Browsing by Subject "Exposure therapy"
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Item A multi-method investigation of the acquisition and treatment of pathological fear(2017-07-28) Lancaster, Cynthia Luethcke; Telch, Michael Joseph; Monfils, Marie; Smits, Jasper; Wolitzky-Taylor, Kate; Hixon, John GAbstract: Over the course of their lifetime, about 25% of the U.S. population will meet criteria for one or more of the anxiety-related disorders, all of which are characterized by pathological fear responding. Researchers have made significant strides in improving treatment efficacy through the development of cognitive-behavioral models for understanding the acquisition and treatment of pathological fear. Although cognitive-behavioral treatments produce marked reductions in pathological fear on average, a subgroup of patients do not respond to treatment. In an effort to improve the prevention and treatment of pathological fear, this dissertation synthesizes data from a series of studies aimed to (a) improve our understanding of factors that contribute to the development of pathological fear in a real-world setting (Study 1), (b) examine factors that influence response to exposure therapy, a technique used across gold-standard treatments pathological fear (Study 2), and (c) investigate novel strategies that could be added to exposure therapy to further improve treatment response (Study 3). Specifically, Study 1 demonstrates the contribution of cognitive appraisal (i.e., threat perception) to the onset of pathological fear in response to stressors encountered in a real-world, high-stress environment (warzone deployment). Study 2 is a meta-analysis exploring the influence of unnecessary protective actions, or safety behaviors (SBs), on outcomes of exposure therapy. Data demonstrate that removing SBs during exposure therapy improves treatment outcomes, whereas adding SBs during exposure therapy produces inferior outcomes under certain conditions, such as when treating specific phobia symptoms. Finally, Study 3 is a randomized clinical trial investigating the use of two behavioral strategies, alone and in combination, to enhance exposure therapy outcomes: (1) a brief pre-exposure fear memory reactivation trial (PE-FMR) and (2) deepened extinction. Results suggest that neither PE-FMR nor deepened extinction improve outcomes at post-treatment or one-week follow-up. However, PE-FMR augmentation produced more rapid fear reduction during treatment, and equivalent outcomes even when the duration of exposure therapy (tailored to speed of fear reduction) was shorted by 21% on average. Together, these lines of research contribute to our understanding of cognitive and behavioral influences on the development and treatment of pathological fear.Item Disentangling perceptual mechanisms maintaining social anxiety disorder using VR and eye tracking(2022-06-28) Rubin, Mikael; Telch, Michael Joseph; Hayhoe, Mary M; Smits, Jasper AJ; Beevers, Christopher G; Hixon, John GSocial anxiety disorder (SAD) is highly prevalent and confers significant life impairment. Attention processes associated with social evaluative threat have been broadly implicated in the conceptualization of SAD. This dissertation investigates specific attentional mechanisms maintaining SAD. Both theoretical and empirical research have emphasized two important attentional processes in SAD: hypervigilance to social threat (e.g. quickly scanning faces) and avoidance of social information (e.g. avoiding looking at people). This dissertation consists of three studies investigating attentional avoidance in social anxiety. Study 1 investigated the relationship between social anxiety and eye movements during a real social-evaluative situation – giving a speech. We used 360º-video because it was both very realistic and allowed for a high degree of experimental control. The primary findings from Study 1 revealed that fear of public speaking was associated with greater avoidance of the uninterested (socially threatening) audience members compared with interested audience members. Drawing from the findings from Study 1, Study 2 addressed whether direct modification of attentional (through attention guidance) during virtual reality exposure therapy could enhance intervention outcomes compared with standard virtual reality exposure. Our pilot randomized controlled trial (n =21) indicated a strong effect of both intervention groups on fear of public speaking as well as evidence that the guidance component engaged the target attentional mechanism (decreased avoidance of audience members). However, our Bayesian analyses provided no conclusive support for either the null or alternative hypotheses. Further research with larger sample sizes is needed to elucidate the link between attentional avoidance and social anxiety disorder. Study 3 used data from study 2 to test whether a machine learning approach well suited to high-eye dimensional eye movement data (hidden Markov models) could identify heterogenous attentional styles among those with social anxiety disorder and predict differential treatment outcomes. We identified two distinct groups reflecting “avoidant” and “vigilant” styles pre-treatment. Moreover, we found meaningful differences between the groups post-treatment – with only the hypervigilant group showing treatment response to virtual reality exposure therapy. These findings suggest that evaluating attentional processes in flexible, data-driven ways may provide unique insights into social anxiety disorder and has implications for treatment.Item The effects of emotional acceptance and suppression upon emotional processing in exposure treatment of claustrophobia(2009-08) Horowitz, Jonathan David; Telch, Michael JosephRecent investigations have suggested that the use of emotion-avoidance or emotion- suppression strategies to cope with anxiety contributes to the development and maintenance of anxiety disorders, and that substituting these strategies with emotional acceptance can lead to effective symptom reduction. We wished to consider whether attempts to suppress the negative emotions associated with exposure therapy would serve to impede emotional processing and symptom reduction, and conversely, whether acceptance of these emotions would augment treatment efficacy. Fifty-nine participants displaying marked claustrophobic fear were assigned to receive 30 minutes of exposure (enclosure in a small chamber) while receiving, A) instructions to accept and allow the experience of unpleasant emotions (ACC), B) instructions to control and suppress the experience of unpleasant emotions (SUP), or C) no instructions regarding emotion regulation (exposure only; EO). Outcome assessments were conducted prior to treatment, immediately following treatment, and at one-month follow-up, and included fear and heart rate reactivity in response to a behavioral approach test. We predicted that ACC participants would display greater reductions in claustrophobic fear than EO participants, and that EO participants would in turn display greater reductions in claustrophobic fear than SUP participants. These hypotheses were not supported. In addition, a detailed analysis of treatment process data was conducted. Peak fear ratings, claustrophobic threat expectancies, self-efficacy, and acceptance of anxiety were collected over the course of the treatment session, and hierarchical linear modeling (HLM) was used to produce individual growth curves for these variables. Three hypotheses were formulated: 1) ACC participants would display a more rapid improvement in these measures than SUP and EO participants, 2) threat expectancies, self-efficacy and anxiety would mediate reductions in fear over the course of treatment, and 3) mediational pathways would be moderated by treatment condition. Though no support was found for our first process hypothesis, treatment specific mediation was found. Among ACC participants, self-efficacy and suffocation expectancies mediated the session-fear relationship, and among EO participants, entrapment expectancies mediated this relationship. Among SUP participants, no significant mediators were identified.Item Enhancing exposure therapy with acute exercise : an initial test(2016-08) Jacquart, Jolene Ann; Smits, Jasper A. J.; Monfils, MarieExposure-based therapies are one of the most effective strategies for treating a large range of anxiety disorders; yet there remains a substantial (20-50%) non-response rate. Since exposure therapies are based on fear extinction principles, strategies that can enhance the acquisition and retention of fear extinction memories should, theoretically, facilitate the outcome of exposure therapy. Pharmacological agents acting as cognitive enhancers have shown some effectiveness in augmenting exposure therapy. Aerobic exercise may similarly act as a cognitive enhancer as it has been shown to affect learning and memory processes broadly. The current study builds upon the extant literature by conducting an initial test of the efficacy of acute aerobic exercise for enhancing exposure therapy outcomes. Adults with a marked fear of heights were randomized to either 30-minutes of vigorous aerobic exercise or rest immediately prior to 30-minutes of virtual reality exposure therapy (VRET). Participants’ fear of heights was assessed 1- and 2-weeks later by clinician ratings and self-report questionnaires. On average, participants showed significant decreases in fear of heights from baseline to 1- and 2-weeks post-VRET, but these changes did not significantly differ by treatment condition. This remained true even after including potential moderators of treatment condition. These findings do not support acute exercise as an augmentation strategy for exposure therapy. Clinical and research implications are discussed.Item Investigating and targeting potential mechanisms of outcome in exposure therapy for social anxiety disorder(2018-08) Davis, Michelle Lee; Smits, Jasper A. J.; Dominguez, Juan; Roelofs, Karin; Rosenfield, David; Telch, MichaelThough exposure-based treatments for social anxiety disorder (SAD) are efficacious, not everyone benefits, and we still do not fully understand how and under what conditions this treatment works. Fruitful approaches to better understanding and improving exposure therapy 1) identify predictors of treatment outcome based on theory and 2) manipulate proposed predictors to improve outcomes. Theoretical models of exposure therapy implicate reduction in threat-related avoidance (or, increases in threat-related attention and approach) as a mechanism of fear reduction. The studies in this dissertation follow this theory-driven approach by testing the hypothesized relation between changes in implicit measures of threat-related attention and treatment outcome (Studies 1 and 2) and testing the efficacy of a strategy aimed to manipulate threat approach to improve exposure outcomes (Study 3). Specifically, in Study 1 we examined how social threat-related attentional biases change during exposure therapy for SAD, and attempted to relate these changes in attention bias with symptom change. Additionally, we tested a computational method used to yield attention bias scores that may be more reliable for repeated measurement. Our results indicated that while social threat-related attention bias did decrease over the course of exposure therapy, these changes were not predictive of symptom change. Study 2 examines the language used during speech exposures (i.e., linguistic style) as a potential predictor of exposure outcome, relating these variables to SAD symptom severity a week after a single exposure session. We found that increased use of first-person plural pronouns during the public speaking exposure was predictive of superior exposure outcomes, in line with an hypothesis that first-person plural pronoun is indicative of threat-related attentional focus during exposure therapy. Finally, Study 3 tested whether a behavioral manipulation thought to temporarily increase endogenous testosterone (a hormone associated with social threat approach) would augment exposure therapy. We found no evidence to suggest that testosterone levels can be manipulated via our behavioral strategy and were thus unable to test whether increasing testosterone facilitates exposure therapy outcomes. We discuss some limitations to the research, as well as recommendations for future directions.Item Targeted memory reactivation for enhancing exposure therapy(2020-08-07) Lee, Michael David, Ph. D.; Telch, Michael Joseph; Dunsmoor, Joseph; Lapota, Holly; Monfils, MariePrior research has demonstrated that memory consolidation can be enhanced by coupling learning with an olfactory or auditory contextual cue, then presenting that cue again during subsequent sleep. This process, known as targeted memory reactivation (TMR), has been investigated in basic research but has not been translated into clinical application. The current study investigated whether TMR could be used to augment exposure therapy by promoting consolidation of extinction learning. 109 participants with marked fear of spiders, contamination, or enclosed spaces were given standardized in-vivo exposure therapy in the presence of a contextual odor. Following treatment, they were randomized to one of three conditions: (1) EXPCUE, involving sleep in the presence of the contextual odor previously presented during exposure, (2) NOVCUE, involving sleep in the presence of a novel odor, or (3) CNTL, involving sleep without any odor. Electrodermal and fear responding to behavioral approach tests, as well as self- reported anxiety and disgust, were assessed at baseline, post-treatment, one-week, and one-month follow-up visits. We predicted that at follow-up the EXPCUE condition would exhibit lower anxiety than the NOVCUE and CNTL conditions, and that self- reported peak anxiety during the last exposure trial would moderate the relationship between condition and anxiety at follow-up. These hypotheses were not supported, as there were no between-group differences in primary outcomes and the predicted moderation effects were not observed. In contrast to hypothesis, the EXPCUE group exhibited a reduced rate of anxiety decrease in comparison to the NOVCUE or CNTL conditions as measured by self-report questionnaires. Results suggest that TMR does not enhance consolidation of extinction learning during exposure therapy.Item The war at home : a veteran's use of critical design methods for post-deployment reintegration(2015-05) Perez, Jose Manuel; Catterall, Kate; Sonnenberg, StephenMany combat veterans underestimate the on-going traumatic effects of war, effects that eventually surface in civilian life, causing health, relationship and career problems. During a deployment, emotions such as vigilance, anger, and fear are beneficial for the soldier and aide in coping with multiple combat-related adversities. Suppression of emotions that do not assist the soldier or mission during deployment is necessary and becomes habitual as it helps the soldier stay motivated and focused for the duration of the deployment. Post-deployment, the coping mechanisms previously necessary for survival, contribute to the difficulties of reintegration. The problems encountered by veterans can include, but are not limited to: social withdrawal, economic decline, self-medication, and most problematic, suicidal tendencies. As a veteran myself, I began to ask, is there another way to prepare veterans for re-entry to civilian life, to prevent unnecessary hardships and tragedies, educate them in unfamiliar ways, and perhaps contribute to an effective healing process? As a designer I approached these questions, searching for a way to communicate the adversities veterans face from an unexpected angle. Presented here are prototypes, diagrams, and warning systems designed to help veterans 1) be more self-aware and alert to the symptoms of posttraumatic stress and depression, 2) engage the armed forces and the VA in a discussion about innovative and more effective ways to talk about and treat the psychologically damaged soldier, and 3) foster communities to support veterans in their re-entry to civilian life. The objects I designed for my thesis exhibition are not intended to correct a complex problem such as Posttraumatic Stress Disorder (PTSD) or moral injury. Instead, they are created as a collection of tools to facilitate difficult conversations, provoke thought, and as an alternative approach to reach combat veterans who are in their own process of reintegration. My work is one method to process the effects of war through a non-destructive practice for those veterans who may not pay attention to the wall of pamphlets or other forms of disseminating information.