Publications by authors named "Iris M Engelhard"

127 Publications

Safety behaviors toward innocuous stimuli can maintain or increase threat beliefs.

Behav Res Ther 2022 Jun 17;156:104142. Epub 2022 Jun 17.

Department of Clinical Psychology, Utrecht University, the Netherlands.

Safety behaviors can prevent or minimize a feared outcome. However, in relatively safe situations, they may be less adaptive, presumably because people will misattribute safety to these behaviors. This research aimed to investigate whether safety behaviors in safe situations can lead to increased threat beliefs. In Study 1, we aimed to replicate a fear conditioning study (N = 68 students) in which the experimental, but not the control group, received the opportunity to perform safety behavior to an innocuous stimulus. From before to after the availability of the safety behavior, threat beliefs persisted in the experimental group, while they decreased in the control group. In Study 2, we examined whether threat beliefs had actually increased for some individuals in the experimental group, using a multi-dataset latent class analysis on data from Study 1 and two earlier studies (N = 213). Results showed that about a quarter of individuals who performed safety behavior toward the innocuous stimulus showed increased threat expectancy to this cue, while virtually nobody in the control group exhibited an increase. Taken together, safety behavior in relatively safe situations may have maladaptive effects as it generally maintains and sometimes even increases threat beliefs.
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http://dx.doi.org/10.1016/j.brat.2022.104142DOI Listing
June 2022

Stable Anxiety and Depression Trajectories in Late Adolescence for Oral Contraceptive Users.

Front Psychiatry 2022 23;13:799470. Epub 2022 May 23.

Department of Clinical Psychology, Utrecht University, Utrecht, Netherlands.

Background: The use of oral contraceptives (OCs) has been associated with increased incidences of anxiety and depression, for which adolescents seem to be particularly vulnerable. Rather than looking at singular outcomes, we examined whether OC use is associated with depressive and anxiety symptom trajectories from early adolescence into early adulthood.

Materials And Methods: Data from 178 girls were drawn from the Research on Adolescent Development and Relationships (RADAR-Y) younger cohort study. We used assessments on 9 waves from age 13 until 24. Developmental trajectories of ratings on the Reynolds Adolescent Depression Scale (RADS-2) and the Screen for Child Anxiety Related Emotional Disorders (SCARED) were compared between never and ever users of OCs.

Results: Never users showed increases in depressive and anxiety symptoms in late adolescence, whereas OC users showed a stable level of symptoms throughout adolescence. This effect remained after adjusting for baseline differences between groups in romantic relationships, sexual debut, educational level, smoking, drinking, and drug use. Age of OC use onset did not significantly predict symptom development.

Conclusions: OC use in adolescence was related to an altered developmental trajectory of internalizing symptoms, in which OC users did not show an increase in depressive and anxiety symptoms in late adolescence, whereas never users did. The question remains whether this altered symptom trajectory can be considered a protective effect of OC use on psychopathology. Additional research is needed to improve our understanding of the long-term consequences of OC use on mental health.
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http://dx.doi.org/10.3389/fpsyt.2022.799470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168124PMC
May 2022

Future-oriented imagery rescripting facilitates conducting behavioral experiments in social anxiety.

Behav Res Ther 2022 08 29;155:104130. Epub 2022 May 29.

Department of Clinical Psychology, Utrecht University, the Netherlands.

Distressing mental images are common in anxiety disorders and can make it difficult for patients to confront feared situations. This study examined whether imagery rescripting focused on a feared social situation prepares participants to engage in a feared situation. Sixty healthy individuals were asked to formulate a behavioral experiment to test negative beliefs about a social situation they feared. They were assigned to one of two groups: imagery rescripting focused on the feared outcome of the behavioral experiment or no imagery rescripting (i.e., a break). All participants were then asked to complete ratings scales and to conduct the behavioral experiment. Before the behavioral experiment, the imagery rescripting condition, compared to the control condition, showed reduced anticipated probability and severity of the feared outcome, lower anxiety and helplessness levels, and increased willingness to conduct the behavioral experiment. Imagery-based interventions focused on feared outcomes seem promising to prepare anxious individuals to engage in treatment.
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http://dx.doi.org/10.1016/j.brat.2022.104130DOI Listing
August 2022

The relationship between Intolerance of Uncertainty and conditioned fear acquisition: Evidence from a large sample.

Int J Psychophysiol 2022 Jul 30;177:67-75. Epub 2022 Apr 30.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Despite being considered a valid model for the etiology of anxiety disorders, the fear conditioning paradigm does not always show clear correlations with anxious personality traits that constitute risk factors for the development of anxiety disorders. This may in part due to error variance and the fact that fear conditioning studies are typically underpowered to investigate inter-individual differences. In the current study, we focus on the relationship between conditioned fear acquisition and Intolerance of Uncertainty (IU). In a re-analysis of a large previous study (N = 120), which was conducted using a healthy student sample and a partial reinforcement procedure (75%) with words as Conditioned Stimuli (CSs), the relationship between IU and several outcome measures (i.e., fear ratings, expectancy ratings, skin conductance responses, and startle responses) during fear acquisition was examined. We find that IU is positively related to fear ratings towards the CS+ (r = 0.29), even when controlling for the shared variance with trait anxiety. Furthermore, we find a subtle relationship between IU and startle responses to the CS- (r = -0.23), though this correlation did not survive correction for the shared variance with trait anxiety. Taken together, we replicate some of the correlations previously reported in the literature. However, we recommend that future studies employ even larger samples and more advanced statistical techniques such as structural equation modelling to investigate the correlations between fear acquisition indices and anxious traits in a fine-grained manner.
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http://dx.doi.org/10.1016/j.ijpsycho.2022.04.011DOI Listing
July 2022

A meta-analysis of conditioned fear generalization in anxiety-related disorders.

Neuropsychopharmacology 2022 Apr 30. Epub 2022 Apr 30.

Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, Austin, TX, USA.

Generalization of conditioned fear is adaptive in some situations but maladaptive when fear excessively generalizes to innocuous stimuli with incidental resemblance to a genuine threat cue. Recently, empirical interest in fear generalization as a transdiagnostic explanatory mechanism underlying anxiety-related disorders has accelerated. As there are now several studies of fear generalization across multiple types of anxiety-related disorders, the authors conducted a meta-analysis of studies reporting behavioral measures (subjective ratings and psychophysiological indices) of fear generalization in anxiety-related disorder vs. comparison groups. We conducted systematic searches of electronic databases (conducted from January-October 2020) for fear generalization studies involving anxiety-related disorder groups or subclinical analog groups. A total of 300 records were full-text screened and two unpublished datasets were obtained, yielding 16 studies reporting behavioral fear generalization measures. Random-effects meta-analytic models and meta-regressions were applied to the identified data. Fear generalization was significantly heightened in anxiety-related disorder participants (N = 439) relative to comparison participants (N = 428). We did not identify any significant clinical, sample, or methodological moderators. Heightened fear generalization is quantitatively supported as distinguishing anxiety-related disorder groups from comparison groups. Evidence suggests this effect is transdiagnostic, relatively robust to experimental or sample parameters, and that generalization paradigms are a well-supported framework for neurobehavioral investigations of learning and emotion in anxiety-related disorders. We discuss these findings in the context of prior fear conditioning meta-analyses, past neuroimaging investigations of fear generalization in anxiety-related disorders, and future directions and challenges for the field.
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http://dx.doi.org/10.1038/s41386-022-01332-2DOI Listing
April 2022

Bio-Psychological Predictors of Acute and Protracted Fatigue After Burns: A Longitudinal Study.

Front Psychol 2021 24;12:794364. Epub 2022 Jan 24.

Department of Clinical Psychology, Faculty of Social and Behavioral Sciences, Utrecht University, Utrecht, Netherlands.

Objective: Fatigue after burns is often attributed to the hyperinflammatory and hypermetabolic response, while it may be best understood from a bio-psychological perspective, also involving the neuro-endocrine system. This longitudinal multi-center study examined the course of fatigue up to 18 months postburn. The contribution of bio-psychological factors, including burn severity, pain, and acute PTSD symptoms, to the course and persistence of fatigue was studied in a multifactorial model.

Methods: Participants were 247 adult burn survivors. Fatigue symptoms were assessed with the Multidimensional Fatigue Inventory during the acute phase and subsequently at 3, 6, 12, and 18 months postburn, and were compared to population norms. Age, gender, burn severity, acute PTSD symptoms and pain were assessed as potential predictors of fatigue over time in a latent growth model.

Results: At 18 months postburn, 46% of the burn survivors reported fatigue, including 18% with severe fatigue. In the acute phase, higher levels of fatigue were related to multiple surgeries, presence of pain, and higher levels of acute PTSD symptoms. Fatigue gradually decreased over time with minor individual differences in rate of decrease. At 18 months, pain and acute PTSD symptoms remained significant predictors of fatigue levels.

Conclusions: Protracted fatigue after burns was found in almost one out of five burn survivors and was associated with both pain and acute PTSD symptoms. Early detection of PTSD symptoms and early psychological interventions aimed at reducing PTSD symptoms and pain may be warranted to reduce later fatigue symptoms.
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http://dx.doi.org/10.3389/fpsyg.2021.794364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8818679PMC
January 2022

Future-Oriented Positive Mental Imagery Reduces Anxiety for Exposure to Public Speaking.

Behav Ther 2022 01 1;53(1):80-91. Epub 2021 Jul 1.

Utrecht University.

Exposure therapy is the recommended treatment for anxiety disorders, but many anxious individuals are unwilling to expose themselves to feared situations. Episodic simulation of future situations contributes to adaptive emotion regulation and motivates behavior. This study investigated whether future-oriented positive mental imagery reduces anticipatory anxiety and distress during exposure, and increases exposure willingness and duration. Forty-three individuals with moderate public speaking anxiety were randomized to a standardized positive mental imagery exercise about future public speaking or no-task. All participants were then asked to present in a virtual reality environment. Anticipatory anxiety reduced in the positive mental imagery group, but not in the control group. Additionally, the positive mental imagery group reported lower distress during exposure than the control group, but groups did not differ in exposure willingness. Due to limited variance, effects on exposure duration could not be tested. Future-oriented positive mental imagery is promising to prepare individuals for exposure to previously avoided situations.
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http://dx.doi.org/10.1016/j.beth.2021.06.005DOI Listing
January 2022

The effectiveness of dual-task interventions for modulating emotional memories in the laboratory: A meta-analysis.

Acta Psychol (Amst) 2021 Oct 5;220:103424. Epub 2021 Oct 5.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Dual-tasks (e.g., making horizontal eye-movements) while recollecting a memory are often used both in the lab and the clinic (such as in EMDR therapy) to attenuate emotional memories and intrusive mental images. According to working memory theory, dual-task interventions are effective because they limit cognitive resources available for the processing of emotional memories. However, there is still ongoing debate about the extent to which and under what conditions dual-task interventions are effective to interfere with emotional memories. In this meta-analysis, we assessed k = 53 laboratory studies investigating the effects of dual-task interventions on negative and positive memories. The effects were measured with the raw mean reduction in vividness and emotionality self-report ratings of emotional memories before compared to after the intervention on 100-point rating scales. Results showed that the dual-task interventions made both negative and positive memories less vivid (mean reduction negative images = 9.18, 95% CI [7.06, 11.29]; mean reduction positive images = 11.73, 95% CI [8.59, 14.86]) and less emotional (mean reduction negative images = 6.22, 95% CI [4.50, 7.94]; mean reduction positive images = 6.71, 95% CI [2.21, 11.20]). Several moderators were tested and are discussed in the light of working memory theory.
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http://dx.doi.org/10.1016/j.actpsy.2021.103424DOI Listing
October 2021

Conceptual fear generalization gradients and their relationship with anxious traits: Results from a Registered Report.

Int J Psychophysiol 2021 12 1;170:43-50. Epub 2021 Oct 1.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

A hallmark symptom of fear and anxiety disorder is generalization of fear to essentially innocuous stimuli and situations. Such generalization can occur through both perceptual and conceptually similarities. Recent studies indicate that perceptual generalization is inflated in anxiety patients and individuals prone to develop anxiety disorders, suggesting that perceptual generalization may be involved in the etiology of anxiety disorders. In the current Registered Report, we wanted to address whether conceptual generalization is potentially implicated in the development of anxiety disorders as well. Therefore, we used a novel paradigm in which the Dutch word mini [tiny] or enorm [enormous] was paired with an electric shock and assessed fear to the conceptually related words klein [small], medium [medium], and groot [large]. The sample (N = 120) consisted of healthy university students. As hypothesized, we observed clear conceptual fear generalization gradients using both self-report and psychophysiological measures. However, in contrast to our expectations, these conceptual generalization gradients were not correlated with different anxious traits (i.e., trait anxiety, intolerance of uncertainty, and behavioral inhibition). These results show that fear can generalize conceptually along a gradient, without requiring perceptual errors as postulated by traditional models of fear generalization. Instead, our results correspond well with inferential reasoning theories of fear generalization. Additionally, we discuss potential reasons for the absence of the expected correlations between conceptual fear generalization and anxious traits, such as restricted variability in both the generalization task and the sample. We conclude that the paradigm has promise for further research on conceptual fear generalization.
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http://dx.doi.org/10.1016/j.ijpsycho.2021.09.007DOI Listing
December 2021

Old Fears Die Hard: Return of Public Speaking Fear in a Virtual Reality Procedure.

Behav Ther 2021 09 2;52(5):1188-1197. Epub 2021 Feb 2.

Utrecht University.

Exposure-based therapy is an effective treatment for social anxiety, but some patients relapse. We used a novel virtual reality procedure to examine spontaneous recovery (i.e., a return of fear over time) and fear renewal (i.e., the return of fear after a context switch) in individuals with fear of public speaking. On Day 1, 32 participants received exposure training before a virtual audience. On Day 8, participants completed a spontaneous recovery phase, followed by a fear renewal test, in which they gave a presentation in front of a new (context switch) or the same audience (no context switch). After exposure, participants exhibited a lower heart rate, subjective distress, negative valence, and arousal. One week later, participants showed spontaneous recovery of heart rate, and the context switch group showed renewal of subjective distress, negative valence, and arousal. Future studies can use this procedure to test interventions aimed at improving long-term exposure effects in individuals with public speaking fear.
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http://dx.doi.org/10.1016/j.beth.2021.01.005DOI Listing
September 2021

Perceived stigmatization and fear of negative evaluation: Two distinct pathways to body image dissatisfaction and self-esteem in burn survivors.

Psychol Health 2021 Aug 26:1-14. Epub 2021 Aug 26.

Department of Behavioural Research, Association of Dutch Burn Centres, Beverwijk, The Netherlands.

Objective: Scars resulting from burn injury can pose social and psychological problems that may affect body image and self-esteem. This study aimed to investigate whether burn severity, age and female gender are associated with body image dissatisfaction and self-esteem, through an association with perceived stigmatization and fear or negative evaluation.

Design & Main Outcome Measures: Burn survivors (N = 224) completed the Fear of Negative Evaluation scale (FNE) and the Perceived Stigmatization Questionnaire (PSQ) at 3 months post-burn, and the Rosenberg Self-Esteem scale (RSE) and the Satisfaction with Appearance scale (SWAP) at 6 months post-burn. Path analysis was used to test the relationships.

Results: Body image dissatisfaction and self-esteem were moderately associated. Burn severity was directly and indirectly associated with body image dissatisfaction through perceived stigmatization. Female gender and age were indirectly associated with body image dissatisfaction though fear of negative evaluation. Age was indirectly associated with both perceived stigmatization and fear of negative evaluation. Perceived stigmatization and fear of negative evaluation were associated with self-esteem through body image dissatisfaction, the first indirectly and the latter both directly and indirectly.

Conclusions: Findings highlight that both burn-specific factors and psychological vulnerability should be taken into account to deal with social challenges that may affect body image and self-esteem after burns.
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http://dx.doi.org/10.1080/08870446.2021.1970160DOI Listing
August 2021

Does an unconditioned stimulus memory devaluation procedure decrease disgust memories and conditioned disgust? Results of two laboratory studies.

J Anxiety Disord 2021 08 9;82:102447. Epub 2021 Jul 9.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands. Electronic address:

Research has demonstrated that disgust can be installed through classical conditioning by pairing neutral conditioned stimuli (CSs) with disgusting unconditioned stimuli (USs). Disgust has been argued to play an important role in maintaining fear-related disorders. This maintaining role may be explained by conditioned disgust being less sensitive to extinction (i.e., experiencing the CS in the absence of the US). Promising alternatives to extinction training are procedures that focus on the devaluation of US memory representations. In the current study, we investigated whether such devaluation procedures can be successful to counter conditioned disgust. We conducted two laboratory studies (N = 120 and N = 51) in which disgust was conditioned using audio-visual USs. Memory representations of the USs were devalued by having participants recall these USs while they performed a taxing eye-movement task or executed one of several control tasks. The results showed successful conditioned disgust acquisition. However, no strong evidence was obtained that an US memory devaluation procedure modulates disgust memory and diminishes conditioned disgust as indicated by subjective, behavioral, or psychophysiological measures. We discuss the relevance of our results for methodological improvements regarding US memory devaluation procedures and disgust conditioning.
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http://dx.doi.org/10.1016/j.janxdis.2021.102447DOI Listing
August 2021

Verbal suggestions fail to modulate expectations about the effectiveness of a laboratory model of EMDR therapy: Results of two preregistered studies.

J Behav Ther Exp Psychiatry 2021 12 25;73:101673. Epub 2021 Jun 25.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Background And Objectives: For many psychotherapies, like Eye Movement and Desensitization Reprocessing (EMDR) therapy, there is an ongoing discussion about the role of specific versus non-specific mechanisms in their effectiveness However, experimental research directly examining the potential role of non-specific mechanisms is scarce. Here, we address the role of a non-specific factor that is often put forward for EMDR, namely treatment effectiveness expectations, within a laboratory model of EMDR therapy.

Methods: In a lab-based (N = 96) and an online experiment (N = 173), we gave participants verbal instructions to manipulate their treatment expectations. Instructions emphasized EMDR's effectiveness or ineffectiveness. Then, participants were asked to recollect an unpleasant autobiographical memory with or without making eye-movements.

Results: In line with previous studies, we found significant reductions of reported vividness and emotionality of negative autobiographical memories in the eye-movements condition. These reductions did not differ between the verbal suggestions conditions in both experiments, suggesting a limited effect of treatment effectiveness suggestions.

Limitations: Treatment effectiveness expectations were not successfully manipulated by the suggestions manipulation. This suggests that treatment expectations may be more difficult to influence than anticipated, thus limiting the interpretation of our findings.

Conclusions: These findings tentatively corroborate the results of two earlier reports, suggesting that the effects of verbal suggestions about treatment effectiveness in a laboratory model of EMDR therapy may be limited.
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http://dx.doi.org/10.1016/j.jbtep.2021.101673DOI Listing
December 2021

Prevalence and course of posttraumatic stress disorder symptoms in partners of burn survivors.

Eur J Psychotraumatol 2021 May 14;12(1):1909282. Epub 2021 May 14.

Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands.

: Partners of burn survivors may develop posttraumatic stress disorder (PTSD) symptoms in response to the potential life threatening nature of the burn event and the burn survivor's medical treatment. : This longitudinal study examined the prevalence, course and potential predictors of partners' PTSD symptoms up to 18 months post-burn. : Participants were 111 partners of adult burn survivors. In a multi-centre study, PTSD symptoms were assessed with the Impact of Event Scale-Revised during the acute phase and subsequently at 3, 6, 12 and 18 months post-burn. Partners' appraisal of life threat, anger, guilt and level of rumination were assessed as potential predictors of PTSD symptoms in an exploratory piecewise latent growth model. : Acute PTSD symptoms in the clinical range were reported by 30% of the partners, which decreased to 4% at 18 months post-burn. Higher acute PTSD symptoms were related to perceived life threat and higher levels of anger, guilt, and rumination. Over time, mean symptom levels decreased, especially in partners with high levels of acute PTSD symptoms, perceived life threat and rumination. From three months onward, PTSD symptoms decreased less in partners of more severely burned survivors. At 18 months post-burn, higher levels of PTSD symptoms were related to higher acute PTSD symptoms and more severe burns. : One in three partners reported clinical levels of acute PTSD symptoms, of which the majority recovered over time. Perceived life threat, feelings of anger and guilt, and rumination may indicate the presence of acute PTSD symptoms, whereas more severe burns predict long-term PTSD symptom levels. The results highlight the need to screen for acute PTSD symptoms and offer psychological help to partners to alleviate acute elevated stress levels if indicated.
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http://dx.doi.org/10.1080/20008198.2021.1909282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128122PMC
May 2021

Forgetting the Future: Emotion Improves Memory for Imagined Future Events in Healthy Individuals but Not Individuals With Anxiety.

Psychol Sci 2021 04 11;32(4):587-597. Epub 2021 Mar 11.

Department of Clinical Psychology, Utrecht University.

Negative thoughts about future events are a central aspect of anxiety disorders. It is important to gain a deeper understanding of how these imagined events are retained over time when considering the impact of negative future thoughts on anxiety. Prior research indicates that emotional intensity fades faster for negative than positive memories in healthy individuals. This so-called fading-affect bias could extend to recall of imagined future events. Furthermore, several studies have suggested that this bias may be reversed in individuals with high levels of anxiety. In the current study, we examined whether individuals with high anxiety ( = 23), relative to individuals with low anxiety ( = 30), showed faster decay for positive than negative future-event simulations. The results show that emotion facilitated cued recall for imagined future events in the low-anxiety group but not in the high-anxiety group. In addition, individuals with high anxiety showed decreased episodic specificity during recall across all emotional conditions.
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http://dx.doi.org/10.1177/0956797620972491DOI Listing
April 2021

Threat memory devaluation by a dual-task intervention: Testing return of fear and intrusive memory over 48 hours.

J Behav Ther Exp Psychiatry 2021 09 13;72:101639. Epub 2021 Feb 13.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Background And Objectives: In dual-tasking, individuals recall a threat-related memory while performing a demanding dual-task. This is a fruitful approach to reduce the unpleasantness and vividness of aversive memories and to reduce conditioned fear responses. Crucially, it remains unclear whether dual-tasking can also reduce conditioned fear responses and intrusive memories over time. In this pre-registered two-day fear conditioning paradigm, we examined whether a dual-task intervention reduces return of fear and the frequency of intrusive memories of an aversive film over time.

Methods: On Day 1, 76 healthy participants underwent fear acquisition with aversive film clips. They were then randomly allocated to one of three conditions: dual-tasking, memory recall without a dual-task ('recall only'), or no task. Afterwards, they underwent an extinction phase and were asked to record intrusive film memories over 48 h. On Day 3, return of fear was assessed.

Results: On Day 1, fear acquisition and extinction were successful. On Day 3, spontaneous recovery and renewal were evident, but, overall, participants reported few intrusions. The dual-task and recall only groups reported reduced unpleasantness of threat memory compared to the no task group, but they did not show reduced (return of) fear responses or fewer intrusions.

Limitations: Intrusion frequency was low in all three groups, which limits the detection of intervention effects.

Conclusions: Even though dual-tasking and recall only devalued threat memory temporarily compared to no task, these interventions did not reduce (return of) fear responses and intrusions. Future studies could focus on improving the potency of imagery-based interventions.
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http://dx.doi.org/10.1016/j.jbtep.2021.101639DOI Listing
September 2021

Latent class growth analyses reveal overrepresentation of dysfunctional fear conditioning trajectories in patients with anxiety-related disorders compared to controls.

J Anxiety Disord 2021 03 18;78:102361. Epub 2021 Jan 18.

Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands; Altrecht Academic Anxiety Center, Utrecht, The Netherlands; Department of Psychiatry, University Medical Center Groningen and University of Groningen, GGZ Drenthe, Department of Specialist Training, The Netherlands. Electronic address:

Recent meta-analyses indicated differences in fear acquisition and extinction between patients with anxiety-related disorders and comparison subjects. However, these effects are small and may hold for only a subsample of patients. To investigate individual trajectories in fear acquisition and extinction across patients with anxiety-related disorders (N = 104; before treatment) and comparison subjects (N = 93), data from a previous study (Duits et al., 2017) were re-analyzed using data-driven latent class growth analyses. In this explorative study, subjective fear ratings, shock expectancy ratings and startle responses were used as outcome measures. Fear and expectancy ratings, but not startle data, yielded distinct fear conditioning trajectories across participants. Patients were, compared to controls, overrepresented in two distinct dysfunctional fear conditioning trajectories: impaired safety learning and poor fear extinction to danger cues. The profiling of individual patterns allowed to determine that whereas a subset of patients showed trajectories of dysfunctional fear conditioning, a significant proportion of patients (≥50 %) did not. The strength of trajectory analyses as opposed to group analyses is that it allows the identification of individuals with dysfunctional fear conditioning. Results suggested that dysfunctional fear learning may also be associated with poor treatment outcome, but further research in larger samples is needed to address this question.
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http://dx.doi.org/10.1016/j.janxdis.2021.102361DOI Listing
March 2021

Human fear conditioning is moderated by stimulus contingency instructions.

Biol Psychol 2021 01 25;158:107994. Epub 2020 Nov 25.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Recent research findings indicate that human fear conditioning is affected by instructions, particularly those concerning the contingency between the conditioned stimulus (CS) and the unconditioned stimulus (US). However, whether or not such instructions were provided to participants often remains unsaid in fear conditioning studies. In the current study (N = 102), we investigated whether conditioned fear acquisition depends on CS-US contingency instructions. Participants were randomly assigned to one of three groups. The first group was instructed about the precise CS-US contingency before conditioning. The second group was instructed to discover the CS-US contingency. The third group did not receive any contingency instructions. We found facilitated fear acquisition (using skin conductance and startle) and increased contingency awareness in the first and second group compared to the third group. Furthermore, contingency reversal instructions immediately reversed conditioned responses. Based on these results, we advise to systematically report the contingency instructions used in fear conditioning research.
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http://dx.doi.org/10.1016/j.biopsycho.2020.107994DOI Listing
January 2021

Individual recovery of health-related quality of life during 18 months post-burn using a retrospective pre-burn measurement: an exploratory study.

Qual Life Res 2021 Mar 22;30(3):737-749. Epub 2020 Oct 22.

Association of Dutch Burn Centres, P.O. Box 1015, 1940 EA, Beverwijk, The Netherlands.

Purpose: This study explored the individual trajectories of health-related quality of life (HRQL) compared to recalled pre-burn level of HRQL and investigated whether burn severity and post-traumatic stress disorder (PTSD) symptoms increase the risk of not returning to pre-burn level of HRQL.

Methods: Data were obtained from 309 adult patients with burns in a multicenter study. Patients completed the EQ-5D-3L questionnaire with a Cognition bolt-on shortly after hospital admission, which included a recalled pre-injury measure, and, again, at 3, 6, 12 and 18 months post-burn. Burn severity was indicated by the number of surgeries, and PTSD symptoms were assessed with the IES-R at three months post-burn. Pre- and post-injury HRQL were compared to norm populations.

Results: Recalled pre-injury HRQL was higher than population norms and HRQL at 18 months post-burn was comparable to population norms. Compared to the pre-injury level of functioning, four HRQL patterns of change over time were established: Stable, Recovery, Deterioration, and Growth. In each HRQL domain, a subset of patients did not return to their recalled pre-injury levels, especially with regard to Pain, Anxiety/Depression, and Cognition. Patients with more severe burns or PTSD symptoms were less likely to return to pre-injury level of functioning within 18 months post-burn.

Conclusion: This study identified four patterns of individual change. Patients with more severe injuries and PTSD symptoms were more at risk of not returning to their recalled pre-injury HRQL. This study supports the face validity of using a recalled pre-burn HRQL score as a reference point to monitor HRQL after burns.
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http://dx.doi.org/10.1007/s11136-020-02678-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952339PMC
March 2021

Enhancing extinction with response prevention via imagery-based counterconditioning: Results on conditioned avoidance and distress.

J Behav Ther Exp Psychiatry 2021 03 13;70:101601. Epub 2020 Aug 13.

Department of Clinical Psychology, Utrecht University, the Netherlands.

Background And Objectives: Maladaptive avoidance is a core characteristic of anxiety-related disorders. Its reduction is often promoted using extinction with response prevention (ExRP) procedures, but these effects are often short-lived. Research has shown that pairing a feared stimulus with a stimulus of an incompatible valence (i.e., counterconditioning) may be effective in reducing fear. This laboratory study tested whether positive imagery during ExRP (i.e., imagery counterconditioning protocol) can also reduce avoidance.

Methods: In the counterconditioning procedure, participants imagined a positive sound. There were four phases. First, participants were presented with squares on a computer screen of which one (CS+) was paired with an aversive sound and another (CS-) was not. Second, they learned to avoid the negative sound in the presence of the CS+, via a key press. Third, they were assigned to either the Counterconditioning (that was asked to imagine a positive sound during ExRP) or No Counterconditioning group (standard ExRP). Finally, they performed a test phase that consisted of two parts: in the first part, avoidance responses were available for each CS and in the second part, these responses were prevented.

Results: The Counterconditioning intervention resulted in a short-lived reduction of distress associated with the CS+. However, groups did not differ in avoidance or distress during the test phases.

Limitations: US-expectancy ratings were collected only at the end of the experiment.

Conclusions: The results indicate that positive imagery during ExRP may be effective in reducing distress during the intervention. Explanations for the persistence of avoidance and fear are discussed.
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http://dx.doi.org/10.1016/j.jbtep.2020.101601DOI Listing
March 2021

Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020.

J Anxiety Disord 2020 08 10;74:102258. Epub 2020 Jun 10.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Fear is an adaptive response in the presence of danger. However, when threat is uncertain and continuous, as in the current coronavirus disease (COVID-19) pandemic, fear can become chronic and burdensome. To identify predictors of fear of the coronavirus, we conducted an online survey (N = 439) three days after the World Health Organization declared the coronavirus outbreak a pandemic (i.e., between March 14 and 17, 2020). Fear of the coronavirus was assessed with the newly developed Fear of the Coronavirus Questionnaire (FCQ) consisting of eight questions pertaining to different dimensions of fear (e.g., subjective worry, safety behaviors, preferential attention), and an open-ended question. The predictors included psychological vulnerability factors (i.e., intolerance of uncertainty, worry, and health anxiety), media exposure, and personal relevance (i.e., personal health, risk for loved ones, and risk control). We found four predictors for the FCQ in a simultaneous regression analysis: health anxiety, regular media use, social media use, and risks for loved ones (R = .37). Furthermore, 16 different topics of concern were identified based participants' open-ended responses, including the health of loved ones, health care systems overload, and economic consequences. We discuss the relevance of our findings for managing people's fear of the coronavirus.
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http://dx.doi.org/10.1016/j.janxdis.2020.102258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286280PMC
August 2020

Induction of conditioned avoidance via mental imagery.

Behav Res Ther 2020 Jun 1;132:103652. Epub 2020 Jun 1.

Department of Clinical Psychology, Utrecht University, the Netherlands.

There is a growing interest on how mental imagery may be involved in the onset and maintenance of anxiety-related disorders. Here, we used an experimental design to investigate whether a key symptom across anxiety-related disorders, namely avoidance, can be induced via mental imagery. Healthy participants first learned that one neutral stimulus (A) was associated with a mild electric shock and two other neutral stimuli (B and C) were not. They then learned to cancel the shock when A was presented, by pressing a button on a keyboard ('behavioral avoidance'). Next, they were asked to imagine that stimulus B was followed by the shock (i.e., without actual B or shock presentations; Experiment 1; N = 66) or they were shown B and asked to imagine the shock (i.e., without actual shock presentations; Experiment 2; N = 60). Finally, in the test phase, they were shown each of the three stimuli (without the shock) and given the opportunity to make the avoidance response. Results showed that participants tended to avoid B in the test phase in Experiment 1, even though it had never been presented with the shock but not in Experiment 2. We discuss how the findings may explain the acquisition of avoidance in the presentation of innocuousstimuli across anxiety-related disorders.
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http://dx.doi.org/10.1016/j.brat.2020.103652DOI Listing
June 2020

Side effects of induced lateral eye movements during aversive ideation.

J Behav Ther Exp Psychiatry 2020 09 4;68:101566. Epub 2020 Mar 4.

Utrecht University, Utrecht, the Netherlands. Electronic address:

Background And Objectives: Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for posttraumatic stress disorder. It uses a dual-task approach, in which patients recall an aversive memory while making lateral eye movements. Research has shown that this 'eye movements' intervention reduces subjective memory vividness and emotionality. This study examined whether it also reduces memory accuracy on a visual discrimination task.

Methods: Participants (68 undergraduates) underwent an aversive conditioning phase, in which two pictures of male faces were followed by shock. Then they recalled one face with (experimental condition) and one without (control condition) making lateral eye movements. Finally, they completed a stimulus discrimination test with slightly different faces shortly after the intervention and one day later.

Results: Results showed that the eye movements intervention led to increased false-positive rates one day later.

Limitations: Our intervention targeted newly formed memory rather than consolidated memory.

Conclusions: The results inform theory about EMDR's mechanisms of change and suggest that the treatment may have side effects regarding memory accuracy.
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http://dx.doi.org/10.1016/j.jbtep.2020.101566DOI Listing
September 2020

Reduction of conditioned avoidance via contingency reversal.

Cogn Emot 2020 09 16;34(6):1284-1290. Epub 2020 Feb 16.

Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands.

There is an increased interest in how excessive avoidance can diminish. Avoidance reduction is typically tested by using Extinction with Response Prevention (ExRP) protocols, where feared stimuli are presented without any aversive outcome while avoidance is prevented. These effects, however, often do not persist. Here, we tested whether pairing an avoidance response with the presence of an aversive event would reduce avoidance more than ExRP. Participants ( = 58) first saw a picture of a square (A) being paired with a shock whereas another picture of a square (B) not being paired with a shock. Then, they learned to press a button during the presentation of A to avoid the shock. Afterwards, the ExRP group saw unreinforced presentations of A and B without being able to press the avoidance button, whereas the Contingency Reversal group (ConR) received a shock whenever they pressed the button in presence of A. In the test phase, participants saw unreinforced presentations of A and B. Results showed that after successful acquisition of fear and avoidance, in the test phase the ConR group avoided A less often than did the ExRP group. Research on contingency reversal could prove helpful for developing avoidance reduction protocols.
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http://dx.doi.org/10.1080/02699931.2020.1727417DOI Listing
September 2020

A review on mental imagery in fear conditioning research 100 years since the 'Little Albert' study.

Behav Res Ther 2020 03 22;126:103556. Epub 2020 Jan 22.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Since the seminal 'Little Albert' study by Watson and Rayner (1920), fear conditioning has become one of the most commonly used paradigms for studying the etiology of anxiety-related disorders. In a fear conditioning procedure, a (neutral) conditioned stimulus (CS) is paired with an aversive unconditioned stimulus (US), resulting in fear-related conditioned responses (CRs) to the CS. Whereas fear conditioning research initially focused on observable elements in the environment (i.e., CSs, USs, and their contingency) and their effects (i.e., CRs), subsequent research indicated that attention should also be given to unobservable mental events (e.g., intrusive memories of aversive outcomes) to more fully account for the symptomatology of anxiety disorders. In this paper, we review the research relating to four major research questions on the relationship between mental imagery and fear conditioning: (1) Can mental imagery substitute for actual stimulus administration? (2) Can mental imagery inflate CRs? (3) Can fear conditioning result in the installment of mental images as CRs (i.e., intrusions)? (4) Can mental imagery-based interventions reduce CRs? For all these research questions, tentative confirmatory evidence has been found and these findings corroborate contemporary conditioning theories. Nonetheless, we point to several open questions and methodological issues that require further research.
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http://dx.doi.org/10.1016/j.brat.2020.103556DOI Listing
March 2020

Mothers' emotions after pediatric burn injury: Longitudinal associations with posttraumatic stress and depressive symptoms 18 months postburn.

J Affect Disord 2020 02 30;263:463-471. Epub 2019 Nov 30.

Association of Dutch Burn Centres, Beverwijk, the Netherlands; Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Background: Various emotions are implicated in posttraumatic stress disorder (PTSD). Longitudinal studies examining temporal associations between emotions and posttraumatic stress may reveal who is at risk of chronic psychological problems. This study examined the longitudinal relationships of mothers' trauma-related emotions with posttraumatic stress and depressive symptoms after pediatric burn injury.

Methods: Data from two cohort studies were used (n = 296). Mothers reported the intensity of burn-related emotions within the first month (T1) and 12 months postburn (T2). The Impact of Event Scale (IES) and the Hospital and Anxiety Depression Scale (HADS-D; depression subscale) were administered at T1 and 18 months postburn (T3).

Results: Based on two exploratory factor analyses, emotion variables were combined into acute and long-term basic emotions (fear, sadness, horror, anger) and self-conscious emotions (guilt, shame). The path model showed a positive relationship between acute and long-term basic emotions. Higher long-term basic emotions were related to persistence of posttraumatic stress and depressive symptoms. Acute self-conscious emotions showed associations with posttraumatic stress and depressive symptoms at T1 and were longitudinally related to depressive, but not posttraumatic stress, symptoms.

Limitations: The posttraumatic stress measure was not based on DSM-5 PTSD criteria and results require replication using these criteria.

Conclusions: This study suggests that mothers' acute self-conscious and long-term basic emotions in relation to their child's burn injury are involved in the development of posttraumatic stress and depressive symptoms. Clinically, assessing and monitoring parents' early posttraumatic stress, depressive symptoms and burn-related emotions may be useful to identify parents at risk.
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http://dx.doi.org/10.1016/j.jad.2019.11.140DOI Listing
February 2020

Devaluation of threat memory using a dual-task intervention does not reduce context renewal of fear.

Behav Res Ther 2020 01 17;124:103480. Epub 2019 Sep 17.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Many patients who benefit from exposure-based therapy for anxiety disorders fail to maintain their gains. Learned fear may return when they encounter phobic stimuli in a different context than the one in which extinction occurred. In the current pre-registered experiment, we tested whether threat memory devaluation reduces context renewal of fear. A dual-task intervention was used to devalue threat memory. During this intervention, individuals recall the threat memory while simultaneously performing a demanding secondary task (e.g., making eye movements). On day 1, participants (N = 75) underwent fear acquisition with an aversive film clip in context A. On day 2, 25 participants were assigned to each group, namely a dual-task group, or one of two control groups: recall only task (without the dual-task) or no intervention. Afterwards, all participants underwent extinction training in context B and were then exposed to context A again in a test phase. The dual-task intervention effectively degraded threat memory compared to no intervention, but the recall only intervention was also partly effective. However, all three groups showed comparable fear renewal on subjective and physiological measures. This indicates that threat memory devaluation was not effective to prevent context renewal.
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http://dx.doi.org/10.1016/j.brat.2019.103480DOI Listing
January 2020

Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders: A Systematic Review and Meta-analysis.

JAMA Psychiatry 2020 03;77(3):265-273

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Importance: Cognitive behavioral therapy is recommended for anxiety-related disorders, but evidence for its long-term outcome is limited.

Objective: This systematic review and meta-analysis aimed to assess the long-term outcomes after cognitive behavioral therapy (compared with care as usual, relaxation, psychoeducation, pill placebo, supportive therapy, or waiting list) for anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).

Data Sources: English-language publications were identified from PubMed, PsycINFO, Embase, Cochrane, OpenGrey (1980 to January 2019), and recent reviews. The search strategy included a combination of terms associated with anxiety disorders (eg, panic or phobi*) and study design (eg, clinical trial or randomized controlled trial).

Study Selection: Randomized clinical trials on posttreatment and at least 1-month follow-up effects of cognitive behavioral therapy compared with control conditions among adults with generalized anxiety disorder, panic disorder with or without agoraphobia, social anxiety disorder, specific phobia, PTSD, or OCD.

Data Extraction And Synthesis: Researchers independently screened records, extracted statistics, and assessed study quality. Data were pooled using a random-effects model.

Main Outcomes And Measures: Hedges g was calculated for anxiety symptoms immediately after treatment and at 1 to 6 months, 6 to 12 months, and 12 months or more after treatment completion.

Results: Of 69 randomized clinical trials (4118 outpatients) that were mainly of low quality, cognitive behavioral therapy compared with control conditions was associated with improved outcomes after treatment completion and at 1 to 6 months and at 6 to 12 months of follow-up for a generalized anxiety disorder (Hedges g, 0.07-0.40), panic disorder with or without agoraphobia (Hedges g, 0.22-0.35), social anxiety disorder (Hedges g, 0.34-0.60), specific phobia (Hedges g, 0.49-0.72), PTSD (Hedges g, 0.59-0.72), and OCD (Hedges g, 0.70-0.85). At a follow-up of 12 months or more, these associations were still significant for generalized anxiety disorder (Hedges g, 0.22; number of studies [k] = 10), social anxiety disorder (Hedges g, 0.42; k = 3), and PTSD (Hedges g, 0.84; k = 5), but not for panic disorder with or without agoraphobia (k = 5) and could not be calculated for specific phobia (k = 1) and OCD (k = 0). Relapse rates after 3 to 12 months were 0% to 14% but were reported in only 6 randomized clinical trials (predominantly for panic disorder with or without agoraphobia).

Conclusions And Relevance: The findings of this meta-analysis suggest that cognitive behavioral therapy for anxiety-related disorders is associated with improved outcomes compared with control conditions until 12 months after treatment completion. At a follow-up of 12 months or more, effects were small to medium for generalized anxiety disorder and social anxiety disorder, large for PTSD, and not significant or not available for other disorders. High-quality randomized clinical trials with 12 months or more of follow-up and reported relapse rates are needed.
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http://dx.doi.org/10.1001/jamapsychiatry.2019.3986DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902232PMC
March 2020

A systematic review and meta-analysis of the evidence for unaware fear conditioning.

Neurosci Biobehav Rev 2020 01 17;108:254-268. Epub 2019 Nov 17.

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.

Whether fear conditioning can take place without contingency awareness is a topic of continuing debate and conflicting findings have been reported in the literature. This systematic review provides a critical assessment of the available evidence. Specifically, a search was conducted to identify articles reporting fear conditioning studies in which the contingency between conditioned stimuli (CS) and the unconditioned stimulus (US) was masked, and in which CS-US contingency awareness was assessed. A systematic assessment of the methodological quality of the included studies (k = 41) indicated that most studies suffered from methodological limitations (i.e., poor masking procedures, poor awareness measures, researcher degrees of freedom, and trial-order effects), and that higher quality predicted lower odds of studies concluding in favor of contingency unaware fear conditioning. Furthermore, meta-analytic moderation analyses indicated no evidence for a specific set of conditions under which contingency unaware fear conditioning can be observed. Finally, funnel plot asymmetry and p-curve analysis indicated evidence for publication bias. We conclude that there is no convincing evidence for contingency unaware fear conditioning.
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http://dx.doi.org/10.1016/j.neubiorev.2019.11.012DOI Listing
January 2020
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