Geänderte Inhalte

Exposure is a highly effective treatment for pathological fear and anxiety, but rarely used in routine care. Issues of practicability and lack of therapists in rural areas are main barriers for the dissemination of exposure. Smartglass devices may enable therapists to guide exposure from their own office via real-time feedback and may thereby increase practicability. The present study explored the technological usability and clinical feasibility of Smartglass-guided exposure in a behavioral approach test in spider-fearful individuals (N = 40). Fearful individuals were asked to start the Smartglass themselves and established a connection to a therapist, who guided the exposure test from afar. Clinical severity of spider fear was assessed via questionnaire. Technological usability was assessed with established measures of usability, user experience, and user acceptance. Exploratory, individual characteristics of exposure were collected (e.g., within-session fear reduction, duration, safety behavior). Overall, fearful individuals (94.9%) and therapists (100%) were able to establish a connection. Usability of Smartglass-guided exposure was evaluated as positive. Within-session fear reduction was large (d = 1.91). Adverse events were minimal. There were, however, some associations between exposure characteristics and usability evaluation (e.g., lower user-friendliness and exposure duration). Two case examples further highlight chances and risks of Smartglass-guided exposure. These findings provide first evidence that Smartglass-guided exposure could be useful in exposure therapy. Smartglass-guided exposure may ultimately help to increase practicability of exposure and increase dissemination, also in rural areas. These findings are promising for future research on the long-term outcome of evidence-based exposure in treatment seeking patients.

Exposure-based treatment involves repeated presentation of feared stimuli or situations in the absence of perceived threat (i.e., extinction learning). However, the stimulus or situation of fear acquisition (CS+) is highly unlikely to be replicated and presented during treatment. Thereby, stimuli that resemble the CS+ (generalization stimuli; GSs) are typically presented. Preliminary evidence suggests that depending on how one generalizes fear (i.e., different generalization rules), presenting the same GS in extinction leads to differential effectiveness of extinction learning. The current study aimed to extend this finding to safety behaviors. After differential fear and avoidance conditioning, participants exhibited discrete generalization gradients that were consistent with their reported generalization rules (Similarity vs Linear). The Linear group showed stronger safety behaviors to a selected GS compared to the Similarity group, presumably due to higher threat expectancy. After extinction learning to this GS, the Linear group exhibited stronger reduction in safety behaviors generalization compared to the Similarity group. The results show that identifying distinct generalization rules allows one to predict expectancy violation to the extinction stimulus, in addition to corroborating the idea that strongly violating threat expectancy leads to better extinction learning and its generalization. With regard to clinical implications, identifying one's generalization rule (e.g., threat beliefs) help designing exposure sessions that evoke strong expectancy violation, enhancing the reduction in the generalization of maladaptive safety behaviors.

Enhancing the reduction of avoidance may optimize treatment for anxiety disorders. Past research focused on boosting fear extinction to reduce avoidance, however, with limited success. Directly extinguishing avoidance may be more promising. This preregistered study tested the impact of incentives and instruction for non-avoidance compared to passive fear extinction on long-term avoidance and fear reduction. On Day 1, participants acquired conditioned fear and avoidance to a conditioned stimulus (CS) paired with an aversive outcome. Next, incentives or instructions encouraged non-avoidance to the CS, which was no longer reinforced by a US regardless of avoidance (Incentives and Instruction group). In a third group, avoidance was unavailable and the CS was passively presented in absence of the US (Passive Fear Extinction group). On Day 2, avoidance retention and reinstatement and return of fear were tested. In the short term, incentives and instruction strongly reduced avoidance with similar fear reduction compared to passive fear extinction. Importantly, incentives and instruction were linked to lower long-term avoidance retention. Avoidance reinstatement was evident in all groups, but avoidance remained higher after passive fear extinction. Finally, incentives yielded a lower return of threat expectancies. Thus, targeting avoidance instead of fear better reduced long-term avoidance and, for incentives, the return of fear. Especially, incentives could be a promising add-on to exposure.

Exposure-based psychological interventions currently represent the empirically best established first line form of cognitive-behavioural therapy for all types of anxiety disorders. Although shown to be highly effective in both randomized clinical and other studies, there are important deficits: (1) the core mechanisms of action are still under debate, (2) it is not known whether such treatments work equally well in all forms of anxiety disorders, including comorbid diagnoses like depression, (3) it is not known whether an intensified treatment with more frequent sessions in a shorter period of time provides better outcome than distributed sessions over longer time intervals. This paper reports the methods and design of a large-scale multicentre randomized clinical trial (RCT) involving up to 700 patients designed to answer these questions. Based on substantial advances in basic research we regard extinction as the putative core candidate model to explain the mechanism of action of exposure-based treatments. The RCT is flanked by four add-on projects that apply experimental neurophysiological and psychophysiological, (epi)genetic and ecological momentary assessment methods to examine extinction and its potential moderators. Beyond the focus on extinction we also involve stakeholders and routine psychotherapists in preparation for more effective dissemination into clinical practice.

Exposition ist eine wirksame Behandlung bei Angststörungen, jedoch zeigt eine substanzielle Anzahl von Klienten keine signifikante Symptomreduktion oder ein Wiederkehren der Angst. Es wird angenommen, dass ängstliche Personen Defizite in grundlegenden Mechanismen der Expositionstherapie, wie dem inhibitorischen Lernen, aufweisen. Ein gezieltes Ansprechen dieser Defizite könnte demnach die Wirksamkeit von Exposition optimieren. Allerdings fehlen bisher Vorschläge zur konkreten Umsetzung in der Praxis. Der vorliegende Beitrag verdeutlicht anhand verschiedener Strategien, wie das Modell zur Optimierung der Behandlung von Angststörungen praktisch umsetzbar ist. Die vorgeschlagenen Strategien unterscheiden sich hierbei von einem reinen habituationsbasierten Ansatz oder kognitiven Ansätzen zur Widerlegung von Überzeugungen. Die Strategien umfassen: (1) das Widerlegen angstbezogener Erwartungen, (2) vertiefte Extinktion, (3) Extinktion mit gelegentlicher Verstärkung, (4) Entfernen von Sicherheitssignalen, 5) Variabilität, 6) Erinnerungsreize, 7) multiple Kontexte und 8) affektives Labeling. Durch Fallbeispiele wird die Anwendung dieser Strategien bei verschiedenen Angststörungen illustriert.

This study aimed to build on the relationship of well-established self-report and behavioral assessments to the latent constructs positive (PVS) and negative valence systems (NVS), cognitive systems (CS), and social processes (SP) of the Research Domain Criteria (RDoC) framework in a large transnosological population which cuts across DSM/ICD-10 disorder criteria categories. One thousand four hundred and thirty one participants (42.1% suffering from anxiety/fear-related, 18.2% from depressive, 7.9% from schizophrenia spectrum, 7.5% from bipolar, 3.4% from autism spectrum, 2.2% from other disorders, 18.4% healthy controls, and 0.2% with no diagnosis specified) recruited in studies within the German research network for mental disorders for the Phenotypic, Diagnostic and Clinical Domain Assessment Network Germany (PD-CAN) were examined with a Mini-RDoC-Assessment including behavioral and self-report measures. The respective data was analyzed with confirmatory factor analysis (CFA) to delineate the underlying latent RDoC-structure. A revised four-factor model reflecting the core domains positive and negative valence systems as well as cognitive systems and social processes showed a good fit across this sample and showed significantly better fit compared to a one factor solution. The connections between the domains PVS, NVS and SP could be substantiated, indicating a universal latent structure spanning across known nosological entities. This study is the first to give an impression on the latent structure and intercorrelations between four core Research Domain Criteria in a transnosological sample. We emphasize the possibility of using already existing and well validated self-report and behavioral measurements to capture aspects of the latent structure informed by the RDoC matrix.

Inhibition of return (IOR) refers to a bias against returning the attention to a previously attended location. As a foraging facilitator it is thought to facilitate systematic visual search. With respect to neutral stimuli, this is generally thought to be adaptive, but when threatening stimuli appear in our environment, such a bias may be maladaptive. This experiment investigated the influence of phobia-related stimuli on the IOR effect using a discrimination task. A sample of 50 students (25 high, 25 low in spider fear) completed an IOR task including schematic representations of spiders or butterflies as targets. Eye movements were recorded and to assess discrimination among targets, participants indicated with button presses if targets were spiders or butterflies. Reaction time data did not reveal a significant IOR effect but a significant interaction of group and target; spider fearful participants were faster to respond to spider targets than to butterflies. Furthermore, eye-tracking data showed a robust IOR effect independent of stimulus category. These results offer a more comprehensive assessment of the motor and oculomotor factors involved in the IOR effect.

Background: Increases in emotional distress in response to the global outbreak of the SARS-CoV-2 (COVID-19) pandemic have been reported. So far, little is known about how anxiety responses in specific everyday public life situations have been affected. Method: Self-reported anxiety in selected public situations, which are relevant in the COVID-19 pandemic, was investigated in non-representative samples from the community (n = 352) and patients undergoing psychotherapy (n = 228). Situational anxiety in each situation was rated on a 5-point Likert scale (0 = no anxiety at all to 4 = very strong anxiety). Situational anxiety during the pandemic was compared with retrospectively reported situational anxiety before the pandemic (direct change) and with anxiety levels in a matched sample assessed before the pandemic (n = 100; indirect change). Results: In the community and patient sample, indirect and direct change analyses demonstrated an increase in anxiety in relevant public situations but not in control situations. Average anxiety levels during the pandemic were moderate, but 5-28% of participants reported high to very high levels of anxiety in specific situations. Interestingly, the direct increase in anxiety levels was higher in the community sample: patients reported higher anxiety levels than the community sample before, but not during the pandemic. Finally, a higher increase in situational anxiety was associated with a higher perceived danger of COVID-19, a higher perceived likelihood of contracting COVID-19, and stronger symptoms of general anxiety and stress. Conclusions: Preliminary findings demonstrate an increase in anxiety in public situations during the COVID-19 pandemic in a community and a patient sample. Moderate anxiety may facilitate compliance with public safety measures. However, high anxiety levels may result in persistent impairments and should be monitored during the pandemic.

Avoidance is a transdiagnostic symptom of clinical anxiety and its reduction a major focus of cognitive-behavioral treatments. This study examined the instrumental extinction of goal-directed avoidance by means of incentives, verbal instruction, and social observation and their influence on fear extinction. Participants acquired conditioned fear and instrumental avoidance responses (N = 160). In four randomized groups, the reduction of avoidance by incentives for non-avoidance, instructions to refrain from avoidance, and social observation of non-avoidance was compared to no intervention before removing the aversive outcome. Conditioned fear when avoidance became unavailable subsequently was tested. Incentives, instruction, and observation all reduced avoidance better than no intervention, however, with different degrees and influence on conditioned fear. Incentives and instructions strongly reduced avoidance despite high levels of fear (i.e., fear-opposite actions). This initiated fear extinction, thereby reducing conditioned fear when avoidance became unavailable. Social observation directly reduced conditioned fear, presumably because it conveyed additional information about the absence of the aversive outcome. However, observation only moderately reduced avoidance and resulted in higher fear when avoidance became unavailable. The effects of social observation may depend on the nuances of the demonstrator's behavior. The clear effects of incentive and instructions provide support for clinical interventions to reduce avoidance during exposure therapy and can serve as experimental models for their controlled investigation.

Maladaptive safety behavior maintains fear and anxiety by prohibiting inhibitory learning about the non-occurrence of feared outcomes (known as protection from extinction). Not engaging in safety behavior, however, requires to act opposite to fear-motivated behavioral tendencies. The initiation of such fear-opposite action by positive outcomes, which were in conflict with safety behavior, was tested. Following fear acquisition to a warning signal (CS+), participants acquired safety behavior to prevent the aversive outcome (n = 48). Next, safety behavior also prevented gaining rewards. In a control group (n = 50), neutral outcomes were presented to control for novelty effects of the second outcome. Subsequently, no aversive outcome occurred anymore. Phases with safety behavior were intermitted by phases without safety behavior being available to examine cognitive and physiological indicators of fear and anxiety. Without competing positive outcomes, safety behavior was frequently executed, persisted in absence of the aversive outcome, and prohibited extinction learning. Positive outcomes clearly reduced safety behavior despite equal levels of acquired fear. This enabled fear extinction as soon as the aversive outcome was absent. Importantly, this extinction learning resulted in attenuated fear and anxiety responses when safety behavior became unavailable. Post-hoc findings indicated that the mere anticipation of positive outcomes slightly reduced safety behavior. Thus, competing positive outcomes triggered fear-opposite action that prevented persistent safety behavior and protection from extinction.

None

Background: Pathological avoidance is a transdiagnostic characteristic of anxiety disorders. Avoidance conditioning re-emerged as a translational model to examine mechanisms and treatment of avoidance. However, its validity for anxiety disorders remains unclear. Methods: This study tested for altered avoidance in patients with anxiety disorders compared to matched controls (n = 40/group) using instrumental conditioning assessing low-cost avoidance (avoiding a single aversive outcome) and costly avoidance (avoidance conflicted with gaining rewards). Autonomic arousal and threat expectancy were assessed as indicators of conditioned fear. Associations with dimensional symptom severity were examined. Results: Patients and controls showed frequent low-cost avoidance without group differences. Controls subsequently inhibited avoidance to gain rewards, which was amplified when aversive outcomes discontinued. In contrast, patients failed to reduce avoidance when aversive and positive outcomes competed (elevated costly avoidance) and showed limited reduction when aversive outcomes discontinued (persistent costly avoidance). Interestingly, elevated costly avoidance was not linked to higher conditioned fear in patients. Moreover, individual data revealed a bimodal distribution of costly avoidance: Some patients showed persistent avoidance, others showed little to no avoidance. Persistent versus low avoiders did not differ in other task-related variables, response to gains and losses in absence of threat, sociodemographic data, or clinical characteristics. Conclusions: Findings suggest that anxious psychopathology is associated with a deficit to inhibit avoidance in presence of competing positive outcomes. This offers novel perspectives for research on mechanisms and treatment of anxiety disorders.

Background: The need to optimize exposure treatments for anxiety disorders may be addressed by temporally intensified exposure sessions. Effects on symptom reduction and public health benefits should be examined across different anxiety disorders with comorbid conditions. Methods: This multicenter randomized controlled trial compared two variants of prediction error-based exposure therapy (PeEx) in various anxiety disorders (both 12 sessions + 2 booster sessions, 100 min/session): temporally intensified exposure (PeEx-I) with exposure sessions condensed to 2 weeks (n = 358) and standard nonintensified exposure (PeEx-S) with weekly exposure sessions (n = 368). Primary outcomes were anxiety symptoms (pre, post, and 6-months follow-up). Secondary outcomes were global severity (across sessions), quality of life, disability days, and comorbid depression. Results: Both treatments resulted in substantial improvements at post (PeEx-I: dwithin  = 1.50, PeEx-S: dwithin  = 1.78) and follow-up (PeEx-I: dwithin = 2.34; PeEx-S: dwithin = 2.03). Both groups showed formally equivalent symptom reduction at post and follow-up. However, time until response during treatment was 32% shorter in PeEx-I (median = 68 days) than PeEx-S (108 days; TRPeEx-I = 0.68). Interestingly, drop-out rates were lower during intensified exposure. PeEx-I was also superior in reducing disability days and improving quality of life at follow-up without increasing relapse. Conclusions: Both treatment variants focusing on the transdiagnostic exposure-based violation of threat beliefs were effective in reducing symptom severity and disability in severe anxiety disorders. Temporally intensified exposure resulted in faster treatment response with substantial public health benefits and lower drop-out during the exposure phase, without higher relapse. Clinicians can expect better or at least comparable outcomes when delivering exposure in a temporally intensified manner.

Despite striking empirical support, exposure-based treatments for anxiety disorders are underutilized. This is partially due to clinicians’ concerns that patients may reject exposure or experience severe side effects, particularly in intensive forms of exposure. We examined acceptance and side effects of two randomly assigned variants of prediction error-based exposure treatment differing in temporal density (1 vs. 3 sessions/week) in 681 patients with panic disorder, agoraphobia, social anxiety disorder, and multiple specific phobias. Treatment acceptance included treatment satisfaction and credibility, engagement (i.e., homework completion) and tolerability (i.e., side effects, dropout and perceived treatment burden). Side effects were measured with the Inventory for the Balanced Assessment of Negative Effects of Psychotherapy (INEP). We found treatment satisfaction, credibility, and engagement to be equally high in both variants of exposure-based treatment, despite higher treatment burden (β = 0.25) and stronger side effects (β = 0.15) in intensified treatment. 94.1% of patients reported positive effects in the INEP. 42.2% reported side effects, with treatment stigma (16.6%), low mood (14.8%) and the experience to depend on the therapist (10.9%) being the most frequently reported. The mean intensity of side effects was low. We conclude that prediction error-based exposure treatment is well accepted by patients with different anxiety disorders and that patients also tolerate temporally intensified treatment, despite higher perceived treatment burden and stronger side effects. Clinicians should be aware of the most frequent side effects to take appropriate countermeasures. In sum, temporal intensification appears to be an acceptable strategy to achieve faster symptom reduction, given patients’ well-informed consent.

The so-called ‘replicability crisis’ has sparked methodological discussions in many areas of science in general, and in psychology in particular. This has led to recent endeavours to promote the transparency, rigour, and ultimately, replicability of research. Originating from this zeitgeist, the challenge to discuss critical issues on terminology, design, methods, and analysis considerations in fear conditioning research is taken up by this work, which involved representatives from fourteen of the major human fear conditioning laboratories in Europe. This compendium is intended to provide a basis for the development of a common procedural and terminology framework for the field of human fear conditioning. Whenever possible, we give general recommendations. When this is not feasible, we provide evidence-based guidance for methodological decisions on study design, outcome measures, and analyses. Importantly, this work is also intended to raise awareness and initiate discussions on crucial questions with respect to data collection, processing, statistical analyses, the impact of subtle procedural changes, and data reporting specifically tailored to the research on fear conditioning.

Avoidance habits potentially contribute to maintaining maladaptive, costly avoidance behaviors that persist in the absence of threat. However, experimental evidence about costly habitual avoidance is scarce. In two experiments, we tested whether extensively trained avoidance impairs the subsequent goal-directed approach of rewards. Healthy participants were extensively trained to avoid an aversive outcome by performing simple responses to distinct full-screen color stimuli. After the subsequent devaluation of the aversive outcome, participants received monetary rewards for correct responses to neutral object pictures, which were presented on top of the same full-screen colors. These approach responses were either compatible or incompatible with habitual avoidance responses. Notably, the full-screen colors were not relevant to inform approach responses. In Experiment 1, participants were not instructed about post-devaluation stimulus-response-reward contingencies. Accuracy was lower in habit-incompatible than in habit-compatible trials, indicating costly avoidance, whereas reaction times did not differ. In Experiment 2, contingencies were explicitly instructed. Accuracy differences disappeared, but reaction times were slower in habit-incompatible than in habit-compatible trials, indicating low-cost habitual avoidance tendencies. These findings suggest a small but consistent impact of habitual avoidance tendencies on subsequent goal-directed approach. Costly habitual responding could, however, be inhibited when competing goal-directed approach was easily realizable.