Indirect measures of associations and psychopathology: applications to Spider Phobia

To study of cognitive fear networks and associations, indirect experimental paradigms like the Implicit Association Test (IAT, Greenwald et al., 1998) or the Extrinsic Affective Simon Task (EAST, De Houwer, 2003) may be helpful, as they promise to assess the structure of specific associations using a performance based approach without having to ask the participant for a verbal report. Three studies investigated the usefulness and characteristics of IAT and EAST. The aim of the first study was to measure fear associations towards spiders among spider phobic and non-phobic participants as well as in a group of spider enthusiasts. Results indicate that the IAT paradigm is sensitive to the strength of fear relevant associations and able to predict anxious behavior beyond the predictions of direct measures such as questionnaires. The second study focused on some of the mechanisms that underlie IAT effects. With a newly developed masked IAT, these experiments investigated the influences of individual stimuli and superordinate categories on IAT performance. Besides theoretical implications, the results also provide practical, relevant applications for the use of IAT experiments. A third study applied the EAST to investigate how different context conditions lead to differential activation of cognitive schemata in fear of spiders. One can conclude that the impact of automatic threat associations depends on the activated context, and that the EAST is suitable for the assessment of fear associations and their current activation level. This dissertation leads to the conclusion that the performance based methodology of the IAT and EAST is a useful and practical approach to reflect fear associations in phobia indirectly. At this point, the use of indirect measures is still at its beginning, and requires intensive methodological and theoretical efforts. These paradigms, however, may become useful for possible implications in psychopathology and other fields of psychology

Virtual Reality Exposure Therapy for Adolescents with Public Speaking Anxiety

Bakgrunn: Presentasjonsangst er en av de vanligste fryktene blant ungdom. Angsten innebærer en redsel for å bli negativt evaluert, etterfulgt av en følelse av å bli flau eller ydmyket når man snakker foran andre. Eksponeringsterapi for presentasjonsangst er utfordrende å gjennomføre, da en trenger et reelt publikum som kan fungere som det fryktede stimuli. Virtual Reality (VR) kan være løsningen, da teknologien er i stand til å skape et virtuelt publikum, som kan oppleves som ekte. For voksne med presentasjonsangt finnes det flere randomiserte kontrollerte VR-studier som viser gode kliniske effekter, men en vet lite om effekten relatert til ungdom. Ingen studier har tidligere evaluert effekten av selvveiledet, automatiserte og spillbaserte VR-intervensjoner for ungdom med presentasjonsangst. Mål: Denne oppgaven adresserte aktuelle kunnskapshull ved å kartlegge den kliniske effekten og gjennomførbarheten av to VR-intervensjoner for ungdom med presentasjonsangst: en terapeutveiledet og en selvveiledet, automatisert og spillbasert intervensjon. Målet med Artikkel I var å undersøke gjennomførbarheten og den kliniske effekten av en terapeutveiledet, enkelt-sesjons VR-intervensjon for ungdom med presentasjonsangst. Hovedmålet med Artikkel II var å undersøke den kliniske effekten av en selvveiledet, automatisert og spillbasert VR-intervensjon sammenlignet med venteliste og en selvveiledet nettbasert intervensjon. Et sekundært mål var å undersøke om VR-intervensjonen førte til en økning i påfølgende eksponeringsøvelser under det nettbaserte eksponeringsprogrammet, sammenlignet med de som mottok nettbasert psykoedukasjons- og eksponeringsprogram. Målet med Artikkel III var å undersøke om intervensjonene rettet mot presentasjonsangst også førte til en reduksjon i symptomer på perfeksjonisme og om symptomer på perfeksjonisme modererte den kliniske effekten av intervensjonene for presentasjonsangst. Metode: To kliniske studier ga data for tre studier: en ikke-randomisert gjennomførbarhet- og pilotstudie (papir I) og en to-faset, firearmet randomisert kontrollert studie (papir II og III). Begge studiene undersøkte effekter og moderatorer av behandling: symptomer på generalisert sosial angst ved baseline og tilstedeværelse i det virtuelle miljøet (artikkel I) og om perfeksjonisme modererte behandlingsresultatet (artikkel III). Selvrapporterte symptomer på presentasjonsangst ble innhentet under intervensjons- og oppfølgingsperioden i begge studiene, i tillegg til hjertefrekvensmålinger under VR-eksponeringen i Artikkel I, selvrapporterte symptomer på generalisert sosial angst i Artikkel II og III, og perfeksjonisme i Artikkel III. Gjennomførbarhets- og pilotstudien i Artikkel I inkluderte N=27 ungdommer som deltok i en terapeutveiledet, 90-minutters VR-intervensjon på én sesjon ved klinikken. To-faset, firearmede randomiserte kontrollerte studien i Artikkel II og III inkluderte N=100 ungdommer som deltok i et seks ukers digitalt selvveiledet intervensjonsprogram. Ungdommene ble randomisert i fire grupper, med følgende fase én + fase to intervensjon; 1) Kun VR, 2) VR + nettbasert eksponeringsprogram, 3) Nettbasert psykoedukasjon + eksponeringsprogram, 4) Venteliste + nettbasert psykoedukasjonsprogram. Resultater: Resultater fra Artikkel I viste en signifikant reduksjon i presentasjonsangstsymptomer fra pre til post, og symptomene holdt seg stabile ved en og tre måneders oppfølging. Basert på tilbakemeldinger fra ungdommene, ble gjennomførbarheten av intervensjonen økt i løpet av studien, noe som resulterte i ingen manglende besvarelser ved oppfølging. Symptomer på generalisert sosial angst ved baseline og tilstedeværelse modererte ikke de kliniske effektene. Det var en liten økning i hjertefrekvensen under VR-eksponeringsoppgavene. Resultater fra Artikkel II viste en signifikant større reduksjon i presentasjonsangstsymptomer blant ungdommene som mottok VR-intervensjonen sammenlignet med ventelistegruppen. Resultatene viste også at VR + nettbasert eksponeringsprogram var like effektivt sammenlignet med kun VR og nettbasert psykoedukasjon + eksponeringsprogram. I tillegg hadde alle fire grupper en signifikant reduksjon i presentasjonsangstsymptomer. I motsetning til hypotesen fullførte ikke ungdommer som mottok VR-intervensjon et høyere antall in-vivo-eksponeringsoppgaver i løpet av nettbasert eksponeringsprogram sammenlignet med de som mottok nettbasert psykoedukasjon og eksponeringsprogram. De kliniske effektene holdt seg stabile ved tre måneders oppfølging. Resultater fra Artikkel III viste at intervensjonene ikke reduserte perfeksjonisme på gruppenivå, men det var signifikante individuelle forskjeller i endringer over tid. En nedgang i perfeksjonisme var assosiert med en større reduksjon på alle utfallsmål fra post til oppfølging. Det var ingen signifikante interaksjonseffekter mellom presentasjonsangstsymptomer og nivået av perfeksjonisme før behandling. Høye nivåer av perfeksjonisme før behandling var assosiert med dårligere langsiktige resultater for begge gruppene som mottok det nettbaserte eksponeringsprogrammet. Konklusjon: Denne oppgaven bidrar til det voksende evidensgrunnlaget for VR-eksponeringsterapi, og den første som demonstrerer potensialet til både terapeutveiledet og selvveiledet VR-behandling for ungdom generelt, og spesielt for de med presentasjonsangst. Resultatene indikerer at VR-behandling kan fungere som et indisert forebyggingsprogram for ungdom med PSA. Studiene som inngår i oppgaven er gjennomført ved hjelp av et solid design. Gjennomførbarhet og pilotering var første trinn, før man for første gang med denne målgruppen evaluerte de kliniske effektene i en randomisert kontrollert studie. I tillegg har oppgaven undersøkt relevante moderatorer av behandlinger; rollen til perfeksjonisme og hvordan den kan hindre bedring. Disse resultatene kan være veiledende for hvordan optimalisere fremtidige intervensjoner for ungdom med presentasjonsangst. Fremtidige studier bør undersøke om VR-terapi har en langsiktig forebyggende effekt på utvikling av generalisert sosial angst da dette fortsatt er uklart for denne aldersgruppen.Background: Public Speaking Anxiety (PSA) is one of the most common fears reported by adolescents. PSA involves the fear of being negatively evaluated, followed by a feeling of being embarrassed or humiliated when speaking in front of others. Providing state-of-the-art in-vivo exposure therapy for PSA is difficult due to the logistics of recruiting an actual audience trained to act as the feared stimuli. An attractive way of resolving this obstacle is through Virtual Reality (VR) technology, which is capable of creating an immersive experience of being in front of a virtual audience, as if it was real. Although there are several randomized controlled trials demonstrating the clinical efficacy of VR exposure therapy for adults with PSA, little is known about its clinical effects on adolescents. Moreover, no past study has evaluated self-guided and automated VR interventions for adolescents with PSA. Aims: This thesis addressed these key knowledge gaps by exploring the clinical effects and feasibility of both therapist-guided and self-guided, and automated VR interventions for adolescents with PSA. The aim of Paper I was to investigate the feasibility and the clinical effects of a therapist-guided, single-session VR-intervention for adolescents with PSA, using low-cost consumer VR hardware. The primary aim of Paper II was to investigate the clinical efficacy of a self-guided, automated, and gamified VR intervention compared with waitlist and self-guided online programs. A secondary aim was to explore whether the VR intervention led to an increase in subsequent exposure tasks during the online exposure program compared to those receiving the online psychoeducation and exposure program. The aim of Paper III was to investigate whether interventions targeting PSA also led to a reduction in symptoms of perfectionism and whether symptoms of perfectionism moderated the clinical efficacy of self-guided interventions for PSA. Methods: Two clinical trials provided data for three studies: one non-randomized feasibility and pilot study (Paper I) and a two-phased, four-armed randomized controlled study (Paper II and III). Both trials investigated effects and moderators of treatment: baseline generalized social anxiety symptoms and presence in the virtual environment (Paper I) and whether perfectionism moderated treatment outcome (Paper III). Self-reported PSA were assessed during the intervention and follow-up period in both studies, in addition to heart rate measurements during the VR exposure in Paper I, self-reported symptoms of generalized SAD in Paper II and III, and perfectionism in Paper III. The non-randomized feasibility and pilot study in Paper I included N=27 adolescents who participated in a therapist-guided, 90-minutes single-session VR intervention at the clinic. The two-phased, four-armed randomized controlled study in Paper II and III included N=100 adolescents who participated in a six weeks digital self-guided interventions program. The adolescents were randomized into four groups, with the following phase one + phase two intervention; 1) VR only, 2) VR + online exposure program, 3) Online psychoeducation + exposure program, 4) Waitlist + online psychoeducation program. Results: Results from Paper I revealed a significant decrease in PSA symptoms from pre to post, and symptoms remained stable at one- and three-month follow-up. Based on feedback from the adolescents, the feasibility of the intervention was increased during the trial, resulting in no missing data. Baseline generalized social anxiety symptoms and presence did not moderate the clinical effects. There was a small increase in heart rate during the VR exposure tasks. Results from Paper II revealed a significantly greater reduction in PSA symptoms among the adolescents who received the VR intervention compared to the the waitlist group. The results also demonstrated that VR + online exposure program was as equally effective as compared to VR only and online psychoeducation + exposure program. Moreover, all groups had a significant reduction in PSA symptoms. Contrary to the hypothesis, adolescents who received VR training did not complete a higher number of in-vivo-exposure tasks during the online exposure program compared to those receiving online psychoeducation and exposure program. The clinical effects remained stable at three-month follow-up. Results from Paper III revealed that the interventions did not reduce perfectionism at a group level, however, there were significant individual differences in changes over time. A decrease in perfectionism was associated with a larger reduction on all outcome measures from post to follow-up. There were no significant interaction effects between PSA symptoms and the pre-treatment level of perfectionism. High pre-treatment levels of perfectionism was associated with poorer long-term outcomes for both groups receiving the online exposure program. Conclusions: In sum, this thesis contributes to the growing evidence base for VR exposure therapy, and is among the first to demonstrate the potential of both therapist-guided and self-guided, VR interventions for adolescents in general and with PSA in particular. The results indicate that VR may serve as an indicated prevention program for adolescents with PSA. The studies included in the thesis is conducted through a strong design with feasibility and piloting as a first step before evaluating, for the first time with this target group, the clinical effects in a randomized controlled trial. Moreover, the thesis has investigated relevant moderators of treatments, specifically the role of perfectionism and how it may hinder treatment improvement. These results can provide guidance on how to optimize future interventions for the large group of adolescents with PSA. Future studies should investigate whether VR interventions have a long-term preventive effect on the development of generalized social anxiety as this remains unclear for this age group.Doktorgradsavhandlin

A Nonconcurrent Multiple Baseline Evaluation of an Independence Intervention to Treat Child Anxiety

Rates of child and adolescent anxiety have increased markedly over the past decade (Haidt & Twenge 2021; Parodi et al., 2021). Exposure-based cognitive-behavioral therapy is considered the gold standard in the treatment of anxious children (Hofmann et al., 2012). However, many clinicians refrain from using exposure due to concerns about its safety, effectiveness, and ethics (Deacon et al., 2013; Whiteside et al., 2016). We propose a novel treatment approach for child and adolescent anxiety that draws on research in child development (e.g. Daddis, 2011) and is considerably simpler to administer than traditional exposure-based approaches. This new approach is composed of independence activities (IAs), which are defined as child-directed, fun, unstructured, developmentally challenging tasks that are performed without any help from parents. These tasks are purposely topographically unrelated to the stimuli that cause anxiety, in direct contrast to exposure therapy, which is topographically similar to anxiety-causing stimuli. Despite this dissimilarity, IAs target the hypothesized mechanisms involved in the development and maintenance of child anxiety (e.g. parental accommodation and overinvolvement, child avoidance, and unhelpful thinking styles). IAs also target decreasing rates of child independence from parents, which may in and of itself be an important mechanism in the development of child anxiety (Skenazy, 2021). It was hypothesized that treating child anxiety in this way, without requiring exposure exercises, would result in high treatment acceptability from children and parents. This study employed a nonconcurrent multiple baseline design to examine independence activities as an intervention for child anxiety and independence as a mechanism of child anxiety. Small to large improvements in child (behavioral and cognitive) mechanisms involved in the maintenance of child anxiety, measures of child anxiety and avoidance, parent (behavioral and cognitive) mechanisms involved in the maintenance of child anxiety, and untargeted secondary outcomes such as child happiness were observed. Results have valuable theoretical implications for our understanding of the role that parental overinvolvement plays in child anxiety

Comorbid psychopathology in children with Autism Spectrum Disorders - cut-off scores for the Autism Specturm Disorders-comorbidity for children (ASD-CC)

Once considered rare, Autism Spectrum Disorders (ASD) are increasingly becoming viewed as common disorders. Prevalence rates of ASD have increased drastically in recent years. Recent studies suggest comorbid psychopathology within ASD to be more common than previously thought. Though these deficits exist, specific instruments to diagnose psychopathology in this population do not yet exist. This highlights the underlying need for instruments to identify psychopathology in individuals with ASD. The aim of this study was to establish cut-off scores for the Autism Spectrum Disorder – Comorbidity for Children, an instrument designed to assess for comorbid psychopathology within individuals with ASD

Use of Mental Imagery in Psychotherapy: A Critical Review

The paper presents arguments in favor of the use of mental imagery for therapeutic purposes. Several existing imagery approaches to psychotherapy are critically examined and suggestions for future inquiry are offered. The intimate relation between imagery and the affective-somatic processes is stressed

A Review of the Role of Anxiety in Diagnosis of Children and Adolescents with Autism Spectrum Disorder: A Paradigm Shift in Conceptualization and Diagnosis

Early evidence of co-occurring anxiety symptoms in children and adolescents with autism spectrum disorder (ASD) dates back to the first descriptions of ASD by Leo Kanner (1943) and Hans Asperger (Frith & Mira, 1992). While current research has identified anxiety disorders as one of the most prevalent co-occurring disorders in children and adolescents with ASD, little is known about the nature of the relationship between these disorders. In an effort to explain these high prevalence rates, recent research has started to investigate the relationship between these two disorders. To join these efforts, this clinical research project explored the role of anxiety in diagnosis of children and adolescents with ASD. To guide the exploration of this role, the following research questions were answered: How prevalent or significant is anxiety in children and adolescents with ASD?; How do symptoms of anxiety manifest in children and adolescents with ASD?; and How is anxiety conceptualized, assessed, and treated in ASD? Results from this literature review indicate that there are current limitations in this area of research that need to be addressed to form an accurate conceptualization of anxiety symptoms in this population. Steps to resolve these limitations are discussed and areas of further research are explored. Recommendations for accurately assessing and treating co-occurring symptoms of anxiety in youth with ASD are provided and a suggested conceptualization model based off current research is proposed

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Characteristics of Internalizing Social-Emotional Behaviors of Southwestern Native American Children

The knowledge base targeting internalizing symptomatology in Native American children is surprisingly limited. As yet, it is not clear if the process and symptoms of internalizing disorders are the same across cultures. The need for further investigation is heightened by the fact that, compared to the majority population, Native Americans are believed to be at greater risk for psychological problems because of impoverished conditions, high unemployment, and high numbers of traumatic events on the reservations. Additionally, the losses of traditional culture and language are considered risk factors for greater psychopathology. The negative ramifications of internalizing disorders (e.g., depression and anxiety) include academic failure, lowered social skills and self-esteem, and greater risk for substance abuse and suicide. Furthermore, evidence suggests that all children with mental disorders are at high risk for severe psychopathology when left unidentified or untreated. It seems clear that additional research is needed to better understand internalizing symptoms among members of this cultural group. To help meet this need, the present study focused on internalizing disorders among Native American children from the southwest, utilizing a portion of extant data from the Flower of Two Soils Project. This project was one of very few methodologically sound studies that have been successful in obtaining multisource. multimethod data on social, emotional, and behavioral functioning of Native American children. Data were collected using a modified version of the Child Behavior Checklist (CBCL), Youth Self-Report (YSR), and Teacher\u27s Report Form (TRF) assessment instruments for parents, teachers, and children. Findings with respect to elementary school-aged children found relatively high rates of depression, anxiety, somatization symptoms and, potentially, disorders. These findings are a cause for concern among parents, teachers, and all agencies responsible for children\u27s mental health. Across all three informant groups a consistent pattern of negative correlations was observed between internalizing symptoms and child competencies. This finding is consistent with previous findings for the general population. However,. competitiveness and academic achievement were positively correlated with internalizing symptoms, perhaps indicating that an emphasis on competitiveness and individual achievement is stressful for children from a collectivistic Native American culture. This was a descriptive study providing broad exploratory information, but there remains a need for more focused research identifying multivariate relationships among relevant variables. These findings should be cautiously interpreted and with due consideration for the specific cultural and historical context of children and families. Recommendations are included for research and practice