Marieke Effting

Cognitive–behavioural therapies and exercise programmes for patients with fibromyalgia: state of the art and future directions

This review provides an overview of the effects of non-pharmacological treatments for patients with fibromyalgia (FM), including cognitive–behavioural therapy, exercise training programmes, or a combination of the two. After summarising and discussing preliminary evidence of the rationale of non-pharmacological treatment in patients with FM, we reviewed randomised, controlled trials for possible predictors of the success of treatment such as patient and treatment characteristics. In spite of support for their suitability in FM, the effects of non-pharmacological interventions are limited and positive outcomes largely disappear in the long term. However, within the various populations with FM, treatment outcomes showed considerable individual variations. In particular, specific subgroups of patients characterised by relatively high levels of psychological distress seem to benefit most from non-pharmacological interventions. Preliminary evidence of retrospective treatment analyses suggests that the efficacy may be enhanced by offering tailored treatment approaches at an early stage to patients who are at risk of developing chronic physical and psychological impairments.

Avoidance Learning: A Review of Theoretical Models and Recent Developments

Avoidance is a key characteristic of adaptive and maladaptive fear. Here, we review past and contemporary theories of avoidance learning. Based on the theories, experimental findings and clinical observations reviewed, we distill key principles of how adaptive and maladaptive avoidance behavior is acquired and maintained. We highlight clinical implications of avoidance learning theories and describe intervention strategies that could reduce maladaptive avoidance and prevent its return. We end with a brief overview of recent developments and avenues for further research.

Avoided by Association Acquisition, Extinction, and Renewal of Avoidance Tendencies Toward Conditioned Fear Stimuli

Traditional theoretical models hold that avoidance reflects the interplay of Pavlovian and instrumental learning. Here we suggest that avoidance tendencies to intrinsically neutral cues may be established by mere Pavlovian association. Following fear conditioning, in which pictures of one object were paired with shock (CS+) whereas pictures of another object were not (CS−), CS+ pictures facilitated avoidance reactions and interfered with approach responses, relative to CS− pictures, in a symbolic approach/avoidance reaction time task. This was achieved without any instrumental relation between responses and CS continuation or unconditioned stimulus presentation. Moreover, those avoidance tendencies were sensitive to Pavlovian extinction (they were reduced after repeated presentations of the CS+ without shock) and renewal (recovery of conditioned responding upon returning to the initial conditioning context after extinction in a different context). The present results may help us understand the self-perpetuating nature of pathological fear and anxiety.

Individual differences in discriminatory fear learning under conditions of ambiguity: a vulnerability factor for anxiety disorders?

Complex fear learning procedures might be better suited than the common differential fear-conditioning paradigm for detecting individual differences related to vulnerability for anxiety disorders. Two such procedures are the blocking procedure and the protection-from-overshadowing procedure. Their comparison allows for the examination of discriminatory fear learning under conditions of ambiguity. The present study examined the role of individual differences in such discriminatory fear learning. We hypothesized that heightened trait anxiety would be related to a deficit in discriminatory fear learning. Participants gave US-expectancy ratings as an index for the threat value of individual CSs following blocking and protection-from-overshadowing training. The difference in threat value at test between the protected-from-overshadowing conditioned stimulus (CS) and the blocked CS was negatively correlated with scores on a self-report tension-stress scale that approximates facets of generalized anxiety disorder (GAD), the Depression Anxiety Stress Scale-Stress (DASS-S), but not with other individual difference variables. In addition, a behavioral test showed that only participants scoring high on the DASS-S avoided the protected-from-overshadowing CS. This observed deficit in discriminatory fear learning for participants with high levels of tension-stress might be an underlying mechanism for fear overgeneralization in diffuse anxiety disorders such as GAD.

Effects of Approach-Avoidance Training on the Extinction and Return of Fear Responses

Background and Objectives Exposure therapy for anxiety involves confronting a patient with fear-evoking stimuli, a procedure based partially on Pavlovian extinction. Exposure and other extinction-based therapies usually lead to (partial) reduction of fear symptoms, but a substantial number of patients experience a return of fear after treatment. Here we tested whether the combination of fear extinction with modification of approach-avoidance tendencies using an Approach-Avoidance Task (AAT) would result in the further reduction of conditioned fear and/or help prevent return of fear after extinction. Methods Two groups of participants underwent a fear acquisition procedure during which pictures of one neutral object were sometimes paired with shock (CS+), whereas pictures of another neutral object were not (CS−). The next day, in a fear extinction procedure, both objects were presented without shock. During the subsequent joystick AAT, one group primarily pulled CS+ pictures towards themselves and pushed CS− pictures away from themselves; reversed contingencies applied for the other group. Results Approach training was effective in modifying conditioned action tendencies, with some evidence for transfer to a different approach/avoidance task. No group differences in subjective fear or physiological arousal were found during subsequent post- training and return-of-fear testing. Limitations No reliable return-of-fear was observed in either group for either subjective or physiological fear measures. Conclusions Our results suggest that approach training may be of limited value for enhancing the short- and long-term effects of extinction-based interventions.

Moving threat : Attention and distance change interact in threat responding

Defensive reactions need to be quick and appropriate to ensure survival. Thus, it is crucial that threats trigger immediate action upon detection, even in the absence of awareness. In addition, the form of such action should be appropriate to the imminence of the threat. Thus, attention should be guided by signals of increasing threat imminence. We examined whether subliminally presented threat stimuli provoke automatic avoidance tendencies, and whether threat cues’ distance change and threat potential determine attention allocation. Following fear conditioning, participants performed an approach-avoidance task with subliminally presented conditioned threat and safety stimuli, and an attentional bias task with approaching versus distancing signals of threat and safety. Preattentive processing of threat cues resulted in approach rather than avoidance tendencies; attention was captured preferentially by signals of increasing threat imminence. The results support the importance of threat imminence and extend findings of previous research on preattentive influences on defensive responding.

Fearing shades of grey: individual differences in fear responding towards generalisation stimuli

ABSTRACT Individual differences in fear generalisation have been proposed to play a role in the aetiology and/or maintenance of anxiety disorders, but few data are available to directly support that claim. The research that is available has focused mostly on generalisation of peripheral and central physiological fear responses. Far less is known about the generalisation of avoidance, the behavioural component of fear. In two experiments, we evaluated how neuroticism, a known vulnerability factor for anxiety, modulates an array of fear responses, including avoidance tendencies, towards generalisation stimuli (GS). Participants underwent differential fear conditioning, in which one conditioned stimulus (CS+) was repeatedly paired with an aversive outcome (shock; unconditioned stimulus, US), whereas another was not (CS−). Fear generalisation was observed across measures in Experiment 1 (US expectancy and evaluative ratings) and Experiment 2 (US expectancy, evaluative ratings, skin conductance, startle responses, safety behaviours), with overall highest responding to the CS+, lowest to the CS− and intermediate responding to the GSs. Neuroticism had very little impact on fear generalisation (but did affect GS recognition rates in Experiment 1), in line with the idea that fear generalisation is largely an adaptive process.

Implicit and explicit measures of spider fear and avoidance behavior: Examination of the moderating role of working memory capacity.

BACKGROUND AND OBJECTIVES Avoidance behavior is central to several anxiety disorders. The current study tested whether avoidance behavior for spiders depends on a dynamic interplay between implicit and explicit processes, moderated by the availability to exert control through working memory capacity (WMC). METHODS A total of 63 participants completed an approach-avoidance task, an implicit association test, a spider fear questionnaire and a behavioral avoidance test that included an assessment of approach distance as well as approach speed. WMC was measured by a complex operation span task. It was hypothesized that in individuals with low WMC, implicit avoidance tendencies and implicit negative associations predict avoidance behavior for a spider better than the explicit measure, whereas in high WMC individuals, the explicit measure should better predict avoidance behavior than the implicit measures. RESULTS Results revealed that WMC moderated the influence of implicit negative associations, but not implicit avoidance tendencies, on spider approach distance but not the speed of approaching. Although explicit spider fear directly influenced avoidance behavior, its impact was not modulated by WMC. LIMITATIONS Participants in our study were from a non-clinical sample, which limits the generalizability of our findings. CONCLUSIONS These findings suggest that implicit processes might become more pertinent for fear behavior as the ability to control such processes wanes, which may be particularly relevant for anxiety disorders given their association with lowered executive control functioning. As such, training procedures that specifically target implicit processes or control abilities might improve treatment outcomes for anxiety disorders.

Fibromyalgie: een overzicht van niet-farmacologische behandelingen

Fibromyalgie is een chronisch pijnsyndroom waarvan de etiologie onbekend is. Het belangrijkste criterium is de aanwezigheid van wijdverspreide pijn die langer dan drie maanden bestaat, samen met een pijngevoeligheid ter hoogte van minstens elf van achttien tender points. Dit zijn nauwkeurig omschreven punten op het lichaam die bij uitoefening van een bepaalde druk pijnlijk zijn. Behalve pijn rapporteren patienten vaak symptomen als vermoeidheid, slaapproblemen, ochtendstijfheid, darmklachten, angst en depressieve gevoelens (Wolfe e.a., 1990). De prevalentie van fibromyalgie wordt in westerse landen geschat op 2 procent van de algemene bevolking en het syndroom komt vaker voor bij vrouwen dan bij mannen (Wolfe e.a., 1995).

Manipulating affective state influences conditioned appetitive responses

ABSTRACT Affective states influence how individuals process information and behave. Some theories predict emotional congruency effects (e.g. preferential processing of negative information in negative affective states). Emotional congruency should theoretically obstruct the learning of reward associations (appetitive learning) and their ability to guide behaviour under negative mood. Two studies tested the effects of the induction of a negative affective state on appetitive Pavlovian learning, in which neutral stimuli were associated with chocolate (Experiment 1) or alcohol (Experiment 2) rewards. In both experiments, participants showed enhanced approach tendencies towards predictors of reward after a negative relative to a positive performance feedback manipulation. This increase was related to a reduction in positive affect in Experiment 1 only. No effects of the manipulation on conditioned reward expectancies, craving, or consumption were observed. Overall, our findings support the idea of counter-regulation, rather than emotional congruency effects. Negative affective states might therefore serve as a vulnerability factor for addiction, through increasing conditioned approach tendencies.