Virtual reality (VR) treatments for anxiety disorders are unambiguously successful, so why are so few therapists using it? Barriers to adoption and potential solutions.

Anxiety disorders are a significant cause of disability globally, yet only one in ten sufferers receives adequate quality treatment. Exposure-based therapies are effective in reducing symptoms associated with a number of anxiety disorders. However, few therapists use exposure techniques to treat these conditions, even when they are adequately trained in them, often because of concerns about provoking distress, drop out, logistical barriers, and other concerns. Virtual reality exposure therapy (VRET) can address many of these concerns, and a large body of research decisively shows that VRET is as efficacious for treating these conditions as in vivo exposures. Yet, use of VRET remains low. In this article, we discuss several factors we believe are contributing to low VRET adoption among therapists and raise potential solutions to address them. We consider steps that VR experience developers and researchers might take, such as leading studies of VRET's real-world effectiveness and treatment optimization trials and continuing to improve the fit of platforms with clinicians' workflows. We also discuss steps to address therapist reservations using aligned implementation strategies, as well as barriers for clinics, and the roles that professional organizations and payers could have in improving care by encouraging adoption of VRET.

The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel.

BACKGROUND: Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT). METHODS: Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership. RESULTS: Five classes, namely rapid responder (7-17%), steep linear responder (14-22%), gradual responder (30-34%), non-responder (27-33%), and symptom exacerbation (7-13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT. CONCLUSIONS: Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.

The effects of safety behavior availability versus utilization on inhibitory learning during exposure.

This study re-analyzes data from Sy and colleagues (2011; Behaviour Research and Therapy, 49, 305-314) comparing safety behavior availability (SBA) to safety behavior utilization (SBU) during exposure therapy for claustrophobic concerns. The present investigation assessed differential rates of inhibitory learning (i.e. change in danger expectancy and coping self-efficacy) between SBA and SBU before, during, and after a single-session treatment. Thirty-nine participants with marked claustrophobic fear completed six consecutive 5-minute exposure trials in a claustrophobia chamber. Participants in the SBA condition exhibited more interference with inhibitory learning relative to the SBU condition. Danger expectancy was significantly higher in the SBA group and decreased at a markedly slower rate across exposure trials relative to SBU. Coping self-efficacy was also significantly lower among participants in the SBA condition, although groups demonstrated similar rates of change across trials. Limitations, clinical implications, and future directions are discussed.

PATTERNS OF CHANGE IN RESPONSE TO PROLONGED EXPOSURE: IMPLICATIONS FOR TREATMENT OUTCOME.

BACKGROUND: Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change. METHODS: Archival records were examined for veterans receiving PE through a specialty Veterans Affairs Medical Center (VAMC) clinic (N = 109). Latent profile analysis was used to extract response trajectories defined by change in weekly PTSD Checklist (PCL) scores. Associations with provider status (staff vs. intern), setting (in-person vs. telehealth), initial severity (PTSD; depression), and eventual treatment gains were examined. RESULTS: Three profiles were observed. Rapid Responders (18.3%) evidenced sharp reductions at Week 2 and again between Weeks 5 and 6. Linear Responders (40.4%) demonstrated gradual reductions throughout the 10-week assessment window. Delayed Responder (41.3%) scores were relatively stable over the evaluation period although final session outcomes indicated reliable change (PCLΔ > 10) in 40% of patients. Profiles were similar with respect to provider status, treatment setting, and initial symptom severity. Rapid Responders evidenced lower final session scores relative to Linear (g = 1.13) and Delayed (g = 1.85) groups, with Linear Responders reporting lower end scores than Delayed Responders (g = 1.02). CONCLUSIONS: Anticipating patterns of recovery and their association with therapeutic outcome is of immense clinical value. Sudden gains emerged as a strong predictor of enhanced response. Data also suggest potential benefits of extending standard intervention for patients who fail to demonstrate an immediate response to PE.

Targeting clinician concerns about exposure therapy: A pilot study comparing standard vs. enhanced training.

Owing to concerns about the safety and tolerability of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, which may limit its effectiveness. Although didactic training in exposure reduces clinician concerns about the treatment to a moderate extent, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an "enhanced" training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two training approaches. Relative to standard training, clinicians who received enhanced training showed: (a) significantly greater reductions in concerns about exposure from pre- to post-training, and (b) superior self-reported delivery of the treatment. Reduction in concerns during training mediated the effects of training condition on clinicians' self-reported exposure delivery. These findings underscore the importance of addressing clinician concerns about exposure therapy in training contexts.

Interoceptive exposure exercises for social anxiety.

Individuals with social anxiety disorder (SAD) commonly experience panic attacks and evidence increased anxiety sensitivity (AS) specific to noticeable anxiety sensations. Interoceptive exposure (IE) is an effective treatment for reducing AS, but few IE tasks target fears of blushing, sweating, or trembling, which are incorporated within AS social concerns and especially feared by individuals with SAD. The primary study aims were trifold: (1) identify novel IE tasks that produce blushing, sweating, and/or trembling; (2) assess the intensity of sensations and anxiety produced by a series of novel and validated IE tasks; and (3) evaluate the incremental validity of combining an IE task and a speech task. Individuals (N = 55) with heightened fear of noticeably blushing, sweating, and/or trembling completed a control task and 8 IE tasks (e.g., hot sauce, hyperventilation). All tasks produced greater intensity of anxiety and sensations compared to the control task (ps < .001; range of η(p)(2) = .20-.50). Responses to the combination of an IE task and social task compared to a social task alone did not differ significantly. Future directions for research and clinical implications of the findings are discussed.

Effects of a chemical imbalance causal explanation on individuals' perceptions of their depressive symptoms.

Although the chemical imbalance theory is the dominant causal explanation of depression in the United States, little is known about the effects of this explanation on depressed individuals. This experiment examined the impact of chemical imbalance test feedback on perceptions of stigma, prognosis, negative mood regulation expectancies, and treatment credibility and expectancy. Participants endorsing a past or current depressive episode received results of a bogus but credible biological test demonstrating their depressive symptoms to be caused, or not caused, by a chemical imbalance in the brain. Results showed that chemical imbalance test feedback failed to reduce self-blame, elicited worse prognostic pessimism and negative mood regulation expectancies, and led participants to view pharmacotherapy as more credible and effective than psychotherapy. The present findings add to a growing literature highlighting the unhelpful and potentially iatrogenic effects of attributing depressive symptoms to a chemical imbalance. Clinical and societal implications of these findings are discussed.

Why do clinicians exclude anxious clients from exposure therapy?

Despite research demonstrating the effectiveness of exposure therapy for pathological anxiety, this treatment is underutilized by clinicians. Anecdotal evidence and clinical experience suggest that therapists who possess reservations about exposure therapy tend to exclude clients from this treatment based on client characteristics believed to predict worse response. When exceptions are made based on characteristics that do not reliably predict poor outcomes, clients face the opportunity cost associated with investment in less effective treatments. The present investigation assessed therapists' likelihood of excluding clients from exposure due to different client and therapist characteristics. Exposure therapists (N = 182) completed an online survey that included the Therapist Beliefs about Exposure Scale, Anxiety Sensitivity Index-3, and the Broken Leg Exception Scale (BLES), a novel measure assessing the likelihood of excluding clients from exposure based on 25 different client characteristics. The BLES demonstrated good psychometric properties. Client characteristics most likely to result in exclusion from exposure therapy were comorbid psychosis, emotional fragility, and reluctance to participate in exposure. Greater likelihood of excluding clients from exposure was associated with higher therapist anxiety sensitivity and endorsement of negative beliefs about exposure therapy. Clinical and training implications of these findings are discussed.

Therapist perceptions and delivery of interoceptive exposure for panic disorder.

Interoceptive exposure (IE) is widely regarded as an essential procedure in the cognitive-behavioral treatment of panic disorder (PD). However, treatment manuals differ substantially in their prescribed delivery of IE, and little research exists to inform the optimal manner of its implementation. The present study examined therapists' perceptions and delivery of IE for PD. Results revealed substantial variability in how clinicians provide IE. In contrast to the prolonged and intense manner in which exposure techniques are traditionally applied, many therapists reported delivering a low dose of IE accompanied by controlled breathing strategies. Concerns about the potential adverse effects of IE were common despite the fact that participants reported the actual occurrence of negative outcomes of IE in their own practice to be extremely infrequent. It is possible that some therapists deliver IE in a cautious manner in an attempt to minimize the perceived risks associated with this treatment.

Do negative beliefs about exposure therapy cause its suboptimal delivery? An experimental investigation.

Despite its effectiveness, exposure therapy is underutilized and frequently implemented in suboptimal fashion. Research has shown negative beliefs about exposure are related to its underutilization, and these beliefs are held by exposure therapists and may play a causal role in its suboptimal delivery. This study examined the effect of negative beliefs about exposure on treatment delivery. Participants (n=53) received training in basic exposure implementation and were given additional information intended to elicit either positive or negative beliefs about the treatment's safety, tolerability, and ethicality prior to conducting an exposure session with a confederate client. Results indicated that participants with experimentally induced negative beliefs about exposure delivered the treatment more cautiously (e.g. creation of a less ambitious exposure hierarchy, selection of a less anxiety-provoking exposure task, attempts to minimize client anxiety during exposure) compared to participants with positive beliefs who pursued more ambitious delivery of exposure (e.g. encouraging clients' use of oppositional actions). The present findings suggest that therapist reservations about exposure cause suboptimal delivery and may adversely affect client outcomes.

A Comparison of Cognitive and Behavioral Approaches for Reducing Cost Bias in Social Anxiety.

Cognitive-behavioral theories suggest that anxiety is maintained in part by estimates of the probability and cost of feared negative outcomes. Social phobia may be unique among the anxiety disorders in that it is characterized by overestimates of the cost of events that are objectively noncatastrophic (e.g., committing social mishaps). As such, treatment approaches that target cost bias may be particularly effective in reducing social phobia symptoms. This study examined the efficacy of 2 cost-specific techniques in a single-session intervention for social anxiety. Individuals (n = 61) with elevated social interaction anxiety were randomly assigned to an expressive writing control condition, a cognitive restructuring condition, or a behavioral experiment condition. Results demonstrated that the cognitive restructuring condition produced significantly greater improvement in indices of social anxiety than the other conditions. Reduction in cost bias fully mediated the significantly greater improvement in social interaction anxiety in the cognitive restructuring condition relative to the behavioral experiment condition. The present findings highlight the value of techniques designed to reduce cost biases in social anxiety. Clinical implications are discussed.

Assessing therapist reservations about exposure therapy for anxiety disorders: the Therapist Beliefs about Exposure Scale.

Exposure therapy is underutilized in the treatment of pathological anxiety and is often delivered in a suboptimal manner. Negative beliefs about exposure appear common among therapists and may pose a barrier to its dissemination. To permit reliable and valid assessment of such beliefs, we constructed the 21-item Therapist Beliefs about Exposure Scale (TBES) and examined its reliability and validity in three samples of practicing clinicians. The TBES demonstrated a clear single-factor structure, excellent internal consistency (αs=.90-.96), and exceptionally high six-month test-retest reliability (r=.89). Negative beliefs about exposure therapy were associated with therapist demographic characteristics, negative reactions to a series of exposure therapy case vignettes, and the cautious delivery of exposure therapy in the treatment of a hypothetical client with obsessive-compulsive disorder. Lastly, TBES scores decreased markedly following a didactic workshop on exposure therapy. The present findings support the reliability and validity of the TBES.

Maximizing the efficacy of interoceptive exposure by optimizing inhibitory learning: a randomized controlled trial.

Cognitive-behavioral treatments for panic disorder (PD) emphasize interoceptive exposure (IE) to target anxiety sensitivity (AS) but vary considerably in its manner of delivery. This randomized controlled trial was conducted to compare the efficacy of the low-dose delivery of IE exercises often prescribed in treatment protocols to an intensive form of IE hypothesized to optimize inhibitory learning. Participants (N = 120) with elevated AS were randomly assigned to one of four single-session interventions: (a) low-dose IE as prescribed in Barlow and Craske's Panic Control Treatment, (b) low-dose IE without controlled breathing or a lengthy between-trial rest period, (c) intensive IE, or (d) expressive writing control. Compared to the other conditions, intensive IE produced significantly greater reductions in AS and fearful responding to a straw breathing task from pretreatment to posttreatment. Maintenance of gains during the follow-up period did not differ between conditions. Changes in fear toleration and negative outcome expectancies fully mediated the superior efficacy of intensive IE over low-dose IE. The two low intensity IE conditions produced particularly high rates of fear sensitization on between-trial and outcome variables. The findings suggest that the intensive delivery of IE exercises has the potential to improve the efficacy of exposure-based treatments for PD.

Testing tic suppression: comparing the effects of dexmethylphenidate to no medication in children and adolescents with attention-deficit/hyperactivity disorder and Tourette's disorder.

OBJECTIVE: The aim of this study was to conduct a pilot study testing whether single-dose, immediate-release dexmethylphenidate (dMPH) can facilitate tic suppression in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and Tourette's disorder (TD) or chronic tic disorders. The primary hypothesis is that dMPH will improve behaviorally reinforced tic suppression in a standard tic suppression paradigm (TSP). METHODS: Ten children with ADHD and TD were given dMPH on one visit and no medication on another, using a random crossover design. On both days, following a baseline period, subjects were reinforced for suppressing tics using a standard TSP. RESULTS: Thirteen subjects were enrolled; 10 subjects (mean age 12.7 +/- 2.6; 90% male) completed all study procedures. Relative to the no-medication condition, tics were reduced when children were given a single dose of dMPH. Behavioral reinforcement of tic suppression resulted in lower rates of tics compared to baseline, but dMPH did not enhance this suppression. CONCLUSION: Preliminary results indicate replication of prior studies of behavioral tic suppression in youths with TD and without ADHD. In addition, our findings indicate tic reduction (and not tic exacerbation) with acute dMPH challenge in children and adolescents with ADHD and TD.

The development of stimulus control over tics: a potential explanation for contextually-based variability in the symptoms of Tourette syndrome.

Research has demonstrated that providing reinforcement for tic-free intervals can decrease tic frequency in controlled analogue settings. The aim of the current study was to determine whether reinforcement could be used to create stimulus control over tic expression. Ten children with chronic tic disorders (including Tourette syndrome) completed four discrimination training sessions. Each session consisted of three exposures to each of three, 5 min. conditions presented in a random order. In one condition, participants were reinforced for tic absence on a 10-s fixed interval schedule in the presence of a purple light. In a second condition, participants were instructed to suppress their tics, but were not reinforced for doing so in the presence of an orange light. In a third condition, participants were instructed not to suppress their tics in the presence of two non-illuminated lights. Confirming findings from other studies, results showed that reinforcing tic suppression reduced tic frequency to a greater extent than only providing instructions to suppress. To test for stimulus control, a fifth session was conducted following the aforementioned discrimination training sessions. The fifth session consisted of three exposures to each of three 5 min. conditions presented in a random order. In one condition, a purple light was illuminated. In a second condition, an orange light was illuminated. In a third condition, neither light was illuminated. Across all three conditions, instructions to suppress (or not suppress) tics were not provided, and reinforcers for successful suppression were not delivered. Results indicated that in the presence of the purple light, tics were significantly lower than when neither light was illuminated. These findings provide preliminary support for the idea that a history of differential reinforcement in various contexts may play a role explaining variability in tic symptom expression.