Effects of a safe person on induced distress following a biological challenge in panic disorder with agoraphobia

Acceptability, feasibility, and utility of a safety aid reduction treatment in underserved veterans: a pilot investigation

Access to mental health services, particularly for veterans residing in underserved communities, remain scarce. One approach to addressing availability barriers is through the use of group-based transdiagnostic or unified treatment protocols. One such protocol, Safety Aid Reduction Treatment (START), previously termed False Safety Behavior Elimination Treatment (FSET), has received increasing empirical support. However, prior research has only examined this treatment among civilians with a primary anxiety diagnosis. Thus, the purpose of the current study was to replicate and extend prior research by examining the acceptability, feasibility, and utility of START among veterans, particularly those living in underserved communities, and across a wider array of diagnoses. Veterans (n = 22) were assessed prior to, immediately after, and one month following the 8-week treatment. The majority of veterans found START useful and acceptable. Additionally, recruitment and retention rates suggest that the treatment was feasible. Notably, results revealed reductions in overall anxiety, depression, and safety aid usage, which were maintained throughout the brief follow-up period. These findings add to a growing body of literature highlighting the utility of transdiagnostic approaches in the amelioration of various anxiety and related disorders. Limitations include the small sample size and uncontrolled design.

A Current Learning Theory Approach to the Etiology and Course of Anxiety and Related Disorders

The authors describe how contemporary learning theory and research provide the basis for models of the etiology and maintenance of anxiety and related disorders. They argue that contemporary learning theory accounts for much of the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the limitations of earlier behavioral approaches, which were overly simplistic and have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term likelihood that experiences with stressful events will lead to the development of anxiety disorders. They also discuss how contextual variables during and after stressful learning experiences influence the maintenance of anxiety disorder symptoms. Thus, contemporary learning models provide a rich and nuanced understanding of the etiology and course of anxiety and related disorders. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Learning About Safety: Conditioned Inhibition as a Novel Approach to Fear Reduction Targeting the Developing Brain

Adolescence is a peak time for the onset of psychiatric disorders, with anxiety disorders being the most common and affecting as many as 30% of youths. A core feature of anxiety disorders is difficulty regulating fear, with evidence suggesting deficits in extinction learning and corresponding alterations in frontolimbic circuitry. Despite marked changes in this neural circuitry and extinction learning throughout development, interventions for anxious youths are largely based on principles of extinction learning studied in adulthood. Safety signal learning, based on conditioned inhibition of fear in the presence of a cue that indicates safety, has been shown to effectively reduce anxiety-like behavior in animal models and attenuate fear responses in healthy adults. Cross-species evidence suggests that safety signal learning involves connections between the ventral hippocampus and the prelimbic cortex in rodents or the dorsal anterior cingulate cortex in humans. Particularly because this pathway follows a different developmental trajectory than fronto-amygdala circuitry involved in traditional extinction learning, safety cues may provide a novel approach to reducing fear in youths. In this review, the authors leverage a translational framework to bring together findings from studies in animal models and humans and to bridge the gap between research on basic neuroscience and clinical treatment. The authors consider the potential application of safety signal learning for optimizing interventions for anxious youths by targeting the biological state of the developing brain. Based on the existing cross-species literature on safety signal learning, they propose that the judicious use of safety cues may be an effective and neurodevelopmentally optimized approach to enhancing treatment outcomes for youths with anxiety disorders.

Understanding coronaphobia

COVID-19 pandemic, in addition to being a global health emergency, has multiple socioeconomic and psychological ramifications. COVID-19 research and media reports have revealed a rise in fears related to contracting the virus. Though fear is a common psychological outcome during pandemics, the COVID-19 pandemic is a continuously evolving disease outbreak and has unique risk factors. Therefore, fear related to COVID-19 might manifest in not only fear and anxiety related to disease contraction and dying, but also associated sociooccupational stress. We attempt to understand the psychosocial process of the development of coronaphobia and postulate what constitutes coronaphobia, a new emerging phobia specific to COVID-19. We present a conceptual model delineating the risk factors causing coronaphobia and the underlying mechanisms, for a better understanding of its developmental process. From review of relevant research, the factors identified are, an unforeseen reality, unending uncertainties, need of acquiring new practices and avoidance behavior, loss of faith in health infrastructure, contraction of COVID-19 by head of states, cautionary statements from international bodies, and infodemia. These factors are assumed to cause interference with routine life, catastrophizing interpretation of benign symptoms, and social amplification of risk which lead to coronaphobia. The conceptualization of coronaphobia and the model will aid future research in developing psychometric measure of coronaphobia for use in clinical and research settings and design of policies and interventions for mitigating risk factors.

Social context and the real-world consequences of social anxiety

BACKGROUND

Social anxiety lies on a continuum, and young adults with elevated symptoms are at risk for developing a range of psychiatric disorders. Yet relatively little is known about the factors that govern the hour-by-hour experience and expression of social anxiety in the real world.

METHODS

Here we used smartphone-based ecological momentary assessment (EMA) to intensively sample emotional experience across different social contexts in the daily lives of 228 young adults selectively recruited to represent a broad spectrum of social anxiety symptoms.

RESULTS

Leveraging data from over 11 000 real-world assessments, our results highlight the central role of close friends, family members, and romantic partners. The presence of such close companions was associated with enhanced mood, yet socially anxious individuals had fewer confidants and spent less time with the close companions that they do have. Although higher levels of social anxiety were associated with a general worsening of mood, socially anxious individuals appear to derive larger benefits - lower levels of negative affect, anxiety, and depression - from their close companions. In contrast, variation in social anxiety was unrelated to the amount of time spent with strangers, co-workers, and acquaintances; and we uncovered no evidence of emotional hypersensitivity to these less-familiar individuals.

CONCLUSIONS

These findings provide a framework for understanding the deleterious consequences of social anxiety in emerging adulthood and set the stage for developing improved intervention strategies.

Reassurance seeking in the anxiety disorders and OCD: Construct validation, clinical correlates and CBT treatment response

BACKGROUND

Reassurance seeking has been hypothesized to be a key factor in the maintenance of anxiety and obsessive-compulsive disorders according to contemporary cognitive-behavioural therapy (CBT) approaches. The present study sought to examine the structure, clinical correlates, and malleability of reassurance seeking in the context of CBT treatment.

METHODS

Treatment-seeking participants (N = 738) with DSM-IV-TR (American Psychiatric Association, 2000) panic disorder with agoraphobia (PD/A), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) completed the Reassurance Seeking Scale (RSS) with other symptom measures prior to and following CBT treatment.

RESULTS

A confirmatory factor analysis supported a three factor solution: the need to seek excessive reassurance regarding decisions, attachment and the security of relationships, and perceived general threat and anxiety. The RSS was moderately correlated with general measures of anxiety and depression as well as disorder-specific symptom scales. Further, CBT was found to produce changes in reassurance seeking across CBT treatments and these reductions were significantly associated with disorder-specific clinical improvement.

CONCLUSION

Reassurance seeking appears to be a common factor across anxiety disorders and its reduction in CBT treatment is associated with improved clinical outcomes.

The Future of Intervention Science: Process-Based Therapy

Clinical science seems to have reached a tipping point. It appears that a new paradigm is beginning to emerge that is questioning the validity and utility of the medical illness model, which assumes that latent disease entities are targeted with specific therapy protocols. A new generation of evidence-based care has begun to move toward process-based therapies to target core mediators and moderators based on testable theories. This could represent a paradigm shift in clinical science with far-reaching implications. Clinical science might see a decline of named therapies defined by set technologies, a decline of broad schools, a rise of testable models, a rise of mediation and moderation studies, the emergence of new forms of diagnosis based on functional analysis, a move from nomothetic to idiographic approaches, and a move toward processes that specify modifiable elements. These changes could integrate or bridge different treatment orientations, settings, and even cultures.

Attentional set to safety recruits the ventral medial prefrontal cortex

Early detection of danger is highly adaptive, yet fast orientation towards safety is also key to survival. This study aimed to explore how human brain searches for safety by manipulating subjects' attentional set. Subjects were asked to judge random dots motion (RDM) direction and could be shocked for incorrect responses (RDM trials) while keeping alert in detecting shock probability cues (cue detection trials). Relative to safe condition, where attention was set to search cues associated with no shock, incorrect responses to 'dangerous+' cues would increase and correct responses to 'dangerous-' cues would decrease shock probability. In RDM trials, relative to the 'dangerous+', the safe and 'dangerous-' attentional set induced stronger activation in the ventral medial prefrontal cortex (vmPFC), a core region involved in flexible threat assessment and safety signalling. In cue detection trials, shorter response times and greater accuracy were observed for 'dangerous+' than 'dangerous-' and safe cues. At neural level 'dangerous+' cues induced stronger activity in the frontoparietal attention network than safe cues. Overall, our findings demonstrate that attentional set for searching safety recruits the vmPFC, while detection of threat-related cues elicits activity in the frontoparietal attention network, suggesting new roles for these regions in human defensive survival circuitry.

Emotion regulation during threat: Parsing the time course and consequences of safety signal processing

Improved understanding of fear inhibition processes can inform the etiology and treatment of anxiety disorders. Safety signals can reduce fear to threat, but precise mechanisms remain unclear. Safety signals may acquire attentional salience and affective properties (e.g., relief) independent of the threat; alternatively, safety signals may only hold affective value in the presence of simultaneous threat. To clarify such mechanisms, an experimental paradigm assessed independent processing of threat and safety cues. Participants viewed a series of red and green words from two semantic categories. Shocks were administered following red words (cue+). No shocks followed green words (cue-). Words from one category were defined as safety signals (SS); no shocks were administered on cue+ trials. Words from the other (control) category did not provide information regarding shock administration. Threat (cue+ vs. cue-) and safety (SS+ vs. SS-) were fully crossed. Startle response and ERPs were recorded. Startle response was increased during cue+ versus cue-. Safety signals reduced startle response during cue+, but had no effect on startle response during cue-. ERP analyses (PD130 and P3) suggested that participants parsed threat and safety signal information in parallel. Motivated attention was not associated with safety signals in the absence of threat. Overall, these results confirm that fear can be reduced by safety signals. Furthermore, safety signals do not appear to hold inherent hedonic salience independent of their effect during threat. Instead, safety signals appear to enable participants to engage in effective top-down emotion regulatory processes.

Emotional and physiological reactivity in Complicated Grief

BACKGROUND

Grief is a psychobiological response to the loss of a loved one. Some grief theorists suggest that this predictable response may arise from withdrawal of psychobiological regulation previously provided by the deceased (e.g. assistance with emotion regulation). Accordingly, recovery from loss may require bereaved individuals to re-establish self-regulatory control to avoid developing Complicated Grief (CG). This model implies that adults with CG may exhibit aberrant emotional responding to environmental stimuli. The present study was designed to test this hypothesis.

METHODS

We recruited a sample of 23 bereaved adults with CG and 26 healthy bereaved adults to complete an emotional reactivity paradigm. Participants watched a series of emotional film clips and provided measures of their self-reported emotional response. We also assessed their heart rate, respiratory sinus arrhythmia (RSA), and skin conductance level in response to these clips.

RESULTS

Though emotional and physiological differences between the groups were rare, the CG group exhibited attenuated RSA reactivity to some emotional film clips, suggesting blunted parasympathetic nervous system reactivity in those with the disorder.

LIMITATIONS

Limitations include the modest sample size and unequal group sizes.

CONCLUSIONS

Individuals with CG do not exhibit pervasive differences in emotional and physiological reactivity compared to healthy bereaved individuals. However, we did observe evidence of blunted parasympathetic nervous system reactivity in individuals with CG, which may mediate emotional inflexibility among those who develop the disorder.

An experimental investigation of contamination-related reassurance seeking: Familiar versus unfamiliar others

BACKGROUND AND OBJECTIVES

Repeated reassurance seeking (RS) is a hallmark feature of obsessive-compulsive disorder (OCD). Research in related areas of psychopathology suggests that familiarity with a partner can influence symptom expression. We hypothesized that participants in the company of a familiar (vs. unfamiliar) partner would seek more reassurance following an ambiguous task involving contamination-related threat.

METHODS

Participants completed an ambiguous dishwashing task in the company of a familiar or unfamiliar other, and were subsequently given an opportunity to seek reassurance. Participants and their assigned partners completed a measure of RS wherein they reported the number of times the participant sought reassurance; actual reassurance seeking was coded based on a recording of the interaction.

RESULTS

Results demonstrated that participants sought more reassurance from familiar (vs. unfamiliar) others F(3, 86) = 9.20, p < .001, partial η(2) = .24); this effect was robust when partner-reported (F(1, 88) = 27.04, p < .001, partial η(2) = .24), a trend when participant-reported (F(1, 88) = 2.72, p = .10, partial η(2) = .03), but not significant when using objectively-coded data (F(1, 88) = 0.14, p = .71, partial η(2) = .00).

LIMITATIONS

As this experiment was a preliminary attempt to examine RS in an interpersonal context, the study may not have captured compulsive or excessive RS.

CONCLUSIONS

Overall, results suggest that RS may be perceived as more excessive by familiar (versus unfamiliar) others, which may contribute to the distress experienced by carers of individuals with OCD.

The ecology of human fear: survival optimization and the nervous system

We propose a Survival Optimization System (SOS) to account for the strategies that humans and other animals use to defend against recurring and novel threats. The SOS attempts to merge ecological models that define a repertoire of contextually relevant threat induced survival behaviors with contemporary approaches to human affective science. We first propose that the goal of the nervous system is to reduce surprise and optimize actions by (i) predicting the sensory landscape by simulating possible encounters with threat and selecting the appropriate pre-encounter action and (ii) prevention strategies in which the organism manufactures safe environments. When a potential threat is encountered the (iii) threat orienting system is engaged to determine whether the organism ignores the stimulus or switches into a process of (iv) threat assessment, where the organism monitors the stimulus, weighs the threat value, predicts the actions of the threat, searches for safety, and guides behavioral actions crucial to directed escape. When under imminent attack, (v) defensive systems evoke fast reflexive indirect escape behaviors (i.e., fight or flight). This cascade of responses to threat of increasing magnitude are underwritten by an interconnected neural architecture that extends from cortical and hippocampal circuits, to attention, action and threat systems including the amygdala, striatum, and hard-wired defensive systems in the midbrain. The SOS also includes a modulatory feature consisting of cognitive appraisal systems that flexibly guide perception, risk and action. Moreover, personal and vicarious threat encounters fine-tune avoidance behaviors via model-based learning, with higher organisms bridging data to reduce face-to-face encounters with predators. Our model attempts to unify the divergent field of human affective science, proposing a highly integrated nervous system that has evolved to increase the organism's chances of survival.

Avoidance behavior: a free-operant lever-press avoidance task for the assessment of the effects of safety signals

This protocol details a free-operant avoidance paradigm that has been developed to evaluate the relative contribution of different sources of reinforcement of avoidance behavior that may play an important role in the development and maintenance of human anxiety disorders. The task enables the assessment of the effects of safety cues that signal a period free from danger on lever-press avoidance behavior. Avoidance behavior trained using this protocol has been shown to be sensitive to both behavioral and pharmacological manipulations and has been optimized so that it takes approximately 1 month for rats to perform at high levels of stable avoidance responding.

Safety signals as instrumental reinforcers during free-operant avoidance

Safety signals provide "relief" through predicting the absence of an aversive event. At issue is whether these signals also act as instrumental reinforcers. Four experiments were conducted using a free-operant lever-press avoidance paradigm in which each press avoided shock and was followed by the presentation of a 5-sec auditory safety signal. When given a choice between two levers in Experiment 1, both avoiding shock, rats preferentially responded on the lever that produced the safety signal as feedback, even when footshock was omitted. Following avoidance training with a single lever in Experiment 2, removal of the signal led to a decrease in avoidance responses and an increase in responses during the safety period normally denoted by the signal. These behavioral changes demonstrate the dual conditioned reinforcing and fear inhibiting properties of the safety signal. The associative processes that support the reinforcing properties of a safety signal were tested using a novel revaluation procedure. Prior experience of systemic morphine during safety signal presentations resulted in an increased rate of avoidance responses to produce the safety signal during a drug-free extinction test, a finding not seen with d-amphetamine in Experiment 3. Morphine revaluation of the safety signal was repeated in Experiment 4 followed by a drug-free extinction test in which responses did not produce the signal for the first 10 min of the session. Instrumental avoidance in the absence of the signal was shown to be insensitive to prior signal revaluation, suggesting that the signal reinforces free-operant avoidance behavior through a habit-like mechanism.

The effect of a clinically effective and non-effective dose of lorazepam on 7.5% CO₂-induced anxiety

Symptoms of anxiety induced by 7.5% CO₂ inhalation can be attenuated by acute administration of GABA(A) receptor anxiolytics such as lorazepam and alprazolam. This study investigated if these effects are dose-related, by comparing a 0.5 mg dose (considered non-clinically effective) and a 2 mg dose of lorazepam (clinically effective) on 7.5% CO₂ inhalation. Eighteen healthy males (mean age 20.6 years, SD 1.29), judged physically and mentally fit, attended three visits, each one week apart, to take each treatment in a randomised double-blind crossover design. Drugs were given 60 min prior to 20 min air inhalation, followed by 20 min 7.5% CO₂ inhalation. The order of gas presentation was single blind. Subjective ratings using visual analogue scales (VAS) and questionnaires were recorded before and after each inhalation. Blood pressure (BP), heart rate (HR), respiration rate (RR) and expired CO₂ were recorded during each inhalation. Inhalation of 7.5% CO₂ significantly raised BP, HR, RR and expired CO₂. Ratings of feeling like leaving the room were significantly lower on 2 mg compared with 0.5 mg and placebo, and dose-dependent trends were seen in scores for VAS fearful, anxious, stressed, tense, and worried. Results may be indicative of dose-dependent effects of lorazepam in a CO₂ model of anxiety.

Anxiety and its treatment: promoting science-based practice

In this article we analyze ways that psychological science can inform the treatment of anxiety disorders. We focus on experimental psychopathology research to describe the structure of anxiety and the functions of danger, safety, predictability and controllability in contributing to disorder. We then address science-based practice in terms of principles of change and the benefits from the self-corrective nature of science, contrasting this form of practice with treatments that are not grounded in basic learning theory. Models for dissemination and implementation of science-based practices are described and related to practitioner attitudes regarding scientific evidence. Finally, we consider practice implications when treatments are, and are not, based on the informative role of clinical psychological science.

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.

Assessing excessive reassurance seeking in the anxiety disorders

Reassurance seeking has long been hypothesized to be a key factor in the maintenance of anxiety within contemporary cognitive-behavioral approaches to the conceptualization and treatment of anxiety disorders. However, empirical studies have lagged due to the absence of a reliable and valid measure of reassurance seeking. The present study sought to develop and examine the psychometric properties of a theoretically derived measure of reassurance seeking in treatment-seeking participants with DSM-IV-TR (American Psychiatric Association, 2000) social phobia (n=116), generalized anxiety disorder (n=75), panic disorder with or without agoraphobia (n=50), and obsessive compulsive disorder (n=42). Participants (N=283) completed the Reassurance Seeking Scale (RSS), Depression Anxiety Stress Scale, Beck Anxiety Inventory, and Beck Depression Inventory-II. An exploratory factor analysis resulted in a coherent three factor solution reflecting the need to seek excessive reassurance regarding: (1) uncertainty about decisions, (2) attachment and the security of relationships, and (3) perceived general threat and anxiety. The RSS was found to possess good internal consistency and was moderately correlated with measures of anxiety, stress, and depression. The psychometric properties of the RSS appear promising for the promotion of programmatic research on reassurance seeking and its treatment in the anxiety disorders.

Reduction of claustrophobia with short-bore versus open magnetic resonance imaging: a randomized controlled trial

BACKGROUND

Claustrophobia is a common problem precluding MR imaging. The purpose of the present study was to assess whether a short-bore or an open magnetic resonance (MR) scanner is superior in alleviating claustrophobia.

METHODS

Institutional review board approval and patient informed consent were obtained to compare short-bore versus open MR. From June 2008 to August 2009, 174 patients (139 women; mean age = 53.1 [SD 12.8]) with an overall mean score of 2.4 (SD 0.7, range 0 to 4) on the Claustrophobia Questionnaire (CLQ) and a clinical indication for imaging, were randomly assigned to receive evaluation by open or by short-bore MR. The primary outcomes were incomplete MR examinations due to a claustrophobic event. Follow-up was conducted 7 months after MR imaging. The primary analysis was performed according to the intention-to-treat strategy.

RESULTS

With 33 claustrophobic events in the short-bore group (39% [95% confidence interval [CI] 28% to 50%) versus 23 in the open scanner group (26% [95% CI 18% to 37%]; P = 0.08) the difference was not significant. Patients with an event were in the examination room for 3.8 min (SD 4.4) in the short-bore and for 8.5 min (SD 7) in the open group (P = 0.004). This was due to an earlier occurrence of events in the short-bore group. The CLQ suffocation subscale was significantly associated with the occurrence of claustrophobic events (P = 0.003). New findings that explained symptoms were found in 69% of MR examinations and led to changes in medical treatment in 47% and surgery in 10% of patients. After 7 months, perceived claustrophobia increased in 32% of patients with events versus in only 11% of patients without events (P = 0.004).

CONCLUSIONS

Even recent MR cannot prevent claustrophobia suggesting that further developments to create a more patient-centered MR scanner environment are needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00715806.

Vulnerability factors in anxiety: Strain and sex differences in the use of signals associated with non-threat during the acquisition and extinction of active-avoidance behavior

Rats that exhibit a behaviorally inhibited temperament acquire active-avoidance behaviors quicker, and extinguish them slower, than normal outbred rats. Here we explored the contribution of stimuli that signal periods of non-threat (i.e. safety signals) in the process of acquiring active-avoidance behavior. Utilizing a discrete lever-press escape-avoidance protocol, outbred Sprague-Dawley (SD) rats and inbred, behaviorally inhibited, Wistar-Kyoto (WKY) rats were tested under conditions where a flashing light was either presented or not during periods of non-threat (the inter-trial interval, ITI). For males, we found the absence of the ITI-signal slowed the acquisition of avoidance behavior selectively in WKY rats. However, extinction of the avoidance behavior was not influenced by training with or without the ITI-signal; WKY males extinguished slower than SD males. For females, the presence of the ITI-signal did not affect acquisition in either strain. However, after training with the ITI-signal, females of both strains extinguished quicker in its absence than in its presence. In order to determine if facilitated acquisition of avoidance learning in male WKY rats was due to a paradigm-independent influence of the visual stimulus used as ITI-signal upon associative learning, we conducted eyeblink conditioning in the presence or absence of a similar visual stimulus. No differences in acquisition, as a function of this visual stimulus, were observed within the male WKY rats, but, as was observed in avoidance learning, male WKY rats extinguished slower than male SD rats. Thus, avoidance susceptibility for male WKY rats may be tied both to the presence of non-threat signals as well as a resistance to extinguish Pavlovian-conditioned associations. Female susceptibility to resist extinguishing avoidant behavior is discussed with respect to the possible role of stimuli serving as occasion setters for threat contexts.

Reduction of claustrophobia during magnetic resonance imaging: methods and design of the "CLAUSTRO" randomized controlled trial

Background

Magnetic resonance (MR) imaging has been described as the most important medical innovation in the last 25 years. Over 80 million MR procedures are now performed each year and on average 2.3% (95% confidence interval: 2.0 to 2.5%) of all patients scheduled for MR imaging suffer from claustrophobia. Thus, prevention of MR imaging by claustrophobia is a common problem and approximately 2,000,000 MR procedures worldwide cannot be completed due to this situation. Patients with claustrophobic anxiety are more likely to be frightened and experience a feeling of confinement or being closed in during MR imaging. In these patients, conscious sedation and additional sequences (after sedation) may be necessary to complete the examinations. Further improvements in MR design appear to be essential to alleviate this situation and broaden the applicability of MR imaging. A more open scanner configuration might help reduce claustrophobic reactions while maintaining image quality and diagnostic accuracy.

Methods/Design

We propose to analyze the rate of claustrophobic reactions, clinical utility, image quality, patient acceptance, and cost-effectiveness of an open MR scanner in a randomized comparison with a recently designed short-bore but closed scanner with 97% noise reduction. The primary aim of this study is thus to determine whether an open MR scanner can reduce claustrophobic reactions, thereby enabling more examinations of claustrophobic patients without incurring the safety issues associated with conscious sedation. In this manuscript we detail the methods and design of the prospective "CLAUSTRO" trial.

Discussion

This randomized controlled trial will be the first direct comparison of open vertical and closed short-bore MR systems in regards to claustrophobia and image quality as well as diagnostic utility.

Trial Registration

ClinicalTrials.gov: NCT00715806

Effects of threat context and cardiac sensitivity on fear responding to a 35% CO2 challenge: a test of the context-sensitivity panic vulnerability model

The present study tested several predictions of a context-sensitivity panic vulnerability model emphasizing the interaction between threat context and threat sensitivities. Participants without a history of panic (N=47) completed both global and domain-specific panic relevant sensitivity measures and were then randomized to undergo a 35% CO2 inhalation challenge in the presence or absence of a cardiac defibrillator (threat context). As predicted by the model, cardiac sensitivity (but not trait anxiety or anxiety sensitivity) potentiated the effects of the presence of the defibrillator on CO2 fear responding. Moreover, as predicted by the model, the observed potentiation effects of cardiac sensitivity on CO2 fear responding were mediated by participants' threat appraisals connected to the presence of the defibrillator. Theoretical and clinical implications are discussed.

Threat of pain influences social context effects on verbal pain report and facial expression

Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 x 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.

Appearing Socially Competent: The Effects of a Friend's Presence on the Socially Anxious

As hypothesized, while introducing themselves to another person via video, participants high in social anxiety appeared more socially competent with a friend present than when alone. We also examined three potential explanations for this effect and found that while sharing information about themselves on video, most participants high in social anxiety were verbally prompted by their friends. Furthermore, on an open ended question, participants high in social anxiety expressed less negative self-focused thoughts with a friend present than when alone, but friends' presence did not affect their self-reports of anxiety. As predicted, the presence of friends had no effect on social performance or anxiety for participants low in social anxiety. Although more research is needed to ascertain how being with a friend versus alone results in better social performance for people high in social anxiety, friends' support may be part of a repertoire of “safe” social interaction strategies.

Cardiophobia: a critical analysis

Cardiophobia, a clinical syndrome that affects hundreds of thousands of individuals in the USA, is characterized by abrupt, recurrent sensations and pain in the chest in the absence of physical pathology. This conceptual article seeks to address the significance of cardiophobia in western culture and to distinguish it from related disorders. In addition, a model of cardiophobia that highlights the role of heart-focused anxiety and interoceptive conditioning in the generation of limited-symptom panic attacks and acute chest pain is presented and vulnerability factors for cardiophobia are discussed. Future research directions relevant to the assessment and treatment of this clinically significant phenomenon are reviewed.

Social anxiety and romantic relationships: the costs and benefits of negative emotion expression are context-dependent

In general, expressing emotions is beneficial and withholding emotions has personal and social costs. Yet, to serve social functions there are situations when emotions are withheld strategically. We examined whether social anxiety influenced when and how emotion expressiveness influences interpersonal closeness in existing romantic relationships. For people with greater social anxiety, withholding the expression of negative emotions was proposed to preserve romantic relationships and their benefits. We examined whether social anxiety and emotion expressiveness interacted to predict prospective changes in romantic relationship closeness over a 12-week period. For people with less social anxiety, relationship closeness was enhanced over time when negative emotions were openly expressed whereas relationship deterioration was found for those more likely to withhold emotions. The reverse pattern was found for people with greater social anxiety such that relationship closeness was enhanced over time for those more likely to withhold negative emotions. Related social anxiety findings were found for discrepancies between desired and actual feelings of closeness over time. Findings were not attributable to depressive symptoms. These results suggest that the costs and benefits of emotion expression are influenced by a person's degree of social anxiety.

Anxiety Sensitivity Amelioration Training (ASAT): a longitudinal primary prevention program targeting cognitive vulnerability

Fear of arousal symptoms, often referred to as anxiety sensitivity (AS) appears to be associated with risk for anxiety pathology and other Axis I conditions. Findings from a longitudinal prevention program targeting AS are reported. Participants (n=404) scoring high on the Anxiety Sensitivity Index (ASI) were randomly assigned to receive a brief intervention designed to reduce AS (Anxiety Sensitivity Amelioration Training (ASAT)) or a control condition. Participants were followed for up to 24 months. Findings indicate that ASAT produced greater reductions in ASI levels compared with the control condition. Moreover, reductions were specific to anxiety sensitivity relative to related cognitive risk factors for anxiety. ASAT also produced decreased subjective fear responding to a 20% CO(2) challenge delivered postintervention. Data from the follow-up period show a lower incidence of Axis I diagnoses in the treated condition though the overall group difference was not statistically different at all follow-up intervals. Overall, findings are promising for the preventative efficacy of a brief, computer-based intervention designed to decrease anxiety sensitivity.

A contemporary learning theory perspective on the etiology of anxiety disorders: it's not what you thought it was

The authors describe how contemporary learning theory and research provide the basis for perspectives on the etiology and maintenance of anxiety disorders that capture the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the shortcomings of earlier overly simplistic behavioral approaches, which sometimes have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term outcomes of experiences with stressful events. They also demonstrate how contextual variables during and following stressful learning events affect the course of anxiety disorder symptoms once they develop. This range of variables can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.

Differential effects of safety in extinction of anxious responding to a CO₂ challenge in patients with panic disorder

Safety-relevant parameters are hypothesized to be important to the maintenance of pathological anxiety. The authors examined the effects of safety information and safety cues on anxious responding to a repeated 35% CO2 challenge in 31 patients with panic disorder. Patients were randomly assigned to one of three conditions: (a) safety information, (b) safety information plus a safety cue, or (c) no safety information. In the safety information group, patients received accurate information regarding the benign effects of the CO2 challenge. In the combined group, patients also received a safety cue that is salient for many patients with panic disorder (i.e., access to an anxiolytic pill during the challenge). The experimental manipulations did not differentially affect anxious responding following an initial challenge. However, after access to the anxiolytic was removed and the challenge procedure was repeated, those in the safety information alone condition showed lower subjective anxiety compared to those in the combined safety information/safety cue group. Findings suggest that safety information facilitates extinction of anxiety but only in the absence of safety cues.

Does coping predict CO2-induced panic in patients with panic disorder?

Patients with panic disorder (PD) show maladaptive coping but the role of coping in the pathogenesis of panic is unclear. This study examined general coping and panic-specific coping as predictors of fear responding to CO2 inhalation. Subjective and physiological responses including panic attacks were assessed in 45 patients with PD and 45 matched nonclinical controls. Measures of coping were the primary predictors used in the analyses. Consistent with other reports, patients with PD reported increased emotion-focused coping and there was an association between emotion-focused coping and subjective reactivity. However, only panic-specific coping predicted panic attacks in response to the CO2 challenge.

The impact of smoking on panic disorder: an initial investigation of a pathoplastic relationship

A disproportionate number of persons with panic disorder (PD) smoke cigarettes compared to individuals with other anxiety disorders and people in the general population. Currently, there is little theoretical or empirical understanding as to how smoking impacts those with PD. The present descriptive psychopathology study provided a test of the pathoplastic relationship between smoking and PD by investigating the additive negative impact of smoking on PD in terms of emotional, functional, and physical health impairment indices. Patients with PD who regularly smoke (PDSM) were compared to PD alone (N=122) in a cross-sectional analysis. As expected, persons with PDSM reported significantly more severe and intense anxiety symptoms and social impairment compared to persons with PD alone. No differences were evident for panic attacks or physical illness variables. These findings are discussed in relation to Pathoplastic models of dysfunction.

Panic-related responses to pentagastrin, flumazenil, and thyrotropin-releasing hormone in healthy volunteers

Thyrotropin-releasing hormone ( TRH) induces some somatic symptoms that resemble those of a panic attack, without being considered to be a laboratory panicogen in panic disorder (PD) patients. This study aimed to identify doses of TRH and the laboratory panicogens, pentagastrin and flumazenil, that would produce a similar intensity of panic-related somatic symptoms in healthy volunteers because comparison of the effects of these doses in PD patients could be used to test the hypothesis that these agents have specific panicogenic effects that are not explained solely by cognitively mediated reactions to somatic symptoms. Nine subjects were administered pentagastrin (0.2 micro g/kg) and TRH (600 or 1,200 micro g) in a double-blind, randomized order, within-subjects design. Fifteen subjects received pentagastrin (0.1 micro g/kg), TRH (600 or 1200 micro g) and flumazenil (2 mg) in a double-blind, randomized order within-subjects design. Although low dose pentagastrin (0.1 micro g/kg) induced comparable cardiorespiratory responses to those of TRH, it induced greater anxiety, suggesting that TRH would not be a credible comparator for pentagastrin in challenge studies in PD. However, TRH produced equal or greater symptom and physiological responses compared with flumazenil, suggesting that flumazenil may act as a panicogen in PD via a GABAergic mechanism rather than via a cognitively mediated response to somatic symptoms. This now requires confirmation in PD patients.

Coping strategies of panic and control subjects undergoing lactate infusion during magnetic resonance imaging confinement

The psychological reactions and coping strategies used in response to a behavioral contingency (confinement in a magnetic resonance imaging [MRI] scanner) during a biological challenge (sodium lactate infusion) were systematically studied in 13 subjects with panic disorder (PD) and 11 control subjects using the Claustrophobia Questionnaire (CQ) and the Revised Ways of Coping Checklist (RWCCL). All participants were able to successfully complete the experimental procedure. Findings suggest between-group coping strategy differences in response to general stressors, but relative convergence of coping strategies in response to the experimental procedure, with relatively greater emphasis on problem-focused coping approaches. These observations suggest that PD patients are able to engage in effective coping strategies in response to stressful but highly structured experimental situations. An overall pre-post MR scanning reduction in the fear of restriction but not suffocation was observed for the combined sample, primarily reflecting changes in the control group. Among PD subjects, higher levels of suffocation fears were maintained despite emergence of more problem-focused coping in the experimental situation.

Relationship satisfaction moderates the association between catastrophic cognitions and asthma symptoms

The tendency to have catastrophic beliefs and interpretations when anxious has been associated with less optimal disease management among persons with asthma. The goal of the present study was to examine the mediating effect of relationship satisfaction on the association between catastrophic cognitions and asthma symptom reporting in a sample of couples in which one partner has asthma. The participants were 50 patients with mild-to-moderate asthma and their partners. The results indicated that catastrophic cognitions were significantly associated with greater asthma symptoms related to rapid breathing, irritability, and panic/fear, after controlling for asthma severity. Among participants with high relationship satisfaction, catastrophic cognitions were significantly associated with panic/fear, irritability, anger, and loneliness. Among participants with low relationship satisfaction, catastrophic cognitions were significantly associated with dyspnea, congestion, and rapid breathing. These results are discussed in terms of potentially reflecting patients' perceptions of the fit between their coping needs and the support available in their intimate relationships.

Attachment and panic disorder

A dysfunctional relationship between parents and children can influence cognitive and emotional development and contribute to the development of psychiatric disorders, particularly panic disorder (PD). With the aim of exploring childhood experiences of parenting in PD patients, we compared subjectively perceived climate and objective recall by administering the Parental Bonding Instrument and 10 adjunctive items to 22 out-patients and 22 matched controls. Our analysis showed that DSM-III-R-diagnosed PD patients reported their parents to be significantly less caring than did the control group, while there was no significant difference in objective recall of parenting experiences.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with panic disorder

Traumatic life events during childhood and parental attitudes are discussed as possible etiological factors for panic disorder (PD). Patients with PD (n = 115) and subjects without a history of psychiatric disorders (n = 124) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders, and birth risk factors. The frequency of reports of some traumatic childhood experiences was significantly different between patients and controls, including death of father, separation from parents, childhood illness, parents' alcohol abuse, violence in the family, sexual abuse, and other factors. On a 0 to 9 "severe trauma scale" patients had significantly more severe traumatic events (mean score, 1.31; SD 1.21) than control subjects (0.52; SD 0.80; P <.0001). Only 31.3% of the panic patients, but 62.9% of the controls, did not report any severe traumatic events at all (P <.0001). Compared to controls, patients described the attitude of their parents as more restricting and providing less loving care and attention. Patients reported significantly higher rates of psychiatric disorders in their families in general, in particular PD and generalized anxiety disorder. Birth risk factors did not differ significantly. In a logistic regression model, the following possible etiological factors showed a significant influence: family history of anxiety disorders, severe traumatic events during childhood, and unfavorable parental attitudes. The present data support the hypothesis that the etiology of PD is multifactorial and that traumatic life events may be a contributing factor. Owing to the retrospective nature of the data, the results have to be interpreted with caution.

The effects of safety-seeking behavior and guided threat reappraisal on fear reduction during exposure: an experimental investigation

We examined the effects of safety-seeking behavior and guided threat focus and reappraisal on fear reduction during exposure. Participants (N=46) displaying marked claustrophobic fear were randomized to one of three 30-min exposure conditions: (a) guided threat focus and reappraisal; (b) safety-behavior utilization; or (c) exposure only control. Tripartite outcome assessments during a behavioral approach test, along with measures of suffocation and restriction fears were obtained at pre- and post-treatment, and at a 2-week follow-up. Treatment process measures were collected throughout treatment and consisted of indices of fear activation; within and between-trial fear habituation; and suffocation and entrapment expectancies. Measures of safety behavior utilization and attentional focus were also collected to assess the integrity of the experimental manipulations. Consistent with prediction, those encouraged to utilize safety-behaviors during exposure showed significantly more fear at post-treatment and follow-up relative to those encouraged to focus and reevaluate their core threat(s) during exposure. Moreover, growth curve analyses of treatment process data analyses revealed that safety-behavior utilization exerted a detrimental effect on between-trial habituation; whereas guided threat reappraisal enhanced between-trial habituation.

Offset control during recurrent 20% carbon dioxide-enriched air induction: relation to individual difference variables

Although control over aversive events maintains a central role in contemporary models of anxiety pathology, particularly panic disorder, there is little understanding about the emotional consequences of specific types of control processes. In the present study, offset control over 8 20% carbon dioxide-enriched air administrations was experimentally manipulated in a large nonclinical population (n = 96) varying in anxiety sensitivity (high or low) and gender. Dependent measures included self-reported anxiety, affective reports of valence, arousal, emotional control, and physiological indices of heart rate and skin conductance. High anxiety-sensitive participants who lacked offset control reported significantly greater elevations in self-reported anxiety, emotional displeasure, arousal, and dyscontrol relative to their yoked counterparts with offset control. In contrast, low anxiety-sensitive individuals responded with similar levels of cognitive and affective distress regardless of the offset control manipulation. Although the provocation procedure reliably produced bodily arousal relative to baseline, at a physiological level of analysis, no significant differences emerged across conditions. These findings are discussed in relation to offset control during recurrent interoceptive arousal, with implications for better understanding anxiety about abrupt bodily sensations.

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.

A modern learning theory perspective on the etiology of panic disorder

Several theories of the development of panic disorder (PD) with or without agoraphobia have emerged in the last 2 decades. Early theories that proposed a role for classical conditioning were criticized on several grounds. However, each criticism can be met and rejected when one considers current perspectives on conditioning and associative learning. The authors propose that PD develops because exposure to panic attacks causes the conditioning of anxiety (and sometimes panic) to exteroceptive and interoceptive cues. This process is reflected in a variety of cognitive and behavioral phenomena but fundamentally involves emotional learning that is best accounted for by conditioning principles. Anxiety, an anticipatory emotional state that functions to prepare the individual for the next panic, is different from panic, an emotional state designed to deal with a traumatic event that is already in progress. However, the presence of conditioned anxiety potentiates the next panic, which begins the individual's spiral into PD. Several biological and psychological factors create vulnerabilities by influencing the individual's susceptibility to conditioning. The relationship between the present view and other views, particularly those that emphasize the role of catastrophic misinterpretation of somatic sensations, is discussed.

The efficacy of habituation in decreasing subjective distress among high anxiety-sensitive college students

While there is mounting evidence that the concept of anxiety sensitivity (AS) is linked to the expression of anxiety (specifically, panic), there has been little research comparing the efficacy of interoceptive exposure alone with interoceptive exposure coupled with cognitive restructuring among high AS participants. The present investigation addressed this issue in a sample of high anxiety-sensitive college students (scores above 29 on the Anxiety Sensitivity Index). Participants were randomly assigned to receive either five consecutive trials of voluntary hyperventilation or five consecutive trials of hyperventilation with cognitive restructuring instructions. It was expected that while repeated hyperventilation would be associated with a significant reduction in self-reported anxiety, catastrophic cognitions, and somatic sensations across trials, the greatest reduction in symptoms would occur with the addition of cognitive restructuring. These predictions were partially supported. As expected, high AS participants evidenced significant decreases in anxiety symptoms when habituation was accompanied by cognitive restructuring. Contrary to predictions, however, interoceptive exposure alone was not effective in reducing anxious symptoms. These results suggest that brief habituation alone may not be an effective strategy for high AS participants and are discussed as providing further support for a cognitive model of anxiety.

Catastrophic cognitions in panic disorder with and without agoraphobia

The cognitive models of panic disorder with (PDA) or without (PD) agoraphobia are now widely recognised. These models propose that patients misinterpret external or internal cues in a catastrophic manner and as a result of these catastrophic cognitions the symptoms are maintained. There is now a large body of empirical evidence for this proposal and the aim of this paper is to systematically review the literature to evaluate whether the empirical evidence supports the contribution of catastrophic cognitions to PD and PDA. Empirical studies using different methodologies, such as interview, questionnaire, self-monitoring, and in vivo techniques are reviewed. The results indicate there is substantial empirical evidence in support of the central role of catastrophic cognition in cognitive models. Different methodologies provided convergent support for the importance of catastrophic cognitions in the maintenance of panic disorder and agoraphobia. Limitations in the interpretation of the existing research are highlighted and future research directions are proposed.