Specific Phobia, Fear, and the Autism Spectrum in Children and Adolescents: Adapting OST for ASD.

Fears and phobias are a common mental health concern for youth, and particularly for autistic youth. The following review briefly summarizes the extant literature on specific phobias and specific phobias in autistic youth. The evidence base is briefly highlighted pointing to the strong base behind behavioral and cognitive-behavioral treatments and techniques. A broad discussion of key evidence-based treatment findings is presented, leading up to the impactful work of Thomas H. Ollendick in researching Öst's One-Session Treatment (OST) with children and adolescents. OST for child specific phobias is discussed, and particular emphasis is given to this treatment's ongoing adaptation for use with youth on the autism spectrum.

A Smartphone-Gamified Virtual Reality Exposure Therapy Augmented With Biofeedback for Ailurophobia: Development and Evaluation Study.

BACKGROUND: To the best of our knowledge, no specialized research has been conducted to address ailurophobia (fear of cats) in Iran or globally. This has driven our project, along with the prevalence of ailurophobia and the absence of a gamified virtual reality exposure therapy (VRET) that incorporates affordable and easily accessible biofeedback (BF) tools. We hypothesize that a gamified VRET augmented with BF will yield more positive effects than a similar device lacking BF. OBJECTIVE: This study primarily focuses on the development and preliminary evaluation of a smartphone-gamified VRET integrated with BF, targeting animal phobia, with a specific case study on ailurophobia. The secondary objectives are using affordable and readily available BF found in devices such as smart bands and smartwatches and creating a mobile virtual reality gamified app to improve patients' adherence to treatments while simultaneously enhancing the app's accessibility, scalability, and outreach. METHODS: Evaluations encompassed 3 methods. First, we identified the tool's potential positive effects on phobia interventions, exploring 4 effects: intrinsic motivation, simulation of fearful situations, management of stressful circumstances without therapists' presence and mitigation of catastrophic thoughts, and preliminary effects on ailurophobia treatment. Participants were divided into BF and non-BF groups. Second, we gathered user preferences and opinions about the treatment. Third, we conducted heuristic evaluations using 44 heuristics from existing system usability scales assessing user interfaces, virtual reality platforms, and video games' playability. To interpret the data, mean scores; ANOVA, single factor; and ANOVA, 2-factor with replication were used. A total of 29 individuals were identified, of which 10 met the eligibility criteria or were accessible. RESULTS: The smartphone-gamified VRET augmented with BF exhibited better results on the identified effects compared with the non-BF version and contributed to normalizing encounters with cats. Moreover, 41 of the 44 heuristics achieved a percentage above 62%, indicating its potential as a therapeutic product and its ability to enhance patient adherence to treatments. Patient preferences on the treatment and its strengths and weaknesses were provided for further improvement. CONCLUSIONS: The tool has the potential to evolve into a comprehensive solution by incorporating various types of cats and their behaviors, simulating environments in which they are commonly found, and enhancing its appeal through an increased sense of adventure without inducing unrealistic fears. By adapting fear elements, the game can be tailored to treat various animal phobias. Phobia-focused games should avoid action and combat scenarios to prevent reinforcement of fear responses. After rigorous evaluation, further exploration is required to provide remote use beyond clinical settings.

The natural history of lifetime psychiatric disorders in patients with obsessive-compulsive disorder followed over half a century.

OBJECTIVE: Few long-term studies have examined the life-time prevalence of comorbid psychiatric conditions in patients with obsessive-compulsive disorder (OCD). We therefore studied the frequency of comorbid psychiatric disorders, and their relation to onset and prognosis, in patients with OCD who were followed for almost half a century. METHODS: During 1947-1953, 285 OCD patients were admitted as inpatients to a university hospital in Gothenburg, Sweden. Among those, 251 (88%) accepted a structured comprehensive psychiatric examination in 1954-1956. In 1989-1993, 176 survivors were eligible and 144 (response rate 82%) were re-examined. The same psychiatrist performed both examinations. OCD was diagnosed according to the Schneider criteria, and other mental disorders according to DSM-IV. Mean follow-up since onset was 47 years. RESULTS: The lifetime frequency of depressive disorders was 84.7% (major depression 43.8%), generalized anxiety disorder (GAD) 71.5%, panic anxiety disorder 47.9%, agoraphobia 52.1%, specific phobias 64.6%, social phobia 47.9%, paranoid conditions 40.3% (29.1% paranoid ideation), psychotic disorders 15.3%, alcohol abuse 13.2% (men 39%, women 3%) and substance abuse 17.4%. Specific phobia most often started before OCD, while depression had a varied onset in relation to OCD. Social phobia, agoraphobia, GAD, alcohol and substance abuse, psychotic disorders and paranoid conditions most often started after OCD. Presence of GAD, psychotic disorder and substance abuse worsened prognosis of OCD. CONCLUSION: Comorbid psychiatric conditions are common in OCD patients, and have onset throughout the course. OCD signals vulnerability for other psychiatric conditions, which are important to detect in clinical practice as they negatively affect the outcome.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial.

BACKGROUND: Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking. OBJECTIVE: This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment. METHODS: We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and 1 parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires. RESULTS: All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes-dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events. CONCLUSIONS: ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079.

An Examination of the Association between Emotion Regulation and Emetophobia Symptoms.

BACKGROUND: Specific phobia of vomiting, referred to as emetophobia, is a specific phobia characterized by persistent and severe fear of vomit. Individuals with emetophobia engage in a variety of emotional and behavioral avoidance strategies to distance themselves from perceived vomit-related threat. As such, individuals may struggle to effectively use emotion regulation (ER) skills; however, to date, limited work has examined the association between emotion regulation and emetophobia symptoms. The present study aimed to address this gap in the literature and examine the association between ER and emetophobia symptoms. METHODS: Participants (N = 508) were a remote, clinical sample of individuals recruited via social media forums dedicated to the disorder who self-identified as experiencing emetophobia. Hierarchical linear regressions were used to assessed unique contributions of ER to emetophobia symptoms. Age, gender, and depressive symptoms were entered as covariates in the hierarchical regression. RESULTS: Results demonstrated ER was significantly related to emetophobia symptoms above and beyond the effects of depressive symptoms, age and gender in the current sample. CONCLUSIONS: The findings provide initial support for an association between ER and emetophobia, and suggest future directions for refining the conceptualization of emetophobia. Limitations and considerations include the recruitment strategy via social media websites for individuals with emetophobia, limited diversity of the sample, and cross-sectional nature.

Mechanisms of action underlying virtual reality exposure treatment in spider phobia: Pivotal role of within-session fear reduction.

Although virtual-reality exposure treatment (VRET) for anxiety disorders is an efficient treatment option for specific phobia, mechanisms of action for immediate and sustained treatment response need to be elucidated. Towards this aim, core therapy process variables were assessed as predictors for short- and long-term VR treatment outcomes. In a bi-centric study, n = 186 patients with spider phobia completed a baseline-assessment, a one-session VRET, a post-therapy assessment, and a 6-month-follow-up assessment (ClinicalTrials.gov, ID: NCT03208400). Short- and long-term outcomes regarding self-reported symptoms in the spider phobia questionnaire (SPQ) and final patient-spider distance in the behavioral avoidance test (BAT) were predicted via logistic regression models with the corresponding baseline score, age, initial fear activation, within-session fear reduction and fear expectancy violation as predictors. To predict long-term remission status at 6-month-follow-up, dimensional short-term changes in the SPQ and BAT were additionally included. Higher within-session fear reductions predicted better treatment outcomes (long-term SPQ; short- and long-term BAT). Lower initial fear activation tended to be associated with better long-term outcomes (SPQ), while fear expectancy violation was not associated with any outcome measure. Short-term change in the SPQ predicted remission status. Findings highlight that in VRET for spider phobia, the experience of fear reduction is central for short- and long-term treatment success and should be focused by therapists.

Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia.

INTRODUCTION: Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE). METHODS: Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS: TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up. CONCLUSIONS: These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

Anticipated fear and anxiety of Automated Driving Systems: Estimating the prevalence in a national representative survey

Background: Automated Driving Systems (ADS) may reshape mobility. Yet, related fear and anxiety are largely unknown. We estimated the prevalence and risk factors of anticipated anxiety towards ADS. Method: In a nationally representative face-to-face household survey, we assessed anticipated levels of anxiety towards ADS based on DSM-5 specific phobia criteria, using structured diagnostic interviews. We estimated weighted prevalences and conducted adjusted logistic regression models. Results: Of N = 2076 respondents, 40.82% (95%-confidence interval (CI) 37.73–43.98) anticipated experiencing some symptoms of phobia of ADS, 15.22% (CI 13.19–17.51) anticipated subthreshold phobia, and 3.39% (CI 2.42–4.75) anticipated full-blown phobia of ADS. Of subjects anticipating subthreshold phobia, 74.02% showed no strong, enduring fears of driving non-automated cars and 65.07% presented no other specific phobias (full-blown anticipated phobia: 50.37% and 50.03%, respectively). Anticipated phobia highly overlapped with anticipating marked or strong fears of passively encountering ADS in traffic (odds ratio 312.4–1982.2). Conclusion: About 20% of subjects anticipated at least subthreshold and 4% of subjects anticipated full-blown phobia of ADS. It appears to be distinct from fears related to non-automated driving and other specific phobias. Our findings call for prevention and treatment of phobia of ADS as they become increasingly ubiquitous. (AU)

Looking fear in the eye: Gamified virtual reality exposure towards spiders for children using attention based feedback.

Many children around the globe suffer from spider phobia. Virtual reality exposure therapy is an effective phobia treatment, but so far predominantly tailored for adults. A gamified approach utilizing gaze interaction would allow for a more child-friendly and engaging experience, and provide the possibility to foster working mechanisms of exposure therapy. We developed an application in which children make spiders change in positively connoted ways (e.g., make them dance or shrink) if sufficient visual attention towards them is captured via eye tracking. Thereby, motivation for and positive affects during exposure towards spiders are aspired. In this pilot study on 21 children without (n = 11) and with fear of spiders (n = 10), we examined positive and negative affect during exposure to a virtual spider and to different gaze-related transformations of the spider within a quasi-experimental design. Within a one-group design, we additionally examined fear of spiders in spider fearful children before and one week after the intervention. We found that significantly more positive than negative affect was induced by the spiders' transformations in children without and with fear of spiders. Fear of spiders was furthermore significantly reduced in spider-fearful children, showing large effect sizes (d > .80). Findings indicate eligibility for future clinical use and evaluation in children with spider phobia.

Extinction-Based Exposure Therapies Using Virtual Reality.

The focus of this chapter is an overview of integrating virtual reality (VR) technology within the context of exposure therapy for anxiety disorders, a gold standard treatment, with a focus on how VR can help facilitate extinction learning processes integral to these interventions. The chapter will include an overview of advantages of incorporating VR within exposure therapy, and benefits specifically within an inhibitory learning approach for extinction training. A review of the empirical literature on the effectiveness of VR exposure therapy for specific phobia and PTSD will be provided, as well as practical overview of how to effectively incorporate VR within exposure therapy.

Treating specific phobia in youth: A randomized controlled microtrial comparing gradual exposure in large steps to exposure in small steps.

INTRODUCTION: Exposure may be especially effective when within exercises, there is a strong violation of threat expectancies and much opportunity for fear reduction. Outcomes of exposure may therefore improve when exposure is conducted in large steps (LargeSE) relative to small steps (SmallSE). METHODS: Children and young people with a specific phobia (SP) (N = 50, age 8-17, 64 % girls) participated in a preregistered single-blind, randomized controlled microtrial comparing LargeSE and SmallSE in a four-week baseline-treatment design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS: Within exercises, LargeSE resulted in higher initial fear levels and more within-session expectancy violation. Nevertheless, SmallSE resulted in a larger decline of SP severity from baseline to post-treatment and follow-up, and a larger decline of anxiety and avoidance towards one's individual goal from baseline to follow-up. There were no differences between LargeSE and SmallSE regarding changes in general self-efficacy or behavioral avoidance. Although session duration was standardized and similar for both conditions, participants in SmallSE received more (shorter) exercises. DISCUSSION: SmallSE might be more effective in reducing SP severity because children in SmallSE were exposed to a larger number and variety of exercises than children in LargeSE.

The first steps in facing your fears: The acceptability of virtual reality and in vivo exposure treatment for specific fears.

Phobic individuals are often reluctant to engage in exposure in vivo (IVE). We examined whether providing exposure in virtual reality (VRE) can increase the acceptability. In Study 1, we provided 186 fearful participants with (hypothetical) VRE and IVE treatment offers and examined their willingness to engage in treatment, estimated success, negative beliefs, acceptance/refusal and their preference. Almost 70 % preferred VRE over IVE and acceptance rates were higher for the VRE offer (58 %) than for IVE (35 %). Although participants held fewer negative beliefs about VRE, they did rate IVE as slightly more successful. In Study 2, we examined whether VRE can serve as a stepping stone to IVE in a sample of 102 spider fearful individuals. Willingness to engage, estimated success and negative beliefs about IVE were assessed before and after VRE. After VRE, participants rated IVE as more successful, but were not more willing to engage in IVE, nor were they more inclined to accept an IVE offer. No decreases in negative beliefs were observed. In conclusion, VRE is deemed more acceptable than IVE and could lower refusal rates, hereby resulting in more phobic individuals receiving treatment. Future research should shed light on underlying motivations and associations.

Anticipated fear and anxiety of Automated Driving Systems: Estimating the prevalence in a national representative survey.

Background: Automated Driving Systems (ADS) may reshape mobility. Yet, related fear and anxiety are largely unknown. We estimated the prevalence and risk factors of anticipated anxiety towards ADS. Method: In a nationally representative face-to-face household survey, we assessed anticipated levels of anxiety towards ADS based on DSM-5 specific phobia criteria, using structured diagnostic interviews. We estimated weighted prevalences and conducted adjusted logistic regression models. Results: Of N = 2076 respondents, 40.82% (95%-confidence interval (CI) 37.73-43.98) anticipated experiencing some symptoms of phobia of ADS, 15.22% (CI 13.19-17.51) anticipated subthreshold phobia, and 3.39% (CI 2.42-4.75) anticipated full-blown phobia of ADS. Of subjects anticipating subthreshold phobia, 74.02% showed no strong, enduring fears of driving non-automated cars and 65.07% presented no other specific phobias (full-blown anticipated phobia: 50.37% and 50.03%, respectively). Anticipated phobia highly overlapped with anticipating marked or strong fears of passively encountering ADS in traffic (odds ratio 312.4-1982.2). Conclusion: About 20% of subjects anticipated at least subthreshold and 4% of subjects anticipated full-blown phobia of ADS. It appears to be distinct from fears related to non-automated driving and other specific phobias. Our findings call for prevention and treatment of phobia of ADS as they become increasingly ubiquitous.

A novel probe of attentional bias for threat in specific phobia: Application of the "MouseView.js" approach.

Although attentional bias for threat has been implicated in anxiety disorders, traditional attentional bias measures have been criticized for lack of reliability and validity, and eye tracking technologies can be cost-prohibitive. MouseView.js was recently developed to mimic eye tracking online by using the computer cursor as a proxy for gaze, and although it is equally reliable, MouseView.js' utility for capturing attentional bias for threat in anxiety-related disorders remains unclear. To fill this knowledge gap, snake phobic and non-phobic participants (N = 62) completed a behavioral avoidance task (BAT) and the MouseView.js task which consisted of 10-second exposures to blurred, side-by-side images of either pleasant-neutral or threat-neutral pairings and were instructed to freely move the mouse to reveal the images. Results demonstrated that snake phobic participants had significantly shorter average mouse dwell time on threat images than non-phobic individuals and showed a significant reduction in average dwell time on threat images following the first presentation of the threat-neutral pairing. Additionally, dwell time on threat images significantly mediated the group differences in steps completed on the BAT. Results highlight the utility of MouseView.js in capturing avoidant patterns of attentional bias for threat that may also partially drive avoidance in snake phobia. Implications for capturing attentional bias for threat in anxiety disorders more broadly are discussed.

Relationships between fear of flying, loudness dependence of auditory evoked potentials and frontal alpha asymmetry.

Previous research has suggested that fear of flying, which is defined as a situational, specific phobia, could overlap with depressive and anxiety disorders. Whether the neuronal dysfunctions including altered serotonergic activity in the brain and altered neural oscillations observed for depressive and anxiety disorders also overlap with alterations in fear of flying is unclear. Here, thirty-six participants with self-reported fear of flying (FF) and forty-one unaffected participants (NFF) were recruited. The participants completed the Beck Depression Inventory (BDI-II), the State-trait Anxiety Inventory (STAI) and the Fear of Flying Scale (FFS). EEG-recording was conducted during resting-state and during presentation of auditory stimuli with varying loudness levels for analysis of the Loudness Dependence of Auditory Evoked Potentials (LDAEP), which is suggested to be inversely related to central serotonergic activity. Participants with fear of flying did not differ from the control group with regard to BDI-II and STAI data. The LDAEP was higher over F4 electrode in the FF group compared to controls, whereas exploratory analysis suggest that differences between groups were conveyed by female participants. Moreover, the FF group showed relatively higher right frontal alpha activity compared to the control group, whereas no difference in frequency power (alpha, beta and theta) was observed. Thus, this study brought the first hint for reduced serotonergic activity in individuals with fear of flying and relatively higher right frontal activity. Thus, based on the preliminary findings, future research should aim to examine the boundaries with anxiety and depressive disorders and to clarify the distinct neural mechanisms.

Pre- and post-task resting-state differs in clinical populations.

Resting-state functional connectivity has generated great hopes as a potential brain biomarker for improving prevention, diagnosis, and treatment in psychiatry. This neuroimaging protocol can routinely be performed by patients and does not depend on the specificities of a task. Thus, it seems ideal for big data approaches that require aggregating data across multiple studies and sites. However, technical variability, diverging data analysis approaches, and differences in data acquisition protocols introduce heterogeneity to the aggregated data. Besides these technical aspects, a prior task that changes the psychological state of participants might also contribute to heterogeneity. In healthy participants, studies have shown that behavioral tasks can influence resting-state measures, but such effects have not yet been reported in clinical populations. Here, we fill this knowledge gap by comparing resting-state functional connectivity before and after clinically relevant tasks in two clinical conditions, namely substance use disorders and phobias. The tasks consisted of viewing craving-inducing and spider anxiety provoking pictures that are frequently used in cue-reactivity studies and exposure therapy. We found distinct pre- vs post-task resting-state connectivity differences in each group, as well as decreased thalamo-cortical and increased intra-thalamic connectivity which might be associated with decreased vigilance in both groups. Our results confirm that resting-state measures can be strongly influenced by prior emotion-inducing tasks that need to be taken into account when pooling resting-state scans for clinical biomarker detection. This demands that resting-state datasets should include a complete description of the experimental design, especially when a task preceded data collection.

oVRcome - Self-guided virtual reality for specific phobias: A randomised controlled trial.

OBJECTIVE: Mobile health applications for mental health are widely accessible but most have had limited research evaluation. Virtual reality exposure therapy is an emerging treatment for specific phobias. Most virtual reality studies have investigated high-end virtual reality devices, typically only available in research and limited clinical settings for a single phobia. This study evaluated the effectiveness of oVRcome, a mobile health application combining self-guided virtual reality exposure and cognitive behaviour therapy, for five specific phobias. METHODS: This is a 2-arm 6-week randomised controlled trial, with a waitlist control group and follow-up at week 12. Participants were required to live in New Zealand; be aged 18-64 years; have a fear of flying, heights, spiders, dogs and needles; score above 4 on the Brief Standard Self-rating scale for phobic patients; and have access to a smartphone and Internet. oVRcome consists of six modules of psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through virtual reality and relapse prevention over 6 weeks. The primary outcome was the change from baseline to week 6 on the Severity Measures for Specific Phobia - Adults. All analyses were performed on intention-to-treat set. RESULTS: A total of 126 participants were randomised, and 109 completed the follow-up at week 6, for a retention rate of 86.5%. The mean change in Severity Measures for Specific Phobia - Adults score from baseline to week 6 was greater in the active group compared with the waitlist group (active group -20.53 [standard deviation = 8.24]; waitlist group: - 12.31 [standard deviation = 10.66]; p < 0.001). The effect size for this difference was 0.86. CONCLUSION: Self-guided use of the oVRcome app was effective at reducing severity of specific phobia symptoms in a sample of people with a self-reported fear of flying, heights, spiders, dogs or needles.Trial registry clinicaltrials.gov NCT04909177.

One session treatment (OST) is equivalent to multi-session cognitive behavioral therapy (CBT) in children with specific phobias (ASPECT): results from a national non-inferiority randomized controlled trial.

BACKGROUND: 5%-10% children and young people (CYP) experience specific phobias that impact daily functioning. Cognitive Behaviour Therapy (CBT) is recommended but has limitations. One Session Treatment (OST), a briefer alternative incorporating CBT principles, has demonstrated efficacy. The Alleviating Specific Phobias Experienced by Children Trial (ASPECT) investigated the non-inferiority of OST compared to multi-session CBT for treating specific phobias in CYP. METHODS: ASPECT was a pragmatic, multi-center, non-inferiority randomized controlled trial in 26 CAMHS sites, three voluntary agency services, and one university-based CYP well-being service. CYP aged 7-16 years with specific phobia were randomized to receive OST or CBT. Clinical non-inferiority and a nested cost-effectiveness evaluation was assessed 6-months post-randomization using the Behavioural Avoidance Task (BAT). Secondary outcome measures included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety Depression Scale, goal-based outcome measure, and EQ-5DY and CHU-9D, collected blind at baseline and six-months. RESULTS: 268 CYPs were randomized to OST (n = 134) or CBT (n = 134). Mean BAT scores at 6 months were similar across groups in both intention-to-treat (ITT) and per-protocol (PP) populations (CBT: 7.1 (ITT, n = 76), 7.4 (PP, n = 57), OST: 7.4 (ITT, n = 73), 7.6 (PP, n = 56), on the standardized scale-adjusted mean difference for CBT compared to OST -0.123, 95% CI -0.449 to 0.202 (ITT), mean difference -0.204, 95% CI -0.579 to 0.171 (PP)). These findings were wholly below the standardized non-inferiority limit of 0.4, suggesting that OST is non-inferior to CBT. No between-group differences were found on secondary outcomes. OST marginally decreased mean service use costs and maintained similar mean Quality Adjusted Life Years compared to CBT. CONCLUSIONS: One Session Treatment has similar clinical effectiveness to CBT for specific phobias in CYP and may be a cost-saving alternative.

Automated mobile virtual reality cognitive behavior therapy for aviophobia in a natural setting: a randomized controlled trial.

BACKGROUND: Access to evidence-based psychological treatment is a challenge worldwide. We assessed the effectiveness of a fully automated aviophobia smartphone app treatment delivered in combination with a $5 virtual reality (VR) viewer. METHODS: In total, 153 participants from the Dutch general population with aviophobia symptoms and smartphone access were randomized in a single-blind randomized controlled trial to either an automated VR cognitive behavior therapy (VR-CBT) app treatment condition (n = 77) or a wait-list control condition (n = 76). The VR-CBT app was delivered over a 6-week period in the participants' natural environment. Online self-report assessments were completed at baseline, post-treatment, at 3-month and at 12-month follow-up. The primary outcome measure was the Flight Anxiety Situations Questionnaire (FAS). Analyses were based on intent-to-treat. RESULTS: A significant reduction of aviophobia symptoms at post-test for the VR-CBT app compared with the control condition [p < 0.001; d = 0. 98 (95% CI 0.65-1.32)] was demonstrated. The dropout rate was 21%. Results were maintained at 3-month follow-up [within-group d = 1.14 (95% CI 0.46-1.81)] and at 12-month follow-up [within-group d = 1.12 (95% CI 0.46-1.79)]. Six participants reported adverse effects of cyber sickness symptoms. CONCLUSIONS: This study is the first to show that fully automated mobile VR-CBT therapy delivered in a natural setting can maintain long-term effectiveness in reducing aviophobia symptoms. In doing so, it offers an accessible and scalable evidence-based treatment solution that can be applied globally at a fraction of the cost of current treatment alternatives.

The relative efficacy and efficiency of single- and multi-session exposure therapies for specific phobia: A meta-analysis.

Exposure therapy is the preferred treatment for specific phobia (SP), with evidence supporting its efficacy whether delivered over multiple sessions or as a single session, such as One-Session Treatment. In this meta-analysis, we compared the efficiency and effectiveness of single- and multi-session exposure for SP. PsycINFO, Embase, MEDLINE, and Cochrane were systematically searched for peer-reviewed articles reporting the effects of multi-session (k = 30) and/or single-session (k = 55) in vivo exposure on SP symptoms in clinical populations (n = 1758 participants). A random-effects model was used to synthesise and compare the pre-post treatment effects (Hedges' g) on approach behaviour and self-reported SP symptoms. Mean total treatment time was significantly longer for multi-session exposure than for single-session. There were no significant differences in the pooled effect sizes of single-session and multi-session exposure at post-treatment and follow-up assessments; effect sizes were large for all outcomes. Phobia subtype significantly moderated the effect size for both treatment approaches, although the direction of association differed according to the outcome measures. Results suggest no evidence for differences in the effectiveness of single- and multi-session exposure, but single-session is more time efficient. These outcomes suggest that policies to facilitate access to single-session exposure would be beneficial.