CONCLUSION

Among persons experiencing chronic pain, tailoring coping strategies to match an individual's preferred coping style--in particular, those with a high level of monitoring--may enhance the benefit of psychological approaches to management of anxiety.

An integrative review of attention biases and their contribution to treatment for anxiety disorders

Models of exposure therapy, one of the key components of cognitive behavioral therapy for anxiety disorders, suggest that attention may play an important role in the extinction of fear and anxiety. Evidence from cognitive research suggests that individual differences may play a causal role in the onset and maintenance of anxiety disorders and so it is also likely to influence treatment. We review the evidence concerning attention and treatment outcomes in anxiety disorders. The evidence reviewed here suggests that that attention biases assessed at pre-treatment might actually predict improved response to treatment, and in particular that prolonged engagement with threat as measured in tasks such as the dot probe is associated with greater reductions in anxious symptoms following treatment. We examine this research within a fear learning framework, considering the possible role of individual differences in attention in the extinction of fear during exposure. Theoretical, experimental and clinical implications are discussed, particularly with reference to the potential for attention bias modification programs in augmenting treatment, and also with reference to how existing research in this area might inform best practice for clinicians.

Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders

INTRODUCTION

The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders.

METHODS

To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search.

RESULTS

474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive-compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education.

LIMITATIONS

Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria.

CONCLUSIONS

Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.

Moderators and mediators of the relationship between stress and insomnia: stressor chronicity, cognitive intrusion, and coping

STUDY OBJECTIVES

To assess moderators, such as stressor chronicity, and mediators, including stress response in the form of cognitive intrusion and coping behavior, of the prospective association between naturalistic stress and incident insomnia.

DESIGN

Longitudinal.

SETTING

Epidemiological.

PARTICIPANTS

A community-based sample of good sleepers (n = 2,892) with no lifetime history of insomnia.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Participants reported the number of stressful events they had encountered at baseline, as well as the perceived severity and chronicity of each event. Similarly, volitional stress responses such as coping, as well as more involuntary responses such as cognitive intrusion were assayed for each stressor. Follow-up assessment 1 y hence revealed an insomnia incidence rate of 9.1%. Stress exposure was a significant predictor of insomnia onset, such that the odds of developing insomnia increased by 19% for every additional stressor. Chronicity significantly moderated this relationship, such that the likelihood of developing insomnia as a result of stress exposure increased as a function of chronicity. Cognitive intrusion significantly mediated the association between stress exposure and insomnia. Finally, three specific coping behaviors also acted as mediators: behavioral disengagement, distraction, and substance use.

CONCLUSIONS

Most studies characterize the relationship between stress exposure and insomnia as a simple dose-response phenomenon. However, our data suggest that certain stressor characteristics significantly moderate this association. Stress response in the form of cognitive intrusion and specific maladaptive coping behaviors mediate the effects of stress exposure. These findings highlight the need for a multidimensional approach to stress assessment in future research and clinical practice.

CITATION

Pillai V, Roth T, Mullins HM, Drake CL. Moderators and mediators of the relationship between stress and insomnia: stressor chronicity, cognitive intrusion, and coping.

Nine Session Treatment of a Blood–Injection–Injury Phobia With Manualized Cognitive Behavioral Therapy

The treatment of blood-injection-injury (BII) phobia has a unique treatment component as compared with other types of specific phobias. In particular, many patients with a BII phobia distinctively experience an increased susceptibility to fainting when exposed to feared medical-related stimuli due to a diphasic physiological response. Moreover, effective treatment protocols must not only include therapeutic techniques to ameliorate the patient’s fear response but also teach strategies that will allow the patient to remain conscious during exposure to feared stimuli. The current case study describes a manualized, cognitive behavioral therapy that utilized applied muscle tension techniques to comprehensively address the multifaceted components of an adult male’s BII phobia. Treatment included a combination of psychoeducation and cognitive restructuring that provided the patient with an empirically based understanding of BII phobia, practiced using applied muscle tension techniques to better manage his physiological processes during exposure followed by the utilization of in vivo graduated exposure to reduce distress and avoidance of feared stimuli. After completing nine sessions, the patient demonstrated considerable improvement as evidenced by reductions in anxiety and the willful seeking of medical care following treatment. Further implications and future directions for research are discussed.

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.

Feelings into words: contributions of language to exposure therapy

A growing body of research has revealed that labeling an emotion, or putting one's feelings into words, can help to downregulate that affect, as occurs with intentional forms of emotion regulation, such as reappraisal and distraction. We translated this basic research to a real-world clinical context, in which spider-fearful individuals were repeatedly exposed to a live spider. Using a between-subjects design, we compared the effects of affect labeling, reappraisal, distraction from the feared stimulus, and exposure alone during this brief course of exposure therapy on subsequent fear responding. At a 1-week posttest involving a different spider in another context, the affect-labeling group exhibited reduced skin conductance response relative to the other groups and marginally greater approach behavior than the distraction group; however, the affect-labeling group did not differ from the other groups in self-reported fear. Additionally, greater use of anxiety and fear words during exposure was associated with greater reductions in fear responding. Thus, perhaps surprisingly, affect labeling may help to regulate aspects of emotion in a clinical context.

One-session treatment of specific phobias: a detailed description and review of treatment efficacy

One-Session Treatment (OST) is a form of massed exposure therapy for the treatment of specific phobias. OST combines exposure, participant modeling, cognitive challenges, and reinforcement in a single session, maximized to three hours. Clients are gradually exposed to steps of their fear hierarchy using therapist-directed behavioral experiments. Although there are several studies in the literature examining the efficacy of OST, little has been done to summarize this research. In the following review, research on and empirical support for OST are reviewed with an emphasis on the types of stimuli, samples, and methodologies utilized. Research generally supports OST's efficacy, although replication by independent examiners using adult and child samples is needed using more rigorous comparisons (e.g., psychological placebo or other treatments). Overall, OST continues to be a promising treatment for specific phobias; however, a great deal more investigation is needed to identify mechanisms of change, mediators, and moderators.

Effects of internal and external distraction and focus during exposure to blood-injury-injection stimuli

The present study examined the effects of attentional focus on fear reduction during exposure. Participants were randomly assigned to experimental conditions: exposure plus internal focus, exposure plus external focus, exposure plus internal distraction, exposure plus external distraction or exposure alone. Fifty blood-injury-injection fearful participants received 3 weekly exposure sessions. Participants in the distraction group reported the greatest fear reduction, with most notable reductions occurring for the external distraction condition. The distraction group also achieved a greater number of steps on a behavioral avoidance task at post-treatment, with the external distraction condition displaying greater approach behavior at follow-up. At follow-up the distraction group also displayed a greater increase in perceived control than the focusing group. Thus, distraction reduces fear within and between sessions and increases approach behavior in the longer-term, with exposure plus external distraction further facilitating this effect.

Attention focusing versus distraction during exposure in dental phobia

A survey of the discrepant findings regarding the effects of attention focusing and distraction on exposure suggested that subjective measures of anxiety and avoidance respond better to the latter condition, and heart rate (HR) reaction responds to the former. To test this hypothesis, 63 dental phobics were recruited who had not visited a dentist for a mean of 6.6 (1.5-25) years. Participants received a 1-h exposure session with either attention focusing or distraction. Subjective anxiety and HR to phobia-related pictures were assessed before and after the treatment session and again after 1 week. Avoidance was recorded in terms of adherence to the dental treatment schedule in the following 6 months. Contrary to expectation, state anxiety showed a greater decrease in the attention focusing than the distraction condition after 1 week. Both treatment conditions were similarly effective with regard to HR and avoidance. HR habituated in both groups after exposure and 73% of followed-up patients adhered to the dental treatment schedule. Comparison of the present with previous results suggests that the differences between attentional conditions tend to be more pronounced during shorter exposure sessions than were employed in the present study.

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.

Combining Cognitive-Behavioral Therapy and Pharmacotherapy for the Treatment of Panic Disorder

This article focuses on the role of combination treatment strategies in the management of panic disorder (PD). Despite short-term benefits, there is not consistent evidence for a longer-term advantage of combined treatment over cognitive-behavior therapy alone. In discussing this result, we place emphasis on ways in which medication treatment may interfere with the learning of safety in relation to feared cues in PD. These considerations are placed in the context of animal and human studies of factors that interfere with the extinction of fears. Strategies to overcome this interference are also discussed as are novel approaches to combination treatment.

Psychometric validation of a monitoring-blunting measure for social anxiety disorder: the coping styles questionnaire for social situations (CSQSS)

The purpose of this investigation was to conduct a psychometric validation of the Coping Styles Questionnaire for Social Situations (CSQSS). The CSQSS was developed to measure monitoring and blunting coping styles in social situations based on Miller's conceptualization of how individuals cope with threat-related information. Study 1 evaluated the content validity of the CSQSS monitoring and blunting items. Study 2 examined factor structure, reliability, and construct validity of the CSQSS in a sample of 443 college students. Evidence supported the content and face validity of the CSQSS. In addition, an exploratory factor analysis revealed a two-factor solution consistent with the monitoring and blunting constructs. Both monitoring and blunting scores were positively correlated with measures of social anxiety, with blunting having a stronger relationship. Moreover, individuals with high social anxiety engaged in a significantly higher degree of monitoring and blunting than did individuals with low social anxiety. Taken together, these results provide support for the reliability and validity of the CSQSS. The CSQSS may serve as a useful measure for further examination of monitoring and blunting coping styles in a social anxiety disorder sample.

Effects of cognitive-behavioral therapy on brain activation in specific phobia

Little is known about the effects of successful psychotherapy on brain function in subjects with anxiety disorders. The present study aimed to identify changes in brain activation following cognitive-behavioral therapy (CBT) in subjects suffering from specific phobia. Using functional magnetic resonance imaging (fMRI), brain activation to spider videos was measured in 28 spider phobic and 14 healthy control subjects. Phobics were randomly assigned to a therapy-group (TG) and a waiting-list control group (WG). Both groups of phobics were scanned twice. Between scanning sessions, CBT was given to the TG. Before therapy, brain activation did not differ between both groups of phobics. As compared to control subjects, phobics showed greater responses to spider vs. control videos in the insula and anterior cingulate cortex (ACC). CBT strongly reduced phobic symptoms in the TG while the WG remained behaviorally unchanged. In the second scanning session, a significant reduction of hyperactivity in the insula and ACC was found in the TG compared to the WG. These results propose that increased activation in the insula and ACC is associated with specific phobia, whereas an attenuation of these brain responses correlates with successful therapeutic intervention.

The effects of fear on performance monitoring and attentional allocation

Evidence from event-related potential (ERP) studies indicates abnormal error processing and attentional allocation in "trait"-anxious individuals. However, few studies have been conducted that evaluate relevant ERP components during the induction of an anxious state (i.e., fear). In the present study, ERPs were measured in 16 undergraduates during control and fear induction conditions to examine the effects of fear on error processing and attentional allocation. Despite comparable performance in both experimental conditions, the ERP data indicated reductions in attentional allocation and error salience during fear induction. Fear did not appear to directly alter early error processing, as indicated by the error-related negativity, however. The implication of these results for understanding how trait and state anxiety may affect error processing and attentional allocation are discussed.

Attention to phobic stimuli during exposure: the effect of distraction on anxiety reduction, self-efficacy and perceived control

To replicate and extend the finding that distraction facilitates between session anxiety reduction (), 27 spider phobics underwent three 10-min sessions of in vivo exposure followed by one 10-min exposure session at a 4-week follow-up, while having either stimulus-relevant focused conversation or stimulus-irrelevant distracting conversation with the experimenter. Physiological arousal and subjective anxiety were measured during exposure, and self-efficacy, perceived control and performance on a behavioural task were measured at pre-treatment, post session-3, and follow-up. Monitoring and blunting coping styles were also measured at pre-treatment to assess their impact on treatment outcome. Despite equal physiological activation between the groups, those who underwent distracted exposure showed greater reductions in subjective fear within and between sessions, and showed greater increases in self-efficacy ratings, internal perceived control and performance on a behavioural task. Coping style did not interact with the effect of distraction or focusing during exposure, however blunters had less subjective anxiety reduction overall, particularly when they underwent focused exposure. Results are discussed in terms of the emotional processing model and self-efficacy theory.