Does disconfirmatory evidence shape safety-and danger-related beliefs of trauma-exposed individuals?

Recent accounts of predictive processing in posttraumatic stress disorder (PTSD) suggest that trauma-exposed individuals struggle to update trauma-related hypotheses predicting danger, which may be involved in the etiology and maintenance of this disorder. Initial research supports this account, documenting an association between trauma-exposure, impaired expectation updating, and PTSD symptoms. Yet, no study to date has examined biased belief updating in PTSD using a scenario-based approach.Objective: Here, we examined the predictive processing account among trauma-exposed and non-trauma-exposed individuals using a modified Trauma-Related version of the Bias Against Disconfirmatory Evidence task.Method: The task presents both danger-and safety-related scenarios highly relevant for trauma-exposed individuals. For each scenario, participants viewed several explanations and rated their plausibility. Their ability to update their initial interpretation following new-contradictory information was assessed.Results: Preregistered analyses did not reveal any significant findings. Based on indications that our sample may not have been sufficiently powered, we conducted exploratory analyses in an extended sample of participants. These analyses yielded a significant association between reduced belief updating and PTSD symptoms which was evident for disconfirming both safety and danger scenarios. However, the effect sizes we found were in the small-to-medium range.Conclusion: Although preliminary, our current findings support initial evidence that individuals with higher PTSD symptoms show a higher resistance to update their beliefs upon new disconfirmatory evidence. Our results should be interpreted cautiously in light of the extended sample and the limitations of the current study.

We developed a modified version of the Bias Against Disconfirmatory Evidence task.We found significant associations between PTSD symptoms and belief updating.The association was evident for disconfirming both safety and danger scenarios.

Are depressive symptoms linked to a reduced pupillary response to novel positive information?-An eye tracking proof-of-concept study.

Introduction: Depressive symptoms have been linked to difficulties in revising established negative beliefs in response to novel positive information. Recent predictive processing accounts have suggested that this bias in belief updating may be related to a blunted processing of positive prediction errors at the neural level. In this proof-of-concept study, pupil dilation in response to unexpected positive emotional information was examined as a psychophysiological marker of an attenuated processing of positive prediction errors associated with depressive symptoms. Methods: Participants (N = 34) completed a modified version of the emotional Bias Against Disconfirmatory Evidence (BADE) task in which scenarios initially suggest negative interpretations that are later either confirmed or disconfirmed by additional information. Pupil dilation in response to the confirmatory and disconfirmatory information was recorded. Results: Behavioral results showed that depressive symptoms were related to difficulties in revising negative interpretations despite disconfirmatory positive information. The eye tracking results pointed to a reduced pupil response to unexpected positive information among people with elevated depressive symptoms. Discussion: Altogether, the present study demonstrates that the adapted emotional BADE task can be appropriate for examining psychophysiological aspects such as changes in pupil size along with behavioral responses. Furthermore, the results suggest that depression may be characterized by deviations in both behavioral (i.e., reduced updating of negative beliefs) and psychophysiological (i.e., decreased pupil dilation) responses to unexpected positive information. Future work should focus on a larger sample including clinically depressed patients to further explore these findings.

Change in pain expectations but no open-label placebo analgesia: An experimental study using the heat pain paradigm.

BACKGROUND: Open-label placebos (OLP) prescribed without deception and with a convincing rationale have been shown to evoke powerful treatment effects. Patients' treatment expectations seem to influence the magnitude of the effect. OBJECTIVE: We examined if two different OLP rationales increased pain tolerance and reduced pain intensity and unpleasantness in a standardized heat pain experiment. METHODS: Participants (N = 71) who self-reported reoccurring pain for at least the last 3 months were randomly assigned to one of three groups. We compared a personal-emotional and a scientific-matter-of-fact rationale with a control group (CG) that received the same placebo without any rationale. The rationale suggested a desensitizing effect on pain perception and improved pain coping of the placebo, whereas in the CG it was introduced as an ointment for measurement. The primary outcomes were pre-post changes in pain tolerance, expected and experienced pain intensity and unpleasantness. RESULTS: Participants showed a decrease in expected pain intensity, but not expected pain unpleasantness for both rationales. There were no differences in pain tolerance and experienced pain intensity and unpleasantness. CONCLUSIONS: Our study suggests that evoking positive treatment expectations is not sufficient to elicit an OLP response. Possibly, the magnitude of expectations change in this study was not powerful enough to evoke an OLP effect. Additionally, it is possible that OLP effects in pain are unrelated to positive treatment expectations. The failure of OLP in our study is in contrast to a number of previous studies examining the effects of OLP in experimental and clinical pain. SIGNIFICANCE: This study provides evidence that positive treatment expectations are not sufficient to evoke an open-label placebo effect in a standardized heat pain experiment. We showed that two different rationales improved participants treatment expectations, but failed to evoke a placebo effect in comparison to a control group that received the same placebo, labelled as an ointment to improve measurement quality.

Factors influencing the update of beliefs regarding controversial political issues.

Selectively integrating new information contributes to belief polarization and compromises public discourse. To better understand factors that underlie biased belief updating, I conducted three pre-registered studies covering different controversial political issues. The main hypothesis was that cognitively devaluing new information hinders belief updating. Support for this hypothesis was found in only one of the three issues. The only factor that consistently influenced belief updating across issues was the discrepancy between prior beliefs and new information. These results suggest that usually people do use evidence to correct their beliefs, but may refuse to do so if doubts about its generalizability arise.

Biased belief updating in depression.

Cognitive approaches to depression have benefitted from recent research on belief updating, examining how new information is used to alter beliefs. This review presents recent advances in understanding various sources of bias in belief updating in depression. Specifically, research has demonstrated that people with depression have difficulty revising negative beliefs in response to novel positive information, whereas belief updating in depression is not related to an enhanced integration of negative information. In terms of mechanisms underlying the deficient processing of positive information, research has shown that people with depression use defensive cognitive strategies to devalue novel positive information. Furthermore, the disregard of novel positive information can be amplified by the presence of state negative affect, and the resulting persistence of negative beliefs in turn perpetuates chronically low mood, contributing to a self-reinforcing negative feedback loop of beliefs and affect. Synthesising previous research, this review proposes a coherent framework of when belief change is likely to occur, and argues that future research also needs to elucidate why people with depression hesitate to abandon negative beliefs. Recent insights from belief updating have not only improved the understanding of the psychopathology of depression, but also have the potential to improve its cognitive-behavioural treatment.

Same same, but different: effects of likelihood framing on concerns about a medical disease in patients with somatoform disorders, major depression, and healthy people.

BACKGROUND: Research has shown that patients with somatoform disorders (SFD) have difficulty using medical reassurance (i.e. normal results from diagnostic testing) to revise concerns about being seriously ill. In this brief report, we investigated whether deficits in adequately interpreting the likelihood of a medical disease may contribute to this difficulty, and whether patients' concerns are altered by different likelihood framings. METHODS: Patients with SFD (N = 60), patients with major depression (N = 32), and healthy volunteers (N = 37) were presented with varying likelihoods for the presence of a serious medical disease and were asked how concerned they are about it. The likelihood itself was varied, as was the format in which it was presented (i.e. negative framing focusing on the presence of a disease v. positive framing emphasizing its absence; use of natural frequencies v. percentages). RESULTS: Patients with SFD reported significantly more concern than depressed patients and healthy people in response to low likelihoods (i.e. 1: 100 000 to 1:10), while the groups were similarly concerned for likelihoods ⩾1:5. Across samples, the same mathematical likelihood caused significantly different levels of concern depending on how it was framed, with the lowest degree of concern for a positive framing approach and higher concern for natural frequencies (e.g. 1:100) than for percentages (e.g. 1%). CONCLUSIONS: The results suggest a specific deficit of patients with SFD in interpreting low likelihoods for the presence of a medical disease. Positive framing approaches and the use of percentages rather than natural frequencies can lower the degree of concern.

How to modify expectations of social rejection? An experimental study using a false-feedback paradigm.

BACKGROUND AND OBJECTIVES: Negative expectations (NEs) are fundamental to various mental disorders. Finding ways to modulate NEs would help to improve clinical treatment. The present study investigated how previously formed expectations of social rejection are revised in the context of novel positive social experiences, and whether their revision can be modulated by differentially shifting participants' attentional focus. METHODS: Our sample of 124 healthy participants was randomly assigned to four experimental conditions and received manipulated social feedback in multiple alleged webcam conferences. All groups went through three experimental phases that began with predominantly negative social feedback, then either transitioned to predominantly positive social feedback or continued to predominantly negative social feedback, and ultimately transitioning to a phase with no explicit social feedback. The experimental conditions differed in what they were instructed to focus on when receiving positive social feedback. RESULTS: Receiving novel positive social feedback led to substantial changes in social expectations, but this effect was not modulated by the instructions the participants were given. Descriptive trends revealed that both instructions improved NE modification, although this effect was not robust to extinction in one condition. LIMITATIONS: To prevent our cover story from being compromised, we could not perform an immediate manipulation check of the instructions given. Nevertheless, some of the sample seemed suspicious about the cover story. CONCLUSION: Our results suggest that established expectations of social rejection can be revised when unexpectedly experiencing social acceptance. Nevertheless, more research is needed on potential instructions that could be used to optimize the modification of NEs.

The relationship between multiple traumatic events and the severity of posttraumatic stress disorder symptoms - evidence for a cognitive link.

Background: Previous research has shown that multiple traumatic experiences cumulatively increase the risk for the development of severe symptoms of posttraumatic stress disorder (PTSD). Yet, little is known about the specific psychological mechanism through which this increased risk comes about.Objective: In the present study, we examined a possible cognitive link between multiple traumatic events and PTSD symptom severity through dysfunctional cognitions and expectations.Methods: A sample of patients with a diagnosed PTSD (N = 70; MAge = 42.06; 82% female) and high symptom burden (IES-R M = 79.24) was examined. On average, patients had experienced 5.31 different traumatic events. In a structural equation model, we tested the hypothesis that the relationship between multiple traumatic experiences and PTSD symptom severity is mediated through dysfunctional general cognitions and dysfunctional situation-specific expectations. General trauma-related cognitions were assessed with the Posttraumatic Cognition Inventory (PTCI) and trauma-related situational expectations were assessed with the Posttraumatic Expectations Scale (PTES).Results: The direct effect of the number of traumatic events on PTSD symptom severity was non-significant. Instead, as hypothesised, there was evidence for a significant indirect effect via dysfunctional general cognitions and situation-specific expectations.Conclusions: The current results further specify the cognitive model of PTSD by indicating that the relationship between the number of traumatic events and PTSD symptom severity is mediated through dysfunctional cognitions and expectations. These findings emphasise the importance of focused cognitive treatment approaches that seek to modify dysfunctional cognitions and expectations in people with multiple traumatic experiences.

This study shows a cognitive link between the experience of multiple traumatic events and the severity of posttraumatic stress disorder (PTSD) symptoms.The aforementioned relationship is mediated through trauma-related general cognitions and situational expectations.The results provide further evidence for the cognitive model of PTSD and further specify it by considering different types of trauma-related cognitions.

If the discrepancy between expectations and actual information is too large, expectation change decreases - A replication study.

BACKGROUND AND OBJECTIVES: Mental disorders have been related to aberrations in using novel positive information to revise established negative beliefs. Previous research used to make a binary distinction between belief-confirming vs. -disconfirming information, but recently it has been examined how varying levels of positive information is used to update beliefs. The present study aimed to replicate a recent finding suggesting that positive information that deviates to a large extent from people's prior expectations raises doubts about the credibility of new information and therefore hardly leads to change in expectations. METHODS: In a heterogenous sample (N = 144), participants were provided with slightly positive, moderately positive, or extremely positive information in relation to their prior expectations about other people's behaviour. RESULTS: Replicating previous research, the present study found that expectation change was greatest for moderately positive information. It also provided evidence for a possible mechanism underlying the inverse U-shaped relationship between the positivity of new information and change in expectations: Extremely positive information was devalued through defensive cognitive strategies, referred to as cognitive immunisation. LIMITATIONS: Unlike previous research, the belief update task used in this study did not show any association with depressive symptoms, so it is questionable how suitable it is to study biased belief updating in depression. CONCLUSIONS: Unlike traditional learning models, the present results suggest a tipping point above which the discrepancy between expectation and outcome is suspiciously large, so that the degree of expectation change decreases.

How the integration of normal medical test results can be improved in patients with somatoform disorders-An experimental study.

BACKGROUND: We examined whether the difficulties of patients with somatoform disorders (SFDs) in integrating medical reassurance can be altered by preventing patients from devaluing reassuring information through defensive cognitive strategies. METHOD: Patients with SFD (n = 60), patients with major depression (n = 32), and healthy volunteers (n = 37) watched a videotaped doctor's report, which provided medical reassurance for gastroenterological complaints. Subsequently, participants were asked about their perception of the report. In the SFD sample, patients' appraisal of the reassuring was experimentally modulated: In one condition, doubts about the validity of the doctor's diagnostic assessment were triggered; in another condition, the devaluation of medical reassurance was blocked through underscoring the validity of the doctor's diagnostic assessment; and a control condition received no manipulation. RESULTS: As evident on all outcome variables, patients with SFD had more difficulty integrating medical reassurance than depressed and healthy people. Within the SFD sample, participants from the experimental condition blocking the devaluation of medical reassurance rated the likelihood of an undetected serious disease to be significantly lower than the other two conditions. They also reported less emotional concern and a lower desire to seek the opinion of another doctor. CONCLUSIONS: By comparing patients with SFD to both a healthy and a clinical control group, the current study suggests that the difficulty in processing reassuring medical information is a specific psychopathological feature of SFD. Furthermore, our results suggest that the integration of medical reassurance can be improved by preventing patients from devaluing reassuring information through dismissive cognitive strategies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Doctors Speak: A Qualitative Study of Physicians' Prescribing of Antidepressants in Functional Bowel Disorders.

Tricyclic antidepressants (TCAs) are frequently prescribed for chronic functional pain disorders. Although the mechanism of action targets pain perception, treating patients with TCAs for disorders conceptualized as "functional" can promote stigmatization in these patients because it hints at psychological dimensions of the disorder. The goal of this study was to understand how physicians prescribe TCAs in the face of this challenge. We interviewed eleven gastroenterologists in tertiary care clinics specializing in functional gastrointestinal disorders, such as irritable bowel syndrome. We found that the physicians interviewed (1) were aware of the stigma attached to taking antidepressants for a medical condition, (2) emphasized biological, as opposed to psychological, mechanisms of action, (3) while focusing on biological mechanisms, they nevertheless prescribed TCAs in a way that is highly attentive to the psychology of expectations, making specific efforts to adjust patients' expectations to be realistic and to reframe information that would be discouraging and (4) asked patients to persist in taking TCAs despite common and, at times, uncomfortable side effects. In this context of shared decision making, physicians described nuanced understanding and behaviours necessary for treating the complexity of functional disorders and emphasized the importance of a strong patient-provider relationship.

How negative mood hinders belief updating in depression: results from two experimental studies.

BACKGROUND: In two experimental studies, we tested the hypothesis that negative mood would hinder the revision of negative beliefs in response to unexpectedly positive information in depression, whereas positive mood was expected to enhance belief updating. METHODS: In study 1 (N = 101), we used a subclinical sample to compare the film-based induction of sad v. happy mood with a distraction control group. Subsequently, participants underwent a well-established paradigm to examine intra-individual changes in performance-related expectations after unexpectedly positive performance feedback. In study 2, we applied the belief-updating task from study 1 to an inpatient sample (N = 81) and induced sad v. happy mood via film-clips v. recall of autobiographic events. RESULTS: The results of study 1 showed no significant group differences in belief updating; the severity of depressive symptoms was a negative predictor of belief revision, though, and there was a non-significant trend suggesting that the presence of sad mood hindered belief updating in the subgroup of participants with a diagnosed depressive episode. Study 2 revealed that participants updated their expectations significantly less in line with positive feedback when they underwent the induction of negative mood prior to feedback, relative to positive mood. CONCLUSIONS: By indicating that the presence of negative mood can hinder the revision of negative beliefs in clinically depressed people, our findings suggest that learning from new experiences can be hampered if state negative mood is activated. Thus, interventions relying on learning from novel positive experiences should aim at reducing state negative mood in depression.

Assessing Dysfunctional Expectations in Posttraumatic Stress Disorder: Development and Validation of the Posttraumatic Expectations Scale (PTES).

Dysfunctional expectations are a particularly important subset of cognitions that influence the development and maintenance of various mental disorders. This study aimed to develop and validate a scale to assess dysfunctional expectations in posttraumatic stress disorder (PTSD), the "Posttraumatic Expectations Scale" (PTES). In a cross-sectional study, 70 PTSD patients completed the PTES, the Posttraumatic Cognitions Inventory (PTCI), as well as measures of the severity of symptoms of PTSD and depression. The results show that the PTES has excellent internal consistency and correlates significantly with the PTCI and PTSD symptom severity. A regression analysis revealed that the PTES explained variance of PTSD symptom severity above the PTCI, supporting the incremental validity of the PTES. While the original version of the PTES comprises 81 items, short scales were constructed using the BISCUIT (best items scales that are cross-validated, unit-weighted, informative and transparent) method. The current findings provide preliminary psychometric evidence suggesting that the PTES is an internally consistent and valid novel self-report measure in patients with PTSD. However, conclusions about the psychometric properties of the PTES are limited because of the absence of criterion-related validity, factor structure evidence, variability over time/response to intervention, and test-retest reliability. Future research should use the PTES in large-scale longitudinal studies to address these aspects to further validate the scale.

Differential associations of positive and negative expectations with depressive symptoms.

BACKGROUND: Recent research suggests that dysfunctional expectations are a particularly important subtype of cognitions in depression. However, it is unclear whether depressive symptoms are related to the presence of negative expectations, the absence of positive expectations, or both. METHODS: Using hierarchical linear regression analyses, the present study examined the predictive value of positive situation-specific expectations, negative situation-specific expectations, dispositional optimism, and dysfunctional attitudes for depressive symptoms 8 weeks later in a nonclinical sample (N = 157). It also examined whether the relationship between dispositional optimism and dysfunctional attitudes with depressive symptoms is mediated through situational expectations. RESULTS: Cross-sectionally, depressive symptoms were more strongly associated with the presence of negative expectations than with the absence of positive expectations. In the longitudinal and mediation analyses, none of the cognitive variables had significant associations with depressive symptoms at follow-up beyond the strong influence of baseline depressive symptoms. CONCLUSIONS: The presence of negative expectations was cross-sectionally more strongly associated with depressive symptoms than a lack of positive expectations, presumably due to higher variability in negative expectations in this nonclinical sample. The longitudinal and mediation analyses failed to find significant incremental effects of any of the cognitive variables because baseline depression explained the largest proportion of variance.

Testing Bayesian models of belief updating in the context of depressive symptomatology.

OBJECTIVES: Predictive processing approaches to belief updating in depression propose that depression is related to more negative and more precise priors. Also, belief updating is assumed be negatively biased in comparison to normative Bayesian updating. There is a lack of efficient methods to mathematically model belief updating in depression. METHODS: We validated a novel performance belief updating paradigm in a nonclinical sample (N = 133). Participants repeatedly participated in a non-self-related emotion recognition task and received false feedback. Effects of the feedback manipulation and differences in depressive symptoms on belief updating were analysed in Bayesian multilevel analyses. RESULTS: Beliefs were successfully manipulated through the feedback provided. Depressive symptoms were associated with more negative updating than normative Bayesian updating but results were influenced by few cases. No evidence of biased change in beliefs or overly precise priors was found. Depressive symptoms were associated with more negative updating of generalised performance beliefs. CONCLUSIONS: There was cautious support for negatively biased belief updating associated with depressive symptoms, especially for generalised beliefs. The content of the task may not be self-relevant enough to cause strong biases. Further explication of Bayesian models of depression and replication in clinical samples is needed.

Can placebos reduce intrusive memories?

After traumatic experiences, intrusive memories can flash back and evoke significant distress. Here, we investigated whether the frequency and severity of intrusions can be reduced by the provision of placebo. After the (online) exposure to the trauma-film paradigm, healthy participants (N = 112) received deceptive placebo (DP), open-label placebo (OLP), or no treatment. In the DP group, participants were led to believe to receive a dopamine-modulating drug, which was supposed to disrupt the consolidation of traumatic memories, although they in fact received the same placebo tablets as the OLP group for one week. The results show that the groups did not differ in the frequency of intrusive memories after one week. However, participants receiving OLP reported a significantly reduced intensity of intrusions as compared to DP. Across groups, negative expectations about the intensity and controllability of intrusions were associated with a higher frequency of intrusions, higher distress, higher burden, and more negative appraisal. The results suggest that expectations play an important role in the emergence of intrusive memories and that some of the disabling aspects of intrusive memories can be reduced by placebo. This may carry clinical potential because placebos are an accessible, cost-effective intervention to reduce the risk of intrusive memories.

Oversampled and undersolved: Depressive rumination from an active inference perspective.

Rumination is a widely recognized cognitive deviation in depression. Despite the recognition, researchers have struggled to explain why patients cannot disengage from the process, although it depresses their mood and fails to lead to effective problem-solving. We rethink rumination as repetitive but unsuccessful problem-solving attempts. Appealing to an active inference account, we suggest that adaptive problem-solving is based on the generation, evaluation, and performance of candidate policies that increase an organism's knowledge of its environment. We argue that the problem-solving process is distorted during rumination. Specifically, rumination is understood as engaging in excessive yet unsuccessful oversampling of policy candidates that do not resolve uncertainty. Because candidates are sampled from policies that were selected in states resembling one's current state, "bad" starting points (e.g., depressed mood, physical inactivity) make the problem-solving process vulnerable for generating a ruminative "halting problem". This problem leads to high opportunity costs, learned helplessness and diminished overt behavior. Besides reviewing evidence for the conceptual paths of this model, we discuss its neurophysiological correlates and point towards clinical implications.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder.

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Remotely Provided Open-Label Placebo Reduces Frequency of and Impairment by Allergic Symptoms.

OBJECTIVE: Placebos being prescribed with full honesty and disclosure (i.e., open-label placebo [OLP]) have been shown to reduce symptom burden in a variety of conditions. With regard to allergic rhinitis, previous research provided inconclusive evidence for the effects of OLP, possibly related to a separate focus on either symptom severity or symptom frequency. Overcoming this limitation of previous research, the present study aimed to examine the effects of OLP on both the severity and frequency of allergic symptoms. METHODS: In a randomized-controlled trial, patients with allergic rhinitis ( N = 74) were randomized to OLP or treatment as usual (TAU). Because of the COVID-19 pandemic, OLP was administered remotely in a virtual clinical encounter. Participants took placebo tablets for 14 days. The primary outcomes were the severity and frequency of allergic symptoms. The secondary end point was allergy-related impairment. RESULTS: OLP did not significantly improve symptom severity over TAU ( F (1,71) = 3.280, p = .074, η2 = 0.044) but did reduce symptom frequency ( F (1,71) = 7.272, p = .009, η2 = 0.093) and allergy-related impairment more than TAU ( F (1,71) = 6.445, p = .013, η2 = 0.083), reflecting medium to large effects. The use of other antiallergic medication did not influence the results. CONCLUSIONS: Although OLP was able to lower the frequency of allergic symptoms and allergy-related impairment substantially, its effects on symptom severity were weaker. The remote provision of OLP suggests that physical contact between patients and providers might not be necessary for OLP to work.