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Rewards for approaching a feared stimulus may compete with fear reduction inherent to avoidance and thereby alter fear and avoidance learning. However, the impact of such competing rewards on fear and avoidance acquisition has rarely been investigated. During acquisition, participants chose between one option (CS+ option) associated with a neutral stimulus followed by an aversive unconditioned stimulus (US) and another option (CS− option) associated with another neutral stimulus followed by no US (N = 223 randomized into three groups). In a subsequent test, no more USs occurred. In one group, competing rewards were established by linking the CS+ option to high rewards and the CS− option to low rewards during acquisition and test (Reward Group). In a second group, rewards were present during acquisition, but discontinued during test (Initial-Reward Group). In a third group, rewards were completely absent (No-Reward Group). Without competing rewards, significant avoidance was acquired and persisted in the absence of the US. Competing rewards attenuated avoidance acquisition already after the first experience of the aversive US. Avoidance remained attenuated even when rewards were discontinued during test. Rewards did, however, not change the level of fear responses to the CS+ (US expectancy, skin conductance). Finally, rewards did not change the level of fear reduction during test, which was, however, experienced earlier. Summarized, rewards for approaching aversive events do not buffer fear acquisition, but can prevent avoidance. This damping of avoidance may initiate fear extinction.

Symptoms of depersonalization during feared social situations are commonly experienced by individuals with social anxiety disorder (SAD). Despite its clinical relevance, it is not addressed in standard treatment manuals and it remains unclear if depersonalization is reduced by well-established treatments. This study investigated whether cognitive therapy (CT) for SAD effectively reduces depersonalization and whether pre-treatment severity of depersonalization predicts or mediates treatment outcome. In a randomized controlled trial, patients underwent the standardized Trier Social Stress Test before and after CT (n = 20) or a waitlist period (n = 20) and were compared to healthy controls (n = 21). Self-reported depersonalization was measured immediately after each stress test. Depersonalization significantly decreased following CT, especially in treatment responders (ηp2 = 0.32). Pre-treatment depersonalization did neither predict nor mediate post-treatment severity of social anxiety. Further prospective studies are needed for a better scientific understanding of this effect. It should be scrutinized whether SAD-patients suffering from depersonalization would benefit from a more specific therapy.

Background and Objectives: Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient. Methods: Forty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life. Results: Public speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure. Limitations: Results were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward. Conclusions: Findings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance.

Background and objectives: Identifying for whom and under what conditions a treatment is most effective is an essential step toward personalized medicine. The current study examined pre-treatment physiological and behavioral variables as predictors and moderators of outcome in a randomized clinical trial comparing cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for anxiety disorders. Methods: Sixty individuals with a DSM-IV defined principal anxiety disorder completed 12 sessions of either CBT or ACT. Baseline physiological and behavioral variables were measured prior to entering treatment. Self-reported anxiety symptoms were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-up from baseline. Results: Higher pre-treatment heart rate variability was associated with worse outcome across ACT and CBT. ACT outperformed CBT for individuals with high behavioral avoidance. Subjective anxiety levels during laboratory tasks did not predict or moderate treatment outcome. Limitations: Due to small sample sizes of each disorder, disorder-specific predictors were not tested. Future research should examine these predictors in larger samples and across other outcome variables. Conclusions: Lower heart rate variability was identified as a prognostic indicator of overall outcome, whereas high behavioral avoidance was identified as a prescriptive indicator of superior outcome from ACT versus CBT. Investigation of pre-treatment physiological and behavioral variables as predictors and moderators of outcome may help guide future treatment-matching efforts.

Objective: Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination. Method: As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models. Results: Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor. Conclusions: The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Objective: This study examined the effectiveness of manualized cognitive therapy (mCT) following the Clark-Wells approach versus non-manualized cognitive-behavioral treatment-as-usual (CBTAU) for social anxiety disorder (SAD) in routine practice. Methods: Forty-eight private practitioners were recruited within a multi-center trial and either received training in manualized CT for SAD or no such training. Practitioners treated 162 patients with SAD in routine practice (N = 107 completers, n = 57 for mCT, n = 50 for CBTAU). Social anxiety symptoms (Liebowitz Social Anxiety Scale; LSAS) and secondary measures were assessed before treatment, at treatment-hour 8, 15, and 25, at end of treatment, as well as 6 and 12 months after treatment. Results: Patients in both groups showed significant reductions of SAD severity after treatment (d = 1.91 [mCT] and d = 1.80 [CBTAU], within-group effect sizes, intent-to-treat analyses, LSAS observer ratings), which remained stable at follow-up. There were no differences between groups in terms of symptom reduction and treatment duration. Conclusions: The present trial confirms the high effectiveness of CBTAU and mCT for SAD when practitioners conduct the treatments in routine practice. Additional training in the CT manual did not result in significant between-group effects on therapy outcome. Explanations for this unexpected result are discussed.

Anxiety can boost the detection of potential threats in many ways. There is evidence that one and the same facial expression can be perceived differently depending on whether it is seen in a neutral or in a threatening situation. The present study investigated how aversive anticipation influences the accuracy of facial emotion recognition and the perceived emotional intensity of faces that had their objective emotional intensity manipulated. Forty-three participants categorized and rated the intensity of morphed faces (20%, 40%, 60%, and 80%) of fearful, angry, and happy expressions. Differently colored picture frames indicated either threat of electric shock or safety. Threat of shock enhanced the categorization accuracy specifically for fearful faces. During threat, 80% fearful and happy faces, and all levels of angry faces (20%–80%) were rated as more intense. In addition, we found that more trait-anxious individuals more frequently erroneously categorized neutral faces as fearful. Thus, state anxiety enhanced accurate fear categorization and boosted the perceived intensity of emotional faces, whereas trait anxiety led to a biased threat perception in nonthreatening faces. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

It remains unclear if diminished high frequency heart rate variability (HF-HRV) can be found across anxiety disorders. HF-HRV and heart rate (HR) were examined in panic (PD), generalized anxiety (GAD), social anxiety (SAD), and obsessive-compulsive disorder (OCD) relative to healthy controls at baseline and during anxiety stressors. All disorders evidenced diminished baseline HF-HRV relative to controls. Baseline HRV differences were maintained throughout relaxation. For hyperventilation, PD and GAD demonstrated greater HR than controls. Psychotropic medication did not account for HF-HRV differences except in OCD. Age and sex evidenced multiple main effects. Findings suggest that low baseline HF-HRV represents a common index for inhibitory deficits across PD, GAD, and SAD,which is consistent with the notion of autonomic inflexibility in anxiety disorders. Elevated HR responses to hyperventilation, however, are specific to PD and GAD. (PsycInfo Database Record (c) 2022 APA, all rights

Potential threat can prime defensive responding and avoidance behavior, which may result in the loss of rewards. When aversive consequences do not occur, avoidance should, thus, be quickly overcome in healthy individuals. This study examined the impact of threat anticipation on reward-based decisions. Sixty-five participants completed a decision-making task in which they had to choose between high- and low-reward options. To model an approach-avoidance conflict, the high-reward option was contingent with a threat-of-shock cue; the low-reward option was contingent with a safety cue. In control trials, decisions were made without threat/safety instructions. Overall, behavioral data documented a typical preference for the profitable option. Importantly, under threat-of-shock, participants initially avoided the profitable option (i.e., safe, but less profitable choices). However, when they experienced that shocks did actually not occur, participants overcame initial avoidance in favor of larger gains. Furthermore, autonomic arousal (skin conductance and heart rate responses) was elevated during threat cues compared to safety and non-threatening control cues. Taken together, threat-of-shock was associated with behavioral consequences: initially, participants avoided threat-related options but made more profitable decisions as they experienced no aversive consequences. Although socially acquired threat contingencies are typically stable, incentives for approach can help to overcome threat-related avoidance.

The human face conveys emotional and social information, but it is not well understood how these two aspects influence face perception. In order to model a group situation, two faces displaying happy, neutral or angry expressions were presented. Importantly, faces were either facing the observer, or they were presented in profile view directed towards, or looking away from each other. In Experiment 1 (n ¼ 64), face pairs were rated regarding perceived relevance, wish-to- interact, and displayed interactivity, as well as valence and arousal. All variables revealed main effects of facial expression (emotional > neutral), face orientation (facing observer > towards > away) and interactions showed that evaluation of emo- tional faces strongly varies with their orientation. Experiment 2 (n ¼ 33) examined the temporal dynamics of perceptual- attentional processing of these face constellations with event-related potentials. Processing of emotional and neutral faces differed significantly in N170 amplitudes, early posterior negativity (EPN), and sustained positive potentials. Importantly, selective emotional face processing varied as a function of face orientation, indicating early emotion-specific (N170, EPN) and late threat-specific effects (LPP, sustained positivity). Taken together, perceived personal relevance to the observer— conveyed by facial expression and face direction—amplifies emotional face processing within triadic group situations.

Ergebnisse des Symposiums "Barrieren bei der Anwendung expositionsbasierter Verfahren in der niedergelassenen Praxis" im Rahmen des 30. DGVT-Kongresses für Klinische Psychologie, Psychotherapie und Beratung werden präsentiert. Dargestellt werden zum einen Befunde einer Befragung niedergelassener Verhaltenstherapeuten zur Anwendung und Hindernissen von Exposition, die zu Beginn des Symposiums vorgestellt wurden. Zum anderen wird die Diskussion des Symposiums nachgezeichnet. Dabei wird unter anderem auf folgende Themen eingegangen: (1) Einsatz von Exposition in der ambulanten Praxis, (2) Einstellungen gegenüber Exposition und (3) systemische Barrieren bei der Durchführung von Exposition.

Objective: In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity—despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters. Method: As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models. Results: Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for. Conclusion: The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult.

Fear generalization refers to the spread of acquired fear to novel stimuli that resemble the original fear-related stimulus. Preliminary evidence suggests that excessive fear generalization is a pathogenic feature of anxiety disorders, however, it remains unclear how fear generalization affects pathological avoidance. The current study thus aimed to examine the link between categorical fear generalization and costly avoidance. By combining a fear acquisition training phase and an avoidance test, the current findings showed that acquired fear spreads to novel stimuli that belonged to the same category of the original fear-related stimuli, but not to those that belonged to the fear-irrelevant categories. Importantly, participants avoided these fear-related novel stimuli despite costs. The current findings indicate that categorical fear generalization triggers costly avoidance. In terms of clinical implication, a decrease in costly avoidance aligned with a decrease in US expectancies. This emphasizes that behavioral approach may initiate extinction learning.

Background and objectives: When avoiding threat conflicts with approaching rewards, balanced responses to threat and reward information is required to guide functional behavior. Elevated threat avoidance characterizes anxious psychopathology. However, little is known about the mutual impact of threat and reward information on approach-avoidance behavior and its link to anxiety. Methods: High trait-anxious and low-anxious individuals (N = 74) repeatedly choose between two options. A threat/high-reward option was linked to two outcomes: a varying chance to receive an aversive stimulus and a varying high reward. A safe/low-reward option was linked to absence of the aversive stimulus and a low reward. Results: Avoidance of the threat/high-reward option increased with increasing threat. Despite threat, low-anxious individuals increasingly approached the threat/high-reward option when rewards increased. High- compared to low-anxious individuals showed elevated avoidance, but only in the presence of high competing rewards. Limitations: Future research should examine boundary conditions by manipulating type and motivational value of appetitive and aversive outcomes (e.g., food as primary reinforcer). Conclusions: These findings suggest that a weaker impact of rewards competing with threat contributes to elevated threat avoidance in anxious psychopathology. Costly avoidance may thus be a factor involved in anxious psychopathology.

As a core component of cognitive-behavioral therapies (CBT), behavioral exposure is an effective treatment for anxiety disorders. Still, recent treatment studies demonstrate relatively high rates of treatment dropout, nonresponse, and relapse, indicating a substantial need for optimizing and personalizing existing treatment procedures. In the present article, we aim to address current challenges and future demands for translational research in CBT for the anxiety disorders, including (a) a better understanding of those mechanisms conferring behavioral change, (b) identifying important sources of individual variation that may act as moderators of treatment response, and (c) targeting practical barriers for dissemination of exposure therapy to routine care. Based on a recursive process model of psychotherapy research we will describe distinct steps to systematically translate basic and clinical research "from bench to bedside" to routine care, but also vice versa. Some of these aspects may stimulate the future roadmap for evidence-based psychotherapy research in order to better target the treatment of anxiety disorders as one core health challenge of our time.

Avoiding stimuli that were previously associated with threat is essential for adaptive functioning, but excessive avoidance that persists in the absence of threat can turn dysfunctional and results in severe impairments. Fear and avoidance conditioning models have substantially contributed to the understanding of safety behaviors towards learnt fear stimuli. Safety behaviors are executed in the presence of a feared stimulus to prevent the upcoming threat and are well-established in laboratory models. Avoidance of learnt fear, i.e., avoidance of the feared stimulus itself, is typically initiated before the onset of a feared stimulus: individuals oftentimes avoid fear stimuli to prevent negative emotions evoked by them or ultimately the associated threat. Avoidance of learnt fear is surprisingly understudied despite its prevalence in pathological anxiety. The current overview proposes potential behavioral mechanisms and neural circuits of avoidance of learnt fear in humans, and discusses findings and paradigms suitable for examining it. Specifically, higher-order conditioning, decision making paradigms, and context-cue conditioning investigate distinct forms of avoidance of learnt fear. We also discuss the clinical prospects and future directions of research in avoidance of learnt fear.

Avoidance of learnt fear prevents the onset of a feared stimulus and the threat that follows. In anxiety-related disorders, it turns pathological given its cost and persistence in the absence of realistic threat. The current study examined the acquisition of costly avoidance of learnt fear in healthy individuals (n = 45), via a sensory preconditioning paradigm. Two neutral preconditioning stimuli (PSs) were paired with two neutral conditioned stimuli (CSs). One CS then came to predict an aversive outcome whereas the other CS came to predict safety. In test, participants engaged in stronger avoidance to the PS associated with the fear-related CS than the PS associated with the safety-related CS. Of note, executing behavioral avoidance led to missing out a competing reward, thus rendering avoidance costly. The results also provide preliminary evidence that threat anticipation and a negative change in valence play a role in driving costly avoidance of learnt fear. Future studies should examine how avoidance of learnt fear maintains pathological anxiety.

Individuals avoid stimuli which are associated with aversive experience to preserve safety. However, behavioral avoidance also causes impairments and prevents the individual from attaining positive rewards. Little is known about the link between fear acquisition and the development of behavioral avoidance in the presence of potential rewards. Therefore, two experiments investigated the impact of fear conditioning on a subsequent gambling task. In an experimental group (n = 30) advantageous choices (higher reward probability) were linked to a fear-relevant stimulus that was associated with an aversive unconditioned stimulus (US) during fear conditioning (conditioned stimulus, CS+). A disadvantageous choice (lower reward probability) was, however, linked to a safe stimulus that was never associated with the US (CS−). In a control group (n = 25), fear conditioning was followed by a similar gambling task with novel stimuli. A second experiment focused on individual predictors of avoidant decisions (n = 81). Compared with the control group, individuals in the experimental groups avoided the advantageous CS + choice despite fewer gains. The predictor analysis further clarified that avoidant decisions were pronounced in highly trait anxious participants who exhibited higher fear responses. On the other hand, findings also indicated a reduction in absolute avoidance across the task. Combined, these findings demonstrate that fear conditioning can lead to avoidant decision making, especially in vulnerable individuals. The resulting costs parallel impairments caused by behavioral avoidance. Such an emotional decision-making style may be a link between aversive experience and the development of habitual pathological avoidance. Introducing rewards for approach, however, may counteract avoidant decisions. (PsycInfo Database Record (c) 2022 APA, all rights reserved)