Dissertations / Theses on the topic 'Specific phobias'

There is now considerable evidence that phobic responding is associated with a bias towards expecting aversive or traumatic outcomes following encounters with the phobic stimulus (e.g. Davey, 1995). In terms of conditioning contingencies, this can be described as a bias towards expecting an aversive or traumatic outcome (the unconditioned stimulus - UCS) following a phobic stimulus (the conditioned stimulus - CS). Research into the role of UCS expectancy biases in the development and maintenance of specific phobias has three basic requirements. First, it is not clear whether the ues expectancy biases evidenced in specific phobias represent a stimulus specific response or a more generalised associative phenomenon. Second, it is not clear what dispositional or state factors might contribute to the development and maintenance of such ues expectancy biases. Third, it is not clear what type of cognitive mechanisms might underlie UCS expectancy biases. This thesis uses a thought experiment version of a threat conditioning procedure to explore these requirements. The key findings indicate that spider phobics tend to overestimate the likelihood of aversive outcomes following phobic, but not other fear relevant stimuli, and tend to underestimate the likelihood of aversive outcomes following fear irrelevant stimuli in comparison to non-phobic controls. This dichotomous ues expectancy bias is mirrored both in the evaluation of stimuli in terms of dangerousness and valance, and in the generation of harm and safety cues with regards to these stimuli. Both positive and negative mood states, but not arousal states contributed to ues expectancy inflation, and in the case of revulsive animals induced state disgust also increased reported ues expectancies. The thesis concludes with an evaluation of the role of UCS'S expectancies in the development and maintenance of specific phobias, and a discussion of the implications of these findings for our understanding of the information processing mechanisms underlying the specific phobias.

The present dissertation consists of three empirical studies on children and adolescents presenting with various specific phobias in Stockholm, Sweden and in Virginia, USA. The overall aim was to contribute to our understanding of childhood fears, anxiety and phobias and to evaluate the efficacy and portability of a one-session treatment of specific phobias in youth. Study I tested the dimensionality of the Parental Bonding Instrument, across three generations and for two countries, and examined if parenting behaviors of indifference and overprotection were associated with more anxiety problems in children. The results showed that the four-factor representation of parental behavior provided an adequate fit for the instrument across informants. Perceived overprotection was associated with significantly more anxiety symptoms and comorbid diagnosis in children. Study II explored parent-child agreement on a diagnostic screening instrument for youths. The results indicated that children scoring high on motivation at treatment entry had generally stronger parent-child agreement on co-occurring diagnoses and severity ratings. Parents reported overall more diagnoses for their children, and parents who themselves qualified for a diagnosis seemed more tuned in to their children’s problematic behavior. Study III compared a one-session treatment with an education-supportive treatment condition, and a wait-list control condition for children presenting with various types of specific phobias. The results showed that both treatment conditions were superior to the wait-list control condition and that one-session exposure treatment was superior to education-supportive treatment on several measures. Treatment effects were maintained at a 6-month follow-up. Overall, the above findings suggest that the one-session treatment is portable and effective in treating a variety of specific phobias in children and adolescents.

Specific phobia of the animal subtype has been employed as a model disorder exploring the neurocircuitry of anxiety disorders, but evidence is lacking whether the detected neural response pattern accounts for all animal subtypes, nor across other phobia subtypes. The present study aimed at directly comparing two subtypes of specific phobia: snake phobia (SP) representing the animal, and dental phobia (DP) representing the blood-injection-injury subtype. Using functional magnetic resonance imaging (fMRI), brain activation and skin conductance was measured during phobogenic video stimulation in 12 DP, 12 SP, and 17 healthy controls. For SP, the previously described activation of fear circuitry structures encompassing the insula, anterior cingulate cortex and thalamus could be replicated and was furthermore associated with autonomic arousal. In contrast, DP showed circumscribed activation of the prefrontal and orbitofrontal cortex (PFC/OFC) when directly compared to SP, being dissociated from autonomic arousal. Results provide preliminary evidence for the idea that snake and dental phobia are characterized by distinct underlying neural systems during sustained emotional processing with evaluation processes in DP being controlled by orbitofrontal areas, whereas phobogenic reactions in SP are primarily guided by limbic and paralimbic structures. Findings support the current diagnostic classification conventions, separating distinct subtypes in DSM-IV-TR. They highlight that caution might be warranted though for generalizing findings derived from animal phobia to other phobic and anxiety disorders. If replicated, results could contribute to a better understanding of underlying neurobiological mechanisms of specific phobia and their respective classification.

Specific phobia of the animal subtype has been employed as a model disorder exploring the neurocircuitry of anxiety disorders, but evidence is lacking whether the detected neural response pattern accounts for all animal subtypes, nor across other phobia subtypes. The present study aimed at directly comparing two subtypes of specific phobia: snake phobia (SP) representing the animal, and dental phobia (DP) representing the blood-injection-injury subtype. Using functional magnetic resonance imaging (fMRI), brain activation and skin conductance was measured during phobogenic video stimulation in 12 DP, 12 SP, and 17 healthy controls. For SP, the previously described activation of fear circuitry structures encompassing the insula, anterior cingulate cortex and thalamus could be replicated and was furthermore associated with autonomic arousal. In contrast, DP showed circumscribed activation of the prefrontal and orbitofrontal cortex (PFC/OFC) when directly compared to SP, being dissociated from autonomic arousal. Results provide preliminary evidence for the idea that snake and dental phobia are characterized by distinct underlying neural systems during sustained emotional processing with evaluation processes in DP being controlled by orbitofrontal areas, whereas phobogenic reactions in SP are primarily guided by limbic and paralimbic structures. Findings support the current diagnostic classification conventions, separating distinct subtypes in DSM-IV-TR. They highlight that caution might be warranted though for generalizing findings derived from animal phobia to other phobic and anxiety disorders. If replicated, results could contribute to a better understanding of underlying neurobiological mechanisms of specific phobia and their respective classification.

Thesis (M.A.) -- University of Maryland, College Park, 2005.
Thesis research directed by: Dept. of Psychology. Title from t.p. of PDF. Includes bibliographical references. Published by UMI Dissertation Services, Ann Arbor, Mich. Also available in paper.

The current study examined the effects of specific phobia on an individual's quality of life (QOL) and life satisfaction. To that end, 29 individuals with DSM-IV diagnoses of specific phobia and 30 control participants with no current diagnosable psychopathology completed several widely utilized self-report questionnaires and an interview on QOL. Trained and reliable clinicians also completed ratings of participants QOL. Results were divided into participant-rated QOL findings and clinician-rated QOL findings. Participant-rated findings suggested phobic individuals experienced significantly more dissatisfaction with their ability to learn and acquire new skills than did controls. Phobic participants, however, also rated themselves as having less impairment than controls from pain—presumably related to their phobic avoidance. Clinician-rated findings suggested significant distress and impairment in phobic individuals' QOL relative to controls across a variety of domains (e.g., school, family, etc.). Discrepant findings between participant ratings and clinician ratings were explained using a cognitive dissonance model. Implications for future QOL research in those individuals with specific phobia as well as implications for their treatment were discussed.
Ph. D.
[Appendix D: Quality of Life Inventory, p. 68-74, was removed Nov. 8, 2011 GMc]

BACKGROUND.One group of theories aiming at providing a framework explaining the etiology, maintenance and phenomenology of anxiety disorders is classified as cognitive models of anxiety. These approaches assume that distortions in specific levels of information processing are relevant for the onset and maintenance of the disorder. A detailed knowledge about the nature of these distortions would have important implications for the therapy of anxiety, as the implementation of confrontative or cognitive elements precisely fitting the distortions might enhance efficacy. Still, these models and related empirical evidence provide conflicting assumptions about the nature of disorder-linked processing distortions. Many cognitive models of anxiety (e.g., Fox, Russo, & Dutton, 2002; Mathews & Mackintosh, 1998; Williams, Watts, MacLeod, & Mathews, 1997) postulate that anxiety-linked biases of attention imply hypervigilance to threat and distractibility from other stimuli in the presence of feared materials. This is convincingly confirmed by various experimentalclinical studies assessing attention for threat in anxious participants compared to non-anxious controls (for a review, seeMathews &MacLeod, 2005). In contrast, assumptions concerning anxiety-linked biased memory for threat are less convincing; based on the shared tendency for avoidance of deeper elaboration in anxiety disorders, some models predict memory biases only for implicit memory tasks (Williams et al., 1997) or even disclaim the relevance of memory in anxiety at all (e.g., Mogg, Bradley, Miles, & Dixon, 2004). Other theories restrict the possibility of measuring disorder-specific memory biases to tasks that require merely perceptual encoding of the materials instead of verbal-conceptual memory (e.g., Fox et al., 2002; Mathews &Mackintosh, 1998). On the one hand, none of these models has integrated all the inconsistencies in empirical data on the topic. On the other hand, the numerous empirical studies on memory in anxiety that have been conducted with varying materials, anxiety disorders, encoding and retrieval conditions do not allow final conclusions about the prerequisites for finding memory biases (for a review, see MacLeod & Mathews, 2004). A more detailed investigation of the complete spectrum of memory for threat utilizing carefully controlled variations of depth of encoding and materials is needed. In view of these inconsistencies, it is all the more surprising that one important part of this spectrum has so far remained completely uninvestigated: visual working memory (VWM). No study has ever differentially addressed VWM for threat in anxious vs. nonanxious participants and none of the cognitive models of anxiety provides any predictions concerning this stage of information processing. Research on cognitive biases in anxiety has thus far only addressed the two extremes of the processing continuum: attention and longer-term memory. In between, a gap remains, the bridging of which might bring us closer to defining the prerequisites of memory biases in anxiety. As empirical research has provided substantial and coherent knowledge concerning attention in anxiety, and as attention and VWM are so closely linked (see, for instance, Cowan, 1995), the thorough investigation of VWM may provide important clues for models of anxiety. Is anxiety related to VWM biases favoring the processing of threatening information, or does the avoidance presumed by cognitive models of anxiety already begin at this stage? RESEARCH AIMS. To investigate the relevance of biased VWM in anxiety, the present research focused in eight experiments on the following main research questions: (1) Is threat preferably stored in VWM in anxious individuals? (2) Does threat preference occur at the cost of the storage of other items, or is extra storage capacity provided? (3) Would the appearance of threat interrupt ongoing encoding of non-threatening items? (4) Does prioritized encoding of threat in anxiety occur strategically or automatically? (5) Are disorder-specific VWM biases also materials-specific? (6) Are VWM biases in anxiety modifiable through cognitive-behavioral therapy? METHODS. In Experiments 1-4, a spatial-sequential cueing paradigm was used. A subset of real-object display items was successively cued on each trial by a sudden change of the picture background for 150 ms each. After the cueing, one of the display pictures was hidden and probed for a memory test. On most trials, a cued item was tested, and memory accuracy was determined depending on the item’s position within the cue string and depending on its valence. In some cases, memory for an uncued item was tested. Experiment 1 and 2 were directed at discovering whether spider fearfuls and non-anxious controls would differ with respect to the accuracy in memorizing cued spiders and uncued spiders and, thus, reveal disorder-specific biases of VWM. In addition, the question whether the presence of a spider image is related to costs for the memorization of other images was tested. Experiment 3 addressed whether any disorder-specific VWM biases found earlier were specific to the feared spiders. Therefore, the critical stimuli here were a snake and a spider. Participants were spider fearfuls and non-anxious controls, both without snake anxiety. In Experiment 4, it was tested whether disorder-specific biases found in Experiment 1 and 2 were modifiable through cognitive-behavioral treatment. The critical stimulus was a spider image. Spider fearfuls were tested three times. Half of them received a cognitive-behavioral intervention after the first test, the other half only after the second test. In two additional experiments, VWM was assessed with a change-detection paradigm. The main aim was to clarify whether disorder-specific effects found in the previous experiments were associated with automatic or with strategic selective encoding of threatening materials, and whether any group differences in spider change detection were materials-specific to spiders, but not to snakes. In Experiment 5, several images were presented simultaneously in a study display for either 100 or 500 milliseconds. After a short interruption, a test display was presented including either the same items as the first one or one changed item. Participants’ accuracy in determining whether displays were the same or different was measured depending on the valence of the changed item, set size, and presentation time of the display. There were trials with and without spiders. If a change was made, it could involve either a non-spider or a spider item. Of specific interest was the condition in which a spider image was presented initially, but not in the test phase, as noticing this specific change would require storage of that image in VWM. Would group differences be particularly pronounced in the shorter encoding condition suggesting automatic encoding of threat, or would they occur in the longer encoding condition, suggesting strategic encoding of spiders? In Experiment 6, change detection accuracy for spiders vs. snakes was tested. The participants in both experiments were spider fearfuls vs. controls, but those of Experiment 6 were additionally required to lack snake anxiety. Moreover, a temporal VWM paradigm - an attentional blink task - was applied to assess whether a biased encoding of spider images in spider fearfuls would occur at the expense of non-threatening items undergoing concurrent processing, and whether this effect was specific to spiders, but not to snakes. Series of real-object pictures were presented at rates of 80 ms at the display center. The observer’s task was to identify and report the two target pictures indicated by a brighter background. In Experiment 7, the first target always depicted a neutral item. The valence of the second target was varied - either negative depicting a spider, positive, or neutral. Participants varied with respect to their spider anxiety. In Experiment 8, spider fearfuls and non-anxious controls, both without snake anxiety, were tested. The experiment was nearly the same as the previous one, but two negative target types were tested: disorder-relevant spiders and negative but not feared snakes. Of specific interest was whether the appearance of a threatening target would reduce the report probability of the earlier attended target, indicating the interruption of its VWM encoding in favor of the threat item. RESULTS. (1) Both anxious and non-anxious controls, showed VWM advantages for negative materials such as spider or snake images. (2) In addition, there were disorderspecific VWM biases: some effects were larger in spider fearfuls than in non-anxious controls and some effects occurred exclusively in spider fearfuls. (3) Group differences and, thus, disorder-specificity were particularly pronounced under competitive circumstances, that is, under the condition of numerous stimuli competing for processing resources: when only little orientation time was allowed, when only little time was provided for selecting and encoding items from a crowd, and when VWMfor the critical item required reflexive instead of voluntary attention. (4) Pronounced memory for task-relevant, voluntarily attended spiders was related to difficulties in disengaging attention from these items in the fearful group, reflected in reduced memory accuracy for the item following it. (5) Disorder-specific VWM biases seem to be based on attentional biases to threatening materials resulting in a very quick, automatic memory consolidation. However, this preferential encoding was not at the cost of neutral materials currently undergoing encoding processes. (6) All disorder-specific VWM biases occured only with fear-related materials, not with other negative materials. (7) Automatic and highly disorder-specific fear-related VWM biases – but not strategic VWM biases occuring in both groups - were modifiable through cognitive-behavioral intervention. CONCLUSIONS. This work provides additional information about informationprocessing distortions related to specific anxiety. With the experimental investigation of biased VWM, this work has been performed to fill a gap within research on cognitive biases in anxiety. Moreover, this dissertation contributes to cognitive theories of anxiety by proposing several recommendations for refinements of current theoretical approaches. Most important, it was suggested to extend existing models by a more detailed consideration of attention and memory. In view of numerous previous empirical studies on the topic and the conclusions of this dissertation, a differentiation of the attentional engagement and disengagement component appears inevitable. Even more important, in view of the data presented here predictions concerning VWM for threatening materials need to be taken into account. In addition, suggestions are provided for the differential consideration of biases occuring from prepotent threat value of negative stimuli vs. individual threat value. A proposal for a cognitive model of anxiety extended by all these aspects is provided to serve as an invitation of further research in the investigation of the nature of memory biases in anxiety disorders. REFERENCES: Cowan, N. (1995). Attention and Memory. An integrated framework.New York: Oxford University Press. Fox, E., Russo, R., & Dutton, K. (2002). Attentional bias for threat: Evidence for delayed disengagement from emotional faces. Cognition and Emotion, 16, 355-379. MacLeod, C., & Mathews, A. (2004). Selective memory effects in anxiety disorders: An overview of research findings and their implications. In D. Reisberg & P. Hertel (eds.), Memory and Emotion. Oxford: Oxford University Press. Mathews, A., & Mackintosh, B. (1998). A cognitive model of selective processing in anxiety. Cognitive Therapy and Research, 22 (6), 539-560. Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emotional disorders. Annual Review of Clinical Psychology, 1, 167-195.Mathews, Mogg, May, & Eysenck (1989). Mogg, K., Bradley, B.P., Miles, F., & Dixon, R. (2004). Time course of attentional bias for threat scenes: Testing the vigilance avoidance hypothesis. Cognition and Emotion, 18(5), 689-700. Williams, J.M.G., Watts, F.N., MacLeod, C., & Mathews, A. (1997). Cognitive psychology and emotional disorders. Chichester: John Wiley.

This volume contains three parts. Part 1 is a literature review. This systematically reviews evidence for maintenance factors of specific phobias in adults. The maintenance factors are derived from cognitive-behavioural models. The review includes studies which demonstrate that the maintenance factor has a causal influence on phobic symptoms. Part 2 is an empirical paper. This paper describes an exploratory study of intrusive mental imagery in adults with a specific phobia of vomiting. Information about the presence and nature of imagery was derived using quantitative semi-structured interviews. Imagery data was compared against severity of phobia data. The study also includes a single case experiment which investigates the effectiveness of imagery rescripting for phobia of vomiting. Part 3 is a critical appraisal. This paper provides reflections on the research process and an expanded discussion of the findings.

Die Spezifischen Phobien stellen die häufigste Gruppe der Angststörungen dar. Die Angst vor dem Verschlucken bzw. dem Ersticken wurde jedoch nur sehr selten beschrieben. Bei der Behandlung der Spezifischen Phobien wird fast immer eine Konfrontation in vivo eingesetzt. Die Angst vor dem Verschlucken scheint aber eine der Spezifischen Phobien zu sein, bei der eine Konfrontation schwierig ist. Die hier vorgestellte Fallgeschichte schildert eine mögliche Vorgehensweise, die Ängste vor dem Verschlucken mit einer Reizkonfrontation in vivo zu behandeln. Dabei werden die verschiedenen Schwierigkeiten, die aufgetreten sind, und ihre Lösungen geschildert. Die Therapie wurde erfolgreich abgeschlossen, und auch die Ergebnisse der Nachuntersuchungen zeigten eine stabile Verbesserung
Specific phobias are the most common anxiety disorders. However, the fear of swallowing the wrong way and choking has rarely been described. Specific phobias are usually treated using exposure therapy. The excessive fear of swallowing the wrong way does not seem to be very well suited for an exposure in vivo. In this case study, a patient afflicted with the fear of swallowing and choking was treated with flooding. The various difficulties encountered during treatment and their remedies will be described. The therapy was successful. The patient showed stable and lasting improvements at posttreatment and at one-year follow-up
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

Background: Anxiety in the workplace is a special problem as workplaces are especially prone to provoke anxiety: There are social hierarchies, rivalries between colleagues, sanctioning through superiors, danger of accidents, failure, and worries of job security. Workplace phobia is a phobic anxiety reaction with symptoms of panic occurring when thinking of or approaching the workplace, and with clear tendency of avoidance. Objectives: What characterizes workplace-related anxieties and workplace phobia as domain-specific mental disorders in contrast to conventional anxiety disorders? Method: 230 patients from an inpatient psychosomatic rehabilitation center were interviewed with the (semi-)structured Mini-Work-Anxiety-Interview and the Mini International Neuropsychiatric Interview, concerning workplace-related anxieties and conventional mental disorders. Additionally, the patients filled in the self-rating questionnaires Job-Anxiety-Scale (JAS) and the Symptom Checklist (SCL-90-R)measuring job-related and general psychosomatic symptom load. Results: Workplace-related anxieties occurred together with conventional anxiety disorders in 35% of the patients, but also alone in others (23%). Workplace phobia could be found in 17% of the interviewed, any diagnosis of workplace-related anxiety was stated in 58%. Workplace phobic patients had significantly higher scores in job-anxiety than patients without workplace phobia. Patients with workplace phobia were significantly longer on sick leave in the past 12 months (23,5 weeks) than patients without workplace phobia (13,4 weeks). Different qualities of workplace-related anxieties lead with different frequencies to work participation disorders. Conclusion: Workplace phobia cannot be described by only assessing the general level of psychosomatic symptom load and conventional mental disorders. Workplace-related anxieties and workplace phobia have an own clinical value which is mainly defined by specific workplace-related symptom load and work-participation disorders. They require special therapeutic attention and treatment instead of a “sick leave” certification by the general health physician. Workplace phobia should be named with a proper diagnosis according to ICD-10 chapter V, F 40.8: “workplace phobia”.
Hintergrund: Angst am Arbeitsplatz ist ein spezielles Phänomen, da Arbeitsplätze ihrer Natur nach angstauslösende Charakteristika aufweisen: Vorgesetzte die sanktionieren, Rangkämpfe mit Kollegen, reale Unfallgefahren, Scheitern und Leistungsversagen, Unklarheit um plötzliche Veränderungen, Arbeitsplatzunsicherheit. Arbeitsplatzphobie ist eine phobische Angstreaktion mit Panikerleben beim Gedanken an oder bei Annäherung an den Arbeitsplatz. Fragestellung: Was charakterisiert arbeitsplatzbezogene Ängste und Arbeitsplatzphobie als lebensbereichsspezifische Angsterkrankungen in Abgrenzung zu klassischen Angsterkrankungen? Methode: 230 Patienten einer stationären psychosomatischen Rehabilitation wurden im halbstrukturierten Interview (Mini-Arbeits-Angst-Interview, Mini International Neuropsychiatric Interview) hinsichtlich arbeitsplatzbezogener Ängste und klassischer psychischer Erkrankungen befragt. Selbsteinschätzungsurteile wurden hinsichtlich des Schweregrads der arbeitsbezogenen (Job-Angst-Skala, JAS) und allgemeinen psychosomatischen (Symptom-Checkliste, SCL-90-R) Symptombelastung erhoben. Ergebnisse: 58% der befragten Patienten litten an mindestens einer arbeitsplatzbezogenen Angstvariante. Arbeitsplatzbezogene Ängste kamen bei 35% der Befragten zusammen mit einer klassischen Angsterkrankung vor, bei 23% jedoch als allein stehende Angsterkrankung. 17% der Befragten erfüllten die Kriterien einer Arbeitsplatzphobie. Arbeitsplatzphobie-Patienten hatten signifikant höhere Job-Angst-Werte als Patienten ohne Arbeitsplatzphobie, und sie waren signifikant länger arbeitsunfähig in den letzten 12 Monaten (23,5 Wochen versus 13,4 Wochen). Schlussfolgerung: Arbeitsplatzbezogene Ängste und Arbeitsplatzphobie haben eine spezielle klinische Wertigkeit, die sich anhand arbeitsbezogener Partizipationsstörungen und spezifischer arbeitsbezogener Symptombelastung beschreiben lässt. Arbeitsplatzphobie erfordert besondere therapeutische Herangehensweisen anstelle von angsterhaltender da Vermeidungsverhalten fördernder „Krankschreibung“. Arbeitsplatzphobie sollte als Diagnose benannt werden entsprechend ICD-10 Kapitel V, F 40.8: “Arbeitsplatzphobie”.

Objective: Although findings have been mixed, accumulating evidence suggests that co-occurring attention-deficit/hyperactivity disorder (ADHD) diagnoses and symptoms negatively predict cognitive-behavioral therapy (CBT) outcomes for anxious youth. The current study extends past research by examining the association of not only ADHD but also other features of ADHD with treatment outcomes of youth who received an intensive CBT for a specific phobia. Method: 135 youth (ages 6-15; 52.2% female; 88.2% white) were randomized to either an individual or parent-augmented intensive CBT targeting a specific phobia. Latent growth curve models were used to explore the association of ADHD symptoms, effortful control, sluggish cognitive tempo, maternal depression and the two treatment conditions (i.e., individual versus parent-augmented) with pre-treatment severity of the specific phobia and the trajectory of change in the severity of the specific phobia from pre-treatment to the 6-month follow up after the intervention. Results: As expected, higher levels of ADHD symptoms were associated with lower levels of effortful control and increased maternal depression at pre-treatment. Contrary to expectations, ADHD symptoms and its associated difficulties were not significantly associated with treatment outcomes. Conclusion: Overall, the findings lend support to the generalizability of intensive CBT for a specific phobia to youth with comorbid ADHD and associated difficulties. Implications and limitations of the study are discussed.
Ph. D.

A growing body of literature suggests that Virtual Reality is a successful tool for exposure therapy for anxiety disorders. Virtual Reality (VR) researchers posit the construct of presence, interpreting an artificial stimulus as if it were real, as the mechanism that enables anxiety to be felt during virtual reality exposure therapy (VRE). However, empirical studies on the relation between presence and anxiety in VRE have yielded mixed findings. The current study tested the following hypotheses 1) Presence is related to in session anxiety and treatment outcome; 2) Presence mediates the extent that pre-existing (pre-treatment) anxiety is experienced during exposure with VR; 3) Presence is positively related to the amount of phobic elements included within the virtual environment. Results supported presence as the mechanism by which anxiety is experienced in the virtual environment as well as a relation between presence and the phobic elements, but did not support a relation between presence and treatment outcome

Die Spezifischen Phobien stellen die häufigste Gruppe der Angststörungen dar. Die Angst vor dem Verschlucken bzw. dem Ersticken wurde jedoch nur sehr selten beschrieben. Bei der Behandlung der Spezifischen Phobien wird fast immer eine Konfrontation in vivo eingesetzt. Die Angst vor dem Verschlucken scheint aber eine der Spezifischen Phobien zu sein, bei der eine Konfrontation schwierig ist. Die hier vorgestellte Fallgeschichte schildert eine mögliche Vorgehensweise, die Ängste vor dem Verschlucken mit einer Reizkonfrontation in vivo zu behandeln. Dabei werden die verschiedenen Schwierigkeiten, die aufgetreten sind, und ihre Lösungen geschildert. Die Therapie wurde erfolgreich abgeschlossen, und auch die Ergebnisse der Nachuntersuchungen zeigten eine stabile Verbesserung.
Specific phobias are the most common anxiety disorders. However, the fear of swallowing the wrong way and choking has rarely been described. Specific phobias are usually treated using exposure therapy. The excessive fear of swallowing the wrong way does not seem to be very well suited for an exposure in vivo. In this case study, a patient afflicted with the fear of swallowing and choking was treated with flooding. The various difficulties encountered during treatment and their remedies will be described. The therapy was successful. The patient showed stable and lasting improvements at posttreatment and at one-year follow-up.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

The present study attempted to answer two general questions: (1) what is the relation between expected and actual reactions to a spider in individuals afraid of spiders? and (2) are inaccurate expectancies updated on the basis of experience? Behavioral and cognitive-behavioral learning models of fear, treatment protocols developed in relation to these, and recent findings from our laboratory necessitated answers to two additional questions: (3) does the expectation accuracy of individuals who meet DSM-IV criteria for diagnosis with a specific phobia differ from that of individuals who are fearful but do not meet criteria? and (4) does expectation accuracy vary as a function of context? Two final questions were obvious: (5) do the actual reactions of individuals who meet criteria for diagnosis differ predictably from those of fearful individuals? and (6) do reactions vary contextually? Student participants reported and tested a series of trial-specific expectancies about their reactions to a live, mechanical, or virtual tarantula over seven trials. Participants then completed three final trials in the presence of a live tarantula. Participants poorly anticipated the quality and intensity of their initial reactions, but expectation accuracy increased quickly. No clear tendencies for over- or under-prediction emerged. Participants updated expectancies in relation to prior trial expectation accuracy, either increasing or decreasing their predicted reactions relative to the original expectancy. Participants who met criteria for diagnosis with a specific phobia consistently anticipated and reported more intense reactions than did those who were fearful, but diagnostic status was not predictive of expectation accuracy. Participants in the live and virtual spider groups reported similar levels of fear that were greater than those in the mechanical spider group. Participants in the virtual spider group more readily reduced the distance maintained between themselves and the spider stimulus than did those in the live or mechanical spider groups. Expectation accuracy did not vary contextually. Results are discussed in light of the theoretical models presented, with findings lending greater support to behavioral models of fear learning relative to cognitive models that postulate a substantial role for conscious processing and appraisal in specific fear. Practical recommendations are made to researchers and clinicians based on present findings.

Specifik fobi är en vanlig psykiatrisk åkomma som kan leda till stora individuella begränsningar. Symtomen kan framgångsrikt behandlas med kognitiv beteendeterapi där 85–90 % blir kliniskt signifikant förbättrade. Forskning påvisar lovande behandlingsutfall för virtuell exponeringsbehandling (VRET) mot spindelfobi. Tekniken är intressant då den kringgår de problem med anskaffning och förvaring av fobiska stimuli som sedvanlig behandling medför och dessutom kan innebära ökad tillgänglighet och flexibilitet vid behandling. Syftet med föreliggande studie är att jämföra behandlingseffekten av ensessionsbehandling (OST) med en nyutvecklad spelifierad virtuell exponeringsbehandling (VIMSE), som sker under en fristående behandlingssession. Totalt randomiserades 73 deltagare mellan de två behandlingsmetoderna. Båda behandlingarna medförde statistiskt signifikanta förbättringar med stora effektstorlekar för såväl det beteendetest (BAT), som utgjorde det primära utfallsmåttet (OST d = 1,94; VIMSE d = 1,41), som för de sekundära utfallsmåtten Spider Phobia Questionnaire och Fear of Spiders Questionnaire. OST resulterade i signifikant fler kliniskt signifikant förbättrade än VIMSE.
VIMSE (VIrtual reality Method for Spider phobia Exposure therapy)

Anxiety disorders are very common and the primary feature is abnormal or inappropriate anxiety. Fear and anxiety is often mediated by the amygdala, a brain structure rich in substance P (SP) and neurokinin 1 (NK1) receptors. To learn more about how the human amygdala is modulated by fear and anxiety in event-triggered anxiety disorders and to investigate if the SP/NK1 receptor system is affected, regional cerebral blood flow (rCBF) ([15O]-water; Study I and II) and the SP/NK1 receptor system ([11C]GR205171; Study III and IV) were studied with positron emission tomography (PET). In Study I we investigated the neural correlates of affective startle modulation in persons with specific phobia by measuring rCBF during exposure to fearful and non-fearful pictures, paired and unpaired with acoustic startle stimuli. Fear-potentiated startle was associated with activation of the affective part of the anterior cingulate cortex and the left amygdaloid–hippocampal area. In Study II short-term drug treatment effects on rCBF in patients diagnosed with social phobia was evaluated, comparing the NK1 receptor antagonist GR205171 to the selective serotonin reuptake inhibitor citalopram and placebo. Social anxiety and neural activity in the medial temporal lobe including the amygdala was significantly reduced by both drugs but not placebo. In Study III we investigated if activity in the SP/NK1 receptor system in the amygdala would be affected by fear provocation in individuals with specific snake or spider phobia. Fear provocation was associated with a decreased uptake of the NK1 antagonist [11C]GR205171 in the amygdala, possibly explained by an increase in endogenous SP release occupying the NK1 receptors. Study IV was conducted to explore the resting state NK1 receptor availability in PTSD patients as compared to healthy controls. Increased resting state binding of the tracer [11C]GR205171 in the amygdala of patients with PTSD suggested an increased amount of available receptors. In summary, fear and fear-potentiated startle modulates the human amygdala, possibly through the SP/NK1 receptor system.

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

Virtual reality exposure therapy (VRET) is an effective cognitive-behavioral treatment for anxiety disorders that comprises systematic confrontations to virtual representations of feared stimuli and situations. However, not all patients respond to VRET, and some patients relapse after successful treatment. One explanation for this limitation of VRET is that its underlying mechanisms are not yet fully understood, leaving room for further improvement. On these grounds, the present thesis aimed to investigate two major research questions: first, it explored how virtual stimuli induce fear responses in height-fearful participants, and second, it tested if VRET outcome could be improved by incorporating techniques derived from two different theories of exposure therapy. To this end, five studies in virtual reality (VR) were conducted. Study 1 (N = 99) established a virtual environment for height exposure using a Computer Automatic Virtual Environment (CAVE) and investigated the effects of tactile wind simulation in VR. Height-fearful and non-fearful participants climbed a virtual outlook, and half of the participants received wind simulation. Results revealed that height-fearful participants showed stronger fear responses, on both a subjective and behavioral level, and that wind simulation increased subjective fear. However, adding tactile wind simulation in VR did not affect presence, the user's sense of 'being there' in the virtual environment. Replicating previous studies, fear and presence in VR were correlated, and the correlation was higher in height-fearful compared to non-fearful participants. Study 2 (N = 43) sought to corroborate the findings of the first study, using a different VR system for exposure (a head-mounted display) and measuring physiological fear responses. In addition, the effects of a visual cognitive distractor on fear in VR were investigated. Participants' fear responses were evident on both a subjective and physiological level---although much more pronounced on skin conductance than on heart rate---but the virtual distractor did not affect the strength of fear responses. In Study 3 (N = 50), the effects of trait height-fearfulness and height level on fear responses were investigated in more detail. Self-rated level of acrophobia and five different height levels in VR (1 m--20 m) were used as linear predictors of subjective and physiological indices of fear. Results showed that subjective fear and skin conductance responses were a function of both trait height-fearfulness and height level, whereas no clear effects were visible for heart rate. Study 4 (N = 64 + N = 49) aimed to advance the understanding of the relationship between presence and fear in VR. Previous research indicates a positive correlation between both measures, but possible causal mechanisms have not yet been identified. The study was the first to experimentally manipulate both presence (via the visual and auditive realism of the virtual environment) and fear (by presenting both height and control situations). Results indicated a causal effect of fear on presence, i.e., experiencing fear in a virtual environment led to a stronger sense of `being there' in the virtual environment. However, conversely, presence increased by higher scene realism did not affect fear responses. Nonetheless, presence seemed to have some effects on fear responding via another pathway, as participants whose presence levels were highest in the first safe context were also those who had the strongest fear responses in a later height situation. This finding indicated the importance of immersive user characteristics in the emergence of presence and fear in VR. The findings of the first four studies were integrated into a model of fear in VR, extending previous models and highlighting factors that lead to the emergence of both fear and presence in VR. Results of the studies showed that fear responses towards virtual heights were affected by trait height-fearfulness, phobic elements in the virtual environment, and, at least to some degree, on presence. Presence, on the other hand, was affected by experiencing fear in VR, immersion---the characteristics of the VR system---and immersive user characteristics. Of note, the manipulations of immersion used in the present thesis, visual and auditory realism of the virtual environment and tactile wind simulation, were not particularly effective in manipulating presence. Finally, Study 5 (N = 34) compared two different implementations of VRET for acrophobia to investigate mechanisms underlying its efficacy. The first implementation followed the Emotional Processing Theory, assuming that fear reduction during exposure is crucial for positive treatment outcome. In this condition, patients were asked to focus on their fear responses and on the decline of fear (habituation) during exposures. The second implementation was based on the inhibitory learning model, assuming that expectancy violation is the primary mechanism underlying exposure therapy efficacy. In this condition, patients were asked to focus on the non-occurrence of feared outcomes (e.g., 'I could fall off') during exposure. Based on predictions of the inhibitory learning model, the hypothesis for the study was that expectancy-violation-based exposure would outperform habituation-based exposure. After two treatment sessions in VR, both treatment conditions effectively reduced the patients' fear of heights, but the two conditions did not differ in their efficacy. The study replicated previous studies by showing that VRET is an effective treatment for acrophobia; however, contrary to the assumption, explicitly targeting the violation of threat expectancies did not improve outcome. This finding adds to other studies failing to provide clear evidence for expectancy violation as the primary mechanism underlying exposure therapy. Possible explanations for this finding and clinical implications are discussed, along with suggestions for further research
Die Expositionstherapie in virtueller Realität (VRET) ist ein wirksames kognitiv-verhaltenstherapeutisches Verfahren zur Behandlung von Angststörungen. Bei einer VRET werden Patienten nach psychoedukativer Vorbereitung mit virtuellen Repräsentationen der von ihnen gefürchteten Objekte oder Situationen konfrontiert. Die VRET zeigt allerdings nicht bei allen Patienten die gewünschte Wirksamkeit, und einige Patienten erleben selbst nach erfolgreicher Therapie eine Rückkehr der Angst. Da die zugrunde liegenden Wirkfaktoren der VRET noch nicht ausreichend aufgeklärt sind, lässt sich ihre Effektivtät möglicherweise noch weiter verbessern. Ziel der vorliegenden Arbeit war es daher zwei Fragen zu untersuchen. Zum einen, wie genau virtuelle Reize Furchtreaktionen bei höhenängstlichen Personen auslösen, und zum anderen, ob sich VRET durch den Einsatz spezifischer Techniken, welche aus Theorien zur Expositionstherapie abgeleitet wurden, verbessern lässt. Um die Fragen zu beantworten, wurden im Rahmen der Dissertation fünf Studien durchgeführt. In Studie 1 (N = 99) wurde eine virtuelle Umgebung für Höhenexposition etabliert und Effekte von taktiler Windsimulation in virtueller Realität (VR) untersucht. In der Studie hatten höhenängstliche und nicht-ängstliche Probanden die Aufgabe einen virtuellen Turm zu besteigen, wobei die Hälfte der Probanden währenddessen eine Windsimulation dargeboten bekam. Die Ergebnisse zeigten, dass höhenängstliche Probanden stärkere Furchtreaktionen zeigten, was sich sowohl im Bericht als auch im Verhalten äußerte. Zusätzlich erhöhte die Windsimulation die subjektiv Furcht der Probanden. Die Windsimulation hatte allerdings keinen Einfluss auf das Präsenzerleben, d. h. wie sehr sich Probanden so gefühlt hatten als seien sie tatsächlich in der virtuellen Umgebung gewesen. In der Studie konnten darüber hinaus zwei Befunde vorheriger Studien zum Präsenzerleben repliziert werden. Furcht und Präsenz korrelierten positiv, und dieser Zusammenhang war bei höhenängstlichen Probanden stärker als bei nicht-ängstlichen Probanden. Die Studie konnte zeigen, dass sich VR eignet um Furcht auf verschiedenen Reaktionsebenen zu untersuchen und es darüber hinaus möglich ist, Furcht in VR experimentell zu manipulieren. In Studie 2 (N = 43) sollten die Ergebnisse der ersten Studie bestätigt werden. Hierfür wurden ein anderes VR-System für die Exposition eingesetzt sowie die Erfassung von Furchtreaktionen um physiologische Maße ergänzt. Zusätzlich wurde der Einfluss einer visuell-kognitiven Distraktionsaufgabe in VR auf Furchtreaktionen untersucht. Die Furchtreaktionen der Probanden zeigten sich sowohl auf subjektiver als auch physiologischer Ebene, wobei Reaktionen der Hautleitfähigkeit stärker ausgeprägt waren als Veränderungen der Herzrate. Ein Einfluss der ablenkenden visuell-kognitiven Aufgabe auf Furchtreaktionen konnte nicht gezeigt werden. Die Studie konnte insgesamt verdeutlichen, dass die Eigenschaft von VR, Furcht zu erzeugen, nicht an einen bestimmten Versuchsaufbau gebunden ist und sich Furcht in VR auf allen Reaktionsebenen zeigt. Studie 3 (N = 50) hatte das Ziel, den Einfluss von Höhenängstlichkeit und Höhe auf Furchreaktionen genauer zu untersuchen. Hierfür wurde per Fragebogen erfasste Höhenängstlichkeit sowie fünf verschiedene Höhen (1 m--20 m) als lineare Prädiktoren für subjektive und physiologische Furchtindizes verwendet. Die Ergebnisse zeigten, dass subjektive Furcht und Hautleitfähigkeitsreaktionen in Abhängigkeit von sowohl Höhenängstlichkeit als auch Höhe zunahmen. Für die Herzrate zeigten sich hingegen keine eindeutigen Effekte. Die Studie konnte zusammenfassend zeigen, dass sich die Furchtreaktionen in VR spezifisch auf Höhe zeigten. In Studie 4 (N = 64 + N = 49) sollte der Zusammenhang zwischen Furcht und Präsenzerleben in VR genauer untersucht werden. Vorangegangene Studien zeigten eine positive Korrelation zwischen beiden Maßen, konnten jedoch keine Aussagen über einen möglichen Kausalzusammenhang machen. Die vorliegende Studie war daher die erste, welche sowohl Präsenz als auch Furcht experimentell manipulierte. Präsenz wurde über die Darbietung unterschiedlich realistischer virtueller Umgebungen, Furcht über die Darbietung von Höhen und Kontrollumgebungen manipuliert. Die Ergebnisse der Studie zeigten, dass es einen kausalen Effekt von Furcht auf Präsenzerleben gab, d. h. das Erleben von Furcht in einer Höhensituation in VR führte zu erhöhtem Präsenzerleben. Umgekehrt gab es jedoch keinen Effekt von experimentell manipuliertem Präsenzerleben auf die Stärke der Furchtreaktion. Es zeigte sich allerdings, dass Personen, welche in der ersten sicheren Situation das stärkste Präsenzerleben berichteten, später auch die stärksten Furchtreaktionen zeigten, was darauf schließen lässt, dass es möglicherwiese dennoch Effekte von Präsenzerleben auf Furcht gibt. Dieses Ergebnis weist auf die Bedeutung von möglichen Persönlichkeitsunterschieden hin, welche für das Erleben von Präsenz und Furcht in VR von Bedeutung sind. Die Studie verdeutlichte damit zum einen die Komplexität des Zusammenhangs zwischen Furcht und Präsenzerleben und erlaubte zum anderen erstmals Kausalschlüsse zwischen beiden Maßen. Die Ergebnisse der ersten vier Studien wurden in einem Modell zur Furcht in VR zusammengefasst. Basierend auf bestehenden Modellen zeigt das neue Modell Faktoren auf, welche für die Entstehung von Furcht und Präsenz bedeutsam sind. So konnten die Studien zeigen, dass Furchtreaktionen in Abhängigkeit von habitueller Höhenangst, der furchtbezogenen Relevanz der virtuellen Umgebung (z. B. Höhe), sowie zum Teil vom Präsenzerleben, auftreten. Bezüglich des Präsenzerlebens betont das Modell die Relevanz von aktuellem Furchterleben, Immersion (den Charakteristika des VR-Systems) und immersiven Nutzercharakteristika (z. B. Absorption). Zu erwähnen ist, dass die in der vorliegenden Dissertation untersuchten Manipulationen von Immersion (visueller und auditiver Realismus der virtuellen Umgebung und taktile Windsimulation) jedoch keine sonderlich starken Effekte auf Präsenz hatten. In Studie 5 (N = 34) wurden abschließend im Rahmen einer Therapiestudie zwei verschiedene VRET-Ansätze miteinander verglichen. Die erste Gruppe von Patienten erhielt hierbei eine Therapie auf Basis der Emotional Processing Theory. In dieser Bedingung wurden die Patienten während der Exposition gebeten, sich auf ihr Furchterleben und dessen Rückgang über die Zeit (Habituation) zu konzentrieren. Die zweite Gruppe von Patienten erhielt eine Therapie auf Basis des Inhibitory Learning Models. In dieser Bedingung wurden die Patienten gebeten, gezielt ihre Befürchtungen (z. B. "Ich könnte herunterfallen") zu überprüfen und zu widerlegen. Es wurde auf Basis der Vorhersage des Inhibitory Learning Models, dass Erwartungswiderlegung der zentrale Wirkfaktor der Expositionstherapie ist, angenommen, dass eine Therapie auf Basis der Widerlegung von Befürchtungen effektiver ist als eine Therapie auf Basis von Habituation. Nach zwei Therapiesitzungen berichteten die Patienten in beiden Gruppen einen signifikaten Rückgang ihrer Höhenangst, es zeigten sich jedoch keine Wirksamkeitsunterschiede zwischen den Gruppen. Die Studie konnte damit zwar vorherige Befunde replizieren, die zeigten, dass VRET eine effektive Behandlung für Höhenangst ist, die spezifische Fokussierung auf Erwartungswiderlegung zeigte jedoch keinen Vorteil. Dieser Befund reiht sich damit in eine Reihe von Studien ein, die Erwartungswiderlegung als zentralen Wirkfaktor der Expositionstherapie nicht nachweisen konnten. Mögliche Gründe für diesen Befund sowie daraus folgende klinische Implikationen und Vorschläge für weitere Forschung werden diskutiert

Recent animal and human research suggest that a behavioral prime before extinction training lessens the spontaneous recovery of learned fear. These findings would have large ranging implications, if they could be applied to the treatment of specific phobias in which spontaneous recovery is often problematic. The present study examined the effects of a behavioral prime paired with exposure therapy versus exposure therapy alone on snake and spider phobics return of fear at one-month follow-up. The findings did not support the proposed hypothesis that those in the primed group would show a significant lessening in return of fear. The study findings do not support the current research, but there are a number of steps that may be taken in the future to gain more objective measurements that may lead to hypothesis support.
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The non-associative framework on fear argues that evolutionary-relevant fears, such as heights and water, are largely innate and do not require associative conditioning experiences to develop (Menzies & Clarke, 1993a, b; Poulton & Menzies, 2002a). However, this framework has been criticized for its reliance on retrospective recall for empirical support (Mineka & Öhman, 2002), which has been found to be highly unreliable (Taylor, Deane, & Podd, 1999). Thirty height-fearful undergraduate students completed the Origins Questionnaire-II (OQ-II; Menzies & Parker, 2001) and were classified into one of the several associative and non-associative pathways of fear onset based on their responses. A control group of 43 non-fearful students completed a modified version of the OQ-II to report any past experiences with heights. To examine the stability of these responses over time, the same questionnaires for both groups were completed again three months (Time 2) and 12 months (Time 3) after the initial administration of the test, along with measures of fear severity. Results showed that neither associative nor non-associative accounts took precedence over the other in explaining the onset of height fear. Instabilities in pathway ascriptions were observed in 18.18% of cases over three months (between Time 1 and Time 2), and 27.27% of cases over nine months (between Time 2 and Time 3). The theoretical and practical implications of the results are discussed with consideration of some of the study’s procedural and instrumental limitations. In light of these limitations, this study identified a substantial role of non-associative pathways on the development of height fear, and provided further support for the limitations of retrospective recall for ascertaining the pathway to fear onset.

Safety behaviour consists of actions, thoughts, and/or protective objects that fearful individuals use to reduce their anxiety. It can potentially interfere with the progress of exposure therapy, which entails exposing patients to a feared stimulus or situation, but other hypotheses suggest that it may not be entirely detrimental to treatment effectiveness. This study aims to elucidate the role of safety behaviour in exposure-based treatments for anxiety disorders and uses a paradigm of exposure treatment for snake fear. Participants are randomized to one of two conditions, whereby they use either safety gear, such as gloves and goggles, or do not use any safety gear during 45 minutes of systematic exposure to a live snake. Measures are administered pre-treatment, immediately following treatment, and 10 minutes post-treatment to assess participants' fear-related cognitions, subjective ratings of fear, and their distance of closest approach to the snake. The results demonstrate that exposure treatment for snake fear is effective irrespective of safety behaviour use, as indicated by pre- to post-treatment differences for both groups of participants on all outcome measures. It was found that participants who used safety gear reported cognitive change equivalent to those who did not use safety gear post-treatment, supporting the notion that use of safety behaviour during exposure treatment may promote adaptive cognitive change. Results are discussed in terms of cognitive-behavioural theories of and treatments for anxiety disorders.

The diploma thesis deals with an emotional state called fear and it's pathological form - phobia. The thesis is focused on frequency and form of fears of pupils in older school age and on influence of these fears on teaching of Natural Sciences. The analysis of educational field of Natural Sciences, the interview and the questionnaire investigation of pupils were used in the diploma thesis. On the basis of research results I suggested basic recommendations for teachers who meet pupils with fear or specific phobia during classes. The diploma thesis uses methods of qualitative and quantitative research.

Neuroimaging research has highlighted the relevance of well-balanced functional brain interactions as an essential basis for efficient emotion regulation. In contrast, abnormal coupling of fear-processing regions such as the amygdala, the anterior cingulate cortex (ACC) and the insula could be an important feature of anxiety disorders. Although activity alterations of these regions have been frequently reported in specific phobia, little is known about their functional interactions during phobogenic stimulus processing. To explore these interrelationships in two subtypes of specific phobia – i.e., the blood-injection-injury subtype and the animal subtype – functional connectivity (FC) was analyzed in three fMRI studies. Two studies examined fear processing in a dental phobia group (DP), a snake phobia group (SP) and a healthy control group (HC) during visual phobogenic stimuli presentation while a third study investigated differences between auditory and visual stimuli presentation in DP and HC. Due to a priori hypotheses of impaired interactions between the amygdala, the ACC and the insula, a first analysis was conducted to explore the FC within these three regions of interest. Based on emerging evidence of functionally diverse subregions, the ACC was further divided into a subgenual, pregenual and dorsal ACC and the insula was divided into a ventral-anterior, dorsal-anterior and posterior region. Additionally, an exploratory seed-to-voxel analysis using the amygdala, ACC and insula as seeds was conducted to scan for connectivity patterns across the whole brain. The analyses revealed a negative connectivity of the ACC and the amygdala during phobogenic stimulus processing in controls. This connectivity was predominantly driven by the affective ACC subdivision. By contrast, SP was characterized by an increased mean FC between the examined regions. Interestingly, this phenomenon was specific for auditory, but not visual symptom provocation in DP. During visual stimulus presentation, however, DP exhibited further FC alterations of the ACC and the insula with pre- and orbitofrontal regions. These findings mark the importance of balanced interactions between fear-processing regions in specific phobia, particularly of the inhibitory connectivity between the ACC and the amygdala. Theoretically, this is assumed to reflect top-down inhibition by the ACC during emotion regulation. The findings support the suggestion that SP particularly is characterized by excitatory, or missing inhibitory, (para-) limbic connectivity, reflecting an overshooting fear response based on evolutionary conserved autonomic bottom-up pathways. Some of these characteristics applied to DP as well but only under the auditory stimulation, pointing to stimulus dependency. DP was further marked by altered pre- and orbitofrontal coupling with the ACC and the insula which might represent disturbances of superordinate cognitive control on basal emotion processes. These observations strengthen the assumption that DP is predominantly based on evaluation-based fear responses. In conclusion, the connectivity patterns found may depict an intermediate phenotype that possibly confers risks for inappropriate phobic fear responses. The findings presented could also be of clinical interest. Particularly the ACC – amygdala circuit may be used as a predictive biomarker for treatment response or as a promising target for neuroscience-focused augmentation strategies as neurofeedback or repetitive transcranial magnetic stimulation
Neurowissenschaftliche Erkenntnisse der letzten Jahre verdeutlichten die Relevanz intakter neuronaler Netzwerke als Grundlage adäquater Emotionsregulationsmechanismen. Funktionelle Dysregulationen zwischen angstverarbeitenden Regionen wie der Amygdala, der Insula oder dem anterioren cingulären Cortex (ACC) könnten hingegen einen wichtigen pathophysiologischen Mechanismus von Angststörungen darstellen. Obwohl Aktivitätsunterschiede dieser Regionen wiederholt für spezifische Phobien beschrieben wurden, sind deren funktionelle Interaktionen während phobischer Stimulusverarbeitung kaum erforscht. Zur Untersuchung dieser Interaktionen in zwei Subtypen der spezifischen Phobie – dem Blut-Spritzen-Verletzungs-Typus und dem Tier-Typus – wurden im Rahmen dieser Arbeit funktionelle Konnektivitäts-Analysen (FK) anhand dreier fMRT- (funktionelle Magnetresonanztomographie) Studien durchgeführt. Zwei Studien untersuchten die neurale Verarbeitung visueller phobischer Stimuli in einer dentalphobischen Gruppe (DP), einer schlangenphobischen Gruppe (SP) sowie einer Kontrollgruppe (KG). Ergänzend verglich eine dritte Studie den Einfluss visueller und akustischer Stimuli für die DP und eine KG. Basierend auf der a priori-Hypothese einer veränderten FK zwischen der Amygdala, der Insula und dem ACC wurden deren spezifische Konnektivitätsmuster untersucht. Aufgrund funktionell unterschiedlicher Subregionen erfolgte eine Untergliederung des ACC in eine subgenuale, perigenuale und dorsalen Region. Analog dazu wurde die Insula in eine ventral-anteriore, dorsal-anteriore und posteriore Region unterteilt. Um darüberhinausgehender Konnektivitätsmuster über das gesamte Gehirn zu ermitteln, wurde eine abschließende Seed-to-Voxel-Analyse mit den Seeds Amygdala, Insula und ACC durchgeführt. In der Auswertung zeigte sich eine negative FK der Amygdala und des ACC während phobischer Stimulusverarbeitung in der KG, die insbesondere auf die ventrale Division des ACC zurückzuführen war. Die phobischen Gruppen hingegen waren im Vergleich zu der Kontrollgruppe durch eine erhöhte Konnektivität der untersuchten Regionen gekennzeichnet. Dieser Effekt war bei der DP spezifisch für die akustische Stimulusmodalität. Bei visueller Stimuluspräsentation zeigten sich hingegen veränderte Konnektivitätsmuster des ACC und der Insula mit prä- und orbitofrontalen Regionen. Insbesondere die negative FK der Amygdala und des ACC, die theoretisch auf einer top-down-Inhibition des ACC über die Amygdala basiert, erscheint einen wichtigen Bestandteil einer effektiven emotionalen Kontrolle darzustellen. In beiden phobischen Gruppen fehlte diese Inhibition. Die erhöhte FK (para-)limbischer Konnektivität der SP könnte hingegen die verstärkte Rekrutierung autonomischer bottom-up-Prozesse als zugrundeliegendem Mechanismus der überschießenden und irrationalen Angstreaktion repräsentieren. Diese Charakteristika konnten in der DP nur für die akustische Stimulusmodalität beobachtet werden. Während der visuellen Stimuluspräsentation war die DP durch Dysregulationen prä- und orbitofrontaler Regionen gekennzeichnet, welche eine beeinträchtigte kognitive Kontrolle über grundlegende Emotionsprozesse widerspiegeln könnte. Dies entspricht der Annahme, dass die DP vor allem durch evaluationsbasierte Furchtreaktionen gekennzeichnet ist, während in der SP als Vertreter des Tier-Typus evolutionär konservierte, limbische Prozesse dominieren. Zusammenfassend bestätigen die Ergebnisse die Bedeutung funktioneller Netzwerke in der spezifischen Phobie, wobei die gefundenen Konnektivitätsmuster einen intermediären Phänotyp darstellen könnten, der möglicherweise das Risiko für das Auftreten dysfunktionaler phobischer Angstreaktionen vermittelt. Von klinischem Interesse ist vor allem die Amygdala – ACC-Vernetzung, die als prädiktiver Biomarker für das Therapieansprechen genutzt oder im Rahmen neuromodulatorischer Therapieansätze wie dem Neurofeedback oder der repetitiven transkraniellen Magnetstimulation gezielt angesteuert werden könnte