A multi-method investigation of the acquisition and treatment of pathological fear
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Abstract: 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.