The generalization of threat beliefs to novel safety stimuli induced by safety behaviors.

Safety behaviors are responses that can reduce or even prevent an expected threat. Moreover, empirical studies have shown that using safety behaviors to a learnt safety stimulus can induce threat beliefs to it. No research so far has examined whether threat beliefs induced this way generalize to other novel stimuli related to the safety stimulus. Using a fear and avoidance conditioning model, the current study (n=116) examined whether threat beliefs induced by safety behaviors generalize to other novel generalization stimuli (GSs). Participants first acquired safety behaviors to a threat predicting conditioned stimulus (CSthreat). Safety behaviors could then be performed in response to one safe stimulus (CSsafeShift) but not to another (CSsafe). In a following generalization test, participants showed a significant but small increase in threat expectancies to GSs related to CSsafeShift compared to GSs related to CSsafe. Interestingly, the degree of safety behaviors used to the CSsafeShift predicted the subsequent increase in generalized threat expectancies, and this link was elevated in trait anxious individuals. The findings suggest that threat beliefs induced by unnecessary safety behaviors generalize to other related stimuli. This study provides a potential explanation for the root of threat belief acquisition to a wide range of stimuli or situations.

Positive mood induction does not reduce return of fear: A virtual reality exposure study for public speaking anxiety.

Previous laboratory work has shown that induction of positive mood prior to fear extinction decreases the negative valence of the conditional stimulus (CS) and reduces reinstatement of fear. Before translating these insights to clinical practice, it is important to test this strategy in anxious individuals. Students with a high fear of public speaking (N = 62) were randomized to either a positive mood induction, a negative mood induction, or no induction control group. All participants performed two weekly sessions of virtual reality exposure and a 1-week follow-up test including a spontaneous recovery test and reinstatement test after a social rejection (unconditional stimulus). We used self-reported fear measures and skin conductance responses. We expected that the positive group, compared to the other groups, would evaluate the CS (i.e., speaking in front of an audience) as less negative following exposure and would show less spontaneous recovery and reinstatement of fear following a social rejection. Although mood was successfully manipulated, there were no group differences in CS valence following exposure. In all conditions, VR exposure successfully reduced public speaking fear, and these effects were stable at follow-up. In contrast with expectations, the positive group showed more spontaneous recovery of CS negative valence than the negative group. To conclude, we found no evidence that positive mood induction prior to exposure optimizes exposure effects for anxious individuals.

Mental threat rehearsal increases fear generalization.

BACKGROUND AND OBJECTIVES: Fear generalization to harmless stimuli characterizes anxiety-related disorders, but much remains unknown about its determinants. Based on studies showing that mental imagery of threat can increase conditioned fear responding, we tested whether it also facilitates fear generalization, and whether threat inflation moderates this effect. METHODS: In a fear conditioning study, 120 participants first completed an acquisition phase, in which one of two pictures was followed by an aversive sound (human scream). Then, the sound was presented 11 times at an increasing (threat inflation) or constant volume (no threat inflation). Finally, a generalization stimulus was presented, and some participants were asked to imagine the last sound (threat rehearsal) and others were not (no threat rehearsal). RESULTS: Bayesian informative hypotheses tests indicated that imagery-based threat rehearsal increased generalization of threat expectancy, and, combined with threat inflation, it also resulted in stronger generalized distress. LIMITATIONS: due to the absence of a test phase, it is unclear whether our effects would transfer to other GSs and whether they would persist beyond the manipulation phase. CONCLUSIONS: Mental imagery of threat may put individuals at risk for fear generalization. Future studies should examine whether modulating imagery may prevent clinical anxiety.

The effectiveness of two novel approaches to prevent intrusions: A pilot study comparing Tetris_dualtask and imagery rescripting to control.

BACKGROUND AND OBJECTIVES: Post-traumatic stress disorder (PTSD) is a global health problem. Although effective treatments for it exist, early interventions that prevent PTSD from developing are lacking. The aim of this pilot analogue trauma study was to compare the effects of two potential early intervention strategies, namely Tetris_dualtask and imagery rescripting (IR) to a no-intervention control group on intrusion frequency and the vividness and emotionality of aversive film memory. METHODS: Sixty healthy students were subjected to the trauma film paradigm and randomly allocated to either: Tetris_dualtask, IR or no-intervention. Main outcomes were the number of film-related intrusions at one week and vividness and emotionality ratings of the most aversive film memory. Secondary outcomes were PTSD-like symptoms, intrusion intensity, and explicit film memory. RESULTS: The Tetris_dualtask group reported significant fewer intrusions compared to the no-intervention group; whereas the IR group did not. No effect was found on vividness and emotionality ratings, PTSD-like symptoms, intrusion intensity, and explicit memory. LIMITATIONS: The sample size was small, and analogue trauma in healthy individuals was examined, thus generalizability may be limited. Also, to increase comparability between interventions, the duration of Tetris_dualtask and IR was standardized. As a result, the IR intervention was shorter compared to other studies, which might have decreased its efficacy. CONCLUSIONS: The results of this pilot study suggest that playing Tetris during retrieval of traumatic images, might hold potential as an early intervention strategy to reduce intrusions in the early aftermath of trauma and adversity. However, future large-scale replication research is needed.

The degree of safety behaviors to a safety stimulus predicts development of threat beliefs.

Safety behaviors are behavioral responses that aim to prevent or minimize an imminent threat when confronting a feared stimulus. Despite its adaptive purpose, preliminary evidence suggests that unnecessary safety behaviors to a safety stimulus induce threat beliefs to it. By allowing participants to engage in safety behaviors dimensionally, this study tested whether the degree of safety behaviors to a safety stimulus predicts the subsequent level of threat expectancies to it. To this end, participants first acquired safety behaviors to a threat-related stimulus (A). Safety behaviors then became available only for one safety stimulus (C), but not to another safety stimulus (B). After engaging in safety behaviors to C, participants exhibited greater threat expectancies to C compared to B, albeit with a small effect size. Importantly, the degree of safety behaviors predicted an increase in threat expectancies. The current findings suggest that safety behaviors to safety stimuli are linked to the development of threat beliefs.

Context reexposure to bolster contextual dependency of emotional episodic memory.

Contextual overgeneralization of emotional memory is a core aspect of anxiety disorders. Identifying methods to enhance contextual dependency of emotional memory is therefore of significant clinical interest. Animal research points to a promising approach: reexposure to the context in which fear is acquired reduces generalization to other contexts. However, the exact conditions for this effect are unknown, complicating translation to effective interventions. Most notably, exposure to a context that resembles-but is not identical to-the learning context may diminish contextual dependency of memory by integration of additional contextual cues. Here, we therefore assessed in a large-scale study (N = 180) whether context reexposure enhances contextual dependency of emotional episodic memory whereas exposure to a similar context impairs it. We also tested whether relatively strong memory retrieval during context (re)exposure amplifies these effects. We replicated prior research showing that correct recognition depends on context and contextual dependency is lower for emotional than neutral memories. However, exposure to the encoding context or a similar context did not affect contextual dependency of memory, and retrieval strength did not interact with such effects. Thorough insight into factors underlying the effects of context (re)exposure on contextual dependency seems key to eventually attain a memory recontextualization intervention.

Positive future thinking without task-relevance increases anxiety and frontal stress regulation.

Negative anticipatory biases can affect the way we interpret and subjectively experience events. Through its role in emotion regulation, positive future thinking may provide an accessible way to attenuate these biases. However, it is unclear whether positive future thinking works ubiquitously, independent of contextual relevance. Here, we used a positive future thinking intervention (task-relevant; task-irrelevant and control condition) prior to a social stress task to adapt the way this task was experienced. We assessed subjective and objective stress measures and also recorded resting state electroencephalography (EEG) to assess intervention related differences in the level of frontal delta-beta coupling, which is considered a neurobiological substrate of stress regulation. Results show that the intervention reduced subjective stress and anxiety, and increased social fixation behavior and task performance, but only if future thinking was task-relevant. Paradoxically, task-irrelevant positive future thoughts enhanced negative perceptual biases and stress reactivity. This increase in stress reactivity was corroborated by elevated levels of frontal delta-beta coupling during event anticipation, which suggests an increased demand for stress regulation. Together, these findings show that positive future thinking can mitigate the negative emotional, behavioral and neurobiological consequences of a stressful event, but that it should not be applied indiscriminately.

Managing Fear During Pandemics: Risks and Opportunities.

Fear is an emotion triggered by the perception of danger and motivates safety behaviors. Within the context of the COVID-19 pandemic, there were ample danger cues (e.g., images of patients on ventilators) and a high need for people to use appropriate safety behaviors (e.g., social distancing). Given this central role of fear within the context of a pandemic, it is important to review some of the emerging findings and lessons learned during the COVID-19 pandemic and their implications for managing fear. We highlight factors that determine fear (i.e., proximity, predictability, and controllability) and review several adaptive and maladaptive consequences of fear of COVID-19 (e.g., following governmental health policies and panic buying). Finally, we provide directions for future research and make policy recommendations that can promote adequate health behaviors and limit the negative consequences of fear during pandemics.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE).

BACKGROUND: Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness. METHODS: A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment. DISCUSSION: The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach. TRIAL REGISTRATION: ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.

Perceived stigmatization and fear of negative evaluation: Two distinct pathways to body image dissatisfaction and self-esteem in burn survivors.

OBJECTIVE: Scars resulting from burn injury can pose social and psychological problems that may affect body image and self-esteem. This study aimed to investigate whether burn severity, age and female gender are associated with body image dissatisfaction and self-esteem, through an association with perceived stigmatization and fear or negative evaluation. DESIGN & MAIN OUTCOME MEASURES: Burn survivors (N = 224) completed the Fear of Negative Evaluation scale (FNE) and the Perceived Stigmatization Questionnaire (PSQ) at 3 months post-burn, and the Rosenberg Self-Esteem scale (RSE) and the Satisfaction with Appearance scale (SWAP) at 6 months post-burn. Path analysis was used to test the relationships. RESULTS: Body image dissatisfaction and self-esteem were moderately associated. Burn severity was directly and indirectly associated with body image dissatisfaction through perceived stigmatization. Female gender and age were indirectly associated with body image dissatisfaction though fear of negative evaluation. Age was indirectly associated with both perceived stigmatization and fear of negative evaluation. Perceived stigmatization and fear of negative evaluation were associated with self-esteem through body image dissatisfaction, the first indirectly and the latter both directly and indirectly. CONCLUSIONS: Findings highlight that both burn-specific factors and psychological vulnerability should be taken into account to deal with social challenges that may affect body image and self-esteem after burns.

The effect of imagery rescripting on prospective mental imagery of a feared social situation.

BACKGROUND AND OBJECTIVES: Negative mental imagery appears to play a role in anxiety disorders and can involve aversive memories or anticipated future threats. Modulating aversive memories through imagery rescripting generally reduces negative memory appraisals and associated anxiety. This pre-registered two-day analog study investigated whether imagery rescripting of aversive memories also reduces negative imagery of future threats. METHODS: On Day 1, socially anxious individuals (N = 52) were randomly assigned to imagery rescripting of an aversive memory or progressive relaxation (control condition). Before each intervention, they were asked to imagine a feared social situation that may happen in their future and evaluate this situation. They also rated the aversive memory before and after the intervention phase. The feared future situation was again evaluated at follow-up on Day 2. RESULTS: Unexpectedly, no group differences were found on the main outcome measures. That is, negative memory appraisals reduced after both interventions. Likewise, in both groups, negative details decreased, and positive details increased in prospective mental imagery, and anxiety and avoidance towards the imagined event decreased. On the exploratory measures, the imagery rescripting group showed increased positive appraisals of memory and future threat, and decreased negative future-threat appraisals, compared to the progressive relaxation group. LIMITATIONS: No passive control group was included, so potential time or placebo effects cannot be precluded. CONCLUSIONS: The interventions had similar effects on the main outcomes and influenced mental imagery of future threats. Some differences were found on the exploratory measures that warrant further investigation with a passive control condition.

Stable Anxiety and Depression Trajectories in Late Adolescence for Oral Contraceptive Users.

Background: The use of oral contraceptives (OCs) has been associated with increased incidences of anxiety and depression, for which adolescents seem to be particularly vulnerable. Rather than looking at singular outcomes, we examined whether OC use is associated with depressive and anxiety symptom trajectories from early adolescence into early adulthood. Materials and Methods: Data from 178 girls were drawn from the Research on Adolescent Development and Relationships (RADAR-Y) younger cohort study. We used assessments on 9 waves from age 13 until 24. Developmental trajectories of ratings on the Reynolds Adolescent Depression Scale (RADS-2) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) were compared between never and ever users of OCs. Results: Never users showed increases in depressive and anxiety symptoms in late adolescence, whereas OC users showed a stable level of symptoms throughout adolescence. This effect remained after adjusting for baseline differences between groups in romantic relationships, sexual debut, educational level, smoking, drinking, and drug use. Age of OC use onset did not significantly predict symptom development. Conclusions: OC use in adolescence was related to an altered developmental trajectory of internalizing symptoms, in which OC users did not show an increase in depressive and anxiety symptoms in late adolescence, whereas never users did. The question remains whether this altered symptom trajectory can be considered a protective effect of OC use on psychopathology. Additional research is needed to improve our understanding of the long-term consequences of OC use on mental health.

Future-oriented imagery rescripting facilitates conducting behavioral experiments in social anxiety.

Distressing mental images are common in anxiety disorders and can make it difficult for patients to confront feared situations. This study examined whether imagery rescripting focused on a feared social situation prepares participants to engage in a feared situation. Sixty healthy individuals were asked to formulate a behavioral experiment to test negative beliefs about a social situation they feared. They were assigned to one of two groups: imagery rescripting focused on the feared outcome of the behavioral experiment or no imagery rescripting (i.e., a break). All participants were then asked to complete ratings scales and to conduct the behavioral experiment. Before the behavioral experiment, the imagery rescripting condition, compared to the control condition, showed reduced anticipated probability and severity of the feared outcome, lower anxiety and helplessness levels, and increased willingness to conduct the behavioral experiment. Imagery-based interventions focused on feared outcomes seem promising to prepare anxious individuals to engage in treatment.

Safety behaviors toward innocuous stimuli can maintain or increase threat beliefs.

Safety behaviors can prevent or minimize a feared outcome. However, in relatively safe situations, they may be less adaptive, presumably because people will misattribute safety to these behaviors. This research aimed to investigate whether safety behaviors in safe situations can lead to increased threat beliefs. In Study 1, we aimed to replicate a fear conditioning study (N = 68 students) in which the experimental, but not the control group, received the opportunity to perform safety behavior to an innocuous stimulus. From before to after the availability of the safety behavior, threat beliefs persisted in the experimental group, while they decreased in the control group. In Study 2, we examined whether threat beliefs had actually increased for some individuals in the experimental group, using a multi-dataset latent class analysis on data from Study 1 and two earlier studies (N = 213). Results showed that about a quarter of individuals who performed safety behavior toward the innocuous stimulus showed increased threat expectancy to this cue, while virtually nobody in the control group exhibited an increase. Taken together, safety behavior in relatively safe situations may have maladaptive effects as it generally maintains and sometimes even increases threat beliefs.

The relationship between Intolerance of Uncertainty and conditioned fear acquisition: Evidence from a large sample.

Despite being considered a valid model for the etiology of anxiety disorders, the fear conditioning paradigm does not always show clear correlations with anxious personality traits that constitute risk factors for the development of anxiety disorders. This may in part due to error variance and the fact that fear conditioning studies are typically underpowered to investigate inter-individual differences. In the current study, we focus on the relationship between conditioned fear acquisition and Intolerance of Uncertainty (IU). In a re-analysis of a large previous study (N = 120), which was conducted using a healthy student sample and a partial reinforcement procedure (75%) with words as Conditioned Stimuli (CSs), the relationship between IU and several outcome measures (i.e., fear ratings, expectancy ratings, skin conductance responses, and startle responses) during fear acquisition was examined. We find that IU is positively related to fear ratings towards the CS+ (r = 0.29), even when controlling for the shared variance with trait anxiety. Furthermore, we find a subtle relationship between IU and startle responses to the CS- (r = -0.23), though this correlation did not survive correction for the shared variance with trait anxiety. Taken together, we replicate some of the correlations previously reported in the literature. However, we recommend that future studies employ even larger samples and more advanced statistical techniques such as structural equation modelling to investigate the correlations between fear acquisition indices and anxious traits in a fine-grained manner.

A meta-analysis of conditioned fear generalization in anxiety-related disorders.

Generalization of conditioned fear is adaptive in some situations but maladaptive when fear excessively generalizes to innocuous stimuli with incidental resemblance to a genuine threat cue. Recently, empirical interest in fear generalization as a transdiagnostic explanatory mechanism underlying anxiety-related disorders has accelerated. As there are now several studies of fear generalization across multiple types of anxiety-related disorders, the authors conducted a meta-analysis of studies reporting behavioral measures (subjective ratings and psychophysiological indices) of fear generalization in anxiety-related disorder vs. comparison groups. We conducted systematic searches of electronic databases (conducted from January-October 2020) for fear generalization studies involving anxiety-related disorder groups or subclinical analog groups. A total of 300 records were full-text screened and two unpublished datasets were obtained, yielding 16 studies reporting behavioral fear generalization measures. Random-effects meta-analytic models and meta-regressions were applied to the identified data. Fear generalization was significantly heightened in anxiety-related disorder participants (N = 439) relative to comparison participants (N = 428). We did not identify any significant clinical, sample, or methodological moderators. Heightened fear generalization is quantitatively supported as distinguishing anxiety-related disorder groups from comparison groups. Evidence suggests this effect is transdiagnostic, relatively robust to experimental or sample parameters, and that generalization paradigms are a well-supported framework for neurobehavioral investigations of learning and emotion in anxiety-related disorders. We discuss these findings in the context of prior fear conditioning meta-analyses, past neuroimaging investigations of fear generalization in anxiety-related disorders, and future directions and challenges for the field.

Future-Oriented Positive Mental Imagery Reduces Anxiety for Exposure to Public Speaking.

Exposure therapy is the recommended treatment for anxiety disorders, but many anxious individuals are unwilling to expose themselves to feared situations. Episodic simulation of future situations contributes to adaptive emotion regulation and motivates behavior. This study investigated whether future-oriented positive mental imagery reduces anticipatory anxiety and distress during exposure, and increases exposure willingness and duration. Forty-three individuals with moderate public speaking anxiety were randomized to a standardized positive mental imagery exercise about future public speaking or no-task. All participants were then asked to present in a virtual reality environment. Anticipatory anxiety reduced in the positive mental imagery group, but not in the control group. Additionally, the positive mental imagery group reported lower distress during exposure than the control group, but groups did not differ in exposure willingness. Due to limited variance, effects on exposure duration could not be tested. Future-oriented positive mental imagery is promising to prepare individuals for exposure to previously avoided situations.

Posttraumatic stress symptoms and interpersonal processes in burn survivors and their partners.

Background: A burn event can elicit symptoms of posttraumatic stress disorder (PTSD) in survivors and their partners and may impact the way these couple members interact with each other. They may try to protect each other from further emotional distress by avoiding talking about the burn event, but they may also show concern towards each other.Objective: The aim of this study was to investigate bidirectional relationships between survivor's and partner's PTSD symptoms and two interpersonal processes: partner-oriented 'self-regulation', which is avoidance-oriented, and 'expressed concern', which is approach-oriented.Method: In this longitudinal multi-centre study, 119 burn survivors and their partners participated. Measures of PTSD symptoms, self-regulation, and expressed concern were administered in the acute phase following the burns, and follow-ups took place up to 18 months postburn. Intra- and interpersonal effects were examined in a random intercept cross-lagged panel model. Exploratory effects of burn severity were also investigated.Results: Within individuals, survivor's expressed concern predicted later higher levels of survivor's PTSD symptoms. In their partners, self-regulation and PTSD symptoms reinforced each other in the early phase postburn. Between the two couple members, partner's expressed concern predicted later lower levels of survivor's PTSD symptoms. Exploratory regression analyses showed that burn severity moderated the effect of survivor's self-regulation on survivor's PTSD symptoms, indicating that self-regulation was continuously related to higher levels of PTSD symptoms over time within more severely burned survivors, but not in less severely burned survivors.Conclusion: PTSD symptoms and self-regulation reinforced each other in partners and possibly also in more severely burned survivors. Partner's expressed concern was related to lower levels of survivor's PTSD symptoms, whereas survivor's expressed concern was related to higher levels of survivor's PTSD symptoms. These findings emphasize the importance of screening for and monitoring PTSD symptoms in burn survivors and their partner and of encouraging couple's self-disclosure.

PTSD symptoms in burn survivors and their partners are related to both avoidance- and approach-oriented interpersonal processes.In partners, higher levels of self-regulation were bidirectionally related to higher levels of posttraumatic stress symptoms.Concern expressed by partners may mitigate posttraumatic stress symptoms in burn survivors.

Conceptual fear generalization gradients and their relationship with anxious traits: Results from a Registered Report.

A hallmark symptom of fear and anxiety disorder is generalization of fear to essentially innocuous stimuli and situations. Such generalization can occur through both perceptual and conceptually similarities. Recent studies indicate that perceptual generalization is inflated in anxiety patients and individuals prone to develop anxiety disorders, suggesting that perceptual generalization may be involved in the etiology of anxiety disorders. In the current Registered Report, we wanted to address whether conceptual generalization is potentially implicated in the development of anxiety disorders as well. Therefore, we used a novel paradigm in which the Dutch word mini [tiny] or enorm [enormous] was paired with an electric shock and assessed fear to the conceptually related words klein [small], medium [medium], and groot [large]. The sample (N = 120) consisted of healthy university students. As hypothesized, we observed clear conceptual fear generalization gradients using both self-report and psychophysiological measures. However, in contrast to our expectations, these conceptual generalization gradients were not correlated with different anxious traits (i.e., trait anxiety, intolerance of uncertainty, and behavioral inhibition). These results show that fear can generalize conceptually along a gradient, without requiring perceptual errors as postulated by traditional models of fear generalization. Instead, our results correspond well with inferential reasoning theories of fear generalization. Additionally, we discuss potential reasons for the absence of the expected correlations between conceptual fear generalization and anxious traits, such as restricted variability in both the generalization task and the sample. We conclude that the paradigm has promise for further research on conceptual fear generalization.