TY - THES A1 - Schwarzmeier, Hanna T1 - From fear extinction to exposure therapy: neural mechanisms and moderators of extinction T1 - Von der Furchtextinktion zur Expositionstherapie: Neuronale Mechanismen und Moderatoren der Extinktion N2 - Emotional-associative learning processes such as fear conditioning and extinction are highly relevant to not only the development and maintenance of anxiety disorders (ADs), but also to their treatment. Extinction, as the laboratory analogue to behavioral exposure, is assumed a core process underlying the treatment of ADs. Although exposure-based treatments are highly effective for the average patient suffering from an AD, there remains a gap in treatment efficacy with over one third of patients failing to achieve clinically significant symptom relief. There is ergo a pressing need for intensified research regarding the underlying neural mechanisms of aberrant emotional-associative learning processes and the neurobiological moderators of treatment (non-)response in ADs. The current thesis focuses on different applications of the fundamental principles of fear conditioning and extinction by using two example cases of ADs from two different multicenter trials. First, we targeted alterations in fear acquisition, extinction, and its recall as a function of psychopathology in panic disorder (PD) patients compared to healthy subjects using fMRI. Second, exposure-based therapy and pre-treatment patient characteristics exerting a moderating influence on this essential learning process later on (i.e. treatment outcome) were examined using multimodal functional and structural neuroimaging in spider phobia. We observed aberrations in emotional-associative learning processes in PD patients compared to healthy subjects indicated by an accelerated fear acquisition and an attenuated extinction recall. Furthermore, pre-treatment differences related to defensive, regulatory, attentional, and perceptual processes may exert a moderating influence on treatment outcome to behavioral exposure in spider phobia. Although the current results need further replication, on an integrative meta level, results point to a hyperactive defensive network system and deficient emotion regulation processes (including extinction processes) and top-down control in ADs. This speaks in favor of transdiagnostic deficits in important functional domains in ADs. Deficits in transdiagnostic domains such as emotion regulation processes could be targeted by enhancing extinction learning or by means of promising tools like neurofeedback. The detection of pre-treatment clinical response moderators, for instance via machine learning frameworks, may help in supporting clinical decision making on individually tailored treatment approaches or, respectively, to avoid ineffective treatment and its related financial costs. In the long run, the identification of neurobiological markers which are capable of detecting non-responders a priori represents an ultimate goal. N2 - Emotional-assoziative Lernprozesse wie Furchtkonditionierung und Extinktion sind für die Entstehung und Aufrechterhaltung, aber auch für die Behandlung von Angststörungen (AS) von hoher Relevanz. Extinktion, als Laboranalog der Verhaltensexposition, gilt als ein der Behandlung von AS zugrundeliegender Kernprozess. Obwohl expositionsbasierte Behandlungen für den durchschnittlichen Angstpatienten hoch wirksam sind, besteht weiterhin eine Behandlungslücke, da über ein Drittel der Patienten keine klinisch signifikante Verbesserung erzielt. Daher besteht ein dringender Bedarf an intensivierter Forschung hinsichtlich der neuronalen Grundlagen veränderter emotional-assoziativer Lernprozesse und der neurobiologischen Moderatoren des (Nicht-)Ansprechens bei der Behandlung von AS. Die vorliegende Arbeit konzentriert sich daher auf verschiedene Anwendungen des grundlegenden Prinzips der Furchtkonditionierung und Extinktion anhand zweier Anwendungsbeispiele aus zwei multizentrischen Studien. Zuerst wurden psychopathologisch bedingte Veränderungen der basalen Mechanismen des Furchtlernens, der Extinktion und des Extinktionsabrufs bei Patienten mit Panikstörung im Vergleich zu gesunden Probanden untersucht. Anschließend wurde mittels multimodaler funktioneller und struktureller Bildgebung der moderierende Einfluss von Patientencharakteristika vor der Behandlung auf das spätere Behandlungsergebnis bei Spinnenphobie untersucht. Bei Panikpatienten wurden Abweichungen in emotional-assoziativen Lernprozessen im Sinne einer beschleunigten Furchtakquisition und eines abgeschwächten Extinktionsabrufs beobachtet. Bei Spinnenphobikern üben Unterschiede in Bezug auf Defensiv-, Regulations-, Aufmerksamkeits- und Wahrnehmungsprozesse vor der Behandlung möglicherweise einen moderierenden Einfluss auf das Behandlungsergebnis einer Verhaltensexposition aus. Obwohl diese Ergebnisse noch weiterer Replikation bedürfen, weisen sie auf der transdiagnostischen Metaebene auf ein hyperaktives Defensivnetzwerk und mangelhafte Emotionsregulationsprozesse (einschließlich Extinktionsprozesse) sowie Top-Down-Kontrolle bei Angstpatienten hin. Defizite in transdiagnostischen Bereichen wie Emotionsregulationsprozessen könnten durch eine Verbesserung des Extinktionslernens oder durch vielversprechende Verfahren wie Neurofeedback angegangen werden. Die Identifizierung von Moderatoren und neurobiologischen Markern des Behandlungs(miss-)erfolgs bereits vor der Behandlung, z.B. durch maschinelles Lernen, könnte personalisierte Behandlungsansätze unterstützen bzw. ineffektive Behandlungen und damit verbundene Kosten ersparen und stellt somit ein Langzeitziel dar. KW - Extinktion KW - Angststörung KW - Funktionelle Kernspintomografie KW - Expositionstherapie KW - extinction KW - exposure therapy KW - anxiety disorders KW - fMRI Y1 - 2023 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-223304 ER - TY - JOUR A1 - Pittig, Andre A1 - Heinig, Ingmar A1 - Goerigk, Stephan A1 - Thiel, Freya A1 - Hummel, Katrin A1 - Scholl, Lucie A1 - Deckert, Jürgen A1 - Pauli, Paul A1 - Domschke, Katharina A1 - Lueken, Ulrike A1 - Fydrich, Thomas A1 - Fehm, Lydia A1 - Plag, Jens A1 - Ströhle, Andreas A1 - Kircher, Tilo A1 - Straube, Benjamin A1 - Rief, Winfried A1 - Koelkebeck, Katja A1 - Arolt, Volker A1 - Dannlowski, Udo A1 - Margraf, Jürgen A1 - Totzeck, Christina A1 - Schneider, Silvia A1 - Neudeck, Peter A1 - Craske, Michelle G. A1 - Hollandt, Maike A1 - Richter, Jan A1 - Hamm, Alfons A1 - Wittchen, Hans-Ulrich T1 - Efficacy of temporally intensified exposure for anxiety disorders: A multicenter randomized clinical trial JF - Depression and Anxiety N2 - Background The need to optimize exposure treatments for anxiety disorders may be addressed by temporally intensified exposure sessions. Effects on symptom reduction and public health benefits should be examined across different anxiety disorders with comorbid conditions. Methods This multicenter randomized controlled trial compared two variants of prediction error-based exposure therapy (PeEx) in various anxiety disorders (both 12 sessions + 2 booster sessions, 100 min/session): temporally intensified exposure (PeEx-I) with exposure sessions condensed to 2 weeks (n = 358) and standard nonintensified exposure (PeEx-S) with weekly exposure sessions (n = 368). Primary outcomes were anxiety symptoms (pre, post, and 6-months follow-up). Secondary outcomes were global severity (across sessions), quality of life, disability days, and comorbid depression. Results Both treatments resulted in substantial improvements at post (PeEx-I: d\(_{within}\) = 1.50, PeEx-S: d\(_{within}\) = 1.78) and follow-up (PeEx-I: d\(_{within}\) = 2.34; PeEx-S: d\(_{within}\) = 2.03). Both groups showed formally equivalent symptom reduction at post and follow-up. However, time until response during treatment was 32% shorter in PeEx-I (median = 68 days) than PeEx-S (108 days; TR\(_{PeEx-I}\)-I = 0.68). Interestingly, drop-out rates were lower during intensified exposure. PeEx-I was also superior in reducing disability days and improving quality of life at follow-up without increasing relapse. Conclusions Both treatment variants focusing on the transdiagnostic exposure-based violation of threat beliefs were effective in reducing symptom severity and disability in severe anxiety disorders. Temporally intensified exposure resulted in faster treatment response with substantial public health benefits and lower drop-out during the exposure phase, without higher relapse. Clinicians can expect better or at least comparable outcomes when delivering exposure in a temporally intensified manner. KW - randomized controlled trial KW - anxiety disorders KW - exposure therapy KW - intensified treatment KW - public health Y1 - 2021 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-257331 VL - 38 IS - 11 ER - TY - JOUR A1 - Prelog, Martina A1 - Hilligardt, Deborah A1 - Schmidt, Christian A. A1 - Przybylski, Grzegorz K. A1 - Leierer, Johannes A1 - Almanzar, Giovanni A1 - El Hajj, Nady A1 - Lesch, Klaus-Peter A1 - Arolt, Volker A1 - Zwanzger, Peter A1 - Haaf, Thomas A1 - Domschke, Katharina T1 - Hypermethylation of FOXP3 Promoter and Premature Aging of the Immune System in Female Patients with Panic Disorder? JF - PLoS ONE N2 - Immunological abnormalities associated with pathological conditions, such as higher infection rates, inflammatory diseases, cancer or cardiovascular events are common in patients with panic disorder. In the present study, T cell receptor excision circles (TRECs), Forkhead-Box-Protein P3 gene (FOXP3) methylation of regulatory T cells (Tregs) and relative telomere lengths (RTLs) were investigated in a total and subsamples of 131 patients with panic disorder as compared to 131 age- and sex-matched healthy controls in order to test for a potential dysfunction and premature aging of the immune system in anxiety disorders. Significantly lower TRECs (p = 0.004) as well as significant hypermethylation of the FOXP3 promoter region (p = 0.005) were observed in female (but not in male) patients with panic disorder as compared to healthy controls. No difference in relative telomere length was discerned between patients and controls, but significantly shorter telomeres in females, smokers and older persons within the patient group. The presently observed reduced TRECs in panic disorder patients and FOXP3 hypermethylation in female patients with panic disorder potentially reflect impaired thymus and immunosuppressive Treg function, which might partly account for the known increased morbidity and mortality of anxiety disorders conferred by e.g. cancer and cardiovascular disorders. KW - DNA methylation KW - antidepressants KW - regulatory T cells KW - panic disorder KW - treatment guidelines KW - telomere length KW - inflammatory diseases KW - anxiety disorders Y1 - 2016 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-179684 VL - 11 IS - 6 ER - TY - JOUR A1 - Diemer, Julia A1 - Alpers, Georg W. A1 - Peperkorn, Henrik M. A1 - Shiban, Youssef A1 - Mühlberger, Andreas T1 - The impact of perception and presence on emotional reactions: a review of research in virtual reality JF - Frontiers in Psychology N2 - Virtual reality (VR) has made its way into mainstream psychological research in the last two decades. This technology, with its unique ability to simulate complex, real situations and contexts, offers researchers unprecedented opportunities to investigate human behavior in well controlled designs in the laboratory. One important application of VR is the investigation of pathological processes in mental disorders, especially anxiety disorders. Research on the processes underlying threat perception, fear, and exposure therapy has shed light on more general aspects of the relation between perception and emotion. Being by its nature virtual, i.e., simulation of reality, VR strongly relies on the adequate selection of specific perceptual cues to activate emotions. Emotional experiences in turn are related to presence, another important concept in VR, which describes the user's sense of being in a VR environment. This paper summarizes current research into perception of fear cues, emotion, and presence, aiming at the identification of the most relevant aspects of emotional experience in VR and their mutual relations. A special focus lies on a series of recent experiments designed to test the relative contribution of perception and conceptual information on fear in VR. This strand of research capitalizes on the dissociation between perception (bottom up input) and conceptual information (top-down input) that is possible in VR. Further, we review the factors that have so far been recognized to influence presence, with emotions (e.g., fear) being the most relevant in the context of clinical psychology. Recent research has highlighted the mutual influence of presence and fear in VR, but has also traced the limits of our current understanding of this relationship. In this paper, the crucial role of perception on eliciting emotional reactions is highlighted, and the role of arousal as a basic dimension of emotional experience is discussed. An interoceptive attribution model of presence is suggested as a first step toward an integrative framework for emotion research in VR. Gaps in the current literature and future directions are outlined. KW - exposure therapy KW - flight phobics KW - environments KW - virtual reality KW - anxiety KW - presence KW - emotion KW - fear KW - perception KW - anxiety disorders KW - presence questionnaire KW - public speaking KW - spider phobia KW - social phobia KW - immersion Y1 - 2015 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-144200 VL - 6 IS - 26 ER - TY - JOUR A1 - Straube, B. A1 - Reif, A. A1 - Richter, J. A1 - Lueken, U. A1 - Weber, H. A1 - Arolt, V. A1 - Jansen, A. A1 - Zwanzger, P. A1 - Domschke, K. A1 - Pauli, P. A1 - Konrad, C. A1 - Gerlach, A. L. A1 - Lang, T. A1 - Fydrich, T. A1 - Alpers, G. W. A1 - Stroehle, A. A1 - Wittmann, A. A1 - Pfleiderer, B. A1 - Wittchen, H.-U. A1 - Hamm, A. A1 - Deckert, J. A1 - Kircher, T. T1 - The functional - 1019C/G HTR1A polymorphism and mechanisms of fear JF - Translational Psychiatry N2 - Serotonin receptor 1A gene (HTR1A) knockout mice show pronounced defensive behaviour and increased fear conditioning to ambiguous conditioned stimuli. Such behaviour is a hallmark of pathological human anxiety, as observed in panic disorder with agoraphobia (PD/AG). Thus, variations in HTR1A might contribute to neurophysiological differences within subgroups of PD/AG patients. Here, we tested this hypothesis by combining genetic with behavioural techniques and neuroimaging. In a clinical multicentre trial, patients with PD/AG received 12 sessions of manualized cognitive-behavioural therapy (CBT) and were genotyped for HTR1A rs6295. In four subsamples of this multicentre trial, exposure behaviour (n = 185), defensive reactivity measured using a behavioural avoidance test (BAT; before CBT: n = 245; after CBT: n = 171) and functional magnetic resonance imaging (fMRI) data during fear conditioning were acquired before and after CBT (n = 39). HTR1A risk genotype (GG) carriers more often escaped during the BAT before treatment. Exploratory fMRI results suggest increased activation of the amygdala in response to threat as well as safety cues before and after treatment in GG carriers. Furthermore, GG carriers demonstrated reduced effects of CBT on differential conditioning in regions including the bilateral insulae and the anterior cingulate cortex. Finally, risk genotype carriers demonstrated reduced self-initiated exposure behaviour to aversive situations. This study demonstrates the effect of HTR1A variation on defensive behaviour, amygdala activity, CBT-induced neural plasticity and normalization of defence behaviour in PD/AG. Our results, therefore, translate evidence from animal studies to humans and suggest a central role for HTR1A in differentiating subgroups of patients with anxiety disorders. KW - randomized-controlled trial KW - panic disorder KW - 5-HT1A receptor KW - defensive reactivity KW - major depression KW - cognitive-behavioral therapy KW - receptor gene polymorphism KW - C(-1019)G polymorphism KW - anxiety disorders KW - serotonin(1A) receptor Y1 - 2014 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-114369 SN - 2158-3188 VL - 4 ER -