Measuring emotion in therapy: Imagery, activation, and feeling*

Rotten food, maggots, bodily waste—all elicit disgust in humans. Disgust promotes survival by encouraging avoidance of disease vectors¹ but is also implicated in prejudice toward minority groups; avoidance of environmentally beneficial foods, such as insect protein; and maladaptive avoidance behavior in neuropsychiatric conditions.2, 3, 4, 5 Unlike fear, pathological disgust is not improved substantially by exposure therapy clinically,⁶ nor in experimental work does behavioral avoidance of disgusting images habituate following prolonged exposure.^7,8 Under normal physiological conditions, perception of disgusting stimuli disrupts myoelectrical rhythms in the stomach,9, 10, 11, 12, 13 inducing gastric dysrhythmias that correlate with neural signatures of disgust.¹¹ However, the causal role of gastric rhythm in disgust avoidance is unknown. We manipulated gastric rhythm using domperidone, a peripheral dopamine D2/D3 antagonist and common anti-emetic, at a dose (10 mg) that acts to convert gastric dysrhythmias to normal rhythms.⁹ In a preregistered, randomized, double-blind, placebo-controlled crossover design in 25 healthy volunteers (aged 18–25), we measured the effects of domperidone on core disgust avoidance, using eye tracking to measure implicit (oculomotor) avoidance of disgusting images (feces) before and after an “exposure” intervention (monetary reinforcement for looking at disgusting images).^7,8 We find that domperidone significantly reduces oculomotor disgust avoidance following incentivized exposure. This suggests that domperidone may weaken the “immunity” of disgust to habituation, putatively by reducing gastric dysrhythmias during incentivized engagement with disgusting stimuli. This indicates a causal role for disgust-related visceral changes in disgust avoidance, supporting the hypothesis that physiological homeostasis contributes to emotional experience.

This is an updated version of the chapter on anxiety published in the first edition of this book. Unfortunately, advances in the functional perspective on anxiety have been few since publication of that edition. Hundreds of papers on anxiety have been published since, but very few of these add to the anxiety literature with a functional perspective that was available then. The vast majority of new papers on anxiety continue with the same formal rather than functional perspective. The new literature, just like the old, is rife with category errors, specifically referring to anxiety as a thing or entity rather than a category that groups things or entities with a collective term. To be fair, we will make the same mistake throughout this paper. It also continues the practice, now universal outside the field of behavior analysis and actually quite common within it, of referring to anxiety as something people have rather than something people do. This is not to say that humans do not have feelings consistent with what is commonly called anxiety (i.e., fear) but the feelings are not the primary, nor even secondary, concern. What people do in the presence of those feelings is the primary (i.e., only?) concern. All human beings after a certain age experience those feelings from time to time—not just in the course of their life but actually in the course of their typical day. This has no clinical significance whatsoever and frankly, little psychological significance. Anxiety and its synonymous experiential referents (e.g., fear, apprehension, worry, fretting, etc.) are simply part of the normal human makeup. But a substantial percentage of people exhibit behavior in the presence of those feelings that is clinically and psychologically significant and this behavior is of the utmost concern to persons with a functional perspective whereas persons with a more formal perspective seem more (or only) concerned with the feelings.

Individuals with specific phobias (SPs) often experience catastrophic cognitions and compromised efficacy regarding their ability to cope when in the presence of the phobic object/situation. In the current study, 165 children (7–16 years; 62% male) received either One Session Treatment or Educational Support Therapy for their SP. The children identified their feared belief and rated “how bad” it was, “how likely” it was to occur, and their ability to cope if it did occur. All of these ratings were reduced from pre-treatment to 6-month follow-up, across both treatment conditions. However, ratings of “how bad” and “how likely” reduced to a significantly greater degree for children who received OST. Greater change in each of the three beliefs predicted lower clinician severity ratings (CSRs) at post-treatment and 6-month follow-up. Additionally, changes in “how bad” and “how likely” the children rated their beliefs, and their reported ability to cope, partially mediated the relationship between treatment and post-treatment and follow-up CSRs. Overall, these findings suggest that although both treatment conditions produced changes in harm beliefs and coping efficacy, OST elicited greater changes and these changes may be important mechanisms in reduction of SP clinical severity.

Two behavioural strategies for reducing learned fear are extinction and counter-conditioning, and in this study we compared the relative effectiveness of the two procedures at diminishing fear in children. Seventy-three children aged 7–12 years old (M = 9.30, SD = 1.62) were exposed to pictures of two novel animals on a computer screen during the fear acquisition phase. One of these animals was paired with a picture of a scared human face (CS+) while the other was not (CS-). The children were then randomly assigned to one of three conditions: counter-conditioning (animal paired with a happy face), extinction (animal without scared face), or control (no fear reduction procedure). Changes in fear beliefs and behavioural avoidance of the animal were measured. Counter-conditioning was more effective at reducing fear to the CS + than extinction. The findings are discussed in terms of implications for behavioural treatments of childhood anxiety disorders.

The tripartite model of fear posits that the fear response entails three loosely coupled components: subjective distress, behavioral avoidance, and physiological arousal. The concept of synchrony vs. desynchrony describes the degree to which changes in the activation of these components vary together (synchrony), independently, or inversely (both forms of desynchrony) over time. The present study assessed synchrony–desynchrony and its relationship to treatment outcome in a sample of 98 children with specific phobias both prior to and 1 week after receiving one-session treatment, a 3 h cognitive-behavioral intervention. The results suggest an overall pattern of desynchronous change whereby youth improved on behavioral avoidance and subjective distress following treatment, but their level of cardiovascular reactivity remained stable. However, we found evidence that synchronous change on the behavioral avoidance and subjective distress components was related to better treatment outcome, whereas desynchronous change on these components was related to poorer treatment outcome. These findings suggest that a fuller understanding of the three response systems and their interrelations in phobic youth may assist us in the assessment and treatment of these disorders, potentially leading to a more person-centered approach and eventually to enhanced treatment outcomes.

Identifying for whom and under what conditions a treatment is most effective is an essential step toward personalized medicine. The current study examined pre-treatment physiological and behavioral variables as predictors and moderators of outcome in a randomized clinical trial comparing cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for anxiety disorders.

Sixty individuals with a DSM-IV defined principal anxiety disorder completed 12 sessions of either CBT or ACT. Baseline physiological and behavioral variables were measured prior to entering treatment. Self-reported anxiety symptoms were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-up from baseline.

Higher pre-treatment heart rate variability was associated with worse outcome across ACT and CBT. ACT outperformed CBT for individuals with high behavioral avoidance. Subjective anxiety levels during laboratory tasks did not predict or moderate treatment outcome.

Due to small sample sizes of each disorder, disorder-specific predictors were not tested. Future research should examine these predictors in larger samples and across other outcome variables.

Lower heart rate variability was identified as a prognostic indicator of overall outcome, whereas high behavioral avoidance was identified as a prescriptive indicator of superior outcome from ACT versus CBT. Investigation of pre-treatment physiological and behavioral variables as predictors and moderators of outcome may help guide future treatment-matching efforts.