Therapists' characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth:A survey among Dutch-speaking mental health practitioners

INTRODUCTION: Although there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders. METHODS: An internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety, depression and stress. RESULTS: The current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists' age, and non-CBT orientation. DISCUSSION: Findings point to the importance of addressing negative beliefs about exposure in therapists' training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders

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.</p

Clinical Features, Prevalence and Psychiatric Complaints in Subjects with Fear of Vomiting

Specific phobia of vomiting (also known as emetophobia) is a relatively understudied phobia with respect to its aetiology, clinical features and treatment. In this stage, research is mostly based on people with self-reported fear of vomiting. This paper presents a survey on the clinical features of fear of vomiting of individuals. Self-reported vomit-fearful subjects from the Dutch community and from an Internet support group are included. Both vomit-fearful groups were characterized by high reports of fear, the presence of panic symptoms, and by extensive avoidance and safety behaviours. They also reported other psychiatric complaints, which were measured with a structured screening instrument. Vomiting complaints started mostly in late puberty. A significant proportion of the vomit-fearful participants had a treatment history. The prevalence rate of fear of vomiting in the community sample was established at 8.8% (female?:?male ratio?=?4:1). Overall, results show that fear of vomiting is a common phenomenon, which can seriously impair daily functioning. Finally, clinical questions to be addressed in future research are formulated. Copyright (c) 2011 John Wiley & Sons, Ltd. Key Practitioner Message Specific phobia of vomiting (also known as emetophobia) is among the least studied phobias. Most clinical data come from research with self-described fear of vomiting. This paper presents data on the clinical features, prevalence and additional psychiatric complaints of fear of vomiting in two vomit-fearful samples and one control sample with no fear of vomiting. Estimates of prevalence of fear of vomiting in a Dutch community sample were established at 1.8% for men and 7% for women. Evidence suggests that fear of vomiting is a chronic and disabling condition that may cause significant impairment in daily functioning

Overprediction of fear in panic disorder patients with agoraphobia:Does the (mis)match model generalize to exposure in vivo therapy?

The purpose of this study was to test the (mis)match model of Rachman and co-workers during real life exposure therapy in panic disorder patients with agoraphobic avoidance. The results showed that although the patients tended to overpredict their expected fear before the exposure sessions, their predictions did not show a tendency to become more accurate in the course of treatment. After an overprediction predicted fear tended to decrease and self-efficacy tended to increase; after a correct match both predicted fear and self-efficacy remained unchanged. Patients reports of fear tended to decrease within and across exposure sessions regardless of the occurrence of correct or incorrect matches. Patients reported significantly more positive self-statements in underprediction sessions compared to overprediction and correct match sessions. Positive self-statements increased both in underprediction and correct match sessions, but decreased in overprediction sessions. The largest reduction in negative self-statement within an exposure session was found in correct match sessions. The theoretical and clinical relevance of the results are discussed in line of the match/mismatch model of Rachman and co-workers

Disgust- and anxiety-based emotional reasoning in non-clinical fear of vomiting

Background and objectives Emotional reasoning has been described as a dysfunctional tendency to use subjective responses to make erroneous inferences about threatening outcomes in objectively safe situations (e.g., ”If I feel anxious/disgusted, there must be danger/risk of becoming ill”). Prior studies found evidence for anxiety-based emotional reasoning (ER) in several anxiety disorders as well as disgust-based ER in healthy individuals scoring above the clinical cut-off on a measure of contamination fear. The current study tested whether disgust- and anxiety-based ER might be involved in fear of vomiting, a phobic disorder in which both fear/anxiety and disgust are assumed to play an important role. Methods Non-clinical participants scoring high (>75%; n = 35) and low (<25%; n = 38) on a measure of fear of vomiting were presented with a series of scripts describing objectively safe everyday situations that systematically varied in the absence/presence of the actor's disgust/anxiety response. Following each script, participants rated their perceived danger and threat of contamination/illness. Results In line with hypotheses, specifically high vomit-fearful individuals used experienced disgust and anxiety to overestimate risk of becoming ill. Follow up analyses taking into account shared variance between both emotions revealed that more pronounced ER in the high vomit fearful group was mainly driven by the emotion of disgust. Limitations Current study asked participants to imagine experienced emotions in scenarios instead of experimentally inducing real-life emotions. Conclusions These findings are consistent with the view that disgust-based ER is involved in fear of vomiting

The role of negative self-statements during exposure in vivo. A process study of eight panic disorder patients with agoraphobia

The purpose of this study was to evaluate the pattern of cognitive change, and in particular the role of negative self-statements, in relation to improvement during an in vivo exposure treatment. Eight panic disordered patients with agoraphobia, of whom 4 were most and 4 were least improved on a composite measure, were exposed to standardized agoraphobic situations. During the exposure, heart rate, self-statements, and subjective anxiety were registered throughout the sessions. Fixed criteria were set for habituation of heart rate and reduction of subjective anxiety within a session. Results showed that the total frequency of negative self-statements at the start, during, as well as at the end of treatment differentiated best between the most and least improved patients. These results suggest that it may be therapeutically wise to continue exposure therapy not only until habituation of anxiety (subjectively and physiologically) is achieved, but also until the frequency of negative self-statements is reduced until zero

"If I feel disgusted, I must be getting ill":Emotional reasoning in the context of contamination fear

<p>Patients suffering from anxiety disorders have been shown to infer danger on the basis of their anxiety responses "if heel anxious, there must be danger." This tendency logically hampers the identification of false alarms and may thus act in a way to confirm the a priori threat value of the feared stimuli/situations. Since disgust is assumed to play a critical role in the persistence of contamination fears in OCD, the question rises whether individuals suffering from fear of contamination perhaps similarly infer danger on the basis of their disgust response: "If I feel disgusted, it must be contagious." Therefore, this study tested whether indeed disgust-based reasoning might be involved in fear of contamination. On the basis of the contamination fear subscale of the Padua Inventory (PI), we selected a group of participants scoring higher than the established clinical range (n = 31, PI > 13) and a group of participants low (n = 27, PI <5) in contamination fear. Each participant was presented with a series of 2 times 4 types of scripts that systematically varied in the absence/presence of objective threat of contamination and the absence/presence of the actor's disgust response. Following each script, participants rated their perceived threat of contamination/illness. In line with the hypothesis that disgust-based reasoning might be involved in fear of contamination, specifically high contamination fearful individuals inferred risk of becoming ill on the basis of experienced disgust (in addition to objective threat), as was evidenced by a significant Group (high vs. low) x Threat (yes vs. no) x Disgust response (yes vs. no) interaction. This finding might not only help to explain the persistence of contamination fears, but also provides some fresh clues to improve currently available treatment options. (C) 2012 Elsevier Ltd. All rights reserved.</p>

Covariation bias for social events and signs of (dis)approval in high and low socially anxious individuals

In two covariation bias experiments, we investigated whether socially anxious women overestimate the contingency between social events and signs of rejection and/or to underestimate the contingency between social events and approval. Participants were exposed to descriptions of ambiguous or negative social events, situations involving animals, and nature scenes that were randomly paired with disgusting, happy, and neutral faces. Socially anxious participants reported enhanced belongingness between ambiguous events and signs of rejection, together with reduced belongingness between negative events and approval. This contributes to previous findings suggesting that socially anxious individuals suffer from fear-confirming interpretive biases. There was no evidence for enhanced negative or reduced positive covariation bias in socially anxious individuals. (C) 2009 Elsevier Ltd. All rights reserved

Effectiveness of exposure-based treatment for childhood anxiety disorders:An open clinical trial to test its relation with indices of emotional processing and inhibitory learning

BACKGROUND AND OBJECTIVES: The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises.METHODS: Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change.RESULTS: From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations.LIMITATIONS: As patients also received other treatment elements, the results cannot be interpreted unequivocally.CONCLUSIONS: The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.</p

An internet-based study on the relation between disgust sensitivity and emetophobia

In the etiology of disgust-relevant psychopathology, such as emetophobia (fear of vomiting), two factors may be important: disgust propensity, i.e., how quickly the individual experiences disgust, and disgust sensitivity, i.e., how negatively does the individual evaluate this disgust experience [van Overveld, W. J. M., de Jong, P. J., Peters, M. L., Cavanagh, K., & Davey, G. C. L. (2006). Disgust propensity and disgust sensitivity: separate constructs that are differentially related to specific fears. Personality and Individual Differences, 41, 1241-1252]. Hence, the current study examines whether emetophobic participants display elevated levels of disgust propensity and sensitivity, and whether these factors are differentially related to emetophobia. A group of emetophobic members of a Dutch website on emetophobia (n = 172), and a control group (n = 39) completed an internet survey containing the Emetophobia Questionnaire, Disgust Propensity and Sensitivity Scale-Revised, Disgust Scale, and Disgust Questionnaire. Results showed that the emetophobic group displayed significantly elevated levels of both disgust propensity and disgust sensitivity compared to the control group. Most importantly, disgust sensitivity consistently was the best predictor of emetophobic complaints. (C) 2007 Elsevier Ltd. All rights reserved