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Background Social anxiety is a prevalent mental health concern. Models of social anxiety incorporate multifaceted components from cognitive appraisals to attention as factors maintaining the disorder. Multimodal research investigating multiple facets of social anxiety simultaneously offers an important avenue to advance our understanding of the disorder. Methods The current study tested a novel, internet-based simulated teleconferencing interaction social stressor challenge and included the collection of self-report, eye-tracking, and auditory vocal data during the challenge. Participants (N = 262) completed two interactions. The pre-recorded male and female audience members (assigned to display interest or uninterest) discussed a topic and then prompted the participant to speak on that topic. Results Fidelity indices revealed that most participants rated the interactions with the simulated audience as realistic; reported heightened subjective distress during the simulated teleconferencing interactions; and correctly rated audience members’ level of interest. As predicted, social anxiety predicted participants’ subjective distress during the simulated teleconferencing interactions. Findings from audio vocal and eye tracking analyses largely corresponded to prior research – indicating that social anxiety influences audio vocal responses and patterns of attention during social stressors. Conclusions Taken together, these findings suggest that the simulated teleconferencing interaction framework introduced here offers a potentially useful approach for the remote investigation of mechanisms underpinning social anxiety.

Biased attention to social threats has been implicated in social anxiety disorder. Modifying visual attention during exposure therapy offers a direct test of this mechanism. We developed and tested a brief virtual reality exposure therapy (VRET) protocol using 360°-video and eye tracking. Participants (N = 21) were randomized to either standard VRET or VRET + attention guidance training (AGT). Multilevel Bayesian models were used to test (1) whether there was an effect of condition over time and (2) whether post-treatment changes in gaze patterns mediated the effect of condition at follow-up. There was a large overall effect of the intervention on symptoms of social anxiety, as well as an effect of the AGT augmentation on changes in visual attention to audience members. There was weak evidence against an effect of condition on fear of public speaking and weak evidence supporting a mediation effect, however these estimates were strongly influenced by model priors. Taken together, our findings suggest that attention can be modified

It has recently become feasible to study selective visual attention to social cues in increasingly ecologically valid ways. In this secondary analysis, we examined gaze behavior in response to the actions of others in a social context. Participants (N = 84) were asked to give a 5-minute speech to a five-member audience that had been filmed in 360° video, displayed in a virtual reality headset containing a built-in eye tracker. Audience members were coached to make movements that would indicate interest or lack of interest (e.g., nodding vs. looking away). The goal of this paper was to analyze whether these actions influenced the speaker's gaze. We found that participants showed reliable evidence of gaze towards audience member actions in general, and towards audience member actions involving their phone specifically (compared with other actions like looking away or leaning back). However, there were no differences in gaze towards actions reflecting interest (like nodding) compared with actions reflecting lack of interest (like looking away). Participants were more likely to look away from audience member actions as well, but there were no specific actions that elicited looking away more or less. Taken together, these findings suggest that the actions of audience members are broadly influential in motivating gaze behaviors in a realistic, contextually embedded (public speaking) setting. Further research is needed to examine the ways in which these findings can be elucidated in more controlled laboratory environments as well as in the real world.

The COVID-19 pandemic has had a profound impact on the global economy, physical health, and mental health. This pandemic, like previous viral outbreaks, has resulted in spikes in anxiety, depression, and stress. Even though millions of individuals face the physical health consequences of infection by COVID-19, even more individuals are confronted with the mental health consequences of this pandemic. This significantly increased demand for mental health services cannot be easily met by existing mental health systems, which often rely on courses of therapy to be delivered over months. Single session interventions (SSIs) may be one important approach to meeting this increased demand, as they are treatments designed to be delivered over the course of a single meeting. SSIs have been found to be effective for a range of mental health challenges, with durable effects lasting months to years later. Here, we describe an SSI designed for the COVID-19 pandemic. This Brief Assessment-informed Skills Intervention for COVID-19 (BASIC) program draws upon therapeutic skills from existing empirically supported treatments to target common presenting complaints due to this pandemic. We discuss the process of developing and implementing this intervention, as well as explore feasibility and initial clinical insights. In short, BASIC is an easy-to-adopt intervention that is designed to be effective in a single session, making it well-suited for handling the increased demand for mental health services due to COVID-19.

Objectives Loneliness, perceived stress, depression, and anxiety have increased during the COVID-19 pandemic. Many of existing mindfulness and compassion-based intervention are effective, but are time-intensive, decreasing overall accessibility and scalability. Single-session interventions (SSIs) serve as a promising alternative. The current pre-registered clinical trial evaluated a newly developed, manualized, mindfulness-based SSI. Methods 91 adults were randomly assigned to one of three conditions: (1) one-hour mindfulness only telehealth intervention; (b) one-hour mindfulness and compassion telehealth intervention; or (c) one-week waitlist control (before randomization to an active intervention). Intervention sessions were conducted by graduate students in clinical psychology. The primary outcome was self-reported loneliness; secondary outcomes were self-reported perceived stress, depression, and anxiety. Bayesian multi-level models were conducted to test differences between active interventions and waitlist at the 1-week follow-up and between active interventions at the 2-week follow-up. Results We found overall reductions in self-reported loneliness at the 2-week follow-up b = -2.36, 95% Highest Density Interval (HDI) [-3.36, -1.36], however there was no difference between the active interventions and waitlist at the 1-week follow-up. Compared to the waitlist-control, the inclusion of a compassion component led to meaningful reductions in perceived stress b = -3.75, 95% HDI [-6.95, -0.59], anxiety b = -3.79, 95% HDI [-6.99, -0.53], and depression b = -3.01, 95% HDI [-5.22, -0.78] at the 1-week follow-up. Conclusions Results suggest that a single-session mindfulness and compassion intervention may lead to meaningful reductions in perceived stress, symptoms of anxiety, and symptoms of depression, but not loneliness. Implications of these findings are discussed.

Objectives Depression is a highly heterogeneous disorder, and meta-analyses of mindfulness-based interventions show moderate efficacy for reducing depressive symptoms. However, the mechanisms governing their efficacy remain unclear, highlighting the need for hypothesis-generating analyses to guide future research. Methods We used Bayesian network analysis in three cross-sectional samples (N = 1135) of undergraduates and participants from the community to identify links between individual symptoms of depression and specific facets of mindfulness. In two exploratory studies, we assessed depression using the Patient Health Questionnaire (n = 384) or the Depression Anxiety and Stress Scale (n = 350) and mindfulness using the Five-Facet Mindfulness Scale. Results Across these samples and measures, exploratory analyses indicated that non-judging was a central bridge between facets of mindfulness and symptoms of depression. We confirmed this finding in a pre-registered replication (n = 401) using a recently developed confirmatory testing framework for network analysis. Non-judging was consistently a central bridge in the networks and specifically linked to the symptoms of depression related to feelings of failure and worthlessness. Conclusions These findings provide strong evidence that non-judging is an essential feature of mindfulness in the context of depression and provides direction for future research testing mindfulness-oriented treatment prescriptions for depression. Supplementary Information The online version contains supplementary material available at 10.1007/s12671-021-01726-1.

Posttraumatic stress disorder (PTSD) is related to dysfunctional emotional processing, thus motivating the search for physiological indices that can elucidate this process. Toward this aim, we compared pupillary response patterns in response to angry and fearful auditory stimuli among 99 adults, some with PTSD (n = 14), some trauma-exposed without PTSD (TE; n = 53), and some with no history of trauma exposure (CON; n = 32). We hypothesized that individuals with PTSD would show more pupillary response to angry and fearful auditory stimuli compared to those in the TE and CON groups. Among participants who had experienced a traumatic event, we explored the association between PTSD symptoms and pupillary response; contrary to our prediction, individuals with PTSD displayed the least pupillary response to fearful auditory stimuli compared those in the TE, B = -0.022, p = .077, and CON, B = -0.042, p = .002, groups, but they did not differ on angry auditory stimuli, B = 0.019, p = .118 and B = 0.006, p = .634, respectively. It is important to note that within-group analyses revealed that participants with PTSD differed significantly in their response to angry versus fearful stimuli, B = -0.032, p = .015. We also found a positive association between PTSD symptoms and pupillary response to angry stimuli. Our findings suggest that differential pupil response to anger and fear stimuli may be a promising way to understand emotional processing in PTSD.

The burden of illness for PTSD is staggering and confers significant interference in work, social functioning, as well as increased risk for other physical and mental health problems. Recently, there's been considerable attention paid to the potential therapeutic use of cannabidiol (CBD) products in the treatment of a variety of physical and mental health problems. The endocannabinoid system (ECS) is a logical therapeutic target for combating PTSD and other fear-based disorders given that cannabinoid receptors and other molecular mediators crucial for ECS signaling are richly expressed in a variety of brain regions that govern the regulation of learned fear and defensive behavior.This is an 8-week single-site Phase II randomized double-blind placebo-controlled fixed dose clinical trial. Participants recruited throughout the United States (N = 150) meeting DSM-5 criteria for posttraumatic stress disorder are randomly assigned to one of three treatment arms: (a) 300 mg CBD Isolate; (b) 300 mg CBD Broad Spectrum; and (c) Placebo oil. The primary outcome is PTSD symptom severity as indexed by the PTSD Checklist for DSM-5 (PCL-5) assessed at post treatment (Week 9) and follow-up (Week 13). Secondary outcomes including patient-rated depression, overall disability, anxiety, quality of life, and alcohol use are assessed weekly throughout the trial. Safety and CBD adherence are assessed daily throughout the trial.This is the first placebo-controlled clinical trial investigating (a) CBD for the treatment of PTSD; and (b) the first study to test the relative efficacy of CBD Isolate vs CBD Broad Spectrum. Trial registration ClinicalTrials.gov registered (12/12/2019), trial identifier NCT04197102.issued 08/04/2022, protocol amendment number #2019-05-0123.

BackgroundEvidence suggests a link between smaller hippocampal volume (HV) and post-traumatic stress disorder (PTSD). However, there has been little prospective research testing this question directly and it remains unclear whether smaller HV confers risk or is a consequence of traumatization and PTSD.MethodsU.S. soldiers (N = 107) completed a battery of clinical assessments, including structural magnetic resonance imaging pre-deployment. Once deployed they completed monthly assessments of traumatic-stressors and symptoms. We hypothesized that smaller HV would potentiate the effects of traumatic stressors on PTSD symptoms in theater. Analyses evaluated whether total HV, lateral (right v. left) HV, or HV asymmetry (right – left) moderated the effects of stressor-exposure during deployment on PTSD symptoms.ResultsFindings revealed no interaction between total HV and average monthly traumatic-stressors on PTSD symptoms b = −0.028, p = 0.681 [95% confidence interval (CI) −0.167 to 0.100]. However, in the context of greater exposure to average monthly traumatic stressors, greater right HV was associated with fewer PTSD symptoms b = −0.467, p = 0.023 (95% CI −0.786 to −0.013), whereas greater left HV was unexpectedly associated with greater PTSD symptoms b = 0.435, p = 0.024 (95% CI 0.028–0.715).ConclusionsOur findings highlight the importance of considering the complex role of HV, in particular HV asymmetry, in predicting the emergence of PTSD symptoms in response to war-zone trauma.

Network analysis has been increasingly applied in an effort to understand complex interactions among symptoms in posttraumatic stress disorder (PTSD). Although methods that initially focused on identifying central symptoms in cross-sectional networks have been extended to longitudinal data that can reveal the relative roles of acute symptoms in the emergence of the PTSD syndrome, the association between network metrics and symptom change during treatment have yet to be explored in PTSD. To address this gap, we estimated pretreatment PTSD symptom networks in a sample of patients from a multisite clinical trial for women with full or subthreshold PTSD and substance use. We tested the hypothesis that node metrics calculated in the pretreatment network would be predictive of the strength of the association between a symptom's change and the change in the severity of all other symptoms through the course of treatment. A symptom node's strength and predictability in the pretreatment network were each strongly correlated with the association between that symptom's change and overall change across the symptom network, r(15) = .79, p < .001 and r(15) = .75, p < .001, respectively, whereas a symptom's mean severity at pretreatment was not, r(15) = .27, p = .292. These findings suggest that a node's centrality prior to treatment engagement is a predictor of its association with overall symptom change throughout the treatment process.

There is some evidence for heterogeneity in attentional processes among individuals with social anxiety. However, there is limited work considering how attentional processes may differ in a naturalistic task-based context (e.g., public speaking). In this secondary analysis we tested attentional heterogeneity among individuals (N = 21) with social anxiety disorder in the context of a virtual reality exposure treatment study. Participants completed a public speaking challenge in an immersive 360º-video virtual reality environment with eye tracking at pre-treatment, post-treatment, and at 1-week follow-up. Using a Hidden Markov Model (HMM) approach with clustering we tested whether there were distinct profiles of attention pre-treatment and whether there were changes following the intervention. As a secondary aim we tested whether the distinct attentional profiles at pre-treatment predicted differential treatment outcomes. We found two distinct attentional profiles pre-treatment that we characterized as vigilant/diffuse attention control and avoidant/high attention control. By the 1-week follow-up the two profiles were no longer meaningfully different. We found a difference between HMM groups for fear at public speaking at post-treatment b = -8.54, 95% Highest Density Interval (HDI) [-16.00, -0.90], Bayes Factor (BF) = 8.31 but not at one-week follow-up b = -5.83, 95% HDI [-13.25, 1.81], BF = 2.28. These findings provide support for heterogeneity in attentional processes among socially anxious individuals is likely, but that this may change following treatment. Moreover, our results provide evidence that attentional avoidance may be related to poorer treatment outcomes.

Biased attention to social threat has been implicated in social anxiety disorder. Modifying visual attention during exposure therapy offers a direct test of this mechanism. We developed and tested a brief virtual reality exposure therapy (VRET) protocol using 360º-video and eye tracking. Participants (N = 21) were randomized to either standard VRET or VRET + attention guidance training (AGT). Multi-level Bayesian models were used to test (1) whether there was an effect of condition over time and (2) whether post-treatment changes in gaze patterns mediated the effect of condition at follow-up. There was a large overall effect of the intervention on symptoms of social anxiety, as well as an effect of the AGT augmentation on changes in visual attention to audience members. There was weak evidence against an effect of condition on fear of public speaking and weak evidence supporting a mediation effect, however these estimates were strongly influenced by model priors. Taken together, our findings suggest that attention can be modified within and during VRET and that modification of visual gaze avoidance may be casually linked to reductions in social anxiety. Replication with a larger sample size is needed.

Adolescent depression is a clinically relevant concern that has major implications for mental and physical health. The trajectory of depressive symptoms among adolescents suggests that there is likely variability throughout this developmental period. The aim of the study was to assess the longitudinal relationship between individual symptoms of depression among early and middle adolescents to provide guidance for future research investigating targeted intervention efforts. Data were extracted from electronic medical records (2015–2017) from a pediatric primary care clinic in an urban setting. Cross-Lagged Panel Network analysis was used to evaluate symptoms of depression measured with the Patient Health Questionnaire (PHQ-9) measured twice over a 1-year period among early adolescents (ages 11–13 years; n = 309) and middle adolescents (ages 14–16 years; n = 255). The sample was predominantly Hispanic (90%) and 56% female. The analyses highlighted key differences and similarities between early and middle adolescence, largely focused on the role of suicidal ideation and tightly linked with feelings of failure and appetitive disturbance. In early adolescence suicidal ideation was highly likely to lead to other symptoms. In middle adolescence, however, suicidal ideation no longer had connections to other symptoms and instead the strongest connections were toward suicidal ideation. Interestingly, across both early and middle adolescence feelings of failure and appetitive disturbance were highly likely to lead to suicidal ideation. These exploratory findings highlight several longitudinal associations between early and middle adolescence that provide insight into differences and similarities regarding how symptoms might progress within those developmental periods. Taken together these results can provide direction for future research to evaluate brief, targeted interventions for adolescents.

A large body of research has provided evidence that Posttraumatic Stress Disorder (PTSD) symptoms are associated with broad changes in attentional processes which are in turn implicated in core facets of emotion regulation. However, prior research has primarily focused on specific task-based evaluations of attention. In the current study, we evaluated eye movement behaviour among adults that endorsed a traumatic event meeting Criterion A and were experiencing a range of PTSD symptoms (N = 55) while they read short trauma-related or neutral passages. We found evidence that PTSD symptoms were associated with a small difference in attentional processes between the two types of passages, with longer first fixations to words in trauma-related passages b = 1.92, 95% CI [0.31, 3.56]. Moreover, within the trauma-related texts we found that greater PTSD symptoms were associated with longer total fixation times b = 9.53, 95% CI [2.20, 16.83] and a greater number of regressions b = 0.07, 95% CI [0.01,0.13] to trauma-related words. Inclusion of an additional 25 participants not endorsing a trauma that met Criterion A did not influence the results in any meaningful way. For the first time, we provide evidence that PTSD symptoms are linked to bias for trauma-related information during a naturalistic, everyday activity – reading.

Decision-making processes in everyday life are complex. Research on decision-making has focused on self-report or experimental paradigms to understand this process. Recent work has highlighted the potential for complex iterative decision-making frameworks. We developed a simulated decision-making paradigm to assess the relationship between in-game and real-world behaviors and symptoms of depression through exploratory and then pre-registered, confirmatory analyses. Our pre-registered and post-hoc confirmatory analyses highlighted the link between in-game technology use and real-world technology use. We also explored decision-making through transition probabilities to evaluate how specific decisions might unfold over time. The findings emphasized the stability of discrete decision-making in two independent samples. Taken together, these findings suggest that some behavioral patterns appear to be quite stable. Our novel “game” has the potential to provide important insights into decision-making processes and may provide a unique method for identifying and intervening on specific targeted behaviors.

Addressing mental health challenges related to the COVID-19 outbreak can be facilitated through research that characterizes the needs of subpopulations and identifies specific pathways to targeted intervention. Toward this aim, we examined the impact of the COVID-19 outbreak on anxiety symptoms among college students (N = 487) and explored the relative impact of coping strategies using a psychological network approach, which models complex interactions to identify potential pathways to symptom-level intervention. Although students showed several significant fluctuations in pre- to post-outbreak anxiety symptom levels measured with the GAD-7, anxiety network connectivity was not significantly different across timepoints. Consistent with hypotheses, the post-outbreak symptom+coping network revealed that increased use of the adaptive coping strategies of acceptance, behavioral activation, and values-based action was associated with lower levels of fear, restlessness, and trouble relaxing. The symptom+coping network also revealed that increased use of the maladaptive strategies of excessive cleaning, reassurance seeking, and excessive checking was associated with higher levels of irritability and fear. Surprisingly, the use of reappraisal and avoidance, two strategies with putatively opposing adaptive value, highly overlapped and showed positive associations with fear and irritability. These symptom+coping associations can guide the assessment and treatment of anxiety in the face of COVID-19.

Background. The application of psychopathological symptom networks requires reconciliation of the observed cross-sample heterogeneity. We leveraged the largest sample to be used in a PTSD network analysis (N = 28,594) to examine the impact of criteria-based and data-driven sampling approaches on the heterogeneity and interpretability of networks.Methods. Severity and diagnostic criteria identified four overlapping subsamples and cluster analysis identified three distinct data-derived profiles. Networks estimated on each subsample were compared to a respective benchmark network at the symptom-relation level by calculating sensitivity, specificity, correlation, and density of the edges. Negative edges were assessed for Berkson’s bias, a source of error that can be induced by threshold samples on severity.Results. Criteria-based networks showed reduced sensitivity, specificity, and density but edges remained highly correlated and a meaningfully higher proportion of negative edges was not observed relative to the benchmark network of all cases. Among the data-derived profile networks, the Low Severity network had the highest proportion of negative edges not present in the benchmark network of symptomatic cases. The High Severity profile also showed a higher proportion of negative edges, whereas the Medium Severity profile did not. Conclusion. Although networks showed differences, Berkson’s bias did not appear to be a meaningful source of systematic error. These results can guide expectations about the generalizability of symptom networks across samples that vary in their ranges of severity. Future work should continue to explore whether network heterogeneity is reflective of meaningful and interpretable differences in the symptom relations from which they are composed.

The efficacy of expressive writing for bereavement remains unclear, although some evidence suggests that writing about positive memories of one's loved one may be particularly beneficial. The current pilot study compared the effects of a brief positive expressive writing intervention for enhancing positive affect among bereaved adults (

Social anxiety (SA) is thought to be maintained in part by avoidance of social threat, which exacerbates fear of negative evaluation. Yet, relatively little research has been conducted to evaluate the connection between social anxiety and attentional processes in realistic contexts. The current pilot study examined patterns of attention (eye movements) in a commonly feared social context – public speaking. Participants (N = 84) with a range of social anxiety symptoms gave an impromptu five-minute speech in an immersive 360°-video environment, while wearing a virtual reality headset equipped with eye-tracking hardware. We found evidence for the expected interaction between fear of public speaking and social threat (uninterested vs. interested audience members). Consistent with prediction, participants with greater fear of public speaking looked fewer times at uninterested members of the audience (high social threat) compared to interested members of the audience (low social threat) b = 0.418, p = 0.046, 95% CI [0.008, 0.829]. Analyses of attentional indices over the course of the speech revealed that the interaction between fear of public speaking and gaze on audience members was only significant in the first three-minutes. Our results provide support for theoretical models implicating avoidance of social threat as a maintaining factor in social anxiety. Future research is needed to test whether guided attentional training targeting in vivo attentional avoidance may improve clinical outcomes for those presenting with social anxiety.

BACKGROUND: Brain structures underlying posttraumatic stress disorder (PTSD) have been a focus of imaging studies, but associations between treatment outcome and alterations in brain structures remain largely unexamined. We longitudinally examined the relation of structural changes in the rostral anterior cingulate cortex (rACC), a previously identified key region in the PTSD fear network, to outcome of prolonged exposure (PE) treatment. METHOD: The sample included 78 adults (53 women): 41 patients with PTSD and 37 trauma-exposed healthy volunteers (TE-HCs). Patients underwent a 10-week course of PE treatment and completed pre- and posttreatment assessments and magnetic resonance imaging (MRI) structural scans. TE-HCs also underwent assessment and MRI at baseline and 10 weeks later. PE remitters (n = 11), nonremitters (n = 14), and TE-HCs, were compared at baseline on demographic and clinical characteristics and ACC structure. Remitters, nonremitters, and TE-HCs were compared for pre- to posttreatment clinical and structural ACC change, controlling for potential confounding variables. RESULTS: There were no baseline differences in structure between PTSD and TE-HCs or remitters and nonremitters. Following treatment, PTSD remitters exhibited cortical thinning and volume decrease in the left rACC compared with PTSD nonremitters and TE-HCs. CONCLUSIONS: These results, while in need of replication, suggest that PE treatment for PTSD, by extinguishing maladaptive trauma associations, may promote synaptic plasticity and structure change in rACC. Future research should explore possible underlying mechanisms. Language: en

Previous research associates smaller hippocampal volume with posttraumatic stress disorder (PTSD). It is unclear, however, whether treatment affects hippocampal volume or vice versa. Seventy-six subjects, 40 PTSD patients and 36 matched trauma-exposed healthy resilient controls, underwent clinical assessments and magnetic resonance imaging (MRI) at baseline, and 10 weeks later, during which PTSD patients completed ten weeks of Prolonged Exposure (PE) treatment. The resilient controls and treatment responders (n=23) had greater baseline hippocampal volume than treatment non-responders (n=17) (p=0.012 and p=0.050, respectively), perhaps due to more robust fear-extinction capacity in both the initial phase after exposure to trauma and during treatment.

Fear is central in human experience, function, and survival, and commonly evoked by exposure to threat. Yet threat may also constitute a psychological trauma (e.g., physical and/or sexual assault, wars, and natural disasters). However, the primary difference between fear and trauma is that fear is a response to an event, while trauma is the event itself. As is increasingly the case in contemporary discourse, the term trauma can both refer to the time of the traumatic event (the event itself), as well as the psychosocial and cognitive ramifications of experiencing intense fear during a traumatic event (the result of the event). To clarify this distinction, we explore in this chapter the multiple relationships between fear and trauma and examine how they intertwine in the context of their most relevant psychopathology—posttraumatic stress disorder (PTSD).