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.

Omitting continuous memory recall from dual-task interventions does not reduce intervention effectiveness.

In Eye Movement Desensitization and Reprocessing a patient recalls a traumatic memory, while simultaneously performing a dual-task (e.g., making horizontal eye movements, tapping a pattern). Earlier lab studies show that increasing the load of a dual-task -and leaving fewer resources for memory recall-results in larger decreases in memory vividness and emotionality compared to control conditions. Therefore, we investigated whether it is necessary to continuously and deliberately recall the memory next to performing high taxing dual-tasks. In two online experiments, participants (N = 172, N = 198) recalled a negative autobiographical memory and were randomly assigned to (1) Memory Recall + Dual-Tasks, (2) Dual-Tasks Only, or (3) No Intervention Control. The dual-tasks were complex pattern tapping and spelling out loud. Before and after the intervention the memory was rated on vividness, emotionality, and accessibility. High taxing dual-tasks, regardless of whether there was continuous memory recall, resulted in the largest reductions in all dependent variables compared to control. Unexpectedly, there was no evidence that the addition of continuous memory recall added to these reductions. These results suggest that continuous memory recall might not, or only minimally needed for the beneficial effects of the dual-task procedure. We discuss the necessity of memory (re)activation, alternative explanations, and implications for practice.

Linguistic dual tasking reduces emotionality, vividness and credibility of voice memories in voice-hearing individuals: Results from a controlled trial.

Dual taxation of the working memory during recall is an effective strategy to reduce the emotionality and vividness of visual intrusive memories and potentially changes dysfunctional beliefs associated with the memories. This study tested the hypothesis that dual tasking decreases emotionality, vividness and credibility of auditory intrusive images (i.e., memories of auditory hallucinations) with a two-level (time: pre and post; condition: dual tasking and recall only) within-subjects design. Thirty-seven voice-hearing participants selected two negative voice-hearing experiences. They recalled one of these experiences while performing a lingual dual task (i.e., language game on smartphone app) and recalled one memory without a dual task (in counterbalanced order). During the pre-test and post-test, emotionality and vividness of the voice-hearing memories were rated, as well as the credibility of the voice statements. There was a significantly greater decrease in emotionality, vividness and credibility during dual tasking than during recall only. This study provides proof of principle that the salience and credibility of the content of auditory hallucinations can be reduced by dual tasking; the clinical implications are also discussed.

Making eye movements during imaginal exposure leads to short-lived memory effects compared to imaginal exposure alone.

BACKGROUND AND OBJECTIVES: A plethora of eye movement desensitization and reprocessing (EMDR) analogue studies has shown that, in the short term, making eye movements (EM) during brief imaginal exposure ("recall + EM") blurs memories more than just imaginal exposure ("recall only"). Yet, results of the few studies that included a follow-up test are inconsistent. We improved this paradigm's ecological validity by including an extended intervention phase and multiple assessments per phase. We hypothesized that recall + EM results in larger immediate and 24 h reductions in memory vividness, negative valence, and distress than recall alone. We explored the persistence of the effects, as well as the predictive value of memory characteristics and individual differences. METHODS: Students (N = 100) selected a negative autobiographical memory and were randomized to recall + EM or recall alone; both interventions lasted 32 intervals of 24s. During the interventions they rated the memory after every four intervals. RESULTS: After 4 × 24s intervention, recall + EM resulted in memory deflation, while recall only caused memory inflation. After the full intervention (i.e., 32 × 24s), both conditions resulted in immediate and 24 h reductions on all outcome measures. Crucially, memory effects in the recall + EM condition partially relapsed 24 h later, while the effects in the recall only condition persisted. Change patterns were hardly explained by predictive variables. LIMITATIONS: We used a non-clinical sample; replication in clinical samples is warranted. CONCLUSION: Making EM during imaginal exposure leads to short-lived effects compared to imaginal exposure alone. However, EM may offer a response aid for those who avoid imaginal exposure.

Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis.

Importance: Cognitive behavioral therapy is recommended for anxiety-related disorders, but evidence for its long-term outcome is limited. Objective: This systematic review and meta-analysis aimed to assess the long-term outcomes after cognitive behavioral therapy (compared with care as usual, relaxation, psychoeducation, pill placebo, supportive therapy, or waiting list) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). Data Sources: English-language publications were identified from PubMed, PsycINFO, Embase, Cochrane, OpenGrey (1980 to January 2019), and recent reviews. The search strategy included a combination of terms associated with anxiety disorders (eg, panic or phobi*) and study design (eg, clinical trial or randomized controlled trial). Study Selection: Randomized clinical trials on posttreatment and at least 1-month follow-up effects of cognitive behavioral therapy compared with control conditions among adults with generalized anxiety disorder, panic disorder with or without agoraphobia, social anxiety disorder, specific phobia, PTSD, or OCD. Data Extraction and Synthesis: Researchers independently screened records, extracted statistics, and assessed study quality. Data were pooled using a random-effects model. Main Outcomes and Measures: Hedges g was calculated for anxiety symptoms immediately after treatment and at 1 to 6 months, 6 to 12 months, and 12 months or more after treatment completion. Results: Of 69 randomized clinical trials (4118 outpatients) that were mainly of low quality, cognitive behavioral therapy compared with control conditions was associated with improved outcomes after treatment completion and at 1 to 6 months and at 6 to 12 months of follow-up for a generalized anxiety disorder (Hedges g, 0.07-0.40), panic disorder with or without agoraphobia (Hedges g, 0.22-0.35), social anxiety disorder (Hedges g, 0.34-0.60), specific phobia (Hedges g, 0.49-0.72), PTSD (Hedges g, 0.59-0.72), and OCD (Hedges g, 0.70-0.85). At a follow-up of 12 months or more, these associations were still significant for generalized anxiety disorder (Hedges g, 0.22; number of studies [k] = 10), social anxiety disorder (Hedges g, 0.42; k = 3), and PTSD (Hedges g, 0.84; k = 5), but not for panic disorder with or without agoraphobia (k = 5) and could not be calculated for specific phobia (k = 1) and OCD (k = 0). Relapse rates after 3 to 12 months were 0% to 14% but were reported in only 6 randomized clinical trials (predominantly for panic disorder with or without agoraphobia). Conclusions and Relevance: The findings of this meta-analysis suggest that cognitive behavioral therapy for anxiety-related disorders is associated with improved outcomes compared with control conditions until 12 months after treatment completion. At a follow-up of 12 months or more, effects were small to medium for generalized anxiety disorder and social anxiety disorder, large for PTSD, and not significant or not available for other disorders. High-quality randomized clinical trials with 12 months or more of follow-up and reported relapse rates are needed.

The effects of dual-tasks on intrusive memories following analogue trauma.

Patients with post-traumatic stress disorder frequently and involuntarily experience intrusions, which are strongly linked to the trauma hotspot. Voluntary memory characteristics (i.e., vividness and unpleasantness) of this hotspot can be reduced by performing a dual-task, such as making horizontal eye movements, which is frequently used in Eye Movement Desensitization and Reprocessing. We tested whether such dual-task interventions would also reduce involuntary memory (i.e., intrusions). Moreover, we examined if changes in hotspot vividness and unpleasantness predicted intrusion frequency. Additionally, we examined whether the effects were dependent on dual-task modality. We tested this in three experiments. Participants watched a trauma film and performed one of the interventions 10-min post-film (1) Recall + Eye movements, (2) Recall + Counting, or (3) No-Task Control. Before and after the intervention, participants rated the hotspot vividness and unpleasantness. They recorded intrusive memories about the film in a diary for a week. Unexpectedly, we found that hotspot vividness and unpleasantness ratings were not affected by the intervention. However, the prolonged (experiment 2), but not standard (experiment 1), dual-task interventions resulted in a lower number of intrusions, regardless of modality. However, this effect was not replicated in experiment 3. We discuss potential explanations and present suggestions for future research.

On EMDR: Measuring the working memory taxation of various types of eye (non-)movement conditions.

BACKGROUND AND OBJECTIVE: A recent, large randomized controlled trial employing different forms of eye (non-)movements in eye movement desensitization and reprocessing (EMDR) showed that fixating the eyes either on a therapist's moving or non-moving hand led to equal reductions in symptoms of post-traumatic stress disorder (PTSD). However, numerous EMDR lab analogue studies found that eye movements produce larger memory effects than eyes stationary. These beneficial effects are typically explained by differences in working memory (WM) taxation. We tested the degree of WM taxation of several eye (non-)movement conditions used in the clinical trial. METHODS: All participants (N = 40) performed: (1) eyes moving by following the experimenter's moving finger, (2) eyes fixed on the experimenter's stationary finger, (3) eyes closed, or (4) looking unfocused into the room. Simultaneously they performed a simple reaction time task. Reaction times are an objective index of the extent to which different dual attention tasks tax WM. RESULTS: Eyes moving is more taxing than eyes fixed, while eyes fixed did not differ from eyes unfocused. All conditions were more taxing than eyes closed. LIMITATIONS: We studied WM taxation in a laboratory setting; no clinical interventions were applied. CONCLUSIONS: In line with previous lab studies, making eye movements was more taxing than eyes fixed. We discuss why this effect was not observed for reductions in PTSD symptoms in the clinical trial (e.g., differences in dependent variables, sample population, and intervention duration). For more comprehensive future insights, we recommend integration of mechanistically focused lab analogue studies and patient-oriented clinical studies.

Changing negative autobiographical memories in the lab: a comparison of three eye-movement tasks.

There is strong evidence that executing eye-movement (EM) tasks that load working memory (WM) while thinking of an emotional memory reduces the emotionality and vividness of this memory. According to WM theory, EM tasks that load WM more should be more effective to devalue emotional memories. In this study, we compared three EM tasks: dot tracking, letter identification, and a combination of dot tracking and letter identification. First, participants completed a reaction time (RT) task to assess the WM load of the three EM tasks relative to a control task (viewing a black screen). Then, participants were asked to think of a negative autobiographical memory while executing one of these EM tasks and asked to recall another negative memory while executing the control task. Before and after each task, participants rated emotionality and vividness of the memory. All EM tasks slowed down RTs relative to the control task, and the letter identification task induced the largest RTs. Reductions of vividness relative to the control task, however, were comparable across the EM tasks, and there were no reliable reductions of emotionality. We discuss these findings in light of the WM theory and alternative theories for the effects of dual-task interventions.

Modification of episodic memories by novel learning: a failed replication study.

Background: After reactivation, memories can become unstable and sensitive to modification before they are restored into long-term memory. Using behavioural manipulations, reactivated memories may be disrupted via the mechanism of interference (i.e. novel learning). In a laboratory study, Wichert et al. (2013a) showed that new learning after reactivation changed episodic memory, while new learning alone or reactivation alone did not. Objective: Given the potential clinical application of such a procedure in trauma-focused psychological treatments, such as CBT or EMDR, the aim of this study was to replicate Wichert et al. Method: On Day 1, participants (N = 96) viewed and recalled a series of emotional and non-emotional pictures. Then, participants were randomized to one of four groups. One week later, on Day 8, Group 1 reactivated the previously learned pictures and learned new pictures. To control for specific effects of reactivation or new learning, Group 2 only reactivated the previously learned pictures, and Group 3 only learned new pictures. Group 4 received no reactivation and no new learning. On Day 9, all groups indicated for each picture out of a series whether they had seen it on Day 1. Results: The data were analysed using Bayesian hypothesis testing, which allows for quantifying the evidence in favour of the alternative and the null hypothesis. In general, results showed that Group 1 recognized fewer pictures from Day 1 compared to Groups 2 and 4 on Day 9. However, the expected difference between new learning following reactivation (i.e. Group 1) and new learning alone (i.e. Group 3) was not substantially supported by the data for any of our dependent measures. Conclusions: We replicated some of the findings by Wichert et al., but did not find substantial support for the critical difference between new learning following reactivation and new learning alone.

Intervention strength does not differentially affect memory reconsolidation of strong memories.

Recently, it has become clear that retrieval (i.e., reactivation) of consolidated memories may return these memories into a labile state before they are restored into long-term memory ('reconsolidation'). Using behavioral manipulations, reactivated memories can be disrupted via the mechanism of novel learning. In the present study, we investigated whether changing a strong memory during reconsolidation depends on the strength of novel learning. To test this, participants (N=144) in six groups acquired a relatively strong memory on Day 1 by viewing and recalling a series of pictures three times. On Day 8, these pictures were reactivated in three groups, and they were not reactivated in the other three groups. Then, participants viewed and recalled new pictures once (weak new learning) or three times (strong new learning), or they did not learn any new pictures. On Day 9, participants performed a recognition test in which their memory for Day 1 pictures was assessed. Two main results are noted. First, the groups that reactivated pictures from Day 1 and received weak or strong new learning did not differ in memory performance. Second, these two groups consistently performed similar to groups that controlled for new learning without reactivation. Because these results contradict what was expected based on the reconsolidation hypothesis, we discuss possible explanations and implications.

Blurring emotional memories using eye movements: individual differences and speed of eye movements.

BACKGROUND: In eye movement desensitization and reprocessing (EMDR), patients make eye movements (EM) while recalling traumatic memories. Making EM taxes working memory (WM), which leaves less resources available for imagery of the memory. This reduces memory vividness and emotionality during future recalls. WM theory predicts that individuals with small working memory capacities (WMCs) benefit more from low levels of taxing (i.e., slow EM) whereas individuals with large WMC benefit more from high levels of taxing (i.e., fast EM). OBJECTIVE: We experimentally examined and tested four prespecified hypotheses regarding the role of WMC and EM speed in reducing emotionality and vividness ratings: 1) EM-regardless of WMC and EM speed-are more effective compared to no dual task, 2) increasing EM speed only affects the decrease in memory ratings irrespective of WMC, 3) low-WMC individuals-compared to high-WMC individuals-benefit more from making either type of EM, 4) the EM intervention is most effective when-as predicted by WM theory-EM are adjusted to WMC. METHOD: Undergraduates with low (n=31) or high (n=35) WMC recalled three emotional memories and rated vividness and emotionality before and after each condition (recall only, recall + slow EM, and recall + fast EM). RESULTS: Contrary to the theory, the data do not support the hypothesis that EM speed should be adjusted to WMC (hypothesis 4). However, the data show that a dual task in general is more effective in reducing memory ratings than no dual task (hypothesis 1), and that a more cognitively demanding dual task increases the intervention's effectiveness (hypothesis 2). CONCLUSIONS: Although adjusting EM speed to an individual's WMC seems a straightforward clinical implication, the data do not show any indication that such a titration is helpful.

The effects of eye movements on emotional memories: using an objective measure of cognitive load.

BACKGROUND: Eye movement desensitization and reprocessing (EMDR) is an effective treatment for posttraumatic stress disorder. The working memory (WM) theory explains its efficacy: recall of an aversive memory and making eye movements (EM) both produce cognitive load, and competition for the limited WM resources reduces the memory's vividness and emotionality. The present study tested several predictions from WM theory. OBJECTIVE: We hypothesized that 1) recall of an aversive autobiographical memory loads WM compared to no recall, and 2) recall with EM reduces the vividness, emotionality, and cognitive load of recalling the memory more than only recall or only cognitive effort (i.e., recall of an irrelevant memory with EM). METHOD: Undergraduates (N=108) were randomly assigned to one of three conditions: 1) recall relevant memory with EM, 2) recall relevant memory without EM, and 3) recall irrelevant memory with EM. We used a random interval repetition task to measure the cognitive load of recalling the memory. Participants responded to randomly administered beeps, with or without recalling the memory. The degree to which participants slow down during recall provides an index of cognitive load. We measured the cognitive load and self-reported vividness and emotionality before, halfway through (8×24 s), and after (16×24 s) the intervention. RESULTS: Reaction times slowed down during memory recall compared to no recall. The recall relevant with EM condition showed a larger decrease in self-reported vividness and emotionality than the control conditions. The cognitive load of recalling the memory also decreased in this condition but not consistently more than in the control conditions. CONCLUSIONS: Recall of an aversive memory loads WM, but drops in vividness and emotionality do not immediately reduce the cognitive load of recalling the memory. More research is needed to find objective measures that could capture changes in the quality of the memory.