When Is Seeking Safety Functional? Taking a Pragmatic Approach to Distinguishing Coping From Safety

Currently, most exposure-based treatments call for clinicians to assess for and remove all safety behaviors during exposure tasks. However, the notion that safety behaviors are detrimental across all scenarios has recently been challenged, and research regarding the effects of safety behaviors on exposure outcomes is limited and inconsistent. In clinical practice, classifying a strategy as a safety behavior can be a complex and challenging endeavor, particularly when distinguishing between harmful safety behaviors and helpful coping behaviors. We outline an approach that emphasizes the pragmatic truth criterion and uses functional outcomes to classify behaviors as serving either safety or coping functions. Our focus on doing what “works” simplifies decision-making for clinicians and maintains the focus of treatment on enhancing functioning. We propose a model for using functional outcomes to distinguish between safety and coping behaviors and illustrate our approach through case examples.     

The interplay between relationship effectiveness,life stress,and sleep: A prospective study

Research has shown that greater stress responses predict worse sleep and that the quality of one's current romantic relationship predicts one's sleep. Despite these established links, research has not examined connections between ongoing patterns of interpersonal experiences and competencies (relationship effectiveness) and stress exposure on sleep. Participants in the Minnesota Longitudinal Study of Risk and Adaptation (MLSRA) completed measures assessing relationship effectiveness and stress exposure at ages 23 and 32 years, as well as sleep quality/duration at age 37 years. Analyses demonstrate that relationship effectiveness at age 23 years positively predicts sleep quality—but not sleep duration—at age 37 years via reduced stress exposure at age 32 years. These findings highlight the effects of relationship effectiveness and stress exposure across early to middle adulthood on sleep.     

Inhibitory Learning for Anxiety-Related Disorders

This article reviews the articles in this issue that describe the strategies derived from the inhibitory learning model as applied to exposure therapy for anxiety disorders. The major principles of inhibitory learning are to create and strengthen nonthreat associations in memory (largely by engaging prefrontal cortical regions), and to effectively retrieve those nonthreat associations in the long term. Several case vignettes are provided that demonstrate how the principles of inhibitory learning (which include maximizing expectancy violations, limiting distraction, fear antagonistic actions, deepened extinction, elimination of safety behaviors, occasional reinforced extinction, increasing variability of exposures and offsetting reinstatement and context renewal effects) can be applied in clinical practice.     

Using Multiple Contexts and Retrieval Cues in Exposure-Based Therapy to Prevent Relapse in Anxiety Disorders

The benefits of exposure-based interventions for anxiety disorders are substantial but not stable for everyone, given that these interventions are often followed by relapse of symptoms. A body of research provides a background on how to add certain strategies in exposure-based therapy to prevent relapse in anxiety disorders. This review summarizes some of these strategies and provides clear-cut clinical implications. Studies that provide support for two types of strategies to prevent relapse have been reviewed—the use of multiple contexts and the use of retrieval cues. The use of multiple contexts reduces context and stimulus specificity of extinction learning during exposure, while the use of retrieval cues enhances memory (re)consolidation and retrieval after exposure. The described strategies to enhance the accessibility and therefore the retrievability of exposure-based learning to prevent relapse in anxiety disorders can be summarized as advice to conduct exposure under variable conditions. This way, the generalizability of what is learned during exposure to the patients’ daily life after treatment improves. Therefore, adding these strategies in the course of exposure-based treatment of anxiety disorders seems beneficial. However, future replications and translational studies are needed to verify ecological validity.     

Dropping Safety Aids and Maximizing Retrieval Cues: Two Keys to Optimizing Inhibitory Learning During Exposure Therapy

The inhibitory learning model of exposure therapy posits that clinical anxiety is most effectively treated when clinicians employ strategies that maximize the (a) violation of negative expectancies and (b) generalization of nonthreat associations. Translation of basic learning research to exposure therapy via this explanatory model underscores two keys to optimizing inhibitory learning during exposure: dropping safety aids and maximizing retrieval cues. Although topographically similar, safety aids and retrieval cues are functionally distinct as well as therapeutically incompatible. In the present article, we delineate safety aids and retrieval cues in the context of exposure therapy from an inhibitory learning perspective, providing illustrative case examples of how clinicians may address the two when treating patients with clinical anxiety.     

Thirdhand smoke beliefs and behaviors among healthcare professionals

Thirdhand smoke (THS) refers to tobacco smoke contaminants and by-products that remain in the environment after a cigarette is extinguished. The purpose of this study was to assess beliefs and behaviors regarding THS among healthcare professionals, and to examine associations among smoking attitudes/beliefs, provider demographics, and THS beliefs and behaviors. Healthcare professionals (N = 204) at a comprehensive cancer center and affiliated general hospital in a northeastern urban area completed online questionnaires. About one third of the respondents had heard of THS before completing the survey, and more than two thirds of the sample believed that THS issues do not receive enough attention. Being female, likelihood of discussing THS with others, endorsing the belief that smoking affects the quality of parenting, and support for government action towards smoking bans were significantly associated with providers’ belief that THS is harmful. Endorsing the belief that smoking affects the quality of parenting and belief that THS is harmful were significantly associated with the likelihood of discussing THS with others. Findings shed light on THS beliefs and behaviors of healthcare providers (a group of individuals that could be trained to educate and advise patients about THS) and inform recommendations for new tobacco policies and clinical guidelines for best practices in tobacco control and prevention.     

Creating state of the art,next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions

Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic “Big Data” that promises to inform learning theory and behavioral therapy in general.     

Why did adolescents have sleep problems after earthquakes? Understanding the role of traumatic exposure,fear, and PTSD

To examine the relationships between trauma exposure, fear, post‐traumatic stress disorder, and sleep problems in adolescents, 746 adolescent survivors of the 2008 Wenchuan earthquake in China were assessed at 1 year (T1) and 1.5 years (T2) after the earthquake using a trauma exposure questionnaire, a fear questionnaire, a child posttraumatic stress disorder symptom scale, and a subscale on child sleep problems. The results showed that T1 trauma exposure were not directly associated with sleep problems at T1 and T2, but played a positive role in sleep problems at both T1 and T2 indirectly through T1 posttraumatic stress disorder and T1 fear. T1 trauma exposure was also positively and indirectly associated with T2 sleep problems through T1 posttraumatic stress disorder via T1 sleep problems, or through T1 fear via the path from T1 posttraumatic stress disorder to T1 sleep problems. These findings indicated that fear and posttraumatic stress disorder 1 year after the earthquake played a mediating role in the relationship between trauma exposure at 1 year after the earthquake, and sleep problems at both 1 year and 1.5 years after the earthquake, respectively. In particular, posttraumatic stress disorder also had a multiple mediating effect in the path from trauma exposure to sleep problems via fear. Furthermore, the findings indicated that sleep problems were relatively stable between 1 and 1.5 years after an earthquake.     

MATERNAL TRAUMA AFFECTS PRENATAL MENTAL HEALTH AND INFANT STRESS REGULATION AMONG PALESTINIAN DYADS

We examined how diverse and cumulated traumatic experiences predicted maternal prenatal mental health and infant stress regulation in war conditions and whether maternal mental health mediated the association between trauma and infant stress regulation. Participants were 511 Palestinian mothers from the Gaza Strip who reported exposure to current war trauma (WT), past childhood emotional (CEA) and physical abuse, socioeconomic status (SES), prenatal mental health problems (posttraumatic stress disorder and depression symptoms), and perceived stress during their secondtrimester of pregnancy as well as infant stress regulation at 4 months. While all trauma types were associated with high levels of prenatal symptoms, CEA had the most wide‐ranging effects and was uniquely associated with depression symptoms. Concerning infant stress regulation, mothers’ CEA predicted negative affectivity, but only among mothers with low WT. Against hypothesis, the effects of maternal trauma on infant stress regulation were not mediated by mental health symptoms. Mothers’ higher SES was associated with better infant stress regulation whereas infant prematurity and male sex predisposed for difficulties. Our findings suggest that maternal childhood abuse, especially CEA, should be a central treatment target among war‐exposed families. Cumulated psychosocial stressors might increase the risk for transgenerational problems.     

Effects of Group Functional Behavior-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Behavior in a Youth With Autism Spectrum Disorder

Individuals with Autism Spectrum Disorder (ASD) often present with comorbid Obsessive Compulsive Behaviors (OCBs), but little research exists on effective intervention for OCBs. Using a single-case experimental design, this study highlights the efficacy of a Group Functional Behavior-based Cognitive-Behavior Therapy (Fb-CBT) to reduce OCBs in an 11-year-old youth with ASD. Tailored to the individual needs of this youth, Fb-CBT included traditional CBT components (e.g., psychoeducation, cognitive-behavioral skills training, and exposure and response prevention) coupled with functional behavior assessment and intervention. Time-series parent report data and standardized measures showed clinically significant decreases in OCBs, an increase in psychosocial functioning, and high consumer satisfaction.