A brand new research leverages math in bettering generally used publicity remedy to beat concern.
New concern and publicity remedy analysis gives basic “Newtonian physics” to behavioral well being remedy – main the best way for higher, customized therapies.
To assist sufferers face and get previous their distressing and impairing fears, clinicians typically flip to publicity remedy as a number one remedy possibility. Nevertheless, in as many as 50% of sufferers, the fears can return.
Groundbreaking behavioral well being fashions have been offered in a research by College of Colorado researchers that was not too long ago revealed within the journal Computational Psychiatry. Boosted by an AB Nexus grant, the research revealed that fears are prone to linger as a result of concern reminiscences outlast competing security reminiscences gained in publicity remedy.
Within the following Q&A, Joel Stoddard, MD, affiliate professor within the Division of Psychiatry on the College of Colorado Faculty of Medication, explains the place our fears come from and the way the brand new analysis and mathematical modeling will assist strengthen publicity remedy, based mostly on the person affected person’s expertise. He additionally explains how the analysis was made attainable by robust collaboration throughout two College of Colorado campuses with Sarah Kennedy, PhD, and Sam Paskewitz, PhD, at CU Anschutz and Matt Jones, PhD, at CU Boulder.
As a clinician and researcher, how do you outline concern?
Concern is an individual’s whole-body response to a risk.
You’re strolling within the forest, and also you see a snake. Your physique responds, “that is harmful!” Your complete mind-body response to the snake is often a concern response. So, you’re going to have the response you’ve come to label as concern, a combined state of emotions, ideas, behaviors, and physiologic adjustments. Everybody experiences concern a bit in a different way based mostly on how they combine the part responses.
It’s your complete response to the threatening state of affairs, not simply how you are feeling about it. Classically your physique will get able to cope with the risk with a “freeze, flight, or struggle” response.
The freeze: “Don’t discover me, please.” Flight: “I’m going to run away whereas I nonetheless can.” And struggle, our final resort.
A snake on a hike looks like an innate response. What about discovered or conditioned fears?
In order that’s the following step. Once we’re speaking about concern, we’re speaking about mainly a sort of risk response. Issues which are threatening to you might be issues which are going to hurt you.
There’s a bunch of stuff on this planet that will evoke a concern response the place we don’t precisely know why it does. Some individuals are afraid of snakes although they have been by no means harmed by one. That’s known as an unconditioned concern.
Conditioned fears are completely different in that they’re discovered. For instance, a automobile accident is a big, life-threatening occasion. Plenty of occasions, people will be taught to concern sure issues that weren’t scary earlier than the automobile accident. Just like the steering wheel. Steering wheels don’t usually damage folks. However our automobile accident sufferer was targeted on the wheel on the time of the accident. And so now every time they see a steering wheel, they’ve a major life-or-death response. Steering wheels are actually a part of a brand new risk reminiscence. The response to steering wheels is a conditioned concern response.
So taking conditioned fears under consideration, what are the completely different sorts of concern that you simply see in your work?
First off, let’s be clear right here and differentiate completely different issues of the risk response:
- Publish-traumatic stress (Anxiety disorders. Anxiety disorders are a fear response to a threat you haven’t encountered yet or to an anticipated threat. “I didn’t do well on that test,” for example.
- Panic disorders. That’s like having a severe fear reaction out of the blue. To many, this can feel like a heart attack.
- Phobias: Simply put, these are extreme fear responses.
Broadly, those exemplify different types of disorders where people have problems with their fear responses. Panic: fear response without the threat. Anxiety: fear response to an anticipated threat. Post-traumatic stress: response to a threat memory.
What is exposure therapy, and historically has it been the best treatment option for fear?
Exposure therapy is a very efficacious, highly evidence-based intervention that came out of mid-20th-century psychiatry.
Let’s say you are afraid of heights. There’s this ladder, and you’ve got to climb it in order to fix something. But you’re paralyzed by your fear. You just can’t get up that ladder. It’s just too scary for you to do that.
In general, the therapy is placing yourself in a situation to do what you’re afraid of while being in a safe environment. You learn that you’re safe, then carry forward that learned safety memory. The safety memory competes with the threat association to heights.
Our work has much broader implications to just exposure therapy. Exposures are actually a technique which are an active ingredient in many therapies that target a threat association.
In PTSD, for example, indicated therapies can include trauma-focused cognitive behavioral therapy, narrative therapy, or eye movement desensitization and reprocessing. These are all very different kinds of therapies that in looking under the hood, one finds that they have some sort of exposure element to target the threat association. They bring the individual closer to their feared threat memory, but they also empower the individual and provide safety memories that compete with the threat memories through different ways.
Why did you and your team decide to research improving exposure therapy?
It really was a serendipitous, chocolate-meets-peanut butter moment. I was recruited to CU Anschutz to learn different mathematical models of the mind and how we can apply them to treatment.
Exposure therapy is generally super effective, but for 50% of people it’s not as effective and for many it is not long-lasting. That’s because their fears can come back over time. Without an enduring safety memory, a patient’s memories are tenacious and lead to recurrent fear responses. A fear response can come back if the person gets threatened again or maybe finds themselves triggered in a different context. Sometimes their symptoms are milder. Unfortunately, full-blown symptoms can return.
My colleagues and I were in Matt Jones’s office chatting. Matt is a prolific genius of rigorously mapping psychological processes to math. He and Sam Paskewitz had been working on how stimuli compete to trigger memories. I had already studied the brain basis of threat/safety memory competition in humans. Lightbulbs were going off. So, when I heard about their new experiment, I immediately asked them to apply it to threat learning. We later asked Sarah Kennedy for help because she had a deep understanding of how fear learning theory may be applied to therapy and is a leading behavioral experimental therapeutics expert on campus. It was just all here at CU. The next year the AB Nexus solidified our partnership.
We had to figure out a mathematical framework that explained all of that – what is observed in people and experiments. All of it with no exceptions. Once you get it mathematically expressed, it means now you have a precise theory. This is a hot topic, and people have been trying to understand how we can map this for some time mostly because the basic science is so good. Luckily, we have connections between CU Boulder and CU Anschutz, and AB Nexus, in both the modeling and clinical health aspects. So, to avoid pulling punches and honor my colleagues’ work, they frankly integrated a profound body of work into a coherent theory of treating fear, expressed in math.
What is the takeaway from your math and equations? How does it show a new model and paradigm for exposure therapy to make it more durable?
The big takeaway has been the potential for precision medicine in behavioral health, to borrow a popular phrase.
What if instead of months of exposure therapy, we could tell you within a week or two whether it is the right therapy? What if you are in exposure therapy, are very invested, but are having trouble with threat learning? We can tell you that early as well.
Mathematically, this research is analogous to Newton’s equations in physics. These are simple, elegant equations that help describe motion and force. They aren’t perfect, but they are powerfully predictive for day-to-day gross motion. You can land a person on the moon with them. More complex elaborations, like relativity and quantum physics exist for narrow problems. We actually did stress test elaborate models for therapy, but found they need a little more work.
We were successful because we built on a tremendous body of experimental and mathematical work- translating and in some places revising the Rescorla-Wagner family of equations. This is specifically for use in measuring and predicting learning processes involving threat memories. By detailing a set of equations to measure and predict how people acquire and forget both safety and threat memories, we may be able to better help individuals who have trouble with their fear responses to threat memories. That impacts on a staggering percentage of people over the lifetime and is a leading cause of disability worldwide, accounting for all diseases.
Already, supported directly by the AB Nexus, we have preliminary evidence that we can use this family of equations to predict how well patients will respond to treatment by how much they learn in their treatment sessions.
Let’s say you’re in your therapist’s office: You’re associating your therapist and that office with safety. It’s really those safety signals that are helping you prevent that threat response. And so, as soon as you’re out of your therapist’s office, if you don’t learn to generalize those safety memories your fear response can return. Unfortunately, experiments and models suggest that safety memories are less stable than threat memories.
Because the equations summarize all of our theory in compact form, it’s easy to see how things precisely relate. It’s an exciting future for behavioral health research. There are actually numerous implications for practice and predicting individual responses for those who brave reading the paper. It’s the beginning of an exciting new program of research to test a theory integrating over 50 years of work in threat learning to patient care.
Reference: “Explaining the Return of Fear with Revised Rescorla-Wagner Models” by Samuel Paskewitz, Joel Stoddard and Matt Jones, 14 September 2022, Computational Psychiatry.