A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders

Generalization of exposure therapy: Systematic review and recommendations for future research

Limited generalization of exposure therapy effects from treatment-related to treatment-unrelated contexts and/or stimuli is a potential factor contributing to relapse after successful exposure treatment. Investigating the processes underlying exposure therapy generalization (ETG) and developing strategies to promote ETG has become a significant research area. This systematic review provides an overview of the current state of ETG research, outlining its operationalization and the methodological diversity used to detect changes in ETG. We also summarize and discuss findings from studies aimed at enhancing ETG through pharmacological and behavioral interventions. A total of 34 studies were identified, investigating ETG across therapy-related and unrelated contexts and fear stimuli. These studies primarily used physical and/or social context/stimuli manipulations to investigate ETG. Multiple response systems (subjective, psychophysiological, behavioral) were used as indices of diminished ETG, but most studies found increased subjective fear in treatment-unrelated contexts/stimuli compared to treatment-related ones. We conclude that clear definitions and criteria for assessing ETG are urgently needed. Behavioral interventions, such as multiple context exposure or sleep after exposure, seem effective in promoting ETG across different contexts/stimuli. In contrast, findings from pharmacological approaches are less encouraging, but more research is needed. We identify research gaps that require further investigation to better understand the mechanisms governing and promoting ETG. Experimental paradigms offer a clear advantage for this purpose and for screening novel strategies to maximize ETG.

Elevations in depression and anxiety symptoms prior to discharge from partial hospitalization

Discharge from psychiatric treatment has been established as an emotionally intense and vulnerable time for patients; however, to date no studies have investigated symptoms directly preceding discharge and the impact on post-discharge outcomes. Our primary aim was to assess the prevalence of elevations in depression and anxiety symptoms prior to discharge from a partial hospitalization program (PHP). Our secondary aim was to assess whether these pre-discharge elevations predict post-discharge outcomes. We analyzed daily depression and anxiety symptom severity from 4211 patients attending a PHP. Two subsamples (n = 113 and n = 70) completed post-discharge outcome measures of symptom severity, well-being, and/or functional impairment at two-weeks, one-month, and three-months post-discharge. Approximately two-thirds of patients demonstrated a significant increase in depression (p < .001) and anxiety (p < .001) symptom severity prior to discharge. These pre-discharge elevations did not significantly predict post-discharge measures when controlling for symptom severity at discharge. Our results suggest patients experience an increase in symptom severity preceding discharge, even after improvement; however, these elevations do not provide additional prognostic information. Clinicians may consider sharing these results with patients to normalize the experience of symptom elevation prior to discharge and highlight that it is not a prognostic indicator.

Using computational models of learning to advance cognitive behavioral therapy

Many psychotherapy interventions have a large evidence base and can help a substantial number of people with symptoms of mental health conditions. However, we still have little understanding of why treatments work. Early advances in psychotherapy, such as the development of exposure therapy, built on theoretical and experimental evidence from Pavlovian and instrumental conditioning. More generally, all psychotherapy achieves change through learning. The past 25 years have seen substantial developments in computational models of learning, with increased computational precision and a focus on multiple learning mechanisms and their interaction. Now might be a good time to formalize psychotherapy interventions as computational models of learning to improve our understanding of mechanisms of change in psychotherapy. To advance research and help bring together a new joint field of theory-driven computational psychotherapy, we first review literature on cognitive behavioral therapy (exposure therapy and cognitive restructuring) and introduce computational models of reinforcement learning and representation learning. We then suggest a mapping of these learning algorithms on change processes presumably underlying the effects of exposure therapy and cognitive restructuring. Finally, we outline how the understanding of interventions through the lens of learning algorithms can inform intervention research.

Perceptions and Use of Extended-Duration Exposure Therapy Amongst Psychologists

BACKGROUND

Extended-duration exposure therapy, in which treatment is delivered over a single prolonged session or cluster of long-duration sessions, is a highly efficacious and efficient treatment for anxiety disorders such as specific phobias. Despite this, little is known about the use of extended-duration exposure therapy in clinical practice.

METHODS

In the present study we investigated the perceptions and use of extended-duration exposure therapy amongst a sample of Australian psychologists via a survey, and the Therapist Beliefs about Exposure Scale. Additionally, we compared theoretical understanding of exposure therapy, and therapy delivery strategies (using a case study vignette), between psychologists who deliver exposure therapy via an extended-duration mode, versus the more traditional multi-session mode.

RESULTS

Extended-duration exposure therapy is widely underutilised, and this is associated with negative beliefs about exposure therapy in general, as well as several practical barriers. There were no differences in the reported theoretical mechanisms of exposure therapy between those who do and do not use extended-duration exposure therapy. However, psychologists who use extended-duration exposure therapy reported greater use of strategies with demonstrated efficacy (e.g., more intense delivery) and less use of therapy-interfering strategies (e.g., distress reduction techniques) relative to those who do not use extended-duration exposure therapy.

CONCLUSION

These findings identify potential mechanisms accounting for extended-duration exposure therapy's efficiency and point to strategies that may increase the uptake of extended-duration exposure therapy in clinical practice.

Associations among threat prediction error, prediction change, and anxiety during an exposure therapy analogue in adults with healthy to clinical social anxiety

Contemporary exposure therapy models for anxiety argue that exposures must generate threat prediction error to be effective. More research is needed to test this claim in clinical settings. This study explored how threat prediction error learning relates to outcomes during an exposure analogue procedure. Adult undergraduate psychology students (N = 125) experiencing a broad range of social anxiety symptoms from healthy to clinical levels of social anxiety completed 667 online speech performance exposures over two testing sessions separated by a week (approx. 3 speeches/session). Self-reported anxiety, threat prediction, threat outcome, and surprise were measured for each exposure and used to derive learning indicators. These included threat prediction error, prediction change, and the extent that prediction errors were converted to prediction change (i.e., learning rate). We examined between- and within-person relationships between these learning indicators and outcomes over exposure using multilevel modelling. Average prediction change and prediction error learning rate, but not average prediction error per se, was associated with more anxiety reduction across the exposure. Within-person, anxiety was lower after exposures that triggered more prediction change. Threat prediction error was not linearly associated with anxiety at the next exposure. Higher threat prediction error during an exposure was associated with greater subjective surprise for that exposure. We concluded that exposure outcomes depend on how much the patient converts exposure-related prediction errors into threat prediction change. Future research should focus on strategies to enhance the prediction-error learning rate from exposures.

Mediating effect of social anxiety on the association between self-esteem and internet addiction among Chinese vocational school students

Introduction

In today's digital age, concerns about internet addiction among adolescents have escalated alongside the widespread use of the internet. Simultaneously, research has spotlighted the influence of psychological factors like self-esteem and social anxiety on addictive behaviors. The aim of this study was to verify the hypothesis regarding social anxiety as a mediator in the association between self-esteem and internet addiction.

Methods

A total of 10,158 participants were randomly selected from five vocational schools in Anhui Province, China, with a mean age of 18.5 years. They completed a series of self-administered questionnaires, including the Young Internet Addiction Test (IATS), the Liebowitz Social Anxiety Scale (LSAS), and the Self-Esteem Scale (SES). Structural equation modeling (SEM) was employed to examine the mediating role of social anxiety between self-esteem and internet addiction, adjusting for demographic variables such as age, gender, and parental education.

Results

The correlation analysis revealed that self-esteem was significantly negatively correlated with internet addiction, while social anxiety was significantly positively correlated with internet addiction. The indirect effect of self-esteem on internet addiction through social anxiety was 0.11 (p < 0.01), constituting 28.35% of the total effect. Additionally, the total impact of self-esteem on internet addiction was 0.278 (p < 0.01). Subgroup analyses by age and gender confirmed the robustness of these findings, with significant total effects observed across different age groups (14-18 years: total effects = 0.637; 18-24 years: total effects = 0.744; p < 0.01) and genders (male: total effects = 0.385; female: total effects = 0.744; p < 0.01).

Discussion

The results indicate that social anxiety plays a significant mediating role in the relationship between self-esteem and internet addiction, affecting both directly and indirectly this association. These findings underscore the importance of addressing self-esteem and social anxiety in interventions aimed at reducing internet addiction among adolescents, suggesting that targeted psychological support could be pivotal in mitigating the risk of developing addictive behaviors online.

Treating anxiety comorbidity: Lessons from exposure generalization studies

Comorbidity is a characteristic hallmark of anxiety disorders. Presence of comorbid anxiety and depression is challenging to the diagnosis and treatment. Conventional and transdiagnostic treatment options for anxiety disorders strongly depend on the use of exposure. Recent compelling evidence suggests that the beneficial effects of exposure therapy are transferable across different fear- and anxiety provoking situations and might even affect depressive symptomatology. We provide an overview of findings on existing studies on generalization of exposure effects to untreated stimuli and depression. Potential mechanisms which contribute to generalization of beneficial exposure therapy effects, such as extinction generalization, mastery-related increases in self-efficacy and underlying neural changes are presented and discussed. Understanding and promoting mechanisms related to exposure therapy efficacy and generalization can expedite and enhance the development of more effective transdiagnostic therapy approaches for comorbid anxiety disorders.

A novel virtual reality fear conditioning paradigm to investigate the influence of expectancy violation on fear extinction

Exposure therapy is an efficient treatment for pathological anxiety, yet its underlying mechanisms are not fully understood. Prediction error models suggest that optimizing the violation of threat-related expectancies improves treatment outcomes, however, causal evidence is still sparse. The aim of the current study was therefore to provide causal evidence for the influence of the extent of expectancy violations on extinction retention using a novel virtual reality fear conditioning paradigm. In total, 100 participants completed a two-day fear conditioning paradigm in which the approach behavior of an animated stimulus was differentially reinforced with an electrical stimulus (i.e., closer distances were associated with a higher probability for receiving the aversive stimulation). To experimentally manipulate the extent of expectancy violations during fear extinction, participants were presented only with distances to the conditioned stimulus that either weakly (i.e., far distances) or strongly predicted the aversive outcome (i.e., close distances), resulting in low vs. high expectancy violations. We found successful fear acquisition and extinction, as well as an influence of the extent of expectancy violations on US-expectancy and threat ratings after extinction on day 1. On the second day, at a spontaneous recovery and reinstatement test, however, there was only weak evidence for improved extinction retention in the high expectancy violation condition. Optimizing expectancy violations might be a necessary but not sufficient condition for improved extinction retention. Future research needs to address the conditions under which expectancy violations lead to robust expectancy adjustments and how these conditions can be met in exposure therapy for anxiety disorders.

App-Based Psychotherapy of Panic Disorder With Self-Guided Exposure in Virtual Reality—A Randomized Controlled Trial

BACKGROUND

Patients with panic disorder often suffer from tempo rary unavailability of care. The smartphone app Invirto (IVT) provides digital treatment for panic disorder comprising self-guided exposure in virtual reality. The aim of this trial was to assess the efficacy of Invirto.

METHODS

In a randomized, controlled, non-blinded trial, IVT was compared with care as usual (CAU) in patients with panic disorder (preregistration: DRKS00027585). The endpoints were assessed online before treatment (t0) and at 3 months (t1). The primary endpoint was the change in symptoms of anxiety, as measured with the Beck Anxiety Inventory (BAI), between the groups. The secondary endpoints were the patients' scores on the following assessment instruments, all in their German versions: the Panic and Agoraphobia Scale (PAS), the Beck Depression Inventory (BDI-II), a questionnaire on patient satisfaction (Client Satisfaction Questionnaire, CSQ-8), the Acceptance and Action Questionnaire (AAQ-II), and quality of life as a global item in the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF).

RESULTS

One hundred twenty-four participants were included. The intention-to-treat analysis revealed greater improvement with IVT than with CAU with respect to both the primary endpoint (BAI, d = -0.46; 95% confidence interval [-0.87; -0.04]) and the secondary endpoints (PAS, d = -0.63 [-1.05; -0.22]; BDI-II, d = -0.44 [-0.86; -0.02]; AAQ-II, d = -0.42 [-0.84; -0.01]), except for WHOQOL-BREF (p = 0.216).

CONCLUSION

A digital treatment with virtual exposure can lessen anxiety, panic, and depressive symptoms and improve mental flexibility. In further studies, IVT should be compared with an active control group.

Optimizing in vivo exposure using occasional reinforced extinction with aversive imagery in spider fearful individuals

Although exposure-based therapy is widely recognized as effective for treating various anxiety disorders, a significant proportion of patients fail to benefit or experience a return of fear following successful treatment. One promising strategy involves occasional presentation of fear-evoking stimuli during extinction (occasional reinforced extinction, ORE). This study investigates a novel approach to translate ORE into clinical practice by incorporating occasional vivid imagery of individuals' worst-case fear scenarios during in-vivo exposure. Forty-seven spider-fearful individuals were randomly assigned to receive either a one-session in-vivo standard exposure treatment (Exp-Only) or an one-session in-vivo exposure treatment supplemented with occasional mental imagery of their worst-case spider scenario (Exp + ORE). Fear of spider questionnaires and a generalization behavioral approach test were administered prior to and one week after treatment. Both groups showed improvement from baseline to post-assessment, but the Exp + ORE group demonstrated significantly greater reductions in self-reported fear and avoidance of spiders compared to standard exposure training. During the generalization behavioral approach test, subjective distress and approach behavior toward the spider significantly improved from baseline to post-assessment in all participants, with no discernible group differences. Findings moreover indicate that occasional imagery during exposure lead to greater expectancy violation compared to standard exposure, providing insights into potential underlying mechanisms of the ORE approach. Incorporating mental imagery into the occasional reinforced extinction approach could hold promise for enhancing the efficacy of exposure-based treatments for anxiety disorders in clinical settings.

Mindfulness-Based Stress Reduction Program for reducing anxiety and depression in hospital staff during a pandemic: A randomized controlled trial

Hospital staff have experienced an increase in psychopathological symptoms such as anxiety or depression during the COVID-19 pandemic. Thus, the aims of the present research were, firstly, to study the effectiveness of the Mindfulness-Based Stress Reduction Program in reducing psychopathological symptoms in hospital staff during the COVID-19 pandemic, as well as, its effectiveness in increasing mindfulness-related skills, self-compassion, body awareness, and reducing stress levels. This parallel randomized controlled trial consisted of 97 hospital workers who were divided into two groups: the experimental group (n = 54) and the control group (n = 44). To test the efficacy of the program, participants' levels of psychopathological symptoms, mindfulness-related skills, self-compassion, body awareness, and stress were assessed and compared before and after the intervention. The results show a significant group × time interaction and significant differences in somatizations (p = .03; η2p = .047), depression (p = .01; η2p = .103) and anxiety (p = .02; η2p = .054). As well as in the following secondary outcomes: from the Five Facet Mindfulness Questionnaire: Observing (p = .001; η2p = .176), acting with awareness (p = .01; η2p = .151), nonjudging; (p = .01; η2p = .103) and nonreactivity (p = .02; η2p = .101). In the Self-Compassion Scale: self-kindness (p = .029; η2p = .049), mindfulness (p = .033; η2p = .047), self-judgment (p = .016; η2p = .060) and isolation (p = .025; η2p = .051. And finally, in the Body awareness subscale from Self-Body Connection (p = .044; η2p = .042). These results highlight the importance of providing hospital staff with skills that help them connect in the present with their feelings and thoughts, without judgment and with self-compassion, to protect them from suffering an increase in their symptoms of somatization, anxiety, and depression, in adverse times like a pandemic.

Developmental Differences in a Hippocampal-Cingulate Pathway Involved in Learned Safety Following Interpersonal Trauma Exposure

OBJECTIVE

Nearly 65% of youth experience trauma, and up to one-third of youth with trauma exposure face profound mental health sequelae. There remains a need to elucidate factors that contribute to psychopathology following trauma exposure, and to optimize interventions for youth who do not benefit sufficiently from existing treatments. Here, we probe safety signal learning (SSL), which is a mechanism of fear reduction that leverages learned safety to inhibit fear in the presence of threat-associated stimuli and has been shown to attenuate fear via a hippocampal-cingulate--specifically, a dorsal anterior cingulate cortex (dACC)--pathway.

METHOD

The present study used behavioral and task-based functional magnetic resonance imaging data to examine age-related associations between interpersonal trauma exposure and the behavioral and neural correlates (ie, activation and functional connectivity) of SSL in a group of 102 youth (aged 9-19 years; 46 female, 56 male) with (n = 52) and without (n = 50) interpersonal trauma exposure. Primary analyses examined anterior hippocampal activation and anterior hippocampus-dACC functional connectivity. Exploratory analyses examined centromedial amygdala (CMA) and laterobasal amygdala (LBA) activation and anterior hippocampal, CMA, and LBA functional connectivity with additional anterior cingulate subregions (ie, subgenual anterior cingulate cortex [sgACC] and rostral anterior cingulate cortex [rosACC]).

RESULTS

Both youth with and without interpersonal trauma exposure successfully learned conditioned safety, which was determined by using self-report of contingency awareness. Youth with interpersonal trauma exposure (relative to youth in the comparison group) exhibited age-specific patterns of lower hippocampal activation (F2,96 = 3.75, pFDR = .049, ηp2 = 0.072), and, in exploratory analyses, showed heightened centromedial amygdala activation (F1,96 = 5.37, pFDR = .046, ηp2 = 0.053) and an age-related decrease in hippocampal-sgACC functional connectivity during SSL (F1,94 = 10.68, pFDR = .015, ηp2 = 0.102). We also show that hippocampal-sgACC functional connectivity mediated the association between interpersonal trauma exposure and post-traumatic stress disorder symptoms in an age-specific manner in the overall sample.

CONCLUSION

Together, these findings suggest that although age- and trauma-specific differences in the neural correlates of SSL may relate to the development of psychopathology, youth with interpersonal trauma exposure demonstrate successful learning of conditioned safety over time.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science.

Behavioural interventions to treat anxiety in adults with autism and moderate to severe intellectual disabilities: the BEAMS-ID feasibility study

Background

Interventions for anxiety need to be adapted to meet the needs of autistic people with moderate to severe learning disabilities and successfully modelled before evidence about efficacy can be generated from clinical trials.

Objectives

The objectives were to: (1) adapt a behavioural intervention for anxiety, develop an intervention fidelity checklist and logic model, and appraise candidate outcome measures, together with carers, autistic people, and clinicians, (2) characterise treatment-as-usual, (3) model the adapted intervention to determine the acceptability and feasibility for all stakeholders, judge the appropriateness of outcome measures, examine the feasibility and acceptability of consent and associated processes and (4) describe factors that facilitate or challenge intervention delivery.

Design

This study had two phases. Phase 1a: using consensus methods, an intervention adaptation group was formed who met to adapt the intervention, appraise candidate outcome measures, and contribute to the development of the intervention fidelity checklists and logic model. Phase 1b: a national online survey was conducted with professionals to characterise treatment-as-usual. Phase 2: this was a single-group non-randomised feasibility study designed to model the intervention to test intervention feasibility and acceptability, outcome measures, and aspects of the research process.

Setting

Participants were recruited from National Health Service community adult learning disabilities teams in England.

Participants

Participants aged 16 and over with a diagnosis of autism, moderate to severe learning disabilities, an anxiety disorder, and a carer who was available to take part in the intervention. For those who lacked capacity to make a decision about taking part, a consultee had to provide advice that the participant should be included in the study.

Interventions

The intervention comprised 12 sessions alongside treatment-as-usual.

Main outcome measures

The feasibility and acceptability of the intervention and research processes, outcome measure completion rates, and intervention adherence.

Results

The intervention was successfully adapted and modelled with 28 autistic participants with moderate to severe learning disabilities. The intervention was judged to be feasible and acceptable by autistic adults with learning disabilities, carers, and therapists. Carers and therapists suggested minor intervention revisions. Carers completed 100% of outcome measures and the missing data rate was low; however, they indicated that some of the questions were repetitive and said they had difficulty responding to some items. The use of the Mental Capacity Act, 2005, led to an average 5-week delay to participant enrolment. The accrual rate was affected by the COVID-19 pandemic and improved during the summer and early autumn of 2022.

Limitations

Randomisation was not modelled within this feasibility study, although carers and therapists indicated that this would be acceptable.

Conclusions

The BEAMS-ID intervention and associated study processes were judged to be feasible and acceptable. The intervention required minor revision.

Future work

The BEAMS-ID intervention should be tested further within a trial.

Study registration

This study is registered as ISRCTN12637590.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129804) and is published in full in Health Technology Assessment; Vol. 28, No. 72. See the NIHR Funding and Awards website for further award information.

Brief modular anxiety intervention for primary care: Hybrid I pilot randomized controlled trial of feasibility, acceptability, effectiveness, and implementation potential

BACKGROUND

Anxiety is highly prevalent, but undertreated, in primary care. Brief, non-pharmacological interventions are needed. Modular Anxiety Skills Training (MAST), a cognitive-behavioral anxiety intervention, was developed for primary care and tailored for a Veteran sample (MAST-V). The purpose of this mixed methods pilot study was to evaluate MAST-V's feasibility, acceptability, and implementation potential, and preliminarily examine its effectiveness compared to Primary Care Behavioral Health (PCBH) usual care.

METHODS

This hybrid I randomized controlled trial (conducted 2019-2021) assigned 35 primary care patients (Mage = 47, 17 % female, 27 % racial/ethnic minority) with clinically significant anxiety symptoms to receive MAST-V or PCBH usual care. Participants completed validated measures of anxiety symptoms and functional impairment at 0, 4, 8, 12, and 16 weeks.

RESULTS

Participants attended more sessions in MAST-V than usual care. After necessary adjustments to reduce session duration, MAST-V will likely fit within PCBH practice parameters. Participants in both conditions valued treatment, but treatment satisfaction, credibility, and therapeutic alliance were higher for MAST-V. Study therapists achieved high treatment fidelity and rated MAST-V as highly feasible, acceptable, and appropriate for PCBH. They identified ways to address potential barriers to implementation. MAST-V was more effective than usual care in reducing anxiety symptoms and impairment.

LIMITATIONS

This was a small pilot study at a single site using study therapists. Results should be considered preliminary until replicated in a full-scale clinical trial.

CONCLUSIONS

This brief modular anxiety intervention, which was designed with implementation in mind, may help to address the anxiety treatment gap in primary care.

Effects of cognitive behavioural therapy and exposure-response prevention on brain activation in obsessive-compulsive disorder patients: systematic review and meta-analysis

Current psychotherapeutic treatments for OCD, while effective, have complex outcomes with mixed efficacy. Previous research has observed baseline brain activation patterns in OCD patients, elucidating some of the implications of this disorder. Observing the effects of evidence-based psychotherapeutics for OCD on brain activation (through MRI) may provide a more comprehensive outline of pathology. This systematic review and meta-analysis evaluated the effects of cognitive behavioural therapy (CBT) with exposure-response prevention (ERP) on brain activation in OCD patients. Academic databases were systematically searched, and the outcomes evaluated included changes in brain activation and symptom severity between baseline and post-treatment. Patients (n = 193) had confirmed OCD diagnosis and underwent protocolized CBT with ERP programs delivered by trained therapists. Participants in the CBT with ERP programs demonstrated significant improvements in symptom severity (Cohen's d = - 1.91). In general, CBT with ERP resulted in decreased activation post-treatment in the frontal (Cohen's d = 0.40), parietal (Cohen's d = 0.79), temporal (Cohen's d = 1.02), and occipital lobe (Cohen's d = 0.76), and cerebellum (Cohen's d = - 0.78). The findings support CBT with ERP's ability to improve brain activation abnormalities in OCD patients. By identifying regions that improved activation levels, psychotherapy programs may benefit from the addition of function-specific features that could improve treatment outcomes.

Work-Related Cognitive Behavioral Therapy for racially and economically diverse unemployed persons with social anxiety: A randomized clinical trial

Individuals with Social Anxiety Disorder (SAD) are at risk for employment problems. This multi-site trial examined the efficacy of Work-Related Cognitive Behavioral Therapy provided alongside vocational services as usual (WCBT+VSAU), a group-based treatment designed to improve mental health and employment outcomes for individuals with SAD. Vocational service-seeking participants with SAD (N = 250) were randomized to either WCBT+VSAU or VSAU-alone. Hypotheses were that participants randomized to WCBT+VSAU would report less social anxiety, less depression, and more hours worked than participants randomized to VSAU-alone. WCBT+VSAU participants had significantly greater improvements on the Liebowitz Social Anxiety Scale (LSAS; d=-.25, CI=-0.49 to -0.02, p = .03) at post-assessment compared to VSAU-alone. The conditions did not differ on any variable at later time points or on secondary outcomes. Unexpectedly, participants randomized to VSAU-alone experienced LSAS improvements, similar to WCBT+VASU at later timepoints. Baseline psychological flexibility (beta=-.098 [-0.19-0.008]) and depression (beta=-0.18 [-0.34-0.009]) moderated change in social anxiety. Participants with lower psychological flexibility and higher depression responded more strongly to WCBT+VSAU than VSAU-alone over the duration of the study, suggesting that WCBT+VSAU may particularly benefit those with greater psychopathology. Results indicate that vocational centers are promising settings for treating SAD and employment-focused refinements are likely needed to improve work outcomes.

Interventions Targeting Negative Mental Imagery in Social Anxiety: A Systematic Review and Meta-Analysis of Characteristics and Outcomes

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta-analysis aimed to evaluate the possibilities and effects of imagery-based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta-analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = -0.50, k = 10) and imagery distress (d = -0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted.

Symptom distress and psychosocial functioning improve bidirectionally during cognitive-behavioral therapy for anxiety disorders

The efficacy of cognitive-behavioral therapy (CBT) for reducing anxiety disorder symptoms is well documented. However, limited research has investigated how symptom amelioration is temporally associated with changes in psychosocial functioning, such as interpersonal and social role functioning, during CBT. Participants were 288 (M age = 37.00 [SD = 14.41]; 59.0% female; 69.0% White; 6.6% Hispanic/Latino) outpatients diagnosed with an anxiety disorder who received CBT at a specialized hospital-based clinic. Participants completed the Outcome Questionnaire-45, a measure of symptom distress, social role performance, and interpersonal problems, at initial assessment and prior to each treatment session. Symptom distress and indicators of psychosocial functioning were robustly related during 25 sessions of CBT. Cross-lagged analyses revealed that reductions in symptom distress predicted subsequent improvements in psychosocial functioning during treatment, and vice versa. Associations from symptom distress to subsequent psychosocial functioning evidenced larger effect sizes than the reverse. Lower levels of severity at intake and presence of comorbid depression attenuated the association between symptom reduction and subsequent social role performance improvement. In sum, anxiety symptoms and psychosocial functioning bidirectionally improve during CBT for anxiety disorders. Maximally effective treatments may be those that simultaneously ameliorate symptoms and focus on improving functioning in key domains.

Good moments to stimulate the brain - A randomized controlled double-blinded study on anodal transcranial direct current stimulation of the ventromedial prefrontal cortex on two different time points in a two-day fear conditioning paradigm

It is assumed that extinction learning is a suitable model for understanding the mechanisms underlying exposure therapy. Furthermore, there is evidence that non-invasive brain stimulation (NIBS) can elevate extinction learning by enhancing frontal brain activity and therefore NIBS can augment symptom reduction during exposure therapy in phobias. But, the underlying processes are still not well established. Open questions arise from NIBS time points and electrode placement, among others. Therefore, we investigated in a 2-day fear conditioning experiment, whether anodal transcranial direct current stimulation (tDCS) of the ventromedial prefrontal cortex (vmPFC) modulates either fear memory consolidation or dampened fear reaction during fear extinction. Sixty-six healthy participants were randomly assigned either to a group that received tDCS after fear acquisition (and before fear memory consolidation), to a group that received tDCS directly before fear extinction, or to a control group that never received active stimulation (sham). Differential skin conductance response (SCR) to CS+ vs. CS- was significantly decreased in both tDCS-groups compared to sham group. Our region of interest, the vmPFC, was stimulated best focally with a lateral anode position and a cathode on the contralateral side. But this comes along with a slightly lateral stimulation of vmPFC depending on whether anode is placed left or right. To avoid unintended effects of stimulated sides the two electrode montages (anode left or right) were mirror-inverted which led to differential effects in SCR and electrocortical (mainly late positive potential [LPP]) data in our exploratory analyses. Results indicated that tDCS-timing is relevant for fear reactions via disturbed fear memory consolidation as well as fear expression, and this depends on whether vmPFC is stimulated with either left- or right-sided anode electrode montage. Electrocortical data can shed more light on the underlying neural correlates and exaggerated LPP seems to be associated with disturbed fear memory consolidation and dampened SCR to CS+ vs. CS-, but solely in the right anode electrode montage. Further open questions addressing where and when to stimulate the prefrontal brain in the course of augmenting fear extinction are raised.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.

Development of decision rules for an adaptive aftercare intervention based on individual symptom courses for agoraphobia patients

As other mental illnesses, agoraphobia is associated with a significant risk for relapse after the end of treatment. Personalized and adaptive approaches appear promising to improve maintenance treatment and aftercare as they acknowledge patients' varying individual needs with respect to intensity of care over time. Currently, there is a deficit of knowledge about the detailed symptom course after discharge from acute treatment, which is a prerequisite for the empirical development of rules to decide if and when aftercare should be intensified. Therefore, this study aimed firstly at the investigation of the naturalistic symptom course of agoraphobia after discharge from initial treatment and secondly at the development and evaluation of a data-driven algorithm for a digital adaptive aftercare intervention. A total of 56 agoraphobia patients were recruited in 3 hospitals. Following discharge, participants completed a weekly online monitoring assessment for three months. While symptom severity remained stable at the group level, individual courses were highly heterogeneous. Approximately two-thirds of the patients (70%) reported considerable symptoms at some time, indicating a need for medium or high-intense therapeutic support. Simulating the application of the algorithm to the data set resulted in an early (86% before week six) and relatively even allocation of patients to three groups (need for no, medium, and high-intense support respectively). Overall, findings confirm the need for adaptive aftercare strategies in agoraphobia. Digital, adaptive approaches may provide immediate support to patients who experience symptom deterioration and thus promise to contribute to an optimized allocation of therapeutic resources and overall improvement of care.

The effectiveness of telehealth versus face-to face interventions for anxiety disorders: A systematic review and meta-analysis

INTRODUCTION

Worldwide, it is estimated that 264 million people meet the diagnostic criteria for anxiety conditions. Effective treatment regimens consist of cognitive and behavioural therapies. During the COVID-19 pandemic, treatment delivery relied heavily on telemedicine technologies which enabled remote consultation with patients via phone or video platforms. We aim to identify, appraise and synthesise randomised controlled trials comparing telehealth to face-to-face delivery of care to individuals of any age or gender, diagnosed with anxiety disorders, and disorders with anxiety features.

METHODS

To conduct this systematic review and meta-analysis, we searched three electronic databases, clinical trial registries and citing-cited references of included studies.

RESULTS

A total of five small randomised controlled trials were includable; telehealth was conducted by video in three studies, and by telephone in two. The risk of bias for the 5 studies was low to moderate for most domains. Outcomes related to anxiety, depression symptom severity, obsessive-compulsive disorder, function, working alliance, and satisfaction were comparable between the two modes of delivery at each follow-up time point (immediately post-intervention, 3 months, 6 months and 12 months), with no significant differences reported (p > 0.05). None of the trials reported on the costs of telehealth compared to face-to-face care.

DISCUSSION

For effectively treating anxiety and related conditions, interventions delivered by telehealth appear to be as effective as the same therapy delivered in-person. However, further high-quality trials are warranted to determine the effectiveness, acceptability, feasibility, and cost-effectiveness of telehealth interventions for the management of a wider range of anxiety disorders and treatments.

The High Impact of Low Intensity: Effectiveness of the BounceBack Program for Depression and Anxiety in Ontario

High costs, long wait times, and lack of access to mental health supports in Ontario are leaving millions with unmet treatment needs. To address this need, Ontario launched BounceBack, a large-scale coach-supported intervention grounded in cognitive behavioral therapy (CBT) to target symptoms of anxiety, depression, and functional impairment. The objective of this program evaluation was to examine the effectiveness of the BounceBack program in Ontario by exploring (a) changes in participants' depression and anxiety symptoms and functional impairment (as measured by the PHQ-9, GAD-7, and WSAS, respectively); and (b) rates for recovery and reliable improvement. Multilevel modelling (MLM) results indicated that participants reported significant improvements in their depression, anxiety, and functioning symptoms over time, which are not better accounted for by other demographic factors. Higher baseline severity of symptoms were associated with greater decreases in these symptoms. The strong recovery and reliable improvement rates identified further support the effectiveness of BounceBack as a potent intervention that leads to improvements in symptoms of anxiety and/or depression for the majority of its participants.

The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

Background

People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease.

Aim

Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation.

Design

We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity.

Setting

Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant's own home or at a local NHS facility, and by telephone.

Participants

Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate.

Intervention

The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral.

Main outcome measures

Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use.

Results

We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference £770.24, 95% confidence interval -£27.91 to £1568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants' lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants.

Conclusions

The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients.

Trial registration

This trial is registered as ISRCTN59537391.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.

Reciprocal and Indirect Effects Among Intervention, Perceived Social Support, and Anxiety Sensitivity Within a Randomized Controlled Trial for Anxiety Disorders

Social support may facilitate adaptive reappraisal of stressors, including somatic symptoms. Anxiety sensitivity refers to negative beliefs about somatic symptoms of anxiety, which may influence one's perception of social support. Evidence-based treatment may impact these associations. The current longitudinal study evaluated reciprocal relationships between perceived social support and anxiety sensitivity, and explored indirect intervention effects, in a randomized controlled trial for anxiety disorders that compared cognitive behavioral therapy with or without medications (CALM) to usual care. Data collected over 18 months from 940 primary care patients were examined in random intercept cross-lagged panel models. There were significant reciprocal associations between perceived social support increases and anxiety sensitivity decreases over time. There were significant indirect effects from intervention to perceived social support increases through anxiety sensitivity decreases and from intervention to anxiety sensitivity decreases through perceived social support increases. These data suggest that, relative to usual care, CALM predicted changes in one construct, which predicted subsequent changes in the other. Secondary analyses revealed an influence of anxiety and depressive symptoms on reciprocal associations and indirect effects. Findings suggest that future treatments could specifically address perceived social support to enhance reappraisal of somatic symptoms, and vice versa.

Generalization of beneficial exposure effects to untreated stimuli from another fear category

Previous research has shown that fear associated with one stimulus often spreads to other stimuli with similar perceptual features as well as across different stimulus categories. Exposure is considered as the most effective intervention to attenuate exaggerated fear. The extent to which exposure treatment effects can generalize to fears not targeted during treatment remains elusive. Previous studies on possible generalization of beneficial effects of exposure used stimuli sharing the same stimulus category and/or stimuli having high perceptual similarity. The current study examined whether exposure treatment generalization can be achieved for untreated stimuli which do not share any perceptual resemblance and belong to a different fear category. An analogue sample of fifty participants with fear of spiders (animal-related fears) and heights (natural environment-related fears) was tested. Participants have been randomly assigned to either an exposure treatment (n = 24) or a control condition (n = 26). Exposure treatment was designed to only target participants' fear of spiders, leaving their fear of heights untreated. Results demonstrated that the effects of exposure treatment generalized to fear of heights, as indicated by a reduction in behavioral avoidance, as well as self-reported acrophobia symptoms. The present study confutes the assumption that generalization of exposure effects to untreated fears is based on perceptual similarity. Clearly, further research is required to determine the decisive factors, in order to expand the generalization effect permanently to any given type of fear.

Exposure therapy for health anxiety: Effectiveness and response rates in routine care of an outpatient clinic

OBJECTIVE

Many randomized controlled trials (RCTs) have demonstrated the efficacy and benefits of exposure therapy in the treatment of health anxiety. However, the application of these research results to routine care has not been considered sufficiently. The aim of this study is to analyze the effectiveness of exposure therapy in the routine treatment of health anxiety patients.

METHOD

Data were available for 35 patients, who repeatedly filled in comprehensive general questionnaires, and those specific to health anxiety.

RESULTS

The data analysis showed that health anxiety symptoms decreased significantly both posttreatment (Cohen's d = 0.97-1.00) and at follow-up (Cohen's d = 1.33-1.34). In addition, the scores of depressiveness, somatic symptoms, and psychological distress showed improvements with effect sizes of d = 0.35-0.51. Regarding the primary outcome measures for health anxiety, response rates were 51%-63%, and remission rates were 29%-43%.

CONCLUSION

Exposure therapy is effective and sustainable regarding the treatment of health anxiety, even under naturalistic conditions, whereas response and remission rates are lower than for RCT.

Multi-voxel neuro-reinforcement changes resting-state functional connectivity: A pilot study

Background

Multi-voxel neuro-reinforcement has been shown to selectively reduce amygdala reactivity in response to feared stimuli, but the precise mechanisms supporting these effects are still unknown. The current pilot study seeks to identify potential intermediaries of change using functional brain connectivity at rest.

Methods

Individuals (N = 11) diagnosed with at least two animal subtype specific phobias took part in a double-blind multi-voxel neuro-reinforcement clinical trial targeting one of two phobic animals, with the untargeted animal as placebo control. Changes in whole-brain resting state functional connectivity from pre-treatment to post-treatment were measured using group ICA. These changes were tested to see if they predicted the previously observed decreases in amygdala reactivity in response to images of target phobic animals.

Results

A common functional connectivity network overlapping with the visual network was identified in resting state data pre-treatment and post-treatment. Significant increases in functional connectivity in this network from pre-treatment to post-treatment were found in higher level visual and cognitive processing regions of the brain. Increases in functional connectivity in these regions also significantly predicted decreases in task-based amygdala reactivity to targeted phobic animals following multi-voxel neuro-reinforcement. Specifically, greater increases of functional connectivity pre-treatment to post-treatment were associated with greater decreases of amygdala reactivity to target phobic stimuli pre-treatment to post-treatment.

Conclusions

These findings provide preliminary evidence that multi-voxel neuro-reinforcement can induce persisting functional connectivity changes in the brain. Moreover, these changes in functional connectivity were not limited to the direct area of neuro-reinforcement, suggesting neuro-reinforcement may change how the targeted region interacts with other brain regions. Identification of these brain regions represent a first step towards explaining the underlying mechanisms of change in previous multi-voxel neuro-reinforcement studies. Future research should seek to replicate these effects in a larger sample size to further assess their role in the effects observed from multi-voxel neuro-reinforcement.

The effect of lavender aroma for anxiety disorder: a study protocol for a multicenter, double-masked, randomized, placebo-controlled clinical trial

BACKGROUND

Anxiety disorder is the most prevalent psychiatric disorder. Benzodiazepines, which are often used for anxiety in patients with anxiety disorder, have various side effects. Lavender, one of the most commonly used essential oils in aromatherapy, has the potential to reduce benzodiazepine use for anxiety disorders.

METHODS

This study is a multicenter, double-masked, randomized, placebo-controlled clinical trial. The study will recruit patients aged 20-59 years old with generalized anxiety disorder and panic disorder among anxiety disorders. The bottle containing the test solution (lavender aroma essential oil or distilled water) will be given to the patients. Patients will carry the bottles with them in their daily life and use the drops on tissue paper when anxious. The primary endpoint is the number of times anxiolytics used in 28 days.

DISCUSSION

If the use of benzodiazepines could be reduced by sniffing lavender aroma, which is inexpensive and safe, it would contribute not only to the risks associated with benzodiazepine use but also to the health care economy and could even be added as a standard treatment.

TRIAL REGISTRATION

University hospital Medical Information Network Clinical Trials Registry (UMIN-CTR), ID: UMIN000034422 Registered 17 January 2019.

The impact of physical exercise on the consolidation of fear extinction memories

Based on the mechanisms of fear extinction, exposure therapy is the most common treatment for anxiety disorders. However, extinguished fear responses can reemerge even after successful treatment. Novel interventions enhancing exposure therapy efficacy are therefore critically needed. Physical exercise improves learning and memory and was also shown to enhance extinction processes. This study tested whether physical exercise following fear extinction training improves the consolidation of extinction memories. Sixty healthy men underwent a differential fearconditioning paradigm with fear acquisition training on day 1 and fear extinction training followed by an exercise or resting control intervention on day 2. On day 3, retrieval and reinstatement were tested including two additional but perceptually similar stimuli to explore the generalization of exercise effects. Exercise significantly increased heart rate, salivary alpha amylase, and cortisol, indicating successful exercise manipulation. Contrary to our expectations, exercise did not enhance but rather impaired extinction memory retrieval on the next day, evidenced by significantly stronger differential skin conductance responses (SCRs) and pupil dilation (PD). Importantly, although conditioned fear responses were successfully acquired, they did not fully extinguish, explaining why exercise might have boosted the consolidation of the original fear memory trace instead. Additionally, stronger differential SCRs and PD toward the novel stimuli suggest that the memory enhancing effects of exercise also generalized to perceptually similar stimuli. Together, these findings indicate that physical exercise can facilitate both the long-term retrievability and generalization of extinction memories, but presumably only when extinction was successful in the first place.

Patient and therapist experiences of exposure therapy for anxiety-related disorders in pregnancy: qualitative analysis of a feasibility trial of intensive versus weekly CBT

BACKGROUND

Approximately 15% of pregnant women experience anxiety disorders. Effective treatments exist but their acceptability during pregnancy, particularly exposure therapy, is not known.

AIMS

To understand patient and therapist experiences of time-intensive and weekly exposure-based therapy for anxiety disorders delivered during pregnancy. Trial registration: ISRCTN81203286.

METHOD

In-depth interviews were conducted with patients and therapists who had taken part in a feasibility trial of predominantly online time-intensive versus weekly cognitive-behavioural therapy in pregnancy in a primary care setting in the UK. Data were analysed using reflexive thematic analysis.

RESULTS

In total, 45 women participating in the trial and 6 therapists who had delivered the treatments were interviewed. Five themes were developed from the data that showed convergence from therapist and patient perspectives: 'Acquiring tools to navigate the perinatal period'; 'Motivated yet constrained by pregnancy'; 'Having the confidence to face fears and tolerate uncertainty'; 'Momentum with the need for flexibility'; 'Being removed from the face-to-face world'.

CONCLUSIONS

Exposure therapy is acceptable and helpful in pregnancy and can lead to lasting gains. Exposure is a key element of treatment and needs to be confidently conducted by therapists with perinatal knowledge and expertise. Treatments need to consider the unfolding context of pregnancy. The momentum of intensive therapy can lead to rapid improvements, but is demanding for both patients and therapists, especially fitting round other commitments. Online treatments can work well and are a good fit for perinatal women, but this needs to be balanced with the need for social connection, suggesting a hybrid model is the ideal.

Inactivation of medial or lateral orbitofrontal cortex during fear extinction did not interfere with fear renewal

Hyperactive orbitofrontal cortical activation is commonly seen in patients of obsessive-compulsive disorder (OCD). Previous studies from our laboratory showed that for rats with aberrant activation of the orbitofrontal cortex (OFC) during the extinction phase, they were unable to use contexts as the reference for proper retrieval of fear memory during renewal test. This result supported the phenomenon that many OCD patients show poor regulation of fear-related behavior. Since there are robust anatomical connections of the OFC with the fear-circuit, we aim to further examine whether the OFC is actively engaged in fear regulation under normal circumstances. In this study, the lateral or medial OFC was inactivated during the extinction phase using the ABA fear renewal procedure. We found that these animals showed intact fear renewal during retrieval test with their freezing levels equivalent to the control rats, revealing that the OFC did not have decisive roles in extinction acquisition. Together with our previous study, we suggest that the OFC only interferes with fear regulation when it becomes pathophysiologically hyperactive.

Neuropsychology of Generalized Anxiety Disorder in Clinical Setting: A Systematic Evaluation

This research paper provides a systematic review of the neuropsychology of generalized anxiety disorder (GAD), examining relevant articles' methodologies and subject matter and highlighting key findings. It suggests potential cognitive deficits in GAD patients, such as subtle attention, executive function, and working memory deficiencies. It also discusses neural correlates of GAD, particularly the hyperactivity in the amygdala and insula, and the additional impact of comorbidity with other psychiatric disorders. The paper uses the PRISMA methodology and draws data from the PsycINFO, Scopus, PubMed, and Elsevier databases. Although the reviewed research has contributed to understanding GAD's cognitive and neural mechanisms, further research is required. Additionally, the paper mentions the clinical neuropsychology of GAD, including strategies and treatments, such as cognitive behavioral therapy (CBT), mindfulness, and medication. Lastly, the review identifies the limitations of the existing research and recommends future directions to enhance the understanding of GAD's underlying cognitive and neural mechanisms. The neural underpinnings of GAD encompass heightened activity within the amygdala and insula, which are brain regions implicated in processing adverse emotional reactions. Co-occurring psychiatric disorders, such as major depressive disorder (MDD), can also impact neuropsychological functioning. Additional investigation is warranted to better understand the intricate interplay between GAD, cognitive performance, and underlying neural processes.

Efficacy of an Internet-based intervention with self-applied exposure therapy in virtual reality for people with panic disorder: study protocol for a randomized controlled trial

BACKGROUND

Due to several treatment barriers, many individuals with panic disorder do not receive evidence-based treatment. One promising option to narrow this treatment gap is Internet-based psychotherapy, which has been shown particularly effective in guided formats. Still, there remains room for improvement to make these digital therapies more accessible, cost-efficient, and aligned with best practices for in-person interventions (e.g., exposure). The smartphone app "Invirto - Treatment for Anxiety" offers digitally guided, evidence-based treatment of panic disorders including virtual reality (VR) for exposure therapy. The aim present study is to investigate the efficacy, safety, and acceptance of Invirto in comparison to a care-as-usual (CAU) control group.

METHODS

We plan to conduct a randomized controlled trial with two conditions (intervention vs. CAU), three assessment times via online surveys (t0: baseline; t1: 3 months after baseline; t2: follow-up assessment 6 months after baseline), and a total of 128 participants with a clinical diagnosis of panic disorder (symptoms must be experienced ≥ 1 year). Recruitment will take place via email, phone, and the study website. The primary outcome will be the change in anxiety symptoms as measured by Beck's Anxiety Inventory from t0 to t1. Secondary outcomes will be the change in anxiety symptoms (measured by the Panic and Agoraphobia Scale, PAS; Questionnaire on panic-related Anxieties, Cognitions and Avoidance, ACA), depressive symptoms (measured by the Beck-Depression-Inventory, BDI-II), treatment satisfaction (measured by the Client Satisfaction Questionnaire, CSQ-8; Treatment Adherence Perception Questionnaire, TAPQ-adapt; Positive and Negative Effects of Psychotherapy Scale, PANEPS-I), psychological flexibility (measured by the Acceptance and Action Questionnaire-II, AAQ-II), and dissociation during VR exposure (measured by an adapted version of the Peritraumatic Dissociative Experiences Questionnaire, PDEQ-adapt). Participants in the intervention group will receive access to the intervention (Invirto) right after t0, while the CAU group will receive access to Invirto after t1. We expect a larger change in both the primary and secondary outcomes from t0 to t1 in the intervention group in comparison to the CAU group.

DISCUSSION

This study is one of the first to evaluate an Internet-based intervention for people with panic disorder that includes self-application of VR exposure therapy. The findings are expected to extend the body of knowledge about effective Internet-based treatment options for people with panic disorder. The empirical and clinical implications and the limitations of the study are discussed.

TRIAL REGISTRATION

DRKS00027585 ( www.drks.de/drks_web/ ), date of registration: 13 January 2022.

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial

Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A randomized clinical trial of behavioral activation and exposure-based therapy for adults with generalized anxiety disorder

Objective

Exposure-based therapy (EXP) and behavioral activation (BA) are empirically-supported behavioral intervention techniques that target avoidance and approach behavior to alleviate symptoms. Although EXP is an established treatment for generalized anxiety disorder (GAD), the effectiveness of BA for GAD has not been directly tested or compared with that of EXP. This study examined the efficacy of EXP and BA for adults with GAD.

Method

In a randomized clinical trial (clinicaltrials.gov: NCT02807480) with partial blinding in Tulsa, OK, 102 adults with GAD were allocated to manualized, 10-session EXP or BA between April 2016-April 2021. Primary analyses were intention-to-treat and included the 94 (46 EXP, 48 BA) participants who started treatment. The GAD-7 self-report scale was the primary outcome measure.

Results

Similar GAD-7 declines were observed at post-treatment for EXP (d=-0.97 [95% CI -1.40 to -0.53]) and BA (d=-1.14 [95% CI -1.57 to -0.70]), and were maintained through 6-month follow-up (EXP: d=-2.13, BA: d=-1.98). Compared to EXP, BA yielded more rapid declines in anxiety and depression scores during therapy (d=0.75-0.77), as well as lower anxiety and depression scores (d=0.13-0.14) and greater participant-rated improvement (d=0.64) at post-treatment. Bayesian analyses indicated 74-99% probability of greater change in BA than EXP at post-treatment.

Conclusions

BA and EXP are both effective in treating GAD, and BA may confer greater benefit during treatment. Future research is warranted to inform personalized treatment approaches.

The Role of Expectancy Violation in Extinction Learning: A Two-Day Online Fear Conditioning Study

Background

Exposure therapy is at the core of the treatment of pathological anxiety. While the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. Therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning.

Method

In total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. To experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. Consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively.

Results

We found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. On Day 2, inhibitory CS-noUS associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings.

Conclusion

These findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety.

Manipulating expectancy violations to strengthen the efficacy of human fear extinction

Recent theoretical and clinical articles have emphasized a role for expectancy violations in improving the effectiveness of exposure therapy. Expectancy violations are critical to extinction learning and strengthening these violations has been suggested to improve the formation and retention of extinction memories, which should result in lasting symptom reductions after treatment. However, more detailed mechanistic insights in this process are needed to better inform clinical interventions. In two separate fear-conditioning experiments, we investigated whether stronger expectancy violations (Exp1) or fostering awareness of expectancy violations (Exp2) during extinction could reduce the subsequent return of fear. We measured fear potentiated startle (FPS) and skin conductance responses (SCR) as physiological indices of fear, and US expectancy ratings to assess our manipulations. While we successfully created stronger expectancy violations in Exp1, we found no evidence that these stronger violations reduced the return of fear at test. Interestingly, fostering awareness of violations (Exp2) reduced differential SCRs, but not FPS responses. These findings provide novel insights into the effect of US expectancies on fear extinction in the lab, but they also illustrate the complexity of capturing clinically relevant processes of change with fear-conditioning studies.

In safe hands: Attachment figures' safety properties and the link with attachment style

According to the Learning Theory of Attachment, naturalistic learning experiences about others' responsiveness during distress are an underlying mechanism in the development of attachment. Previous studies have demonstrated attachment figures' unique safety-inducing effects in highly controlled conditioning procedures. Yet, neither have studies examined the presumed influence of safety learning on state attachment, nor have they examined how attachment figures' safety-inducing effects relate to attachment styles. To address these gaps, a differential fear conditioning paradigm was used in which pictures of participants' attachment figure and two control stimuli served as safety cues (CS-). US-expectancy and distress ratings were measured as indicators of fear responding. Results indicate that attachment figures evoked enhanced safety responding compared to control safety cues at the start of acquisition, which was maintained throughout acquisition and when presented together with a danger cue. Attachment figures' safety-inducing effects were reduced in individuals with higher attachment avoidance, although attachment style did not affect the rate of new safety learning. Finally, safe experiences with the attachment figure in the fear conditioning procedure resulted in diminished anxious state attachment. Adding to previous work, these findings underscore the importance of learning processes for attachment development and attachment figures' provision of safety.

Effects of virtual reality-based intervention on depression in stroke patients: a meta-analysis

As one of the most common neuropsychiatric complications after stroke, post-stroke depression can significantly affect the initiative of rehabilitation exercise and the rehabilitation of neurological function of patients. Virtual reality (VR) has been widely used in health-related fields in recent years. There is some evidence that VR-based interventions have benefits for depression. The aim of this study was to assess the effectiveness of VR-based intervention on depression in stroke patients. A total of 752 patients with stroke from 11 randomized controlled trials (RCTs) studies were included in this meta-analysis and the studies derived from seven electronic databases searched from database inception to August 2021. Different tools were used to measure depression. For continuous results, the standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated to synthesize the effects. We assessed the risk of bias by using the Cochrane Collaboration criteria. The results showed that compared to the control group, VR-based interventions significantly decreased the depression scale score (SMD =  - 0.75, 95% CI - 1.35, - 0.15). The meta-analysis indicated that VR-based intervention had a moderate effect on depression in stroke patients compared to control group. There was no evidence of potential publication bias as assessed by visual inspection of funnel plots in Egger and Begg tests. Substantial heterogeneity between studies was observed, meta-regression analysis showed that mean age might be the source of heterogeneity.

Incremental Validity of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy Mechanisms for Anxiety and Panic Symptomology

Background: acceptance and commitment therapy (ACT) and cognitive-behavioral therapy (CBT) are empirically supported treatments for anxiety and panic disorder (PD), though they differ in their putative vulnerability and maintenance processes. The present study examined the incremental validity of several of these models' proposed core processes, including anxiety sensitivity (AS), dispositional avoidance, experiential avoidance (EA), cognitive fusion (CF), and mindfulness, as well as the interaction of the processes within each model, in the prediction of anxiety and panic symptomology. Methods: a sample of US adults (n = 316) completed self-report measures of AS, dispositional avoidance, EA, CF, mindfulness, anxiety, and PD symptoms. A series of hierarchical multiple regression analyses were conducted. Results: hierarchical regression analyses indicated that AS, dispositional avoidance, and EA predicted anxiety and panic symptoms even after controlling for one another, CF, mindfulness, and demographic variables. Although mindfulness and CF was correlated with anxiety and panic at the univariate level, they did not predict either outcome above and beyond AS, dispositional avoidance, and EA. When interaction terms were added to the models, the interaction between AS and -dispositional avoidance was a significant predictor of panic and anxiety symptoms, whereas the interaction between EA and CF only predicted panic symptoms. None of the interactions that included mindfulness were significant predictors. Conclusions: these findings provide support the independent and interactive predictive value of traditional CBT (AS, dispositional avoidance, and AS-dispositional avoidance) and ACT (EA) processes for anxiety and panic symptoms, but raise questions about the incremental predictive utility of CF and mindfulness.

A brief transdiagnostic group (the take control course) compared to individual low-intensity CBT for depression and anxiety: a randomized non-inferiority trial

Few studies have examined brief transdiagnostic groups. The Take Control Course (TCC) was developed for patients with mild to moderate common mental health problems. We examined whether TCC is non-inferior to individual low-intensity cognitive behaviour therapy (CBT) in a single-blind individually randomised parallel non-inferiority trial. The primary outcomes were depression (PHQ9) and anxiety (GAD7) at 6-month follow-up (primary outcome point) and 12-month follow-up. The non-inferiority margin that we set, based on previous trials, corresponds to approximately 3 points on the PHQ9 and approximately 2.5 points on the GAD7. Intention-to-treat (ITT) and per-protocol (PP) analyses of 6-month data of 156 randomised patients indicated that TCC was non-inferior to individual low-intensity CBT on anxiety (ITT Coefficient = 0.24; 95% CI: -1.45 to 1.92; d = 0.04; p = .79), and depression (ITT Coefficient = 0.82; 95% CI: -1.06 to 2.69; d = 0.14; p = .39) outcomes, and functioning (ITT Coefficient = 0.69; 95% CI: -2.56 to 3.94; d = 0.08; p = .68). The findings at 12 months were inconclusive and require further testing. This randomised trial provides preliminary support that TCC is not less effective than short-term individual CBT within Improving Access to Psychological Therapies (IAPT) services.

Extinction-Based Exposure Therapies Using Virtual Reality

The focus of this chapter is an overview of integrating virtual reality (VR) technology within the context of exposure therapy for anxiety disorders, a gold standard treatment, with a focus on how VR can help facilitate extinction learning processes integral to these interventions. The chapter will include an overview of advantages of incorporating VR within exposure therapy, and benefits specifically within an inhibitory learning approach for extinction training. A review of the empirical literature on the effectiveness of VR exposure therapy for specific phobia and PTSD will be provided, as well as practical overview of how to effectively incorporate VR within exposure therapy.

The Sexual Communication Scale (SeCS)

Many measures of comfort and frequency of sexual communication between partners are limited in gender/sex and sexual orientation inclusivity, how constructs are measured, and for whom. We conducted two studies to investigate a revised and extended version of the Female Partner's Communication During Sexual Activity Scale: the Sexual Communication Scale (SeCS). We revised the gender/sex language to improve inclusion and added items to assess frequency and comfort with sexual communication. In Study 1, an exploratory factor analysis (n = 578) supported a three-factor structure (Frequency of bidirectional communication, α = .96; Ease of own communication, α = .90; Ease of partner's communication, α = .83). In Study 2, a confirmatory factor analysis (n = 1479) further supported the three-factor structure. Specifically, the three-factor model provided a reasonably good fit (χ2 (44) = 511.35, p < .001, CFI = .97, GFI = .95, AGFI = .91, SRMR = .00, RMSEA = .08). In both studies, we found small or no differences in men and women's comfort and frequency of sexual communication. The results provide initial support that the SeCS is an internally consistent, multidimensional gender/sex inclusive tool for future research on sexual communication.

Biomarkers of Anxiety Acquisition and Generalization in Virtual Reality Experiments

Abstract. Anxiety disorders are characterized by exaggerated responses to a threatening situation and overgeneralization. Context conditioning has been used for the identification of risk factors. This systematic literature search identifies 16 articles published between 1990 and 2021 on differential anxiety conditioning and generalization in humans. Additionally, we provide example data for individuals suffering from panic attacks with and without depressive symptoms. Successful anxiety acquisition (discrimination between anxiety and safety context) was found on the subjective level of anxiety and US-expectancy, on the physiological level of electrodermal activity, and in the defensive behavior of startle response. Anxiety generalization (discrimination between generalization and safety context) was found on the verbal but not on the physiobehavioral level. In sum, we emphasize the impact of virtual reality on anxiety research. Verbal and physiobehavioral responses serve as reliable biomarkers for anxiety. Few studies found ratings to be the best predictor for anxiety generalization. Genetic predisposition or personality traits might foster overgeneralization.

Does prediction error during exposure relate to clinical outcomes in cognitive behavior therapy for social anxiety disorder? A study protocol

Facing your fears, or exposure therapy, is an effective psychological intervention for anxiety disorders that is often thought to work through fear extinction learning. Fear extinction learning is a type of associative learning where fear reduces through repeated encounters with a feared situation or stimulus in the absence of aversive outcomes. Laboratory research suggests fear extinction learning is driven by threat prediction errors, defined as when fearful predictions do not eventuate. Threat prediction error and its relationship to exposure therapy outcomes haven't been studied enough in actual therapy settings. It remains unclear whether prediction error and extinction learning are central mechanisms of exposure therapy. We are conducting a longitudinal and observational study of how threat prediction error during exposure in social anxiety disorder (SAD) treatment relates to session-by-session symptom change and treatment outcome in addition to exposure surprise and learning outcome. We aim to recruit 65 adults with a primary diagnosis of SAD through an outpatient psychology clinic. Participants will receive 12 sessions of individual manualized cognitive behavioral therapy (CBT), adapted from an efficacious group protocol, that includes graded exposure. Exposure processes, including self-report measures of anxiety, threat prediction, threat outcomes, surprise, and learning outcome, will be measured with smartphone-based event-contingent ecological momentary assessments (EMAs) of all behavioral experiments completed during treatment. Clinical outcomes include self-reported social anxiety symptoms and social threat appraisals, at each session, post and 3-months after treatment. Prediction error will be operationalized as the mismatch between the threat prediction and threat outcome. The joint effect of threat prediction and threat outcome on session-by-session symptom change, treatment outcome, exposure surprise, and learning outcome will be explored using multilevel modeling. The present study will help determine whether threat prediction error during exposures in SAD treatment is related to theoretically implied clinical outcomes. This would contribute to the larger research aim of clarifying exposure therapy mechanisms.

Patient characteristics and changes in anxiety symptoms in patients with panic disorder: Post-hoc analysis of the PARADIES cluster randomised trial

Anxiety disorders are among the most common mental health problems in primary care. The PARADIES (Patient Activation foR Anxiety DIsordErS) intervention combined elements of cognitive behavioural therapy with case management and has demonstrated efficacy. Our aim was to explore patient characteristics, which may influence the course of anxiety symptoms over a 12 months period. Multiple linear regression was used to quantify associations of baseline characteristics (demographics, clinical parameters, medication use) with changes in anxiety symptoms as measured by the Beck anxiety inventory. Treatment modalities (e.g. adherence to appointment schedules) were considered as confounders. We examined univariate associations between dependent and independent variables before considering all independent variables in a multivariate final model. To find the best model to explain BAI score changes, we performed step-wise selection of independent variables based on Akaike information criteria. We tested for interaction terms between treatment allocation (intervention vs control) and independent variables using the multivariate model. We repeated these analyses in control vs intervention groups separately. From the original trial (N = 419), 236 patients (56.3%) were included. In the multivariate model, receiving the intervention (p<0.001), higher anxiety symptom severity (p<0.001) and longer illness duration at baseline (p = 0.033) were significantly associated with changes in anxiety symptom severity to the better while depression severity at baseline (p<0.001) was significantly associated with changes in anxiety symptoms to the worse. In stratified analyses, the control group showed significant associations between depression symptom severity and illness duration with anxiety symptom changes while baseline severity of anxiety symptoms remained significantly associated with anxiety symptom changes in both groups. A brief primary-care-based exposure training combined with case management is effective in a broad range of patients with panic disorder with/without agoraphobia, including those with longer illness duration and co-existing symptoms of depression at baseline.