Search

This chapter provides the introductory information necessary for therapists interested in using the Positive Affect Treatment (PAT) program. It starts by describing anhedonia, which is a symptom cluster linked to the loss of interest or joy in usual activities. Anhedonia is a transdiagnostic symptom frequently found among people suffering from depression, anxiety, psychosis, and substance abuse. Advances in behavioral science and neuroscience suggest that specific mechanisms may contribute to anhedonia. The chapter covers the principles and procedures of PAT, a program that addresses the deficits of the reward system. Therapists familiar with basic principles of cognitive–behavioral interventions and mindfulness are recommended to conduct the treatment.

This chapter explores the general format and guiding principles of the Positive Affect Treatment (PAT) program. As it was developed with theory, science, and clinical experience in mind, PAT follows the rationale, components, and structure of traditional evidence-based therapies. However, flexibility is vital as individuals with anhedonia are lacking the prerequisites for cognitive–behavioral therapy to be successful. Treatments are expected to be tailored to each client’s particular deficits to ensure that maximum benefits ensue. The chapter covers the treatment module designed to deliver psychoeducation on the nature of anhedonia, therapy expectations and structure, and the concepts of the mood cycle.

This chapter focuses on using behavioral science and neuroscience to identify targets for the treatment of anhedonia. The appetitive systems and withdrawal systems are considered to be the two core systems that regulate thoughts and behavior or actions. On the other hand, anxiety and depression have long been understood to involve excesses in the defensive system. The chapter discusses the main components of the reward system as well. It also explores how individuals with depression tend to have difficulty in labeling their emotions. The process of labeling positive emotions is likely to enhance attention to positive experiences and improve the attainment of reward.

This chapter covers the long-term goals after the completion of the Positive Affect Treatment (PAT) program. It highlights the importance of continued practice to maintain therapy gains. Long-term goals are known to promote continued practice. Having a plan for overcoming barriers help clients anticipate and cope with circumstances that might prevent them from continuing to use the skills they have learned. Awareness and a management plan could reduce the likelihood of high-risk triggers sparking a lapse or a relapse. The therapist can prepare clients for treatment termination by reviewing the client’s progress, long-term treatment goals, and coping strategies. Progress is assessed by examining the objective change in the weekly scores on the standardized questionnaires.

This chapter covers the psychoeducation that should be provided to clients participating in the Positive Affect Treatment (PAT) program. This educational material includes an explanation of mood cycles and how to identify them and how one’s emotions, thoughts, behavior, and physical sensations are interrelated. Clients are expected to learn thinking and behavioral skills that can indirectly change how they feel. Clients will learn how to label their positive emotions, which increases attention to and experience of positivity. The difference between downward spirals and upward spirals is explained in this chapter as well. A primary goal of PAT is to help clients reach upward spirals.

Positive Affect Treatment for Depression and Anxiety: Therapist Guide contains step-by-step detailed procedures for assessing and treating specific problems and diagnoses. According to the growing consensus, evidence-based practice offers the most responsible course of action for mental health professionals. The guide is intended for clinicians familiar with cognitive–behavioral therapy (CBT) and clinical presentations of depression, anxiety, and anhedonia. Positive Affect Treatment (PAT) was developed to specifically target areas of reward sensitivity that are believed to contribute to anhedonia. The treatment is expected to be an indispensable resource for all practitioners who wish to effectively and efficiently help individuals regain and improve their quality of life.

Research from recent decades has highlighted the distinction between excitatory and inhibitory Pavlovian learning mechanisms. Based on this distinction, state-of-the-art exposure therapy for anxiety disorders emphasizes inhibitory learning and retrieval as its primary mechanism for long-term reduction in fear, anxiety, and avoidance. Seven years ago, we (Craske, et al., 2014) summarized exposure therapy from an inhibitory learning approach, focusing on eight exposure optimization strategies. Here, we update this model based on recent work and describe how to conduct exposure therapy from an inhibitory retrieval approach and encourage further empirical investigation of its basic premises. To this end, we guide the reader in the use of the OptEx Nexus: a clinician's tool for conducting exposure therapy from an inhibitory retrieval approach. We categorize exposure strategies as fundamental (expectancy violation, attention to feared stimulus/situation, removal of safety signals, and mental rehearsal after exposure), advanced (deepened extinction, occasional reinforced extinction), and promoting generalization of learning (retrieval cues, multiple contexts, stimulus variability, positive affect). We additionally discuss extinction learning with distal future feared outcomes, the role of avoidance, and alternative models/approaches to exposure therapy, including counterconditioning, novelty-enhanced extinction, latent cause models, and reconsolidation. Lastly, we illustrate clinical implementation via vignettes of exposure therapy from an inhibitory retrieval approach (see Supplemental materials).

Deficits in associative and Pavlovian learning are thought to lie at the center of anxiety-related disorders. However, the majority of studies have been carried out in adult populations. The aim of this review was to critically examine the behavioral and neuroimaging literature on Pavlovian learning in pediatric anxiety disorders. We conclude that although there is evidence for deficits in Pavlovian processes (e.g., heightened reactivity to safety cues in anxious samples), the extant literature suffers from key methodological and theoretical issues. We conclude with theoretical and methodological recommendations for future research in order to further elucidate the role of Pavlovian learning in the etiology, maintenance, and treatment of pediatric anxiety disorders.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Fear activation and reduction have traditionally been considered important mechanisms of exposure therapy. Evidence to date is mixed and impeded by inadequate methodology. This study examined the extent to which fear activation and reduction within and across exposures predicted treatment outcomes for social anxiety disorder within a paradigm suitable for their measurement.Sixty-eight adults with social anxiety disorder and fear of public speaking completed seven exposure sessions, each consisting of seven speeches conducted in virtual reality. Exposures were identical in duration, task requirements, and virtual public speaking situation. Fear was measured with skin conductance and subjective distress ratings. At baseline and post-treatment, participants completed a public speaking behavioral approach test with a panel of confederate judges; subjective fear was measured. A standardized questionnaire of anxiety symptoms was administered at baseline, post-treatment, and one-month follow-up.No indices of within- or between-session fear reduction, measured by subjective distress and skin conductance response, predicted treatment outcome. One measure of fear activation was associated with outcomes such that less activation predicted greater symptom reduction; remaining indices did not predict outcomes.Data were collected in the context of a randomized controlled trial of scopolamine; drug group was included in analytic models to account for drug influence. VR exposures elicited mild levels of distress that may underestimate levels of distress in clinical settings.Findings failed to support fear activation or reduction within or across exposure sessions as significant predictors of treatment outcome for social anxiety. Treatment implications are discussed.

Training Future Health Justice Leaders Medical–legal partnerships integrate lawyers directly into health care teams to help patients address health-harming legal needs. Schools could integrate thes...

Background and objectives Following an aversive experience, fears often generalize across contexts. Contextual fear generalization is modeled in a laboratory paradigm in which one context (CTX+) is paired with an aversive unconditional stimulus (US), while the other context (CTX-) is not. The current study sought to validate a novel paradigm assessing contextual fear generalization, and to determine the extent to which stress and anxiety symptoms enhanced contextual fear generalization. Methods Fifty-nine participants were randomized to a stress induction or control arithmetic test, followed by a differential context fear conditioning paradigm. One to three days later, participants completed a generalization gradient test with CTX+, CTX, and four generalization contexts. Results We found successful contextual fear conditioning on measures of US expectancy, self-report fear and valence, and startle reflex, and linear generalization across the contextual gradient on expectancies and self-report measures. Acute stress induction impaired learning of the US-CTX + association during context fear acquisition. Anxiety significantly predicted greater contextual fear generalization as measured by US expectancy. Limitations Our study provides pilot data introducing a novel fear conditioning paradigm to assess contextual generalization of fear. There is a need for further replication to validate its utility. Conclusions Findings suggest that individuals high in anxiety show greater contextual fear generalization as measured by US expectancy. Results are discussed in terms of potential mechanisms that contribute to pervasive anxiety.

The purpose of this study was to explore whether individual differences in glucocorticoid concentrations were associated with symptom improvement following exposure therapy for patients with social anxiety disorder. To do this, 60 participants with social anxiety disorder completed a randomized-controlled trial of exposure therapy, where participants were randomized to receive scopolamine-augmentation or placebo during their 7 exposure sessions. Scopolamine is an antimuscarinic which blocks the effects of acetylcholine and reduces autonomic arousal. During sessions 1, 4, 7, and during the post-treatment extinction assessment, participants provided up to 16 saliva samples (4 in each session). Pre-treatment, post-treatment, and at 1-month follow-up, participants completed the Liebowitz Social Anxiety Scale to monitor change in fear and avoidance symptoms. Elevated endogenous in-session cortisol during exposure sessions was associated with less symptom improvement from pre- to post-treatment and at 1-month follow-up. The association between elevated endogenous in-session cortisol and attenuated symptom change was not moderated by scopolamine treatment condition. Individuals with social anxiety disorder who have elevated neuroendocrine signaling may under-benefit from exposure therapy. This is the first study, to our knowledge, to examine whether endogenous in-session cortisol concentrations predict symptom changes following exposure therapy for the treatment of social anxiety disorder. More investigation of non-invasive and reliable biological markers that explain variability in responses to effective treatments are needed.

Background and objectives Fear conditioning paradigms use various measures to assess learned fear, including autonomic arousal responses like skin conductance, and self-reports of both associative (US-expectancies) and evaluative (affective ratings) learning. The present study uses a dimensional approach to examine associations among fear indices directly. Methods Seventy-three participants completed a differential fear conditioning experiment, during which a neutral stimulus (CS+) was paired with an electric shock (US), while another stimulus (CS-) was never paired with the shock (partially instructed fear acquisition). Ten minutes later, both stimuli were presented without any shocks (fear extinction). Skin conductance responses and US-expectancy ratings were recorded during each phase, while self-reported negative affect was assessed for each CS at the end of extinction. Results Results showed a positive association among US-expectancy ratings and skin conductance responses during acquisition and early extinction. US-expectancy ratings during overall extinction were positively associated with post-extinction negative affect. Limitations The lack of affective ratings post-acquisition may have obscured associations between associative and evaluative learning indices. Conclusions Results provide evidence for the expected correspondence among different indices of associative fear learning. Findings emphasize the need for incorporating both associative and evaluative learning measures in fear conditioning paradigms., Highlights • Fear conditioning studies use physiological and self-report measures to assess fear. • We examined the association among these indices using a dimensional approach. • Autonomic arousal was associated with US-expectancy ratings. • US-expectancy ratings during extinction predicted post-extinction negative affect. • Results support the need for both associative and evaluative indices of learned fear.

Background In rodents, context specificity of Pavlovian extinction is attenuated by manipulations that impair hippocampal function, including systemic administration of scopolamine, a muscarinic-cholinergic receptor antagonist. Context renewal translates into return of fear following exposure therapy to feared situations. We evaluated the effectiveness of scopolamine for attenuating context renewal of phobic fear in humans. Methods A total of 60 participants (35 female, 22 male, 1 transgender, 2 undeclared) with social anxiety disorder and fear of public speaking were randomized to placebo, 0.5 mg scopolamine, or 0.6 mg scopolamine. They completed seven exposure sessions in an exposure context and subsequently tested in the exposure context (extinction retest) versus a different context (context renewal test), which were counterbalanced. Testing 1 month later occurred in the exposure context (long-term extinction retest). Fear measures included skin conductance and self-reported distress during speeches. Hippocampus-dependent cognitive tasks were completed as well. Results Scopolamine augmented extinction across exposure sessions on skin conductance response and skin conductance level. Lower skin conductance response at context renewal in scopolamine groups relative to the placebo group was constrained to simple effects and complicated by unexpected outcomes within placebo and on self-reported fear. Scopolamine led to lower skin conductance response at long-term extinction retest. Scopolamine impaired performance on a cognitive task of hippocampal function. Conclusions Noninvasive and well-tolerated scopolamine impaired hippocampal processes and augmented extinction during exposure. Drug-free effects persisted 1 month later. Findings at context renewal were limited and suggestive only. Further investigation is warranted with varying scopolamine dosages.

Anxiety disorders are the most common mental disorders and are often chronic and disabling. Although exposure-based treatments are effective, a substantial number of individuals fail to fully remit or experience a return of symptoms after treatment. Understanding the critical processes underlying the development and treatment of anxiety disorders will help identify individuals at risk and optimize treatments. Aversive associative learning offers explanatory pathways through which fear and anxiety emerge, spread, persist, and resurge. This narrative review examines the advances made in our understanding of associative fear and avoidance learning in anxiety disorders. Overall, the extant literature supports a key role of aversive associative learning in the development and treatment of anxiety disorders. However, research targeting specific mechanisms such as extinction generalization and avoidance, the fragility of extinction, and moderating influences of individual differences pertinent to anxiety disorders (e.g., age, sex, depression) is needed. We discuss the need for more ecological valid and complex paradigms to model ambiguity and conflict as well as for clinical translation studies to optimize treatment.

Our recent trial demonstrated individuals suffering from social anxiety with performance-related concerns who received virtual reality exposure augmented with scopolamine, a cholinergic antagonist, experienced significantly less post-treatment context renewal (CX) than placebo (Craske et al., 2019). The purpose of the present investigation was to determine who specifically benefits from scopolamine by examining hippocampal (HPC) functioning as a moderator of treatment response (Placebo n = 15, SCOP 0.5 mg n = 15, SCOP 0.6 mg n = 15). Skin conductance response to conditional stimulus (SCR-to-CS) termination suggested a dose-response relationship for enhanced HPC functioning individuals, wherein individuals receiving scopolamine demonstrated less fear at CX. In addition, SCR-to-CS onset indicated reduced fear at CX for impaired HPC individuals receiving SCOP 0.5 mg and SCOP 0.6 mg relative to Placebo. Our findings, however, lacked consistency across measures. Scopolamine remains a promising agent and additional research required to further understand its effects.

Background Response rates to first-line treatments for depression and anxiety remain unsatisfactory. Identification of predictors or moderators that can optimize treatment matching is of scientific and clinical interest. This study examined the role of prolonged laboratory-induced stress cortisol reactivity as a predictor of outcome for a treatment of affective dimensions (TAD). Patients received 15-sessions of a treatment targeting reductions in negative affect or increases in positive affect ( Craske et al., 2019 ). A second aim was to examine whether treatment type would moderate the association between cortisol reactivity and treatment outcome. Methods Thirty-five participants underwent a 36-minute intermittent stress induction task composed of a mental arithmetic task and a fear-potentiated startle task one week before treatment initiation. Cortisol was collected at five-time points with reactivity being quantified as peak during the task minus basal level of cortisol the evening before the assessment. Using multilevel modeling, we examined the associations between cortisol reactivity and slopes of symptom improvement. Results Cortisol reactivity was related to treatment outcome, with average and higher levels of stress-induced cortisol response predicting greater decreases in symptoms throughout treatment and 6-month follow-up. Treatment condition differences (moderation) were not observed in the effect of cortisol reactivity on symptoms. Conclusion Our findings demonstrate the impact of greater cortisol stress reactivity on treatment outcome. Future studies should investigate how to enhance this therapeutic benefit through capitalizing on endogenous diurnal fluctuations or exogenous cortisol manipulation.

Fear conditioning models key processes related to the development, maintenance and treatment of anxiety disorders and is associated with group differences in anxiety. However, laboratory administration of tasks is time and cost intensive, precluding assessment in large samplesnecessary for the analysis of individual differences. This study introduces a newly developed smartphone app that delivers a fear conditioning paradigm remotely using a loud human scream as an aversive stimulus. Three groups of participants (total n = 152) took part in three studies involving a differential fear conditioning experiment to assess the reliability and validity of a smartphone administered fear conditioning paradigm. This comprised of fear acquisition, generalisation, extinction, and renewal phases during which online US-expectancy ratings were collected during every trial with evaluative ratings of negative affect at three time points. We show that smartphone app delivery of a fear conditioning paradigm results in a pattern of fear learning comparable to traditional laboratory delivery and is able to detect individual differences in performance that show comparable associations with anxiety to the prior group differences literature., Highlights • A smartphone app reliably delivers a differential fear conditioning paradigm using an aversive human scream. • Within-person associations of fear conditioning between laboratory and app delivery do not differ from those across time. • App-based administration is able to detect individual differences in anxiety related processes. • Fear conditioning data can be collected with minimal financial and time cost.

OBJECTIVE Loss of pleasure or interest in activities (i.e., anhedonia) is a risk factor for suicidality, treatment nonresponse, and relapse. Extant treatments that focus on reducing negative affect have limited effects upon positive affect (a core feature of anhedonia). We investigated whether a novel intervention aimed at increasing reward sensitivity was more efficacious for positive affect than a cognitive-behavior treatment aimed at reducing threat sensitivity, in individuals with clinically severe symptoms of depression or anxiety, and functional impairment. METHOD The Treatment for Affective Dimensions trial was offered in a 2-site randomized study at outpatient treatment centers in Los Angeles and Dallas. Ninety-six patients were randomized to 15 weekly, individual sessions of Positive Affect Treatment (PAT) or Negative Affect Treatment (NAT). The primary outcome was improvement in positive affect (Positive and Negative Affect Schedule-Positive) from pretreatment to 6-month follow-up (6MFU). Secondary outcomes were improvements in negative affect (Positive and Negative Affect Schedule-Negative), suicidal ideation, and symptoms (Depression Anxiety Stress Scales). RESULTS PAT resulted in greater improvements in positive affect, p = .009, d = .52, and higher positive affect at 6MFU, p = .002, d = .67, than NAT. Participants in PAT also reported lower negative affect, p = .033, d = .52, and lower symptoms of depression, p = .035, d = .34, anxiety, p < .018, d = .30, and stress, p = .006, d = .43 at 6MFU. Finally, probability of suicidal ideation at 6MFU was lower in PAT than NAT (1.7% vs. 12.0%), p < .001. CONCLUSIONS Compared to NAT, PAT demonstrated better outcomes (at 6MFU) on positive affect, depression, anxiety, stress, and suicidal ideation, for patients with symptomatic pretreatment levels of these outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

PURPOSE To explore the feasibility and utility of using a workshop, and supervision-consultation plus external facilitation to disseminate and implement cognitive-behavioral therapy in Veterans Affairs (VA) community-based outpatient clinics (CBOCs). METHODS This study occurred in the context of a randomized controlled trial aimed at comparing 2 methods for implementing Coordinated Anxiety Learning Management (CALM) in VA CBOCs. A 3-phase (workshop, supervision-consultation, external facilitation) model was used to support 32 VA CBOC mental health providers in learning and adopting CALM in their clinical practice. Qualitative data describe training activities and the feasibility and utility of each training phase in addressing challenges to adopting CALM. FINDINGS All 3 phases of the model were feasible to use with our sample of CBOC mental health providers. Providers reported challenges learning CALM during the workshop and concerns about not having enough training post-workshop to use CALM in practice. Providers primarily utilized supervision-consultation to tailor CALM to their practice, including learning how to prioritize a target disorder, "switch" the focus of treatment to a different disorder when comorbidities were present, and modify CALM sessions to fit shorter treatment visits. Providers primarily utilized external facilitation to further tailor CALM to their practice through implementation (eg, concrete help) and support-oriented help. Key lessons for implementing CALM in CBOCs are presented and discussed. CONCLUSIONS Findings provide initial evidence for the feasibility and utility of using each component of a facilitation-enhanced training model to promote CBOC VA providers' implementation of a computer and manual version of CALM in their practice.

Fear conditioning models key processes related to the development, maintenance and treatment of anxiety disorders and is associated with group differences in anxiety. However, laboratory administration of tasks is time and cost intensive, precluding assessment in large samples, necessary for analysis of individual differences. This study introduces a newly developed smartphone app that delivers a fear conditioning paradigm remotely. Three groups of participants (total n=152) took part in three studies involving a differential fear conditioning experiment to assess the reliability and validity of a smartphone administered fear conditioning paradigm. This comprised of fear acquisition, generalisation, extinction, and renewal phases. We show that smartphone app delivery of a fear conditioning paradigm results in a pattern of fear learning comparable to traditional laboratory delivery, and is able to detect individual differences in performance that show comparable associations with anxiety to the prior group differences literature.

At the end of the Constitutional Convention, the delegates appointed the Committee of Style and Arrangement to bring together the textual provisions that the Convention had previously agreed to and to prepare a final constitution. Pennsylvania delegate Gouverneur Morris drafted the document for the Committee, and, with few revisions and little debate, the Convention adopted Morris’s draft. For more than two hundred years, questions have been raised as to whether Morris covertly altered the text in order to advance his constitutional vision, but modern legal scholars and historians studying the Convention have either ignored the issue or concluded that Morris was an honest scrivener. No prior article has systematically compared the Committee’s draft to the previously adopted resolutions or discussed the implications of those changes for constitutional law. This Article undertakes that comparison. It shows that Morris made fifteen significant changes to the Constitution and that many of the Constitution’s central elements were wholly or in critical part Morris’s work. Morris’s changes strengthened the national executive and judiciary, provided the textual basis for judicial review, increased presidential accountability through an expansive conception of impeachment, protected private property, mandated that the census report reflect “actual enumeration,” removed the constitutional text suggesting that slavery was just, and fought slavery’s spread. This Article also shows that Morris created the basis for the Federalist reading of the Constitution. Federalists—notably including fellow Committee member Alexander Hamilton—repeatedly drew on language crafted by Morris as they fought for their vision of the Constitution. Because the changes Morris made to the Convention’s agreed language were subtle, both Republicans and Federalists were able to appeal to text in the great constitutional battles of the early republic. Modern originalists claim that the Republican reading reflects the original understanding of the Constitution, but this Article argues that the largely dismissed Federalist reading explains words, phrases, and punctuation that the Republican reading ignores or renders unintelligible. By contrast, the Federalist reading of the Preamble (which they saw as a grant of substantive power), the Article I and Article II Vesting Clauses (which were contrasted to argue for expansive executive power), the Article III Vesting Clause (which they read to mandate the creation of lower federal courts), the Contracts Clause (which they read to cover public as well as private contracts), the Impeachment Clause (which they read to cover both nonofficial and official acts), and the “law of the land” provision (which they construed as a basis for judicial review) gives effect to Morris’s—and the Constitution’s—words.

At the end of the Constitutional Convention, the delegates appointed the Committee of Style and Arrangement to bring together the textual provisions that the Convention had previously agreed to and to prepare a final constitution. Pennsylvania delegate Gouverneur Morris drafted the document for the Committee, and, with few revisions and little debate, the Convention adopted Morris’s draft. For more than two hundred years, questions have been raised as to whether Morris covertly altered the text in order to advance his constitutional vision, but modern legal scholars and historians studying the Convention have either ignored the issue or concluded that Morris was an honest scrivener. No prior article has systematically compared the Committee’s draft to the previously adopted resolutions or discussed the implications of those changes for constitutional law. This Article undertakes that comparison. It shows that Morris made fifteen significant changes to the Constitution and that many of the Constitution’s central elements were wholly or in critical part Morris’s work. Morris’s changes strengthened the national executive and judiciary, provided the textual basis for judicial review, increased presidential accountability through an expansive conception of impeachment, protected private property, mandated that the census report reflect “actual enumeration,” removed the constitutional text suggesting that slavery was just, and fought slavery’s spread. This Article also shows that Morris created the basis for the Federalist reading of the Constitution. Federalists—notably including fellow Committee member Alexander Hamilton—repeatedly drew on language crafted by Morris as they fought for their vision of the Constitution. Because the changes Morris made to the Convention’s agreed language were subtle, both Republicans and Federalists were able to appeal to text in the great constitutional battles of the early republic. Modern originalists claim that the Republican reading reflects the original understanding of the Constitution, but this Article argues that the largely dismissed Federalist reading explains words, phrases, and punctuation that the Republican reading ignores or renders unintelligible. By contrast, the Federalist reading of the Preamble (which they saw as a grant of substantive power), the Article I and Article II Vesting Clauses (which were contrasted to argue for expansive executive power), the Article III Vesting Clause (which they read to mandate the creation of lower federal courts), the Contracts Clause (which they read to cover public as well as private contracts), the Impeachment Clause (which they read to cover both nonofficial and official acts), and the “law of the land” provision (which they construed as a basis for judicial review) gives effect to Morris’s—and the Constitution’s—words.

Anhedonia, or loss of interest or pleasure in usual activities, is characteristic of depression, some types of anxiety, as well as substance abuse and schizophrenia. Anhedonia is a predictor of poor long-term outcomes, including suicide, and poor treatment response. Because extant psychological and pharmacological treatments are relatively ineffective for anhedonia, there is an unmet therapeutic need for this high-risk symptom. Current psychological and drug treatments for anxiety and depression focus largely on reducing excesses in negative affect rather than improving deficits in positive affect. Recent advances in affective neuroscience posit that anhedonia is associated with deficits in the appetitive reward system, specifically the anticipation, consumption, and learning of reward. In this paper, we review the evidence for positive affect as a symptom cluster, and its neural underpinnings, and introduce a novel psychological treatment for anxiety and depression that targets appetitive responding. First, we review anhedonia in relation to positive and negative valence systems and current treatment approaches. Second, we discuss the evidence linking anhedonia to biological, experiential, and behavioral deficits in the reward subsystems. Third, we describe the therapeutic approach for Positive Affect Treatment (PAT), an intervention designed to specifically target deficits in reward sensitivity.

Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a 'fear habituation' approach and 'belief disconfirmation' approach within standard cognitive-behavior therapy. Exposure optimization strategies include 1) expectancy violation, 2) deep- ened extinction, 3) occasional reinforced extinction, 4) removal of safety signals, 5) variability, 6) retrieval cues, 7) multiple contexts, and 8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.

Recent research suggests that the mere act of retrieving a memory can temporarily make that memory vulnerable to disruption. This process of “reconsolidation” will typically restabilize the neural representation of the memory and foster its long-term storage. However, the process of reconsolidating the memory takes time to complete, and during this limited time window, the original memory may be modified either by the presentation of new information or with pharmacological agents. Such findings have prompted rising interest in using disruption during reconsolidation as a clinical intervention for anxiety, posttraumatic stress, and substance use disorders. However, “boundary conditions” on memory reconsolidation may pose significant obstacles to clinical translation. The aim of this article is to critically examine the nature of these boundary conditions, their neurobiological substrates, and the potential effect they may have on disruption of reconsolidation as a clinical intervention. These boundary conditions also highlight potential constraints on the reconsolidation phenomenon and suggest a limited role for memory updating consistent with evolutionary accounts of associative learning for threat and reward. We conclude with suggestions for future research needed to elucidate the precise conditions under which reconsolidation disruption may be clinically useful.

© 2016 Elsevier Ltd By virtue of adopting the core symptomatic fear (i.e., a fear of weight gain) as a primary treatment target, the treatment of AN centrally involves exposure-driven processes. However, exposure trials targeting the fear of weight gain in AN have been sparse, yielding mixed results to date. In translating extinction theory to the treatment of AN, it is likely that the absence of a clear distinction between what constitutes the core feared cue and the core feared outcome has stymied the application of exposure treatments in AN. This review considers several configurations of the core fear association in AN, noting distinct therapeutic strategies which may allow for more precise efforts in violating fear-based expectancies. Specific guidance is offered in the clinical decision making process as to which strategies might best promote inhibitory learning, and a clinical case is discussed, in which treatment was adjusted to specifically violate the core underlying fear association.

Mindfulness has shown promise in the treatment of several disorders, but the empirical literature regarding mindfulness and post-traumatic stress symptoms is limited. The current study examined the relationship among self-reported levels of mindfulness facets and post-traumatic stress symptoms after controlling for negative affect, age, number of traumas, and years since the trauma occurred. Participants were 157 students at an urban commuter university who completed measures online and endorsed experiencing fear, horror, or helplessness during a potentially traumatic event. Participants were predominantly female (77 %) and ranged in age from 18 to 64 years (mean = 26, SD = 4.73). Results indicated that the ability to describe emotional experiences was uniquely associated with lower hyperarousal scores, while non-reactivity to inner experiences was uniquely associated with lower overall post-traumatic stress symptoms, as well as lower re-experiencing and hyperarousal scores. Results are discussed in terms of the potential for mindfulness as an intervention for post-traumatic stress symptoms.

Pathological avoidance of benign stimuli is a hallmark of anxiety and related disorders, and exposure-based treatments have often encouraged the removal of avoidance, or safety behaviors, due to their negative effects on extinction learning. Unfortunately, empirical evidence suggests that avoidance behaviors can persist following treatment, and the mere availability of avoidance behavior can be sufficient to renew fear following successful extinction learning. The present paper critically examines the function of avoidance behavior through the lens of modern learning theory, and speculates on novel behavioral and pharmacological strategies for targeting avoidance as an adjunct to current evidence-based treatments.

Mindfulness based approaches have shown promise in the treatment of various anxiety disorders. However, further research is needed to more precisely elucidate mechanisms of action through which mindfulness practice may enhance treatment for anxiety. Given centrality of exposure-based procedures in the treatment of anxiety, it is important to consider ways in which mindfulness may affect exposure and extinction processes. In fact, numerous findings in the basic science of extinction point to the possible ways in which mindfulness may facilitate extinction learning. The present paper aims to critically review the literature surrounding mindfulness and extinction learning in order to more fully explore the ways in which mindfulness-based treatments may positively impact exposure and extinction processes in the treatment of anxiety disorders. This will provide a unique synthesis of newer, acceptance-based behavior therapies with established principles of effective behavioral treatments.

Anhedonia, or loss of interest or pleasure in usual activities, is characteristic of depression, some types of anxiety, as well as substance abuse and schizophrenia. Anhedonia is a predictor of poor long-term outcomes, including suicide, and poor treatment response. Because extant psychological and pharmacological treatments are relatively ineffective for anhedonia, there is an unmet therapeutic need for this high-risk symptom. Current psychological and drug treatments for anxiety and depression focus largely on reducing excesses in negative affect rather than improving deficits in positive affect. Recent advances in affective neuroscience posit that anhedonia is associated with deficits in the appetitive reward system, specifically the anticipation, consumption, and learning of reward. In this paper, we review the evidence for positive affect as a symptom cluster, and its neural underpinnings, and introduce a novel psychological treatment for anxiety and depression that targets appetitive responding. First, we review anhedonia in relation to positive and negative valence systems and current treatment approaches. Second, we discuss the evidence linking anhedonia to biological, experiential, and behavioral deficits in the reward subsystems. Third, we describe the therapeutic approach for Positive Affect Treatment (PAT), an intervention designed to specifically target deficits in reward sensitivity.

Despite the effectiveness of exposure therapy for treating anxiety disorders, a number of patients fail to benefi t or experience a return of fear after treatment. Research suggests that anxious individuals show defi cits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the effi cacy of expo- sure-based procedures. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a "fear habituation" approach and "belief disconfi rma- tion" approach within standard cognitive-behavior therapy. Exposure optimization strategies include 1) expectancy violation, 2) deepened extinction, 3) occasional reinforced extinction, 4) removal of safety signals, 5) variability, 6) retrieval cues, 7) multiple contexts, and 8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders.

Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a 'fear habituation' approach and 'belief disconfirmation' approach within standard cognitive-behavior therapy. Exposure optimization strategies include (1) expectancy violation, (2) deepened extinction, (3) occasional reinforced extinction, (4) removal of safety signals, (5) variability, (6) retrieval cues, (7) multiple contexts, and (8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder. publisher: Elsevier articletitle: Maximizing exposure therapy: An inhibitory learning approach journaltitle: Behaviour Research and Therapy articlelink: http://dx.doi.org/10.1016/j.brat.2014.04.006 content_type: article copyright: Copyright © 2014 Elsevier Ltd. All rights reserved. ispartof: Behaviour Research and Therapy vol:58 pages:10-23 ispartof: location:England status: published

Although cognitive-behavioral therapy (CBT) is efficacious in the treatment of generalized anxiety disorder (GAD), many individuals remain symptomatic following treatment, indicating a need for further treatment development. As a result, many researchers have developed unique cognitive-behavioral therapies that highlight specific targets for intervention.The current study examined the effect of an acceptance-based behavioral therapy for GAD on the proposed targets for intervention highlighted in several theoretical models: emotion regulation difficulties, intolerance of uncertainty, and low perceptions of control. Clients were randomly assigned to immediate (n=15) or delayed (n=16) treatment.Individuals treated with the acceptance-based behavioral therapy reported significantly fewer difficulties in emotion regulation and fear of emotional responses, as well as greater tolerance of uncertainty and perceived control over anxiety than individuals in the waitlist control condition. In addition, these effects were maintained at 3- and 9-month follow-up assessments.The present study provides promising evidence that an acceptance-based behavioral therapy for GAD has significant effects on the unique targets of intervention highlighted in several prominent theoretical models of GAD.

Alterations in central networks involved in the regulation of arousal, attention, and cognition may be critical for irritable bowel syndrome (IBS) symptom maintenance and exacerbation. Differential sensitivities in these networks may underlie sex differences noted in IBS. The current study examined prepulse inhibition (PPI), a measure of sensorimotor gating, in male and female IBS patients. Relationships between PPI and symptom severity were examined, as well as potential menstrual status effects. Compared to healthy controls, male IBS patients had significantly reduced PPI; whereas female IBS patients (particularly naturally cycling women) had significantly enhanced PPI suggesting hypervigilance. Considering previously demonstrated sex-related differences in perceptual and brain imaging findings in IBS patients, the current findings suggest that different neurobiological mechanisms underlie symptom presentation in male and female IBS patients. Compromised filtering of information in male IBS patients may be due to compromised top down (prefrontal, midcingulate) control mechanisms while increased attention to threat due to increased limbic and paralimbic circuits may be characteristic of female IBS patients.

The present study examined threat interpretation biases in children 7-12 years of age with separation, social and generalised anxiety disorders (N=15), non-anxious offspring at risk due to parental anxiety (N=16) and non-anxious controls of non-anxious parents (N=14). Children provided interpretations of ambiguous situations to assess cognitive, emotional and behavioural responses. In comparison with non-anxious control children and at-risk children who did not differ from each other, anxious children reported stronger negative emotion and less ability to influence ambiguous situations. These results suggest that threat interpretation bias may be a cognitive factor associated with ongoing childhood anxiety but not a vulnerability factor associated with parental anxiety.

Championed on the Supreme Court by Justices Scalia and Thomas and championed in academia most prominently by Professor Akhil Amar, textualism has in the past twenty years emerged as a leading school of constitutional interpretation. Textualists argue that the Constitution should be interpreted in accordance with its original public meaning and, in seeking that meaning, they closely parse the Constitution's words and grammar and the placement of clauses in the document. They have assumed that this close parsing recaptures original meaning, but, perhaps because it seems obviously correct, that assumption has neither been defended nor challenged. This article uses Professor Amar's book, The Bill of Rights, the widely acclaimed masterpiece of the textualist movement, as a case study to test the validity of that assumption. Amar's work has profoundly influenced subsequent scholarship and case law with its argument that the Bill of Rights primarily reflected republican rights of the people, rather than individual rights. This article shows that Amar's republican reading is incorrect and that his textualist interpretive approach repeatedly leads him astray. Amar incorrectly assumes that words have the same meaning throughout the document, assigns a significance to the placement of clauses that is belied by the drafting history, and incorrectly posits that the Bill of Rights reflects a unitary ideological vision. The textualist search for original public meaning cannot be squared with an interpretive approach that assumes that all word choices were made with a high degree of care, that the significance of location can be assessed simply by examining the four corners of the document, and that the Constitution must be understood holistically. Analysis of Professor Amar's The Bill of Rights indicates that, paradoxically, close reading is a poor guide to original meaning.

In 1964, as the welfare state emerged in full force in the United States, Charles Reich published The New Property, one of the most influential articles ever to appear in a law review. Reich argued that in order to protect individual autonomy in an "age of governmental largess," a new property right in governmental benefits had to be recognized. He called this form of property the "new property." In retrospect, Reich, rather than anticipating trends, was swimming against the tide of history. In the past forty years, formal claims to government benefits have become more tenuous rather than more secure. "Overseers of the Poor: Surveillance, Resistance and the Limits of Privacy," by John Gilliom, an associate professor of political science at Ohio State University, demonstrates both the tenuousness of welfare rights today and the costs that this system imposes on individual autonomy. In "Overseers of the Poor," Gilliom uses his case study of welfare recipients as the occasion for an attack on classic notions of privacy rights. Gilliom finds that welfare clients do not engage in "privacy talk" - indeed, he finds the concept to be devoid of value for the welfare recipients. Here, another comparison can be made with Reich's new property. Reich explicitly tied his idea of a new property right in government entitlements to privacy. He felt that the new property was needed to protect privacy, and, in particular, an individual's autonomy. Reich's notion of privacy reaches back to a classic concept of privacy, one that we term the "old privacy." It is precisely this classic idea that Gilliom finds welfare recipients to have rejected. Theoretical work inside and outside of the legal academy has pointed, however, to a "new privacy." The new privacy is centered around Fair Information Practices (FIPs) and is intended to prevent the threats to autonomy. This Review begins by examining Gilliom's methodology and findings. It credits the insights of his look at the inner world of welfare recipients, but finds that he appears to ignore the need for income limits on aid recipients and the concomitant need for at least some personal information to enforce these limits. It also criticizes his failure to explore an interaction of an "ethics of care" among welfare recipients with possible use of retooled privacy rights or interests. In the second part of this Review, we consider the extent to which theoretical work inside and outside of the legal academy points to a new privacy and discuss how Gilliom's empirical research provides support for that scholarship. We will also evaluate the extent to which the new privacy, centered on FIPs, can prevent the threats to personal autonomy so poignantly identified by Gilliom.

Since the ratification of the constitution, intellectual property law in the United States has always been, in part, constitutional law. Among the enumerated powers that Article I of the Constitution vests in Congress is the power to create certain intellectual property rights. To a remarkable extent, scholars who have examined the Constitution's Copyright Clause have reached a common position. With striking unanimity, these scholars have called for aggressive judicial review of the constitutionality of congressional legislation in this area. The champions of this position - we refer to them as the IP Restrictors - represent a remarkable array of constitutional and intellectual property scholars. In this terms's Eldred v. Aschroft, leading IP Restrictor Lawrence Lessig, representing petitioner Eric Eldred, sought to convince the Supreme Court that the IP Restrictors' view of the Copyright Clause was the correct one. By a vote of 7-2, the Supreme Court rejected Eldred's claim and upheld the statute. But while the Court rejected the IP Restrictors' vision, it did not offer a satisfactory competing conception of the Copyright Clause and how the courts should construe it. Critically, even though the standard of review was of central significance, the Court applied a deferential form of rational basis scrutiny without explaining why this was the appropriate standard. This paper develops the case for deferential review of congressional legislation in the area of intellectual property and, at a deeper level, offers a new paradigm for understanding the Copyright Clause. We propose that from the vantage point of constitutional law, intellectual property should be treated as a form of constitutional property. Deference to congressional judgments is warranted because congressional legislation affecting intellectual property is analytically similar to congressional legislation affecting other forms of property. Courts subject congressional legislation affecting traditional forms of property to deferential review because of concerns about institutional competence and respect for majoritarian decisionmaking. These two concerns in conjunction with proper regard for holistic constitutional interpretation should also lead courts to deferential review of congressional legislation affecting intellectual property. In developing our position, we draw on constitutional history and, in particular, the lessons of Lochner v. New York. In defense of their vision of the Constitution, the IP Restrictors and the dissenters in Eldred make claims about the original understanding that, to an astonishing extent, echo those made by proponents of Lochner-era jurisprudence. We argue, however, that these claims fail for two reasons. First, the IP Restrictors and the dissenters disregard the limited scope of judicial review at the time of the Founding. Additionally, the IP Restrictors and dissenters disregard the range of views among the Founders about monopolies.